TITLE: Pulmonary embolism in a pregnant woman with COVID-19
infection: a case
report
Sogand Goudarzi, M.D.1; Fatemeh Dehghani Firouzabadi,
M.D.2; Fatemeh Mahmoudzadeh, M.D3;
Soheila Aminimoghaddam, M.D.4*
1Division of Cardiovascular Medicine, Department of
Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School,
Boston, MA, United States
2ENT and Head and Neck Research Center and
Department, Five Senses Health Research
Institute, Hazrat Rasoul Akram Hospital, Iran University of Medical
Sciences, Tehran, Iran
3Department of Emergency Medicine, Tehran University
of Medical Sciences, Tehran, Iran
4Department of Gynecology Oncology, Iran University of
Medical Sciences, Tehran, Iran
ORCID:
*Corresponding author : Dr. Soheila Aminimoghaddam
Address: Firoozgar Hospital, Iran University of Medical Sciences,
Tehran, Iran
Tel: +98 21 222 11 688
Email:
Aminimoghaddam.s@iums.ac.ir
ORCID:
Sogand Goudarzi: 0000-0001-9552-2511
Fatemeh Dehghani Firouzabadi: 0000-0002-2665-3910
Soheila Aminimoghaddam: 0000-0001-6988-5722
Word Count: 1154
Table Count: 1
Figure Count: 1
Conflict of Interest: Authors of this manuscript declare no
conflict of interest of any nature.
Running Head: Pulmonary embolism in a COVID-19 pregnant female
patient
Abstract
Coronavirus can lead to overcoagulation, blood stasis, and endothelial
damage resulting in thromboembolic disorders. We report a 22-year-old
pregnant woman with coronavirus admitted due to the pulmonary emboli.
This case highlights the importance of considering a new category for
COVID-19 pregnant patients with venous and arterial thromboembolic
disorders.
Keywords: pregnancy, thrombosis, COVID-19, pulmonary embolism,
case report, coagulopathy
Key clinical message
COVID-19 pregnant patients with venous and arterial thromboembolic
disorders should be studied and treated in a separate category.
Introduction
Ever since the first case of coronavirus disease 2019 (COVID-19) in
Wuhan, China, the world has been struggling to overcome this crisis. The
rapid spread of the underlying severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) around the world, and its various
complications imposed on the human body (which are not completely
understood yet), have made the World Health Organization (WHO) declare a
pandemic on March 11, 2020{Cucinotta, 2020 #22;Firouzabadi, 2020
#816}. Common symptoms of COVID-19 include but are not limited to dry
cough, chest pain, shortness of breath, dyspnea, pneumonia, fever,
fatigue, and in some cases death 1-3. In addition to
respiratory symptoms, COVID-19 can cause multi-organ disorders, the
mechanism of which includes the release of inflammatory cytokines that
stimulate tissue production and active thrombin 4.
Anticoagulant treatments are recommended for non-pregnant COVID-19
patients 5.
Pregnant patients who are diagnosed with COVID-19 and show severe
symptoms have a higher risk of thromboembolic disorders and can be
treated with prophylactic weight-adjusted doses of heparin6. This study aims to introduce the uncommon
manifestation of COVID-19 in pregnancy and its rarity, as wells as the
more common thrombosis and DIC without any bleeding.
Case Presentation:
On April 22, 2020, a 22-year-old pregnant female with no past medical
history and one-time previous natural delivery (gravid 2 para 1 live 1),
with a gestational age of 30 weeks and 5 days was admitted to the
emergency ward at Firoozgar Hospital, Tehran, Iran due to the loss of
consciousness and double mydriasis. According to the patient’s spouse,
the patient has shown tonic-clonic seizure at home followed by loss of
consciousness. Six days before admission, the patient had presented
shortness of breath for several days what she consumed inhaled opioids,
which she declared that she did not have an addiction before.
In the emergency room, the patient was intubated due to the loss of
consciousness and a low score on the Glasgow Coma Scale. Cardiopulmonary
resuscitation (CPR) was performed on her. The fetal heartbeat was not
detected. After consulting with the anesthesiologist and the
cardiologist, the patient was then quickly transferred to the operation
room for monitoring and possible cesarean delivery. The pregnancy was
terminated prematurely due to not detecting the fetal heartbeat and
saving the mother’s life because of the unstable condition leading to
eight rounds of CPR. The CPR on the patient was performed with 2 doses
atropine (2 mg intravenously), 2 vials calcium gluconate, 5 vials sodium
bicarbonate, and 10 intravenous vials of epinephrine (10 mg). Emergency
echocardiography in the operating room was performed, which showed a
very dilated right atria and ventricle, leading to the full pressure of
the intercostal wall on the left ventricle. The pulmonary artery
pressure was measured to be 50 and ejection fraction (EF) was 30%,
resulting in a diagnose of a massive pulmonary embolism and the right-
and left-sided heart failure (additional echocardiography results are as
follows: right ventricle enlargement, severe dysfunction McConnell Sign,
moderate tricuspid regurgitation and no tricuspid stenosis, systolic
pulmonary pressure (sPAP) of 35, dilated pulmonary artery, mild
pulmonary insufficiency and no pulmonic stenosis, no aortic
insufficiency and aortic stenosis, no mitral regurgitation and mitral
stenosis, dilated inferior vena cava, andq normal left ventricle size).
An intravenous single dose (100 mg) alteplase was immediately infused
due to the critical condition of the mother with the very low EF, and
the fetal death in the mother’s uterus confirmed with ultrasound. In
consultation with a cardiologist, they offered to do embolectomy, but it
was not possible at this center. Also, the patient was not at a stable
stage to be transferred to another place. So, alteplase was started.
The patient was transferred to the Intensive Care Unit (ICU) when she
became stable. She was treated with 3 mg of Midazolam injection
(intravenously if necessary), 500 mg Levebel injection (intravenously
twice a day), 1 mg intravenous injection of cefepime twice a day, 25 µg
of Fentanyl injection (intravenously as needed), daily intravenous
injection of 40 mg Pantoprazole, 40 µg/min of norepinephrine infusions,
3-5 µg/hr of midazolam infusions, 25-50 µg/hr of fentanyl infusions, and
one intravenous vial of bicarbonate for pH levels lower than 7.2.Table 1 shows the results of the lab reports, which confirmed
that the patient was tested positive COVID-19. Chest X-Ray also
confirmed the same diagnosis, which demonstrated diffuse consolidative
opacities in both lungs with the left side being predominant(Figure 1) .
The extra-amniotic saline infusion (EASI) was installed to end the
pregnancy, the dilation was 5 cm while it was removed, and the patient
expired before delivery. During ICU admission, despite receiving
norepinephrine infusions, the patient’s blood pressure was very low
(70/40) with the clubbed vascular resulting in putting a central venous
line on her femur with extreme difficulty. The patient expired due to
respiratory-cardiovascular arrest and unsuccessful cardiopulmonary
resuscitation on April 23, 2020
Discussion
COVID-19, which initially presents with symptoms of respiratory illness,
may lead to dysfunction of a single organ or multiple organs and even
death. In non-pregnant patients admitted to the ICU with COVID-19
pneumonia, the prevalence of venous and arterial thromboembolic
disorders is reported to be about 25% to 31% 7,8.
A recent study considered a new category for COVID-19 patients with
venous and arterial thromboembolic disorders (named as COVID-19
associated coagulopathy) and compared it to other thromboembolic
disorders such as disseminated intravascular coagulation, hemophagocytic
syndrome, antiphospholipid syndrome, thrombotic microangiopathy,
thrombotic thrombocytopenic purpura, and Heparin-induced
thrombocytopenia 9. Our patient had some parameters of
COVID-19 associated coagulopathy such as high PTT, fibrinogen, and
D-Dimer levels. Higher D-dimer levels (more than 0.5 µg/mL) are
considered as an indirect indicator for increased thrombin production
and are associated with an increased risk of death10,11. Anticoagulant therapy with low molecular weight
heparin (LMWH) shows promising results in the prognosis of severe
COVID-19 patients with higher levels of D-dimer by limiting the extent
of coagulopathy 12.
Treatment by Heparin can also reduce the inflammatory biomarkers leading
to a decline in the severity of COVID-19 infection 13.
According to a study by Betoule et al., preventive anticoagulant
treatments should be considered in COVID1-19 non-pregnant patients with
D-dimer ≥ 3 μg/ml (11 mdf). Dashraath et al. determined that pregnant
women suspected of the severe form of COVID-19 infection during the
third trimester are at a higher risk of thromboembolic disorders.
Therefore, they suggested that these pregnant women be given the
prophylactic weight-adjusted dose of heparin during hospitalization,
continued until delivery, and six weeks postpartum 6.
Like ours, a report in Milan, Italy, presented a case of a 17-year-old
obese pregnant on 29th week of pregnancy with
shortness of breath lasted for a few days After initial assessment –
she was diagnosed with pulmonary embolism at the hospital and was
received immediately antithrombotic treatment before and after the
delivery, which saved her from further complications14.
To our best knowledge, this is the first report of maternal death due to
COVID-19 associated coagulopathy. As a high number of pregnant women (25
to 30%) with MERS and SARS dead 15, it is worthwhile
to consider the maternal death in COVID-19 infection especially in the
third trimester due to coagulative disorders that can be prevented via
prophylactic treatment.
The result of this study could increase awareness and help the frontline
worker or doctors to be well prepared to treat such patients promptly
and hopefully, save lives.
Acknowledgements
We would like to thank Dr. Gerald Chi of the Cardiovascular Department
at Harvard Medical School for his critical reviews and valuable
opinions.