Respiratory failure Prone Dexamethasone Acute respiratory distress syndrome (ARDS)
The mainstay of intensive care treatment for acute hypoxic respiratory failure due to severe COVID-19 infection is supportive with supplemental oxygen or invasive mechanical ventilation, judicious fluid management, systemic corticosteroids, and early use of vasoactive medications.
Patients are monitored closely for the development of viral myocarditis, thrombotic events, and superimposed bacterial pneumonia. Several experimental drug and other therapies are currently being studied, including remdesivir, lopinavir-ritonavir, tocilizumab, azithromycin, -and convalescent plasma [1, 2, 3] .
Severe infection with COVID-19 virus in pregnancy offers unique management challenges for the obstetrician and critical care specialist. Special consideration must be undertaken regarding oxygenation and respiratory support, fluid management, use of corticosteroids and experimental therapeutics, anticoagulation, and fetal monitoring, often with limited evidencebased recommendations. This case offers insight into the assessment and use of these J o u r n a l P r e -p r o o f management strategies, most specifically the use of dexamethasone and critical care strategies with early prone positioning in those requiring ventilator support. with placement in prone position, paralysis and sedation, and adjustment of ventilator settings to 6cc/kg with increased PEEP. A low tidal volume strategy was employed for lung protection in the setting of acute respiratory distress syndrome (ARDS) [4] . The patient remained in prone positioning for 16-18 hours daily to assist with ventilation [5, 6] . She received dexamethasone 20mg IV for 5 days followed by 10 mg IV for 5 days [7, 8] , remdesivir 200mg x 1 then 100mg every 24 hours for 9 days [1] , and convalescent plasma [2] on HD2. She received azithromycin and ceftriaxone for empiric treatment of possible superimposed bacterial pneumonia [3] .
Bilateral upper and lower extremity Doppler and coagulation studies were completed to assess however, overall, the infant had an uncomplicated NICU course and was discharged home on DOL 57, a postmenstrual age of 37 weeks, in good condition. With extensive discussion, we elected to administer this for the benefit of decreased morbidity among those receiving invasive respiratory treatment in COVID-19 infection, supported by both RECOVERY trial data [9] and data on use of dexamethasone in ARDS [7, 8] , as this outweighed the risk for fetal harm with prolonged corticosteroid exposure beyond the typical 4 doses of dexamethasone 6mg used for fetal lung maturity [10, 11] . One notable potential outcome for providers when considering use of dexamethasone is adrenal insufficiency in the neonate. The neonate was initially treated with hydrocortisone from DOL 1 to DOL 5 due to in utero prolonged exposure to dexamethasone; however, cortisol levels remained low at both DOL 18 (63.48 nmol/L) and DOL 56 (33.40 nmol/L), diagnosing adrenal insufficiency. This infant will require stress-dosing of steroids with any future surgery or signs of clinical illness.
Beyond low tidal volume strategies for lung protection in ARDS, a conservative fluid management approach has been demonstrated to improve lung function and shorten mechanical ventilation without an increase in non-pulmonary organ failure [15] and this was safely used in the pregnant state. Furosemide was used for fluid management and can be used in pregnancy for diuresis as needed [16] . Another point of discussion is the goal for maintenance of O2 saturations. In pregnancy, it is recommended to maintain SpO2 of 95% or greater [12, 13] and 92% or greater in non-pregnant patients, particularly with COVID-19 [14] .
In this case, permissive hypoxia to SpO2 of 90% or greater was utilized for maternal lung protection given reassuring fetal status by EFM and allowed this pre-term pregnancy to continue an additional week for fetal benefit. COVID-19 cultures were collected from the amniotic fluid and placenta at delivery and returned negative; however, it is worth noting that due to novel testing and laboratory processing procedures, these specimen sources have not yet been validated at our institution. Subsequent negative neonatal testing in this case does, however, strengthen their reliability.
Dexamethasone may provide significant maternal benefit and decrease mortality in pregnant women with severe COVID-19 infection requiring mechanical ventilation and at the same time promote fetal lung maturity. Neonatal concerns regarding its use in pregnancy include hyperglycemia with resulting neonatal hypoglycemia as well as the potential for the development of adrenal insufficiency. Generally, maternal benefit of this protocol outweighs risks of neonatal harm in the critically ill patient. None of the experimental clinical therapeutics are consider contraindicated and compassionate use of these therapeutics should be considered in pregnant women with severe illness due to COVID-19.