Discussion
We report a multidisciplinary approach to treating and complete recovery of acute respiratory failure and severe pneumonia secondary to SARS-COV2 infection during pregnancy. A plethora of studies have demonstrated the management of mild – moderate cases of SARS-COV2 infection in pregnancy with positive outcomes (2,10,20). However, very few studies have reported the management of critically ill patients, particularly in pregnancy. Pneumonia during pregnancy is often accompanied by hospitalization and critical care management including ventilatory support (20). Although the treatment of pneumonia during pregnancy mirrors that of non-pregnant state, the use of convalescent plasma and ECMO in pregnancy is rare (9,11,21).
The clinical presentations, symptoms and the radiological findings in our case were consistent to previous case reports (3,22,23), of SARS-COV2 infection. A nationwide population-based cohort (n=1942) reported, pregnant women with viral pneumonia (other than COVID-19) demonstrated higher risk of preterm birth, intrauterine growth retardation low birthweight and poor Apgar scores when compared to those without pneumonia (24). Hence, as demonstrated in this case, an early delivery is considered as an alternative for critically ill pregnant women with ARDS.
In terms of therapeutic management, no specific pharmacological agent or vaccine to treat COVID-19 is available (12). Once COVID-19 was confirmed, hydroxychloroquine, azithromycin, oseltamivir, intravenous ceftriaxone and methylprednisolone were administered. Hydroxychloroquine and methylprednisolone are considered safe in pregnancy and have been used extensively to treat COVID-19 (25). However, there is a paucity of evidence regarding the use of antimalarial and antiviral therapy in treating SARS-COV2 infections (26), even in this case, it is unclear if the empirical use of these medications had any role in the recovery of our patient. Tocilizumab (monoclonal antibody IL-6 receptor antagonist) was administered post operatively, due to the deteriorating respiratory functions, hemodynamic instability and persistently elevated inflammatory markers. Several COVID-19 studies have demonstrated improved respiratory functions, and successful recovery in patients receiving one dose, (27-30).
Anecdotal evidence from previous viral infections including Ebola, SARS-CoV, H5N1 avian influenza, and H1N1 influenza suggests the use of convalescent plasma containing neutralizing antibody is effective (31-34). Food and Drug Administration (FDA) has recently approved the use of convalescent plasma to treat critically ill COVID-19 patients (35). A meta-analysis investigating effectiveness of convalescent plasma in SARS coronavirus infection and severe influenza, reported significant reduction in viral loads and mortality (36). In this case the transfusion of convalescent plasma demonstrated improved clinical outcomes, and COVID-19 specific inflammatory markers were significantly improved.
There is a scarcity of evidence behind the use of lung-protective ventilation and ECMO in COVID-19 infection during pregnancy (10). The use of ECMO in pregnancy and postpartum is rare. An estimated 40% of pregnant or postpartum women admitted to ICU are complicated by ARDS or cardiac arrest (37,38). Like previous reports demonstrating improved maternal survival (39,40), the use of VV-ECMO in this patient is expected to have potentially resulted in positive respiratory outcomes and successful recovery. Furthermore, providing adequate rest to lungs using VV-ECMO was necessary to avoid ventilator-associated and oxygen-induced lung injury.