Splenic Infarction in a Postpartum Patient with COVID-19

Abstract

Thrombotic events have been reported in patients with coronavirus disease 2019 (COVID-19). Pregnant and postpartumpatients are also known to behypercoagulable and those with COVID-19 may therefore be at an even higher risk of thrombotic complications. Here, we discuss a postpartum patient with COVID-19 who developed an isolated splenic infarction. While describing a rare thrombotic event, this case serves to alert physicians to the higher risk of thrombosis in pregnant or postpartum patients with COVID-19. A previously healthy 27-year-old female who was 37 weeks pregnant, with no past medical history presented to thehospitalwith complaints of fever, cough, and shortness of breath. She tested positive for COVID-19 and as she was improving, was discharged home. She presented to the hospital again 2 days later with worsening fevers and tachypnea and was transferred to our hospital for further management the same day. On day 2 of admission, she vaginally delivered a healthy baby girl. She continued to have worsening tachypnea and increasing oxygen requirements postpartum, eventually requiring endotracheal intubation on day 8. She was proned on the following day for refractory hypoxia with improvement in respiratory parameters. One dose of convalescent plasma (200mL) was given on day 4 of admission and an 800mg dose of tocilizumab on day9 after concomitant bacterial infectionwas ruled out. She was also started on prophylactic heparin 5,000 units subcutaneously three times a day 2 days after delivery and continued throughout her stay. While intubated, the patient was hemodynamically stable and required only minimal vasopressor medications probably due to sedation effect. The patient’s respiratory status started improving and ventilator weaning protocols were initiated. She tolerated supination on day 14. The patient had persistent low-grade fevers post-delivery with an elevation in her white blood cell in the 12 to 20 k/μl range. Multiple blood cultures were sent that were all negative. Her markers of inflammation were elevated initially after intubation with a ferritin of 486.9 ng/mL, Creactive protein of 44.5mg/L, and sedimentation rate of 75mm/h. Thesemarkers improved progressively throughout her course. She did not have any laboratory abnormalities suggesting a hypercoagulable state with an initial fibrinogen of 368mg/dL that stayed in the normal range throughout her stay. Prothrombin time, activated prothrombin time, and platelet count were also normal on admission and during her hospitalization. Her kidney function was also normal throughout in the 0.36 to 1.07mg/dL range. Her D-dimer was elevated to >20 μg/mL immediately post-delivery but then decreased to 8.2 μg/mL a few days later. Her D-dimer level then gradually increased again, peaking at >20 μg/mL. On day 21, she complained of abdominal pain. In the setting of persistent fever and leukocytosis, therewas concern for an abscess or intraabdominal catastrophe related to her delivery, such as, but not limited to, colonic pseudo-obstruction, infection, uterine involution, or foreign body retention. A computed tomography (CT) scan of the abdomen was therefore obtained that revealed multiple new hypodense splenic infarcts with possible prior hemorrhage into one infarct (►Figs. 1, 2). There were no thromboembolic or infarctions noted on a prior CT chest and abdomen done earlier in the admission. Echocardiogram did not reveal any cardiac thrombi or vegetations that along with the negative blood cultures argued against embolic phenomena. The patient was started on therapeutic dose low molecular weight heparin (LMWH). She was successfully extubated on day 23 and was transitioned to apixaban prior to discharge. She is currently doing well. Patients with COVID-19 are predisposed to thrombotic complications with cases of pulmonary embolism, deep vein thrombosis, and ischemic strokes reported.1 The incidence of thrombotic complications is 31% in critically ill patients