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.