Vertical transmission, maternal thrombocytopenia, & postpartum haemorrhage in coronavirus infection - a case report

ABSTRACT

Objective New evidence is emerging regarding the effects of Coronavirus (COVID-19) in pregnancy. We report this case to highlight COVID-19 complications and challenges in the 3rd trimester of pregnancy. Case report A 35 years old, Para 1, had an uneventful pregnancy up to 36 weeks' gestation, when she was admitted with reduced fetal movements, feeling unwell, fever, and cough with a positive COVID-19 PCR. She was febrile, tachycardiac, and normotensive with no proteinuria. Symptomatic treatment was commenced with infection control measures. Cardiotocograph (CTG) was reassuring initially. Her platelet count was 66 9 109/L and her liver function tests (LFT) were mildly deranged. Peripheral blood film showed no signs of Microangiopathic hemolytic anemia. The hematologist suggested that thrombocytopenia was most likely related to COVID-19 & her isolated mildly prolonged APTT was corrected by Vitamin K. She was induced in view of intermittent decelerations on CTG and progressive thrombocytopenia. However, CTG became abnormal and she had a lower segment cesarean section under General Anastasia (because of thrombocytopenia). She delivered a 2.8 kg baby boy (APGAR score of 6 and 9 at 5 and 10 mins respectively, normal cord pH). Delivery was complicated by a Postpartum hemorrhage of 2 L, for which she was transfused one unit of platelets, and two units of red cells, along with oxytocics and antibiotics. Neonate was COVID-19 positive and had hyperbilirubinemia, which settled subsequently. The subsequent recovery of the mother was uneventful, with improvement in her platelet count and LFT. She was discharged home with her baby on the 4th postoperative day after the debriefing. She was prescribed thromboprophylaxis for 6 weeks and followed up as an outpatient. Discussion The management of COVID-19 in pregnancy should include a multidisciplinary approach, foeto-maternal surveillance, infection control measures, delivery planning, and psychological support. Rasmussen SA advocates the use of empiric antibiotics for secondary bacterial infection risk & mechanical support in case of respiratory compromise. Thrombocytopenia is a known complication of COVID-19 in pregnancy. Thromboprophylaxis is challenging in such patients and depends on risks and benefits, clotting profile, and the timing of delivery. Moreover, the differential diagnosis for epigastric pain in pregnancy with COVID-19 infection varies from gastritis and preeclampsia to hepatic and myocardial injury. Vertical transmission is a known risk of maternal COVID-19 infection. Conclusion As obstetric teams face COVID-19 pandemic associated foeto-maternal challenges, there is a need for holistic interventions for caveats arising from COVID-19 complications.