This case describes a 26 year-old G1P0 who presented to a large Manhattan hospital at 37 weeks 6 days for a scheduled external cephalic version. Her past medical history was notable for well-controlled chronic Hepatitis B with an undetectable viral load (<10 IU/mL) and normal liver function tests. In triage, she was found to have oligohydramnios (AFI 4.2cm) and a confirmed frank breech presentation. Accordingly, delivery by cesarean section was recommended. As per routine practice in this hospital, the patient was tested for SARS-CoV-2 in triage. She denied symptoms of the disease at the time, was clinically perceived to be asymptomatic, and had normal vitals and a benign physical exam. While awaiting her results, she was treated as a “person under investigation” (PUI) and healthcare personnel took the recommended precautions, including donning the appropriate personal protective equipment, having a more senior resident with an attending perform the cesarean section, and proceeding with spinal anesthesia to avoid aerosolizing procedures. Laboratory values prior to surgery inclusive of platelets (257 K/μL), prothrombin time (13.4 seconds), and international normalized ratio (1.0) were reported as normal (Table 1).
From the start of the case, there was more than an expected amount of bleeding noted, beginning from the insertion of the spinal needle and continuing through the initial incisions through the subcuticular and subcutaneous layers. The cesarean section proceeded in routine fashion. Following delivery of the fetus, uterine atony was noted with moderate bleeding, which persisted after administration of oxytocin and closure of the hysterotomy. Given that the patient had no history of elevated blood pressures and perioperatively had blood pressures of 90s/40s, the decision was made to administer 0.2mg IV methylergonovine. A second dose was later administered for persistent uterine atony after 30 minutes, with improvement in uterine tone. Hemostasis at the hysterotomy was confirmed and the muscle and fascia were closed. Just prior to closure of the subcuticular layer, it was necessary to cauterize multiple bleeding capillaries within the subcutaneous layer to achieve hemostasis. The subcuticular layer was closed with 4-0 vicryl. At this time, significant and persistent oozing was noted from the skin incision. Pressure was applied for several minutes with an improvement and then a tight pressure dressing was placed. During the case, administration of tranexamic acid was considered given significant intraoperative oozing; however, the decision was made to expectantly monitor the patient, given her unknown COVID status and the possible risk of exacerbating an existing hypercoagulable state, based on the recent literature on COVID-19. After several hours of monitoring, the patient had no further active bleeding from the abdominal incision and her vaginal bleeding was minimal. The total estimated blood loss was 1000mL and her postoperative hematocrit was 27.6%.
Approximately 8 hours after her surgery, nasopharyngeal testing by PCR resulted positive for SARS-CoV-2. Upon further questioning, the patient endorsed that she had been experiencing a very mild cough for several days prior to presentation that she did not find significant nor bothersome; she was not experiencing symptoms during her admission. Labs were drawn in response to the positive COVID testing postoperatively and reflected abnormal COVID labs in the setting of relatively normal coagulation factors. Specifically, postoperative laboratory values revealed an elevated D-Dimer, elevated LDH, elevated CRP, normal PT/INR, and normal fibrinogen values (Table 1).
The patient remained stable and afebrile, and she was ultimately discharged on postoperative day two in excellent condition, asymptomatic, with pain well-controlled, and meeting all postoperative milestones. Upon postpartum evaluation by telehealth several days after discharge, the patient reported that she was recovering well without concerns, and she was asymptomatic without any further symptoms of COVID-19.
Table 1. Preoperative and postoperative laboratory values
|
Preoperative
|
Postoperative Day 1
|
|
Value
|
Units
|
Value
|
Units
|
WBC
|
11.3
|
K/μL
|
19.8
|
K/μL
|
HCT
|
29.5
|
%
|
27.6
|
%
|
Hb
|
9.5
|
g/dL
|
9.3
|
g/dL
|
PLT
|
257
|
K/μL
|
246
|
K/μL
|
D-Dimer
|
-
|
-
|
19.1
|
μg/mL
|
LDH
|
-
|
-
|
271
|
U/L
|
CRP
|
-
|
-
|
12.24
|
mg/dL
|
PT
|
13.4
|
seconds
|
13.3
|
seconds
|
INR
|
1.0
|
|
1.0
|
|
Fibrinogen
|
-
|
-
|
399
|
mg/dL
|