Case Report: Radiographic findings and Management of pregnan
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Imaging modalities play a crucial role in the management of suspected COVID-19- infected patients. Before RT-PCR test results are positive, 60–93% of patients have positive chest CT findings consistent with COVID-19 infection. Here reported a case of positive lung ultrasound findings consistent with COVID-19 in a woman with an initial negative RT-PCR result. The lung ultrasound-imaging findings were present between the negative and subsequent positive RT-PCR tests and correlated with CT findings.

A 32-year-old, primiparous woman, with 35 + 3-week singleton pregnancy, developed symptoms of persistent cough and shortness of breath on 20th March 2020. Her medical history included a diagnosis of thalassemia trait, but she was not anemic at the time of presentation. She had a persistent cough and dyspnea, which had increased in intensity since the negative RT-PCR test 2 days previously. A point-of-care lung ultrasound examination was performed, which revealed thick B-lines bilaterally, located in the basal posterior lung segments. She was referred to the COVID-19 clinic due to persistent symptoms and lung ultrasound findings suspicious for viral pneumonia. Two days later, on 25th March, she presented again at the outpatient obstetrics clinic with complaints of worsening dyspnea, reduced fetal movements and a swollen left leg. She was still afebrile, with a body temperature of 37.1°C. Her vital signs were abnormal.Lung ultrasound imaging findings were consistent with viral pneumonia, with diffuse, thick B-lines bilaterally, with predominantly basal posterior lung involvement (Figure 1, Videoclip S1). The anterior segment of the right upper lobe does not show marked involvement and A-lines were visible on ultrasound (Figure 2, Videoclip S2). After a consultation with a pulmonologist, pulmonary computed-tomographic (CT) angiography was planned, to rule out emboli. She was also retested for SARS-CoV-2 with RT-PCR of nasopharyngeal and throat swabs, which were later found to be positive.

The chest CT angiography ruled out pulmonary emboli and revealed lung involvement typical for COVID-19 infection. There were bilateral, peripheral ground-glass opacities in the basal, posterior segments of her lungs and a crazy-paving appearance. The lung ultrasound findings correlated with those of the CT scan (Figure 1).

A decision was made to admit the woman to the intensive care unit due to worsening lung function and the severity of lung involvement on chest CT. The intensivist recommended delivery to relieve the pressure on the mother’s lungs. The woman was counseled extensively and she opted to undergo elective Cesarean delivery. Cesarean delivery was performed in a negative-pressure operating room under spinal anesthesia and was uneventful. A healthy, active boy was delivered, with a birth weight of 2790 g and a 5-min Apgar score of 9. Multiple swabs were taken from the placenta (maternal and fetal sides) for RT-PCR testing for SARS-CoV-2. A cord-blood sample was also sent for RT-PCR testing. The amniotic fluid sample was discarded as maternal blood contamination had occurred. The initial management plan for the mother was intubation upon arrival in the intensive care unit. However, she was managed on 6 L/min oxygen, as her lung function improved upon delivery. Her postoperative blood panel revealed lymphopenia

without additional abnormalities, and arterial-blood-gas pH indicated acidosis. Treatment with azithromycin, hydroxychloroquine and oseltamivir were commenced, as per national COVID-191 treatment guidelines. Her condition improved daily, and she was moved to a regular patient ward on 27th March, after normalization of her arterial-blood-gas results. She was, however, admitted back into the intensive care unit 1 day later, due to increased shortness of breath, respiratory secretions and oxygen demand. She was intubated, and cytokine storm was suspected due to rapidly increasing procalcitonin levels. A regimen of favipiravir and steroids was added to her treatment, and at the time of writing she was still being managed in the intensive care unit (Figure 3). The baby was managed without ventilatory support, and samples of cord blood and placental, throat and nasal swabs were negative for SARS-CoV-2. RTPCR testing of maternal breast milk was also negative for SARS-CoV-2, and feeding by expressed breast milk was carried out.

In conclusion, the findings in this case from the analysis of neonatal and placental swabs and cord-blood samples were consistent with the published literature suggesting no vertical transmission of SARS-CoV-27

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