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?

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?