key: cord-0840487-9q0r6lfs
authors: Joudi, Noor; Henkel, Andrea; Lock, W. Scott; Lyell, Dierdre
title: Preeclampsia Treatment in SARS-CoV-2
date: 2020-05-20
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100146
sha: c81c5a22eb57ca33fc2e95deaab154689b58bd54
doc_id: 840487
cord_uid: 9q0r6lfs

nan

We have all faced unprecedented challenges caring for pregnant women in the SARS-CoV-2 pandemic 1 with limited experience and rapidly evolving guidelines. We took great interest in AJOG's recent Boelig 2 et al "Labor and Delivery Guidance for COVID-19" (1) . They note a paucity of experience with 3 magnesium for neuroprotection or seizure prevention in patients with SARS-CoV-2. Given potential 4 respiratory complications associated with magnesium sulfate, there is a theoretical concern that 5 treatment could exacerbate SARS-CoV-2 infection. 6 7

We present the first reported case of management of severe pre-eclampsia with known maternal SARS-8

CoV-2 infection, including magnesium sulfate administration. 9

A 26-year-old woman at 37 weeks gestation diagnosed with SARS-CoV-2 for symptoms of sore throat 11 and "allergies'' was also diagnosed with pre-eclampsia based on sustained elevated blood pressures 12 >140/90 and proteinuria. 13 14 Intrapartum, she reported dyspnea and a sensation of "drowning", although she maintained oxygen 15 saturation greater than 97% on room air and lung exam was clear to auscultation bilaterally with no 16 crackles or wheezes. She began to experience sustained severe range blood pressures of 175/111 and 17 166/101 with mild headache. Serum labs were notable for AST 131 U/L, ALT 133 U/L, creatinine 0.67 18 mg/dL, and platelets 199 k/uL. Thromboelastography (TEG) notable for increased platelet and 19 fibrinogen activity. There was brief pause for consideration if intravenous labetalol could be given in 20 patients with SARS-CoV-2, given the recommendation to avoid with reactive airway disease due to risk 21 of bronchoconstriction (2,3). Similarly, a quick literature review was conducted regarding magnesium 22 sulfate infusion in this at-risk patient population given its possibility to worsen respiratory status (4). 23

Given normal oxygenation and benign lung exam, the decision was made to manage severe-range blood 24 pressure with standard first-line agent of 20mg of intravenous labetalol. Next, a loading dose of 4g 25 intravenous magnesium sulfate was initiated for seizure prevention, followed by a maintenance rate of 26 2g per hour infusion. Her blood pressure improved to 147/85 and remained on average 130s/80s 27 following these interventions, and portable AP chest x-ray revealed no acute cardiopulmonary 28 process. The patient had no reported exacerbation of pulmonary symptoms during magnesium sulfate 29 administration and was able to maintain oxygen saturation greater than 97% on room air during 30 treatment.

tracing due to recurrent variable decelerations with slow return to baseline, with subsequent 33 uncomplicated forceps-assisted vaginal delivery for fetal indication and maternal exhaustion. 34

She delivered a vigorous male infant weighing 3042g with Apgar scores of 7 and 9 at 1 and 5 minutes. 36

Delayed cord clamping was performed without placing infant skin-to-skin. The awaiting Pediatrics team 37 took infant to the NICU for assessment where SARS-CoV-2 testing resulted negative. The patient 38 declined separation from her infant; therefore, the infant remained in her postpartum isolation room in a 39 bassinet six-feet away from bed. The patient initially hand-expressed then moved to breastfeeding after 40 washing her hands well and while wearing a mask. The infant was incidentally noted to have penile 41 torsion and was referred to outpatient Pediatric Urology. 42

Blood pressures remained mild-range following delivery, and intravenous magnesium sulfate therapy at 44 a maintenance rate of 2g per hour was continued for 24 hours following delivery. After evaluation by 45 dedicated SARS-CoV-2 ICU team, the patient did not meet inclusion criteria for clinical trial or 46 compassionate use of Remdesivir given clinical stability. She was immediately ambulatory after 47 delivery thus we elected against VTE pharmacoprophylaxis in favor of mechanical prophylaxis. The 48 patient was discharged home on postpartum day two with no symptoms suggestive of SARS-CoV-2 49 infection, and did not require oral medication for blood pressure control. 50 51 There is currently a lack of data regarding the safety of magnesium sulfate administration in patients 52 with SARS-CoV-2 infection. In this case, the patient had mild respiratory symptoms with normal 53 oxygenation on room air and with normal clinical exam and chest x-ray. Given severely elevated blood 54 pressures with headache in the setting of pre-eclampsia, the decision was made to proceed with 55 magnesium sulfate administration. We observed that this patient was able to tolerate a 4g magnesium 56 sulfate loading dose followed by 2g/hour maintenance rate without issue. Additionally, there was 57 concern for administering intravenous labetalol for blood pressure control given the possibility of 58 respiratory compromise; this drug was fortunately administered without adverse consequence and 59

successfully lowered blood pressure with one 20mg dose. Our limited clinical experience supports the 60 authors' expert opinion that "Magnesium sulfate may be used as indicated in patients with

Labor and 64 "Delivery Guidance for COVID-19

Report of the American College of Obstetricians and Gynecologists

Task Force on Hypertension in Pregnancy

Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During 71 Pregnancy and the Postpartum Period

Magnesium sulphate and other anticonvulsants for women with pre-75 eclampsia

Conceptualization, Roles/Writing -original draft Andrea Henkel: Conceptualization, Roles/Writing -original draft W. Scott Lock: Writing -Review & editing Dierdre Lyell: Writing -Review & editing