Investigation and treatment
At primary presentation, the patient’s shortness of breath qualified her for routine SARS-CoV-2 PCR testing. Her blood pressure was 110/70 mm Hg, and she had a heart rate of 120 beats per minute. Her peripheral oxygen saturation was 97 percent and she had a respiratory rate of 35; She also had a history of contacting her husband, who was positive for Covid-19. The SARS-CoV-2 PCR test came back positive in the next day. Due to positive High-Resolution CT-Scan and pulmonary involvement of forty percent and severe tachypnea, she was hospitalized at intensive care unit for four days. Figure.1. According to PH level of 7.33, PCO2 level of 16.7, bicarbonate level of 8.2 and a high anion gap of 21, the patient was diagnosed with ketoacidosis. Table.1.
A number of differential diagnoses were considered for this patient. Serum osmolarity of 296.2 mOsmol/KG and an osmolarity gap of 7 mOsm/kg, ruled out the alcohol intoxication in this patient. High anion gap of 21 mmol/L and stage 2 chronic kidney disease epidemiology collaboration also excluded renal tubular acidosis and uremic acidosis from our differential diagnoses, respectively. D-dimer level of 2130 ng/ml was also checked in this patient for pulmonary embolism ruling out. The patient underwent cardiac echo and had a BNP level checked for cardiomyopathy, which was reported negative. Fetal sonography was also reported to be normal during pregnancy.
Patient’s blood glucose was 70 at the first presentation; therefore, serum dextrose 5% and regular insulin infusion for maintaining blood glucose level in the normal range, were established for patients’ ketoacidosis. Figure.2. Extensive treatment was performed with Oxygen therapy, remdesivir, dexamethasone and tocilizumab for patient’s infection with Covid-19.
Failure to correct severe acidosis of the patient in the first four days of hospitalization despite treatment, high respiratory rate, disorder in nonstress test (NST), closed cervix and patients poor condition led to fetal distress and made us unable to accomplish natural vaginal delivery for this patient; Therefore, termination of pregnancy by cesarean section was performed using induction on the fourth day of hospitalization. Thyroid tests were also suitable for termination of pregnancy. By performing the mentioned workups, patient attained a better condition.
Vital parameters at the next day were a blood pressure of 115/75mmHg, heart rate of 78 beats per minute, temperature of 37.5°C, oxygen saturation of 98% and a respiratory rate of 22 breaths per minute. The newborn’s Apgar score in the first and fifth minutes was 8 and 9, respectively. The patient’s platelets count also improved and increased by 180,000 on the day of discharge.
Due to the lack of sufficient evidence for the management of these patients, based on the Dka treatment protocol in non-pregnant patients, we performed the treatment with serum dextrose infusion 100cc per hour, regular insulin infusion between 6 to 12 units per hour and potassium chloride administration. We also monitored the patient’s blood sugar within a safe range for pregnancy.