ADRS due to COVID-19 in midterm pregnancy: successful management with plasma transfusion and corticosteroids.

BACKGROUND: Management of acute respiratory distress syndrome (ARDS) in pregnant women infected with new severe acute respiratory syndrome Corona virus 2 (SARS-CoV2) is a challenging clinical task. CASE: A 30- year-old woman (gravid 3, parity 2) presented at her 21 and 2/7 weeks gestation (pre pregnancy BMI: 36.1 kg/m2), with ARDS caused by SARS-CoV2 infection. She received lopinavir/ritonavir and azithromycin as well as early methyl prednisolone therapy. Given the persistent hypoxemia despite oxygen therapy via non rebreather face mask (FiO2:80%), convalescent plasma transfusion was administered that led to a mild clinical improvement as well as decrease in inflammatory markers. Growth of her fetus assessed by obstetric sonography was normal during hospital stay. CONCLUSION: Judicious corticosteroid therapy along with convalescent plasma transfusion to suppress viremia and cytokine storm can lead to favorable outcome in the pregnant women with ARDS caused by SARS-CoV2 infection without superimposed bacterial infection.

Clinical course, chest computed tomography severity score and outcome of coronavirus disease 2019 (COVID-19) in patients with rheumatic diseases

Aim of the work To assess the clinical manifestations, imaging findings and outcomes of corona virus disease 2019 (COVID-19) in patients with rheumatic diseases. Patients and methods: In a three-center study, patients with rheumatic diseases who developed COVID-19 were included. Patients were classified into two groups, i) inflammatory arthritis including rheumatoid arthritis (RA), spondyloarthritis (SpA) and undifferentiated arthritis, ii) connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), vasculitis and others. COVID-19 outcomes were assessed based on chest computed tomography severity score (CT-ss), the level of care, the number of patients who died and flare of underlying rheumatic disease. Results: One hundred ninety-six patients with a mean age of 47.9±15.1 years, 73.5% female, were included. Underlying rheumatic diseases were RA (57.7%), SLE and other CTDs (17.9%), SpA (11.2%), vasculitis (11.2%) and undifferentiated arthritis (2%). Myalgia, malaise and fever were the most common clinical manifestations of COVID-19. Pneumonia on computerized tomography (CT), hospitalization, admission in intensive care unit and need to mechanical ventilation were observed in 75.5, 37.2%, 10.7% and 6.6% of patients, respectively. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, diabetes and underlying pulmonary disease were predictors of moderate to severe pneumonia and hospitalization. Fifteen (7.6%) patients died. Flare of underlying rheumatic disease occurred in 16.3% of patients. Flare of disease in patients with CTDs was significantly more than other rheumatic diseases. Conclusions: In rheumatic patients, treatment with NSAIDs or prednisolone, diabetes and pulmonary disease are risk factors of moderate to high CT-ss and hospitalization during COVID-19.

COVID-19 Disease During Pregnancy and Peripartum Period: A Cardiovascular Review.

Pregnancy with various physiological effects on cardiovascular system, makes mothers with borderline cardiovascular reserve at significant risk for adverse events during labor and early postpartum period. Cardiac imaging modalities, have shown that Coronavrus Disease 2019 disease is associated with subclinical myocardial injury in significant numbers of infected people, even in mild or asymptomatic disease and previous healthy ones. Herein, we have discussed the cardiovascular aspects of prepartum pregnant women with Coronavrus Disease 2019, especially patients with moderate to severe illness. Also, we have proposed how to handle the hemodynamic load during labor and the first 48 hours postpartum in the hypoxemic overloaded parturients with possible subclinical myocardial injury.

Presentation and Outcome of Congenital Heart Disease During Covid-19 Pandemic: A Review.

Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-COV2) infection is a rapid evolving pandemic with multiple peaks of outbreak and substantial mortality worldwide. It has been proposed that infants are more vulnerable to SARS-COV-2 infection. On the other hand, children with COVID-19 have generally milder disease compared to infected adults and more often presented with gastrointestinal symptoms compared to respiratory ones. Multisystem inflammatory syndrome in children (MIS-c) is an ominous demonstration of COVID-19 with cardiac involvement and mortality rate <2%. From cardiovascular point of view, wide spectrum of manifestations including subclinical myocardial injury, myocarditis, stress cardiomyopathies, cardiac arrhythmias, pulmonary thromboembolism and thrombus formation in cardiac chambers and vascular bed has been reported in COVID-19 disease. Congenital heart disease (CHD), assumed as the most prevalent form of congenital disease. Advances in medical and surgical treatments for CHD have led to more alive patients with underlying heart disease secondary to congenital defects. These group of pediatric patients are prone to heart failure, arrhythmia and embolic events. In this narrative review, we intended to evaluate the cardiovascular and pediatric presentations of COVID-19 as well as the manifestation and outcomes of SARS-CoV-2 infection on pediatric patients with CHD.

Clinical features and risk factors associated with acute respiratory distress syndrome in pregnant women diagnosed with COVID-19: a multi-center case-control study.

OBJECTIVES: The aim of this study was to evaluate differences in clinical features and laboratory parameters in critically ill pregnant women with acute respiratory distress syndrome (ARDS) compared to moderate and severe pregnant women with coronavirus disease-2019 (COVID-19) but without ARDS. METHODS: This was a retrospective multicenter study of all pregnant women with COVID-19 diagnosed with ARDS between February 15, and May 1, 2020 in nine level III maternity centers in Iran (ARDS group). The control COVID-19 pregnant women were selected from 3 of 9 level III maternity centers between March 15 and April 20, 2020. Univariate statistics were used to look at differences between groups. Cluster dendrograms were used to look at the correlations between clinical and laboratory findings in the groups. A value of p <.05 was considered statistically significant. RESULTS: Fifteen COVID-19 infected women with ARDS were compared to 29 COVID-19 positive and ARDS negative control (moderate: (n = 26) 89.7% and severe: (n = 3)10.3%). The mean maternal age (35.6 vs. 29.4 years; p = .002) and diagnosis of chronic hypertension (20.0% vs. 0%, p = .034) were significantly higher in the ARDS group. There was no significant difference between the two groups in their presenting symptoms. The ARDS group had a significantly higher prevalence of tachypnea (66.6% vs. 10.3%, p = .042) and blood oxygen saturation (SpO2) <93% (66.6% vs. 10.3%, p = .004) at presentation. Relative lymphopenia (lymphocyte ratio < 10.5%, 66.6% vs. 17.2%, p = .002), lymphocytes to leukocytes ratio (11.3% vs. 17.7%, p = .010), and neutrophils to lymphocytes ratio (NLR) >7.5 were significantly different between the two groups (all p < .05). CONCLUSION: Our data demonstrate that symptom-based strategies for identifying the critically ill pregnant women with SARS-CoV-2 are insufficient; however, vital signs and laboratory data might be helpful to predict ARDS in critically ill COVID-19 pregnant patients.

Maternal death due to COVID-19.

BACKGROUND: Despite 2.5 million infections and 169,000 deaths worldwide (as of April 20, 2020), no maternal deaths and only a few pregnant women afflicted with severe respiratory morbidity have been reported to be related to COVID-19 disease. Given the disproportionate burden of severe and fatal respiratory disease previously documented among pregnant women following other coronavirus-related outbreaks (SARS-CoV in 2003 and MERS-CoV in 2012) and influenza pandemics over the last century, the absence of reported maternal morbidity and mortality with COVID-19 disease is unexpected. OBJECTIVE: To describe maternal and perinatal outcomes and death in a case series of pregnant women with COVID-19 disease. STUDY DESIGN: We describe here a multiinstitution adjudicated case series from Iran that includes 9 pregnant women diagnosed with severe COVID-19 disease in their second or third trimester. All 9 pregnant women received a diagnosis of SARS-CoV-2 infection by reverse transcription polymerase chain reaction nucleic acid testing. Outcomes of these women were compared with their familial/household members with contact to the affected patient on or after their symptom onset. All data were reported at death or after a minimum of 14 days from date of admission with COVID-19 disease. RESULTS: Among 9 pregnant women with severe COVID-19 disease, at the time of reporting, 7 of 9 died, 1 of 9 remains critically ill and ventilator dependent, and 1 of 9 recovered after prolonged hospitalization. We obtained self-verified familial/household cohort data in all 9 cases, and in each and every instance, maternal outcomes were more severe compared with outcomes of other high- and low-risk familial/household members (n=33 members for comparison). CONCLUSION: We report herein maternal deaths owing to COVID-19 disease. Until rigorously collected surveillance data emerge, it is prudent to be aware of the potential for maternal death among pregnant women diagnosed as having COVID-19 disease in their second or third trimester.