Survival from Maternal Cardiac Arrest Complicating Coronavir
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A 28-year-old Hispanic female gravida 2 paras 1001 at 38+6 weeks gestation with pregnancy complicated by class III obesity (BMI 60), mixed anxiety and depressive disorder, and Rh-negative status presented to the emergency department (ED) with a 5-day history of cough, congestion, fevers, and shortness of breath. Her vitals on presentation were blood pressure 124/65?mmHg, pulse 131 beats per minute, respiratory rate of 24 breaths per minute, oxygen saturation of 95% on room air, and temperature of 38.7 Celsius. She appeared uncomfortable with difficulty breathing; her physical exam revealed clear lungs bilaterally, tachycardia, and reassuring fetal heart rate tracing. Laboratory evaluation revealed an elevated CRP, AST, procalcitonin, and low vitamin D levels. A chest radiograph demonstrated bilateral pulmonary infiltrates. Blood cultures were obtained. A nasopharyngeal swab for SARS-CoV-2 PCR was obtained and returned positive, and she was admitted to the hospital for treatment of moderate COVID-19. Within 12 hours of presenting to the ED, she required 6?L by nasal cannula (NC) to maintain her oxygen saturation > 92%, and a decision was made to proceed with expedited delivery via cesarean section due to her worsening respiratory status. Intravenous redeliver and dexamethasone were initiated preoperatively. She underwent an uncomplicated primary low transverse cesarean section productive of a female infant weighing 3325?g.

Postoperatively, the patient was improving with a lower supplemental oxygen requirement and decreased work of breathing. On POD#3, her oxygen requirements increased rapidly from supplemental oxygen via nasal cannula up to high-flow nasal cannula oxygen with 100% FiO2. She deteriorated further with increased work of breathing and significant hypoxemia and was placed on Bilevel Positive Airway Pressure (BiPAP). A chest radiograph demonstrated interval worsening of bilateral diffuse airspace opacities. While on BiPAP, she continued to have significant hypoxemia with worsening tachypnea and tachycardia; therefore, she was transferred to the ICU for acute respiratory failure with severe acute respiratory distress syndrome (ARDS), and rapid sequence intubation was performed.

On the ventilator, the patient developed worsening hypoxemia, at which time the endotracheal tube was repositioned and a chest radiograph confirmed correct positioning also demonstrating bilateral pulmonary infiltrates. She continued to desaturate and developed bradycardia and then pulseless electrical activity (PEA) arrest. Cardiopulmonary resuscitation (CPR) was initiated immediately. Return of spontaneous circulation was achieved after 5 minutes of CPR and a dose of IV epinephrine. Chest radiograph revealed interval changes including mild enlargement of the cardiac silhouette, pulmonary edema and/or inflammatory infiltrates, and a right pleural effusion. She was started on low-dose pressor support for hypotension. On POD#5, she developed sinus pauses and periods of sinus arrest, and cardiology and electrophysiology consults were requested. An echocardiogram demonstrated normal left ventricular function with an ejection fraction of 60-65%, a mildly dilated left atrium, mild tricuspid valve regurgitation, and moderately elevated pulmonary systolic pressure with pulmonary artery systolic pressure of 50?mmHg. There was no evidence of myocarditis or sepsis (i.e., blood cultures from admission were negative). A temporary pacer was placed followed by a permanent dual-chamber pacemaker on POD#6. She was weaned off vasopressor support and down to minimal ventilator settings by POD#10, with intermittent nonsustained hypertension with a maximal blood pressure of 165/118?mmHg.

The patient developed a generalized myoclonic-tonic seizure during a trial of spontaneous breathing (TSB) concerning for eclampsia. She was started on IV magnesium therapy for presumed eclampsia complicated by posterior reversible encephalopathy syndrome (PRES) versus COVID encephalopathy. This was subsequently co-managed by consultants in Neurology and Maternal-Fetal Medicine. After several days of seizure management with levetiracetam and lacosamide every 12 hours and the development of encephalopathy syndrome, the patient was weaned from sedation and passed a TSB, and was successfully extubated after remaining mechanically ventilated for a total of 11 days. The patient had no further seizure activity and was discharged home 4 days later (POD#18) on 1?L of oxygen and with home health care services. She was discharged home on 200?mg lacosamide QD, 500?mg levetiracetam BID, and 81?mg aspirin QD with outpatient neurology and electrophysiology follow-up arranged.