A case of COVID-19 in a pregnant patient with severe respiratory compromise, whose clinical status significantly improved after caesarean delivery was described in BMJ Case Reports.
A 35-year-old gravida 10 para 7 at 29 3/7 weeks gestation presented to the labour and delivery unit with a 2-week history of cough and fever. The patient also reported dyspnoea that worsened with ambulation, myalgias and dysuria.
On admission, she was afebrile, with a blood pressure of 109/56, peripheral oxygen saturation (SpO2) of 95%, respiratory rate of 23 breaths per minute and heart rate of 109 beats per minute. SpO2 with ambulation decreased to 92%. On the day of presentation, she became increasingly hypoxic, requiring 8 L/min of oxygen via nasal cannula.
A COVID-19 nasopharyngeal PCR test on admission was positive and her laboratory results were significant for lymphopenia and elevated LDH, D-dimer and C reactive protein (CRP). Additionally, her chest X-ray findings were consistent with COVID-19, with extensive patchy airspace opacities in the middle and lower lung fields.
“The Infectious Disease service was consulted and recommended hydroxychloroquine and azithromycin for 5 days with monitoring of the QT interval by ECG,” Margeaux Oliva, Icahn School of Medicine at Mount Sinai, New York, New York, and colleagues wrote.
However, the patient’s partial pressure of oxygen on an arterial blood gas dropped from 91 to 66 mm Hg over the next 12 hours, and the patient was transferred to the surgical intensive care unit (SICU).
In the SICU, the patient’s condition worsened on hospital day 2 with increasingly elevated oxygen requirements. On hospital day 3, she received tocilizumab 400 mg intravenously. Nonetheless, her respiratory status continued to worsen, and by hospital day 5, she required 15 L/min of oxygen through a Venturi mask with desaturation of her SpO2 to the low 80th percentile on ambulation. Despite worsening respiratory status, the authors reported that the patient’s acute phase reactants “remarkably” improved, where her CRP downtrended from 179 mg/L at admission to 7.4 mg/L by day 5. Throughout her hospitalisation in the SICU from hospital days 2 to 9, the patient remained afebrile but was visibly tachypneic with increased work of breathing. Meanwhile, her D-dimer level continued to rise, peaking at 3037 ng/mL.
The authors noted that because the patient remained dependent on 15 L/min of oxygen and showed signs of clinical worsening with potential imminent need for intubation, an interdisciplinary team agreed on proceeding with caesarean delivery with neuraxial anaesthesia for expedited delivery, and possible intraoperative intubation if the patient was unable to tolerate prolonged supine position.
The patient eventually underwent an uncomplicated primary caesarean delivery at 30 5/7 weeks gestation with spinal anaesthesia on hospital day 10, while being maintained on 15 L/min of oxygen during the procedure and she did not require intubation. A male neonate was delivered and his chest X-ray on day of life 3 showed no evidence of pulmonary disease, and COVID-19 nasopharyngeal PCR testing collected 2 hours after delivery and on day of life 3 were negative.
Meanwhile, the authors said that the patient’s clinical status rapidly improved postoperatively, where she had a SpO2 to the low 90th percentile on room air at 2 hours post-caesarean, which improved to 100% on 15 L/min of oxygen in the recovery room, and her cough and work of breathing significantly improved. Her oxygen requirements gradually decreased, and by postoperative day 2, she was weaned to 4 L/min of oxygen via nasal cannula.
The patient remained on therapeutic enoxaparin postpartum until she was stable enough to obtain a CT angiogram, given the continued concern for a concomitant pulmonary embolism. Her CT angiogram was negative for pulmonary embolism, but consistent with COVID-19 infection, showing extensive bilateral patchy ground glass infiltrates and small consolidations. Meanwhile, COVID-19 nasopharyngeal PCR tests continued to be positive on postoperative days 7, 8 and 9. Nonetheless, the patient was discharged on postoperative day 9 as she was symptomatically improved, saturating well on room air and meeting all postoperative milestones. Eventually, her COVID-19 test was negative on postoperative day 14.
“While there are no established guidelines about timing of delivery with COVID-19, our patient began to clinically recover postpartum. In cases of severe respiratory distress from COVID-19 pneumonia, patients may experience a reversal in poor respiratory status after the physiological changes of pregnancy are removed,” the authors noted. Nonetheless, they said it cannot be excluded that the patient’s recovery was due to other factors, thus this finding needs to be confirmed in larger studies.
“To our knowledge, this is the first case to describe the use of tocilizumab for COVID-19 infection in a pregnant patient,” the authors said, adding that “tocilizumab exposure during pregnancy has mostly been studied in patients with severe rheumatologic diseases”. “Although it is difficult to attribute her clinical improvement solely to the medication, her respiratory status did not further decompensate after receipt of tocilizumab and improved tremendously after caesarean delivery,” the authors wrote.
“Our patient experienced significant improvement in respiratory status postpartum, and the neonate similarly recuperated well without COVID-19 seropositivity,” the authors stated, adding that future studies clarifying whether delivery improves clinical status and the appropriate timing and dosage of medications would be beneficial for obstetric providers.