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Prone Positioning for Severe ARDS in a Postpartum COVID-19 Patient Following Caesarean Section John T Roddy ‍ ‍ ,1 William S Collier,2 Jonathan S Kurman ‍ ‍ 1

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Prone Positioning for Severe ARDS in a Postpartum COVID-19 Patient Following Caesarean Section John T Roddy ‍ ‍ ,1 William S Collier,2 Jonathan S Kurman ‍ ‍ 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2020-240385 on 16 March 2021. Downloaded from Prone positioning for severe ARDS in a postpartum COVID-19 patient following caesarean section John T Roddy ,1 William S Collier,2 Jonathan S Kurman 1 1Pulmonary and Critical Care SUMMARY patients with COVID-19 associated respiratory Medicine, Medical College A 31- year- old pregnant woman presented with failure. Some standards of care for severe acute of Wisconsin, Milwaukee, symptomatic COVID-19, which was complicated by respiratory distress syndrome (ARDS), including Wisconsin, USA progressive hypoxaemia requiring intensive care and prone positioning that has been shown to improve 2Medicine, Medical College emergent delivery by caesarean section. Afterward, she mortality, may require modification based on the of Wisconsin, Milwaukee, 9 10 Wisconsin, USA was successfully supported with mechanical ventilation specific needs of gravid patients. and prone positioning and ultimately recovered. We Correspondence to review literature regarding complications of COVID-19 Dr John T Roddy; affecting pregnancy and evidence- based treatment CASE PRESENTATION johnthomasroddy@ gmail. com strategies. A- 31- year old African- American female G6P1132 with a 36- week live singleton gestation presented Accepted 2 March 2021 with a 3- day history of malaise, myalgias, cough, dyspnoea, sore throat, anosmia and subjective fever BACKGROUND for which she had been taking acetaminophen. Her Since initial reports of a novel respiratory virus partner was diagnosed with pneumonia a day earlier arrived from Wuhan, China, COVID-19 caused by and subsequently tested positive for COVID-19. At SARS- CoV-2 has become a pandemic, causing ever the time of presentation, the partner’s COVID-19 1 increasing morbidity and mortality. One popula- status was unknown. There were no obstetric- tion of particular concern is pregnant women given related complications prior to presentation. the medical experience during prior SARS-CoV -1 She was febrile to 38.4 °C, normotensive, satu- and Middle East respiratory syndrome pandemics, rating 92% on room air, tachypneic to 22 breaths which were accompanied by increased peripartum per minute and tachycardic to 125 beats per minute 2–4 complications and mortality. (BPM). Lungs were clear to auscultation. Chest Studies to date examining the clinical course of X- ray (CXR) revealed a rounded opacity in the pregnant women with COVID-19 have demon- right midlung concerning for pneumonia (figure 1). strated mainly mild cases, with fever, cough and Laboratory results were significant for lymphopenia http://casereports.bmj.com/ dyspnoea being the predominant symptoms. (13%), neutrophilia (80%), anaemia (10.0 g/dL) Demographics of women requiring admission to and elevated C- reactive protein (CRP) (5.9 mg/L). the hospital due to respiratory compromise were COVID-19 infection was confirmed via nasopha- weighted towards those in the third trimester or ryngeal swab. She was admitted for further manage- postpartum, ethnic minorities, being overweight ment of her COVID-19 pneumonia and pregnancy. 2 5 or obese and maternal age greater than 35 years. Supplemental oxygen was not immediately One in 10 women in a population- based study out required after admission. Fetal heart rate moni- of Britain required intensive care, and 1 in 100 died. toring demonstrated a rate of 155 BPM with One in 10 of those requiring critical care received moderate variability (10×10 s vs 15×15 s). Ceftri- extracorporeal membrane oxygenation (ECMO). axone and azithromycin were started for empiric on September 27, 2021 by guest. Protected copyright. Rate of iatrogenic preterm delivery in the context of coverage of community- acquired pneumonia and hospitalisation of pregnant patients varied between atypical pneumonia. Over the ensuing few hours, 60% and 75% according to published reports, with the patient developed worsening hypotension and a high rate of those being via caesarean section tachypnea that was refractory to supplemental (C- section).5 oxygen delivered via high- flow nasal canula. The Care is required in the treatment of late pregnancy hypotension responded appropriately to intrave- hospitalisation for COVID-19 due to the possibility nous fluid resuscitation. Pulmonary embolism was of maternal complications including respiratory ruled out with CT angiography of the chest, which compromise, thrombosis and cardiomyopathy, as revealed bilateral opacities (figure 2). While starting well as the possibility of fetal compromise from empiric anticoagulation and avoiding imaging- delivery complications and vertical transmission, associated radiation exposure was considered, CT © BMJ Publishing Group which has been reported.2 6 7 Delivery via C- section Limited 2021. No commercial was chosen in this case to avoid the possible risks re-use . See rights and is not recommended routinely for patients with inherent to therapeutic anticoagulation in late third permissions. Published by BMJ. COVID-19 given concerns about increased compli- trimester pregnancy and the peripartum period.11 cations, but maternal decompensation and common Steroids were initiated because of mild eleva- To cite: Roddy JT, Collier WS, 8 Kurman JS. BMJ Case fetal complications may necessitate it. tions in her inflammatory markers (CRP 6.3 mg/L, Rep 2021;14:e240385. Consideration of the effects of treatments admin- ferritin 20.8 ng/mL, lactate dehydrogenase 201 U/L doi:10.1136/bcr-2020- istered both on maternal and fetal health is para- and D- dimer 1.42 mcg/mL).12 After a brief period 240385 mount in the intensive care unit (ICU) for gravid of clinical improvement, her respiratory status Roddy JT, et al. BMJ Case Rep 2021;14:e240385. doi:10.1136/bcr-2020-240385 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2020-240385 on 16 March 2021. Downloaded from Figure 1 Disease progression on chest X- ray (day 4, day 6, day 14 of symptoms, respectively). declined again. CXR demonstrated progression of the bilat- DISCUSSION eral opacities. Fetal monitoring identified repeated heart rate Our patient’s presentation with respiratory failure due to deceleration and tachycardia up to 170 BPM that was unre- COVID-19 complicating pregnancy falls into several higher- sponsive to fluid resuscitation. Convalescent plasma was admin- prevalence demographics previously reported for requiring istered. Despite a rise in her inflammatory markers, treatment hospitalisation: she was from a minority group, of elevated body with remdesivir and tocilizumab was declined because of their mass index (BMI), and in the third trimester of pregnancy.2 5 unknown impact on the fetus. Her course was complicated by respiratory failure requiring high The consensus from a multidisciplinary discussion was to flow oxygen, delivery by C-section, and ultimately intubation proceed with delivery because of the declining trajectory. and postpartum prone positioning due to COVID-19 related Vascular access via the internal jugular vein was preemptively ARDS. Unlike some peripartum patients with severe COVID-19 obtained in case ECMO became necessary. After intubation, the infection, she did not require ECMO and was successfully extu- baby was delivered via C-section without complications. Intu- bated and discharged from the hospital with her newborn after bation was chosen over neuroaxial anaesthesia because of the receiving a variety of therapeutic interventions. rapid decline in the patient’s respiratory status and high level Venous access was established prior to her C-section in antic- of oxygen requirements. Postoperatively, the patient remained ipation of the possible need for ECMO given the rapidity of her intubated. Prone positioning was implemented in an effort to respiratory decompensation and hypoxaemia. Although ECMO improve oxygenation. Remdesivir and a heparin infusion were was not required, continued invasive ventilation and prone http://casereports.bmj.com/ also initiated. positioning were necessary to maintain adequate oxygenation. Consistent with severe ARDS, initial P/F ratio on intubation was 87 at a positive end expiratory pressure of 5, which was subse- OUTCOME AND FOLLOW-UP quently titrated higher for oxygenation purposes. The American Prone positioning was required for several days to maintain Journal of Obstetrics and Gynecology Maternal Fetal Medicine adequate oxygenation. Tocilizumab was also initiated in the has supplied guidance for labour and delivery in COVID-19, context of renewed fever and rising inflammatory markers. The recommending the use of modified prone positioning with left patient was liberated from the ventilator after 14 days. Peri- lateral tilt position or full pronation with appropriate support odic proning continued after extubation. She was eventually of the gravid abdomen if required in the ICU based on reports discharged after almost 3 weeks in the hospital. Her infant was on September 27, 2021 by guest. Protected copyright. of successful use of this technique in practice.10 13 Pronation COVID-19 negative without evidence of vertical transmission. was not attempted predelivery given the rapidity of her clinical One- month after discharge, both the patient and baby were decompensation. It was, however, well tolerated after delivery doing well without any obvious residual effects of her illness. and necessary given the refractory hypoxaemia. Prone positioning has proven beneficial in the treatment of ARDS most notably in the Prone Positioning in Severe Acute Respiratory Distress Syndrome
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