key: cord-1000248-yg15inzu
authors: Curi, Berenice; Sabre, Alexander; Benjamin, Israel; Serventi, Lisa; Nuritdinova, Dilfuza
title: Coronavirus infection in a high risk obstetric population of the South Bronx, New York
date: 2020-08-18
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100203
sha: 188636474124ac3d837a64c0e6d462c70797261f
doc_id: 1000248
cord_uid: yg15inzu

COVID-19 in high risk urban populations, Coronavirus clinical course obstetrics.

The coronavirus (COVID-19) pandemic is a serious public health emergency with limited information to guide obstetric management. As of April 22 nd 2020, New York City has documented 10,290 deaths of which 2,272 belong to the Bronx the third largest borough effected [1] It has disproportionately affected higher risk patient populations. The South Bronx is a vulnerable population area, composed mostly of Hispanics (57%) and African Americans (39%), with a median household income below the 8 th percentile. [2] Lower socioeconomic status predisposes many to a plethora of comorbidities such as diabetes, hypertension, asthma and obesity. In this research letter, we outline the clinical course of 33 pregnant patients from a South Bronx community hospital with symptomatic COVID-19 infection, 81.8% of which have underlying medical conditions.

This analysis was conducted in the Obstetric and Gynecological Department at Lincoln Hospital Medical and Mental Health Center, the designated public hospital and COVID-19 center of the South Bronx. Pregnant patients with symptomatic COVID 19 infection were registered and their clinical and laboratory data was retrospectively obtained using the electronic medical record system. NYCHHC investigation Medical Review Board approval was obtained.

Thirty-three COVID-19 positive symptomatic pregnant patients were included in this study, two (6.1%) in first trimester, nine (27.2%) in the second trimester, and twenty-two (66.7%) in the third trimester. Gestational age at diagnosis, co-morbidities, and obstetric complications were recorded. Obesity was present in 70.9% cases and 32.3% had BMI 40 or above. 27 out of 33 (81.8%) had one or more comorbidity. 15% had pre-gestational diabetes mellitus type II. Cough, malaise, and chills were the most common presenting symptoms.

The two patients in the first trimester had severe disease requiring admission for mild hypoxemia. No miscarriage was reported. One patient at 17 weeks required mechanical ventilation but the remainder of the patients in the second trimester presented with mild upper respiratory symptoms and were monitored via telephone encounters. No obstetrical complications were reported in these patients. The twenty-two patients in the third trimester had variable presentations. Four patients in the third trimester had preterm deliveries (18.2%). Two of them presented with mild respiratory symptoms and had abnormal fetal heart rate tracings, requiring delivery before 37 weeks. Seven out of the twenty-two patients were amenable to home monitoring via telephone encounters.

Two patients presented with significant poor obstetric outcomes; both had pre-gestational diabetes type II and presented with diabetic ketoacidosis and intrauterine fetal demise. These cases are further detailed below.

Patient #1: 30 year-old G4P2012 at 28 weeks 5 days with history of poorly controlled insulin dependent pre-gestational diabetes type II (HbA1c 8.8%), morbid obesity (BMI 41), asthma, and chronic hypertension. Initially presented with cough and nasal congestion and was discharged home due to clinical stability. Three days later, she returned with Kussmaul breathing, with tachypnea to 50 respirations/min, tachycardia 135 bpm, temperature 98.1 F, BP: 129/95, and satura-tion 100% on RA. Blood glucose was 360 mg/dL. Maternal stabilization was initiated, severe dehydration required central line placement. During maternal stabilization fetal bradycardia was noted and soon afterwards a demise was confirmed. Laboratory results were significant for pH 7.17, bicarbonate level 5 mEq/L, and beta-hydroxybutyrate of 3.15 mmol/mL. She was transferred to MICU for severe diabetic ketoacidosis and asthma exacerbation, after achieving maternal stabilization labor induction was started, during which an insulin drip was necessary for glycemic control. After delivery the patient was found to have S.aureus methicillin-resistant bacteremia and remained hospitalized until completion of antibiotics.

Patient #2: 33 year-old G4P1023 at 33 weeks 2 days with past medical history of asthma, morbid obesity and uncontrolled pre-gestational diabetes type II (HbA1c 13.9%) with no prenatal care was brought to the emergency room by emergency medical services (EMS) after three seizures. On arrival she was unconscious, apneic, and in cardiac arrest. ROSC achieved in six minutes. Lab work was significant for glucose of 1,753 mg/dL, pH 6.908, bicarbonate level 5 mEq/L, lactic acid of 17.6, complete blood count with lymphopenia of 14%, and liver enzymes AST and ALT of 514 and 533 respectively. Urinalysis had protein >1000 (4+). Patient was 3 cm dilated. She was transferred to ICU for stabilization of severe diabetic ketoacidosis, eclampsia and acute respiratory failure. The patient delivered the fetus spontaneously within twelve hours of admission. Patient never regained consciousness and died one month after admission.

Through this series, adverse events were noted in six of 33 patients (18.2%), with four cases of preterm delivery, two of fetal demise and one maternal death. [ Table 1 ]. Review of literature has demonstrated adverse obstetric outcomes including miscarriage, preeclampsia, preterm delivery, cesarean section, as well as perinatal death (7% of cases). [3] Comparatively, our adverse outcomes were not as elevated for preterm birth in the third trimester (18.2%) or preeclampsia but were higher for perinatal mortality in the third trimester (9.5%). The cases of fetal demise followed maternal instability associated to diabetes ketoacidosis, most likely triggered by coronavirus pneumonia, a scenario commonly observed in non-pregnant patients with diabetes.

Regarding maternal clinical outcomes of coronavirus infection in the obstetric population we present, 4 (12.1%) had severe disease and 3 (9.1%) had critical disease, with a maternal mortality of 3%. These values are higher than what was previously described in the general population [4] and obstetric population, and may be attributed to the high percentage of comorbidities in our population. However, our number of cases is too small to make adequate conclusions.

COVID-19 may complicate the clinical course in patients with specific comorbidities such as diabetes, hypertension, or asthma. Therefore, it seems reasonable to recommend closer monitoring and individualized admission of obstetric patients with comorbidities, especially during the febrile period, to observe and prevent deterioration. Additional data is required in order to understand the relationship of COVID-19 in the high-risk gravid patient and further study is required to create recommendations for the care for these patients. 

New York City Health department

American Community Survey Demographic and Housing Estimates

ACSDP1Y2018.DP05&t=Hispanic%20or%20Latino&vintage=2018. Web

Outcome of coronavirus spectrum infections during pregnancy: a systematic review

Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) Outbreak in China

We wish to thank all the first line responders and healthcare workers who tirelessly fight for patients in this current pandemic.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f Table 1 : Thirty three COVID-19 positive symptomatic pregnant patients were included in this study (Grey is first trimester, blue is second trimester, green is third trimester). Obesity was present in 70.9% cases and 32.3% of the total patients had a BMI 40 or above. 15% had pregestational diabetes mellitus type II. 27 out of 33 (81.8%) had one or more comorbidity. Cough, malaise, and chills were the most common presenting symptoms. Obstetric adverse events were noted in six of our 33 patients (18.2%), with four cases of preterm delivery and two of fetal demise (IUFD).