KIMS Successfully Treats Covid-positive Pregnant Woman with Sickle Cell Anemia Complicated with Vasso-occlusive Crisis and Foetal Compromise
By Dr. Sudhanshu Kumar Rath, Department of Gynaecology, KIMS
Sickle Cell Disease (SCD) is a single gene disorder caused due to a point mutation in codon 6 of beta globin gene and is characterized by sickle shape of normal RBC (red blood cells) and manifests with various complications like pain crisis, stroke, anemia requiring transfusions, renal disorders, etc. Pregnancy in sickle cell anemia is a difficult situation and is associated with an increased incidence of perinatal mortality, premature labour, foetal growth restriction and acute painful crises. Studies also describe an increased risk of spontaneous miscarriage, antenatal hospitalization, maternal mortality. Delivery by caesarean section, infection, thromboembolic events and antepartum haemorrhage can also occur. There is also an increased incidence of PIH and preeclampsia.
SCD and Covid‐19 can present with overlapping clinical features such as respiratory symptoms with ground‐glass infiltrates, hyperinflammatory state, and increased risk of thromboembolism and are more vulnerable to severe health complications than the rest of the population. They also have higher death rates and have been classified as a high-risk group to develop complications as per CDC. The perioperative care of such patients is of paramount concern and needs a multidisciplinary team approach in a tertiary care centre.
Odisha Covid Hospital (OCH) managed by KIMS was faced with a delicate challenge when an elderly primigravida, who was diagnosed with sickle cell anemia, was admitted with vaso occlusive crisis and was detected to be Covid positive. This patient, an elderly primigravidae at 36 weeks of gestational age, presented with complaints of severe pain over back, legs and shoulders since 10 days. She was referred to us after being tested positive for Covid antigen. She was a known case of sickle cell disease. At admission, the patient had respiratory distress, was dehydrated, pale and icteric.
Proper hydration, antibiotic coverage, pain management, oxygen inhalation, monitoring of vitals and oxygen saturation was immediately instituted. On investigating, the patient was found to have deranged LFT with a serum total Bilirubin of 7.21, direct bilirubin of 4.08, SGOT- 56.D-dimer was raised with a value of 4.63.
Fetus was presenting with breech. On cardiotocography (CTG), fetal heart rate tracing showed prolonged decelerations. She was planned for an emergency LSCS in view of the fetal indication. Regional Anaesthesia (CSEA) was the planned technique of choice at L-3-L4 level with epidural catheter. Some of the major advantages of this technique are effective postoperative pain management, less blood loss, less chances of deep venous thrombosis, early ambulation and recovery, maternal satisfaction and avoidance of complications of general anaesthesia. Intra operatively anterior grade 2 placenta praevia was managed by cutting through placenta. Moderate PPH was managed duly with oxytocin and misoprostol. Patient received one unit packed red blood cell transfusion intra operatively. She was shifted to the ICU immediately after closure.
A late preterm male child was delivered who had perinatal depression and was resuscitated with tactile stimulation and suctioning and clearing airways. In view of the critical condition of mother and perinatal depression, the baby was shifted to the Neonatal intensive care section of OCH and was started on supportive management. Post operatively mother made remarkable progress and was soon shifted to the obstetrics ward and the baby was started on breastfeeding. Baby had an uneventful recovery and was negative for sickle cell anemia.
Pregnancy in sickle cell anemia is a precarious situation but supper added with Covid-19 made it more critical. Fetal compromise required early interventions and stringent monitoring by the obstetrics, anaesthetic, intensive care and pediatric team. The presence of all discipline made a successful recovery and possible outcome.
Obstetric team of Dr. Sonali Swetaleena Dash (Senior Resident), Dr. Pallavi, Dr. Tejaswini were guided by Dr. S. K. Rath (HOD O&G), Dr. Asima Das and Dr. Jyochnamayi Panda in making an appropriate management plan. Dr. Akshay Saxena also extended support from the medicine side. Regional Anaesthesia was meticulously planned and managed by Dr. Amrita Panda and post operatively mother was managed in the Intensive Care Unit by Dr. Sashank and team. The Pediatrics Team of Dr. Palash Das (Assistant Professor), Dr. Aranya and Dr. Sushrut ensured the baby had an uneventful recovery.
Treating team is thankful to the managerial team of Covid Hospital who ensured availability of all medication and transfusion which ensured that the mother and neonate could fight out the difficult condition successfully.