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Background: COVID-19 infection during pregnancy is associated with an increased risk of stillbirth, likely due to placental insufficiency through the associated inflammatory response and hypoperfusion. A spectrum of associated placental changes has been reported. Whilst pregnancy alone is a hypercoagulable state, concurrent COVID-19 further increases the risk of coagulopathy. Disseminated intravascular coagulation (DIC) is uncommon in pregnancy but is increased in both COVID-19 infection and fetal death in utero (FDIU). Method(s): Case report. Informed written consent was obtained from the patient. Result(s): A 31-year-old G5P2 presented with a FDIU at 23 + 3 weeks gestation, in the setting of maternal COVID-19 infection without respiratory symptoms or oxygen requirements. The pregnancy had been uncomplicated, and her presenting issue was two days of reduced fetal movements, when FDIU was confirmed on ultrasound. On admission, the case was further complicated by disseminated intravascular coagulopathy (DIC). This DIC could have resulted from COVID-19 infection, FDIU or a combination of both. Placental histopathology showed evidence of inflammation, with chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The inflammatory response, evidenced by histopathological findings of CHI and MPFD, likely contributed to placental insufficiency and FDIU. Conclusion(s): COVID-19 infection is associated with increased risk of hematological abnormalities, placental inflammation and pregnancy loss. This case is the first to report both DIC and CHI in the context of FDIU in COVID-19 infection. We present this case to highlight the impact of COVID-19 infection on placental function, coagulation disturbances and subsequently adverse pregnancy outcomes.
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Introduction: Pregnancy-related acute kidney injury (PR-AKI) in India is largely showing a declining trend due to improved and accessible obstetric care. Nevertheless, PR-AKI continues to cause significant maternal and fetal morbidity and mortality. This study was taken up with the intention to study the incidence and clinical spectrum of AKI in pregnancy in recent times and assess maternal and neonatal outcomes Methods: All pregnant women admitted in the Department of Obstetrics and Gynecology at St John's Medical College Hospital, Bengaluru between January 2018 to June 2020 were screened for AKI with the following criteria 1. Increase in serum creatinine to >0.8mg/dL and/or a sudden increase in serum creatinine by more than 50% when prior renal function was normal. 2. Oligo-anuria 3. Need for renal replacement therapy Women with preexisting CKD were excluded. Patient's clinical and laboratory details recorded. Dialysis support was provided if indicated. The clinical profile and renal outcome of the mother and fetal outcome was assessed at the time of discharge. Mothers' were also followed up at the end of 3 months of postpartum period. Recovery was categorized as Complete recovery- normal serum creatinine (<0.8 mg/dL) or a previously known baseline and no proteinuria /hypertension at the end of 3 months Partial recovery- renal function improved but serum creatinine did not return to normal range and patient was dialysis independent. No recovery- patient continued to require dialysis at the end of 3months. Result(s): Of the 2650 deliveries in the study period 42 women (Mean age 26.9 +/-3.6 years) were diagnosed AKI during pregnancy (1.58%). Baseline characteristics and outcomes are depicted in table 1. Majority of women (n=37) were referred from peripheral hospitals. Hypertension and decreased fetal movements were the common reasons for referral. Third trimester was the most common time of presentation (76.1%). Severe Preeclampsia and HELLP syndrome was the leading cause of AKI (59.5%).ATN secondary to obstetric complications, sepsis and hemolytic uremic syndrome were the other causes. One case each of cortical necrosis, acute fatty liver of pregnancy and COVID 19 associated AKI was seen. Mean duration of hospital stay was 12.1+/-6.9 days. More than one third patients' required ICU stay (35.7%).12 patients (28.5%) required renal replacement therapy. Of them, 3 were dialysis dependent at the end of 3 months and 4 had partial renal recovery. 3 patients expired during hospital stay. Fetal survival was 69.04%.13 babies' required NICU care (44.8%). Neonatal outcomes are summarized in table 2. Close to one third of the pregnancies with AKI were associated with intrauterine fetal demise (28.5%). Low birth weight and prematurity were the common reasons for NICU admission with mean NICU stay of 8.2 +/-2.3 days [Formula presented] [Formula presented] Conclusion(s): Severe preeclampsia was the most common cause of AKI in our study. PR-AKI continues to be a significant problem in the peripheries of developing countries where availability of health care facilities is meager, with late referral to tertiary care centers. One third of the patients required ICU stay & dialytic support. Women who required dialysis had poorer renal prognosis. There was 30% fetal loss seen in PR-AKI and also a higher incidence of low birth weight and prematurity. No conflict of interestCopyright © 2023
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Background. We studied the safety and efficacy of the use of monoclonal antibodies (MAB) against SARS-CoV-2 in pregnant women who developed COVID-19 infection. Methods. We conducted a cross-sectional descriptive multi-center study of pregnant patients who developed SARS-CoV-2 infection from January 2021 to January 2022 and received MAB therapy. Primary outcomes assessed were infusion-related adverse events and pregnancy outcomes within one month of MAB infusion. The secondary outcomes assessed were hospitalization and ICU admission for COVID19 infection and thirty-day all-cause mortality. Results. 141 patients were included in the study (median age 33 +/- 5.3 SD, median BMI 28.9 +/- 8.42 SD). In terms of COVID vaccination status, 49.6% received one dose, 36.1% were fully vaccinated, and 7% received the booster dose. Most patients received casirivimab/imdevimab (105, 74.5%) followed by sotrovimab (33, 23.4%). Four patients developed adverse reactions to MAB infusion (two grade-2 reactions and two grade-1 reactions as per the National cancer institute infusion reaction grading criteria). Only one patient (0.7%) was hospitalized for COVID-19 infection, however, she was not hypoxic nor required ICU admission. Five patients delivered within four weeks of MAB administration, however, four of those patients were of gestational age > 37 weeks. Data for 30-day all-cause mortality was available on 88.7% (125) of the patients and data for 30-day pregnancy adverse outcomes was available on 86.5% (122) of the patients due to lack of follow-up within the Health System. There was no reported 30-Day all-cause mortality within the cohort. Two patients (1.4%) had premature rupture of the membrane and one patient (0.7%) had premature delivery within 30 days of receiving MAB. Two patients had preeclampsia (1.4%) and one patient (0.7%) was admitted for evaluations of decreased fetal movements. Conclusion. Administration of monoclonal antibodies against SARS-CoV-2 was well tolerated during pregnancy. Only 4 out of 141 (2.8%) had mild to moderate infusion-related reactions. The 30-day pregnancy adverse outcomes observed were well below the mean background rate. There was no reported mortality among MAB recipients and only one patient was hospitalized for mild COVID19 infection.
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Introduction: Multisystemic inflammatory syndrome in children (MIS-C) is a rare complication of infection by SARS-CoV-19 thought to be due to hyperinflammation adversely affecting multiple organ systems. Most commonly, the gastrointestinal, cardiovascular, hematologic, respiratory and integumentary systems are affected. Patients presenting with this syndrome often require hospitalization given the potential for rapid deterioration. We present a case of MIS-C and associated shock in a pregnant pediatric patient requiring ICU level care. Case Description: A 16-year-old G1P0 female presented to the ED at 25 weeks gestation with complaints of fever, headache, myalgias, cough and congestion. She denied prior COVID-19 exposure and vaccination, and COVID-19 PCR testing returned negative. She was diagnosed with a viral syndrome. She further reported decreased fetal movement. OB performed a biophysical profile that was overall reassuring, and she was discharged. Due to persistent symptoms and new onset chest pain and dyspnea, she returned to the ED six days after her initial presentation. Bedside ultrasound demonstrated fetal tachycardia. Laboratory work up revealed leukocytosis, anemia, hyponatremia and hypokalemia with markedly elevated inflammatory markers concerning for MIS-C. She was treated empirically with ceftriaxone and vancomycin. She developed fluid refractory shock and ultimately required vasoactive support with norepinephrine necessitating admission to the PICU with OB consultation. Infectious evaluation including respiratory viral panel with COVID-19 PCR and blood and urine cultures were negative. SARS-CoV-2 IgG antibody returned positive, confirming the diagnosis of MIS-C associated with COVID-19. She was treated with IVIG and corticosteroids resulting in quick resolution of her shock and clinical improvement with down trending inflammatory markers. Continuous fetal monitors demonstrated normalization of fetal heart rate. She was transferred to the high risk OB floor on hospital day 3. During her stay, she developed a mild transaminitis thought to be associated with MIS-C given her otherwise negative workup. She was discharged home on hospital day 12 on a prednisone taper and oral iron. Discussion: Pregnancy complications associated with COVID-19 are still not well understood, but include preeclampsia, intrauterine growth restriction and premature birth. Although rare, cases of vertical transmission and fetal demise have been reported, as well. Given the profound effects that both pregnancy and MIS-C have on the body, understanding the potential risks of MIS-C in pregnancy is imperative to ensure favorable outcomes. Our current understanding of the effects of maternal MIS-C on a fetus can only be extrapolated from studies on adult women infected during pregnancy and a single reported case of MIS-A in a pregnant adult. Conclusion: We report a case of a pregnant pediatric patient who presented to the ED with shock secondary to MIS-C and associated fetal tachycardia that was successfully treated with vasopressors, IVIG and steroids to enhance knowledge for this presentation and treatment of this condition in a vulnerable population.
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Introduction: Cardiac disease is the leading cause of maternal death in the UK [1].We present the case of awoman with late intrauterine fetal death (IUFD) and intrapartum cardiac ischaemia. A family history of limb girdle muscular dystrophy (LGMD) may be relevant. Case Report: A 23-year-old nulliparous woman at 39 weeks of gestation presented with reduced fetal movements and IUFD was confirmed. She had no medical history, and despite two first degree relatives with LGMD, she was asymptomatic and had not been tested. Uterine contractions started and epidural analgesia was initiated. Shortly thereafter, the woman was found to be bradycardic at 35– 40 beats/min. All other observations were normal and she was asymptomatic with no detectable sensory or motor block. A 12 -lead ECG showed inferior T-wave inversion and serial troponins were markedly elevated. Caesarean section (CS) under general anaesthesia was performed at maternal request and was uneventful. Postpartum echocardiogram demonstrated a dilated left atrium, left ventricular akinesis and an ejection fraction of 45–50%. The next day the woman developed chest pain and desaturated. CTPA and CT coronary angiogram were normal. Oxygenation improved and other than sporadic chest heaviness she remained well and was discharged 4 days post CS. Cardiology follow-up did not occur due to a communication breakdown. Post-mortem of the fetus found no cause for the IUFD and no features of LGMD. Thewoman suffered a miscarriage four months after this but delivered a healthy baby at elective CS two years later. During the latter pregnancy cardiology input from a tertiary centrewas requested but did not occur due to the COVID-19 pandemic. An echocardiogram in the third trimester was normal and the woman has been well since. Discussion: Troponin rise is abnormal in pregnancy and requires investigation. IUFD in itself can lead to sequelae requiring a low threshold for investigation. The family history in this case is autosomal dominant type 1B LGMD, associated with cardiomyopathy and arrhythmias [2]. The woman has declined testing and the cause for the peripartum cardiac disease remains unknown. The recovery and recent uneventful pregnancy suggest Takotsubo’s cardiomyopathy or coronary vasospasm as additional possible diagnoses. This case also underlines the importance in sensitive communication in cases of IUFD to ensure women are investigated and not lost to follow-up.