In this case report, we present a pregnant woman diagnosed with COVID-19 at 33 weeks gestation and having a vaginal birth at term. The postpartum and neonatal courses were uncomplicated. Anti-SARS-CoV-2-IgG antibodies were detected in the neonate. A vaginal delivery in this case was safe with clinical diagnosis of COVID-19.
COVID-19, Neonate, Pregnancy, SARS-CoV-2, Vertical transmission
To date, there are only limited data about the effect of novel coronavirus (SARS-CoV-2) infection on pregnancy, delivery and placental transfer of antibodies. According to recent publications the clinical features of pregnant women infected with SARS-CoV-2 do not appear to be at an increased risk of severe course of disease [1].
Currently, there is no clear evidence of intrauterine vertical transmission during pregnancy [2-4].
On 3rd March 2020, a 30-year-old female patient from Nigeria at her 31 and 6/7 weeks` gestation (gravida 1, para 0) presented to the outpatient clinic at the Klinik Donaustadt with premature contractions persisting since 3 days. She had no clinical signs of COVID-19. The patient declared no travel history in the last 6 month and no contact with persons diagnosed with COVID-19. She was diagnosed during her pregnancy with gestational diabetes mellitus. On admission, the body temperature was 36.6 °C, the blood pressure 120/85 mmHg, the heart rate 110 beats per minute. The laboratory result showed a leukocyte count of 11.2 × 109/L, absolute neutrophils of 5.3 × 109/L, absolute lymphocytes of 1.4 × 109/L and C-reactive protein of 21.3 mg/L. A fetal ultrasound revealed a normal intrauterine fetus. The estimated fetal weight was 1832 g (30th percentiles) with normal amniotic fluid volume and posterior placenta location. The cervical length measured by transvaginal ultrasound was 8 mm. Tocolysis and antenatal corticosteroid therapy was performed. Routine vaginal swab was obtained for culture and PCR and had a negative result. On the 4th hospital day, the patient developed a body temperature of 39.7 °C without symptoms of a respiratory infection. The blood test showed an elevated C-reactive protein of 51.6 mg/L. An intravenous antibiotic therapy with Unasyn 3 g (ampicillin/sulbactam) 3x/day and antiphlogistic therapy with intravenous paracetamol were started. On the 5th hospital day the patient showed intermittent fever, tachycardia and dyspnoea, consequently a chest X-ray was performed which demonstrated retrocardiac confluent pneumonic infiltrates. These finding were initially considered a bacterial lobar pneumonia. The next laboratory result showed a further elevated C-reactive protein of 86.4 mg/L. The blood and urine culture were negative and an infection with influenza A and B could be excluded by PCR. Because of the beginning pandemic, a SARS-CoV-2 RT-PCR test from a nasopharyngeal swab sample was carried out and showed a positive result (ct-e: 35.28). A serum sample obtained at the same day tested positive for Anti-SARS-CoV-2-IgM (ratio: 1.38; Wantai, Bejing, China), but negative for IgA and IgG (Euroimmun, Lubeck, Germany), indicating a recent infection. On the 6th hospital day, the otherwise asymptomatic patient was released from the hospital at her own risk despite medical advice. A prescription for Augmentin (amoxicillin/clavulanic acid) 625 mg 3x/day for 2 days was given. On 26th March, the woman presented to delivery at her 39 and 4/7 week´s gestation with regularly uterine contractions. She had no clinical symptoms of COVID-19. She underwent an uncomplicated vacuum-assisted vaginal delivery because of failure to progress in second stage of labour. Estimated blood loss was 500 ml, additionally mediolateral episiotomy was sutured. A healthy male infant was delivered weighing 4130 g, with Apgar scores of 6, 9 and 10 at 1st, 5th and 10th minutes. Arterial umbilical cord pH was 7.24 and base excess -3.8. Venous umbilical cord pH was 7.38. RT-PCR from nasopharyngeal swab of the patient was performed and showed a negative result for SARS-CoV-2. However, the mother displayed SARS-CoV-2-specific IgA (ratio: 6.01) and IgG (ratio: 10.64) against SARS-CoV-2, verifying the infection at beginning of March by serology. Of note, high titres of Anti-SARS-CoV-2-IgG (ratio: 7.34), but not of IgA (ratio: 0.08) were detected in the infant, indicating placental transfer of these antibodies. In addition, a SARS-CoV-2 PCR Test of the blood of the newborn was negative. The postpartum blood test indicated anaemia with a haemoglobin level of 7.0 g/dL and an oral iron supplementation was started. Both mother and infant were discharged on the 3rd postpartum day from the hospital.
In this case, we report a pregnant woman in her 33 weeks gestation diagnosed with COVID-19 by PCR and serology, who delivered a healthy, but Anti-SARS-CoV-2-IgG-positive infant. The postpartum and neonatal courses were uneventful. Detection of Anti-SARS-CoV-2-IgG in the newborn furthermore indicates placental transfer of maternal antibodies. Systematic reviews showed that the outcome for mothers and neonates with COVID-19 were generally good in most cases [1,5], however the recent studies demonstrate high cesarean section rates. Della Gatta, et al. reported on a total of 48 women diagnosed with COVID-19 and found that 46 were delivered with a cesarean section [5]. The indications to the cesareans only in 34 cases were known. The described indications were COVID-19 pneumonia (55.9%), premature rupture of membranes (26.5%), fetal distress (17.6%), preterm labour (11.8%), previous cesarean section (8.8%), previous stillbirth (5.9%), pregnancy at term (5.9%), elevated liver enzymes (2.9%), preeclampsia (2.9%), placenta previa (2.9%), abruptio placentae (2.9%), multiple organ dysfunction syndrome (2.9%), oligohydramnios (2.9%) and psychosocial factors (2.9%). Another review evaluated 32 pregnant women with COVID-19. 27 delivered by cesarean, 2 by vaginal delivery and 3 pregnancies were ongoing [2]. The indications were not clearly reported.
In summary, a vaginal delivery with COVID-19 is a safe option. Our case suggests that the newborn was not affected by COVID-19.
We would like to thank all the members of the multidisciplinary teams at the participating institutes and in particular: Univ. Doz. Dr. Walter Krugluger (Institute for Clinical Chemistry and Laboratory Medicine, Wiener Gesundheitsverbund, Klinik Donaustadt), Univ.-Prof. Dr. Stephan Aberle and Assoc. Prof. Priv. Doz. Dr. med. Lukas Weseslindtner (Center for Virology, Medical University of Vienna). The authors state that they have no conflict of interest.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
I confirm that all authors have contributed significantly, and that all authors agree with the content of the manuscript.