LAUSR

In April 2020, a 29-year-old nulliparous Asian woman, in a COVID-19 endemic area (London, United Kingdom), presented to a maternity hospital at 30 weeks gestation with 5 days of dry cough and shortness of breath. Further questioning revealed, anosmia, nausea, poor appetite and decreased fluid intake. She reported normal fetal movements. Her past medical history was significant for end stage kidney disease of unknown aetiology. She had undergone 4 years of haemodialysis before receiving a deceased donor kidney transplant 18 months prior to pregnancy. Before this admission, her pregnancy was managed by the joint obstetric-renal clinic and had been uncomplicated. She was on tacrolimus monotherapy maintenance immunosuppression following alemtuzumab induction. On examination she was tired and short of breath at rest. She was speaking in full sentences and not using her accessory muscles of respiration. Her temperature was 38 °C, heart rate 125beats per minute (bpm), respiratory rate was between 28–32 breaths per minute (Bpm) and her oxygen saturations were 97% on room air. Blood pressure was 123/73 mmHg. She had right basal crepitations. Her abdomen was non-tender and the fundal height was appropriate for gestation. Her cardiotocograph showed fetal tachycardia at 175 bpm (the upper limit of normal being 160 bpm). Given the clinical setting, COVID-19 was immediately suspected with influenza and bacterial pneumonia as differential diagnoses. She was placed in respiratory isolation, and a nasopharyngeal COVID-19 swab was taken, and routine blood tests and a chest x-ray were carried out. Her blood tests showed a neutrophil count of 15.3 × 109(4.2–11.2), lymphocytes of 1.5 × 109 (1.1–3.6) and CRP of 65.9 mg/L (0–5). Creatinine was 86 umol/L from an in-pregnancy baseline of 60umol/L. Her chest X-ray showed multiple opacities in keeping with COVID-19. Her nasopharyngeal swab later confirmed the presence of viral SARS-COV-2 RNA. Inflammatory cytokine assays were not checked. She was started on 5 L of oxygen via nasal prongs and co-amoxiclav, clarithromycin and 0.9% saline intravenously. Given the initial maternal tachycardia and tachypnoea, and the fetal tachycardia, there were concerns that delivery may need to be expedited. She was started on intravenous magnesium sulphate for fetal neuroprotection and intramuscular betamethasone to promote fetal lung maturation. After initial treatment with oxygen, fluid resuscitation and betamethasone, both maternal signs (heart rate 100 bpm, respiratory rate 22 Bpm, oxygen saturation 99%) and fetal condition (resolution of the uncomplicated fetal tachycardia) improved over the subsequent 6 h. The obstetric team discussed her care with the obstetric physicians and renal team and a decision was made to delay delivery and monitor closely. Given the known increased thrombotic risk associated with active COVID-19 infection, she was started on prophylactic low molecular weight heparin. She gradually improved over the next few days. Her requirement for supplemental oxygen stopped on day three and she was discharged on day 5. Her trough tacrolimus levels were within our target range (5-8umol/l) and her dose was not changed. * Sarah Gleeson sarah.gleeson2@gmail.com