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Grand Rounds

Is There a ‘Preeclampsia-Like’ Syndrome in Pregnant Women with COVID-19?

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PURPOSE:

  • There is overlapping symptomatology between preeclampsia (PE) and COVID-19 including liver injury and coagulopathy
    • Being able to differentiate between the two could have significant implications for clinical care as PE with severe features usually requires delivery
  • Mendoza et al. (BJOG, 2020) sought to investigate pregnancies with COVID-19 and determine, based on clinical, ultrasound and biochemical findings if patients with true PE vs ‘PE-like’ features could be distinguished

METHODS:

  • Prospective observational study
    • Tertiary referral hospital
  • Participants
    • Singleton pregnancies
    • Confirmed or suspected COVID-19
    • >20w0d gestation
  • Classified in to two groups: Severe vs nonsevere COVID-19, based on presence of severe pneumonia
  • Aside from clinical outcomes, the following ultrasound and biochemical parameters were also assessed in patients with suspected PE
    • Uterine artery pulsatility index (UtAPI)
    • Angiogenic factors: Soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF)
  • Primary outcome measures
    • Incidence of signs and symptoms related to PE, including
      • Hypertension | Proteinuria | Thrombocytopenia | Elevated liver enzymes | Abnormal UtAPI and increased sFlt-1/PlGF
    • “UtAPI >95th centile for gestational age, and sFlt-1/PlGF values ≥85 (at <34 weeks) or ≥110 (at ≥34 weeks) were considered highly suggestive of underlying placental disease”

RESULTS:

  • 42 consecutive pregnancies were recruited
    • Nonsevere: 34
    • Severe (requiring ICU admission): 8
  • Clinical course of severe group
    • Prior to onset of severe pneumonia, all 8 women were normotensive and only 1 patient had elevated UtAPI
  • Median age of severe cases (39.4 years) were significantly higher than nonsevere (30.9 years); p=0.006
  • Following severe pneumonia onset, 6 women (14.3% of total cohort) met PE criteria including
    • New onset hypertension and proteinuria and/or thrombocytopenia and/or elevated liver enzymes
    • No cases met diagnostic criteria in the nonsevere group
    • All required antihypertensive medication
    • Only 1 patient had abnormal LDH level >600 UI/L, sFlt-1/PlGF, and UtAPI
    • 4 cesarean births
      • HELLP syndrome (1 case)
      • Worsening COVID-19 (3 cases)
  • Two cases were still pregnant after recovery from severe pneumonia
    • PE-like syndrome resolved in both cases

CONCLUSION:

  • Pregnant women with severe COVID-19 can develop a PE-like syndrome
  • The authors suggest that only 1 out of the 8 cases demonstrated ultrasound and biochemical features compatible with placental dysfunction
    • PE-like syndrome vs PE could possibly be differentiated based on these biochemical markers (sFlt-1/PlGF, LDH) and Doppler (UtAPI) features
  • Based on the resolution in 2 of the cases, the authors state that

PE-like syndrome might not be an indication for earlier delivery in itself since it might not be a placental complication and could resolve spontaneously after recovery from severe pneumonia.

Learn More – Primary Sources:

Preeclampsia-like Syndrome Induced by Severe COVID-19: A Prospective Observational Study

Commentary: Can COVID‐19 in pregnancy cause preeclampsia?

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Related ObG Topics:

Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
COVID-19: The SMFM/SOAP Guidelines for Labor and Delivery
COVID-19 and Liver Impairment: How Often Are ALT and AST Elevated?

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