Innovative mid-trimester termination of pregnancy in a COVID-19 critically Ill patient

Abstract

The current COVID-19 pandemic has introduced many challenges on the presentation of the disease, effects of the disease on co-morbidities of the patient and the management of these. This has necessitated innovative ways of managing these patients. This is particularly so in pregnant women with COVID-19. We present a case of a pregnant woman in her mid-trimester who presented with severe COVID-19 disease requiring ICU admission who required termination of pregnancy due to worsening condition while on ventilator. She presented with high fever, cough and difficulty in breathing. These rapidly deteriorated requiring ECMO. Her liver function, kidney function and inflammatory markers equally deteriorated very fast despite various treatments including using convalescence plasma. We decided to terminate the pregnancy to help in managing her condition. The baby died just when we were considering the termination of the pregnancy thus requiring Mid-trimester termination of the non-viable pregnancy. We initially tried to use vaginal misoprostol for the termination but failed thus we had to find a way of using mifepristone pre-treatment for the termination. An innovative used of mifepristone through the nasogastric tube was devised and we successfully terminated the pregnancy with mifepristone pre-treatment followed by a single dose of misoprostol with minimal blood loss. The patient’s condition improved rapidly after the termination of pregnancy and she recovered fully. We feel her pregnant status might have contributed to her severe symptoms and the disease may have contributed to the demised of the baby. We recommend the use of mifepristone through the nasogastric tube in the process of termination of pregnancy in a sick ventilated patient.