Case Presentation: A 28 year old pregnant female G1P0 (31 weeks) presented with shortness of breath and fever. She was Covid-19 positive by PCR. We present a case of a pregnant woman with Covid-19. On admission she was hypoxic with oxygen saturation of 94% on 6 liters oxygen. Pulse 120-130, Temp 101 F. PE was significant for crackles in both lungs. Heart exam was regular with tachycardia. Labs showed WBC of 7 k/mm3, hemoglobin 12.3 g/dL, hematocrit 38.1 %, platelet count 156 k/mm3, lymphocyte 11.7%, elevated d dimer 1163 ng/mL ( normal < 500 ), LDH 166 U/L, ferritin 47.5, procalcitonin 0.05 ng/mL ( reference range 0.02-0.09), creatine kinase 112 U/L. Chest CT showed no PE but bilateral opacity. She was treated with convalescent serum on the evening of admission. She was on dexamethasone 6 mg oral daily. Initially she refused Remdesivir. A couple of days later she changed her mind and she was treated with Remdesivir 200 mg IV on day 1 followed by 100 mg IV on day 2-4. She did not get the final dose of Remdesivir on day 5 because of a rise in in ALT more than 5 times normal increasing from 19 U/L on admission to 165 U/L ( normal reference < 55), AST increased from 20 U/L to 148 U/L ( normal reference < 35 U/L), total bilirubin increased from 1.3 mg/dL to 2.4. D-dimer increased from 1164 ng/mL to 1542 ng/mL on the fourth day of admission and she remained hypoxic requiring high flow oxygen so enoxaparin was increased from 40 mg subcutaneous daily to 1 mg/kg SC every 12 hours. Later in hospital course, her oxygen saturation dropped to 70% despite high flow oxygen and she was intubated and placed on ECMO. Cesarian section delivered a live female baby. The baby was negative for Sars-CoV-2 RNA RT-PCR x 2 and was positive for Sars-CoV-2 IgG qualitative test.
Discussion: The Recovery trial with dexamethasone showed a lower 28 day mortality for patients on mechanical ventilation (29.3% vs 41.4% ) and patients on oxygen but not on the ventilator ( 23.3% vs 26.2% ). However, there was no benefit for patients not requiring oxygen. The ACTT-1 RCT studied 1062 patients with Remdesivir compared to placebo. Mortality was 11.4% with Remdesivir and 15.2% with placebo by day 29. Patients on low flow oxygen and Remdesivir had lower mortality of 4% vs. 12.7% for placebo. There was no difference in mortality for patients on high flow oxygen or intubated patients. Thus giving antiviral treatment early before intubation may be beneficial rather than waiting for clinical deterioration. But the WHO Solidarity Trial with 2750 patients allocated to Remdesivir showed no reduction in mortality. According to NIH, the use of Remdesivir should not be withheld if otherwise needed during pregnancy.
Conclusions: The CDC reported that Covid+ pregnant women were more likely to be admitted to ICU ( 10.5 vs 3.9/1000 cases ), require invasive ventilation ( 2.9 vs 1.1), receive ECMO ( 0.7 vs 0.3), and die ( 1.5 vs 1.2/1000 cases ). As of October 16, 2020 the CDC reported 26,364 cases of Covid-19 in pregnant women in the US. 6011 were hospitalized, 219 admitted to ICU, 81 required mechanical ventilation, and 45 total died. Covid-19 can be transmitted through milk. The Lancet reported detection of SARS-CoV-2 in human milk in one of two mothers for 4 consecutive days. In a study of 31 pregnant women infected with SARS-CoV-2, the virus was detected in umbilical cord plasma (3%), placentas (6%), and in one milk specimen (9%). At this time American College of Obstetricians and Gynecologists advise breast feeding in mothers with COVID-19 with good hand washing and wearing a mask.
