New-onset myocardial injury in pregnant patients with coronavirus disease 2019: a case series of 15 patients.
Mercedes BR, Serwat A, Naffaa L, Ramirez N, Khalid F, Steward SB, Feliz OGC, Kassab MB, Karout L.Am J Obstet Gynecol. 2020 Oct 22:S0002-9378(20)31206-0. doi: 10.1016/j.ajog.2020.10.031. Online ahead of print.PMID: 33098814 Free PMC article.
Take Home Points – Damien Cullington
- Observational study from a single institution from Dominican Republic
- Study period March 20 2020 – June 30 2020
- Total number of symptomatic pregnant patients admitted in study period with COVID-19= 154.
- Assessment of the clinical, laboratory, radiological and outcomes of 15 pregnant women infected with COVID-19 who developed myocardial injury and ventricular dysfunction – 10% of the larger cohort.
- Two thirds of patients in the myocardial injury cohort presented with dyspnoea and 16% with palpitations. Patients were admitted circa 10 days (+/- 3 days) after symptoms began.
- All patients with myocardial injury were admitted to ICU and 87% required ventilation.
- Mean LV ejection fraction in those with COVID-19 myocardial injury measured 38% (+/- 6.4%)
- 2 deaths were reported in the myocardial injury group equating to a 13% mortality rate in women with COVID-19 infection and ensuing ventricular dysfunction.
Commentary from Dr. Damien Cullington (Liverpool, UK), chief section editor of Cardio-Obstetrics Journal Watch: COVID-19 has turned the world on its head and as a healthcare community we continue to grapple with understanding whom it may infect and in whom it may have the most profound effects. We certainly have a much wider understanding now as to which individual risk factors convey added risk of significant complications e.g. age, diabetes, BMI, ethnicity.
Throughout the pandemic in the UK, pregnant women have been viewed as being vulnerable to the potential consequences of COVID-19 infection. This is supported by data from the CDC which states that pregnant women are more likely to require hospitalisation than non-pregnant women (31.5% vs 5.8%). Pregnant women are also more likely to be admitted to the ICU requiring mechanical ventilation than non-pregnant patients although local practice may vary.
COVID-19 infection usually results in myocardial injury and ventricular dysfunction in a minority of patients – more-so in patients with severe infection requiring admission to the ICU.
Angiotensin-converting enzyme 2 (ACE-2) receptors are thought to be the entry for COVID-19 into cells. ACE-2 receptor expression increases during pregnancy. COVID-19 infection down-regulates ACE-2 receptors, eliminating cardio-protective effects and this can result in increasing concentrations of TNF-alfa and inflammation.
In the study period March-June 2020, 154 pregnant symptomatic patients presented to this particular hospital, 77 of whom were admitted with ‘moderate’ disease. Thirty four patients had ‘severe’ disease requiring ICU admission and 15 developed myocardial injury (TnI positive) and LV dysfunction (Table 1 & 2).
Maternal and Foetal Outcomes (Table 3)
All patients delivered by caesarean section – 60% of whom were pre-term, mostly due to maternal clinical instability. The mean gestational age at delivery was 34.2 +/- 4 weeks. Two patients died post-delivery due to ventricular tachyarrhythmias (VT and TdP). There was one foetal death at 23.3 weeks but this was in the setting of the mother being haemodynamically unstable.
Aside from airway and circulatory management, the study cohort predates the use of other guideline based routine therapy used to treat serious COVID-19 infection e.g. dexamethasone – how this and other agents modify outcomes would be of interest. How ethnicity is a risk for COVID-19 infection during pregnancy would certainly be of interest too but cannot be answered by this study. It is not known whether myocardial injury was due to myocarditis or due to Type II myocardial infarction secondary to multi-organ failure. No follow up data is provided regarding myocardial recovery.
This was a single centre observational study reporting outcomes in pregnant women admitted to ICU during the ‘first wave’ of COVID-19 infection in the Dominican Republic. Mortality within this one hospital for pregnant patients admitted with symptomatic COVID-19 infection was 1.3%. Generalisations are difficult to extrapolate to population wide data but provide important insights and highlight important future research questions. Geographic variations in management of COVID-19 together with demographics and risk posed by ethnic status will all be important to understand in time. Treatment for COVID-19 is constantly evolving and inevitably COVID-19 infection and virulence will change too but this study offers a useful snapshot of ‘first wave’ COVID-19 infection in a solely pregnant dataset.