Use of Intravenous Tocilizumab in Pregnancy for Severe Coronavirus Disease 2019 Pneumonia

Two Case Reports

Shazia Abdullah; Nihal Bashir; Nageena Mahmood


J Med Case Reports. 2021;15(425) 

In This Article

Abstract and Introduction


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.


The coronavirus disease 2019 (COVID-19) pandemic has affected more than 180 million people worldwide since its first identification in Wuhan, China in December 2019.[1]

The high-risk groups generally reported in the literature include patients of advanced age and those with comorbidities such as obesity, hypertension, diabetes mellitus, and chronic respiratory and cardiovascular diseases.[2]

During the H1N1 influenza pandemic of 2009, pregnant women had a higher rate of hospitalization and mortality from influenza than the general population.[3,4]

Thus, as a precautionary measure for COVID-19, pregnancy had been categorized in the moderate- and high-risk groups by the UK's Chief Medical Officer in March 2020 as well as the Centers for Disease Control and Prevention (CDC).[5,6]

Immunological changes during pregnancy, particularly in the third trimester, make women more susceptible to severe symptoms from viral infections and hypoxic compromise, as shown in studies from the previous severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks.[7]

Certain antiviral treatments such as favipiravir and camostat, and immunomodulatory treatments such as tocilizumab and anakinra, are not routinely used for COVID-19 treatment in pregnant women, making patient management more challenging.[8]

We report two cases of pregnant women admitted to our facility with COVID-19 pneumonia who deteriorated rapidly despite advanced supportive treatment and needed tocilizumab therapy during the pregnancy. To date, there is only one published case report of tocilizumab use for COVID-19 illness during pregnancy, where it was used for cardiomyopathy associated with COVID-19.[9]