Use of intravenous tocilizumab in pregnancy for severe coronavirus disease 2019 pneumonia: two case reports

BACKGROUND: Tocilizumab, an interleukin-6 inhibitor is part of many international guidelines for the management of cytokine storm associated with severe coronavirus disease 2019 with observed improvements. However, this drug is not recommended during pregnancy owing to the lack of safety data. Restriction of such medication use makes the management of coronavirus disease 2019 in pregnant women more challenging. Pregnant women are more likely to deteriorate from respiratory infections because of the immunological changes during pregnancy and the hypoxic compromise. We report the use of tocilizumab in two pregnant patients who developed severe coronavirus disease 2019 with a successful outcome. To date, there have not been any published data on tocilizumab use in pregnancy for cytokine storm syndrome associated with coronavirus disease 2019. CASE PRESENTATIONS: In 2020, two pregnant women of Asian origin in the last trimester of pregnancy were admitted to our hospital with severe coronavirus disease 2019. Their clinical condition progressed rapidly despite maximum supportive treatments. Blood testing in the second week of illness showed rising ferritin and interleukin-6 levels, indicating the possibility of cytokine storm syndrome. Both developed respiratory failure necessitating mechanical ventilation. Due to their critical clinical condition and lack of response to supportive treatment, a decision was made to use intravenous tocilizumab therapy. Both were treated with one intravenous infusion of tocilizumab and had a successful outcome. They were extubated later and gradually weaned off supplemental oxygen. The first patient continued with her pregnancy during the hospital stay with normal fetal scans. The second patient needed an emergency cesarean section and delivered a healthy infant. CONCLUSION: In critical clinical situations, tocilizumab may have a role in managing coronavirus disease 2019 related cytokine storm during pregnancy.