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.