From 12/1/2020, a 31-year-old pregnant woman with gestation of 36 weeks and four days who lived in Jianghan District, Wuhan, considered as an epidemic region of COVID–19, began to experience cough, expectoration, chest tightness and fever. The sputum was little and white, and her highest temperature was 38°C. At a hospital near her home, she was diagnosed to have an upper respiratory tract infection. Oral medications of Amoxicillin potassium clavulanate and Jinyebaidu granules (Chinese traditional medicine) were prescribed, but she did not show any improvement. On 18/1/2020, the patient began to feel decreased fetal movements, so at 9pm, she was admitted to our emergency department of Tongji Hospital.
The patient had none of comorbid cardiopulmonary diseases, comorbid endocrine diseases, or comorbid infectious diseases before. During pregnancy, the patient presented no symptoms of headache, blurred vision, palpitation or edema. Mild pruritus in the lower extremities appeared from 16/1/2020, and it was tolerable. She had done regular antenatal examinations during pregnancy, and the results of previous visits, including the last one on 10/1/2020, showed no abnormalities in obstetric examination and biochemistry.
On admission, she had a fever of 38.5°C, a heartrate of 98 bpm, a respiratory rate of 28/min, and a blood pressure of 134/72mmHg. She exhibited a bit of polypnea, with SpO2 95% under no oxygen inhalation. Her breathing in both lungs sounded thick and presented with moist rales. Her fundal height was 32cm, and her abdominal circumference was 102cm, with longitudinal lie and cephalic presentation. The fetal heart rate (FHR) was 145bpm and fetal heart monitoring showed no abnormality.
Laboratory tests on admission showed increased white blood cell (WBC) count (9.86×109/L), increased neutrophil percentage (86.8%), decreased lymphocyte count (1.07×109/L), and high TBA (103.93 μmol/L), alanine aminotransferase (ALT) (1574.3U/L), and aspartate aminotransferase (AST) (1593.7 U/L). Some other liver function indexes were elevated as well, such as total bilirubin (TBIL) ( 29.55 μmol/L), direct bilirubin (DBIL) ( 18.8 μmol/L), alkaline phosphatase (AKP) ( 271 U/L), 𝛄-glutamyltranspeptidase (𝛄-GT) (303.6 U/L) and lactate dehydrogenase (LDH) (744U/L). The level of high sensitive C-creative protein (Hs-CRP) rose (67.28mg/L) as well. Chest CT showed multiple ground glass opacities, and patchy and strip shadows in both lungs, indicating an infection in both lungs for viral pneumonia, and a small amount of pericardial effusion (Fig.1 A). Considering her typical epidemiological history, symptoms and CT scanning result, detection of SARS-CoV–2 in oropharyngeal swab specimen was sent for examination.
Under the consultation from a MDT, an emergent cesarean section was performed successfully under spinal anesthesia in a designated negative pressure operating room. All personnel involved wore protective equipment according to the third level prevention of infectious diseases, and the patient wore an N95 mask as well. A female infant was delivered with Apgar scores of 8 and 9 at 1 and 5minutes, and was transferred to neonatology department 10 minutes after birth for close observation and the paitent was transferred to the fever ward under 24-hour ECG monitoring and 5L/min oxygen through nasal cannula.
On the first postoperative day (POD), the result of SARS-CoV–2 detection in oropharyngeal swab specimen of the patient was positive, while the detection of the neonate was negative. Laboratory tests were detected again and blood-routine test showed obviously increased WBC count, increased neutrophil count and normal lymphocyte count (Table 1). The levels of ALT and AST were slightly lower compared with the day before, but still obviously higher than the baseline (Table 1). The other indexes of liver function were still highly increased, including AKP, 𝛄 –GT, LDH, and TBA (Table 1). Inflammatory-related indexes were detected as well, and the results showed the levels of Hs-CRP, erythrocyte sedimentation rate (ESR), procalcitonin (PCT), ferritin, interleukin–2 receptor (IL–2R), interleukin–6 (IL–6), and tumor necrosis factor-𝛂 (TNF-𝛂) were increased (Table 1).
Diagnosed as a general case of confirmed COVID–19 with comorbid severe ICP [3], this patient presented severe liver damage. Accordingly, bicyclol (50 mg administered orally every 8 hours) and ursodeoxycholic acid (250mg administered orally every 12 hours) for liver protection and cholagogic, and mucosolvan (90mg administered intravenously every day) for expectorant were given symptomatically. Ganciclovir (0.25g administered intravenously every 12 hours) for anti-virus was given. Meropenem (1g administered intravenously every 8 hours) and micafungin sodium (0.1g administered intravenously every day) were given for anti-bacterial infection empirically. (Fig.2)
After the operation, the patient’s vital signs were stable with SpO2 ≥98% under 5–8L/min oxygen inhalation through nasal cannula. She had intermittent fever on POD 1 and POD 2, with the highest temperature up to 38.5°C, and loxoprofen sodium (30mg administered orally) was given for antipyretic. On POD 3, her body temperature returned to normal, and pruritus disappeared. On POD 7, her cough and expectoration were alleviated. On POD 12, her chest tightness disappeared as well. (Fig.2)
From POD 4, inhalation of recombinant human interferon 𝛂1b (40 μg every 12 hours) for anti-virus was given (Fig.2). From POD 9, cefoperazone sulbactam sodium (3g administered intravenously every 8 hours) was given to replace meropenem (Fig.2).
On POD 12, the patient was tested negative for SARS-CoV–2(Fig.2), and the repeated test on POD 14 remained negative. On POD 12, blood routine tests and inflammatory-related tests returned normal (Table 1). On POD 12, except LDH, most of liver function indexes returned to normal (Table 1). In addition, the test of classification of peripheral blood lymphocytes was normal. Renal function and coagulation tests remained normal as well.
On POD 7 (25/1/2020), chest CT scan was repeated, and showed ground glass opacities in both lungs, indicating viral pneumonia with improvement (Fig.1B). On POD 12 (30/1/2020), the third chest CT scan showed that the shadows were absorbed and well improved, leaving a small amount of pleural effusion (Fig.1C).
On POD 15, the patient was discharged and sent to the quarantine area for further isolation.