key: cord-0933581-v9e2axf4
authors: Vigil‐De Gracia, P.; Caballero, L. C.; Sánchez, J.; Espinosa, J.; Campana B, S.; Quintero, A.; Luo, C.; Ng C, J.
title: Pregnancies recovered from SARS‐CoV‐2 infection in the second and third trimesters: obstetric evolution
date: 2020-09-30
journal: Ultrasound Obstet Gynecol
DOI: 10.1002/uog.23134
sha: 77f75b7376f3707a753273484c8d8dead279a817
doc_id: 933581
cord_uid: v9e2axf4

nan

Since December 2019, the world has been impacted by a disease called COVID-19 caused by the virus SARS-CoV-2. This disease affects the entire population, with the oldest and those with comorbidities being the most affected. During these first 7 months with COVID-19, findings have been reported in thousands of pregnant women, which has allowed us to understand and know findings generated by SARS-CoV-2 1,2 . We have learned that the possibility of maternal complication, hospitalization, admission to intensive care unit and ventilation is greater in pregnant women with COVID-19. Increased frequencies of cesarean section, premature birth, premature rupture of membranes and other obstetric complications have been associated with COVID-19 1,2 . However we do not know the maternal and perinatal results of pregnant women recovered from SARS-CoV-2 infection continuing the pregnancy.

We use the data from the study approved by the national bioethics committee that records information in 4 hospitals in the Republic of Panama (Complejo metropolitano de la caja de Seguro social, hospital Santo Tomás, hospital Luis ¨Chicho¨ Fabrega y hospital José Domingo De Obaldía). The research protocol includes all pregnant women with covid-19 confirmed by RT-PCR, protocol reference: EC-CNBI-2020-04-45. We analyze pregnant with symptoms and positive RT-PCR for SARS-CoV-2 in the period from March 8 to August 15 and who later became recovered (cured) by negative clinical or RT-PCR and at least 35 days (five weeks) from the onset of symptoms, whose births were attended in one of those 4 hospitals and who signed the consent.

The table 1 shows the findings of the 15 patients, in 10 (66.7%) pregnancies the diagnosis was made during the second trimester and five (33.3%) in the third. There is three severe cases and two required mechanical ventilation for more than a week, but these pregnancies could last for more than 10 weeks. 3 patients were complicated with premature rupture of membranes (PROM) and two of them far from term. Only four patient reached 39-40 weeks, the others did not due to obstetric complication or spontaneous start of labor. Five newborns were admitted to neonatal intensive. There were 3 perinatal deaths; one intrauterine without apparent cause and two postnatal due to prematurity.

This first report of pregnant women infected with COVID-19 and recovered allows us to know that the patient continues to be at high obstetric risk, especially due to the PROM and labor before 39 weeks. These pregnant should be closely monitored until the moment of birth. Eleven of the 15 patients (73.3%) in this series presented PROM, spontaneous labor or maternal complication before 39 weeks of pregnancy and only one of nine (11.1%) woman with the diagnosis in the second trimester reached 39 weeks of gestation.

These findings are of concern as they suggest the possibility of chronic inflammation with alteration at the placental or membrane level that triggers the culmination of pregnancy.

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A study of 16 placentas from SARS-CoV-2 patients reports an increase in the rates of maternal and fetal vascular malperfusion features; two cases were more than 30 days after the appearance of symptoms and these placentas showed fetal vascular malperfusion (clustered avascular villi, hipercoiled umbilical cord, chorangiosis) 3 . The possible inflammatory effect at the uterus or placenta level in patients with COVID-19 has also been suggested as an explanation for excessive uterine activity reported in the cardiotocograph trace 4 and in findings of intrauterine deaths 5 .

More research is needed with pregnant patients recovered from COVID-19 and these studies should involve the analysis of placentas according to the recovery time, in order to obtain more information that allows us to follow up and make appropriate suggestions to these patients. In our opinion, in pregnant patients infected and recovered with SARS-CoV-2, there is a "placental inflammatory syndrome" characterized by spontaneous onset of labor, premature births, premature rupture of membranes, alteration in the cardiotocograph trace, fetal distress, death and placental alterations.

Undoubtedly, the alteration of the mother's state of health during pregnancy caused by the SARS-CoV-2 infection can have long-term effects on the health of the offspring and the 

SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes

Effect of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcome: systematic review

Placental Pathology in COVID-19

Fetal heart rate changes on the cardiotocograph trace secondary to maternal COVID-19

Fetal deaths in pregnancies with SARS-CoV-2 infection in Brazil: A case series. Case Rep Womens Health