A great deal is being learned about the effects of Covid-19 infection and pregnancy. A recent meta-analysis suggests that the overall rate of positive diagnoses in pregnant women admitted to a hospital was 10%.1 Of those, 4% were admitted to an intensive care unit (ICU), 3% required mechanical ventilation, and 0.6% died.2 The percentage of these women who delivered their infants prematurely was 17%.1 A quarter of all infants born to mothers who tested Covid-19 positive required a neonatal intensive care unit (NICU) admission.1 While statistical data regarding Covid-19 infection and pregnancy outcomes are emerging, the long-term effects on both mothers and infants after Covid-19 infection have yet to be determined.

My name is Mallory Goepel. I am a married mother of 3 children and a neonatal nurse practitioner. I have worked in the NICU for 14 years. I found myself pregnant with my third child in the middle of the Covid-19 pandemic. Naturally, I was terrified about all the unknowns regarding the virus and pregnancy. I continued to work, while otherwise strictly quarantining with my family. One weekend in June, I found myself with a new-onset cough. I quickly developed every other identified symptom in the next 24 hours. I was tested the following morning for Covid-19, and on Monday, June 15, 2020, my worst nightmare came true; I was positive at 31 weeks pregnant.

I quarantined for the first week in my bedroom away from my husband and children, which was no small feat with 2- and 4-year-olds. I developed extreme myalgia, fever, cough, shortness of breath, chest pain, arrhythmias, headache, and loss of taste and smell. My husband and children were tested, and all 3 were positive for Covid-19. My husband had mild symptoms, while my children remained asymptomatic. That first week, I continued to have good days and bad. The second I felt I was improving; I would wake up the next day feeling worse than the day before. By Saturday evening, I had developed shortness of breath that did not subside, and my husband drove me to the emergency department to be evaluated. Initially, they were concerned I may have a pulmonary embolism, which was quickly ruled out with a computed tomographic scan. I had a chest radiograph obtained, which showed severe viral pneumonia. Within 6 hours of being admitted to the emergency department, my oxygen saturations steadily dropped and I was placed on oxygen. The decision was made to admit me to the ICU for management of Covid-19-related pneumonia.

Much like my first week battling the virus at home, that first week in the ICU was full of ups and downs. My oxygen requirement steadily increased, at maximum requiring 60 L via nasal cannula and 90% oxygen. Maternal Fetal Medicine were consulted to keep a close eye on my now almost 33-week daughter. She was under continuous monitoring and remained stable throughout the course of my illness. The ICU attending physician had warned me early in my hospital stay that I may require intubation and mechanical ventilation, in which case they would have to prematurely deliver my daughter. Many of the treatments of Covid-19 were not available to me due to my pregnant status; BiPaP (bilevel positive airway pressure) was an aspiration risk, prone positioning was not possible due to my pregnant abdomen, and the antiviral remdesivir was not well studied in pregnancy. I did receive plasma antibody transfusions, as well as dexamethasone, and the maximum amount of flow and oxygen able to be delivered noninvasively. On Friday, June 26, 2020, I made a turn for the worse. I was on maximum support and unable to maintain my oxygen saturations at an acceptable level to oxygenate my baby. The decision was made to take me to the operating room (OR) to intubate and mechanically ventilate me and deliver via cesarean section my daughter at 33²/₇ weeks.

I have never been so scared in my life. I was counseled that at that point in the pandemic, only 50% of people come off the ventilator and go on to recover. I knew my daughter would require a NICU stay and one of the biggest reliefs of the entire experience was knowing that she would be taken care of by my amazing colleagues and friends. She would be admitted to the NICU where I have worked for 14 years. Because of my husband and children's Covid-19 status, they could not visit me before my intubation and surgery. I had to say my potential forever goodbyes via a FaceTime call. The last people I saw were my NICU colleagues and friends in the OR waiting to resuscitate my premature daughter. My husband watched her birth via a Zoom call. Demi Penelope was born June 26, 2020, at 3:40 PM weighing 5 lb 7 oz. She required CPAP (continuous positive airway pressure) but was otherwise healthy and was transferred to the NICU.

After intubation and delivery, I was taken back to the ICU in a medically induced coma. I was critically ill for the first 12 hours. I required paralytics, vasopressors, an insulin drip, and 2 blood transfusions. I had a radial arterial line and an internal jugular line placed. I was placed in prone position on a fresh cesarean-section incision. I was able to receive the antiviral remdesivir. Miraculously, I began to recover, and against all odds was taken off the ventilator on Sunday morning. I was able to FaceTime my husband and kids; I was so overwhelmed with gratitude that I was alive to see their faces again.

I was weaned off all oxygen over the course of the next few days. I began eating again and powered through my physical therapy. I was in a tremendous amount of pain; coughing on a fresh cesarean-section proved to be excruciating. I convinced my physicians to discharge me home instead of transferring me to the floor. I could not wait to see my husband and children after almost 2 weeks, and I had a 6-day-old baby whom I needed to meet. They agreed, and my first stop after discharge on July 2, 2020, was the NICU to meet my darling Demi. She was discharged after 3 short weeks, and we were able to begin life as a family of five.

One of the most profound takeaways for me after living this experience is the important work that is done in hospitals every day. The kindness and compassion exhibited to me by the ICU staff were something I will never forget. I had nurses buy my lunch, French braid my hair before my intubation so it would not get matted, and help me wash my hair in the sink after I was extubated. I had a nurse hook me to a breast pump while I was paralyzed and ventilated after delivery because she knew I wanted to breastfeed. I will carry these examples of humanity and selflessness with me forever. I hope to be a better clinician moving forward because of these experiences.

Much is left to be learned about pregnancy and Covid-19. I am so grateful to have survived this deadly virus. With the widespread distribution of the newly available vaccine, new questions will emerge about the safety and efficacy of the vaccination and pregnancy.

-Mallory Goepel, MSN, RN, NNP-BC

-Lisa M. Steurer, PhD, RN, CPNP-PC, CPN

Manager, Research & Outcomes

St. Louis Children's Hospital

St. Louis, Missouri

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