Case presentation
On March 1, 2020, at 5:30 p.m., a 17-year-old primiparous woman with a gestational age of 14 weeks presented with unilateral leg swelling and sudden abdominal distension beginning in the night before to a health center in Sarbaz, Sistan-Baluchestan, Iran. The patient had a history of fever, abdominal pain, dry coughs and shortness of breath during the previous week and nausea, vomiting and fatigue during the previous two months and no family history of respiratory disorders. As a housewife who had not recently traveled, she did not report a history of hypertension, surgery, allergies and underlying diseases.
In the abdominal examination of the patient by a healthcare provider, the baby’s heartbeat was not heard and a mismatch was observed between gestational age and fundal height, which corresponded to approximately 24 weeks of gestation. Her physical examinations also showed a body temperature of 37.5 ˚C, a blood pressure of 140/90 mmHg, a heart rate of 119 bpm, a respiratory rate of 18 per minute and oxygen saturation of 97% at room temperature using an oximeter pulse. Moreover, the experiments showed HB=8.4 and urinary protein of +1. Given the blood pressure of 140/90 mmHg, four g of a 20% MgSo4.7H2O USP solution added to 100 ml of Ringer’s solution was intravenously injected within 20 minutes and 10 g of a 50% magnesium sulfate solution was injected deep into muscles, 5 g at each buttock.( Table 1) After receiving a Foley catheter, the patient was transferred in an ambulance to Iran Hospital, Iranshahr, Sistan-Baluchestan as a referral center for pregnant women while receiving 6-8 l/min of oxygen in a left lateral recumbent position aided by a midwife.
At 9 p.m., the patient was admitted to the maternity ward. She was conscious and pale with hematuria, uterine contractions and vital signs of blood pressure=110/70 mmHg, pulse rate=99, respiratory rate=18, body temperature=37.3 ºC and urine output=300 ml/hr. After inserting two IV lines into the left brachial vein (n=20) and the right radial vein (n=18) and performing the tests, the patient immediately underwent monitoring and was visited by a gynecologist. Vaginal examination showed a closed cervix with no bleeding. Moreover, the patient received 1000 ml of normal saline and underwent an ultrasound by a radiologist at 9:30 p.m. Complete molar pregnancy was diagnosed with an enlarged heterogeneous uterus 180×90 cm in size and containing 170×80 mm cysts. Afterwards, 400 µg of vaginal misoprostol (Cytotec) was administered. At 22:10, one unit of packed red blood cells (PRBCs) was administered due to HB=5, and the patient did not show any allergies or shortness of breath during the blood transfusion. Two units of PRBCs were also reserved for the following morning. Counseling was performed by an internist, a cardiologist and infectious disease specialist. The internist evaluated the patient for thyroid storm and signs of pulmonary thromboembolism. Stat anti-coagulant, hydration and hydrocortisone injection (stat and TDS) were administered. Thyroid tests, including TSH:0.2, T4:23 and T3:5.6, were also performed. No heart problems were observed in the patient during the cardiac counseling. The infectious disease specialist suggested the risk of lung metastasis due to molar pregnancy.
The patient was transferred for isolation to the corona ward at 22:50 given her risk of developing COVID-19.The treatment began with vancomycin AMP 1 g BID, hydrocortisone AMP 100 mg/ml STAT & TDS, oseltamivir CAP 75 mg for 5 days, kaletra CAP 200 mg for 5 Days and meropenem AMP 1000 mg TDS. The patient’s body temperature and oxygen saturation respectively reached 37.4 ˚C at 98% an hour later.
The patient was provided with a surgical mask. All the healthcare team members were also provided with appropriate personal protective gear, and droplet and contact precautions were observed. The patient underwent monitoring at 00:00 a.m. due to dry coughs and respiratory distress. Her oxygen saturation reached 98% after undergoing oxygen therapy. The RT-PCR sample was taken using oral and throat swabs. The patient was found to be negative for COVID-19 based on the results of the RT-PCR. At 00:10 a.m., 1/3-2/3 IV fluid therapy started at 30 drops/min. At 4:30 a.m., the patient’s urine output was below 100 ml/hr. The patient was transferred to the operating room the following day (March 2, 2020) at 6 a.m. while receiving the second unit of PRBCs. Suction curettage was performed to evacuate the uterus contents. During the curettage, the patient received 20 units of oxytocin in one liter of normal saline plus 0.2 mg of methylergonovine. Samples of the pregnancy products were transferred for pathological examinations.
The patient received the third unit of PRBCs on the second day at 8 a.m. Chest radiography performed by a radiologist at 8:20 a.m. showed multiple nodules in both lungs. After developing severe respiratory distress at 11:40 a.m., the patient was visited by an anesthesiologist, an infectious disease specialist and a gynecologist and then underwent oxygen therapy at 6-8 l/min with a mask. The patient was intubated at 13:30 and transferred with a respiratory rate of 52, a body temperature of 37 ˚C and a pulse rate of 170 to the ICU (Figure 1). Furthermore, CT scan was performed the following day at 16:00 due to shortness of breath, respiratory distress and lowered oxygen saturation (92%).
The CT scan showed bilateral ground glass patches (Figure 2), suggesting COVID-19. The patient then underwent hydration with 1500 ml of normal saline at 30 drops per minute and oxygen therapy at 8 liters per minute with a mask. The patient had a fever of 38.50 ˚C on the third day, i.e. March 3, 2020, at 18:00. The Apotel AMP was injected. Symptoms of the patient began to improve on the fourth day, i.e. March 4, 2020 (Figure 3).
Feeling fine on the fifth day, the patient was discharged from the hospital with a good general health status. The patient was followed up for two weeks at a private recovery center for patients discharged from the hospital. Given the problem of distance, weekly phone follow-ups were performed for 4 weeks after discharge, and the patient did not report any problems during the phone calls.