A case of postpartum maternal death with COVID-19 in the west of Iran

Background: There are a limited number of studies about COVID-19 during delivery and postpartum. Case presentation: A 38-years old G3p2 woman at 35 weeks and 4 days of gestation referred with the chief complaints of dyspnea, cough, headache, and fever. Pharyngeal swab polymerase chain reaction (PCR) was negative for COVID-19; however, in chest computed tomography (CT) angiography, ground glass was observed in the basal lobe of the left lung. The infant was born via cesarean section with gestational age of 36 weeks and an Apgar score of 8/9. No infant document was found about COVID-19 and other infections in several days after delivery. The patient died eight days after the onset of symptoms due to cardiovascular collapse. Conclusions: We reported the �rst death of postpartum maternal with COVID-19 and a healthy baby with no evidence of COVID-19 and gestational age of 36 weeks.


Background
2019 Novel coronavirus (COVID-19) has given rise to an outbreak of viral pneumonia in many countries since December 2019 (1).Novel coronavirus was rst reported in Wuhan, Hubei province, China in December 2019 and spread to many countries (2).
Common symptoms at the beginning of COVID-19 infection in pregnant women include fever and cough, with less occurrence of myalgia, malaise, sore throat, diarrhea, and dyspnea.Also, lymphopenia is reported in laboratory tests (3).
Pregnant women are particularly susceptible to respiratory diseases, because they are at an immunosuppressive condition, and physiological adaptive changes during pregnancy can render them intolerant to hypoxia.For example, the mortality rate in the 1918 in uenza pandemic was 2.6% in the overall population, while it was 37% among pregnant women (4).
Pregnant women are at high risk of developing a viral infection such as in uenza-A, H1N1, SARS-CoV, MERS-CoV, and Ebola viruses.Therefore, they appear to have worse clinical outcomes including maternal mortality, spontaneous abortion, and preterm delivery compared to non-pregnant women (5).The clinical characteristics and vertical transmission potential of COVID-19 pneumonia in pregnant women are unknown.Therefore, there are rare studies on COVID-19 during delivery and postpartum.In this study, we reported the rst death of postpartum maternal with COVID-19, Hamadan City, the west of Iran.

Case Presentation
On March 5, 2020, a 38-years old G3p2 woman, at 35 weeks and 4 days of gestation with two previous normal vaginal delivery referred to women's hospital in Hamadan City (west of Iran) with the chief complaint of dyspnea, cough, headache, and fever.She was a smoker (about 10 cigarettes a day) and had traveled three weeks ago to Qom (the rst city that was polluted with COVID-19 in Iran).
On admission, the physical examination showed a body temperature of 38.5℃, blood pressure of 110/70 mmHg, the pulse of 110 beats per minute, respiratory rate of 24 rpm, and O 2 saturation of 88%.The laboratory results included a leukocyte count of 9400/ul, red blood cell count 4.22*10 6 /ul, platelet count 232*10 3 /ul, neutrophils of 79% Per ml, lymphocytes of 19% Per ml, monocytes of 2% Per ml and level creatinine 0.9 mg/dl.
In lungs auscultation, reduction of pulmonary sounds was detected in basal areas of the left lung.The medical team was suspicious to Pulmunary thrombo Emboli after hydration/oxygenation and cardiologic consultation.Therefore, chest computed tomography (CT) angiography was performed and pulmonary thromboembolism was excluded, but the ground glass was observed in the basal lobe of the left lung (Fig. 1).Pharyngeal swab polymerase chain reaction (PCR) was negative for COVID-19.Fetal ultrasound revealed a normally intrauterine fetus with a cephalic presentation of about 35 weeks of gestational age.COVID-19 antiviral therapy for the patient was started by a specialist in infectious disease using four antiviral drugs Oseltamivir Capsule (75 mg every 12 hours), Chloroquine sulfate Tablet (400 mg stat), Lopinavir and Ritonavir Tablets (400/100mg administered orally every 12 hours).Also, O 2 saturation was increased from 91 to 94% with the oxygen mask.Fever sometimes reduced with Paracetamol (500 mg every 12 hours) prescription, but it was persistent at about 38 to 39℃ without antipyretic therapy.The O 2 saturation without the oxygen mask declined to 93%.
The patient complained of dyspnea and no response was observed using the mentioned four antiviral drugs.On the second day of the admission, severe infection occurred and the low O 2 saturation level proceeded.Then, the cesarean section was planned for the patient due to the severe dyspnea and the risk of intrapartum mother-to-child transmission by vaginal delivery.The cesarean section was performed with local anesthesia and O 2 saturation around 91 to 94%.The infant was born with gestational age of 36 weeks, an Apgar score of 8/9 and birth weight of 3070 g.The infant was examined for COVID-19 and other infections, but no symptom of infection with COVID-19 was found in the infant within several days after delivery.
After a cesarean section, COVID-19 treatment was continued and O 2 saturation was maintained at about 91 to 93% using an oxygen mask.Fever was persisted without Paracetamol.One day after cesarean, she felt less dyspnea, but cough and fever persisted.About 36 hours after the cesarean, in the early morning, she felt that her dyspnea was worsened.O 2 saturation dropped to 83%, and then the anesthesiologist decided to intubate the patient due to the low oxygen saturation.On March 9, 2020, she was transferred to the intensive care unit (ICU) in COVID-19 central hospitals.The CT SCAN of lungs was conducted, which demonstrated bilateral in ltrations in several sections of the lungs (Fig. 2).After the intubation, O 2 saturation was preserved around 95%, but after 4 days (on March 13, 2020) cardiovascular collapse occurred and unfortunately she was expired after two resuscitations.

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