Maternal-neonatal outcomes of pregnant women with COVID-19 requiring extracorporeal membrane support: A case series

ABSTRACT

INTRODUCTION Pregnant women are considered a high-risk group for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Compared with non-pregnant women of reproductive age, pregnant women with severe coronavirus disease 2019 (COVID-19) were less likely to report symptoms;however, they seem to be more likely to need hospitalization, admission to an intensive care unit (ICU) and invasive ventilation and to experience acute respiratory distress syndrome (ARDS). In case of ARDS and critical COVID-19 infection the World Health Organization (WHO) recommends the use of extracorporeal membrane oxygenation (ECMO). However, available data on ECMO in pregnant women with critical COVID-19 are very limited. In these case series, we report maternal and fetal outcomes of 3 critically ill pregnant women who required ECMO support for COVID-19. METHODS We reviewed the literature about pregnant women underwent ECMO due to ARDS caused by COVID-19. Then, we compared the available literature with our case series, focusing on maternal and fetal outcomes. RESULTS Our cohort comprises three women two of them underwent ECMO during pregnancy and the other one just after delivery. The first patient tested positive for COVID-19 during the second trimester (19th week of gestation), she developed ARDS and underwent ECMO for 38 days;in this period, infectious (isolation of methicillin-susceptible Staphylococcus aureus (MSSA) in the Broncho-Alveolar Lavage (BAL) fluid) and thrombotic (clot in right atrium) complications were reported. She was discharged in good general conditions after cesarean-section [CS] (due to previous one) at term. The second patient tested positive during the third trimester (28th week of gestation) and underwent ECMO due to sudden worsening of hypoxia not responding to conventional treatments. She experienced a precipitous vaginal delivery at 32 weeks 2 days of gestation, complicated by postpartum hemorrhage and neonatal complications due to prematurity. Infectious (BAL positivity for MSSA and blood cultures positives for E. Coli) and thrombotic (pulmonary embolism) maternal complications were also reported. She was discharged about a month after delivery in good general conditions. The third woman is an obese patient (BMI 51) with pregnancy obtained with heterologous ICSI, infected by COVID-19 during the third trimester. She underwent CS at 38 weeks of gestation due to the worsening of clinical parameters and subsequently was placed on ECMO;to date, after two months, she is still in critical conditions, with ECMO. Despite that, neonatal outcome is reassuring. The first two newborns were never tested positive for COVID-19;the third one was tested positive after 14 day after delivery, without any clinical consequence. CONCLUSIONS ECMO is a feasible treatment in pregnant women with severe COVID-19. According to the available literature, our case-series showed that complications associated with ECMO in pregnant patients were consistent with those reported in general population including bleeding, thrombosis, infectious and vascular complications, while the most commonly reported fetal complication is preterm delivery. Collecting and sharing data is imperative to allow a better comprehension of the disease and to improve the standard of treatment.