Preeclampsia treatment in severe acute respiratory syndrome
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A 26-year-old woman at 37 weeks’ gestation diagnosed as having SARS-CoV-2 infection for symptoms of sore throat and “allergies” also received a diagnosis of preeclampsia based on sustained elevated blood pressures of more than 140/90 mm Hg and proteinuria. Intrapartum, she reported dyspnea and a sensation of “drowning,” although she maintained oxygen saturation greater than 97%. She began to experience sustained severe-range blood pressures of 175/111 mm Hg and 166/101 mm Hg with mild headache. Thromboelastography was notable for increased platelet and fibrinogen activity. There was a brief pause for consideration if intravenous labetalol could be given in patients with SARS-CoV-2 infection, given the recommendation to avoid reactive airway disease owing to risk of bronchoconstriction.

Given normal oxygenation and benign lung examination, the decision was made to manage severe-range blood pressure with a standard first-line agent of 20 mg of intravenous labetalol. Next, a loading dose of 4 g of intravenous magnesium sulfate was initiated for seizure prevention, followed by a maintenance rate of 2 g per hour infusion. Her blood pressure improved to 147/85 mm Hg and remained on average 130s/80s mm Hg after these interventions, and portable anteroposterior chest x-ray examination revealed no acute cardiopulmonary process. The patient had no reported exacerbation of pulmonary symptoms during magnesium sulfate administration and was able to maintain oxygen saturation greater than 97% on room air during treatment.
She delivered a healthy male infant weighing 3042 g with 1- and 5-minute Apgar scores of 7 and 9, respectively. Delayed cord clamping was performed without placing the infant skin-to-skin. The awaiting Pediatrics team took the infant to the neonatal intensive care unit (ICU) for assessment where the result of the SARS-CoV-2 test was negative.

Blood pressures remained in mild range after delivery, and intravenous magnesium sulfate therapy at a maintenance rate of 2 g per hour was continued for 24 hours after delivery. After evaluation by dedicated SARS-CoV-2 ICU team, the patient did not meet inclusion criteria for clinical trial or compassionate use of remdesivir given clinical stability. She was immediately ambulatory after delivery; thus, elected against venous thromboembolism pharmacoprophylaxis in favor of mechanical prophylaxis. The patient was discharged home at postpartum day 2 with no symptoms suggestive of SARS-CoV-2 infection and did not require oral medication for blood pressure control.

There is currently a lack of data regarding the safety of magnesium sulfate administration in patients with SARS-CoV-2 infection. In this case, the patient had mild respiratory symptoms with normal oxygenation on room air and a normal clinical examination and chest x-ray. Given the severely elevated blood pressures with headache in the setting of preeclampsia, the decision was made to proceed with magnesium sulfate administration. Magnesium sulfate may be used as indicated in patients with mild/moderate symptoms in SARS-CoV-2 infection.

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