Catastrophic Coronavirus Disease COVID Infection Leading to Gangrene of Foot in Peripartum Women.

Introduction: Pregnancy is a physiologically hypercoagulable state and a coronavirus disease 2019 (COVID-19) infection adds to this burden by accentuating the coagulopathy. We report two cases of severe peri-partum COVID infection leading to extremity gangrene secondary to a pro-thrombotic coagulopathy.

Case One: A 37-year-old lady, day-2 postpartum, was brought with severe COVID infection & and respiratory failure. She developed progressive gangrene of the foot. A computed tomography (CT) angiogram confirmed the presence of thrombosis of the left external iliac & and common femoral artery. She was managed with catheter- directed thrombolysis and fasciotomy. The dry gangrene of the foot was managed with a Boyd's amputation. At 1-year follow-up, she is ambulant with a healthy stump.

Case Two: A 34-year-old lady, 36 weeks of gestation, presented with fulminant COVID infection with respiratory failure and pulmonary embolus. The lady developed gangrene of the B/L toes. A CT angiogram revealed thrombosis below the popliteal trifurcation in both limbs along with segmental pulmonary thrombo-embolism involving the right lung and multiple splenic infarcts. She succumbed to the overwhelming infection and sepsis.

Discussion: The pathogenesis of coagulopathy in pregnant COVID patients is attributed to the hypercoagulable effect, which leads to thrombo-embolisms and limb ischemia following a cytokine storm syndrome in severe infections. To date, this is the first experience detailing distal limb gangrene in fulminant COVID infection in peri-partum women. Although, cases have been reported on distal limb gangrene in severe COVID infection among non-pregnant individuals.

Conclusion: A multidisciplinary team must manage COVID infections in the third trimester. A prompt recognition of any forms of lethal coagulopathy and vigilant treatment will prevent loss of life.