 Good afternoon, everyone, and welcome to the 16th installment of our University of the Philippines and the Philippine Health Insurance Corporation's stop COVID-19 webinar series where we tackle clinical management updates on COVID-19 cases. I'm Dr. Raymond Francis Sarmiento, Director of the National Telehealth Center at the National Institutes of Health at the University of the Philippines, Manila. And as always, I'm very happy to share the floor, share the stage with a dear mentor and my beloved friend, Dr. Susie Pineda Mercado. Dr. Susie. Hi, good morning, Raymond. Magandang umaga po, magandang hapon mo, magandang tanghali sa lahat ng mga nakikine. Welcome to our 16th webinar. Manami po tayong magandang pag-usapan. We'd like to greet people who are watching all the way from Saudi Arabia to Kagayan De Oro and just thank everyone for being part of this regular activity on learning more about COVID and how we can stop COVID deaths. Raymond. Thank you, Dr. Susie. For those who are just joining us for today or at least for season two, so alam niyo po na today po, not just for today but starting po last week, we started our season two, which ushers in a new format for our discussions and what we call this format is the virtual grand rounds. So dito po sa virtual grand rounds, we highlight a particular case and last week we were discussing the doctor as a patient where we featured Dr. Roddy C and for today po, we will have a very special, very interesting case to be tackled by our distinguished panelists and roster of speakers po. And in this format, we will be focusing po on the case of the patient using the backdrop po in terms of the different dilemmas that our medical teams experience on a daily basis. Dalila po dito po sa kaso ng COVID-19. Dr. Susie. So Raymond, we've got an interesting case, a COVID negative mother who delivers to a COVID positive baby. But I think beyond that, we're also going to tackle what it means for health workers to continuously see tragic events. So while this webinar is about stopping COVID-19, we cannot avoid the fact that we are going to have patients who will die, who will leave us. And so we're going to talk a little bit more about that, what that means about for our health workers and our spirituality as doctors when we encounter these types of events because truly this pandemic is not just what people getting sick. Raymond, one of my friends once just said to me last night, God is reordering the world. Panong binabago nga yung mundo. And so we have to not just listen but also reflect on what this all means to us as health workers as well as to our patients. Thank you, Dr. Susie. Napaganda po nang sinabi nyo. I mean reordering by being who is higher than us and to be able to just understand all of these things and put everything into context po. Just for those who are again joining us, our format po for the webinar will be initially we will have a case presentation and then moving on to a panel discussion and then moving on to towards our Q&A wherein the questions from our audience will be tackled po by each of our guest speakers. And before we move forward with the introduction of our opening remarks speaker, I would like to acknowledge po the different institutions who make up this incredible team which I am very, very privileged to be part of. It starts po at the office of the president and the office of the executive vice president at the University of the Philippines, the office of the vice president for public affairs, the TV UP po. It will not be possible po for those who are joining us in the playback or those who are joining us po who are not able to join us here at the Zoom webinar and have been directed to the YouTube channel of TV UP. Maraming salamat po sa kano nood po. We also have our partners po over at the University of the Philippines, Manila at the office of the chancellor, the office of the National Institute of Health, National Telehealth Center, the Philippine General Hospital and the UP College of Medicine. And finally, and last but not least po, our partners over at the Philippine Health Insurance Corporation. So before Dr. Susie introduces po our opening remarks speaker, this is the part where I mention po again kasi po by the text na po talaga naging e-mail at nagpapandala po ng mensahi po nungkot po sa kanilang certificates, kailang po wala po po ang certificates. So yung po nga certificates have been distributed po po at least from webinar 1 to webinar 12. For webinar 13 onwards po, the presentations po kasi are still being revised by our resource persons po. So before we upload them, we try to get their consent in terms of the version of the presentations that will be uploaded po. So anta bihan nyo lang po yan kasi kasabay po na inyong certificates ay ang link po to the presentation that was given for that particular webinar. And as always, yung po pangalan na i-inpo po ninyo, maigip po na maging maingat po sa mag-enter po kasi kung ano po yung mag-appear din po sa inyong in-enter sa registration, ay yung po ang pangalan na lalabas po. So over to Dr. Susie. Parang fast work pala yan, Raymond pang nagkamali ng spelling dun sa certificate nyo. Okay, we're just making this a little light for you. We've got a fascinating set of speakers today and we're going to start off with a brief introduction from the newly minted, the newly minted deputy director of the Philippine General Hospital who's been really quietly again, one of those persons who's been quietly working behind the scenes to make this happen. It's really, what should I say? It's really a huge coordination endeavor to bring people together to come up with the grand rounds. And when she was designated by the dean to handle this, wow, I mean this really took off. So may I introduce to you, Dr. Stella Marie Jose, who is the chair of the Curriculum Committee of the College of Medicine but is also now the new deputy director of PGH. Stella, good morning. Good afternoon. Good afternoon, everyone. Susie and Raymond, it's nice to be invited to be the opening remarks. Oh, what does it feel like? Stella, what does it feel like to be the deputy director of PGH? My goodness. How do you balance that with your love life and your friends? How do you manage that? You know, as my predecessor, Dr. Julietse Aguilar said, it's like playing the piano, Stella. There's, you know, one will be for the nurses' concern, the residents' concerns, the other administrative concerns, you know, even diatari is under the health operations and there were so many who became COVID positive in the diatari section, so, so, so a brang investigation namin jang. So it's already remedied and then of course, the HIKO, the Hospital Infection Control Unit, that's also under my, my, my office. So it's a daunting task, but I'm trying to make, you know, I'm trying to keep up with all the things happening in the in the hospital because we're a COVID, that's a COVID referral center but now all hospitals must admit 30% COVID patient so hindi na siya COVID referral center hospital as it is. Everybody is encouraged to have COVID patients. Yeah well yeah I mean if you guys know Stella she plays the piano really well so to say that this is like playing the piano I think we're looking to a very good no no to uh what should I say somebody who's really going to be on top of operations very complicated matter very modern complicated. Thank you po uh Dr. Stella for joining us and for also getting together with all of the department clinical department chairs at PGH so for them to be able to nominate cases for our virtual grand rounds I know that might not be that was not an easy task to be able to do that and that's really one of the many many many reasons po that we are very thankful for your involvement po and for your active participation in this preparation po. Thank you and especially po for the case that you will be well identified po for today Dr. Stella. Stella go ahead and give us your introduction for our audience. I would like to welcome you all to the virtual grand rounds of the UP Phil Health webinar series. We will be presenting an interesting patient that okay that's an open patient an obstetric patient who came in as a COVID negative mother but she gave birth to a COVID positive baby. We are lucky that we have distinguished panelists for today and we have Dr. CBL Bizan Bravo the section chief of the division of infectious diseases in the department of obstetrics and gynecology at the PGH so she's a clinical assistant professor and we have Mary Mel Pagkatipunan associate professor in pediatrics division of infectious infections and tropical diseases in pediatrics and of course we have Dr. Lulu Bravo professor emeritus from the department of psychiatry to discuss the mental health issues in this case so at the end of this webinar we hope that you our audience who would gather would have acquired nuggets of knowledge regarding COVID-19 in pregnancy which can be helpful in your clinical practice. Thank you very much. Thank you very much Stella and um uh by the way Stella it's it's Dr. Lulu Ignacio. I'm sorry Dr. Lulu Ignacio oh my sorry yeah we're with Dr. Ignacio because we're going to we're going we're going to look a little bit at what how do we deal with overwhelming situations and I think in in all of our grand rounds we'll want to to do more than just talk about clinical management let's talk about the human uh the human side of of the pandemic so thanks thanks so much Stella you're staying with us right so you'll be on the panel later and uh Stella Stella was really uh which is very excited about this case as I hope you are okay Raymond over to you. Thank you Dr. Susie and thank you also to pjh deputy director for health operations Dr. Stella Marie Jose for that heartwarming message so last Dr. Susie mentioned uh we will wait for uh Dr. Stella to join our panel discussion later after the presentations have been given by our roster of speakers pa and at this point I think uh this will be the part wherein we launch our fun quiz or ang ating pong uh pre-test webinar questions uh if you click on the polls I think this uh it will show you uh the ones that are the questions uh nominated by each of our uh presenters and each of our discussions po um may we have the polls to be launched po I think the poll po kasi is still close okay as we wait for the for the launching of the pre-test questions in the polls uh I think this will be the part okay we're having or okay I think we're having technical issues po in launching the polls um so while we wait for Ramon ay napatiin tayo from hospital ng palawan uh surgical orthopedic ward nursing staff so good afternoon to you. Good afternoon po. So we have also um attendees po from well not just from local but also from international po as always uh tunahin na rin po natin ang ating mga local attendees we have ones from uh vegan in Ilocos Sur uh we have ones from Nueva Ecija in Central Luzon, from Virac Catanduanis in Bicol Region, from Naga Sibu from Central Visayas, from Sibutad, from Wanga Del Norte, from Wanga Peninsula, and from Coronadal City in Sok Sargen. Internationally I think this is the very first time that we will have attendees from Johannesburg from South Africa um Cardiff Wales in the United Kingdom, Masinagudi in India, from Pematang Siantar North Sumatra in Indonesia, and we also have our resident attendees po from Riverside, California, from Doha Qatar, Saudi Arabia, and from Abu Dhabi. So it really goes to show in terms of the beach ng ating webinar series po and the topic and how important and how interesting po talaga the topic that we will be talking about um so as as we are trying to fix our technical issues with the polls I think uh not to waste any time po but uh I'll give the floor over to Dr. Suzie for um I think oh there we go The poll is up yeah okay so the questions po we will have four questions for the polls for today the very first question states uh the following statements are true except option a further validation of COVID-19 transmission should be facilitated especially if the mother's RTPCR result yielded negative and the newborn's result yielded positive okay that was a mouthful pero I hope you join us in this very fun quiz wala po pressure sa pagsagod po nito it's just a way for us to be able to measure po kung ganap po ang ating nalaman towards the end of the webinar po kasi the answers to these four questions will be provided by our guest speakers options two option two states it may be proven to expedite delivery for COVID-19 mothers with severe to critical symptoms option c the use of nitrous oxide or laughing gas as an anesthetic is highly recommended and option d states severe COVID-19 may result in elevated transaminase so ganda nyo po no so ang kanong po kasi ay alin po dito ang true maliban sa yun po ang katandungan sa question number one for question number two a suspected rare maternal fetal transmission was detected to an infected pregnant woman she was asked to take an investigational drug for COVID-19 which of the following drugs should question due to its detrimental effects on neonates option a chloroquine phosphate option d lopinavir reponavir option c ribavirin and option d remdesivir okay so please feel free to input po your answers in this pre webinar questions po for our question number three the ideal test for a 35 year old pregnant patient at 31 weeks age of gestation is option a pcr swab test option d serum antibody test option c nasal swab antigen test and option d of pcr and antibody test po and last but not least our question number four uh the following are the filipinos a major coping mechanisms option a is ritual option b the bayanihan spirit option c joy or humor and option b all of the above so please feel free to input your answers po uh as we are going through all of the questions and as we went through all of them it looks like uh responses are coming in although uh given that we already have reached our standing room only or our maximum capacity for zoom webinar uh we still would like everyone po as much as possible to join in answering po our poll questions so uh just just continue to input po your uh answers to the questions as we move towards the next section of our webinar so in this webinar po talaga at what we mentioned the concept for for the virtual grand rounds is really about the art of storytelling and to help set our case study in context for our viewers uh a short video po was prepared by the tv up team and i hope we'll be able to show that at this time benita finds herself pregnant at the age of 27 she is single and comes from a conservative family life has not been easy for her she was born with a congenital heart defect patent duktus arteriosus she was given some medications when she was three months old she claims it is difficult for her to sleep without two pillows under her head if she tries to walk up two flights of stairs she would be out of breath on the 28th week of pregnancy she experiences a persistent cough on the 30th week of pregnancy she starts spitting out blood and has difficulty breathing she consulted at the er of a hospital and the chest x-ray was taken chest x-ray results showed hazy densities in the right upper lung fields the initial impression was pulmonary tuberculosis she was given medications and was sent home four hours prior to admission she has regular uterine contractions and a blood issue she consulted at a lying in the center but was transferred to a bigger hospital on admission her blood pressure was 170 over 110 heart rate 85 respiratory rate 24 with oxygen saturation of 82% which improved to 88% with administration of 10 ml oxygen via nasal canya okay so that's uh just such a again a very emotional presentation of the case thank you tv up for that and that sets the tone for uh the case that we're going to hear about today and it's my privilege to uh welcome our presenter dr. Hannah Sambilia she is the infectious disease division fellow of the department of obstetrics obstetrics and gynecology of the philipine general hospital Hannah welcome to our webinar thank you ma'am have a good afternoon and also good afternoon to everyone and to dr. Raymond as well okay Hannah you look great uh you know the i remember in the olden days uh Raymond the ob rotation was really toxic right it's it's physically a physically draining rotation for clerks and interns but uh Hannah's the and Hannah's the fellow for infectious disease so um Hannah how how how are you coping now uh i i don't think you realize that covid was coming when you applied to be a fellow what is it like to be the infectious disease fellow at the philipine general hospital for obstetrics and gynecology um ma'am it was really um a good timing na i'm a fellow ma'am during this pandemic actually i did not expect this i only thought that i would be um handling um hiv cases um but this pandemic um really taught me a lot of things taught me the how to be more careful um in um disease um in disease um particularism um in handling ma'am this patients because um our goal is not only to um give um cure but also to protect ourselves ma'am from being um infected also from of the virus ma'am yeah right huge challenge Raymond no how do we how do we keep our health workers uh free free from covid i'm sure Raymond your colleagues and your classmates who are really in the hospitals in the front line are also facing this a lot of us uh i think uh we're able to see this there was a viral photo po that was shared from the phpgh medical foundation it depicts two health care workers who were in their full ppe gears and they were nakasalam pakusila sa floor and there was assigned their day to not remove the ppes it was just really very symbolic of let's say the amount of work the burden that the health care workers have been uh carrying on their shoulders all of metaphorically po and at the way that uh we have been able to fight this uh pandemic po it really it really would just assure in something from you innately in terms of uh being able to sympathize and empathize with our colleagues who are really in the trenches and who are fighting this disease po uh face to face if you will on a daily basis so uh on behalf of everyone i think uh we would like to like maybe put in the pedestal po ang ating mga front time workers and uh health care workers po in terms of the work that you have been doing and for taking care of all of the patients and because we have been reaching our critical care utilization po uh at near maximum capacity that is something to be to behold you are really uh serving as the last line po in terms of uh if if it were a dam na bago po mag break ang dam kayo po talaga ang naga hawak hawak kamay so marami salamat po sa inyong ginagawa so um dr susie or dr hana yeah so i think reyman that's such an important point no i think i just want to acknowledge also that as reyman that said everyone everyone's tired everyone's working so hard and um it's not easy it is not easy to be a uh doctor a health worker in in this time of the pandemic and just to mention also reyman before we turn the floor over to hana that uh these first two stories we've given have featured uh up in the philippine general hospital but in the next uh in the next webinars we're going to have other medical schools and other hospitals as we did in the first episode so that we really get a good representation of uh what's happening on the ground to all of our health workers and of course what what kind of cases doctors are encountering so hana uh this is now your moment to present your case uh over to you go ahead dr hana please share your screen po okay i think here we go okay um good afternoon um this is a case of a 27 year old gravity no one para zero who came in due to regular uterine contractions one day prior to admission the patient had irregular uterine contractions not accompanied by bloody or watery vaginal discharge at this time no consult was done and no medications were taken few hours prior to admission the patient noted regular uterine contractions it was now accompanied by bloody vaginal discharge hence consult was done the patient went to other health facilities before consulting in the admitting institution our patient is a known case of congenital heart disease patent doctors arteriosus um resolved at three months of life on the interim no follow-up check up with a cardiologist was done the patient developed easy fatigability and two pillow arthropnia but denied episodes of worsening cyanosis the patient was admitted at 28 weeks and three days age of gestation in a government hospital for three weeks history of cough accompanied by hemoptysis and difficulty of breathing she was clinically diagnosed with pulmonary tuberculosis and was started on hrz during her admission rtpcr for COVID-19 was done and the result came in after 10 days and it was negative the personal family and social history were non-contributory for the prenatal work up um the patient had four unremarkable prenatal check ups in a private physician however monitoring monitoring for her car shock problem was not done for the pertinent review of systems the patient is a gcs 15 oriented to time person in place she denied blurring of vision she had an occasional two pillow arthropnia and exertional dyspnea she had cough difficulty of breathing and clubbing of nails upon arriving at the emergency room the patient had a BP of 170 over 110 heart rate of 85 rr of 24 she was a fibril and her auto saturation was 82% on chest examination she had a dynamic precordium regular heart rhythm with distinct s1 and s2 fixed splitting of s2 and palpable s2 was noted with point of maximal impulse at the third intercostal space located at the left parasternal border no thrills no haves no murmurs were noted breath sounds were difficult to auscultate at that time on abdominal examination she had good fetal heart bones with full dick height of 24 centimeters and an estimated fetal weight of 1.2 to 1.4 kilograms on internal examination her cervix was 3cm dilated 50% effaced cephalic head at station minus 3 with intact bags it was also noted that our patient had globed finger nails and grade one bipedal edema at this time the admitting impression was pregnancy uterine 30 weeks and two days age of gestation cephalic in preterm labor gestational hypertension rule out preeclampsia pulmonary tuberculosis clinically diagnosed ongoing intensive phase treatment gravidocardiac functional class 2 secondary to congenital heart disease to consider atrial septal defect rule out patent ductus arteriusus in acute decompensation rule out congestive heart failure COVID-19 probable gravidowon parazero her treatment plan included BP control by giving hydrolysin she was given a total of three doses and her blood pressure was maintained at 150 over 100 seizure prophylaxis was done by giving magnesium sulfate preeclampsia work up was also done by requesting for CBC staturine albumin creatin in LDH AST and ALT to manage her gravidocardiac condition the patient was placed on continuous O2 support at 10 liters per minute via face mask she was also referred to as the cardiology service for co-management and 12-lead ECG chest x-ray electrolytes to the echo were all requested however 12-lead ECG was old was only done the 12-lead ECG revealed regular sinus rhythm right access deviation right atrial enlargement to consider right ventricular hypertrophy versus right ventricular strain and nonspecific ST weight changes to control her preterm labor the patient was given magnesium sulfate dexamethasone was also given to promote fetal lung maturity to investigate the cost of preterm labor urine cs sputum cs rectovaginal and endoservital swab were requested the patient was also referred to the OB infectious diseases and pulmonology service for co-management and to the anesthesiology service for epidural catheter insertion in case the labor progresses on the second hour of labor her BP rose to 160 over 100 another dose of hydrolazine was given and her heartbeat blood pressure was 150 over 100 at this time the patient had a category two trace for minimal variability with strong contractions occurring every four minutes repeat internal examination was done and it showed labor progression with six centimeter cervical dilatation the patient was referred back to the anesthesia service for epidural catheter insertion however after few minutes the patient had labored breathing and developed circumoral cyanosis oxygen saturation was noted to decrease to 65 percent hence she was referred for intubation to secure the airway on the third hour of admission the patient still had elevated BP tachycardia tachypnia and o2 saturation of 60 to 70 percent at 10 liters per minute oxygen support the patient delivered bias contains vaginal delivery to a live baby girl preterm 31 weeks life pediatric aging with an apgar score of seven becoming eight post delivery her BP normalized to 110 over 70 but her o2 saturation dropped to 20 percent his assessment at this time was acute decompensated heart failure the patient was intubated and was given furosimide post intubation the oxygen saturation improved to 40 percent however her blood pressure dropped to 50 over 30 hence norepinephrine drip was started in fluid resuscitation and resuscitation was done however after five minutes the vital signs were noted to decline hence acls was started however after 15 minutes of attempted resuscitation the patient expired postmortem naso fringiswap for COVID-19 was done on the other hand the baby was tested for COVID-19 at the 30th hour of life and the result was positive the baby fought however at the ninth day of life the baby also expired these laboratory results came in postmortem this case was signed out as decompensated right-sided heart failure secondary to pregnancy gravidocardial functional class 2 to 3 congenital heart disease to consider atrial septal defect rule out patent doctors arteriosus with ace and menger syndrome help syndrome pulmonary tuberculosis clinically diagnosed ongoing intensive phase treatment pregnancy uterine delivered vaginally to a pre-term live baby girl small for gestational age early in your natal death secondary to severe COVID-19 infection COVID-19 rule out gravida one power one zero one zero zero in summary sadness frustration helplessness guilt false feeling of incompetence and the weight of informing the bad news to the relatives were some of the things that haunt us whenever a patient dies in our hands COVID-19 pandemic made it worse a lot of patients had limited access to medical care due to various reasons like fear of getting infected limited internet access limited mode of transportation no hospital vacancy and poverty to name a few the patient came in in a decompensating state with available resources at hand limited known past medical history and the difficulty of wearing a PPE the whole team did everything they can in the fastest possible time to save the mother when the mother died they still hope that the baby may survive there are times when things get out of our control and we can only cling to god our ultimate physician with god's help emotional healing is achieved by improving ourselves to be the best physician that we can be for our future patients thank you thank you very much hannah uh for for sharing for sharing that um that case and um also sharing some of your personal thoughts on on this on this case and i think for for those of us who are watching uh this is not an uncommon um sentiment or feeling for doctors who are who have to deal with tragedy uh so i think now rima we let's bring in the rest of our the rest of our test yeah so uh we're going to call on so we can have everyone on screen i believe and we're gonna have um dr. sibilizane bravo uh division chief of infectious diseases uh of the department of obstetrics and gynecology we're going to have also pediatrician dr. marimel pagkatikunan who is on the covid management team for for pedia and dr. lury designasco is professor emeritus of psychiatry so uh can we have all of you open your cameras and turn on your mics so that the audience can see everyone okay i think do we have i think we're seeing dr. sibil and dr. jing magandangapun po hello everyone and uh is dr. ignacio on board ready yes mam lulu is uh okay we're seeing mam lulus video po okay so thank you everyone po for uh for all of our panelists uh for uh being able to uh join us po rima let's ask stella to also join us uh dr. stella who's who's who's also an obstetrician gynecologist and uh we're very fortunate to have chancelor menschick padilya also with us uh and she's going to give us some some of her thoughts also after she's a pediatrician so um chancy please please open your please open your video okay now we're going to start uh with with some some remarks from uh dr. sibil bravo who's the division chief of infectious disease for obstetrics and gynecology of pgh sibil over to you so good afternoon dear doctors and everyone uh in the room thank you very much for having me first of course i wasn't the direct um physician of the case no where the patient the case was referred to us being the ob infectious disease specialist in our institution but of course in these cases i put my foot at the actual case i imagine myself um being hands-on so just like what hannah said donning the PPE and all and of course doing everything trying to save the patient so what hannah said i also felt that way it's just so sad that uh we have been experiencing now not shortages of beds and hospitals and more than half who are patients they would tell us on admission that they have been to from two hospitals to as much as eight hospitals with no vacancy they were turned down they were literally turned away and of course when they came into our emergency section they're at well some of them who would be at the late state of their condition most of them they're an imminent labor okay thank you yes thank you dr sibil um i believe you have a set of slides pa for your discussion of the case uh please feel free to share your screen ma'am there we go okay okay so we have here we are presented no with a mortality case of a pre-migravid who delivered with our mental institution the pertinent data are as follows she had a congenital heart disease that of ASD cannot roll out uh patent duplicates at their uses and of course she also presented with hypertensive disorder of pregnancy and of course right to admission she within this admission she was also diagnosed with pulmonary tuberculosis of another government hospital we're in the initial COVID results were negative and as was mentioned the our initial to center the post-mortem COVID examination for our patient was also negative so this this brings us to really the complexity of the case including the diagnosis that we use in diagnosing COVID infection so we have here uh two situations in mind no we have to investigate the possibility of a false negative PCR result and assume that our patient had COVID infections so to understand it we need to discuss briefly the reasons for a false negative test and then tackle the relationship to infection with congenital heart problem this is fairly complicated by preeclampsia and other uh medical conditions if this were a case of a graphic patient with a false negative PCR result for COVID uh we treat her no as a COVID confirmed case then look into the effects of as I mentioned the infection in pregnancy as well as um of course check the relation of COVID infection with congenital heart problem hypertensive disorder and of course her tuberculosis if these were a case of a patient with a true negative COVID PCR result then of course we treat her as a COVID negative case okay so the course would have been related to her COVID condition aggravated again by her other medical conditions so we need to understand the diagnostic test in order for us to have a grasp of the possibility that this case was a false negative PCR test so what is the positive test result it means that the person um the sample now taken from him or from her is currently infected by the virus whereas the negative test means that uh the person is not currently infected by the virus the virus is not present at the site where the sample was taken from or it was a poor quality or that the sampling was done too early or at the converse site it was done too late in the infection to detect the replicating virus so negative test results require new patient samples to be taken a few days later to reduce the chance of incorrectly um missing and infected versus especially of course when you have high index of suspicion so these are the causes no of false negative stars called the PCR test versus incorrect timing specimen collection the second of your sample collection techniques and the third could be your individual variability in amount of viral shedding so first is incorrect timing of uh sample collection researchers will just hopkins hospital found that obtaining the um sample not too early of course you have very high false negative rates and of course as you um go on with time no especially at the symptom onset kung kala siya magakakaran na respiratory symptoms in particular that would be one of the best times no of obtaining the sample for uh doing the test and at around a week after you know the infection or around three days after um onset of the symptom you will have the highest a false negative rate that of 20% or let's say you would have an 80% uh chances of detecting the infection so we see here um this figure shows estimated timeline of diagnostic markers for detecting the infection the virus in most individuals with symptomatic COVID infection viral viral RNA in the nasopharyngeal swab becomes detectable as early as day one of symptoms so let's just concentrate on the blue line no this is the nasopharyngeal swab using the PCR test we see here that um it's it would yield no the highest for a positive result when you do your collection at the right time but of course it's not a perfect test still because we see here that even for some of our patients there could be really chance no even if you collect it at the ideal time let us say a week after her potential exposure or infection or um at least three days from onset of symptoms if the patient will become symptomatic you will still have false negative results so for our patient they again the initial test done at another government hospital on May 28 to be exact was negative and again on current admission around 10 days after we still got a negative result though again this was taken post mor 10 so clearly we have three scenarios here if the first scenario could be that the patient was not really infected at the first admission at the first government hospital and then the repeat test at the second admission was also negative so she that she was really uh she didn't get the infection the second scenario would be that she had the infection at the first admission but swab was also a false negative result she's mentally recovered and 10 days during her second admission no virus was detected the reason for us obtaining a negative result and that's why it could be that again she was not infected at the first admission then she was discharged she might have gotten the infection at the community level and then had a false negative test during the second admission whatever it would be of course we're considering a false negative test for scenario um numbers two and three and as such the covid infection took its toll no with her pregnancy as i mentioned uh we could do post mor 10 specimen collection when of course again we have high index of suspicion and when it's very very important to do this procedure for contact tracing in the community and of course for those who are involved in crime investigation it could be part of uh estate investigation or part of an autopsy so for our case we did it for our patient but still um considering the fact that of course no her stormy course would really give us a very high index of suspicion for covid demoya considering this is really now a pandemic but still we obtained negative results so for the second cause of false negative PCR test we consider the type of specimen as i've mentioned earlier um the nasopharyngeal specimen no would be according to studies would yield the highest rate of positivity for patients who are really infected but specimens from skew tomb or endothrical aspirates for those who are intubated including bronco alveolar lavage among hospital hospitalized patients may also be sent for laboratory processing and the third reason uh the individual variability in amount of viral shedding um studies have shown that viral shedding may begin to the three days before the symptom onset onset and after symptom onset viral will decrease no consistent with other studies and as such infectiousness may actually decline significantly on day eight after symptom onset as a virus could not anymore be detected by culture or even by swab in most studies okay so analysis suggests that viral shedding again no as i've mentioned may begin before the symptom onset so this again very important to consider so again our patient had um negative initial results and 10 days later her PCR so was still negative assuming she was infected during her stay at the first hospital wherein she was swab she recovered uneventually no and so 10 days later her swab turned out to be negative also but the infection again had negative effects on her pregnancy or she may have been infected no when she got home at the community level the symptoms of covid have been masked and had negative effects on her pregnancy but if this were the case no it would have been not rather it would not have been a false negative result she may really have recovered which is the reason for her negative PCR test 10 days later so if our patient had a false negative PCR test and that she was truly infected we now go into a brief review of the effects of SARS-CoV-2 infection in pregnancy um initial studies done from june january to febno would show us that um this infection had a rather mild course no or mild uh outcomes or rather favorable outcomes in pregnancy but into the latter part of this pandemic let's say starting march until the current time more studies have come up revealing that uh this infection would really produce different adverse maternal and even nanatal outcomes so recent studies demonstrate that for the maternal complications the atrease of having preterm delivery, rupture of membranes, and a tickle intubation and of course admission to ICU and of course the hypertensive complications and for the nanatal complications some studies would show that this virus could again be transmitted transposentally and could result to nanatal death and of course inteririterine infection so for our patient they call that she delivered preterm at 30 weeks and we see here from this systematic review that um preterm birth is a rather um complication of SARS-CoV-2 infection in pregnancy as compared to the general population the incidence of preterm birth global is let's say our packet around 5 to 15 percent but in this review it was packet around 20 percent so about 1-2 of our patients now can deliver preterm due to this infection is the mechanism why or rather you know for all viruses for all viral infection can induce preterm labor so there's battle entry into the trophoblast which could induce apoptosis resulting to preterm birth so again our patient had preterm labor at 30 weeks and delivered a preterm infant so again our patient had also decompensated heart failure coupled with that is of course she also had a congenital heart problem that was uncorrected no it's more likely eto septal defect and she developed isenmanger syndrome um it's really hard to um be sure of our diagnosis because she didn't bring with her any to the echo studies and the history was not reliable but we referred to the cardio service their impression was also eto septal defect of course uncorrected cannot roll out pva but with isenmanger syndrome and the patient was clearly in decompensated heart failure okay so again cardiovascular comorbidities are linked to high mortality risk and um in pregnancy that is and specifically for women know with congenital heart disease they are really at risk of acquiring COVID infection especially if they have additional comorbidities such as of course heart failure or lung disease in our case she also had pulmonary tuberculosis so patients with congenital heart disease are at risk of developing different complicated history and pregnancy arrhythmia and stroke and of course pulmonary hypertension our patient also had polycytemia with this very high hemoglobin and very high hematocrit which results from chronic cyanosis this is the result of her uncorrected um cardio condition and this is in the background of having a very low platelet count so again she was clearly having the health syndrome that's hemolysis elevated liver and signs with low platelet no that's one of the at the other end of spectrum of having the preeclampsia syndrome and as such again uh hemostatic changes may lead to high risk hyperviscosity syndrome thromboembolic events or cerebral vascular complications and other complications associated with isomagor syndrome know with include um hemoptysis which by history are our patient also suffered from and other diseases such as uh having impaired renal function so after delivery as was mentioned by our uh the center our patient had decreasing blood pressure and oxygenation because of an increase in plasma volume during pregnancy shunt volume can increase leading to her symptoms and again this was coupled with the possibility that she really harbored SARS-CoV-2 infection and of course her hypertensive complication of course as we mentioned now the healthcare givers would do everything to make this patient know survive so they did advanced cardiovascular life support but again the patient was not revived anymore now for the next topic that i would want to correlate our patient with is that again assuming that our patient had an infection can SARS-CoV-2 induce preeclampsia like syndrome recalling that our patient on admission had very high blood pressure so compared to the general population women with uh unrepared ASB had high risk of preeclampsia fetal mortality and having small progestational HVDs so how about COVID and its relation with inducing preeclampsia well studies have shown no i came across two studies were in the authors tried to correlate the possibility that it was a COVID infection that induced the preeclampsia not just not really the pregnancy itself so for this um this the prognopropose mechanism uh were in the clinical features of preeclampsia would be mainly the consequence of endothelial damage originated by placental obstetive stress which leads to the appearance of hypertension, proteinuria, elevated liver enzymes which our patient had little failure or thrombocytopenia so an increase is the rest of preeclampsia has been reported again among patients infected with SARS-CoV-2 compared to the general population so in this particular study is a very nice study because the office was done in Barcelona were in the authors correlated again or rather check mo investigated if COVID really induced a preeclampsia not really really pregnancy related so for the purposes of their study they used a certain angiogenic factors such as the anti maternal placental growth factor and maternal serum pyrosine kinase that would be indicators that if the patient was positive for these factors coupled with a rather high very high LDH levels more than 800 IU per ml with um abnormal no uh perfusion by ultrasound then most likely it's an actual case of preeclampsia but if the patient no um was negative for these factors then they um concluded that the preeclampsia was not pregnancy induced it was more of the infection that induced a preeclampsia so again in this particular study five patients had severe preeclampsia and uh eight no or rather five had pneumonia rather or so sorry sorry five that's severe preeclampsia among eight patients who had severe COVID pneumonia so for the four patients they had of course signs of symptoms of preeclampsia health syndrome but they were they had normal levels of these angiogenic factors and their LDH level was not that high coupled with the normal uh double ultrasound they surmised that these patients no um had the preeclampsia that was induced by the infection so for these four patients um all had the solution actually of their severe uh preeclampsia a pan treatment of their severe pneumonia there was only one patient wherein they had very high levels of the lactate hydrogenase and the patient was positive for the different angiogenic um factors serum levels such that they actually had to terminate the pregnancy preterm for control of the labor or for management of the case so again these surmised that preec the preeclampsia in this four patients with severe pneumonia was induced by the infection okay so so much for that again despite these findings vertical transmission still appears to be very low but several reports have shown that prexysplovirus on fatal membranes now would prove that there is still possibility of vertical transmission in the placenta COVID is um thought not to infect the entity or cells leading to a pro-coagulable state so again it's important that the signs of fatal and maternal malprofusion are not specific for COVID infection because it is seen in other hypercoagulable states such as the following even in normal pregnancies so again correlating with our case our patient had severe preeclampsia with this blood pressure she was dysnecone admissional with RRF 24 and of course she was uh really clearly hypoxic and her ABG revealed respiratory ecclosis with severe hypoxia she was of course given oxygen support uh chest actually was um not done no because the events were very fast well it should have been done ideally not to roll pneumonia in other fine gains and into that as i mentioned she had the health syndrome no with uh she fulfilled all of these now she had elevated LDH elevated liver and sentin ready located pounds so for our patient as as i mentioned need to substantiate with additional studies like doing placental studies through molecular and histopathological uh research to prove the presence of the virus and again probably check the maternal angi angiogenic factors to further investigate the relation of preeclampsia with COVID infection so in summary again for our patient naysa footin gel swabs were taken both from the first government hospital and on admission at our institution and she was negative no in both samples which were taken 10 days apart again for my analysis she may have been infected when she got home at the community level a symptoms of COVID may have been masked but then it took effect on her pregnancy no for the worst at all on her pregnancy so considering the unfavorable unfavorable outcomes in pregnant patients and in suspected cases during pregnancy again should undergo systematic screening and close fallout of matters and their neonate should be emphasized so again for those whom we are considering um very high risk no based on clinical presentation we take us go with and of course we continuously give proper advice to our patients on destruction of the hospital and we remind them of course to practice infection control measures so thank you very much for listening. Good afternoon. Thank you Dr. Sebel for that uh interesting discussion po uh for this case uh that we have for today I think a lot of uh the questions in the Q&A portion of this zoom webinar have been but uh will try to get to them later on in the show. Dr. Susi. Yeah so okay from obstetrics we're going to move to pediatrics but before that I'd just like to mention that uh mam Sebel yung bong uh OBGYN section of PGH is watching Dr. Mario Fistien just texted me to say that they're all watching I think there are many in obstetrics and gynecology who are following this because unlike other conditions when you look at maternal health and COVID yun yung nagiging emergency talaga napukunta sa hospital there are many who really iindahin lang no they won't go to the hospital but for OB I think we are seeing more and more cases of patients are being rushed to the hospital because they're going to deliver and these kinds of situations so before we go into some conclusions we're going to listen first to the pediatric side and may I may I invite Dr. Marimel Pagkatikuna who is the COVID management in the COVID management team for the department of pediatrics to uh to give her thoughts on the case Dr. Pagkatikuna please go ahead hi you can just call me Jean okay okay so just a disclaimer that this is a uh conference on the OB side okay I'll just uh give updates on the neonatal side of this uh case Jean go to slide uh Jean go to slide uh to power for Jean okay we we are still not seeing your slide presentation but oh go to uh slideshow it's on my allies and slideshow sorry okay so I think you need to share your screen then wait I'll just open the go ahead Jean so it's very interesting Raymond no maaring ano no maaring the patient may have had COVID and actually recovered COVID affected the pregnancy that's one of the possible ways that we explain the double the double negative may have been caused by COVID no and I think what OB is telling us that they would need to do for their studies but I think I don't think we have been talking a lot about the impact of COVID on pregnant women we know there is a risk but when we listen to all the risks that were shared by Dr. Bravo I mean for me uh that was really an eye opener that so many so many um bad things could happen if a pregnant woman develops uh COVID this case also um opens up the question in terms of the different tests that we are using Dr. Suzy I think the diagnostic dilemma that this presents really just puts into perspective the ones that uh we are experiencing on a daily basis so you in quickly reviewing the case the test results of the patient were really negative for the most part so it's really well it's really baffling that the baby will have a positive COVID test result. What most of our our infection specialists have been saying no that you can't evaluate for COVID based on the test per se you really have to look at the history is so important the clinical presentation is so important so the test is just an additional tool because the tests are are quite imperfect okay jing's got her slides up go ahead jing yeah but i have to start to go ahead go backward that's fine that's okay if you can there you go there we go large na lang there perfect okay so um as i have said earlier no this will be a short presentation at the side of the infant so um so we received the baby a 31 week SGA 930 grams with an upgar score of seven becoming eight but still very unstable so we have to um intubate the patient that is secondary to um probable shock secondary to an early onset sepsis and probably a hypoxia secondary to the placental insufficiency so the patient our um recommendations for uh these infants are actually to do uh swabs nasal nasopharyngeal swabs at the third 24 to um 48 hour of life upon admission at the hospital so uh the patient became stable and was we were able to extubate on day two after the after birth and at this time we just we just did the the ETA PCR and received the result uh on the third day that's um and on admission on the baby because of the early on on sepsis no we had to give antibiotics to to for the sepsis so these were the antibiotics were given but on the third day when we saw the result of the ETA PCR which was confirmed COVID-19 uh infection um that that time also the patient presented with a new onset of nosocomial sepsis um being um presenting as a abdominal distension and so we added um metronidosol or for for the drugs at this time uh we did the repeat chest x-ray but uh it was it has no significant uh chest findings but uh the laboratory showed that there is decreasing uh WBC and uh iluse on x-ray of the abdomen so when we received the the result of the ETA PCR on COVID-19 we did um anti-inflammatory markers the determinations like IL-6, the de-timer, the CKMB and also the ferritin but at that time no when we were able to um address the nosocomial infection we we were able to win again that patient to C-PAP so oxygen oxygenation was decreased but um at on the next day after um winning to C-PAP again the patient was noted to have a decreasing platelet WBC and increasing um oxygenation was noted and at this time we were able to get the results of the IL-6 interleukin 6 CKMB and also the de-dimers which showed very high results so that's why at this time we we the patient was referred to allocology for the uh management of the COVID probable COVID infection because of the increasing uh inflammatory markers and unfortunately after giving of the IVIG and even shifting of the drugs to Meropinem for the patient uh was noted to be on a cytokine storm secondary to probable severe COVID infection but also we got the blood culture that showed that there's an ebomani sepsis and at this time the patient uh became more unstable and um and had demise the day after of uh giving of the IV infusions okay so uh this table shows us although this is the the in adults that shows us in COVID infection there's the first the early stage of the viral response which shows that they may you know have mild symptoms and then the laboratories would show us lymphopinia you know and at this time also if you would look at the anti the inflammatory markers they may now be in uh here at this time may be uh normal but um on the second stage or in the or the third stage of the infection they may have that elevation of the inflammatory markers that would support that that the patient might be coming into the cytokine storm okay in neonates we have this is the first neonate that we manage no and we receive positive for uh COVID-19 PCR in this case the patient um presented with again with shock and uh severe sepsis so as part of the management so this is what we see during a cytokine storm after the viral infection it that it appears on the final stage of the disease frequently uh related to having the extensive tissue damage with lung involvement and other multi organ failure and usually this is seen between the seven to tenth day of illness and um laboratory findings of the high interleukin six and the d dimers and the ferritin ldh uh would support this so uh in pgh we did this um guideline the treatment guideline for the COVID-19 in children and this is the updated version now um at that time when we were able to see this patient it was last June that time there's no um anti red anti viral drugs no when the SIV was not yet available and so for this case we were actually on this side no as a for as a critical for the critical case no the patient cannot be given that tozilusumab because of the age cannot be given in children less than two years of age the convalescent plasma therapy was also not available at that time and so we have to give the IVIG and this um is the the indication for this patient key now in um SARS-CoV infection in children and newborns no uh we just have uh very few studies now because we all know that children are uh presenting with COVID usually are actually uh have mild infections mild to moderate infection and in the in the case 25 cases no in this uh study in europe um of newborns with SARS-CoV uh two identified no again it's all all of them are majority of them are mild and only 12 percent are actually uh severe and 40 percent would present with disney okay fever and also feeding intolerance so uh study also they showed that the mother is is positive only in 84 percent of the cases and the morbidity in newborns may actually be related to the hypoxemia in the infected mother that was discussed earlier because of the increase risk of um also of perinatal adverse events such as birth as fiksha and then premature birth as in our case so these severe cases may also progress they progress to acute respiratory distress syndrome septic shock refractory metabolic acidosis and also coagulation dysfunction but the maternal fetal vertical transmission is still controversial no because in this uh paper uh from turkey they only see viremia in one percent of COVID-19 cases suggesting that the placental and fetal seeding might be rare okay other um join us that uh we have seen and is available the vertical transmission is still a controversial issue okay and that the studies for transplant the placental transmission is still very limited and this is just one of the uh journal that shows that the evidence for and against a vertical transmission for SARS-CoV may um be very rare in by intrauterine infection because we all know that uh there's very low viremia but and also the lack of the viral receptor which is your ACE2 you know in the placental cells but there's also perinatal infection that they have seen that causes the uh during the vaginal delivery because of the potential exposure to the maternal feces 30 percent of them um have got infected no as positive also in their maternal feces so the exposure may be uh through maternal respiratory secretions also after birth and so these are the um the the possibility thing on that getting the positive PCR in the nasal swab in the first week of life may be due to the exposure to the mother but mostly the babies are asymptomatic and if they got infected they will um have lethargy fever or respiratory symptoms again several studies from other um countries they have very low um numbers yet and there is no COVID infection uh being detected from the mother to the uh child and also in Wuhan China where they review non the nine pregnant women we confirm COVID pneumonia and um there's no evidence and they did even the um testing for the presence of the SARS-CoV-2 in amniotic fluid, cord blood even the neonatal uh the throat swab samples and including uh some samples from breast milk and but uh currently there's no evidence yet no to say that there's uh intrauterine transmission okay so as we as I have said earlier all the newborns now um born to a mother with confirmed COVID-19 infection within 14 days or before the birth or at least 28 days after birth and who had had direct contact with any person with confirmed infection they are suspected newborns thus in our um in our institution we do um screen all these newborns born to mothers with COVID probable or confirmed infection uh screen uh we do the NP swab on the 24th hour of life so we we have seen that infected mothers may be at increased risk for severe respiratory complication and thus can also transmit the virus through uh respiratory droplets even um after you know the delivery and during the breastfeeding so we recommend that researchers on the possibility of vertical transmission be done also so with that I would like to share that in our wards COVID wards we are seeing also um neonates uh also young children now being infected with COVID and I think uh we will have our own uh sharing with that next time no for the for this webinar so I hope you reserve your questions for pediatrics on the next webinar for uh or sessions thank you very much thank you very much Jean more questions come up from that presentation no parang ano ano parang kanina kala ko na clinch na natin mukang meron pang ma questions tayo no na I mean of course this this mother died immediately so anyway uh we're going to talk a little bit more and I'm I'm sure there will be a lot of questions but this is essentially a admission mortality for obstetrics and gynecology no but in four hours they did heroic efforts to save this mother's life but they could not and the baby survived but the baby was also intubated right away very very sick child and I think before we go into the technicalities of the management let's uh pause a little bit and talk about what this means for the team and the health workers who are going through this process of you know a mother who dies in front of you and a baby who is very very sick in a pandemic context where we do not know if they're really positive or negative and what is the effect of that on on the team so we've got uh on our panel Dr. Lourdes Ignacio Lulu Ignacio is known to many is our professor emeritus for psychiatry and um she's going to respond and react a little bit to this case and probably give us some some insight on how health workers can can cope in this in this kind of environment where I'm sure for the doctors this is one of many cases that you see in the day so Dr. Lulu welcome to the webinar thank you very much for inviting me to visit them as a psychiatrist I truly feel privileged in participating in this conference although I know that many of you in fact wonder why a psychiatrist in the panel of the doctors but I congratulate the organizers of this event for inserting me in the panel of the and the hosts my dear friend Susie Mercado and Raymond Sarmine for making me see that somehow psychiatry and mental health is part of health and that's a place in the discussion of this place for all of us probably to gain some lessons to learn as we go through our daily lives as health professionals especially as medical doctors amidst this pandemic I also thank Dr. Hannah Somilia for presenting this case at a manner that she could really mirror the reality of the heroic case management of Dr. Alisa Matiput-Poky and Dr. Elia Villia-Opedia. In her case summary as you heard earlier Dr. Hannah has given us a glimpse of the humanity of our young doctors these young doctors have had to contend to this 27 year old young pregnant woman who was battling for her life in the OB delivery room many questions may have come to their minds as they started helping her why was her congenital heart disease not attended to well why did she not have a regular prenatal check up to prepare her for the delivery of her baby why are members of her family who accompany her to the hospital not easily co-operate with giving them clear answers especially about possible COVID exposure Are they scot and neglect in health care or adequate prenatal good simply a consequence of the social deprivation in poverty at this family or are they also afraid that if they are known to have a possible COVID member that their neighbors will discriminate against them in the barangay I am however sure that despite all these questions Dr. Matidro the OB resident went ahead to do the right procedures in the most compassionate way she could to deal with the patient's decompensating heart, her preeclampic state and her failing respiratory function which makes the possibility of a COVID infection more likely increasing the risk of maternal mortality while at the same time coping with delays in administrative support to undertake the necessary procedures she was able to deliver a 930 pounds live preterm baby all these however culminated right in front of her eyes this young woman's death nonetheless the baby was transferred to the pediatric needle and again her pediatricians then within 24 hours found her to be COVID positive however the baby softened again in the eyes of all the young pediatricians after nine days I am glad to read in her case summary that Dr. Sunilu writes sadness, frustration, helplessness, guilt and feelings of incompetence for some of the things that haunted us as the patient died in Kundupan despite the fact that we feel indeed what they could in the fastest possible time this happens almost daily among us and this is heightened at made worse by the continuing uncertainty that it prevailed with the president of the COVID pandemic uncertainty in all of us no one is spared there are times when things get out of control Dr. Sunilu writes and we can only cling to God or ultimate decision emotional healing we gain most of the time this way although we don't ordinarily see the above lines in clinical case protocol and I saw the original of the clinical case protocol and had time to discuss with Dr. Sunilu and she did very well and I also now clearly look forward to the fact that we doctors could start to include this in our case right now our feelings, our dilemmas and the things that help us till we do it because they think to deal with that is to deal not only with a medical situation but the uncertainty of the time and Dr. Sunilu Kesa he said this emotional healing could improve us and be the best decision that we want to be in last week's webinar with Dr. Aspasian our speakers who are among our top and respected decisions affirmed the fact that their recoveries were beyond the range of medications and procedures given to them they affirmed that they recovered because they gained peace in confronting their fears of death through various forms of prayer and reunion with that guy what has therefore become clear to us and we in the mental health field have been on the forefront here that in crisis situations and extreme life experiences like what we have been also subjected to in our country natural disasters, violence, and public now pandemic we in the health professions need to be aware that we start now to reframe our view of health thoroughly with a holistic view to maintain our own health our families and those among the men and women who seek out the health we must remember the health of the state and man's physical, mental, social for now what we call psychosocial and spiritual well-being for this defines our humanity as we extend this to our families, our patients and most anyone that we are asked to help and we must recognize that it is where our compassion screens work as has been proven during this extreme life experience attention to psychosocial and spiritual needs of responders and health care professionals is vital in considering as important as the physical needs the procedures, the medications these professionals generally are really quite sensitive as human being and socially aware with a strong desire to help they have a steadfast dedication to their work however in their seal and commitment to their work they will tend to deny their own view overlook or even deemphasize the frustrations in their work always coming up with the image I am strong despite the fact that we are already going out hence they are at risk for what we now really raised a red flag for which is burnout of secondary traumatization let me deviate there because they think all of us must really be conscious of the fact that even though we extend all these heroic measures we still need to take care of our own health or any physical psychosocial because it only takes 72 hours for one to really burn out if one does not address this burn out being a state of physical and mental exhaustion a feeling of personal depression a worsening of oneself by excessively strong expectations to be strong and oftentimes the word depletion, exhaustion, excessive striving is there could only mean really slowing down, passively not even another risk is that of vicarious for secondary traumatization which is a form of a traumatic stress to those exposed to traumatic events frequent death violence, inclusive injured and thoughts are really there and this can again effectively immobilize the particular person for health professionals to a certain extent some people now prefer to this as compassion but we to preserve his or her own humanity especially when there is endless suffering prostrations and I was listening already to their discussions and it seems to me that as COVID progresses on and there is no seemingly no end to it yet I was just looking into a newspaper clip and Singapore had come up with the fact as we struggle with this with this we put ourselves at risk and since death is really right in front of us we cannot avoid but control our own mortality our own death a study that was done sometime ago by us what's wrong and what's right in the Philippines has identified three major coping mechanisms in most of them these are spirituality a bayanian spirit stemming from a strong sense of family and joy or union this study has categorically stated that there is so many Filipino states are courage daring optimism inner peace as well as capacity to genuinely accept the tragedy or pride even then among those who come to us psychiatrists remember we probably have also just specified as you guys because anxiety, panic and depression is in the air as people don't say that's going to be an anxiety epidemic anxiety has spared no one and often times when they come to us for professional help my question to this patient eventually proceeds from medical facts on a substantial spiritual issue in the psychiatry's room are you afraid to die? these often times lead interestingly enough to a relaxation by this patient to start talking about death and the patients on the topic that of lives and deaths are actually not really within our own control but that of a supreme duty was given as life it may seem quite heavy here but often times there has been difficulty to even talk about death and maybe psychiatrists could people that will control just about pain be there and death is one of the heavy issues community be there but it's important that a big medical professional health professional could control this issue now because as we go through our sessions after the discussions of the anxiety the depression anxiety, fear, panic transforms to calmness relief and relief from apprehension and dread addressing this issue however allows us to find some degree of peace accepting in fact our interconnectedness with the supreme duty and therefore we are not fully alone in the experience time to be limited to find a little bit on that but I would hope that as we now have to do this work we need to confront that because we know that death is really not anybody's choice we psychiatrists are also confronted with death and hurt because they are the suicidal people who will be making a choice but interestingly enough they don't and just quite realize that the choice is not there the choice of really un-dying time hours to freely from one to created us and as we do this to become connected to the time we have to supreme duty and therefore we cannot feel freely alone in the experience in fact to draw strength in the daunting life and death as it keeps us in our practice with a much more reassuring feeling that we have to make strength because we do have these connectedness without the input that's why we have found that the most stopping mechanism from the stopping mechanism in our country and it was really so nice to do that to Dr. Lobley too saying after all this beautiful discussion of his case last week that he finally found peace accepted what is done what are the various medications that are being tested on him when he and his nurse started to deal with the spiritual aspect that this could run to them and as they went through between human beings of COVID illness they went through all the defeats that somehow death might unjust about the same. Thank you very much. Thank you very much Dr. Inesha for helping us frame not just the clinical dimensions of this case but its impact on the team and importance of a discussion of death in a webinar series like this and this is the first time we're actually talking about a truly tragic event when you're seeing the PowerPoint presentation they're just presenting it very factually but these are two lives that were lost by it was really working very hard Dr. Stella Jose who is our Deputy Director for PGH to give a response to all of the three presentations and sort of tie it up tie it up as you see it what does this mean for us in practice at PGH? Stella are you there? At this time during this time of the COVID pandemic the doctor is really in a very difficult position it is like playing dust in quotation because some patients like in the ER the waiting list is already 18 you cannot admit all these patients because there's no vacancy and then there are so many patients that want to get in and then you have to decide it is so difficult for the doctor to say no that we cannot admit you right now it's so hard to say no it's easier to say yes but in like in this case in this obituation she was managed in another hospital and then she was sent home and then she only stayed with us for like four hours if the time was too short so there was even a question from the audience why did we not do a cesarean section in this cases doing a cesarean section will be more dangerous for the patient because there will be more blood loss it will be faster to do a normal delivery and it will facilitate even the management both of the baby and the mother as mentioned by Jean she said that there is sepsis so the baby should be attended to at once so the doctor is in that position to make such critical critical judgment and I think you have to be strong inside strong in your faith strong in your dedication in your willingness to serve without any any other consideration it's not about na babalita ka na babaling ka it's more of patient care ako yun nandapat ilabay sa ulo natin dito yun nandapat natin makandaan na ang importante ay yung patiente hindi yun at mamadalika kailangan nung umales o kaya kulang nito kulang nyan alam na natin yun but the PGH is trying its best to be a healthcare worker so you know that we even had a hospital wide COVID RTPC or for all the healthcare workers we want to show our healthcare workers that we are with them in this pandemic it is not like we are in an ivory tower and they are all down there bahala na kaya no it's not like that even our PGHPA the Physicians Association pag meron silang mga kinakalama face-to-face meeting with them with the IM residents face-to-face hindi kami natatakot magkasaket nagpukunta kami doon sa Gwasun Hall to meet them and to hear them out so the admin is doing its part with the support of Chancellor Menchie Padilla you know it's a very good this situation is really the test for all of us other hospitals are closing hospital na mainila pabelia but PGH should not close we are the last resort of our people and we are here to serve yun ang bottom line of this all alam ko yung sinasabi ni mam lulu mam lulu pasensya na luluhood ako sayo nakamali ako ng pag-introduce pasensya na mam luluhood na ako to apologize what she said is all true what she said is all true every patient that you lose some part of you goes with the patient some part of your mental strength goes with the patient we all felt bad you know my department did not want me to have this percentage sabi nila sa kanistela andami ng mga ibangkaso bakit yan pa na matay ang patient sabi ko kasi kaya siya we should tell the people that there are cases like this and what we should do about them how will you process it in your mind madali mag-kwento ng successful story marami kami niyan mas marami yan siguro more than a hundred ito lang ang alam ko na nag immortality na but this one there is a puzzle here that we have to answer Dr. Wilma Balthazar was asking what happened how did the mother get it ang sabut ko sa kanya as explained by C. Bill it can be that she acquired it in the community and then she cleared the infection but in that process the virus was already transferred to the baby or because of the timing of the swabbing hindi tama yung time kaya nanduntay sa false negative whichever it is the patient was in failure ang kanya ang sabi ko kaya Edison hindi ako ay sabit as ay kompensated heart disease because he was saying na the TB the Eisenmangerd patient can also have hemoptysis true, but she also had TB so at this point since no post-mortem was done we can definitely say for sure what is the post post-mortem findings because there is no autopsy I don't think pathology will allow it because makaparang aerosal generating procedure and patients who are suspected of COVID dapat ikikremit, so immediate cremation. But my point is, you see even the audience, Dr. Wilno Balthazar is the former chairman of surgery. All of them are asking, so ano na ngayon? Even if it's a well discussed, there are some questions in our mind. So I think when doing webinars, it's not only to enlighten us on all that is known about it. We also have to investigate what is not known about it. And not all cases, not all patients can be saved. Some patients are just too far gone in their illness. That is so difficult to save them. But the PGH is doing its part in this pandemic. When everything else has closed, PGH will still remain open. Thank you, Susie, for inviting. Actually, nag-present ako ma-mentyote. Nag-present ako to be opening remarks. Yung nang alam ko opening remarks. Alright, thank you very much. Thank you, Dr. Stella, for that wonderful reaction. And thank you for giving us a sort of a perspective and a critical role that PGH plays in the whole ecosystem as we fight COVID-19. It's very important po that we highlight not just the successes at PGH, but also the human stories, the human element in this whole virtual grand rounds. At this point, may we call on our dear UP Manila Chancellor, Carmencita Padilla, to give a few words and her reactions to the presentations. I actually just want to mention the first few sentences of Hannah when she was asked, How are you? And it's really commendable for her to say in a very positive way that I'm learning and have new lessons. And she said that, you know, one thing I've learned is how that I have to just exactly how to protect myself. And I think, you know, for PGH, and I know there are many residents and fellows who are listening to us. You've got to look at the positive side of work in PGH. And you have to come in with that kind of attitude that every patient, for every patient, there is actually something. For every patient, we can learn something. I also would like to appreciate when she said that we need emotional healing because, you know, when you see patients die right and left, there has to be a process for us in administration to find the way that we address these concerns. And, you know, we can't be talking only about the technical case. And I'm really happy now that we're looking at another dimension on how to deal with death. Because you will only get this case when you're rotating at psychiatry. But what we're saying now is that regardless of whether you are, we have to look at how the patients are feeling. Usually we think of how is the family going to accept this. But today we're saying, what about the health worker? How are we going to help them? And of course, you know, for our reactors, for the pediatrician, Dr. Saibilin, Dr. Jing, we ended up with questions. And I think that's the role of PGH now. My challenge to PGH now is we've got to gather this data so that we can give some answers to these questions. And true enough, you know, for every case that we resolve or not resolve, you probably have, I've listed a number of questions. And of course, you know, to Dr. Lu, it's always a pleasure to listen and I picked up a few points. I'd like to say in closing from what you've said and I think it's meant for everybody. But I'll stop at the point to give some time for people to ask questions from the audience. Thank you, Raymond. Thank you Chancellor Padilla for that wonderful reaction po. Let's start with a few questions that will be directed to Dr. Saibilin. So this probably will not sound too technical, Dr. Bravo, no? But the question would relate to how did you, how was the reaction or how did you fully explain to the family of the patient that even with repeated negative RTPCR tests that the patient may have contracted COVID kasi po medyo mahirap po ang convinceihin ang ito nila na ikita na negative at negative paulit-ulit po. How was that relationship and how did that actually help in trying to convince them that probably that the baby also contracted it through the mother or through some other means? Dr. Saibilin. Yes, thank you for that question first. I wasn't really the one to personally talk to the family of the patient. But of course, I did my own interview with a resident in charge. She was telling me that it was really hard talking to the family. She found it very hard to make the family understand that the patient, although clinically na we saw her course and that would point out to a really probable COVID infection, they found it hard to accept. In fact, I have to say this, upon learning the death of the mother, they were not accepting. The family was not that cooperative. I can use that term. So we can only surmise that they really found it hard to accept her death. Even so, the fact that the repeat PCR test for this patient was still negative. Thank you, Dr. Saibilin. Was that also the same reaction that the Pediatrics Department received? Dr. Patigunan. So we learned of the death of the mother early because after we received the baby the baby was actually also critical at the start. So after a week, when the baby died, we were able to communicate with the father at this point to tell him what is really happening. And we were able to get the swab for the father. And that was also negative. To see that it may happen that the father might be positive and that would prove that there is that infection. But it turned out again negative and the father remained asymptomatic. So again, what we're saying here and also for the other questions, why is there even some tweens? One tween is positive, one tween is negative. COVID-19 will tell us all these patients. That's why we are doing all these studies and surveillance. Just a good news for PGH. We already have around 108 babies born to confirm positive mothers. And there's only two results that we got that is positive. This one, this baby. And the other one is also positive. But we were able to send that baby home because that baby is a full term infant and had a very good course. And we were able to follow up that baby even a few weeks up to one month now. And the baby is doing fine. And also the mother is doing fine. So I hope this will actually be a good data for us. We don't know yet anything about COVID in the neonates and even for the children. So I hope, like our chancellor said, that these are our researches that really help us. And we want to share it to you later on after we have analyzed all this data. Thank you very much, Jing. So I think Raymond, the time has gone so fast. We have time for one more question and then we're going to do a quick evaluation of the entire webinar. We have to close soon. I know there are so many questions on the chat box and I think our panelists are answering them right now. But Raymond, take one more question. One of the questions here revolve around data in relation to COVID, SARS-CoV-2 and TB co-infections in adults, in children. And the other question, I will just tie it up. Would you expect that the course of the mother and also the baby, was that more, was that more, could that be more ascribe to COVID or to the other co-infections that the mother had? There are probably these questions for Dr. Sibel Bravo. Yeah, considering her story course and her other medical comorbidities, even if this mother were not really infected, she would eventually have this morbid course during this admission. So remember she had the congenital heart defect that was unrepaired or uncorrected. She also had pulmonary tuberculosis and at that, it would have been a late stage because she had tissue hemoptysis, although we could also ascribe hemoptysis to other conditions as well. And of course, in her early third trimester, she developed preeclampsia. So all in all, these are all major comorbidities that would really, if not control or manage well ahead before term pregnancy, would really have resulted to morbidity and mortality. So again, we need to ramp up on how to take care of our women. So lala na po, in the pandemic, they do not know where to go in. Lala na po yung mga those women are taking care of at the outpatient department. They're at a loss now where to go to. But of course for good news, we have telehealth, we have returned to our tele-consultation. Yeah, that's very important. I mean, for me, from a public health point of view, I think we have 1.6 million deliveries every year. So in the time of a pandemic, we really have to think of new ways of keeping our moms healthy knowing how terrible the consequences of COVID-B for the pregnant. So Raymond, let's go into our evaluation first and maybe our answers. And then we'll have to wind up, yes. Okay, thank you. Before we do that, Dr. Suza, I think Dr. Stella has something to say just a final word on that question. Go ahead, Stella. Stella, go ahead. Nakamut kayo, mam. For our society, the Philippine Infectious Disease Society in O2GYM, we came up with a guideline and it states there that all pregnant women at 37 to 38 weeks must have an RTPCR test. So the purpose of this is number one, because there is contrary to yung sa nasabing region, meron ng mga studies. There are studies of maternal to fetal transmission as we well earlier, they said na wala. But there are some studies in Wuhan where there is maternal to child transmission. Number two, we want to protect also the healthcare worker. And number three, so that the baby, when you give to the pediatrician, the pediatrician will be also warned about the condition of the possibility that the baby might be COVID positive. So yung lang nasabing ko na, now we are trying to remedy that situation so that the pedia will not be placed in a difficult situation. As I recall, Raymond, when we were looking at pregnant women and her child, this is really one patient, actually. They're really one patient. And I think that's also like an underlying theme in this whole webinar. Okay, over to you, Raymond. So what we are seeing here po are the polling number four, pre-webinar questions here. And these are the answers of our attendees. So mainly ask the, while the resource speaker who submitted this question po, for question number one, the following statements are true except, what is the correct answer po? Yes, the correct answer is option number three. It's the wrong statement. So we learned that first, second and fourth statements are true. Thank you, Dr. Sebel. So for question number one, the answer for this question po, is the use of nitrous oxide or laughing gas as an anesthetic is highly recommended. For question number two, which states a suspected rare maternal fetal transmission was detected to an infected pregnant woman, was asked to take investigational drug for COVID-19, which in the following drug should you question whether or not it affects on neonates? Oh, I think the correct answer here is option number three. It's rebabirin. All the others are classy drugs, US FDA classy category, seed drugs, chloroquine, your low pirito, and remdesivir are quite safe during pregnancy as long as you believe that there will be more benefits than harm for the mom and the baby. For rebabirin take note, rebabirin is a class X drug and it has been shown to have keratogenic effects during pregnancy for the neonates. So the correct answer is C. That will be rebabirin. Thank you so much. Dr. Sibel, question number three states, the ideal test for a 35-year-old pregnant patient at 37 weeks AOG. Okay. Of course we'll learn and we keep on learning and emphasizing that the negative effects that the diagnostic test of choice is still your molecular test that's your PCR swab test. So majority of our patients of our attendees got the right answer. Thank you so much, Dr. Bravo. And last but not the least, our last question, I think this is from Professor Emeritus Ignacio. The following are the Filipinos major coping mechanisms which is the correct answer mamlulu. All of the above. Okay. Okay. Thank you so much mamlulu for that question for sharing the correct answers po. I think in the interest of time and because we are, I think a little bit running over time, at this at the point wherein we call in our chancellor to give a few words as closing remarks for our virtual grand rounds number two. Chancellor Padilla. Okay. Thank you. Thank you again to UP and Phil Health for season two of Stop COVID Deaths and that in today's session we have a few points to bring home in this pandemic and probably in any other case that we have in the hospital, let us care for all the patient, the family and the health worker. Second take-home point is that as a training institution we must gather the data so that we can make proper recommendations for future care of our patients. This is a challenge now for pediatrics and obstetrics to guide us with information that you have. And Dr. Jing, I took note of your 108 neonates who actually went home. We want to know what happened to them. We must be conscious of allow me and in the last point let me, in the technical point just remember that prematurity is a complication of SARS-CoV-2 and we must be aware that comorbidities can really affect the care of our patients. But let me end with a few lines that I picked up from Dr. Lulu Ignacio. And Dr. Lulu Ignacio said that this pandemic is giving us an opportunity to reframe our notion of health but it should not only be physical but also mental, psychosocial and spiritual. And that in this time when we have this opportunity we have to stay connected with a higher being. And with that we can be better doctors to our patients. So once again, thank you to our viewers. We know we have a standing room only right now and also those viewing at Facebook. Maraming salamat ulit sa inyong lahat. Thank you. Back to you Dr. Raymond and Dr. Susie. Thank you Chancellor Padilla for those wonderful closing remarks. Give the floor over to Dr. Susie just to give a brief overview of what will happen for next week's webinar. Okay. So give it us next week. We're going to talk about senior citizen. We're going to talk about seniors. Right. So again, another angle to the COVID response who develops COVID and then has a swollen leg. So next Friday please join us. That's going to be a very interesting discussion. And I think Dr. Enrico Gruet is in the audience from Cebu Doctors. He's going to give the introductory remarks. As I said, this webinar is not, is going to include and has been including many other schools and many other hospitals. So stay with us next week. Very exciting topic. Senior citizen with COVID and a swollen leg. Raymond. Thank you so much. Dr. Susie Pineda, Mercado, who is our Special Envoy of the President for Global Health Initiatives. Maraming salamat po. At 12 na silaipoli, Dr. Susie, magsama-sama po tayo from 12 noon to 2 pm every Friday. Let's make this a Friday habit po. Sana po, kasing dami po na mga nag-register na for this webinar po, we had almost 2300 registrants for this webinar and more than 400 po ang nanonokod, ang nanonokod sa YouTube na live streaming po ng TV UP channel that is in addition to the standing room only po that we have at the Zoom webinar. So on behalf of the UP Phil Health Webinar Series Team, I'm Dr. Raymond Sarmiento. Keep safe, keep healthy and see you online. May I one more time I know you long for home But I am here, you're not alone I'll stay with you until the coast is clear The other's pain before my fears The other's love before my tears But right behind the mask I look into myself and ask Do I have strength to carry on My God, how long must this go on And leave you here to keep me strong I'm here to hold the line I'll keep my hand until my die Say his name to real Just hold on to the word he gave This time we'll come to pass Cause this salvation makes a last You'll carry you to see the breakup The other's pain before my fears The other's love before my tears But right behind the mask I look into myself and ask Do I have strength to carry on My God, how long must this go on And leave you here to keep me strong I'm here to hold the line I'll keep my hand until my die Say his name to real The other's love before my tears But right behind the mask I look into myself and ask Do I have strength to carry on My God, how long must this go on And leave you here to keep me strong I'm here to hold the line I'll keep my hand until my die Say his name to real Just hold on to the word he gave This time we'll come to pass Cause this salvation makes a last You'll carry you to see the breakup