Virginia Research Day 2021

COVID-19 PNEUMONIA IN PREGNANCY Andrew Doyle, DO, Lenworth Beaver, MD, Fatima Guzman-Gawel, MD Sovah Health Family Medicine Residency Program, Danville, VA

RC-21

Clinical Course : She was found to be Covid-19 positive incidentally on admission and underwent a C-section the following day (due to a non-reassuring fetal heart tracing) with no complications. Four days post-partum, she developed hypoxia, and seven days post-partum, she required ICU ventilator support. She received Covid-19 Convalescent Plasma per Mayo Clinic protocol, intravenous remdesivir, ceftriaxone, and piperacillin/tazobactam, plus full dose enoxaparin for with concern for thromboembolism. After 7 ventilator days, she was extubated and subsequently discharged to home on aspirin 81mg, ferrous sulfate 300mg BID, and daily rosuvastatin 10 mg, amlodipine 5mg, zinc sulfate 220 mg, hydrochlorothiazide 25 mg, ascorbic acid 500 mg, cholecalciferol 5,000 units, and to complete an oral course of cefdinir 300 mg BID, and azithromycin 500mg daily. A cardiac ECHO showed grade 2 diastolic dysfunction with EF 60%. The baby initially had respiratory distress and required oxygen for 72 hours before successful weaning. Its chest x-ray had transient tachypnea of a newborn. Ampicillin and gentamycin were initially begun but stopped at discharge. Baby’s tested negative for Covid-19 x 2. Pertinent Diagnostic Studies (Admission Day to ICU Group B Streptococcus positive, UA : +1 protein, +3 blood, WBC 9.46 K, Hct 36.1%, D-dimer post-partum 2.98. Covid 19 Positive on admission.

Background : Maternal infections carry serious risk for the mother and the unborn child. The Covid-19 pandemic has added further to pregnancy risk. Chief Complaint & History : A G1,P0 super morbidly obese 27-year-old African American female presented to Labor and Delivery at 38 4/7 weeks gestation with gestational hypertension to rule out pre-eclampsia. Past Medical History: Gestational hypertension, gestational anemia, pre-diabetes, morbid obesity, asthma, eczema, fibroids Past Surgical History: None Medications : Ferrous sulfate 325mg daily, aspirin 81mg daily, prenatal vitamins. Allergies: Dust and pollen. Pertinent Review of Systems : Several days loss of taste, ample fetal movement, no vaginal bleeding or loss of fluid, leg edema, cough, shortness of breath, fever or chills. Pertinent Physician Exam (Admission) Vital Signs: (Admission) BMI 55.5 kg/m2, Temp 101.8, pulse 102, respirations 25, blood pressure 168/71. Lungs clear to auscultation, uterine fundus palpable at xiphoid process, 3+ bilateral pedal edema, fetal heart tones baseline rate of 150s with moderate variability: Social History: Lives at home with her partner. Her mother and grandmother had been admitted to hospital for Covid-19. Smoked in the past, quit in 9/2019. Prior marijuana use. Said to have quit 9/2019. Denied alcohol use. Family History : Pertinent for history of hypertension and diabetes.

Figure 1: Rotated AP portable chest x-ray with right lower and middle lobe infiltrate on Post Partum Day 4.

Diagnosis: Postpartum maternal Covid-19 pneumonia.

Discussion: Covid-19 is a novel coronavirus that has yet to be fully understood. Covid-19 risk factors for poor outcome include increased age, obesity, cardiovascular disease, lung disease, diabetes, and smoking. In pregnant women, the most prevalent symptoms are cough, headaches, myalgias, fever, throat soreness, and dyspnea. Pregnant women have an increased risk of complications from Covid-19 compared to their non-pregnant counterparts, and are more likely to require ICU admission, require mechanical ventilation, and to die. Covid-19 treatment during pregnancy include maintaining oxygen saturations above 95% to ensure fetal oxygenation, placing the mother in the left lateral decubitus position with proper padding above and below the uterus, and remdesivir. Hydroxychloroquine has been not been efficacious in Covid-19 pregnancy infections, and it has been shown to cross the placenta.

Resources : McIntosh, Kenneth. “Coronavirus Disease 2019 (COVID-19): Clinical Features.” UpToDate, www.uptodate.com/contents/coronavirus-disease-2019-covid-19-clinical-features?search =covid+19&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

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