Discussion:
The COVID-19 pandemic has created an unprecedented global health crisis,
with the rapid spread of the infection and the uncertainty surrounding
its impact on pregnancy due to the lack of scientific data.
Obstetricians have had to adapt their practices based on pragmatic
approaches in response to this challenging situation (1).
Pregnancy triggers physiological changes that primarily affect the
cardiorespiratory and immune systems. These changes include Th2
immunotolerance and alterations in the major histocompatibility complex
expression at the maternal-fetal interface, making pregnant women more
vulnerable to viral infections such as influenza or SARS-CoV-2 (2).
Pregnant women are at a heightened risk of developing respiratory
pathologies and severe pneumonia due to their immunosuppressed state and
adaptive physiological changes during pregnancy. These changes can make
them more intolerant to hypoxia, putting them at higher risk during
pandemics and other respiratory outbreaks.
Historical evidence, such as the influenza pandemic of 1918, highlights
the increased vulnerability of pregnant women during pandemics. During
that pandemic, pregnant women had a mortality rate of 2-6%, compared to
the general population. Similarly, during the H1N1 2009 pandemic
influenza virus outbreak, pregnant women faced a relative risk of 3-4
for complications from infection and were more than four times as likely
as the general population to be admitted to the hospital.
A multicenter study conducted in France since the start of the COVID-19
pandemic examined data from 33 maternity clinics and found that 617
pregnant women tested positive for SARS-CoV-2, with the most commonly
reported symptoms being cough (62.2%), fever (46.2%), anosmia
(27.2%), dyspnea (26.7%), and diarrhea (8.8%). Of the pregnant women,
20.7% required respiratory assistance, with 4.7% requiring mechanical
ventilation, 1% needing extracorporeal membrane oxygenation (ECMO), and
0.2% died. Risk factors for needing respiratory assistance included age
over 35, high pre-pregnancy body mass index (>30 kg/m²),
pre-existing diabetes or a history of pre-eclampsia, and a current
diagnosis of gestational hypertension or pre-eclampsia. These risk
factors are similar to those found in the general population.
A meta-analysis published in September 2020 that included 77 studies
found that pregnant women with COVID-19 had a 40% incidence of fever
and a 39% incidence of cough. They were more likely to require
intensive care unit admission and invasive ventilation. The analysis
found 73 deaths (0.1%). Risk factors for severe disease included age,
high body mass index, chronic hypertension, and diabetes. Women with
pre-existing comorbidities had a higher risk of ICU admission (OR =
4.21) (5).
In a case-control study comparing data from 8,207 pregnant women and
83,205 non-pregnant women with confirmed SARS-CoV-2 infection, it was
found that pregnant women had a higher risk of intensive care
hospitalization (RR 1.2) and mechanical ventilation (RR 1.9) compared to
their non-pregnant counterparts. However, there was no significant
difference in mortality risk between pregnant and non-pregnant women
with the virus.
Various biological abnormalities have been observed in individuals with
COVID-19, as per existing literature. One such abnormality is
lymphopenia, which can be identified in patients as early as the viral
disease phase. During the first week of illness, elevated levels of
transaminases may also be observed. In the second week, which is
considered the inflammatory response phase, markers such as CRP,
procalcitonin, and ferritin may increase (7).
Special attention is required in managing pregnant women with COVID-19,
considering the potential impact of pregnancy on the respiratory and
cardiovascular systems. Close monitoring is particularly crucial during
the first two weeks of the disease’s evolution, as rapid deterioration
can occur during this period.
Hospitalization of pregnant women with confirmed or suspected COVID-19
is not always required, except in cases where there is a need for oxygen
support. In situations where symptoms are not severe, ambulatory
management with symptomatic treatment is generally advised. However, it
is crucial to educate the woman about the symptoms that require medical
reassessment, such as fever, cough, and dyspnea. Self-medication should
be avoided.
Hospitalization is necessary in cases where severe symptoms develop
rapidly, such as a respiratory rate of 25 cycles per minute or higher
and oxygen saturation levels of less than 95% in ambient air.
Management in the hospital may involve a thoracic CT scan, oxygen
therapy, invasive ventilation, and corticosteroid therapy to reduce
inflammation when C-reactive protein (CRP) levels are greater than
50(2).
Oxygen therapy is initiated based on respiratory rate and saturation
levels. The threshold for initiating oxygen therapy is when SpO2 falls
below 95%.
According to the latest recommendations, antibiotic therapy is not
recommended for COVID-19 unless there is a documented co-infection (7).
SARS-CoV-2 infection increases the risk of thrombosis in patients, and
therefore, it is crucial to systematically assess the thrombotic risk in
all patients with confirmed infection. The completion of ongoing
studies, including the FREEDOM COVID-19 trial, is necessary to determine
if therapeutic-dose anticoagulation provides additional efficacy in
reducing thrombotic events, preventing intubation, or improving survival
compared to prophylactic-dose anticoagulation in hospitalized patients
(9).
Vitamin D supplementation may be beneficial for COVID-19 patients with
vitamin D deficiency or insufficiency, but there is no evidence to
support its use in the prevention or reduction of disease severity in
individuals with normal blood vitamin D levels (10). Beigmohammadi et
al. found that vitamin supplementation led to significant changes in
serum levels of various vitamins and inflammatory markers, and reduced
the rate of hospitalization lasting more than 7 days, but did not have a
significant effect on mortality (11).
According to the PAN-COVID study, which is an international multicenter
study conducted in 43 centers across 18 different countries to evaluate
the pregnancy and neonatal outcomes of women with COVID-19. The study
found that infection during pregnancy is associated with preterm birth,
primarily due to fetal distress. Although the incidence of small for
gestational age and fetal growth restriction was not higher than
expected, there was a significant difference in the proportion of
participants affected by stillbirth and FGR, depending on whether they
delivered within two weeks or after. To address this, clinicians should
have a low threshold for delivery if they detect concerns with fetal
movements or heart rate monitoring during this period.
The study also found that SARS-CoV-2 infection during pregnancy does not
seem to affect birth weight or increase the risk of congenital
malformations. However, the effect of infection on miscarriage was not
determined. The rate of pre-eclampsia among the study participants was
not higher than expected, and neonatal infection was uncommon(12).