Key Clinical Message:
In a secondary hospital setting, the dedication shown by health care
staffs, timely management of logistics, careful consideration of
delivery of this SARS-CoV-2 infected patient has prevented possible
complications, set an example for all.
Introduction:
Maternal Health Service has been affected negatively worldwide like any
other services due to the Coronavirus Disease 2019 (COVID-19) pandemic
and a significant rise in maternal death globally has been estimated
over the next six months [1]. The 2002-2003 SARS infection was
associated with unpleasant outcomes for pregnancy that caused
significant morbidity and mortality [2]. Similarly, MERS infection,
2018, resulted in high case fatality among the vulnerable pregnant women
and their fetus [3]. Like SARS and MERS, the causative organism for
COVID-19 is also a corona virus, hence COVID-19 becoming a pandemic
raises alarm for both pregnant women and obstetricians. With COVID-19
cases continuing to hike in significant proportion, the number of
infected pregnant women of all gestational ages has increased [4].
COVID-19 has predominant respiratory complications and various clinical
features of this infection has similarities and differences with MERS
and SARS [5]. According to a recent surveillance report from the US
CDC, it was found that, in comparison to nonpregnant women, pregnant
women were 5.4 times more likely to be hospitalized, 1.5 times more
likely to be admitted to the ICU and 1.7 times more likely to receive
mechanical ventilation when infected with COVID-19 [6]. However, the
frequency of symptomatic disease and mortality were not increased in
pregnant women compared to nonpregnant women[6]
Decreased compliance of chest wall with increased minute ventilation,
tidal volume, oxygen consumption ( raised by 20%); decreased Functional
Residual Capacity and compensated respiratory alkalosis are the notable
changes in respiratory system during pregnancy that puts women in
jeopardy for viral infection [7]. Hypoxia in turn leads to
hyperventilation, thus that women are likely to inhale more air and if
air contains contaminated aerosol or droplets, they are more likely to
be infected than other populations [8]. Suppression of cell-mediated
immunity and a shift to the Th2 immune system from Th1 environment in
pregnancy leads to more inclination on certain viral and bacterial
infections [9, 10].
In Nepal, the first mortality due to COVID-19 was of a woman in her
10th postpartum day of vaginal delivery, who had
delivered a preterm baby, her symptoms being dyspnea and cough [11].
The nasopharyngeal swab for Reverse Transcriptase - Polymerase Chain
Reaction (RT-PCR) of the woman was only taken after she was dead which
came out positive and neonatal RT-PCR test had come out to be negative
[11]. We are presenting a case report of a COVID -19 positive
teenager with term pregnancy who was managed in a rural hospital setting
in Nepal. She was asymptomatic for this infection and normal vaginal
delivery was conducted smoothly in a limited resource setting with
appropriate safety measures applied. The concerned obstetrician and team
had adequate time in planning the delivery with the best possible
limited resource mobilization that could have been available in this
circumstance.
Case:
A 19-year Gravida 2 Para 1, Abortion 0 Living issue 0 at 38 weeks 2 days
period of gestation had been shifted from quarantine of Dhorpatan
Municipality to the isolation ward in Dhaulagiri Hospital on June 21,
2020 when she was tested positive for Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS CoV-2) infection via RT-PCR. She had returned from
Punjab, India, around 12 days back with her husband and both were tested
positive one day prior to being shifted to Hospital’s isolation ward. A
detailed history was taken from the patient and full clinical
examination was done after admission in the ward following appropriate
safety measures. She had only one antenatal checkup during her pregnancy
and had received a single dose of Diptheria and Tetanus Toxoid injection
during that time. Ultrasonography had not been performed on this female
during any period of her pregnancy. She had no history of fever, cough,
chest pain, or shortness of breath. She did not mention any history of
altered taste or smell, diarrhea, or pain in the abdomen. The patient
perceived fetal movements regularly. She also had no history of any
chronic medical illness or surgery. Previous baby was a male child
delivered at term, who died due to respiratory difficulty at around 1
month of life. She had delivered the baby when she was just 16 years of
age.
Her blood pressure during examination was 92/58 mm of Hg, temperature
was 97.2, ºF, heart rate was 92 beats per minute, and peripheral oxygen
saturation was 99% on room air. Her respiratory and cardiovascular
system examinations were normal. Abdominal examination showed term sized
fetus, cephalic in presentation with regular fetal heart sound and there
was no contraction. The head was engaged. On pelvic examination, there
was no any bleeding or excessive vaginal discharge. Bishop score was 5
with cervical os, closed and uneffaced, soft, central cervix and vertex
was on -1 station. Pelvis was an average gynecoid type. Blood
investigation was sent (Table 1) and Ultrasonography (USG) of the
patient was planned. USG was performed by radiologist following
appropriate safety measures. The ultrasound showed regular fetal heart
rate and active fetal movement. The placenta had anterior uterine
insertion and liquor volume was mentioned to be adequate with regular
fetal umbilical artery doppler velocimetry. The estimated fetal weight
was mentioned to be 2831 grams and approximate gestational age as 36
weeks and one day.
A multidisciplinary approach involving obstetrician, critical care
physician, internist, and pediatrician was done in this case for the
plan in management. A common consensus came out from the team to give
the patient options to choose the mode of delivery in view of history of
previous infant death. The patient along with her husband chose for
normal vaginal delivery unless for any obstetric indication cesarean
section would be performed. Her preliminary diagnosis was 19 years
G2P1L0ID1 at 38 weeks and 2 days period of gestation with SARS-CoV-2
positive status, not in labor. Following that, a new room was allocated
for normal delivery of the patient. Oxygen supply, instruments for
vaginal delivery and oxytocin, tranexamic acid, baby warmer were
arranged in that room for this purpose. OT setup was prepared in case
emergency indication for CS would evolve. An Intensive Care Unit, which
had been set up only recently in this hospital, was prepared for this
patient for any possible critical care emergency. Ventilators and
suction machines along with other ICU equipment were standby for any
possible complication. She was well counselled and was examined on a
regular basis by the health care providers. During each interaction with
the patient, use of personal protective equipment was done. Special care
regarding the nutrition of the woman was done and regular assurances was
provided by the nursing in-charge and obstetrician in-charge.
With these findings, the patient was planned for elective induction of
labor at 39 weeks period of gestation. However, on 3rdday of admission, the patient during the early morning had complained of
abdominal pain. When examined, her uterine contraction was found to be
moderate, Bishops score was 10 with cervical os 4 cm dilated, cervix was
soft, central, 60% effaced with head station at +1. She was taken to
the new room assigned as a temporary labor room. Her vital signs,
contractions, fetal heart rate were monitored regularly. She delivered a
male baby of 3300 grams with APGAR score 7/10, 8/10, 9/10. The labor
period was uneventful and there was no excessive blood loss. 10 IU of
Oxytocin was given to her intramuscularly following the childbirth.
Spontaneous vaginal delivery was under supervision of obstetrician and
the baby was received by pediatrician. Her vital recording was taken
regularly following the delivery and was within normal range. Baby had
breastfed regularly from the time of birth and the mother was using the
mask continuously when she was with the baby. After childbirth, her
nasopharyngeal swab samples were taken twice which came out to be
negative. The baby had been tested within 48 hours for IgG/IgM antibody
against the antigen of SARS CoV-2 which came out to be negative. On the
day third of birth, nasopharyngeal swab samples were taken from the baby
which came out to be negative as well. The nasopharyngeal swab samples
taken were in accordance with the World Health Organization (WHO)
guidance. Patient was discharged on July 4, 2020 after a period of 14
day of hospital stay and was asked to follow up for any health issues.
After 28 days of her delivery, a telephone call was done and she was
asked if she or her baby had any health problem. She informed that both
herself and her baby had no problem.