Late in her second trimester, a woman in her early 30s noticed weakness, myalgia and subjective fever. She developed a dry cough for four days, which became productive. She had shortness of breath, which progressively worsened. Her husband was diagnosed with COVID-19. She was tested at an outside facility, and presented at our emergency department with a diagnosis of symptomatic COVID-19.
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The patient had two uncomplicated vaginal deliveries. She had no significant past medical history, with the exception of class IIIb obesity.
At the time of original diagnosis, chest radiograph showed patchy ground-glass opacities in both lungs. Repeat CXR at our facility three days later showed a bilateral alveolar ground-glass pattern, likely compatible with infectious infiltrates. She was diagnosed with COVID-19 pneumonia and acute hypoxemic respiratory failure and was admitted to a unit designated for COVID-19 patients.
Maternal fetal medicine (MFM) rounded with this patient daily, and daily non-stress tests of the fetus were conducted. MFM had extensive discussions with the patient regarding the possibility of a delivery via emergent, classical cesarean section for worsening clinical status, including the risks, benefits and alternatives.
The patient’s clinical condition worsened slowly, with oxygen requirements trending up. Given that she was requiring 4L NC and was intermittently desaturating, she was transferred to the intensive care unit on hospital day 4. Repeat CXR showed worsening bilateral infiltrates, typical of COVID-19. She was placed on HFNC; however, her condition continued to deteriorate, requiring intubation.
Given the progression of disease, cesarean section was performed at 26w2d (hospital day 5), after the patient received betamethasone for fetal lung maturity and magnesium sulfate. Remdesivir was started with convalescent plasma protocol. The extremely premature infant weighed 770 g and had 1- and 5- minute Apgar scores of 5. No pathologic inflammatory processes were noted in the placenta, and the birth weight-to-placenta weight was appropriate for gestational age. The infant died from complications of extreme prematurity. The patient began to recover after delivery, was extubated two days later and discharged home on post-operative day 7.
Preterm delivery a risk in pregnant patients with acute respiratory distress syndrome
“Although pregnant and nonpregnant women have the same risk of acquiring COVID-19, management of pregnant women is complicated, as they have increased risk of complications, such as ICU admission and intubation, in part due to physiologic, anatomic and immunologic changes in pregnancy,” says Oluwatosin Goje, MD, an Ob/Gyn and fellowship-trained reproductive infectious diseases specialist. “This is in line with our experience in prior public health crises, like the 2009 H1N1 influenza virus pandemic and the Zika virus outbreak.”
“It is well-known in the MFM literature that delivery can help to treat mothers in the setting of worsening respiratory failure, and, with intermittent hypoxia, fetal well-being is at risk in utero. In this case, in the setting of acute respiratory distress syndrome (ARDS), emergency cesarean section was performed with consent. Unfortunately, despite high-quality care in a level IV neonatal intensive care unit, the infant passed within its first 24 hours.”
Pregnant women with COVID-19 at higher risk for severe illness
In a recent CDC report, symptomatic nonpregnant women with COVID-19 reported higher frequencies of headache, muscle aches, fever, chills and diarrhea than symptomatic pregnant women with COVID-19. Both groups had relatively similar frequencies of cough and shortness of breath. The severity of some symptoms appears to be higher in pregnant women with COVID-19 than the nonpregnant cohort, as 31.5% of pregnant women with COVID-19 were hospitalized compared with 5.8% of nonpregnant women.
“The risk of acquiring COVID-19 is the same, and there is no difference in the risk for death between pregnant and non-pregnant women. However, now we know that when you compare pregnant women with non-pregnant women in their reproductive years, those who are pregnant are more likely to be hospitalized, be admitted to the ICU, and to be placed on a ventilator,” says Dr. Goje.
Pregnant women with COVID-19 were 5.4x more likely to be hospitalized, 1.5x more likely to be admitted to the ICU and 1.7x more likely to receive mechanical ventilation.
“At this point, we don’t have enough data to determine a causal link with pregnancy, as there may be other comorbidities at play, including diabetes, respiratory and cardiovascular problems. Among COVID-19 cases in female patients with known pregnancy status, the data on race, ethnicity, symptoms, underlying conditions and outcomes were missing for a large proportion of cases. Further research on this is desperately needed,” Dr. Goje explains.
Preterm delivery may be a complication of COVID-19 in pregnancy
“Prematurity is one of the things you’ll find when pregnant women become very sick,” says Dr. Goje.
Emerging studies point to higher incidence of prematurity, with incidence of 28% reported in a review of 37 studies involving 275 pregnant women. More recently, a retrospective analysis of a much smaller cohort of patients from rural France reported preterm delivery in 36% of patients, compared with approximately 10% of live births in the United States in 2018. In the setting of universal maternal screening, a prospective study from New York City found higher rates of cesarean delivery among both symptomatic and asymptomatic patients with COVID-19, compared with women without COVID-19.
“While we still don’t have much information about optimal management of women who are pregnant and positive for COVID-19, we do know how to slow transmission. Perhaps more than ever before, physicians should emphasize the importance of attending prenatal appointments, and focus on optimizing health, especially in women with high-risk pregnancy as diabetes and chronic conditions of the lungs or cardiovascular system may play a role in symptom severity in COVID-19. In prenatal visits, it is incredibly important to discuss prevention measures against SARS-CoV-2 for pregnant women and their families. These include social and physical distancing, hand hygiene, wearing face masks when in public,” Dr. Goje concludes.