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\title{A case of COVID-19 in a pregnancy complicated by fetal pleural effusion}



\author[1]{Łukasz Witek}%
\author[1]{Natalia Filochowska}%
\author[2]{Tomasz Janikowski}%
\author[1]{Helena Sławska}%
\author[1]{Anita Olejek}%
\affil[1]{Medical University of Silesia}%
\affil[2]{Silesian College of Medicine in Katowice}%


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  \date{May 25, 2024}


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\textbf{A case of COVID-19 in a pregnancy complicated by fetal pleural
effusion}

\selectlanguage{polish}Ł\selectlanguage{english}ukasz Witek\textsuperscript{1}, Natalia Filochowska\textsuperscript{1},
Tomasz Janikowski\textsuperscript{2}, Helena S\selectlanguage{polish}ł\selectlanguage{english}awska\textsuperscript{3},
Anita Olejek\textsuperscript{1}

\textsuperscript{1}Department of Gynecology, Obstetrics and Oncological
Gynecology, Medical University of Silesia, Bytom, Poland

\textsuperscript{2}Silesian College of Medicine, Katowice, Poland

\textsuperscript{3}Department of Neonatology in Bytom, Medical
University of Silesia, Katowice, Poland.

\textbf{INTRODUCTION}

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the
virus that mainly affects the respiratory system, leading to severe
respiratory failure and even death (1). Today's knowledge on the effects
of the virus on pregnancy is still poorly understood (1-3). There is
evidence that SARS-CoV-2 can cross the placenta (2-4). Viral RNA and
proteins are detected in placental swabs or biopsies and in the amniotic
fluid (2-6). However, it is not known how long the virus persists in the
placenta after the mother's infection (2). Although the risk of
SARS-CoV-2 transmission from mother to fetus is low (7), pregnancy
complications (2,5,6) are potentially serious.

In the following study we have reported a case of pregnancy complicated
with an exudate in the fetal pleural cavity after the mother was
confirmed to have SARS-CoV-2 infection in the third trimester.

\textbf{REPORT CASE}

A 29-years-old woman, 37 weeks of third gravida, two living children,
has been referred to the Department of Gynecology, Obstetrics and
Oncological Gynecology in Bytom due to diagnosed fetal effusion in right
pleural cavity. The pregnancy was complicated by insulin-requiring
gestational diabetes and cervical insufficiency requiring assumption
suture. Due to Rh-negative blood type anti-D immunoglobulin was
administered at the 28th week of pregnancy. At the gestational age of 34
weeks the woman developed a fever (38.0@\selectlanguage{english}C) and general weakness.
Naso-oropharyngeal swab testing for SARS-CoV-2 (RT-PCR) was positive.

As a standard on admission, COVID-19 rapid antigen test was performed
and was positive. A negative RT-PCR test result excluded an active
infection. The ultrasound showed fluid in the right pleural cavity in
fetus with the dimensions of 7.6 x 4.9 cm (Figure 1). Common laboratory
tests showed no significant deviations from the norm. Similarly,
C-reactive protein (CRP) and procalcitonin (PCT) levels were within the
normal range. The patient was negative for antibodies of TORCH
(toxoplasmosis, cytomegalovirus, parvovirus B19, herpes, syphilis,
rubella and HIV). The fetal condition was systematically monitored by
cardiotocography and ultrasound. The patient was asymptomatic throughout
most of this period. At 38+2 weeks of pregnancy a spontaneous vaginal
delivery has occurred and a full-term male newborn was born with a
birthweight 3650g and 6/7/8/9 points Apgar score. The rapid antigen test
for SARS-CoV-2 performed on a newborn was negative. Due to single,
shallow breaths nCPAP breathing support with FiO2 0,40-0,45 was
administered. The ultrasound showed a collapse of the right lung
compressed by fluid in the pleural cavity, heterogeneous echogenicity,
with dominant B-line artifacts. The maximum fluid thickness was 1.7cm at
the base of the lung. A thymus with a heterogeneous structure was also
revealed. The laboratory tests showed negative parameters of
inflammation. The right pleural cavity was drained and 150 ml of the
yellow, cloudy liquid fluid was evacuated. Thereby improvement in
respiratory efficiency was achieved. The microbiological examination
indicated a fluid of a lymphatic nature. The computed tomography (CT)
scan of the chest excluded pathological changes in the mediastinum.
Serological tests ruled out congenital TORCH infection. Diagnostics was
extended to group B Coxackie virus infection, which was negative. The
karyotyping ruled out genetic disorders. On day 7, a continuous infusion
of octreotide was ordered and reduction in lymphorrhea was observed,
until it resolved. RT-PCR tests for COVID-19 were performed twice at
16th and 19th days of life with negative results. After 19 days of
hospitalization and total evacuation of approximately 850 ml of lymph,
the newborn was discharged in good general condition.

\textbf{DISCUSION}

Secondary pleural effusion is usually caused by generalized fluid
retention in non-immune hydrops (8). The causes of this pathology
include cardiovascular and idiopathic diseases, genetic, metabolic and
hematological disorders, infections, structural abnormalities and chest
tumors (9). To the best of our knowledge there where only reported three
confirmed SARS-CoV-2 infections during pregnancy complicated by hydrops
fetalis (2-4). In each case, the SARS-CoV-2 infection occurred in a
different trimester of pregnancy and all of them were complicated by
intrauterine fetal death. Two patients were infected before diagnosis
(2,4) and one was in active infection (3). Whereas, a PCR SARS-CoV-2
test was performed on a fetal lung biopsy and was positive (3). An
active infection from the TORCH group was ruled out in these patients.
Cytogenetic analysis revealed a normal karyotype in every case.
Moreover, histologic examination of the placenta or fetal tissues was
performed. Shende et al. reported fibrin deposition around the villi,
where the syncytiotrophoblast was lysed, and extensive leukocyte
infiltration suggesting inflammation (2). A similar picture was obtained
in the studies by Rodrigues et al. and Popescu et al. In both cases a
postmortem examination showed systemic thrombosis with thrombi in the
small and medium vessels. Recent blood clots were identified in fetal
circulation (3,4). In the study by Popescu et al. the pregnant was Rh
negative so, Rh immune globulin was given, as in our case. An attempt
was made to perform a thoracocentesis and insert a percutaneous in utero
thoracoamniotic shunt (4). The limitations of our case are no SARS-CoV-2
tests performed in placenta, amniotic fluid, and fetal tissues. After
birth the rapid antigen test was performed, which was negative.
Therefore only the clinical symptoms and the exclusion of other
possibilities, i.e. TORCH infections, genetic disorders, Rh immunization
and the proliferative process may indicate vertical transmission of the
virus. This case may constitute the basis for further studies, as the
pleural effusion is a serious emergency for a newborn.

\textbf{CONCLUSION}

The presented case of a fetal pleural effusion shows differences in
procedures and circumstances, when dealing with SARS-CoV-2 in pregnancy.
Furthemore, the study may suggest a possible transmission of the virus
through the placenta and may indicate risks associated with it. More
research is needed to shed more light on the vertical transmission of
SARS-CoV-2 so that universal screening of all pregnant women can be
performed to avoid the adverse effects of the infection. The addition of
vaccination against COVID-19 to the recommended immunizations for women
trying to become pregnant should also be considered.

\textbf{Funding}

No funding

\textbf{Declarations}

Patient consent for use of medical data and history for article
preparation and publishing was obtained after finishing treatment.

\textbf{References}

(1) Schwartz DA. An Analysis of 38 Pregnant Women With COVID-19, Their
Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal
Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med.
2020; 144 (7): 799-805.

(2) Shende P, Gaikwad P, Gandhewar M, et al. Persistence of SARS-CoV-2
in the first trimester placenta leading to transplacental transmission
and fetal demise from an asymptomatic mother. Hum Reprod. 2021; 36 (4):
899-906.

(3) Rodrigues ML, Gasparinho G, Sep\selectlanguage{ngerman}úlveda F, et al. Signs suggestive of
congenital SARS-CoV-2 infection with intrauterine fetal death: A case
report. Eur J Obstet Gynecol Reprod Biol. 2021; 256: 508-509.

(4) Popescu DE, Cioca A, Muresan C, et al. A Case of COVID-19 Pregnancy
Complicated with Hydrops Fetalis and Intrauterine Death. Matern Health
Neonatol Perinatol. 2021; 7 (1): 6.

(5) Hsu AL, Guan M, Johannesen E, et al. Placental SARS\selectlanguage{english}-CoV\selectlanguage{english}-2 in a
Pregnant Woman with Mild COVID\selectlanguage{english}-19 Disease. J Med Viol. 2021; 93 (2):
1038-1044.

(6) Baud D, Greub G, Favre G, et al. Second-trimester miscarriage in a
pregnant woman with SARS-CoV-2 infection. JAMA. 2020; 323 (21):
2198--2200.

(7) Kiappe OP, Santos da Cruz NF, Rosa PAC, et al. Ocular Assessments of
a Series of Newborns Gestationally Exposed to Maternal COVID-19
Infection. JAMA Ophthalmol. 2021; 139 (7): 777-780.

(8) Yinon Y, Kelly E, Ryan G. Fetal pleural effusions. Best Pract Res
Clin Obstet Gynaecol. 2008; 22 (1): 77-96.

(9) Bellini C, Hennekam RC, Fulcheri E, et al. Etiology of nonimmune
hydrops fetalis: a systematic review. Am J Med Genet A. 2009; 149A (5):
844-51.\selectlanguage{english}
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