DISCUSSION
There have been many instances where COVID-19 patients, either pregnant or non-pregnant have had experienced many hardships when they have visited hospitals, stayed in quarantine or isolation. Fever and dyspnea are common manifestations of COVID-19 infection in pregnancy but there are still chances of maternal and fetal morbidity as well as mortality. Hence, once this infection is established in the pregnant women, it should be taken as high alert [12-14]. Obstetric (including vaginal) examination, Ultrasonography (including vaginal scans),Vaginal or cesarean delivery all fall on moderate risk for health care workers for the transmission of COVID-19 and appropriate safety measures should be applied while these procedures are performed [15]. Moreover, CDC recommends the prevention of COVID-19 to be highlighted for pregnant women and there is a need to address the potential barriers of adherence to these measures [6].
We on our limited resource setting have best supported this case of pregnant lady and completed the delivery successfully. In our case, the patient was asymptomatic. In several of cases with COVID-19 infection, positive clinical and laboratory findings were completely different from what we have detected[13, 14, 16, 17]. The scenario in different cases mentioned below may differ from a single case of COVID-19 pregnant patient of our hospital in rural Nepal.
In Wuhan, China, from December,2019 to March,2020a a total of 118 pregnant women with COVID-19 were identified, out of which 71% had positive polymerase chain reaction and 29% with suggestive findings on computed tomography [13]. Majority of the infected women belonged to the third trimester accounting for 75 of the total cases with fever and cough were the findings in most of the patients [13]. Laboratory findings of lymphopenia and CT findings of infiltrates in bilateral lung fields were other common findings [13]. The disease was mild in 92% of the patients and 8% of the cases developed severe disease [13]. During the study, 68 of total women had undergone childbirth with 93% cases undergone cesarean section [13]. The indication of cesarean in 61% of the cases was due to the concern regarding COVID-19 on pregnancy and there were no maternal or neonatal deaths [13]. Only eight of the neonates were tested for PCR and all of which came to be negative [13].
Another case series by Breslin et al of 43 test-positive cases of COVID-19 from March 13th to 27th, 2020 at Columbia University Irving Medical center, New York, in which one-third of patients were asymptomatic during initial diagnosis [16]. Dry cough and fever remained the most common symptoms [16]. Most of the women had mild disease (86%), 4 had severe disease, and 2 had critical disease [16]. Out of 18 women who gave childbirth during this, around half had undergone cesarean section and all for obstetric indications with no maternal or neonatal deaths and neither of the neonates had nasopharyngeal test positive for COVID-19 [16].
Other case series published in the setting of infection of SARS-CoV-2 infection in pregnancy had similar findings in terms of maternal and fetal outcome with predominantly mild variation of disease in mother, preterm delivery, lesser frequency of neonatal infection [14, 17, 18]. A study in Iran of 9 cases with severe COVID-19 cases illustrated that 7 had died, 1 remained critically ill and ventilator dependent, and 1 had recovery following prolonged hospitalization [12]. Mode of delivery in 4 cases were via Cesarean Section, 1 via normal vaginal delivery and 2 of the undelivered cases were on mid second trimester of all 7 cases[12]. This shows the severity of corona virus infection on pregnancy. Severe cases have recovered and mild cases have gone fatal in COVID-19 infection for both mother and baby [13, 14]. We had prepared ICU and arranged all the equipment necessary for possible mechanical ventilation in our patient.
With these evidences of preterm delivery and low birthweight of the newborns born to SARS CoV-2 infected cases, an issue of whether to give tocolytics and steroids in a COVID-19 woman in early third trimester seems to be a good point of discussion. It also seems clear that arrangement of adequate logistics and human resources in a health care facility saves lives of both mother and baby. Examples of several evidences of maternal and fetal morbidity and mortality even in a tertiary care setting had made us alert. In light of that, we paid special attention in hospitalization of the infected pregnant lady, booked an Intensive Care Unit for her and arranged equipment for the purpose of mechanical ventilation. High priority in applying safety measures while performing examinations and conducting her delivery was done. Health care workers need to apply special precautions to limit cross-infection while conducting procedures like vaginal delivery which increases droplet exposure and contact with the patients.
In our secondary hospital setting, the dedication shown by health care staffs, timely management of logistics, and careful consideration of the delivery of this SARS CoV-2 infected patient have definitely prevented complications. Asymptomatic cases of COVID-19 should not be taken lightly. This is what the pandemic has taught us and we tried our best in implementation of this fact during the management of this patient.