Coronavirus Disease-2019 During Postpartum Period: A Case Report

The novel coronavirus disease (COVID-19), discovered in December 2019 in China, spread rapidly around the world and was declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [1,2]. Public health experts and institutions mentioned COVID-19 as a serious threat and a global health emergency that needed to be urgently addressed [3]. On March 3rd, 2020, WHO reported more than 180,000 COVID-19 confirmed cases worldwide, with an estimated 3.4% global mortality rate [3,4]. The disease affects all age and gender groups, and constitutes as a result, a major public health challenge for all including pregnant and postpartum women [5,6]. Research showed that pregnant and postpartum women were equally susceptible to infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV- 2) [7-10]. In addition, the COVID-19 case-fatality rate in pregnant women could be as high as 25% [3].

Burkina Faso recorded its first confirmed cases of novel coronavirus disease on March 9, 2020. Since then, considerable efforts (physical distancing, avoidance of social gatherings, national and international travel bans, closure of schools and markets, sensitizations on regular handwashing, case management, contact tracing, and many more) have been made to slow down the spread of the disease and flatten the incidence curve. However, despite these unprecedented measures, the country continued to record new daily COVID-19 cases and as of April 20, 2020, had reported more than 600 confirmed cases with 41 deaths [11]. On April 21, 2020, The Department of Obstetrics and Gynecology (OB/GYN) of the Yalgado Ouedraogo Teaching Hospital (YOTH) recorded its first confirmed case of COVID-19 in a woman during her postpartum period. This article describes the COVID-19 case management experience of this postpartum woman admitted at the department of obstetrics and gynecology.

This is a descriptive case report study depicting the clinical features (including patient history) as well as the lab results and treatment of a single COVID-19 postpartum woman admitted on April 21, 2020 at the department of obstetrics and gynecology of the yalgado ouedraogo teaching hospital in Burkina Faso.

Patient history

The patient was a 26 years old married housewife living in Sebba, a city located in the Sahel region of Burkina Faso (around 300 kilometers from the Capital Ouagadougou). She had in total five pregnancies that ended in three living children, one stillborn, and one abortion. Her interview revealed that, for her last pregnancy, she regularly attended antenatal consultations in the district hospital of Sebba until labor time. On that day, after feeling painful contractions and leakage of fluid, she went to the maternity ward of the district hospital of Sebba for delivery. However, after the medical examination, a cesarean was decided and performed because of an absence of fetal movements and a fetopelvic disproportion. No per and post-operative complications were reported. The patient was then discharged five days after the C-section. Unfortunately, 16 days after being discharged, the patient was readmitted to the district hospital of Sebba for headache, asthenia, and oliguria in a postpartum period. She was first transferred to the Regional Hospital Center (CHR) of Dori (where a kidney failure was diagnosed) and then, to the YOTH department of gynecology and obstetrics. Except for the previous C-section, her relatives did not report any particular medical and surgical history, as well as no travel history or known contact with a suspected COVID-19 case.

Clinical examination

General examination: At the hospital admission, the patient’s general examination revealed a bad general condition, clear consciousness (Glasgow score of 15), no conjunctival icterus or pallor, discreet edema of the lower limbs, body temperature of 38.1°C, blood pressure of 118/80mmHg. The pulse and respiration rates were respectively 128 beats and 40 breaths per minute. Unfortunately, the patient oxygen saturation level was not taken at her entrance in the emergency room. A 24-hour urine collection highlighted an oliguria at 200 milliliters.

Physical examination: A physical examination of the patient concluded to an abdominal guarding, preventing a complete pelvic examination. The respiratory examination noted a shortness of breath as well as bilateral crackles. The rest of the examination was normal (including the bimanual palpation of the kidney).

Diagnostic assumptions: Two diagnostic hypotheses were formulated: 1) a pneumopathy (induced by common germs) associated with a kidney failure in a postpartum context, 2) a novel coronavirus disease (COVID-19)-WHO critical stage-complicated with an acute pulmonary edema and a kidney failure.

Complementary exams

At the patient admission in the department of obstetrics and gynecology, blood samples were drawn for lab tests (including complete blood counts and creatinine). The lab results showed a low white blood cell count of 16,000 elements per cubic millimeter (16000/mm3), hemoglobin level of 9 grams per deciliter and platelet count level of 111,000 elements per mm³. The creatinine level was high at 1655 micro-mol per liter (μmol/L). Considering all the patient’s clinical symptoms and the ongoing COVID-19 pandemic, additional samples were collected for COVID-19 detection. The tests results confirmed, 72 hours later, that the patient was positive to COVID-19. Unfortunately, no chest CT scan could not be performed.

Treatment

Since her admission, the patient received the following treatment: oxygen 6 liters per minute, 3rd generation cephalosporin 1 gram per 24 hours through a direct intravenous infusion, imidazole 500 milligrams (mg) every 8 hours in a slow infusion, lactated Ringer’s infusion 1 liter per 24 hours, isotonic glucose solution 1liter per 24 hours, isotonic saline solution 1liter per 24 hours, injectable paracetamol 1 gram every 8 hours in an infusion and finally, 80mg every 12 hours of diuretics in a direct intravenous infusion. An urgent dialysis was prescribed to the patient and her transfer to the department of nephrology was planned.

Evolution

The patient clinical condition deteriorated rapidly, presenting a persistent respiratory distress syndrome, fever with an altered state of consciousness. Unfortunately, the patient’s death occurred a day after her hospital admission. The diagnosis of death suggested was severe acute respiratory distress syndrome and multi-visceral failure.

Our postpartum patient tested positive to COVID-19. She was a resident of the Sahel region of Burkina Faso, area affected by the novel coronavirus disease. Indeed, the first case of COVID-19 was recorded in this region on March 30, 2020, 20 days after the onset of the disease in Burkina Faso [11]. In our case, the information collected from the patient and her relatives revealed no travel history or known contact with any suspected COVID-19 case. However, this information should be analyzed carefully for the following several reasons. It is now widely known that the disease incubation period ranges from 6 to 14 days, and suspected cases can remain asymptomatic until recovery [3]. In addition, Burkina Faso did not implement a massive screening strategy, but rather a screening for only suspected cases [12]. Consequently, it is logical to believe that the screening method did not detect most of the cases, especially those that are asymptomatic. No matter what was the origin of her infection, the late diagnosis could present several potential consequences. First, there is a high risk of COVID-19 spreading among her family members, and the health workers at the hospitals of Sebba, Dori and YOTH. As she was not a COVID-19 suspected case, it is likely that some of those health workers and family members did not take enough precautions while taking care of her. Second, the national COVID-19 preparedness and response level was not enough to induce an early detection of the disease. Many public health teams were not trained to detect and manage any covid-19 case. Only a few people were responsible for the process. This could justify the fact that the diagnosis hypothesis of COVID-19 was never mentioned either at the District Hospital of Sebba or at the Regional Hospital of Dori, even though she was hospitalized in both hospitals.

This clinical case reminds us of the urgent need to identify, at various levels of the health system, a well-equipped health facility or location where all COVID-19 suspected cases would be isolated and treated. These health facilities must be identified in all regions of the country and supplied with adequate equipment and medical personnel including medical doctors, nurses, midwives, obstetricians, pediatricians, anesthetists, lab specialists and so on. The patient had no known medical or surgical history, but her recent delivery is likely to have weakened her immune system. This could therefore explain a potential higher severity of the disease among pregnant or postpartum women. No previous studies had analyzed any particular exposure of women in the postpartum period, let alone post cesarean section, compared with women who have not been pregnant [7]. The patient presented several clinical features including a respiratory distress syndrome and fever. In the description of coronavirus disease, fever is the most common clinical feature described in COVID-19 cases. Additional symptoms also include cough, shortness of breath, asthenia, headache, diarrhea, and in extreme cases, a severe acute respiratory distress leading sometimes to death [7,13,14]. Further lab investigation using Polymerase Chain Reaction (PCR) tests was performed and confirmed a positive COVID-19 diagnosis in in the patient. Regarding the patient’s bad clinical condition (oxygen dependency and other severe clinical symptoms), a chest CT scan could not be performed. The chest CT scan is an important tool for a correct case management of any COVID-19 disease. Therefore, this specific kind of equipment should be made accessible to the health facilities.

The creatinine level was elevated at 1655μmol/L. This result may be justified by the multi-visceral failure observed in this clinical case. Renal failure and acute respiratory distress syndrome are part of the COVID-19 described complications and have unfortunately a potential to increase the patients’ risk of death [15,16]. The patient had a caesarean section at the district hospital of Sebba and was in the postpartum period before her admission to the YOTH. Research showed that many COVID-19 positive cases have been diagnosed in pregnant women and more frequently in the postpartum period, especially in post-caesarean section [17-19]. There is no current report highlighting a possible transmission of the virus during a caesarean section, however health professionals should take more precautions regarding this airborne disease [14,15]. Currently, no specific treatment for coronavirus has yet been approved and clinical trials on chloroquine-azithromycin are still ongoing in Burkina Faso [11,15]. The existing protocols of COVID-19 case management in pregnancy include early detection and isolation, aggressive infection control using prescription drugs, oxygen therapy, prevention of fluid overload, antibiotic management (secondary to the risk of bacterial infection), and early mechanical ventilation to anticipate any respiratory failure [15].

The patient’s clinical course deteriorated rapidly, leading to her death. The COVID-19 diagnosis confirmation was received around 48 hours after the patient was dead. Samples that were collected for the covid-19 diagnosis took at least 72 hours for lab tests’ confirmation. This is due to the fact that collected specimens had to be sent from Ouagadougou to Bobo-Dioulasso, where is found the only laboratory approved at the national level for this type of lab tests. This timing is considered, especially in an epidemic scenario. Efforts should be made to reduce the time for a COVID-19 case confirmation.

The department of obstetrics and gynecology of the Yalgado Ouedraogo teaching hospital registered its first COVID-19 case on April 21, 2020. Several factors including shortage of tests kits, delay in the receiving results, lack of COVID related trainings for the health workers were found to have influenced the late diagnosis in our patient. In these uncertain times due to the COVID-19 pandemic, health workers at all levels of the health system are more exposed and should remain extremely cautious while dealing with any patient. It is recognized that co-morbidity rapidly worsens the clinical picture of patients with covid-19. However, further studies using in-depth statistical methodologies are needed to analyze the association between maternal postpartum period and COVID-19 disease.

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