Severe COVID‐19 pneumonia in pregnant woman treated with pulse corticosteroids therapy and third‐trimester caesarean section: A case report

Abstract

A 44‐year‐old woman at 30 weeks of pregnancy was admitted to the Intensive Care Unit with a diagnosis of severe COVID‐19 pneumonia. Her condition worsened quickly, defined by prolonged hypoxia even with intensive therapy and oxygen supplementation. This led to the decision to perform a caesarean delivery and continue pulse corticosteroids therapy after delivery. Soon after she recovered from COVID‐19 pneumonia, her life was threatened again by septic shock from hospital‐acquired pneumonia. After nearly 1 month of hospitalization, she was discharged and fully recovered on the re‐examination day 10 months later.

In this case report, we present a critical COVID‐19 case of a 44‐year‐old woman at 30 weeks of pregnancy. Her treatment was based on pulse corticosteroid therapy, accompanied by caesarean delivery. After nearly 1 month of hospitalization, with most of the time being in the intensive care unit, she was discharge and showed full recovery upon re‐examination 10 months later.

INTRODUCTION

Gestational status is now recognized as a risk factor for severe COVID‐19 pneumonia due to its hyperinflammatory status. In order for it to be resolved, pulse corticosteroid as well as pregnancy termination can be useful. We present a case of a woman at 30 weeks of gestation suffering from severe COVID‐19 pneumonia, successfully saved by the aforementioned treatments. This case highlighted the role of multidisciplinary consultation and what we can use to stop the cytokine storm in a resource‐limited healthcare system under a large‐scale outbreak.

CASE REPORT

A 44‐year‐old woman without any significant pathological medical history was admitted to the emergency department at 30 weeks of gestation. She complained of fatigue and shortness of breath, while tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by rapid antigen test (RAT). The patient did not receive any COVID‐19 vaccine doses of any kind. As her saturation of peripheral oxygen (SpO₂) was 88% in room air, she received an oxygen mask at 8 L/min, which was then upgraded to 10 L/min. She was also prescribed dexamethasone 3.3 mg × 2 ampoules for moderate/severe COVID‐19 infection as per the COVID‐19 diagnosis and treatment guideline of the Ministry of Health of Vietnam, accompanied by ceftriaxone 2 g × 1 ampoule due to clinical suspicion of bacterial pneumonia; in addition, enoxaparin 40 mg was used every 12 h due to her high level of D‐Dimer (1.67 mcg/mL). ¹ However, the next day, her clinical conditions continued to worsen with a respiratory rate of 40 breaths per minute and SpO₂ fluctuating around 90% on oxygen mask 10 L/min. She was transferred to the COVID‐19 intensive care unit with a diagnosis of severe COVID‐19 pneumonia. A positive result on a real time reverse transcription‐polymerase chain reaction (RT‐PCR) test was also registered within the same day (Figure 1).

FIGURE 1.

A, B, C and D are chest X‐rays taken on intensive care day 5, 14, 26 and 10 months after discharge, respectively. B shows diffuse alveolar damage (DAD), C shows an enlarged heart shadow and diffuse consolidation, and D shows a full recovery of the patient

Due to her negative response to the oxygen mask, she was switched to high flow nasal cannula (HFNC) 60 L/min, FiO₂ 100%. She continued to be treated with enoxaparin, methylprednisolone 40 mg × 4 vials, and antibiotics. Her SpO₂ fluctuated around 95%–98%.

No significant improvements were noted, and her condition worsen on the 10th day with a SpO₂ of 88% and arterial blood gas (ABG) readings indicating respiratory alkalosis. This led to the diagnosis of acute respiratory failure due to severe COVID‐19 pneumonia. An obstetrics consultant was made immediately, which came to a unanimous decision to conduct an emergency caesarean section.

The patient was intubated with the initial ventilator settings of tidal volume (Vt) 365, positive end expiratory pressure (PEEP) 12, fraction of inspired oxygen (FiO₂) 90%. The surgery ended with no obstetrics complication and a live fetus weighing about 1600 g was delivered. Due to neonatal respiratory failure, the baby was immediately transferred to the Paediatric Resuscitation Center and discharged after 10 days.

The patient was then brought back to the intensive care unit, with a SpO₂ of 88% at that time. The ABG readings revealed respiratory acidosis. Besides, her conditions suggested hyperinflammatory response to COVID‐19, represented by high ferritin (722.7 ng/mL), C‐reactive protein (CRP) (61.78 mg/L) and Neutrophil (18.4G/L) levels. As such, she was started on continuous renal replacement therapy (CRRT), with the dose of methylprednisolone upgraded to 40 mg × 6 vials and antibiotics changed to ciprofloxacin (Table 1). This initiation is based on the fact that all of her conditions satisfy multiple criteria simultaneously for CRRT within the COVID‐19 diagnosis and treatment guideline by the Vietnam Ministry of Health (ferritin >250 ng/mL, CRP > 46 mg/L), lung damage presented on X‐rays and Neutrophil >11.4G/L. ¹

TABLE 1.

Summary of corticosteroid use, oxygen support therapy, ferritin, C‐reactive protein (CRP) and procalcitonin (PCT) levels within the first 17 days of intensive care

Date	Corticosteroid use per day	Supportive oxygen therapy	Ferritin value (in ng/mL)	C‐reactive protein value (in mg/L)	Procalcitonin value (in ng/mL)
Intensive care day 1	None	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 2	None	HFNC 60 L/min FiO2 100%	467.0	61.97	N/A
Intensive care day 3	None	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 4	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	706.3	17.75	N/A
Intensive care day 5	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 6	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 7	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	423.7	47.73	N/A
Intensive care day 8	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 9	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	N/A	N/A	N/A
Intensive care day 10	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	722.7	61.78	N/A
Intensive care day 11	Methylprednisolone 40 mg × 4 vials	HFNC 60 L/min FiO2 100%	806.2	62.19	N/A
Intensive care day 12	Methylprednisolone 40 mg × 6 vials	Vt 350 PEEP 12 FiO2 60%	N/A	N/A	2.02
Intensive care day 13	Methylprednisolone 40 mg × 6 vials	Vt 350 PEEP 10 FiO2 80%	N/A	N/A	N/A
Intensive care day 14	Methylprednisolone 40 mg × 2 vials	Vt 350 PEEP 10 FiO2 50%	N/A	N/A	N/A
Intensive care day 15	Methylprednisolone 40 mg × 2 vials	Vt 350 PEEP 10 FiO2 50%	N/A	N/A	1.42
Intensive care day 16	Methylprednisolone 40 mg × 1 vial	Vt 350 PEEP 8 FiO2 50%	N/A	N/A	N/A
Intensive care day 17	Corticosteroid use ended.	Vt 350 PEEP 8 FiO2 50%	N/A	N/A	N/A

Due to her significant clinical improvement, the PEEP and FiO₂ settings were gradually decreased to 8 and 50% respectively. Corticosteroid ended at day 17, while antibiotics were still maintained. The CRRT ended on day 23 with her condition reassessed. Her urine output increased to 3500 mL/24 h and her SpO₂ was maintained between 95 and 97% under mechanical ventilation with Vt 350, PEEP 8, FiO₂ 50%. On the 20th day, she was switched to HFNC 50 L/min FiO2 100%. However, her clinical symptoms worsen, with respiratory rate noted at 40 breaths per minute and SpO₂ decreased to 80%; in addition, a qSOFA score of 2 (respiratory rate >20, systolic blood pressure < 100 mmHg), along with the high levels of blood lactate (67.9 mg/dL), white blood cells (fluctuated around 16.6–21.2 G/L), ferritin (436.8 ng/mL) and PCT (2.65 ng/mL) led to the diagnosis of and the initiation of treatment for septic shock from hospital—acquired bacterial pneumonia. She was intubated again with the setting of Vt 340, PEEP 10, FiO₂ 75% accompanied with vasopressor and meropenem and vancomycin as antibiotics. Her respiratory system gradually stabilized with SpO₂ between 96 and 99%. On day 23, she was extubated and switched back to HFNC 45 L/min, FiO₂ 100%. Her consciousness gradually returned to normal. Therefore, 5 days after HFNC was replaced by oxygen delivery through a nasal cannula at 3 L/min.

On day 28 of hospitalization, her real‐time RT‐PCR result for SARS‐CoV‐2 was negative, and another similar result on the following day led to her discharge. A follow‐up 10 months later confirmed that she had fully recovered, and the evidence of past pneumonia had nearly resolved.

DISCUSSION

There have been several studies demonstrating the effectiveness of corticosteroids on moderate and severe COVID‐19 patients. The RECOVERY trial concluded that low dose dexamethasone reduced mortality by up to one‐third in hospitalized patients with severe respiratory complications of COVID‐19. ² However, pregnant women cannot receive dexamethasone for a prolonged period because of its detrimental effects on the fetus. According to the Royal College of Obstetricians and Gynaecologists (RCOG), pregnant women with moderate to severe COVID‐19 should use oral prednisolone or hydrocortisone, but methylprednisolone was chosen because it achieves greater concentrations in the lung than prednisolone. ³ , ⁴ This patient was given methylprednisolone early, based on her high CRP level.

It is well‐known that mechanical ventilation and supportive therapies are the main treatment for acute respiratory distress syndrome (ARDS). However, high PEEP levels may provoke hypotension and overdistended portions of the lung, thereby causing ventilator‐associated lung injury. Our patient had evidence of good response, with SpO2 levels fluctuating around 94%–98% on PEEP not exceeding 12.

The decision to have an emergency caesarean section is a worthy point to discuss. The mother's lack of oxygen and placental hypoperfusion led to acute fetal distress so an emergency caesarean section at 31 weeks of gestation was compulsory. Moreover, COVID‐19 during pregnancy was associated with an increased risk for stillbirth. In this case, both mother and child were saved, which was a highpoint.

The patient improved significantly after pulse corticosteroid therapy and pregnancy termination; however, she then developed septic shock from hospital‐acquired pneumonia. Grasselli et al showed that critically ill patients with COVID‐19 are at high risk for healthcare‐associated infections (HAIs) resulting from multiple drug resistance (MDR) organisms. HAIs prolonged the mechanical ventilation and hospitalization period, and HAIs complicated by septic shock almost doubled the mortality rate. ⁵ Fortunately, our patient was able to recover again from mechanical ventilation.

AUTHOR CONTRIBUTIONS

Nghia Thinh Bui: Conceptualization; methodology; formal analysis; investigation; writing–review & editing; supervision. Minh Nhat Huynh: Methodology; formal analysis; investigation; data curation; writing–review & editing. Hung Tran: Formal analysis; data curation; writing–review & editing. Dinh Kha Le: Investigation; writing–review & editing. Tan Thanh Pham: Investigation; writing–review & editing. Thanh Tung Pham: Investigation; writing–review & editing. Tien Nhan Nguyen: Investigation; data curation; writing–review & editing. Nguyen‐Huy Do‐Tran: Formal analysis; investigation; writing–original draft; writing–review & editing. Hoang‐Anh Ngo: Conceptualization; investigation; data curation; writing–original draft; writing–review & editing; supervision. Thuy‐Anh Do: Methodology; formal analysis; writing–original draft; writing–review & editing.

CONFLICT OF INTEREST STATEMENT

None declared.

ETHICS STATEMENT

The authors declare that appropriate written informed consent was obtained for the publication of this manuscript and accompanying images.

Bui NT, Huynh MN, Tran H, Le DK, Pham TT, Pham TT, et al. Severe COVID‐19 pneumonia in pregnant woman treated with pulse corticosteroids therapy and third‐trimester caesarean section: A case report. Respirology Case Reports. 2023;11:e01139. 10.1002/rcr2.1139

DATA AVAILABILITY STATEMENT

The data that belong to this patient are available from the corresponding author, Thuy‐Anh Do, upon reasonable request.