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MAY 12, 2020 -- Initial Presentation
A 26-year-old pregnant woman (gravida 3 para 1011) at 38 weeks and 3 days' gestation telephoned an acute care service after having a cough for 3 days. She also reported shortness of breath that was worse from baseline when she coughed. She described fatigue but stated that it was no worse than usual during her current pregnancy.
The patient's medical record was reviewed. Five days prior to her telephoning acute care services, the patient canceled a scheduled iron infusion because she felt unwell. At that time, she described having nausea and diarrhea without vomiting. She attributed these symptoms to eating an undercooked meat sandwich. The patient visited her obstetrician at a primary care site the next day. She received iron infusion therapy the day following that visit. Her cough began the day after her infusion therapy, 2 days prior to her telephone call to acute services. The patient had taken her temperature on multiple occasions and remained afebrile.
The patient's obstetric history was notable for a prior spontaneous vaginal delivery and anemia during her current pregnancy, which was being treated with iron infusions. She had a history of a positive purified protein derivative test result 3 years prior but had a subsequent negative QuantiFERON-TB Gold test result. Her social history was significant for known COVID-19 exposure.
Five days prior to the patient phoning acute care services, she attended a religious ceremony. She discovered that one of the attendees tested positive for COVID-19 4 days after that religious event. The patient had subsequent exposures to family members of the individual who tested positive, including a mother and a preschool-aged child. She was within 6 feet of the child and approximately 6 feet from the mother of the child. The patient's husband, who also attended the religious event, developed a cough on the same day as the patient. He developed a fever that reached 100.6° F (38.1° C). Their 20-month-old daughter developed a cough but remained afebrile.
Diagnosis of COVID-19
Upon receiving the patient's call, acute care triage notified the on-call obstetrician. After further consultation with an established COVID-19 hospital hotline and the team at the outpatient facility, the patient and family were recommended to undergo testing for COVID-19 infection. The acute care physician, the pediatrician, and an obstetrician met the family in the ambulance bay at the outpatient facility the following day. All team members donned full personal protective equipment (PPE). Multiple nasopharyngeal and oropharyngeal swabs were taken for each of the three family members. One set was sent to an institutional investigational lab and another was sent to a commercial lab, both for polymerase chain reaction testing. A third set of samples was sent to the commercial lab for a respiratory viral panel.
The obstetrician checked fetal heart tones, which were normal, and verbally assessed the patient. Positive results from the investigational lab for the patient and husband were received the day after the samples were obtained, and the couple was informed. Confirmatory test results were received 5 days later and were also positive. The child's investigational test and confirmatory nasopharyngeal swab results were both negative; however, her oropharyngeal swab was positive. The patient was contacted by telephone and informed of these results.
Preparations for Delivery
Eight days after her initial telephone call to acute services, the patient had a follow-up visit with an obstetrician, who wore full PPE in a negative pressure room. A significant cough was noted. Otherwise, the patient felt better. She was informed of the hospital policy requiring a healthy caregiver. She was instructed to contact the obstetrician when she was in labor and to contact the labor-floor charge nurse upon arriving at the hospital. That way, she could be met by labor and delivery staff at the entrance of the hospital, in order to be properly masked. Hospital leadership was made aware that she was a patient under investigation and informed of the positive test results. Plans were established for the patient's labor and delivery.
Care management nurses contacted the patient every 48 hours for the remainder of the week and closely monitored her symptoms. Infectious disease specialists were consulted regarding retesting. Fourteen days after symptom onset, the patient continued to experience a mild cough. She was retested 10 days after her initial positive test result. The results of that test were not received until after she delivered her baby. Her spouse was not retested because he had complete symptom resolution and because 14 days had elapsed since his symptom onset. He was considered clinically cleared by the hospital's infection prevention team.
Sixteen days after her initial phone call to acute services, the patient's husband contacted the on-call obstetrician. The patient was at 40 weeks and 5 days' gestation and was in labor. The couple was met by the hospital team at the entrance of the hospital and masks were placed on them. The patient was escorted to a negative pressure room, and care was initiated by a small team wearing full PPE. To reduce the amount of direct face-to-face exposure to the patient, care of the patient was supplemented with video conferencing.
The delivery of a healthy male baby was uncomplicated and occurred within 40 minutes of arrival to the hospital. The infant was placed in a negative pressure room and was separated from the mother during the course of admission. However, the father was allowed to interact with the infant and wore a mask. Infant feeding was supplemented by soy formula (via syringe) during the course of the admission.
The decision was made not to test the infant because the results would not change the course of clinical care. The patient remained in the hospital until postpartum day 2. At that time, results from the second COVID-19 test were received and were positive. No further testing of the mother was recommended by the infectious disease team, as an additional 6 days had elapsed since the test and approximately 3 weeks had passed since symptom onset. As such, the parents were advised that normal contact with the infant was permissible after discharge; however, masks were advised if either developed a cough.
The infant was treated as presumed positive for the first 14 days of life. On postpartum day 3, the patient had a telephone clinical encounter with the outpatient pediatrician, who assessed the infant. The infant remained well and was breastfeeding. On postpartum day 7, the patient had a postpartum telephone visit. She was doing well, with an Edinburgh depression score of 7. She was bonding with her infant and doing well with breastfeeding, despite the separation in the hospital. Plans were made for a 6-week postpartum telephone visit.
On postpartum day 14, the mother opted to replace an in-office infant visit with another telephone visit, in order to further limit the infant's exposure to COVID-19. At that time, the mother reported that the infant was exclusively breastfeeding approximately every 2 hours in the day and approximately every 3 hours at night. The urine output and frequency of bowel movements were deemed appropriate by the pediatric clinician.
This case is an example of a successful vaginal delivery of a woman with COVID-19. Despite being separated from her infant during her hospitalization, the patient was successfully able to bond with her baby. She attributes this success to the nurses in the hospital who fed the baby in a manner that did not affect breastfeeding, her prior experience with childbirth, and her husband's ability to interact with the baby during the hospitalization.
This case is also noteworthy for the fact that the virus was only detected by an oropharyngeal swab for the patient's 20-month-old child. Although many members were infected with COVID-19, the family had a good outcome, and the newborn has remained symptom-free, despite the timing of the maternal infection.
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