Lisseth Hernandez arrived at Massachusetts General Hospital in an ambulance, 29 weeks pregnant with twins and struggling for breath. Within hours, she was fighting to stay alive.
Over the next two days, her heart raced to twice the normal rate despite two experimental treatments — including the antiviral drug remdesivir. Dr. William Barth, a maternal fetal medicine specialist, and his team would have to decide: Deliver the twins 10 weeks early with the risks of prematurity or allow the pregnancy, which was placing enormous stress on Hernandez’s heart and lungs, to continue.
As he cared for Hernandez, Barth recalled an urgent call he had received from a colleague across town 10 days earlier. She had a pregnant patient also sick with COVID-19 and needed advice. Barth had immediately phoned a former mentor in Texas, who said without hesitation, “Get her delivered.”
During the pandemic, medical challenges like this have played out in hospitals across the country, especially in obstetrics, where doctors consider the impact of their decisions not only on the mother, but also on their unborn babies. With no COVID-19 research or textbooks to rely on, obstetricians have turned to each other, trading advice and experiences.
As they waited for the virus to hit the United States, obstetricians were not sure how it would impact their patients. The flu, chickenpox, and other infectious diseases are especially dangerous for pregnant women, even though they are generally young and healthy. Yet reports from China indicated that pregnant women were not getting as sick from COVID-19 as other people.
"When we are talking about a novel disease like this, all expectations are off,'' said Dr. Blair Wylie, the maternal fetal medicine specialist at Beth Israel Deaconess Medical Center who called her friend, Barth, to discuss the recent case.
So far in the United States, pregnant women appear to be getting as sick as others with the virus, no better or worse. But because so many people have gotten infected with the virus, an unusually large number of pregnant women have ended up in ICUs and on ventilators. A study of 427 pregnant women with COVID-19 who were admitted to the hospital in the United Kingdom found that almost one in five of their babies was born prematurely.
But it’s still unclear how many women in the United States have faced this daunting situation. "We lack a true understanding of the numbers,'' said Dr. Sarah Rae Easter, a maternal fetal medicine specialist at Brigham and Women’s Hospital.
Beth Israel Deaconess and Mass. General have each treated six pregnant women with COVID-19 in their ICUs, while the Brigham has treated three critically ill pregnant women with the virus. So far, doctors said last week, they have not lost any mothers or babies.
But at Mass. General last month, doctors worried they would lose Lisseth Hernandez.
Hernandez, 24, came down with a cough and a 100-degree fever on April 3. Her mother, who lives with Hernandez and her family, treated her with home remedies common in her native El Salvador, sprinkling her daughter with water and laying cut onions, believed to have medicinal properties, on her face.
In the previous weeks, Hernandez said, she had left her Everett home only for prenatal appointments at Mass. General’s health center in Chelsea, so she did not think she had COVID-19. And she did not want to enter a hospital where she believed she was at greater risk of catching it.
But by Friday, April 10, she was so short of breath she could not talk, and her husband insisted on calling an ambulance. "I didn’t want to go,'' she said. "He said we have to do it because of the babies.'' Her mother handed her a rosary. As she was driven away, she worried about her 2-year-old son, Jacob.
Hernandez was admitted to a regular medical floor for COVID-19 patients, where Dr. Lorenzo Berra, a critical care specialist, administered the first experimental treatment doctors would try for her: nitric oxide gas, which widens blood vessels in the lungs and can make breathing easier. Berra is leading an international clinical trial on this potential treatment for COVID-19, but the approach did not help Hernandez. She could not tolerate the mask, which made her feel like she was suffocating.
Barth was increasingly worried about her heart rate: At 120 beats per minute, it was far above the normal 80 and even above what’s usual for pregnant women. Every time she tried to speak, it shot higher. The team transferred her to the ICU, where nurses could monitor her vital signs more closely.
Barth called Dr. Andrea Ciaranello, an infectious disease specialist at the hospital, and together they filled out an online form Friday night asking Gilead Sciences for special permission to use the company’s drug remdesivir. It had been originally developed to treat Ebola patients and is now being tested for COVID-19. Because she was pregnant, Hernandez did not qualify for a clinical trial.
As they waited, her heart rate rose dangerously — at one point reaching 160 to 180 beats a minute. Her breathing grew so fast that she was taking a breath almost every second.
"These women tend to get sick and then they seem to do well for a while and then they get sick again, fast and badly,'' Barth said.
The remdesivir was sent by the company and arrived at Logan Airport at 7 a.m. Sunday. A courier drove it to Mass. General. But the medication failed to stop Hernandez’s escalating symptoms. At 11 p.m., the medical team agreed it was time to put her on a ventilator. Visitors are not allowed during the pandemic, so nurses updated her husband and sister by phone.
Because her breathing worsened when she lay down, Dr. Daniel Austin, a critical care fellow at the hospital, inserted the tube into her throat while she was sitting. Dressed in a gown, gloves, mask, and face shield, he reached over her head from behind and succeeded on the first try as doctors and nurses looked on outside the glass doors.
Barth discussed whether to deliver the babies, a boy and a girl. It was 10 weeks before their due date, a day short of 30 weeks gestation. Obstetricians typically like to wait until a pregnancy has reached 32 weeks, after which most premature babies do well. And if there was a complication during surgery, her body would be ill-prepared to handle it.
On the other hand, doctors two days earlier had started giving Hernandez betamethasone, a drug that speeds lung development in babies before they are born. But mostly, Barth thought, there was no other choice.
“We were asking two to three times as much of her heart and lungs as we would anybody else. And the infection, we were not really getting ahead of it,'' he said. "We had exhausted everything. We didn’t have anything else to offer.''
He and a team of 25 medical personnel successfully delivered the twins by emergency caesarean section at 6:30 a.m. the next day.
Hernandez does not recall much about her hospital stay until she awoke a day later. A nurse congratulated her and showed her a photo of the babies. "I was like, wait a second, what happened here?'' she recalled. “They told me everything. I was so happy.”
While she had been sedated, the babies were transferred in two ambulances to the neonatal intensive care unit at Tufts Medical Center. Mass. General was not admitting babies to its own neonatal ICU because it needed the ventilators for dozens of COVID-stricken adults.
The mother’s recovery was remarkably fast.
Barth stopped by Hernandez’s room on Tuesday, and he thought he was in the wrong place. She was sitting up in bed — she had pulled out her own breathing tube — texting family and friends. Barth said that is one of the enduring images of the pandemic for him, a woman on the brink of death, a day later on her phone.
“I don’t think I will ever forget it,'' he said.
Last Wednesday afternoon, Hernandez sat in a rocking chair in the Tufts neonatal ICU, Sebastian resting in the crook of her right arm, Aurora on her left. After she was released from Mass. General on April 18, she had to wait two weeks to see her twins to make sure she was no longer infectious. The first day her husband drove her to see their babies, she was so nervous she was sweating.
Dr. Jacyln Boulais, associate medical director of the Tufts neonatal ICU, said the twins are improving quickly. They have gained weight. They now each weigh more than 4 pounds and are drinking milk from doll-sized bottles. Hernandez said their personalities have emerged. Aurora is feisty, Sebastian is mellow. She spoke to them softly in Spanish, telling them about the family waiting for them at home.
Liz Kowalczyk can be reached at firstname.lastname@example.org.