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.