Late Preterm Pregnant Patient with Severe COVID-19 Pneumonia: Anesthesia Considerations Regarding Expectant Management Vs Early Planned Delivery

Background: Pregnant women are at higher risk of severe illness from Coronavirus Disease 2019 (COVID-19) increasing risks of adverse pregnancy outcomes(1)(2). Due to lack of effective treatments, COVID-19 consequences for the mother and her offspring can be catastrophic. Risk-benefit assessment between expectant management vs earlier delivery is pivotal. In this case, a patient with rapidly- worsening COVID-19 required preterm emergency C-section. Case Report: G3P2 33-year-old morbidly obese, with mood-anxiety disorder. At 34-weeks gestation she was admitted to our Medical Intensive Care Unit (ICU) for acute hypoxic respiratory failure due to COVID-19 infection. Initial treatment included high flow nasal cannula, remdesivir, tocilizumab, dexamethasone, and heparin infusion. Superimposed pneumonia was covered with ceftriaxone and azithromycin. Continuous reassuring fetal tone and biophysical profiling supported expectant management by OB/Gyn-team. Within 24hrs of admission she required emergent intubation with videolaryngoscope and 7.0-endotracheal tube, and emergent cesarean delivery under general anesthesia. Patient's respiratory status continued deteriorating with challenging oxygenation requiring intraoperative Airway Pressure Release Ventilation (APRV). Case was ultimately completed without immediate maternal-neonatal complications. The patient returned intubated to Medical-ICU. Neonate was transported to Newborn-ICU. Discussion: Pregnant patients might be at higher risk for severe COVID-19 disease including pulmonary infection and multi-organ failure, and perinatal/neonatal complications(3)(4)(2). Physiologic changes of pregnancy, and risk factors like obesity, asthma, and cardiovascular disease, likely contribute to elevated morbimortality rates. Risks are higher during labor, especially in acutely-ill parturients. Key considerations include maternal/fetal compromise, maternal oxygenation and hemodynamics (3). Potential challenges include ongoing heparin treatment, contraindications to regional/ neuraxial, difficult airway, difficulty oxygenating mother and fetus(5). Multidisciplinary approach helps assess risks/benefits of earlier delivery in symptomatic COVID-19 parturients and anticipated maternal clinical deterioration. Anesthesiologists should be involved early to improve materno- fetal safety and reduce risks of infection for medical staff.