Discussion
This case report highlights evidence of severe outcomes of COVID-19 infection on the mother and infant. We describe lessons pertaining to the early management of pregnant women with COVID-19 infection. Pregnant women are susceptible to COVID-19, and are therefore likely experience severe adverse pregnancy outcomes. Pregnant women have a highly sensitive inflammatory response to viral respiratory infection. Infections during pregnancy rapidly progresses, especially in the middle and late stages of pregnancy, rendering pregnant women more likely to develop complications or even severe cases. This points to high risk of serious damage to the mother and/or infant. Thus, timely and appropriate management is crucial for pregnant women with COVID-19 infection.
For pregnant women suspected of COVID-19 infection, immediate chest CT examination is recommended before nucleic acid testing is performed. This is because chest CT examination can effectively perform early detection and evaluation of lung injury, which are early symptoms of COVID-19 pneumonia.6 Notably, this should be performed after obtaining the patient’s sufficient informed consent and implemented under necessary radiation protection measures for pregnant women.
Managing pregnant women in the context of COVID-19 epidemic remains extremely complex and challenging.4 Given that viral pneumonia in pregnancy cause complications with potential to rapidly deteriorate, it is recommended that pregnant patients be isolated in a designated unit and co-managed by anti-infection teams, obstetrics, ICU and other related departments. Although treatments of COVID-19 pneumonia are similar for pregnant and non-pregnant patients, the condition of fetus should be carefully and closely monitored, as the clinical signs and symptoms may worsen along disease progression. In case the healthy condition of the pregnant woman becomes critical, her life should always be given priority, and possible termination of pregnancy should be considered. In this report case, the patient showed progressive decline in blood oxygen, and hypoxemia seemed difficult to correct even with progressive increase in oxygen therapy support. Her anoxic state improved after timely cesarean section. However, the sharp decrease in blood oxygen concentration due to severe maternal respiratory complication resulted in acute fetal hypoxia leading to neonatal death. (see Supplementary material, Table S2)
Laboratory tests performed at admission revealed leukopenia and lymphopenia. However, the number and proportion of lymphocytes decreased sharply as the disease progressed. This implies that lymphocytopenia is a prominent feature of critically ill patients with COVID-19 infection, and may reflect the severity of this disease.7 Other biochemical markers that were increased include serum levels of procalcitonin, IL-6 and serum amyloid A and thus may also indicate severity of COVID-19 infection. It worth noting that these inflammatory biomarkers are non-specific, thus they should be applied with caution when assessing pregnant patients with COVID-19. Given the lack of large cohorts of pregnant women with COVID-19 infection, we believe that lessons learnt from the present case are useful in guiding future management of such women.