Volume 7, Issue 4 (2021)                   Pharm Biomed Res 2021, 7(4): 323-328 | Back to browse issues page


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Abbaspour Kasgary H, Moradimajd P, Samaei H, Davoodi L. Healthy Baby Delivery of a COVID-19 Infected Mother in Iran: Process and Protection. Pharm Biomed Res. 2021; 7 (4) :323-328
URL: http://pbr.mazums.ac.ir/article-1-369-en.html
1- Department of Clinical Pharmacy, School of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran.
2- Department of Anesthesia, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran.
3- Department of Infectious Disease, School of Medicine, Antimicrobial Resistance Center, Ghaemshahr Razi Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
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Introduction
In late December 2019, a kind of pneumonia caused by a novel coronavirus (SARS-CoV-2) emerged in Wuhan, Hubei Province, China [1, 2]. Respiratory droplet is the main route of SARS-CoV-2 transmission. Also, it can be transmitted through close contact from person to person [2, 3, 4]. The virus rapidly spread worldwide and infected more than 200 countries and territories, including Iran. By October 7, 2020, this virus affected more than 36000000 people worldwide and caused more than 1000000 deaths [5].
Pregnant women are a vulnerable group to viral infections because partial immune suppression occurs in pregnancy [6]. According to the previous studies, pregnant women are at higher risk for H1N1, SARS-CoV, MERS-CoV, and the Ebola virus [7, 8]. Also, there are reports of adverse clinical outcomes in pregnancy and labor, such as maternal morbidity and mortality, stillbirth, spontaneous abortion, and complicated delivery [6, 7, 8, 9, 10, 11, 12, 13]. Therefore, the COVID-19 epidemic created global concern about its consequences for pregnant women and fetuses. Until now, there is not enough data about the effect of novel coronavirus (SARS-CoV-2) infection on the fetus and postpartum complications. 
We present a 42-year-old pregnant woman (34 weeks gestation) with COVID-19 that gave birth to a healthy baby with no evidence of COVID-19 in Iran.

Case Report
This case is a 44-year-old pregnant woman (32 weeks gestation, 80 kg weight, and 164 cm height) who lives in Mazandaran Province, Iran. She got pregnant through in vitro fertilization (IVF). The mother has gestational diabetes and has been injected with subcutaneous insulin. She had a history of hypothyroidism treated with levothyroxine. This patient had no history of hypertension, heart disease, allergy, or abortion.
On March 19, 2020, the woman was transferred to the Emergency Department with dyspnea, fever, and shivering. The patient had a dry cough. On admission, her vital signs were as follows: temperature= 38.4℃, blood pressure= 105/65 mm Hg, heart rate= 122 beats per minute, respiratory rate=28 breaths per minute, and SpO2= 93%. The triage level was 2 based on the ESI (emergency severity index) triage scale. The patient’s initial evaluation revealed her history of contact with a family member with COVID-19 disease. Because of suspected COVID-19 symptoms, a preliminary CT scan was asked for the assessment of this patient. Also, swap samples were taken from the nose and throat for the RT-PCR test. The CT result after a few hours showed ground-glass opacities in the right upper and lower lobes. Blood tests are presented in Table 1.

The maternal RT-PCR test for SARS-CoV-2 was positive. 
After confirming infection with COVID-19, she was transferred to the intensive care unit (ICU) and stayed there for 3 days (19 to 22 March). On admission to ICU, her body temperature was 38℃, her blood pressure was 111/80 mm Hg, with a respiratory rate of 22 breaths per minute, and pulse rate of 115 beats per minute. She had a dry cough without sputum. Fetal heart rate (FHR) was 140 beats per minute, and fetal monitoring showed no abnormality. Hydroxychloroquine 200 mg PO BD and azithromycin were started for the patient. These drugs were prescribed based on the approved protocol of Iran drug administration for pregnant women. According to this protocol, only oseltamivir and chloroquine can be used [14]. 
Two days later, gynecologists decided to end the pregnancy after considering the mother’s situation. Cesarean section was performed under regional anesthesia (spinal). The patient wore an N95 mask during the operation. Measures in all phases of labor and post-labor were taken to reduce the risk of infection based on guidelines for pregnant women with suspected SARS-CoV-2 infection published on March 3, 2020 [9, 14]. 
At 10:35 PM, a preterm baby girl was delivered. The baby’s weight was 2500 g and her Apgar scores at 5 minutes and 10 minutes were 9 and 10, respectively. The preterm baby was normocephalic, had no icteric sclera, and the heart sounded normal without murmurs. Lung ventilation was normal and clear, without rales and crackles. 
Then, the baby was transferred to the neonate intensive care unit (NICU). Her vital signs in NICU admission were as follows: temperature=36.2℃, blood pressure= 66/36 mm Hg, heart rate= 123 beats per minute, respiratory rate= 74 breaths per minute, and SpO2= 86%. Table 2 presents the laboratory data.

Arterial blood gases (ABG) results were normal (pH=7.32, PaCO2=43.7 mm Hg, PaO2=58 mm Hg, HCO3=23 mEq/L, SpO2=78.6%. BE= -3.2) without acidosis or alkalosis. After 2 days stay in NICU, the hemodynamic situation of the preterm neonate was stable, and her nasopharyngeal swap for SARS-CoV-2 RT-PCR obtained 16 hours after the delivery came back negative. Also, the chest x-ray of the newborn showed a typical presentation (Figure 1).
On March 25, the mother was discharged from the gynecological ward without complications. Her laboratory tests were normal (Table 1), and ABG results were as follows: pH=7.38, PaCO2=29.4 mm Hg, PaO2=98 mmHg, HCO3=17.6 mEq/L, and SpO2=97%.

Discussion 
Influenza is a severe disease for pregnant women and may cause complications for the mother and fetus. In recent years, vaccines have been given to pregnant women due to the seasonal outbreak of the flu [7]. COVID-19 is a novel coronavirus that rapidly spreads and may affect pregnant women [7, 8, 9, 10, 11, 12]. We report the first case of neonatal COVID-19 infection in a referral center for managing COVID-19 in Mazandaran Province, Iran. The baby’s mother was infected with COVID-19. After labor, the clinical manifestations of the mother were moderate, and the baby’s prognosis was satisfactory.
Until now, the consequences of infection with SARS-CoV-2 for pregnancies have remained uncertain [10, 13]. Yu et al. compared the hematological characteristic of SARS-CoV-2 with SARS-CoV-1 and, based on the similarity, concluded that the risk of vertical transmission of the COVID-19 virus is low [14]. But as stated before, there is not enough evidence of clinical characteristics and vertical transmission in pregnancy and labor. As previously reported, the clinical characteristics of this pregnant woman were similar to non-pregnant adults with COVID-19 [3, 13]. The present case manifested the same signs and symptoms, such as fever, dry cough, and dyspnea. But we cannot claim that all pregnant women present with the same manifestations. 
The published case reports and other studies have reported different results about healthy or infected newborns of COVID-19-infected mothers. However, some studies indicated that the maternal, fetal, and neonatal outcomes of infected patients in late pregnancy appeared good, and the infection was not transmitted from mother to infant [11, 12, 13, 14, 15]. But the study of Zhu et al. in China on 19 pregnant women showed that COVID-19 might have adverse effects on newborns, causing problems such as fetal distress, premature labor, respiratory distress, thrombocytopenia accompanied by abnormal liver function, and even death [12]. David A. Schwartz assessed 38 pregnant women with COVID-19 and concluded that anyone could be affected with COVID-19 [16]. 
Based on the early reports in this epidemic, there were two cases of neonatal SARS-CoV-19 infection that had no direct evidence for vertical transmission. However, one was an infant diagnosed at 17 days of life having a history of close contact with 2 confirmed cases of SARS-CoV-2 infection (mother and nanny), and the other was a neonate who was found to be infected 36 hours after delivery. According to the reports, viral testing was delayed, and infection may be acquired postpartum through an infected contact (nosocomial infection) [17, 18]. However, management of pregnant women with COVID-19 in the first and second trimester of pregnancy regarding the transmission and drug prescription is challenging and needs further study. 

Conclusion 
Because of the physiological and immunological changes and shift from cell-mediated to humoral-mediated immunity in pregnancy, viral pneumonia may be severe in pregnant women. Vertical transmission of the COVID-19 virus from mother to child is still unclear. Also, data about short-term and long-term adverse effects on mothers and newborns are still controversial. Fortunately, in this case, the newborn was born healthy, but the risk of long-term harm to the child is unclear, and it will not be known soon. Therefore, we must follow up the newborns and mothers to find the possible effect of COVID-19 on the fetus. Pregnant women must be protected against infection, and more intensive attention to pregnant patients is essential. 

Ethical Considerations
Compliance with ethical guidelines

There were no ethical considerations to be considered in this research.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
We are grateful to all staff of Ghaemshahr Razi Hospital for their assistance in conducting and gathering data for this study.


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Type of Study: case report | Subject: Clinical Pharmacy

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