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\begin{document}

\title{Management considerations for a critically ill 26-gestational week
patient with COVID-19: a case report}



\author[1]{Mohamad  Khatib}%
\author[1]{Victor  Olagundoye}%
\author[1]{Moustafa Elshafei}%
\author[1]{Fadi  El Khatib}%
\author[1]{Ahmed soliman Mohamed}%
\author[1]{Abdulqadir Nashwan}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Coronavirus-2019 (COVID-19) pandemic is a global health challenge where
pregnant women are potentially more vulnerable to respiratory
infections. We describe the successful management of a case a 35 years
old pregnant woman, G3, P1, with a history of caesarian section who
tested positive for COVID-19 and required critical care support%
\end{abstract}%



\sloppy


\textbf{Management considerations for a critically ill 26-gestational
week patient with COVID-19: a case report}

Mohamad Y. Khatib\textsuperscript{1}, Victor O.
Olagundoye\textsuperscript{2}, Moustafa S. Elshafei\textsuperscript{1},
Fadi M. El Khatib\textsuperscript{2}, Ahmed S.
Mohamed\textsuperscript{1}, Abdulqadir J. Nashwan\textsuperscript{1}

\begin{enumerate}
\tightlist
\item
  Medical Intensive Care Department, Hazm Mebaireek General Hospital
  (HMGH), Hamad Medical Corporation (HMC), Doha, Qatar
\item
  Obstetrics and Gynecology Department, Women's Wellness and Research
  Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
\end{enumerate}

\textbf{Corresponding Author}

Abdulqadir J. Nashwan anashwan@hamad.qa

Tel: (+974) 40240487

Mob: (+974) 66473549

P.O.Box 3050 Doha, Qatar

www.hamad.qa

\textbf{Abstract:} Coronavirus-2019 (COVID-19) pandemic is a global
health challenge where pregnant women are potentially more vulnerable to
respiratory infections. We describe the successful management of a case
a 35 years old pregnant woman, G3, P1, with a history of caesarian
section who tested positive for COVID-19 and required critical care
support.

\textbf{Keywo} rds: COVID-19, SARS-CoV-2, Pregnancy, Intubation,
Critical Care

\textbf{Key Clinical Message:} Early aggressive management of pregnant
women severe or critical cases of COVID-19 by the multidisciplinary team
is key to minimizing complications and early recovery.

\textbf{Background}

Coronavirus Disease 2019 (COVID-19) is a disease caused by the Severe
Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
virus.\textsuperscript{1} Which was declared by The World Health
Organization as a pandemic on 11 March 2020. As of August 2020, a total
of more than 21 million cases have been confirmed globally. Qatar has
recorded its first documented case of COVID-19 on February 29, 2020, and
has a total of 124,850 confirmed cases, with a total of 214 deaths
(updated Sep 28, 2020).\textsuperscript{2} With the COVID-19 pandemic;
pregnant women and their newborns were also afflicted significantly due
to anatomical, physiological, and immunological changes. Pregnant women
are a potentially highly vulnerable population.\textsuperscript{3}

Pregnant women are potentially more vulnerable to respiratory pathogens
including COVID-19 \textsuperscript{3} due to anatomical, physiological,
and immunological changes of pregnancy putting them and their unborn
babies at higher risks of adverse outcomes.

\textbf{Case Presentation}

A healthy 35-year-old pregnant woman, gravida 3, para 1, with a history
of previous caesarian section 3 years back for fetal distress was
brought to the emergency department (ED) by emergency medical services
(EMS) at 26+3 weeks gestation with a one-day history of fever and
shortness of breath. Three days ago, she had attended the adult
Ambulatory Care Center (ACC) with a history of contact with COVID-19,
cough and mild shortness of breath. She was apyrexic; her oxygen
saturation was 99\% and was systemically well. COVID-19 swabs were taken
and advised home quarantine while awaiting the results. Telephone
consultation was to take place within three days but advised to return
to the hospital if she experiences worsening symptoms.

On admission to ED, she was tachypnea with respiratory rate (RR) of 50
breaths/min, 88\% oxygen saturation (SpO2) on room air (94-100\%),
febrile at 38.5\selectlanguage{ngerman}° C and tachycardia with a heart rate (HR) of 120
beats/min (60-100 beats/min). She was immediately transferred to the
Intensive Care Unit (ICU); chest x-ray showed a typical COVID-19
presentation (Figure 1).

Her investigations showed: hemoglobin 11.0gm/dl, WBC 9.2 x10\^{}3/uL,
D-Dimer 0.39 mg/L FEU, Fibrinogen 4.7 gm/L (NR 2.0 -- 4.1), LDH 334 U/L
(NR 135 -- 214), Myoglobin 80 ng/mL (NR 25 -- 58), CRP 70.2 (NR 0 -- 5),
Interlukin-6 59 pg/mL (NR \selectlanguage{english}[?] 7), and Albumin level 21 (NR 35 -- 52).
Echocardiogram was normal apart from minimal pericardial effusion and
renal function and liver function tests were normal.

She was managed by MDT involving the ITU, obstetrics, and infectious
disease teams. She was quickly put on CPAP high flow oxygen (Fio2) 50\%
which improved her oxygen saturation to 99\%. She was started on
tazocin~(piperacillin, tazobactam), azithromycin, immune globulin,
convalescent plasma, Dexamethasone, enoxaparin along with other
supportive measures. Bedside ultrasound showed a viable active fetus
with a regular heart rate in cephalic presentation with the anterior
upper placenta and mildly reduced liquor volume. After 30 minutes, she
was tachypneic up to 70bpm (12-20 b/m) and she expressed abdominal
discomfort on non-invasive ventilation (NIV), hence discontinued and
connected to a Non-rebreathing mask (NRBM) 15LPM. Her tachypnea came
down to 50 BPM on NRBM.

On day 2 of ICU admission, she was not tolerating the NIV; she became
tired; hence she was intubated and kept on mechanical ventilation.
Following intubation and MDT was held and a decision was made to deliver
by category 3 cesarean section (CS) in view of deteriorating maternal
condition and to avoid possible sudden fetal demise. The procedure was
done without complication and a baby was delivered in stable condition
and transferred to the Neonatal Intensive Care Unit (NICU). His COVID-19
screening result was negative.

On day 4 of ICU admission, the patient's oxygenation has improved, and
trial extubation was carried out but failed as the patient became
agitated. Her wound site was clean and healing well, post-operative
hemoglobin was stable. There was minimal serosanguinous fluid in her
drain which was removed.

She was successfully extubated on day 6 of hospital admission and kept
on NRBM 10 LPM maintaining 98\% oxygen. After extubating she was kept on
NRBM alternative with HFNC for one week maintaining 95-98 \% oxygen
saturation. Then oxygen requirement decreased and was kept on a nasal
cannula. On day 11 of ICU admission, she was mobilized out of bed and on
day 12 of ICU admission she was saturating well on the nasal cannula.
Ivabradine 5mg BID was added in view of tachycardia. She was discharged
from ICU to home quarantine on day 13 of hospital admission. A chest
X-ray before discharge showed a mild regression of the prior seen
bilaterally airspace shadowing (Figure 2).

\textbf{Discussion}

Pregnancy complicated with pneumonia is not uncommon and can account for
up to 1.5 percent of hospital admission among pregnant women in the
USA.\textsuperscript{4} As COVID-19 is a novel virus current knowledge
on pregnant women who are severely or critically ill with the virus is
still evolving and information is lacking on the overall impact on her
unborn child especially in cases of severe prematurity (\textless{}28
weeks gestation) which often presents a major management dilemma
involving a delicate balance to ensure a good outcome for both mother
and baby.

There is limited data on the course of Covid-19 on pregnancy outcome and
the role played by normal immunogenic changes of pregnancy remains
unclear. Some studies \textsuperscript{5,6} have reported increased
fetal and maternal morbidity and mortality, a higher rate of
hospitalization and ITU admission among pregnant women compared to
non-pregnant women and possibly more severe disease in late pregnancy
compared to early pregnancy. While other studies have reported no
significant worsening of symptoms and possible shortening of clinical
course in pregnant women admitted to hospital with severe or critical
COVID-19.\textsuperscript{7} One systematic review reported maternal
mortality, stillbirth and neonatal mortality rate of 1.6\%, 1.4\% and
1.0\% respectively.\textsuperscript{8} In another review of reports of
32 women with COVID-19 during pregnancy, preterm delivery occurred in
47\% of hospitalized women with one case of stillbirth and one case of
neonatal death.\textsuperscript{9} Our patient was 26+3 weeks at the
time of admission and her only risk factor was being of Asian origin.

Pregnant women who are positive or in close contact with a confirmed or
probable case of COVID-19 must be closely monitored with strict
instructions on what to do if there is a worsening of their symptoms.
Our patient first presented to ACC with mild symptoms following contact
with COVID-19 patient. She has no systemic symptoms and examination was
normal; therefore she was advised home quarantine and to report to ED if
her symptoms worsen as per hospital protocol.

There is no consensus on the best form of fetal monitoring or the
optimal time for delivery in those who are severely or critically ill.
It is widely accepted that delivery should only be carried out for
obstetric indications and mode of delivery should not be determined by
the presence of COVID-19. In one case report\textsuperscript{10}, fetal
heart rate monitoring was carried out thrice daily for 20 minutes to
detect any significant fetal abnormality.

Once our patient was intubated the MDT decision was to deliver by
category 3 cesarean section as soon as all arrangements including
neonatal intensive care support were in place. It was felt that by the
time a significant fetal heart rate abnormality is detected on
intermittent fetal heart rate monitoring it's possible the fetus might
have suffered a significant irreversible hypoxic brain injury. Secondly,
our patient was managed in a dedicated COVID-19 intensive care unit
located more than 30 minutes' drive from the maternity and neonatal unit
making it impossible to get the team across in time for category 1
cesarean section if there is a sudden maternal deterioration or acute
fetal distress. Furthermore, the team felt that planned delivery in a
calm environment would give the baby the best chance of survival and
avoid the increased morbidity associated with an emergency cesarean
section especially if it happened in the middle of the night. It is
interesting to note that following delivery there was a significant
reduction in patient oxygen required.

\textbf{Conclusion}

Early aggressive management of severe or critical cases of COVID-19 by a
multidisciplinary team is key to minimizing complications and early
recovery. The timing of delivery should be determined by a
multidisciplinary team approach, on a case-by-case basis after a
detailed discussion with the patient or her family after considering
both maternal and fetal clinical conditions and local circumstances to
ensure good outcomes for both mother and baby.

\textbf{Abbreviations}

COVID-19: Coronavirus-2019

ACC: Ambulatory Care Center

EMS: Emergency Medical Services

MDT: Multidisciplinary Team

CRP: C-Reactive Protein

LDH: Lactate Dehydrogenase

NIV: None-Invasive Ventilation

NRBM: Non-Rebreathing Mask

\textbf{Declarations}

\textbf{Ethics approval and consent to participate}

The article describes a case report. Therefore, no additional permission
from our Ethics Committee was required.

\textbf{Consent for publication}

The consent for publication was obtained.

\textbf{Availability of data and material}

All data generated or analyzed during this study are included in this
published article.

\textbf{Competing interests}

The authors declare that they have no competing interests.

\textbf{Funding}

This study was not funded.

\textbf{Authors' contributions}

MYK, VOO, MSE, FME, ASM, AJN: Data Collection, Literature Search,
Manuscript Preparation

All authors read and approved the final manuscript

\textbf{Acknowledgments}

We thank the patient for allowing us to share her case. Open Access
funding provided by the Qatar National Library

\textbf{References}

1. Lai C-C, Shih T-P, Ko W-C, Tang H-J, Hsueh P-R. Severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus
disease-2019 (COVID-19): the epidemic and the
challenges.\emph{International journal of antimicrobial agents.}
2020:105924.

2. Organization WH. Coronavirus disease (\selectlanguage{english}\selectlanguage{english} COVID-19)\selectlanguage{english}\selectlanguage{english}: weekly
epidemiological update. 2020.

3. Chen L, Jiang H, Zhao Y. Pregnancy with COVID\selectlanguage{english}-19: Management
considerations for care of severe and critically ill
cases.\emph{American Journal of Reproductive Immunology.} 2020:e13299.

4. Richey SD, Roberts SW, Ramin KD, Ramin SM, Cunningham FG. Pneumonia
complicating pregnancy. \emph{Obstetrics and
gynecology.}1994;84(4):525-528.

5. Ellington S, Strid P, Tong VT, et al. Characteristics of women of
reproductive age with laboratory-confirmed SARS-CoV-2 infection by
pregnancy status---United States, January 22--June 7,
2020.\emph{Morbidity and Mortality Weekly Report.} 2020;69(25):769.

6. Tang P, Wang J, Song Y. Characteristics and pregnancy outcomes of
patients with severe pneumonia complicating pregnancy: a retrospective
study of 12 cases and a literature review. \emph{BMC pregnancy and
childbirth.} 2018;18(1):1-6.

7. Pierce-Williams RA, Burd J, Felder L, et al. Clinical course of
severe and critical COVID-19 in hospitalized pregnancies: a US cohort
study. \emph{American Journal of Obstetrics \& Gynecology
Mfm.}2020:100134.

8. Turan O, Hakim A, Dashraath P, Jeslyn WJL, Wright A, Abdul\selectlanguage{english}-Kadir R.
Clinical characteristics, prognostic factors, and maternal and neonatal
outcomes of SARS\selectlanguage{english}-CoV\selectlanguage{english}-2 infection among hospitalized pregnant women: a
systematic review. \emph{International Journal of Gynecology \&
Obstetrics.} 2020.

9. Mullins E, Evans D, Viner R, O'Brien P, Morris E. Coronavirus in
pregnancy and delivery: rapid review. \emph{Ultrasound in Obstetrics \&
Gynecology.} 2020;55(5):586-592.

10. Hong L, Smith N, Keerthy M, et al. Severe COVID-19 infection in
pregnancy requiring intubation without preterm delivery: A case
report.\emph{Case Reports in Women's Health.} 2020:e00217.

Figure 1: Chest X-ray on Admission

Figure 2: Chest X-ray before discharge showing Mild regression of the
prior seen bilaterally airspace shadowing\selectlanguage{english}
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