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\begin{document}

\title{Polyhydramnios in COVID-19 infected Pregnant Woman}



\author[1]{Yeshey Dorjey}%
\author[2]{Deep Chhettri}%
\affil[1]{Royal Government of Bhutan Ministry of Health Department of Public Health}%
\affil[2]{Royal Government of Bhutan Ministry of Health}%


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  \date{May 24, 2024}


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\begin{abstract}
Bhutan has a total of 2006 cases (1271 Male, 735 Females) with one
death{[}3{]}. Among 735 females, four pregnant mothers had COVID-19
infection. One mother infected with COVID-19 at 16 weeks of gestation
developed polyhydramnios. The present study reports a rare finding of
polyhydramnios in COVID-19 infected pregnant woman.%
\end{abstract}%



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\subsubsection*{Polyhydramnios in COVID-19 infected Pregnant
Woman}

{\label{polyhydramnios-in-covid-19-infected-pregnant-woman}}

Types of the article: A case report

Yeshey Dorjey\textsuperscript{1*}, Deep Kiran Chhetri\textsuperscript{2}

1.Consultant Obstetricians \& Gynaecologist, Gynecology unit,
Phuentsholing Hospital, Bhutan

2.Consultant Obstetricians \& Gynecologist, Gynecology unit, Tashigang
Hosptial, Bhutan

\textbf{*Corresponding author:}

Yeshey Dorjey, Phuentsholing Hospital, Post office: Phuentsholing,
Chukha, Bhutan.

E-mail address: yesheydorjey@gmail.com

\emph{https://orcid.org/0000-0001-7324-3028}

\textbf{Synopsis}

Polyhydramnios in COVID-19 infected pregnant mother is not reported in
the literature. The placental insult caused by the COVID-19 infection
could the causing polyhydramnios.

\textbf{Keyword}

Polyhydramnios; COVID-19 infection; pregnant mother

\textbf{INTRODUCTION}

By December 2019, the first case of COVID-19 was reported in Wuhan city
of China{[}1{]}. COVID-19 spreads rapidly affecting all including
pregnant mothers. The first case of COVID-19 was detected in Bhutan on
5\textsuperscript{th} March 2020{[}2{]}. Bhutan has a total of 2006
cases (1271 Male, 735 Females) with one death{[}3{]}. Among 735 females,
four pregnant mothers had COVID-19 infection. One mother infected with
COVID-19 at 16 weeks of gestation developed polyhydramnios in pregnancy.
The present study reports a rare finding of polyhydramnios in COVID-19
infected pregnant mothers.

\textbf{Case presentation}

A 29-year-old primigravida at 16 weeks of gestation was diagnosed with a
COVID-19 infection. Her dating scan was done at
10\textsuperscript{+4}weeks gestation. She did not have medical or
surgical co-morbidities.

At 16 weeks of gestation on 17\textsuperscript{th} August 2020, she was
tested for COVID-19 as one of the primary contacts of Mini Dry Port
(MDP) loaders who tested positive. Her reverse transcriptase-polymerase
chain reaction (RT-PCR) test was confirmed positive. She was admitted to
Royal Institute for Governance and Strategic Studies (RIGSS) isolation
hospital on 18\textsuperscript{th} August 2020. She was asymptomatic on
admission; her vital parameters were unremarkable. Her chest x-ray
showed the normal study. Vitamin supplementations were continued during
her pregnancy.

She was followed up daily for signs and symptoms of COVID-19 and
obstetrical complications. Repeat RT-PCR was done as per the testing
protocol of the country. On day-7 of isolation, she developed a mild
fever with shortness of breath and a loss of smell. Vital signs got
slightly deranged; Temperature 40-degree Celsius, respiratory rate 28
breaths/min, SpO2 dropped to 94\%, pulse rate 96 beats/min, and BP
slightly raised (Figure 1). Oxygen was administered by face mask at 6-8
L/min and conservatively managed. After 4-6 hours of oxygenation, all
the vital signs were restored to normal and her symptom of shortness of
breath subsided. From day-8 onward the patient was clinically stable and
biochemically normal.

On day-35 RT-PCR test for COVID-19 was negative and confirmed on day-36
with a repeat RT-PCR. The patient was shifted to the de-isolation
facility on day-37 and kept for two weeks. The repeat RT-PCR was
performed at the end of de-isolation and sent for home quarantine for
another week and kept under COVID-19 surveillance by the ministry of
health, Bhutan.

From 24 weeks of gestation, she was followed up at the Maternal and
Child Health (MCH) care unit, Phuentsholing hospital. She had made six
antenatal visits. Her pregnancy was uneventful until 36 weeks of
gestation where she was diagnosed to have polyhydramnios with an
Amniotic Fluid Index (AFI) of 29 cm (Figure 2).

The patient was evaluated for the cause of polyhydramnios: Oral glucose
tolerance test with 75g glucose done, FBS 5.0 mmol/L and 2 hours after
glucose 7.5 mmol/L; Viral markers all negative; detailed anatomical scan
showed no significant fetal anomalies seen. Pregnancy was terminated at
39 weeks of gestation by cesarean section for failed induction. A live
healthy female baby weighing 3550g was delivered with the Apgar score of
8 in 1 minute and 10 in 5 minutes. At birth no gross anomaly or birth
defects were present. After 48-hours of delivery, an ultrasound scan of
the newborn was done and ruled out gastrointestinal tract anomalies. The
baby was feeding well and perfectly normal.

\textbf{Discussion}

In Bhutan, the rate of COVID-19 infection in pregnancy is low as
compared to 27.8\% in India{[}4{]}. The low rate of infection during
pregnancy in Bhutan is due to stringent control measures in place to
curb the spread of COVID-19 infections.

The majority of the pregnant mothers got infected with COVID-19 in their
second and third trimesters {[}5{]}, which is comparable to the current
case.

Preterm delivery is the most reported perinatal effect of COVID-19
infection during pregnancy{[}6{]}. Polyhydramnios in COVID-19 infection
is not reported in the literature. In the current case, a pregnant
mother got infected with COVID-19 at 16 weeks of gestation and developed
polyhydramnios later in the pregnancy. The exact cause of polyhydramnios
could not be established. Viral infection during pregnancy causes the
release of cytokines and cause oxidative stress and disrupts the
placental functions and causes polyhydramnios{[}7{]}. Since COVID-19 is
a viral infection, it may have caused placental insult due to cytokine
storm during the pregnancy and resulted in polyhydramnios. The detailed
effects of COVID-19 at biochemical levels in the body were studied.
However, the effects of COVID-19 at the placenta are not studied; the
exact effects of the COVID-19 virus on the placenta remain uncertain
because it is a new disease and detailed information is not available in
the literature.

This case concludes polyhydramnios may have been caused by COVID-19
infection during pregnancy due to placental insult and oxidative stress.

\subsection*{Acknowledgments}

{\label{acknowledgments}}

The author is grateful to Dr. Tshewang Gyeltshen (Dental surgeon,
Tsirang District Hospital, Bhutan) for reviewing the manuscript and
providing feedback.

\textbf{Author Contributions}

YD performed the clinical diagnosis, conceived the idea, drafted the
manuscript, and submitted the final version of the manuscript for
publication.

DPC conceived the idea, collected the clinical data, revised the
manuscript, and submitted it for publication.

\textbf{ORCID}

\emph{Yeshey Dorjey} https://orcid.org/0000-0001-7324-3028

\subsection*{Conflicts of Interest}

{\label{conflicts-of-interest}}

The authors have no conflicts of interest.

\textbf{Informed consent}

Informed consent was obtained from the patient for the collection of
case history and publication of this case report along with ultrasound
images. The patient consent has been signed and collected in accordance
with the journal's patient consent policy.

\textbf{References}

{[}1{]} WHO, ``Coronavirus disease 2019 (COVID-19) Situation Report --
94,'' 2020. {[}Online{]}. Available:
https://apps.who.int/iris/handle/10665/331865.

{[}2{]} S. LeVine \emph{et al.} , ``Case report: The first case of
COVID-19 in Bhutan,'' \emph{Am. J. Trop. Med. Hyg.} , vol. 102, no. 6,
pp. 1205--1207, 2020, doi: 10.4269/ajtmh.20-0259.

{[}3{]} MOH, ``National Situational Update on COVID-19,'' \emph{Ministry
of Health, Bhutan} , 2021.
http://www.moh.gov.bt/national-situational-update-on-covid-19-95/\#
(accessed Jun. 25, 2021).

{[}4{]} I. News, ``Hindustan Time,'' \emph{India News} , New Delhi, Jun.
17, 2021.

{[}5{]} A. Khalil \emph{et al.} , ``SARS-CoV-2 infection in pregnancy: A
systematic review and meta-analysis of clinical features and pregnancy
outcomes,'' \emph{EClinicalMedicine} , vol. 25, no. December 2019, p.
100446, 2020, doi: 10.1016/j.eclinm.2020.100446.

{[}6{]} K. R. Woodworth \emph{et al.} , ``Birth and Infant Outcomes
Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy ---
SET-NET, 16 Jurisdictions, March 29--October 14, 2020,'' \emph{MMWR.
Morb. Mortal. Wkly. Rep.} , vol. 69, no. 44, pp. 1635--1640, 2020, doi:
10.15585/mmwr.mm6944e2.

{[}7{]} K. M. Adams Waldorf and R. M. McAdams, ``Influence of infection
during pregnancy on fetal development,'' \emph{Reproduction} , vol. 146,
no. 5, 2013, doi: 10.1530/REP-13-0232.

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