Evans Syndrome Associated with Pregnancy and COVID-19 Infect
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Evans syndrome (ES) is a chronic autoimmune disease characterized by autoimmune hemolytic anemia along with immune thrombocytopenic purpura. Few case reports of ES in pregnancy have been published, and ES may be difficult to distinguish from other diagnoses more common in pregnancy. Guidelines for treatment of ES are not well-defined. A 23-year-old gravida 2, para 1, with no known medical history presented at 38 weeks of gestation with spontaneous rupture of membranes, contractions, and blood-tinged discharge.

She was 8 cm dilated on the cervical exam. Due to her desire for pain control, and in anticipation of expeditious delivery in a multiparous patient, anesthesia was consulted for neuraxial analgesia. A review of her obstetric history revealed a prior uncomplicated vaginal delivery at 38 weeks of gestation. Laboratory studies from that admission revealed hemoglobin of 12.5 g/dL and platelet count of 223K/L. While awaiting repeat laboratory results, the patient delivered a male neonate by spontaneous vaginal delivery. Neonatal laboratory studies were normal with a hemoglobin of 18.8 g/dL and platelet count of 245 K/L. Total quantitative blood loss during delivery was 400mL. Epidural was removed immediately post delivery. Subsequently, repeat laboratory tests confirmed the initial results, with hemoglobin of 5.6 g/dL, hematocrit of 17.7%, and platelets of less than 10 K/L.

Peripheral blood smear revealed microcytic anemia with anisocytosis, polychromasia, and thrombocytopenia. Teardrop cells, reticulocytes, and small spherocytes were present. On postpartum day 9,The patient received a second 4-day course of oral dexamethasone, 40 mg daily, with a good response. Her platelet count rose. On postpartum day 18, laboratory results showed the platelet count decreased, and she received a third course of dexamethasone, 20 mg daily for 4 days, and intravenous immunoglobulin (IVIG), 1 mg/kg for 2 days. On postpartum day 34, the patient presented to the emergency department with chest pain and shortness of breath. The evaluation was notable for elevated D-dimer, and a computed tomography scan was obtained due to suspicion of pulmonary embolism. Imaging revealed ground-glass opacities and an acute pulmonary embolism. The patient reported that her mother had tested positive for the recently emerged novel coronavirus (COVID-19). Given her symptoms, sick contact status, and imaging findings, the patient was tested for COVID-19. Nasopharyngeal specimen testing for detection of the 2019 novel coronavirus ribonucleic acid by real-time polymerase chain reaction was positive. The platelet count on readmission was 131 K/L and remained stable over 200 K/L. Rituximab infusion was held for several weeks due to active COVID-19 infection and stable platelet count.