SUCCESSFUL CESAREAN SECTION IN A COVID-19 PATIENT ON EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Objectives: Introduction
Extracorporeal membrane oxygenation (ECMO) support in severe respiratory failure has expanded to diverse patient populations and clinical scenarios. ECMO therapy during pregnancy was first described in 1991 and is supported by current literature as a salvage strategy for refractory respiratory failure. The ongoing SARS-CoV-2 (COVID-19) pandemic has resulted in increased demand and utilization of ECMO for COVID-19-related respiratory failure in patients with severe disease. Limited reports have been published of the use of ECMO in pregnancy, and cases documenting the both the successful delivery of the fetus and survival of the mother while on ECMO are exceptionally rare. We present the case of a 37-year-old female with COVID-19 viral pneumonia and refractory respiratory failure who underwent Cesarean section while on ECMO support with survival of both mother and infant.

Case Report
A 37-year-old Hispanic female with no significant past medical history presented to our emergency department with shortness of breath three days following a positive COVID-19 test. Labs obtained upon presentation were significant for elevated D-dimer and C-reactive protein levels. Chest radiography was consistent with COVID-19 pneumonia. Despite prompt initiation of supplemental oxygen via high-flow nasal cannula, the patient rapidly decompensated with worsening respiratory status and underwent endotracheal intubation within six hours of presentation. The patient was admitted to the intensive care unit (ICU) and had persistently high ventilator requirements with overall worsening oxygenation. The patient was cannulated for veno-venous ECMO in the operating room on hospital day 7 after continuing to worsen. Three days after procedure, sustained fetal heart rate decelerations prompted emergent caesarean delivery. The 27.2-week-old male infant was promptly transferred to the neonatal ICU and progressed well. The patient’s condition continued to improve after delivery and she was discharged to a rehabilitation facility on hospital day 49.

Discussion
ECMO therapy during pregnancy has been described for sequelae of non-infectious peripartum complications and severe respiratory infection. Meta-analyses consisting of patients prior to the COVID-19 pandemic report maternal survival at 77% with fetal survival of 69%. In this case, ECMO allowed survival of both mother and infant in an otherwise non-survivable respiratory failure. Consistent with existing reports, we believe ECMO is a viable strategy for refractory respiratory failure in the pregnant patient.

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