Case report
On Feb 1, 2020, a 31-year-old pregnant woman presented to our emergency department at the Affiliated Xiaolan Hospital, Southern Medical University, Zhongshan City having had fever for 3 hours and a 4-day history of sore throat and occasional dry cough. At the time of hospital visit, she was 35 weeks plus 2 days pregnant. She disclosed that she had returned to Zhongshan on January 24 after a family visit to Xiaogan, Hubei Province, China. She also informed the doctor that she had self-isolated at home immediately after returning from Xiaogan as advised by the Chinese government.
On January 28, 4 days after she returned to Zhongshan from Hubei Province, she developed a high fever. Her body was generally weak, and she had dry cough and sore throat, without dyspnea, expectoration, chest pain, or diarrhea. Physical examination recorded a body temperature of 39.3°C, blood pressure of 118/66 mmHg, pulse of 128 bpm, respiratory rate of 23 bpm, and oxygen saturation of 97% under room air, and a fetal heart auscultation of 160 bpm. No jaundice, bleeding dot nor skin rash were found, but throat congestion and grade I bilateral tonsil swollen were seen. Lung auscultation revealed moist rales in the lower left lung. Chest radiography was not performed after admission because the patient and her family members were concerned about the effects of radiation on the fetus. Complete blood count (CBC) after admission showed normal white-cell count (6.8×109/L, normal range 3.5~9.5×109/L), low lymphocyte count (0.884×109/L, normal range 1.1~3.2×109/L), normal hemoglobin (110×109/L, normal range 110~150g/L) and normal platelets (160×109/L, normal range 125~350×109/L) . Real-time RT-PCR tests for influenza A and B viruses using nasopharyngeal swab samples were negative.
Although the patient reported that she had not travelled to Wuhan and had not come to contact with infected people during her travel to Hubei, the local and municipal health departments were immediately notified about her visit. Consequently, she was isolated, put on supplemental oxygen (delivered by nasal cannula at 1-2/L per minute) and received physical cooling. Supportive therapies and oseltamivir were administered as empirical therapy. Center for Disease Control and Prevention (CDC) staff from Zhongshan City and Guangdong Province recommended that she undergo a test for COVID-19 infection and in-situ isolation treatment on the basis of current Chinese CDC “persons under investigation” case definitions. Nasopharyngeal and oropharyngeal swab specimens were collected in accordance with Chinese CDC guidance and sent to Zhongshan Second People’s Hospital (designated hospital in Zhongshan, China) for further confirmation. A multidisciplinary team (MDT) co-management was initiated by Xiaolan hospital, together with intensive care clinicians to manage her condition.
Four hours after admission, the patient complained of myalgia, nausea and vomiting with a body temperature of 39.4°C, pulse of 170 bpm, respiratory rate of 35 bpm, and her oxygen saturation values dropped to 94% when breathing room air. At this time, she was put on oxygen flow support (delivered by nasal cannula at 4-6/L per minute), antipyretic therapy consisting of 600 mg of ibuprofen and continuous physical cooling. Seven hours after admission, the patient complained of left chest pain and mild breathing difficulty. Her oxygen saturation had decreased (SpO2 87% supplemental oxygen delivered through mask at 6~8/L per minute). The patient and her family members agreed that she undergo a Chest CT scan under radiation protection. Unenhanced chest CT showed a large opaque patchy shadow in the lower lobe of the left lung. (Figure 1) During this time, laboratory tests showed leucopenia (white blood cell count: 1.8×109/L), hypopotassemia, impaired liver function, elevated levels of C-reactive protein and procalcitonin, creatine kinase and D-dimer. Blood gas analysis indicated respiratory failure, respiratory acidosis and metabolic acidosis. (Table 1) Fetal heart rate monitoring showed there was reactive NST (+), the baseline of fetal heart rate was 140 beats per minute, fetal heart rate fluctuated at 130~170 beats per minute. (see Supplementary material, Figure S1)
Although her high fever had resolved, symptoms such as left chest pain, dizziness and shortness of breath, body temperature of 37.4°C, blood pressure of 100/50 mmHg, pulse of 170 bpm, and respiratory rate of 45 bpm were observed. Her oxygen saturation dropped to 80.8% even though she was put on supplemental high flow oxygen delivered at 10~15/L per minute via conventional mask. Thus, blood cultures were carried out. A diagnosis of COVID-19 pneumonia was made. In addition, severe pneumonia with acute respiratory distress syndrome (ARDS), septic shock, liver and renal dysfunction were detected. Oxygen therapy supplementation was changed to high flow nasal cannula (HFNC) oxygen therapy, with a concentration of oxygen 90%, flow rate of 60 L/min, and the temperature was controlled at 34℃. The patient received immediate respiratory and circulatory support, intravenous immunoglobulin, maintenance of internal stability, and antiviral treatment plus imipenem cilastatin sodium (by 1.0 g administered intravenously every 8 hours).
Given her changing clinical condition, the multidisciplinary management team decided to terminate her pregnancy as soon as possible. Preoperative continuous fetal heart rate monitoring result was reactive NST (+), the fetal heart rate fluctuated between 150 and 170 beats per minute. This heart rate dropped to 140 beats per minute half an hour before cesarean section. Caesarean section was performed under general anesthesia in a designated isolation room, by designated personnel with specialized infection control preparation and protective gear. A preterm male infant was delivered within 13 minutes, with a 1-minute APGAR score of 1. The baby was diagnosed with severe neonatal asphyxia and hypoxic-ischemic encephalopathy and neonatal resuscitation was applied immediately. Even with active resuscitation, the baby’s APGAR score remained poor. (see Supplementary material, Table S1 to S2) The patient’s family members requested termination of resuscitation, leading to the death of the baby two hours after birth.
For the patient, postoperative continuous supportive treatments comprising ventilator­assisted breathing, sedation, anti-infection (1.0 g imipenem cilastatin sodium administered intravenously every 8 hours combined with 0.5g levofloxacin administered intravenously every day), intravenous immunoglobulin, blood transfusion, and maintenance of internal environment stability was given. The patient’s hypoxemia resolved, her blood pressure was 103/58 mmHg, pulse was 132 bpm, and oxygen saturation value was 100%. By this time, patient’s nasopharyngeal swabs were positive for COVID-19 on real-time reverse-transcription–polymerase-chain-reaction (RT-PCR) test. A diagnosis of critical COVID-19 pneumonia was confirmed. Once her vital signs stabilized, she was transferred to a designated hospital in Zhongshan, China by Feb 2, 2020. The patient’s shock was corrected, heart, liver and kidney function improved. However, her lung condition deteriorated as a result of continuous aggravation, she received ECMO treatment on Feb 6, 2020. Patient’s vital signs remained stable. (Figure 2) Results of follow-up treatment for the patient are pending.