A Pregnant Woman with a Diagnosis of COVID-19 without Clinical Manifestations: A Case Report

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2021;4(1):e12
Case Report
This open-access article is distributed under the terms of the Creative Commons Attribution Non Commercial 4.0 License (CC BY-NC 4.0).
A Pregnant Woman with a Diagnosis of COVID-19 without Clinical
Manifestations: A Case Report
Amirhossein Lotfia, Masoud Mardanib, Ghanbar Abbasic, Farid Foruzina, Arezou Hosseinia,
Mohammad Taheria, Raha Eskandarid, Sahar Yousefiand, Zahra Mirshafiei Langarid, Farzaneh
Dastand,e,*
a. Critical Care Department, Laleh Hospital, Tehran, Iran.
b. Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
c. Gynecology and Surgery Ward, Laleh Hospital, Tehran, Iran.
d. Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases
(NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.
e. Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Article Info:
Received: July 2021
Accepted: October 2021
Published online:
October 2021
* Corresponding Author:
Farzaneh Dastan
Email:
fzh.dastan@gmail.com
Abstract:
A 41 year old woman, 38 weeks and 3 days pregnant, without any past medical history
and gravida (G) 4, parity (P) 2 and abortion (Ab) 2, gave birth by Cesarean section. The
patient did not have any fever, cough, and dyspnea and did not report any close contact
with COVID-19 patients. She was extubated post-surgery in the recovery room. She had
oxygen saturation (SpO2) of 87-93% with face mask and was transferred to medical
ward. Six hours later, she experienced dyspnea and her SpO2 fell down to 83%. Ten
hours after surgery, due to worsening of her dyspnea and SpO2 of 78%, cardiology
consultation was conducted and patient was admitted to the intensive care unit (ICU)
with the diagnosis of pulmonary thromboembolism (PTE). Cardiac consultation and
echocardiography excluded PTE. In the ICU, her chest computerized tomography scan
(CT-scan) showed bilateral ground glass opacity in favor of COVID -19. Reverse
Transcription-Polymerase Chain Reaction (RT-PCR) for COVID-19 was also positive.
The baby was born with an Apgar score of 9, a normal physical examination and a
positive PCR test for COVID-19.
Keywords: Pregnant; COVID-19; Intensive Care Unit
Please Cite this article as: Lotfi A., Mardani M., Abbasi Gh., Foruzin F., Hosseini A., Taheri M., Eskandari R., Yousefian S.,
Mirshafiei Langari Z., Dastan F. A Pregnant Woman with a Diagnosis of COVID-19 without Clinical Manifestations: A Case Report.
Int. Pharm. Acta. 2021;4(1):e12
DOI: https://doi.org/10.22037/ipa.v4i1.35397
1. Introduction
Since December 2019, new cases of coronavirus
pneumonia, named COVID-19, were identified in
Wuhan city, Hubei province in china. The disease has a
high contagious potential and spreads out through person
to person contact, mainly via aerosol, and respiratory
droplets (1).
There is not much information available about
presentation, severity and symptoms of COVID-19
during pregnancy, however, information on SARS,
MERS and H1N1 could be helpful. The clinical outcome
of Influenza among pregnant women in comparison with
non-pregnant women is worse. Pregnant women are at
higher risk of morbidity and mortality from Influenza
(2). In J .Yan and colleagues study in 2019, COVID-19-
associated acute respiratory distress syndrome
(ARDS) during pregnancy did not enhance the risk of
spontaneous abortion and preterm birth. No evidence is
available on vertical transmission of virus to the fetus
(3).
In a review study done by M.Zaigham and colleagues on
18 clinical trials, among 108 patients from December
2019 to April 2020, most of the reported symptoms were
from mothers in their 3rd trimester including 68% fever,
34% cough, 59% lymphopenia, 70% c-reactive protein

2 A. Lotfi et al. International Pharmacy Acta, 2021;4(1):e12
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(CRP) rise and 91% were in need for delivery through C-
section. Three patients underwent ICU admission and
there were no mortalities; one neonatal death and one
intra uterine fatal death (IUFD) was also reported (4).
In a similar previous pandemic, clinical specialist were
hesitant to vaccinate pregnant mothers due to its possible
effects on the fetus’s health (5). Chen’s study showed
that symptoms reported in COVID-19 pregnant women
were similar to non-pregnant women. Fever, myalgia,
cough, sore throat and weakness in 2 pregnant women
and lymphopenia in 5 pregnant women were reported.
The results of later studies showed that none of the
patients needed mechanical ventilation and no mortality
was reported. All cases gave birth to their infants with C-
section and infants Apgar score was between 8-9 (6).
Our case was a 41 year old pregnant woman, whom after
the C-section developed respiratory symptoms and dyspnea,
which were developed rapidly. This article is written under
CARE guideline and patient’s consent was obtained.
2. Case presentation
A 41 year old pregnant mother with maternity age of 38
weeks and 3 days without any past medical history came
to Laleh Hospital, Tehran, Iran, for baby delivery via C-
section. Because of her hypertension in the last 2 weeks
of pregnancy, she used methyldopa 250 mg twice daily.
She had a history of 4 pregnancies, two healthy children
and 2 abortions (G4-P2-AB2). In the last 2 weeks of
pregnancy she did not mention any problems and her
physical examination on admission were completely
normal. Before transferring to the operating room her
SpO2 was 98% and did not have any signs of dyspnea or
fever. Patient’s systolic blood pressure (BP) was 130 and
her diastolic BP was 75 (BP=130/75mmhg). Her
respiratory rate was 16 and her body temperature was
36.8 degrees Celsius.
In the operating room, general anesthesia was induced
by 30 mg of atracurium, 500mg Na-thiopental and 200
mg fentanyl. Intubation was done by endotracheal tube
size 7 and ventilator setting was TV=600, F=12 with
intermittent positive pressure ventilation (IPPV) mode.
After surgery, anesthesia was reversed by 3 mg of
neostigmine and 1.5 mg atropine. Patient was extubated
and SpO2 was between 87-93%. Patient’s surgery took 3
hours and she was awake and oriented post-operation.
She had spontaneous breathing and was transferred to
regular ward. Six hours post- surgery she developed
dyspnea and her SpO2 fell to 83%. At this time she
received oxygen support via face mask. Ten hours after
the surgery, she experienced respiratory distress and her
SpO2 dropped to 78% and the patient was tachycardic.
Due to the high risk of pulmonary thromboembolism
(PTE), cardiac and intensive care consultation were
requested. Her D-dimer was 3083 microgram/Liter and
troponin was 15.1ng/ml. Based on cardiac consultation
and echocardiography, PTE was ruled out. High-
resolution computed tomography (HRCT) showed
bilateral ground glass opacity which was in favor of
COVID-19 pneumonia (figure 1 and 2). Furthermore,
her RT-PCR test for COVID-19 was reported positive.
In her preoperative lab tests she had CRP level of 3.3,
normal CBC and normal serum electrolytes. Her Ferritin
level was 87. Neonate had Apgar score of 9 and her
physical examination was normal, however, her COVID-
19 PCR was reported positive.
Figure 1. Chest computed tomography scan of patient on admission to the ICU

A Pregnant Woman with a Diagnosis of COVID-19. 3
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Figure 2. Anteroposterior (AP) view of Chest computed tomography
scan
Mother went through respiratory support with reservoir
bag oxygen face mask. Treatment with corticosteroid (8
mg dexamethasone twice a day) and 200 mg
hydroxychloroquine twice a day was initiated. After four
days, her spontaneous respiration was normal and she
was discharged with outpatient medication. Moreover,
patient was educated regarding self-isolation. Neonate
was discharged after 72 hours with acceptable condition.
3. Discussion
Respiratory complications and issues related to
ventilation after anesthesia is common in patients, with a
rate of 0.8% to 6.9% (7). On the other hand, aspiration
has been considered a risk factor in pregnant women. For
the first time in 1946, Mandelson reported aspiration
pneumonia in women with natural delivery which had
been anesthetized with Ether and Nitrogen Oxide. 5.1%
of women who had aspirated had not been intubated.
Women who had aspirated beverages, had variety of
symptoms including dyspnea, cyanosis and tachycardia,
which is known as Mandelson’s Syndrome (8). In some
studies, evidence of covid-19 infection was
demonstrated in CT-Scan of 60%-93% of patients before
they have positive RT-PCR (9).
In young patients without underlying diseases, aspiration
pneumonia and airway obstruction should initially be
considered as anesthesia’s complication (2). Because our
patient was a pregnant woman without any underlying
diseases these complications were assessed and ruled
out, since patient had tachypnea (RR=38) and respiratory
distress with marked decline in SpO2. Her SpO2 was
maintained above 90% by administrating oxygen using
face mask with reservoir bag. Subsequently, an ABG and
a chest CT-Scan -were ordered which showed bilateral
lung involvement and severe pneumonia.
According to RECOVERY trial, in severe noncritical
patients who ought to receive supplemental oxygen
without invasive mechanical ventilation, dexamethasone
administration has been shown to decrease 28-day
mortality significantly (10). Although, pregnancy and
breastfeeding were not excluded from this trial, oral
prednisolone or intravenous hydrocortisone are preferred
in this population based on recent guidelines (11).
Another study conducted by Saad, Antonio F et al,
recommends a four-dose course of dexamethasone over
2 days with the aim of both fetal lung maturity and
SARS-CoV-2 infection, during pregnancy in COVID-19
patients. However, due to the limited data on
dexamethasone use after delivery and its effect on
breastfeeding infants, it is been suggested that
dexamethasone be replaced with methylprednisolone to
complete a 10-day course (12).
Since, in this study, the patient did not breastfeed,
neonatal drug exposure was not of any concern.
Based on recent meta-analyses, hydroxychloroquine
have no benefit over standard care in COVID-19 patients
and its use should be limited to clinical trials. Moreover,
the effect of this drug in special population, including
pregnancy and breastfeeding is not yet well understood
(13).
Recent studies suggest prophylactic dose of
anticoagulants during hospitalization for postpartum
patients with severe/critical COVID-19 infection, if not
contraindicated. Postpartum anticoagulation is not
recommended in asymptomatic or mildly symptomatic
COVID-19 patients who are hospitalized for reasons
other than COVID-19, for instance delivery, unless they
have other thrombotic risk factors (14).
Limited data are available on vertical transmission of
COVID-19. COVID-19 related ARDS during pregnancy
has not been associated with higher risks of spontaneous
abortion nor preterm labor. There is not any strong
documentation for mother-to-fetus transmission ARDS
in 3rd trimester. Also, in a study on 31 pregnant women
infected with COVID-19, fetuses were not infected,
however, there was a higher risk for occurrence of
pneumonia complications in the mothers (15).
4. Conclusion
With the current data, we can come to this conclusion
that extra caution must be practiced with pregnant
woman since COVID-19 lung involvement might be
present without any symptoms during pregnancy and
delivery. During a pandemic, it is necessary that all of
the healthcare providers have personal protective
equipment; however, the neonate with positive test is a
carrier of the disease, hence protecting other neonates
and mothers is crucial in the neonatal wards.
Pregnant women, which go to the hospital for delivery,
should be triaged before admission. Also, these tests
could help find the best treatment option for the patient
and her family, obstetricians and healthcare providers.

4 A. Lotfi et al. International Pharmacy Acta, 2021;4(1):e12
This open-access article is distributed under the terms of the Creative Commons Attribution Non Commercial 4.0 License (CC BY-NC 4.0).
Abbreviations
ARDS: acute respiratory distress syndrome
SpO2: oxygen saturation
CRP: c-reactive protein
ICU: intensive care unit
IUFD: intra uterine fatal death
BP: blood pressure
IPPV: intermittent positive pressure ventilation
PTE: pulmonary thromboembolism
HRCT: High-resolution computed tomography
G: gravida
P: parity
Ab: abortion
CT-scan: computerized tomography scan
RT-PCR: Reverse Transcription-Polymerase Chain
Reaction
Acknowledgements
Thanks to Laleh hospital staff.
Conflict of interest
None.
Funding/ Support
None.
Authors' ORCIDs
Farzaneh Dastan:
https://orcid.org/0000-0001-7253-4333
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