Case Presentation
We present a case of a 33-year old pregnant women at 32 weeks of gestation, was referred to a tertiary care center following 8-day history of malaise, cough, sore throat and shortness of breath. Her past medical history revealed, asthma (>10 years) on inhaled steroids and gestational diabetes. Prior to admission, she was taking vitamins and budesonide and reported no history of allergies to medications. She is non-smoker and no recent travel was reported.
During the current admission, her vital signs were as follows: temperature 37.4°C, heart rate - 98 beats per minute, respiratory rate 25 br/min, blood pressure 98/63 mm Hg, and oxygen saturation (SpO2) 90% room air, 96% with nasal canula. She complained of tiredness, lower back ache while breathing, pertinent dry cough and shortness of breath. No obstetric or fetal concerns were noted. All relevant blood tests, nasopharyngeal swab/real-time reverse transcriptase polymerase chain reaction (RtPCR), and chest X-ray were performed (see table 1). Chest X-ray demonstrated patchy ground glass pneumonic infiltrates in both lung fields suggesting clinical correlation for pneumonia (see figure 1). Nasopharyngeal and throat swabs confirmed positive for SARS-CoV-2 infection.
Insert table 1 : Laboratory values for the first 10 days
Following positive Rt-PCR, on day 1 of the hospital stay the patient was commenced on HMC’s COVID-19 treatment protocol, chloroquine 400 mg once daily for 10 days, azithromycin 500 mg once daily for 10 days, oseltamivir 150 mg twice orally for 10 days, intravenous ceftriaxone 2gm once daily for 10 days. Within few hours, she developed severe hypoxemia and acute respiratory distress (RR: 35 b/min), and was unable to complete sentences. Considering the maternal acuity and gestational age she was transferred to the intensive care unit of an obstetric specialty care.
The patient was admitted to a negative pressure intensive care room with multi-disciplinary expertise to manage critically ill obstetric patients. Additional oxygen support was provided, non-breather mask 15L/mins, with positive end-expiratory pressure (PEEP) at 5 cm H2O, and fraction of inspired oxygen (FiO2) at 100%. However, no improvement was observed, methylprednisolone 40mg was administered to decrease the host inflammatory responses in the lungs. On day 2, as the patient was not tolerating the non-invasive ventilation (NIV) and complained of uneasiness, shortness of breath with pain while breathing. As a part of the treatment protocol Kaletra® lopinavir/ritonavir (80/20mg) and one dose of Tocilizumab 400mg (for hyper-inflammation caused by cytokine release) were administered. On day 3, considering the deteriorating respiratory functions, a multidisciplinary team including, internists, medical team, obstetric specialty, anesthetist decided to intubate her.
As patient required deep sedation to tolerate lung protective ventilation, continuous sedation/analgesia with propofol: 50mcg/kg/min + fentanyl: 5mcg/kg/hr, was administered aiming the Richmond Agitation and Sedation Scale (RASS) (19) more than -4. Despite intubation and other medical interventions, the respiratory functions and static compliance worsened remarkably, and positive end-expiratory pressure (PEEP) and Fi02 was kept high. The ventilator flow was adjusted as follows, peak pressure: 21mbar, plateau pressure: 20mbar, mean pressure: 14mbar, MV: 10.8L/min, minute volume (MV): 0.8L/min, respiratory rate: 22bpm, VT (tidal volume): 393mL, Resistance (R): 7.6mbar/L/s, Compliance: 119.5mL/mbar, PEEP: 14.7mbar. End-tidal carbon dioxide (EtCO2): 29mmHg.
The cardiotocography (CTG) demonstrated no fetal heart acceleration and non-reassuring fetal outcomes anticipated mostly due to maternal hypoxemia. Considering persistent deterioration in maternal respiratory function and signs of fetal distress, it was decided to terminate the pregnancy by cesarean section (C-section). Magnesium sulphate 2gm infusion was commenced for fetal neuroprotection and was monitored for toxicity. The patient underwent an uncomplicated lower segment transverse cesarean section delivering a 1900gms baby boy, with a blood loss of 300ml. As per current recommendations, there was no need for a delayed cord clamping, and the baby was separated from the patient immediately.
On day 4, the patient encountered prolonged QTC intervals anticipated mostly due to hydroxychloroquine /+ Kaletra® lopinavir/ritonavir. Hydroxychloroquine was withheld, and timely monitoring was recommended. The patient encountered life-threatening hypoxia and severe acute respiratory failure post operatively. ECMO team was consulted and veno-venous ECMO bi-femoral cannulation was initiated after consent was obtained from the husband. On day 5, during infectious disease consultation ribavirin was added and 2 units of convalescent plasma was administered to improve her respiratory mechanisms. On day 6, the ECMO team decided to stop cisatracurium and noradrenaline and to wean off sweep gas aiming for oxygen saturation >88% and PH >7.25. Cabergoline 1mg, potent dopamine receptor agonist (to inhibit milk production) was administered to avoid breast engorgement and pain.
On day 14, on ECMO, the liver enzymes were elevated, due to antiviral medications, following which the ribavirin was withheld. The inflammatory markers drastically reduced following administration of methylprednisolone 20mg. On day 18, the patient developed hematuria and hematoma at the C-section wound antibiotics were started, low dose of fibrinogen was replaced. On day 19, the patient developed subcutaneous emphysema due to gram positive galenium bacteria, which was treated cefipime, later changed to piperacillin tazobactum sodium 4500mg. On day 23, following an improved clinical and respiratory functions, ECMO decannulation was performed and was well tolerated. After 24 hrs, the patient was extubated on high flow nasal oxygen (2L), echocardiogram revealed no evidence of infective endocarditis. On day 25, following improved clinical findings, the patient was shifted from the intensive care unit to a step-down unit with continuous monitoring. The patient was clinically stable and was discharged two weeks later.
Insert Picture 1: Radiological Findings
Insert figure 1: Ventilation flowsheet during hospitalization