3. Clinical pesentatioin
Female patient 32 years old admitted the emergency room with history of
fever , cough , dysnea of few days .
Patient is pregnant of 36 weeks
No past history of DM or HTN .
on examination :
pt is alert , conscious, distress , tachypnea , tachycardia .
GCS 15/15
Pregnant of 32 weeks , flashed .
4. Vital signs
Blood pressure : 120/80
Pulse : 90/ min
Respiratory Rate : 28/ min
Temp : 38.5
Oxygen saturation on room air was 76 %
5. Imaging
CT chest: bil lung infiltrations , Ground glass opacities , Corad 5 .
Chest x ray was done : show bilat infeltrations
Abd U/s :
Single living featus, AF: average , Placenta anterior , B/o : +_ 36 weeks .
EKG : sinus rhythm
6. Labs on admission
CBC
HB: 10.3 mg/dl , TLC : 3.9 , Lymph : 0.4 , Plt: 160
S creatinine : 0.6 S Urea : 17
ABG : PH : 7.57 , PCO2 : 19, PO2 : 40 , HCO3 : 19
INR: 1.1 Prothrombin time :12.7
ALT : 15 , Ast : 10 , Albumin : 3.3 Protein : 5.6
Random Blood sugar : 96
Na : 135 mg /dl , K : 4.2 , ionized ca : 0.9
D Dimer : 1.3 , S Ferritin : 750 , CRP : 80
PCR was done and was positive later .
7. Management
Oxygen Therapy :
Pt was put on NR mask of high flow oxygen on admission , the oxygen
saturation was 89 % .
Prone position :
Was difficult due to pregnancy .
Feeding Protocol :
High protein diet , food rich in iron , good hydration .
8. Pharmacological treatment
Pt started treatment as highly suspicion of covid infection and take precutions due
to pregnancy .
Initial treatment )
)
Antibiotics :
Ceftrioxone 2g IV / 24 h .
Remedisvir : 200 mg IV loading then 100 mg IV daily for 5 days
Steriods : Dexamethasone 6 mg IV / 12 h
Anticoagulant : LMWH , prophylactic dose / 24h
PPI : pantoprazole 40 mg IV/ 24 h
Vitamins: Zinc , Vit C , Iron supply , calcium supply
Paracetamol 500 mg / 8 h orally
9. Consultations
Obs and gyana consultations:
They recommend an urgent abd U/S ,
By examination : cervix is closed and no uterine contractions at time of
examination .
there is single living fetus about 36 weeks , placenta anterior .
Add an anticoagulant and get ready to labor if any complications happened
10. Progression 1
On second day of admission :
The patient is still tachypnea , dysnea , hypoxia , oxygen saturation was 90 %
on NR mask , high flow oxygen .
Fever is on and off .
ABG : PH : 7.45 , Pco2 : 33 , PO2 : 55 , Hco3 : 20
Other investigations is accepted .
BP , pulse : accepted , RR : 24-28
11. Progression 2
On 3rd day of admission : the oxygen demand increase and pt is still dysnea
and tachypnea and the saturation on NR mask 88 % .
The pt was put on NI CPAP mode of FIo2 : 100 , PEEP : 8 , P support : 10
Slpoe : 30 .
The patient was on CPAP for the whole day , at the end of the day the oxygen
saturation raised to 97 % .
Vital signs : BP , Pulse accepted , RR 24 , Temp : 37.5 .
ABG : PH :7.44 , PCO2: 35 , : Po2 : 50 , HCO3 : 21
Antibiotics : we add linezolid 600 mg / 12 IV , antitussive syrup
Other investigations accepted .
Obs and gyn consultations : follow up
12. Progression 3
On 5th day on admission : pt was on CPAP mode , Oxygen saturation was 97 % ,
so we descend down with Fio2 to 90 % and down grade again depend on
saturation , PEEP , P sup : the same .
Pt is less dysnea and tachypnea .
Vital signs BP , Pulse , Temp : normal . RR : 25
ABG : PH :7.5 , PCO2: 40 , PO2: 50 , HCo3 : 18 ;
CBC : HB 9.9 , TLC : 13, Lymph : 1.6 , PLT : 155
Creatine : 0.8 , Urea : 30 , Albumen : 3.3 , INR : 1.1 , Na : 133 , K : 4.1
D dimer : 1.1 , S ferritin : 66o , CRP : 44
Obs and gyn consultations : ABD U/s and follow up
13. Progression 4
On 7th day of admission : the saturation improved and was 97 on CPAP , FIO2
descend down to 50 , PEEP : 5 , P sup : 8 , less dysnea and tachypnea , by the
end of the day we start to exchange between CPAP and NR mask of high flow ,
2 hours , 4 hours on CPAP .
Vital signs : BP 110/70 , Temp : 37 , RR : 22 , Pulse 80/ min
ABG : PH: 7.40 , PCO2 :42 , PO2 : 55 , HCo3 : 22
Investigations : CRP : 33 , D dimer : 1 ,others are accepted
Urine analysis was normal .
Obs and gyn consultation : CS was done and the baby was in good condition
and pt received one unit of RBCS .
14. Progression 5
On 9th day of admission : pt is still alternating between CPAP and NR mask of
high flow , the Oxygen saturation 94% , less dysnea .
Vital signs : BP 110/80 , Pulse 75/ min , Temp 37 , RR 22
ABG : PH : 7.38 , PCO2 : 40 , PO2 : 60 , HCo3 : 23
Chest xray : improved
Chest physiotherapy started
Steriod start to deescalating to dexa 6mg / 24 h .
Investigations : withen normal
15. Progression 6
On 10th day of admission , the patient was most of the day on NR mask at flow
10 l /h , oxygen saturation 93 % .put on CPAP at bed time of FIO2 : 40 , PEEP :
5 Psup :5 .
PCR was done and was negative .
Vital signs : BP : 120/ 70 , Pulse : 80/min , Temp : 37 , RR : 19
ABG : accepted .
investigations : D Dimer : 0.8 , S ferritin : 340 , CRP : 25
HB : 10.2 , TLC : 7.7 , PLT : 180
Chest physiotherapy is done , good hydration , suitable feeding .
16. Progression 7
On admission day 12 :
The pt is on NR mask only of 8- 10 l /h , with oxygen saturation 92 to 94 % .
Vital signs : BP : 120/70 , Pulse : 77/ min , temp : 37 , RR: 22
Chest physptherapy is done .
Antibiotics start to descalating : linezolid stopped , ceftriaxone 1g /24 h
Steriods : dexa 6 mg : 0.5 amp daily .
Anticoagulant and antitussive and vitamins continue
Investigations: D Dimer : 0.5 , CRP : 20 , S ferritin : 230
Creatinine : 0.7 , urea : 23 , Na : 134, K : 3.8 ,INR : 1.1
17. Progression 8
On admission day 13:
We start to deescalating oxygen requirement , from NR mask to Ventury 4o , the oxygen
saturation was 91 % , we monitor the saturation the whole day , pt is still in prone postion ,
chest physiotherapy is done regularly .
At the end of the day the saturation was 92 % on ventury 35 , less dysnea , less tachypnea a.
Vital signs : BP : 120/80 , Pulse : 75/ min , temp : 37 .
Investigations : ABG : PH:7.38 , PCO2 : 36 , PO2: 68 . HCO3 : 24
Creatine : 0.8 , Urea : 33 , HB : 11 , TLC : 5.5 . PLT : 190 ,INR : 1
Treatment : antibiotics stopped , steroids shifted to oral dose : prednisolone : 20 mg daily for
aweek , 10 mg next week , 5 mg another week , them stopped
Follow up CT chest was done : improved
The patient was sent ward the next day on ventury 31 , oxygen saturation 94 .the pt stay at
the ward for more 5 days and oxygen requirement descend to simple mask .
Pt discharged home after a week .
