This article describes the case of a 34-year-old pregnant woman with a history of asthma who presented to the emergency department with complaints of dry cough, fever, nausea, vomiting, myalgias and diarrhoea. The patient’s symptoms had a history of 7 days. 3 days prior to her admission, the patient was referred for an RT-PCR test and was positive for COVID-19. She was further referred for a chest X-ray which showed infiltrates in both the lungs. The patient was also mildly hypoxemic, thus, was infused with low-flow oxygen and prescribed remedisvir and dexamethasone 6 mg, daily. However, the patient developed hypoxemia and increased respiratory distress over the next 72 hours with acidosis. This case highlights the management of COVID-19-induced hypoxia in a pregnant female.
Her clinical condition further deteriorated and doctors prescribed her vasopressors. On the 5th day of her hospital admission, her fetal heart rate monitoring was significant for signs of fetal distress. Therefore, in anticipation of a cesarean section delivery, the doctors administered betamethasone. On the 5th day, the patient was started on IVIG which was administered for 3 days. Within 24 hours of the first infusion, the patient was weaned off vasopressor support and the acidosis also resolved.
The patient was extubated on the 14th day at the hospital. The patient’s oxygen was weaned off and she was discharged on the 21st day after admission. The 34-year-old had a normal spontaneous delivery at 37 weeks of gestation with no complications. A year into the delivery, the child was also healthy with no signs of complications. Given the successful outcome of the patient management, the case was also included in a case series of IVIG in COVID-19.
Pregnant patients have been excluded from the initial studies of COVID-19 vaccinations and therapeutic trials. Similarly, pregnant women who are not vaccinated against COVID-19 are at a higher risk of morbidity in case of a severe form of the disease. The use of intravenous immunoglobulins (IVG) is safe for pregnant women and other diseases. Studies have further shown that there are significant benefits of using IVIG for the treatment of hospitalized patients when administered within 14 days of the onset of symptoms.
IVIG and COVID-19
Doctors administered IVIG for 3 consecutive days. She also received concomitant glucocorticoid therapy and was discharged after a hospital stay of 14 days. IVG is considered a safe treatment choice for pregnant women with a severe form of respiratory illness. IVIG is also used to avoid pregnancy complications. This treatment approach paves the way for further studies regarding the use of IVIG in pregnancy with acute respiratory distress syndrome due to COVID-19.
Pregnant patients are typically younger and compared to most COVID-19 patients have fewer comorbidities. But, despite it, younger patients can also present with a high severity of illness. Similarly, because of the relatively immunosuppressed state, it can cause significant morbidity and mortality in patients of this age group. Intrauterine fetal demise may occur even in cases of mild disease. According to the case study, only one other case of IVIG in a pregnant patient with COVID-19 has been reported in the past. The child was delivered at 36 weeks via C-section, and both the child and mother survived.
In this case, doctors treated the patient with off-label IVIG. The patient presented with severe illness and required mechanical ventilation. However, the patient had an excellent outcome despite the high illness severity and degree of hypoxia. Despite the high severity of illness and degree of hypoxia, the patient showed an excellent outcome. Additionally, there were no adverse consequences for the mother or the infant. The patient stayed at the hospital for an average length of 15 days and was discharged from the hospital in 3 weeks. Since the patient was mechanically ventilated, the duration of hospitalisation was shorter than expected despite the severe degree of illness. Similarly, the average length of stay of patients admitted with COVID-19, on average is generally over 12 days.
While the exact mechanism of how IVIG benefits in the treatment of COVID-19 is not yet elucidated. However, it may be because of mitigation of endovascular NET formation which is known to contribute to thrombus formation, especially in COVID-19 patients. Moreover, NET-mediated vascular inflammation is a known driver of morbidity and mortality in COVID-19, malaria and dengue fever. Thus, therapies that target immunothrombosis may be useful for the treatment of respiratory failure and vascular complications in patients with COVID-19.
Source: American Journal of Case Reports