A modo de conclusión, el presente artículo menciona que, sobre la base de los hallazgos preliminares, sugieren que la infección por SARS-CoV-2, al inducir un estado proinflamatorio, predispone a las mujeres embarazadas a una mayor gravedad del curso de la preeclampsia, incluso cuando los síntomas respiratorios graves están ausentes.  Asimismo sugieren la necesidad de más evidencia científica para confirmar esta posible asociación

Concepción-Urteaga, Luis Alberto

Concepción-Zavaleta, Marcio José

Coronado-Arroyo, Julia Cristina

Zavaleta-Gutiérrez, Francisca Elena

English

Repositorio Institucional EsSalud

  Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website.  Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.  European Journal of Obstetrics & Gynecology and Reproductive Biology 256 (2021) 502–526CorrespondenceContents lists available at ScienceDirectEuropean Journal of Obstetrics & Gynecology andReproductive Biologyjournal homepage: www.else vie r .com/ locat e/e jogrbIs COVID-19 a risk factor for severepreeclampsia? Hospital experience in adeveloping countryTo the Editor:We have read with great interest the article published by Todros[1]; it states that severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection and preeclampsia have common patho-physiological characteristics, as shown by inflammatory changes.In the present work, we want to report our experience in areference hospital of Peru regarding the clinical course ofhypertensive disorders of pregnancy in pregnant women withSARS-CoV-2 infection.Coronavirus disease 2019 (COVID-19) has been shown to causesystemic complications such as high blood pressure, kidneydisease, thrombocytopenia, and liver injury [2]. The angiotensin-converting enzyme 2 (ACE2) receptor mediates the SARS-CoV-2action that causes vasoconstriction resulting from renin-angioten-sin system dysfunction [3]. During pregnancy, ACE2 plays animportant role in the regulation of arterial pressure and expressesitself in excessive amounts in placental tissue, including syncytio-trophoblast, cytotrophoblast, endothelium, and vascular smoothmuscle of the villi [4]. Intrauterine infection caused by COVID-19can alter ACE2 expression, promoting a preeclamptic state.Mendoza, in his case series, postulates a preeclampsia-likesyndrome in patients with severe SARS-CoV-2 infection, whomeet the criteria for preeclampsia but who recover withoutdelivery, only after the improvement of the respiratory condition[2].Regarding the histopathological findings, Shaness et al. haveshown that the placentas of patients with SARS-CoV-2 infectionshow a higher prevalence of decidual arteriopathy and othercharacteristics of poor maternal vascular perfusion such asdecidual arteriopathy that includes atherosclerosis; fibrinoidnecrosis and mural hypertrophy of membrane arterioles; changesthat would reflect a systemic inflammatory state of hypercoagula-bility; findings similar to placental changes in hypertensivedisorders of pregnancy; and changes related to oligohydramnios,fetal growth restriction, premature delivery, and fetal death [5].While it is true that the reported cases are of patients with severeSARS-CoV-2 infection, the pathophysiology proposed so far wouldmake us think that SARS-CoV-2 infection is a pro-inflammatoryhttps://doi.org/10.1016/j.ejogrb.2020.09.0200301-2115/© 2020 Elsevier B.V. All rights reserved.state, even in asymptomatic patients, that could be a risk factor fordeveloping preeclampsia.At the Obstetrics Department of a Peruvian Social Securityhospital, from March to April 2020, Huerta et al. [6] reported thefirst series of cases of pregnant women with COVID-19 in Peru. Thisstudy included 41 female patients, of which 68 % wereasymptomatic, 19.5 % had mild infection and 4.8 % had severepneumonia that required enter the intensive care unit and non-invasive ventilation. The most frequent type of delivery wascaesarean section (76.5 %) and the most frequent indication was ahistory of caesarean section (48.3 %) followed by presentingdystocia (20.7 %) and hypertensive disorders of pregnancy in 10.3%. Also, leukocytosis was evidenced in 26.8 %, thrombocytopenia in14.6 % and transaminasemia in 31.7 % of patients. No maternaldeaths or fetal deaths were reported.Furthermore, at the same Department of the above-mentionedHospital, from May 2020 to date, we have treated 20 pregnantwomen with a serological diagnosis of SARS-CoV-2 infection whodeveloped preeclampsia (Table 1). Eleven patients were pregnantat term, and there was only one twin pregnancy. Regarding therespiratory symptoms, 16/20 (80 %) patients were asymptomatic,with the remaining patients exhibiting mild symptoms. The mostfrequent findings in their laboratory tests were as follows:hypertransaminasemia, 40 %–65 %; leukocytosis, 30 %; lympho-penia, 15 %; and elevated C-reactive protein levels, 10 %. Of all thepatients, 15 % (3/20) met the criteria for gestational hypertensionand 15 % (3/20) met the criteria for preeclampsia without signs ofseverity, whereas 70 % (14/20) met the criteria for severehypertensive disorders of pregnancy, comprising nine patientswith severe preeclampsia; two with eclampsia; and five withhemolysis, elevated liver enzymes and low platelet countsyndrome. The main route of delivery was cesarean section, whichwas performed in 85 % (17/20) patients; one hysterectomy wasperformed for placenta accreta. The fetal death rate was 9.5 % (2/20). Furthermore, 71 % of the newborns had appropriate weight fortheir gestational age and 9.5 % were small for gestational age. Onlyone newborn tested positive in the nasopharyngeal swab test forSARS-CoV-2 within the first 24 h of life.In conclusion, based on these preliminary findings, we suggestthat SARS-CoV-2 infection, by inducing a pro-inflammatory state,predisposes pregnant women to a greater severity of the course ofpreeclampsia, even when severe respiratory symptoms are absent.We suggest the need for more scientific evidence to confirm thispossible association.Table 1Clinical and biochemical characteristics of patients with serological diagnosis of COVID-19 and Hypertensive Pregnancy Disorders. Source: Data obtained from the Obstetricsinpatient Department. Hospital Nacional Edgardo Rebagliati Martins. March-August 2020. AST: Aspartate aminotransferase. * Patients with lymphopenia (lymphocytes<1000 cells/mm3). + Patients who had stillbirth.Case Age Gestational Age Parity Symptoms White blood cell x 10 3(Lymphocytes %)AST (U/L) Delivery Hypertensive Pregnancy Disorder1 39 39 Multiparity Asymptomatic 7.5 (16.7) 64 Caesarean Section Severe Preeclampsia2 33 34 Multiparity Asymptomatic 9.1 (31.9) 53 Caesarean Section Severe Preeclampsia3 43 40 Multiparity Asymptomatic 12.3 (28.4) 36 Caesarean Section Severe Preeclampsia4 21 36 Nulliparity Asymptomatic 7.4(25.6) 42 Caesarean Section Mild Preeclampsia5 31 33 Nulliparity Asymptomatic 9.3 (27) 53 Caesarean Section Severe Preeclampsia6 33 38 Multiparity Asymptomatic 7.7 (22.2) 14 Caesarean Section Gestational Hypertension7 45 38 Multiparity Asymptomatic 14.5 (32.8) 25 Caesarean Section Severe Preeclampsia8 42 40 Multiparity Headache 8.8 (19.2) 51 Vaginal Delivery Gestational Hypertension9 32 40 Multiparity Asymptomatic 19.2 (4.73) * 39 Vaginal Delivery Mild Preeclampsia10 37 40 Multiparity Asymptomatic 8.4 (35.3) 16 Caesarean Section Severe Preeclampsia11 45 34 Nulliparity Asymptomatic 6.0 (15.8) * 27 Caesarean Section Severe Preeclampsia and Eclampsia12 33 39 Multiparity Asymptomatic 10.2 (33.9) 27 Caesarean Section Gestational Hypertension13 29 34 Multiparity Asymptomatic 18 (3.7) * 904 Caesarean Section Severe Preeclampsia and Eclampsia14 39 39 Multiparity Asymptomatic 11 (27) 64 Cesarean Hysterectomy Hellp Syndrome15 29 36 Nulliparity Asymptomatic 6.8 (21.6) 449 Caesarean Section Hellp Syndrome16 32 37 Multiparity Asymptomatic 10.1 (27.5) 16 Caesarean Section Mild Preeclampsia17 17 23 Nulliparity Cough 7.9 (17.7) 59 Caesarean Section Hellp Syndrome+18 27 23 Nulliparity Cough 7.8 (17.8) 54 Caesarean Section Hellp Syndrome19 24 39 Nulliparity Asymptomatic 12.7 (22.9) 33 Caesarean Section Severe Preeclampsia20 31 33 Multiparity Fever 9.3 (29.9) 288 Vaginal Delivery Hellp Syndrome +Correspondence / European Journal of Obstetrics & Gynecology and Reproductive Biology 256 (2021) 502–526 503Declaration of Competing InterestThe authors report no declarations of interest.References[1] Todros T, Masturzo B, De Francia S. COVID-19 infection: ACE2, pregnancy andpreeclampsia. Eur J Obstet Gynecol Reprod Biol 2020, doi:http://dx.doi.org/10.1016/j.ejogrb.2020.08.007.[2] Mendoza M, Garcia-Ruiz I, Maiz N, Rodo C, Garcia-Manau P, Serrano B, et al. Pre-eclampsia-like syndrome induced by severe COVID-19: a prospective observa-tional study. BJOG An Int J Obstet Gynaecol 2020, doi:http://dx.doi.org/10.1111/1471-0528.16339 1471-0528.16339.[3] Yan R, Zhang Y, Li Y, Xia L, Guo Y, Zhou Q. Structural basis for the recognition ofSARS-CoV-2 by full-length human ACE2. Science (80-) 2020;367:1444–8, doi:http://dx.doi.org/10.1126/science.abb2762.[4] Ahmed I, Eltaweel N, Antoun L, Rehal A. Severe pre-eclampsia complicated byacute fatty liver disease of pregnancy, HELLP syndrome and acute kidney injuryfollowing SARS-CoV-2 infection. BMJ Case Rep 2020;13:e237521, doi:http://dx.doi.org/10.1136/bcr-2020-237521.[5] Shanes ED, Mithal LB, Otero S, Azad HA, Miller ES, Goldstein JA. Placentalpathology in COVID-19. Am J Clin Pathol 2020;154:23–32, doi:http://dx.doi.org/10.1093/ajcp/aqaa089.[6] Huerta Saenz IH, Elías Estrada JC, Campos Del Castillo K, Muñoz Taya R,Coronado JC. Características maternoperinatales de gestantes COVID-19 en unhospital nacional de Lima, Perú. Rev Peru Ginecol Obstet. 2020;66(2), doi:http://dx.doi.org/10.31403/rpgo.v66i2245.Universal screening identifies asymptomaticcarriers of SARS-CoV-2 among pregnant womenin IndiaDear Editor,Asymptomatic women with coronavirus disease 2019 (COVID-19) are at risk of infecting their newborns and also pose a risk tohealthcare providers and other patients [1,2,3]. Considering this,Indian Council of Medical Research (ICMR) recommended univer-sal testing for SARS-CoV-2 in pregnant women [4]. Maharashtra isthe worst-hit state in India and universal screening strategy forJulia Cristina Coronado-ArroyoDivision of Obstetrics and Ginecology, Hospital Nacional EdgardoRebagliati Martins, Lima, PeruMarcio José Concepción-Zavaleta*Division of Endocrinology, Hospital Nacional Guillermo AlmenaraIrigoyen, Universidad Nacional Mayor de San Marcos, Lima, PeruFrancisca Elena Zavaleta-GutiérrezDivision of Neonatology, Hospital Belén de Trujillo, Department ofPediatrics, Universidad Privada Antenor Orrego, Trujillo, PeruLuis Alberto Concepción-UrteagaDivision of Neumology, Hospital Regional Docente de Trujillo,Department of Medicine, Universidad Nacional de Trujillo, Trujillo,Peru* Corresponding author at: Simon Bolivar 2150 Avenue, Building20, Apartment 303, 15083, Peru.E-mail address: marcio_conc_zav@outlook.es (M. Concepción-Zavaleta).Received 3 September 2020pregnant women was implemented in several public hospitalsduring this time. Herein, we report the outcome of implementationof this strategy.Women presenting in labour or likely to deliver in next 5 dayswere screened for SARS-CoV-2 as per ICMR guidelines [4]. Datafrom 25th April to 20th May, 2020 was collected from 15participating hospitals of PregCovid registry network (https://pregcovid.com/). In all, 141/1140 pregnant women were testedpositive for SARS-CoV-2 resulting in a prevalence of 12.3% (Mean9.4, 95% CI 6.6 – 12.1) in Maharashtra, India [Fig. 1A]. Theprevalence of SARS-CoV-2 infection in women varied (0-40%)across the different hospitals in the state. For estimation ofnumbers of symptomatic and asymptomatic SARS-CoV-2 positive

Is COVID-19 a risk factor for severe preeclampsia? Hospital experience in a developing country

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Is COVID-19 a risk factor for severe preeclampsia? Hospital experience in a developing country

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