Case 1. 36 + 0 weeks

Induction of labor was performed for insulin-treated gestational diabetes mellitus. Patient's husband developed COVID-19 pneumonia three days before. At admission, no clinical signs of COVID-19 were detected. The woman had an uncomplicated vaginal birth. After delivery, she developed fever (39 °C), cough, asthenia and diarrhea. A computed tomography (CT) scan detected interstitial pneumonia (Figure 1(A)). Thrombocytopenia and lymphopenia (0.76 × 10⁹/L) occurred, thus antiviral, antibiotics and Hydroxychloroquine were administered. Given the onset of desaturation (93%) and tachypnea, O₂ therapy was started. Nine days after delivery, her clinical conditions were stable, and she was transferred in a longterm supporting center. The CT-scan performed 40 days after delivery (Figure 1(B)) showed a complete regression. Two months after delivery, the patient was asymptomatic at home.

Considerations on COVID-19 pregnancy: a cases series during outbreak in Bergamo Province, North Italy

All authors

Paola Algeri , Valentina Stagnati, Maria Donata Spazzini, Cristina Bellan, Alessandro Montanelli, Gianluigi Patelli & Massimo Ciammella

https://doi.org/10.1080/14767058.2020.1791817

Published online:

15 July 2020

Figure 1. Computed tomography images-Bilateral interstitial pneumonia, with ground glass opacity (black circles), and consolidation areas (black arrows). (A,B) Case 1 (A: at diagnosis; B: complete regression 40 days after). (C,D) Case 3. (E,F). Case 4. (G,H) Case 5 basal and intravenously contrasted computed tomography, which excluded embolism. (I,L,M) elaborated images with in red the normal functioning lungs and calculation of %aerated parenchyma.

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The neonate presented no symptoms and no adverse outcomes.

Case 2. 27 + 4 weeks

Presented to the emergency room for fever and cough. At admission, the cardiac frequency was 120 min, respiratory frequency 18 min, temperature 37.9 °C and saturation 92%. O₂ therapy improved saturation levels (95%). She was then transferred to HUB-hospital and an urgent C-section was performed for worsening maternal conditions.

Excepted for iatrogenic severe-prematurity, the neonate did not present complications.

The maternal condition improved after she gave birth.

Case 3. 38 + 4 weeks

Admission for rupture of the membranes with no signs of infection. A C-section was performed due to a not-reassuring cardiotocography, associated with fever (38.2 °C) and CRP 7 mg/dL (other blood tests were normal). The neonate was fine. The placental bacterial culture was negative. The placental histology did not report signs of infection/inflammation. The patient was treated with antibiotics, for suspected chorioamnionitis, but despite therapy, she presented fever (39.2 °C) and general malaise. She developed thrombocytopenia and lymphopenia (0.8 × 10^9/L). Interstitial pneumonia was diagnosed at the CT-scan (Figure 1(C,D)). The patient fully recovered 5 days later, then she was discharged with antibiotic and antithrombotic.

Two months later she presented completely recovered; husband and neonate remained both asymptomatic.

Case 4. 37 + 3 weeks

Presented for fever, dyspnea, and reduced fetal movements. At admission, she showed fever (38.4 °C) and desaturation (96%). Cardiotocography showed fetal tachycardia (180 bpm) and a reduction in the short term variability. Her clinical condition rapidly worsened, with tachypnea (44/min) and severe desaturation (86%), without response to O₂ therapy. Thus, an emergent C-section was performed. The newborn was fine. A CT-scan detected interstitial pneumonia (Figure 1(D,E)). The saturation remained low despite intubation, ventilation and prone position, therefore she was transferred to HUB-Hospital, extracorporeal circulation undertaken and removed 15 days later. At 1 month follow-up, she was still in hospital because of the onset of an ascending Guillan Barrè Syndrome. Two months after delivery she was transferred to a long-term supporting center.

The neonate showed no complication.

Case 5. 35 + 6 weeks

Dichorionic-diamniotic twin pregnancy admitted for rupture of the membanes. One week before she developed a Bell’s paralysis (treated with oral deltacortene). She underwent a C-section with no complications. Neonates were in wellbeing. One day later, exactly the day of Italian COVID-19 alert, the patient presented with retrosternal and inter-scapular pain, desaturation (78%) and bradycardia (50 bpm). No laboratory signs of myocardial infarction. At the CT-scan, interstitial pneumonia was suspected and cardiomegaly was described. No pulmonary embolism was observed (Figure 1(G,H)). Legionella and Pneumococco antibodies were negative. Antibiotic therapy was started in association with Enoxaparin. A progressive prolongation in QT interval (658 msec) was detected (interpreted as a possible effect of antibiotic). She presented thrombocytopenia, elevated liver enzymes and increased creatinine. She never developed fever. She progressively improved and was discharged 9 days later, in good clinical condition under enoxaparin and cortisone.

At 2 months follow-up, she declared her suspicion to have had COVID-19 infection during her hospitalization. Therefore, she stayed in a spontaneous quarantine. Her family remained asymptomatic. Accordingly, we proposed to the women a serological evaluation for COVID-19: a rapid test (DiaSorin test) showed IgG+ (with a subsequent sierologic dosage of 16,9AU/mL) and IgM−. We reviewed her CT-scan and observed a 30% of not aerated lung parenchyma, with no sign of embolism, in keeping with COVID-19 lungs involvement (Figure 1(I,L,M).