a 39-year - old woman ( gravida 2 para 1 ) had reversetranscription polymerase chain reaction ( rt - pcr)-confirmed mers - cov at 35 + 4 weeks of gestation . this patient had gestational - related diabetes , but it was well - controlled by diet without medication . she was admitted to obstetrics ward of our institution on april 19 due to premature labor . during the 6-week admission period , she visited her mother who was hospitalized in the emergency department of the same institution on may 27 and 28 , which was the same time that a known mers - cov super - spreader patient was treated there . her mother developed illness with fever on day 7 after contacting the super - spreader and was confirmed positive by mers - cov rt - pcr . our case complained of severe myalgia without fever on june 8 and was admitted to the isolation ward 5 days after discharge . creactive protein ( crp ) was elevated to 1.95 mg / dl and a chest x - ray revealed patchy opacity in both lower lobes , suggesting bronchopneumonia ( fig . 1 ) . a chest x - ray taken 4 days later was improved and crp had decreased to a value within the normal range ( 0.15 mg / dl ) . however , she complained persistently of episodes of dyspnea , sputum , and myalgia without fever . she was provided supportive treatment , but no antiviral agent or steroid because the disease was not progressing . fetal growth was within normal gestational limits , and she recovered gradually from the myalgia and other symptoms . the results of rt - pcr follow - up tests performed on june 19 and 21 were all negative in sputum samples . the division of infectious diseases confirmed a full recovery , and she moved to the obstetrics ward on june 22 where she was expected to have a normal delivery . however , she began sudden bleeding with abdominal pain on the day after recovery was declared . we considered spread of mers - cov because her symptom onset was very recent , and delivery would involve a large volume of contagious body fluids . an emergency c - sec under combined spinal - epidural anesthesia ( cse ) was scheduled with precautions . all designated specialized infection control personnel prepared for the surgery and wore enhanced personal protective equipment ( ppe ) ( fig . she was very anxious in the operating room , so we provided emotional support but no premedication . she was 167 cm tall and weighed 79 kg ( body mass index , 28.33 kg / m ) . her baseline blood pressure and heart rate were 120/50 mmhg and 82 beats / min , respectively . the patient was placed in the right lateral decubitus position , and epidural anesthesia was attempted with a 17-gauge tuohy needle via the median approach at l34 . the epidural space was detected using the loss - of - resistance technique , and a 22-gauge epidural catheter was inserted ( fig . a lumbar puncture was performed with a 25-gauge whitacre spinal needle at the l45 interspace , and 6 mg of 0.2% ropivacaine and 20 g fentanyl were injected intrathecally . the patient was placed in the supine position with a left lateral tilt to avoid aortocaval compression . anesthesia was assessed bilaterally using cold and light touch , and the spinal injection produced a t4 block after 10 min . the baby was 3.14 kg , with apgar scores at 1 and 5 min of 9 and 10 . a 10  10 cm blood clot was extracted and approximately 20% of the placenta appeared to be abrupted . total operation time was 150 min , with an estimated blood loss of 700 ml . a total of 2700 ml of crystalloid solution and 1000 ml of colloid were administered during the surgery . an infusion of oxytocin ( 10 units/1000 ml ringer 's lactate solution ) and carbetocin ( 1000 g/10 ml normal saline ) was administered to produce uterine contractions and minimize blood loss , respectively . she was administered in the operating room until a recovery block to t8 , then the patient was transferred directly to a single room on the obstetrics ward . the baby was isolated in the intensive care unit , and a mers - cov test was negative . we performed an emergency c - sec in a patient with a highly infectious respiratory viral pathogenic disease . sudden placental abruption occurred at midnight , and an immediate c - sec was recommended . our multidisciplinary team had discussed the delivery and had developed emergency scenarios ; thus , the c - sec progressed without delay under the regional anesthesia ( ra ) for several reasons . she was not actively bleeding , and only moderate variability in fhr was detected without deceleration , so we had ample time to perform the cse . although the decision - to - deliver interval for general anesthesia ( ga ) is faster than that for ra , ra is preferred to ga because it is safer and causes less maternal and neonatal morbidity than those of ga . although her chest x - ray and laboratory results improved , the patient had pneumonia within 2 weeks . we were not convinced that the lung parenchyma had fully recovered , and tracheal intubation / extubation in a patient with mers could expose the medical staff to a high aerosolized viral load . potentially high - risk procedures should be performed by experienced medical staff during an infectious disease outbreak period . mers is thought to be transmitted mainly via respiratory droplets and close human contact , but the mode is not completely defined . although we already had some infection - control protocols applicable for the operating room for known infectious diseases , such as pulmonary tuberculosis , viral hepatitis , human immune deficiency virus , and antibiotics - resistance bacterial infection before the mers outbreak , we developed a new operating room protocol for patients with confirmed or suspected mers because of the high infectivity and unknown transmission mode . the patient 's sputum was mers - cov negative based on rtpcr before delivery , so it is unclear if strict precautions were necessary . however , the patient had been declared recovered for only 1 day , and illness onset was within 2 weeks . in addition , a c - sec frequently involves large volumes of blood , amniotic fluid , and other body fluids , and these could be infection sources . no other case reports are available on delivering a baby for a women with mers , but several cases of labor and delivery in women with severe acute respiratory syndrome ( sars ) have been published . viral shedding from maternal body secretions , stool , cerebrospinal fluid , and peritoneal fluid has been reported in sars cases , suggesting that mers - cov could be present in any body fluid and transmitted during c - sec , which is why we treated this patient for confirmed mers perioperatively . we followed our institution protocol for patients with mers and referred to the sars obstetrics guidelines . according to the management guidelines for obstetric patients with sars , all deliveries should be managed in a designated negative - pressure isolation room and by designated personnel with specialized infection control ppe . as we have no permanent negative pressure operating rooms at our institution , two operating rooms were converted to negative - pressure . these rooms were connected , but had separate air - conditioning and humidification units with individual atmospheric air inlet and exhaust systems . we used one as the operating theater and the other as a ppe changing room . the air pressure in these rooms was maintained at -4.7 pa ( operating theater ) and -1.2 pa ( changing room ) . modifications were made to minimize outflow of contaminated air from the mers - related operating rooms . all anesthetic and surgical team staff used enhanced ppe comprised of a n95 mask , surgical cap , double gowns , double gloves , shoe covers , and powered air - purifying respirators . after the patient recovered from anesthesia in the operating room , the patient was transferred back to the ward by the same dedicated anesthesiologist who changed into new ppe to minimize mers - cov exposure . .   reported that use of an n95 mask by a healthy women during late pregnancy did not change any physiological or subjective findings compared with those of healthy , non - pregnant women during sedentary activities and exercise for 1 hour . if a pregnant woman is infectious , they may be able to use an n95 mask without complications . finally , the mers - designated spaces were all ventilated for 100 min and thoroughly decontaminated after the case . placental abruption occurred in our case , which is one of most commonly encountered uteroplacental bleeding disorders with high rates of perinatal - maternal morbidity and mortality . several reports have indicated that maternal acute and chronic respiratory diseases during pregnancy are associated with placental abruption . acute and chronic respiratory conditions may trigger an inflammatory and hypoxic process at the maternal - fetal interface that may lead to placental abruption . however , placental abruption occurs in only about 1% of pregnancies . only two case reports are available on pregnant women with mers who delivered a baby . a woman in abu dhabi died after giving birth to a baby by c - sec , and the other case our patient was complicated by a history of premature labor , gestational diabetes , and advanced maternal age . the reasons for the good outcome are unclear but may be due to the late stage of gestation and earlier detection of mers . long - term follow - ups of infants and mothers are needed to fully define the pregnancy - related risks of mers infection . most human infections result from human - to - human spread , and when particular medical procedures are combined with poor infection control the virus can disseminate within the hospital . thus , protocols and education for medical workers are essential to minimize exposure and protect against transmitting the pathogen during an infectious disease outbreak . surgeries , particularly those performed in an emergency situation , have a high risk for spreading a contagious pathogen . thus , a multidisciplinary team of emergency personnel should be prepared , including surgeons , physicians , nurses , and anesthesiologists . early and strict infection control strategies and clinical guidelines for infectious patients , such as those with mers , should be established .
only a few reports have been published on women with an infectious respiratory viral pathogen , such as middle east respiratory syndrome ( mers ) coronavirus delivering a baby . a laboratory confirmed case of mers 
 was reported during a mers outbreak in the republic of korea in a woman at gestational week 35 + 4 . 
 she recovered , and delivered a healthy baby by emergency cesarean section ( c - sec ) . 
 we present the clinical course and the emergency c - sec in a pregnant woman with mers .