A 25-year-old woman, gravida 3 para 2, at 34 weeks gestation, with no medical history of cardiovascular nor other chronic diseases, was admitted to the labour and delivery unit of the “Hôpital Provincial Général de Référence de Bukavu” (HPGRB), in South-Kivu, for preterm labour contractions in a context of COVID-19. with a history of 2 previous caesarean sections (the first one due to a cervical dystocia and the second indicated because of the prior caesarean)
She had 2 children, all born by caesarean section, the last one aged 16 months. Her husband, tested negative for SARS-Cov-2, was a contact person of a COVID-19 confirmed case.
Three weeks before admission, she complained of fever, not responding to acetaminophen. Her obstetrician prescribed her antibiotics, anti-malaria, and anti-spasmodic drugs. Two weeks later, as fever persisted despite all these medications, a reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs was performed and confirmed she was infected by SARS-Cov-2.
She was then admitted to the provincial center for isolation and care of mild- to moderately-affected COVID-19 patients. Upon arrival to the center, her body temperature was 38.7 °C. Gynecologic examination was unremarkable. All bacteriological tests, including hemocultures and cultures of urines were negative. She received antipyretics (acetaminophen), antispasmodics (Spasfon) and antibiotics (oral azithromycine for five days and intravenous ceftriaxone). Two days later, she complained of hypogastric pain, like uterine contractions of low intensity. Obstetricians of the HPGRB were contacted and recommended the administration of antispasmodics intravenously in perfusion. Despite this treatments, fever and uterine contractions persisted, so intravenous dexamethasone 12 mg daily was administered for fetal pulmonary maturation, associated with a tocolysis using nifedipine for 48 hours. As the frequency, intensity and duration of contractions increased, accompanied by cervical changes (dilation, effacement, softening, and movement to a more anterior position), the patient was transferred to the labour and delivery unit of the HPGRB for an optimal care. A rapid SARS-Cov-2 antigen test was performed and found to be negative.
On admission, the patient had a good general condition. Her temperature (36.5 °C) and blood pressure (120/60 mmHg) were normal. The uterine height was 29 cm, the fœtus was in cephalic presentation. On vaginal examination, the uterine cervix was softened, median, 5 mm long and had a 5 cm dilatation. Membranes were intact and the fœtal head was mobile. An obstetrical ultrasound confirmed the cephalic presentation and estimated the foetal weight at 1600 g. Foetal monitoring confirmed a foetal well-being, with a stable foetal cardiac rhythm around 140 beats per minute. Tocography showed two to three contractions per minute and an intensity of 50 to 60 mmHg. A diagnosis of ineluctable preterm labor was retained in a COVID-19 patient with repeat caesarean deliveries was retained.
A classic Caesarean section with a Pfannestiel incision was performed. The peritoneal cavity and uterus were found to be very inflamed. Fetal appendages as well as the bladder were strewn with eruptive, vesicular lesions bleeding on contact (see Figs. 1 and 2). The amniotic fluid was opalescent. The placenta weighed 500 gr and had a clot on the maternal side on less than 20 percent of the surface. Anatomopathological examination subsequently revealed thrombotic vasculopathy in the placenta and in the umbilical cord vessels (see Figs. 3 and 4) and a diffuse hyalinization with marked angiogenesis of the villous stroma.
About five minutes after skin incision, a female newborn weighing 1760 g was delivered with 1 and 5 min APGAR scores of 9–10. The newborn was immediately transferred to the neonatal ward for specialist neonatal treatment for an optimal care and to minimise the potential risk of infection. Gestational age was estimated at 33 weeks according to the Finnstrom score. The newborn received the usual care (drying, stimulation, vitamin K1, argyrol and care of the umbilical cord). A gastric liquid was collected by gastric tube, and different swabs (especially nasopharyngeal, ear and umbilical cord), as well as blood cultures were immediately performed for bacteriological investigations and for SARS-CoV-2 RT-PCR test.
The newborn was breathing autonomously, had a good control of body temperature and blood sugar. She received a 10% glucose infusion for 48 hours, and on the second day an enteral feeding by nasogastric tube was progressively introduced, using artificial milk formulas adapted to preterm babies. Prophylactic antibiotherapy (penicillin G and amikacin) was initiated, considering the risk of neonatal infections in prematurity.
On postnatal day 3, the newborn baby presented jaundice, respiratory distress and a clinical picture of ulcerative enterocolitis. Hemocultures were found negative, but SARS-CoV-2 RT-PCR was positive in oropharyngeal swab and cultures of gastric liquid isolated multiresistant Citrobacter sp. and Enterobacter cloacae. A phototherapy was prescribed for three days and previous antibiotics were replaced by meropenem and vancomycin based on the antibiogram. Despite this treatment, he died on Day 5 in a picture of severe neonatal sepsis.
The postoperative follow-up in the mother was marked by a persistence of fever for three days, varying between 39 and 40 °C. Although haemocultures and urine cultures were sterile, antibiotic therapy was readjusted at postoperative Day 3 as for the newborn, with ceftriaxone replaced by meropenem. C-reactive protein (CRP) varied from 106.53 mg/l on admission to 186 mg/l on postoperative Day 1, falling to 21.93 mg/l on Day 5 and below 3 mg/l on Day 7. After 7 days of hospitalization, the patient's condition was stable, with no fever nor respiratory symptoms. She was discharged from the hospital and sent back to the Isolation Center. A control of the SARS-Cov-2 RT-PCR was negative at Day 13 so she returned back home. The late postpartum up to six weeks was simple, with no complication.
No medical staff involved in this case was subsequently found to be infected with SARS-CoV-2.