Management of Severe COVID-19 in Pregnancy
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A healthy 30-year-old pregnant woman, gravida 6, para 4, with a history of premature rupture of membranes (PROM) at 20 weeks in a previous gestation, a scarred uterus, and osteoarthritis, was admitted, at 31 weeks of gestation, to the obstetric emergency room 4 days after the onset of the following symptoms: shortness of breath, fever at 38.5°C, and persistent dry cough promptly complicated with PROM. Uterine height was 28?cm with no sign of uterine contraction. The vaginal examination demonstrated ruptured membranes and a cephalic presentation. Ultrasound was performed, showing active fetal movements, normal fetal morphology, normal amniotic fluid quantity, and an estimated fetal weight of 1960?g. A Nasopharyngeal swab returned positive for SARS-CoV-2 using reverse transcription-polymerase chain reactions (RT-PCR). The patient was hospitalized in an isolated room in the reserved COVID-19 maternity ward, wearing a surgical mask during her stay. Initially, the patient received intravenous fluids, acetaminophen, and prophylactic 3rd-generation cephalosporin (ceftriaxone). The patient also received corticosteroids (betamethasone) to ensure fetal pulmonary maturation.

She was administered high-flow oxygen (10?L/min) via a non-rebreather mask and placed in a lateral decubitus position. She received azithromycin, hydroxychloroquine, and a curative dose of tinzaparin sodium, and as she failed to improve, added methylprednisolone 1?mg/kg/day. The patient reported intense and frequent uterine contractions as she went into labor. Consequently, an urgent caesarian section was performed. The healthcare team transported the patient, following the COVID-19-dedicated hallways, to an operating room with negative pressure. A lower segment cesarean section was performed without any incident, as she remained stable

The premature newborn, weighted 1700?g with an Apgar score of <7 at 1?min and at 5?min. The neonate was immediately isolated and transported to the COVID-19 neonatal intensive care unit; no skin-to-skin contact was made with the mother. The newborn experienced severe asphyxia, failing to improve under ventilation. At 1 hour of life, a nasopharyngeal swab viral test was performed, returning negative for SARS-CoV-2 using RT-PCR. The neonate’s condition continued to deteriorate due to septic shock and respiratory failure and died after 5 days of birth.

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