SCCM Resource Library-15-Safety of Remdesivir and Inhaled Nitric Oxide in a Pregnant Patient With Twins: A Case Report

Video Transcription

Hello, everyone. My name is Raj Kamalhansura. I'm a second year pulmonary and critical care fellow at Louisiana State University Health Sciences in Shreveport. Today, we have  an interesting case that we've never encountered before. So I have no disclosures today. Introduction.  So we have limited data on management of COVID patients, specifically in the obstetrics population.  Teratogenicity and safety of remdesivir really have not been well studied. Neither has the  teratogenicity of inhaled nitric oxide. We also don't know much about vertical transmission of the virus, as well as fetal outcomes of maternal COVID infection. And so these are  all the things that we encountered with this case. So the case, we have a unique case of a mother with twin gestations admitted to the intensive care unit with severe COVID  pneumonia and acute respiratory distress syndrome. So we have a 26-year-old female. She had a past history of mild intermittent asthma, morbid obesity. She was 29 weeks gestation  with dichorionic diamniotic twins who presented with shortness of breath and laboratory-confirmed SARS-CoV-2 positive. Four days later, she was discharged from L&D after weaning off  of supplemental oxygen. She returned to the ER on day seven of her COVID infection, worsening  shortness of breath, cough, increased requirements of oxygen by nasal cannula, and later high flow nasal cannula. This is something that it's not particularly unique to this patient  that we commonly see. Day 10, she was diagnosed with preeclampsia without severe features. At this point, we had started her on antenatal corticosteroids, and we did decide to start  her on remdesivir as well as broad-spectrum antibiotics. This was a multidisciplinary discussion and management for this patient regarding really the risks and benefits of  starting the remdesivir, given that we really didn't know much about it in this patient population or how it would affect the fetus. But at this point, we were having trouble  maintaining her goal oxygen saturation, which is decided to be 95%. On day 11, despite 100%  high flow nasal cannula, the decision was made to intubate and begin mechanical ventilation.  Again, this was a multidisciplinary decision with our airway anesthesia team, our high-risk  obstetrics team, our intensive care unit team, really preparing for every worst-case scenario.  Post-intubation, she briefly required norepinephrine to maintain her MAPS, but she was quickly able to wean off of that. We did approach with a low tidal volume, high PEEP strategy.  She was started on inhaled nitric oxide to help with maintaining her oxygenation  with increasing vent settings. Again, this was really a decision made with the obstetrics team  and the ICU team, really with the benefits versus risks of the inhaled nitric oxide versus  inability to maintain her oxygen saturations. We did have her on fentanyl and dexmedetomidine  for analgesia and anxiolysis. On day 14, she began to exhibit severe features of her preeclampsia.  She had severe hypertension, increase in her transaminases, and the decision was made to go  forth with emergency suction at 30 weeks gestation. Twin A was male fetus, APGAR 6 and 8. Twin B was  female fetus, APGAR 7 and 8. Both infants required endotracheal intubation for respiratory distress,  and both actually tested negative for SARS-CoV-2. Test imaging in these infants was consistent with surfactant deficiency, and both received exogenous surfactant.  Eventually, they were both able to be extubated and transitioned to nasal cannula.  As far as the mother, following delivery, she rapidly improved. Her vent settings were able  to be weaned to minimal, and the inhaled nitric was able to be weaned off. On post-op day four,  she was extubated with a total of seven days of mechanical ventilation, and eventually discharged from the hospital on day 23 on room air. Really, the discussion in this case is  they're really determining the benefits versus the risks of these management options that we  typically do in COVID-19 patients, particularly in the obstetrics population. We really do not  have much data regarding the safety profile, or even the efficacy in the obstetrics population.  With few data that exists demonstrating the safety of nitric oxide as well in pregnant patients,  almost all randomized control trials for COVID using these drugs have excluded pregnant patients.  This unique case suggests successful use of remdesivir and inhaled nitric oxide, in addition to our usual low tidal volume mechanical ventilation strategy,  in a patient with pregnant with twin gestations. Both infants underwent an expected neonatal ICU  course for premature delivery at 30 weeks. To our knowledge, no complications were attributed to  remdesivir or inhaled nitric oxide. Thankfully, all three individuals were able to have a good outcome.  The conclusion is, while more research in the form of randomized control trials are needed to demonstrate the safety and efficacy of these therapeutic modalities,  clinicians may consider taking a similar approach. Thank you again, everybody, for listening. If you have any questions at this time, feel free to reach out to me. Thank you.

Video Summary

In this video, Dr. Raj Kamalhansura presents a unique case of a pregnant mother with twin gestations who developed severe COVID pneumonia and acute respiratory distress syndrome. The management of COVID patients in obstetric populations is still largely unknown, and there is limited data on the safety and effectiveness of drugs like remdesivir and inhaled nitric oxide in this population. In this case, the mother was treated with remdesivir, broad-spectrum antibiotics, and inhaled nitric oxide. She required intubation and mechanical ventilation, and ultimately delivered twin infants who were negative for SARS-CoV-2. Both the mother and infants had positive outcomes, suggesting that this approach may be considered for similar cases, although more research is needed.

Asset Subtitle

Obstetrics, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Rajkamal Hansra, MD

Introduction: Limited data is available for management of COVID-19 in pregnant patients and teratogenicity of remdesivir. We present a case of a mother with twin gestation admitted to the intensive care unit with severe COVID19 pneumonia and acute respiratory distress syndrome who was treated with mechanical ventilation, remdesivir and inhaled nitric oxide (iNO).

Description: A 26 year old female with history of mild intermittent asthma and morbid obesity at 29 weeks gestations with dichorionic diamniotic twins who presented with hypoxemia and laboratory confirmed SARS-CoV-2 positive. She failed to maintain goal oxygen saturations despite maximal support with high flow nasal cannula and required intubation and mechanical ventilation. A high PEEP low tidal volume strategy was utilized as well as initiation of iNO to obtain saturation goals of greater than 95% which is the minimal set threshold in pregnancy. The patient received remdesivir, iNO, and steroids on day 1 of ICU admission. On ICU day 6 she developed pre-eclampsia with severe features and she was taken to the operating room for successful delivery via cesarean section at 30 weeks gestation. Following delivery she demonstrated rapid improvement in clinical status and on day 10 was successfully extubated. Twin A was a male fetus born with APGAR scores of 6 and 8 at 1 and 5 minutes respectively. Twin B was a female fetus born with APGAR scores of 7 and 8 at 1 and 5 minutes. Both infants required endotracheal intubation for respiratory distress and tested negative for SARS-CoV-2. They demonstrated chest imaging consistent with surfactant deficiency and received exogenous surfactant. They were diagnosed with bronchopulmonary dysplasia but were able to be extubated and weaned to 0.2L nasal cannula.

Discussion: This case suggests successful use of remdesivir and iNO in addition to low tidal volume ventilation strategy mechanical ventilation in a pregnant patient with twin gestation. Both infants underwent an expected neonatal ICU course for premature delivery at 30 weeks and to our knowledge no complications were attributed to remdesivir or iNO. While more research in the form of randomized clinical trials is needed to demonstrate safety and efficacy of these therapeutic modalities clinicians may consider taking a similar approach.

Meta Tag

Content Type Presentation

Knowledge Area Obstetrics

Knowledge Area Crisis Management

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Pregnancy

Year 2021

Keywords

pregnant mother

COVID pneumonia

acute respiratory distress syndrome

remdesivir

inhaled nitric oxide

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