Key Clinical Message:
In a secondary hospital setting, the dedication shown by health care staffs, timely management of logistics, careful consideration of delivery of this SARS-CoV-2 infected patient has prevented possible complications, set an example for all.
Introduction:
Maternal Health Service has been affected negatively worldwide like any other services due to the Coronavirus Disease 2019 (COVID-19) pandemic and a significant rise in maternal death globally has been estimated over the next six months [1]. The 2002-2003 SARS infection was associated with unpleasant outcomes for pregnancy that caused significant morbidity and mortality [2]. Similarly, MERS infection, 2018, resulted in high case fatality among the vulnerable pregnant women and their fetus [3]. Like SARS and MERS, the causative organism for COVID-19 is also a corona virus, hence COVID-19 becoming a pandemic raises alarm for both pregnant women and obstetricians. With COVID-19 cases continuing to hike in significant proportion, the number of infected pregnant women of all gestational ages has increased [4]. COVID-19 has predominant respiratory complications and various clinical features of this infection has similarities and differences with MERS and SARS [5]. According to a recent surveillance report from the US CDC, it was found that, in comparison to nonpregnant women, pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU and 1.7 times more likely to receive mechanical ventilation when infected with COVID-19 [6]. However, the frequency of symptomatic disease and mortality were not increased in pregnant women compared to nonpregnant women[6]
Decreased compliance of chest wall with increased minute ventilation, tidal volume, oxygen consumption ( raised by 20%); decreased Functional Residual Capacity and compensated respiratory alkalosis are the notable changes in respiratory system during pregnancy that puts women in jeopardy for viral infection [7]. Hypoxia in turn leads to hyperventilation, thus that women are likely to inhale more air and if air contains contaminated aerosol or droplets, they are more likely to be infected than other populations [8]. Suppression of cell-mediated immunity and a shift to the Th2 immune system from Th1 environment in pregnancy leads to more inclination on certain viral and bacterial infections [9, 10].
In Nepal, the first mortality due to COVID-19 was of a woman in her 10th postpartum day of vaginal delivery, who had delivered a preterm baby, her symptoms being dyspnea and cough [11]. The nasopharyngeal swab for Reverse Transcriptase - Polymerase Chain Reaction (RT-PCR) of the woman was only taken after she was dead which came out positive and neonatal RT-PCR test had come out to be negative [11]. We are presenting a case report of a COVID -19 positive teenager with term pregnancy who was managed in a rural hospital setting in Nepal. She was asymptomatic for this infection and normal vaginal delivery was conducted smoothly in a limited resource setting with appropriate safety measures applied. The concerned obstetrician and team had adequate time in planning the delivery with the best possible limited resource mobilization that could have been available in this circumstance.
Case:
A 19-year Gravida 2 Para 1, Abortion 0 Living issue 0 at 38 weeks 2 days period of gestation had been shifted from quarantine of Dhorpatan Municipality to the isolation ward in Dhaulagiri Hospital on June 21, 2020 when she was tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) infection via RT-PCR. She had returned from Punjab, India, around 12 days back with her husband and both were tested positive one day prior to being shifted to Hospital’s isolation ward. A detailed history was taken from the patient and full clinical examination was done after admission in the ward following appropriate safety measures. She had only one antenatal checkup during her pregnancy and had received a single dose of Diptheria and Tetanus Toxoid injection during that time. Ultrasonography had not been performed on this female during any period of her pregnancy. She had no history of fever, cough, chest pain, or shortness of breath. She did not mention any history of altered taste or smell, diarrhea, or pain in the abdomen. The patient perceived fetal movements regularly. She also had no history of any chronic medical illness or surgery. Previous baby was a male child delivered at term, who died due to respiratory difficulty at around 1 month of life. She had delivered the baby when she was just 16 years of age.
Her blood pressure during examination was 92/58 mm of Hg, temperature was 97.2, ºF, heart rate was 92 beats per minute, and peripheral oxygen saturation was 99% on room air. Her respiratory and cardiovascular system examinations were normal. Abdominal examination showed term sized fetus, cephalic in presentation with regular fetal heart sound and there was no contraction. The head was engaged. On pelvic examination, there was no any bleeding or excessive vaginal discharge. Bishop score was 5 with cervical os, closed and uneffaced, soft, central cervix and vertex was on -1 station. Pelvis was an average gynecoid type. Blood investigation was sent (Table 1) and Ultrasonography (USG) of the patient was planned. USG was performed by radiologist following appropriate safety measures. The ultrasound showed regular fetal heart rate and active fetal movement. The placenta had anterior uterine insertion and liquor volume was mentioned to be adequate with regular fetal umbilical artery doppler velocimetry. The estimated fetal weight was mentioned to be 2831 grams and approximate gestational age as 36 weeks and one day.
A multidisciplinary approach involving obstetrician, critical care physician, internist, and pediatrician was done in this case for the plan in management. A common consensus came out from the team to give the patient options to choose the mode of delivery in view of history of previous infant death. The patient along with her husband chose for normal vaginal delivery unless for any obstetric indication cesarean section would be performed. Her preliminary diagnosis was 19 years G2P1L0ID1 at 38 weeks and 2 days period of gestation with SARS-CoV-2 positive status, not in labor. Following that, a new room was allocated for normal delivery of the patient. Oxygen supply, instruments for vaginal delivery and oxytocin, tranexamic acid, baby warmer were arranged in that room for this purpose. OT setup was prepared in case emergency indication for CS would evolve. An Intensive Care Unit, which had been set up only recently in this hospital, was prepared for this patient for any possible critical care emergency. Ventilators and suction machines along with other ICU equipment were standby for any possible complication. She was well counselled and was examined on a regular basis by the health care providers. During each interaction with the patient, use of personal protective equipment was done. Special care regarding the nutrition of the woman was done and regular assurances was provided by the nursing in-charge and obstetrician in-charge.
With these findings, the patient was planned for elective induction of labor at 39 weeks period of gestation. However, on 3rdday of admission, the patient during the early morning had complained of abdominal pain. When examined, her uterine contraction was found to be moderate, Bishops score was 10 with cervical os 4 cm dilated, cervix was soft, central, 60% effaced with head station at +1. She was taken to the new room assigned as a temporary labor room. Her vital signs, contractions, fetal heart rate were monitored regularly. She delivered a male baby of 3300 grams with APGAR score 7/10, 8/10, 9/10. The labor period was uneventful and there was no excessive blood loss. 10 IU of Oxytocin was given to her intramuscularly following the childbirth. Spontaneous vaginal delivery was under supervision of obstetrician and the baby was received by pediatrician. Her vital recording was taken regularly following the delivery and was within normal range. Baby had breastfed regularly from the time of birth and the mother was using the mask continuously when she was with the baby. After childbirth, her nasopharyngeal swab samples were taken twice which came out to be negative. The baby had been tested within 48 hours for IgG/IgM antibody against the antigen of SARS CoV-2 which came out to be negative. On the day third of birth, nasopharyngeal swab samples were taken from the baby which came out to be negative as well. The nasopharyngeal swab samples taken were in accordance with the World Health Organization (WHO) guidance. Patient was discharged on July 4, 2020 after a period of 14 day of hospital stay and was asked to follow up for any health issues. After 28 days of her delivery, a telephone call was done and she was asked if she or her baby had any health problem. She informed that both herself and her baby had no problem.