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Pulmonary embolism in a young pregnant woman with COVID-19

      On March 29, 2020, a 17-year-old obese woman (BMI 32 Kg/m2) was admitted at 29 weeks of gestation to our COVID-19 Maternity Hub in Milan for fever, mild dyspnea and rhinitis in the last three days. Her past medical history was unremarkable and she had a negative family history of venous thromboembolism. Her body temperature was 37.3 °C, heart and respiratory rates, and oxygen saturation were normal. A nasopharyngeal swab revealed a SARS-CoV-2 infection. On March 30, her respiratory function suddenly worsened and she started oxygen supplementation with 2 l per minute via nasal cannula. On April 1, she developed tachypnea (30 breaths per minute) and oxygen flow was increased to 6 l per minute via Venturi mask. Blood culture demonstrated a Staphylococcus aureus bacteremia. The same day antithrombotic prophylaxis with enoxaparin 4000 IU once daily was started. On Apr 4, the patient developed an acute respiratory failure and underwent a chest CT-scan that showed a segmental pulmonary embolus in the right superior lobe, other than a ground-glass opacification and early parenchymal consolidation at lower lobes of the lungs. Laboratory tests did not vary compared to those at admission, except for the neutrophil/lymphocyte ratio and an increase of ferritin concentration (Table 1). At 29 weeks and 6 days, the patient delivered by urgent cesarean section for worsening dyspnea. A female new-born of 1490 g (appropriate for gestational age) was admitted to Neonatal Intensive Care Unit and did well. In the postpartum, enoxaparin was increased to therapeutic doses of 8000 IU twice daily. The patient required a non-invasive ventilation with CPAP, and a gradual improvement of her respiratory function occurred in the following days. On April 9, CPAP ventilation was discontinued and oxygen supplementation with 3 l per minute via nasal cannula was sufficient to reach a SpO2 of 99%. On April 14 the patient was discharged.
      Table 1Laboratory findings at admission and at worsening of respiratory function.
      Mar 29, 2020 - admissionApr 4, 2020 - diagnosis of pulmonary embolism
      White-cell count (per mm3)69106022
      Differential count (per mm3)
      Total neutrophils56603910
       Total lymphocytes7701830
       Total monocytes470430
      Platelet count (per mm3)300,000335,000
      Hemoglobin (g/l)8591
      Albumin (g/l)3424
      Alanine aminotransferase (U/l)1812
      Aspartate aminotransferase (U/l)29ND
      Lactate dehydrogenase (U/l)168223
      Creatinine (μmol/l)4847
      EGFR (mil/min/1.73 m2)144145
      Prothrombin time (sec)10.99.8
      Activated partial-thromboplastin time (sec)31.827.2
      Fibrinogen (g/l)6.025.43
      D-dimer (mg/l)16.415.8
      Serum ferritin (μg/l)117418
      Procalcitonin (ng/ml)ND0.10
      C-reactive protein (mg/l)28.528.1
      Despite the young age and a personal and family history negative for thrombosis, this young obese woman with COVID-19 and Staphylococcus aureus infection developed pulmonary embolism. Although the embolus was small and did not worsen coagulation laboratory parameters, it caused a severe impairment of patient's clinical conditions and prompted an urgent timing of delivery. There is stemming evidence that pulmonary embolism is a complication of COVID-19 [
      • Klok F.A.
      • MJHA Kruip
      • van der Meer N.J.M.
      • et al.
      Incidence of thrombotic complications in critically ill ICU patients with COVID-19.
      ]. Obese pregnant women with COVID-19 may have a particularly high risk of pulmonary embolism because of coexisting prothrombotic conditions. This should be considered for tailoring antithrombotic prophylaxis.

      Funding

      The authors received no specific funding for this work.

      Declaration of competing interest

      The authors do not declare any conflict of interest.

      References

        • Klok F.A.
        • MJHA Kruip
        • van der Meer N.J.M.
        • et al.
        Incidence of thrombotic complications in critically ill ICU patients with COVID-19.
        Thromb Res. 2020; https://doi.org/10.1016/j.thromres.2020.04.013