Unfavorable outcomes in pregnant patients with COVID-19
Authors: Wenhui Huang, Zhiwei Zhao, Zicong He, Shuyi Liu, Qingxia Wu, Xiaoping Zhang, Xiaoming Qiu, Huanchu Yuan, Ke Yang, Xiaomei Tang, Shuixing Zhang
Journal: Journal of Infection (2020)

We read with great interest in a recent article by Liu, et al.1Liu H. Liu F. Li J. et al.Clinical and CT imaging features of the COVID-19 pneumonia: Focus on pregnant women and children.J Infect. 2020; 80: e7-e13https://doi.org/10.1016/j.inf.2020.03.007Abstract Full Text Full Text PDF PubMed Scopus (342) Google Scholar on the clinical and CT findings of pregnant patients and children with COVID-19. It is clinically oriented, and of great value to the medical workers on the frontline. It revealed that the clinical symptoms of pregnant women were atypical, despite unavailable data about pregnancy outcome in the study. We mainly focused on the pregnancy outcome in patients with COVID-19. It seems that SARS-CoV-2 would be more friendly than its members of the coronavirus family,2Chen H. Guo J. Wang C. et al.Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.The Lancet. 2020; 395: 809-815https://doi.org/10.1016/S0140-6736(20)30360-3Abstract Full Text Full Text PDF PubMed Scopus (2648) Google Scholar such as SARS-CoV-1 and MERS-CoV, which caused severe maternal and neonatal complications.3Assiri A. Abedi G.R. Al Masri M. et al.Middle east respiratory syndrome coronavirus infection during pregnancy: a report of 5 cases from Saudi Arabia.Clin Infect Dis. 2016; 63: 951-953https://doi.org/10.1093/cid/ciw412Crossref PubMed Scopus (144) Google Scholar Currently, it is too early yet to explicitly determine the effects of SARS-CoV-2 on pregnant women and their fetuses.4Luo Y. Yin K. Management of pregnant women infected with COVID-19.Lancet Infect Dis. 2020; 20: 513-514https://doi.org/10.1016/S1473-3099(20)30191-2Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Here we explored the impact on pregnancy in patients with COVID-19 from multiple medical centers outside Wuhan, China. We retrospectively analyzed data from 8 pregnant patients who were laboratory-confirmed from January 24 to February 19, 2020. A detailed analysis of clinical features was shown in Table 1. The age range was 27–33 years. Two (20%) patients had uterine scarring and one patient was twin pregnancy. Five patients (62.5%) developed mild symptoms; three patients (37.5%) showed severe or critical illness requiring ICU admission, one of which undergone ECMO support; four patients (50%) were performed emergency deliveries because of fetal distress or premature rupture of the membrane (PROM). Specially, patient 6 with twin pregnancy had preeclampsia with high blood pressure of 180/100 mmHg and later developed into eclampsia; patient 7 presented with mild symptoms at first and her condition deteriorated rapidly within 6 h after admission, with severe complications including septic shock, septic cardiomyopathy, ARDS, MODS, requiring intubation and mechanical ventilation. Six livebirths and one stillbirth were analyzed. Half of the livebirths were premature and admitted to NICU; one twin died at the 18 days of birth with severe pneumonia, referred to "white lung"; another twin showed suspected viral pneumonia on chest CT (Fig. 1) and survived after treatment. RT-PCR tests of throat swab specimens for all livebirths were negative.Table 1Characteristics, maternal and neonatal outcomes from patients of COVID-19.PatientPatientPatientPatientPatientPatientPatientPatientCharacteristics12345678Age (years)2927283329293232Gravida, ParityG3P1G1P0G2P0G4P1G2P1G2P0G5P2G3P1Gestational weeks303439+33837+431+235+228+1Contact historyYesYesYesYesYesYesYesYesMedical historyNoneNoneNoneUterine scarringNoneTwin pregnancyUterine scarringNoneComplicationsMild anemiaNoneNoneNoneMild anemiaHF, RF, Mild anemia Eclampsia, PROMSeptic shock, SICM ARDS, MODSModerate anemiaDelivery modeOngoing pregnancyOngoing pregnancyCesarian sectionCesarian sectionEmergency Caesarean sectionEmergency Vaginal deliveryEmergency Caesarean sectionEmergency Caesarean sectionSigns and symptomsFever ( °C) *Shown are the highest intrafebrile temperature.36.336.637.137.738.639.139.338.9Cough++++−+++Rhinorrhea−−−++−+−Sputum production−++−−−−−Pharyngalgia+−−−−−+−Myalgia or fatigue−+−−−−++Dyspnea−−−−−+++SpO299%98%98%95%98%82%94%93%Blood Pressure103/68134/100118/84110/77114/76180/110100/50113/74Pulse787510095101136140102Respiratory rate1819162119243525Fetal distressNoNoNoNoYesYes, YesYesYesLaboratory Results†Reference ranges are as follows: WBC, 3.5 × 109 to 9.5 × 109/L; NEUT,1.8 × 109 to 6.3 × 109/L; LY, 1.1 × 109 to 3.2 × 109/L; Eosinophils, 0.02 × 109 to 0.032 × 109/L; HGB, 115 to 150 g/L; d-dimer, 0 to 0.5 μg/mL; ALT, 7 to 40 U/L; AST, 13 to 40 U/L; LDH 120 to 250 U/L; CK, 40 to 200 U/L; Creatinine, 41 to 73 μmol/L; BUN, 2.6 to 7.5 mmol/L; CRP, 0.068 to 8.2 mg/L; Procalcitonin, 0 to 0.046 ng/ml.WBC (× 109/L)7.836.987.66.986.4813.166.814.48NEUT (× 109/L)6.255.075.55.075.1811.022.2812.75LY (× 109/L)1.111.531.191.530.011.310.8841.09Eosinophils (× 109/L)0.060.020.000.020.010.000.000.03HGB (g/L)10213413312510210811099D-dimer (μg/mL)0.621.090.400.521.413.762.890.95ALT (U/L)182629131119.113717AST (U/L)10.92922241847.919029LDH (U/L)155NoneNoneNoneNone450529276CK (U/L)20665546None25819023Creatinine (μmol/L)4772.34763.2None27.98538BUN (mmol/L)4.03.65.41.27None3.752.35.1CRP (mg/L)1.318.42.455.88.4373.6>200.062.37Procalcitonin (ng/ml)0.0500.2700.1360.072None3.58026.8000.31Delivery outcomesUmbilical cordNoneNoneA nuchal cordNormalNormalNormalNormalNormalPlacentaNoneNoneNormalNormalNormalNormalNormalNormalAmniotic fluidNoneNoneNormalNormalNormalNormalNormalOpacity, HypamnionMaternal outcomesSurvivedSurvivedSurvivedSurvivedSurvivedSurvivedSurvivedSurvivedNeonatal outcomesGestational ageNoneNone39+338+437+531+235+228+1Birthweight (g)NoneNone4200236725851520,172027001530Apgar score (1,5/min)NoneNone9, 1010, 108, 98,8 and 8,81,18,9Severe neonatal asphyxiaNoneNoneNoNoNoYes, YesYesYesNeonatal deathNoneNoneNoNoNoYes, NoYesNoFetal death or stillbirthNoneNoneNoNoNoNo, NoYesNoAdmitted to NICUNoneNoneNoNoNoYes, YesNoYesRT-PCR testNoneNoneNegativeNegativeNegativeNegative, NegativeNoneNegativeAbbreviations.PROM, Premature rupture of membrane. MODS, Multiple organ dysfunction syndrome. ARDS, Acute Respiratory Distress Syndrome. SCIM, Septic induced ischemic cardiomyopathy. HF, Heart failure. RF, Respiratory failure. BUN, Blood urea nitrogen.RT-PCR, Reverse transcription polymerase chain reaction. Shown are the highest intrafebrile temperature.† Reference ranges are as follows: WBC, 3.5 × 109 to 9.5 × 109/L; NEUT,1.8 × 109 to 6.3 × 109/L; LY, 1.1 × 109 to 3.2 × 109/L; Eosinophils, 0.02 × 109 to 0.032 × 109/L; HGB, 115 to 150 g/L; d-dimer, 0 to 0.5 μg/mL; ALT, 7 to 40 U/L; AST, 13 to 40 U/L; LDH 120 to 250 U/L; CK, 40 to 200 U/L; Creatinine, 41 to 73 μmol/L; BUN, 2.6 to 7.5 mmol/L; CRP, 0.068 to 8.2 mg/L; Procalcitonin, 0 to 0.046 ng/ml. Open table in a new tab Abbreviations. PROM, Premature rupture of membrane. MODS, Multiple organ dysfunction syndrome. ARDS, Acute Respiratory Distress Syndrome. SCIM, Septic induced ischemic cardiomyopathy. HF, Heart failure. RF, Respiratory failure. BUN, Blood urea nitrogen. RT-PCR, Reverse transcription polymerase chain reaction. The cases here highlight three issues that worth stressing. Firstly, unlike previous reports about the favorable outcomes, SARS-CoV-2 might have similar behavior to SARS and MERS, resulting in severe maternal and neonatal outcomes including preterm delivery, PROM, fetal distress, stillborn or neonatal death, admission to ICU or NICU, undergoing endotracheal intubation, septic shock, eclampsia, and MODS. Secondly, those who are older or those who have medical histories such as hypertension and cardiovascular disease tend to fare worse,5Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506https://doi.org/10.1016/S0140-6736(20)30183-5Abstract Full Text Full Text PDF PubMed Scopus (33152) Google Scholar other than that, immunocompromised status and physiological adaptive changes during pregnancy might contribute to the rapid deterioration into severe or critical illness. Considering the unfavorable outcomes in pregnant patients, any suspected cases during pregnancy should be systematic screening; closely follow-up for mothers and their fetuses after diagnosis should be emphasized. Finally, despite all livebirths were tested negative for SARS-CoV-2, the stillbirth and one neonatal death at 18-days of birth indicated the potential risk of intrauterine infection.6Dong L. Tian J. He S. et al.Possible vertical transmission of SARS-CoV-2 from an infected mother to her newborn.JAMA. 2020; https://doi.org/10.1001/jama.2020.4621Crossref PubMed Scopus (884) Google Scholar There should be more evidence to deep investigation in the future study. The limitation of our analysis is the absence of data on the amniotic fluid, cord blood, vaginal secretion, and breastmilk samples, as all resources were stretched in a pandemic. Moreover, no data about patients at the first or second trimester was reported, since SARS-CoV-2 infection in different trimester might be associated with different outcomes. In conclusion, SARS-CoV-2 infection during late pregnancy would have severe maternal and neonatal complications, even the neonatal death. Efforts to limit exposure of pregnant women should be strengthened during the outbreak of COVID-19.