Emergent Bedside Cesarean Section for COVID-19 Patient on Veno-venous Extracorporeal Membrane Oxygenation: A Case Report

Abstract

Background & Case: A 38-year-old Spanish-speaking, pregnant woman at 26.1 weeks’ gestation with two previous Cesarean sections (C-section) presented with acute respiratory distress syndrome secondary to COVID-19 pneumonia. She was intubated and ventilated, complicated by bilateral pneumothoraces and emphysema requiring bilateral chest tubes and blow holes. She had worsening hypoxic respiratory failure ultimately requiring cannulation for venovenous extracorporeal membrane oxygenation (VV-ECMO). She was started on cefazolin for Methicillin-susceptible Staphylococcus aureus bacteremia. On day three of VV-ECMO, there was non-reassuring fetal heart tone necessitating emergent bedside non-sterile Cesarean section at 27.2 weeks’ gestational age in the surgical intensive care unit. Post-Cesarean section, her respiratory failure improved, and she was decannulated from VV-ECMO 13 days later. This case report highlights that VV-ECMO can be a life-saving treatment option for pregnant women with cardiopulmonary failure who are unresponsive to conventional therapy. Literature describing Caesarean section on VV-ECMO is limited. Specifically, there have been only a handful of case reports of C-sections on patients put on VV-ECMO due to respiratory failure. Results: The obvious benefit of proceeding with this emergent bedside C-section was to save the fetus. However, this had to be weighed against the risks of hemorrhage in this high-risk patient since she had two previous C-sections and was on a therapeutic heparin drip while on VV-ECMO. Additionally, there is the risk of infection due to having the C-section done in a non-sterile manner, especially in a patient who is bacteremic. This was mitigated by using additional prophylactic antibiotics post-operatively. The patient’s respiratory status improved significantly after the fetus was delivered, likely due to improvements in respiratory mechanics post-partum. The successful outcome of this patient and her baby required the timely coordination of a multidisciplinary team. Conclusions: Emergent C-section on a pregnant woman with respiratory failure on VV-ECMO can be life-saving for the fetus and the mother. However, the inherent risks associated with it requires close monitoring of the patient and the fetus in order to determine when this is truly necessary. Keywords: Acute respiratory distress syndrome, Cesarean-section, COVID-19, Pregnancy, Veno-venous extracorporeal membrane oxygenation