Haemostatic and thrombo-embolic complications in pregnant women with COVID-19: a systematic review and critical analysis.

BACKGROUND: As pregnancy is a physiological prothrombotic state, pregnant women may be at increased risk of developing coagulopathic and/or thromboembolic complications associated with COVID-19. METHODS: Two biomedical databases were searched between September 2019 and June 2020 for case reports and series of pregnant women with a diagnosis of COVID-19 based either on a positive swab or high clinical suspicion where no swab had been performed. Additional registry cases known to the authors were included. Steps were taken to minimise duplicate patients. Information on coagulopathy based on abnormal coagulation test results or clinical evidence of disseminated intravascular coagulation (DIC), and on arterial or venous thrombosis, were extracted using a standard form. If available, detailed laboratory results and information on maternal outcomes were analysed. RESULTS: One thousand sixty-three women met the inclusion criteria, of which three (0.28, 95% CI 0.0 to 0.6) had arterial and/or venous thrombosis, seven (0.66, 95% CI 0.17 to 1.1) had DIC, and a further three (0.28, 95% CI 0.0 to 0.6) had coagulopathy without meeting the definition of DIC. Five hundred and thirty-seven women (56%) had been reported as having given birth and 426 (40%) as having an ongoing pregnancy. There were 17 (1.6, 95% CI 0.85 to 2.3) maternal deaths in which DIC was reported as a factor in two. CONCLUSIONS: Our data suggests that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Detection of the former may be useful in the identification of women at risk of deterioration.

COVID-19 during pregnancy: non-reassuring fetal heart rate, placental pathology and coagulopathy.

We report a case of a pregnant woman with COVID-19 who developed coagulopathy in the absence of severe clinical symptoms. A polymerase chain reaction test of a vaginal swab was positive for SARS-CoV-2 RNA, suggesting a possibility of perinatal transmission. Cesarean delivery was performed because of a non-reassuring fetal heart rate; the placenta showed increased perivillous fibrin deposition and intervillositis. Moreover, placental infection with SARS-CoV-2 was demonstrated by placental immunostaining. The findings suggest a possible relationship between placental fibrin deposition and chronic and acute intervillositis, non-reassuring fetal heart rate and coagulopathy in pregnant women with COVID-19. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19 and acute coagulopathy in pregnancy.

We present a putative link between maternal COVID-19 infection in the peripartum period and rapid maternal deterioration with early organ dysfunction and coagulopathy. The current pandemic with SARS-CoV-2 has already resulted in high numbers of critically ill patients and deaths in the non-pregnant population, mainly due to respiratory failure. During viral outbreaks, pregnancy poses a uniquely increased risk to women due to changes to immune function, alongside physiological adaptive alterations, such as increased oxygen consumption and edema of the respiratory tract. The laboratory derangements may be reminiscent of HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, and thus knowledge of the COVID-19 relationship is paramount for appropriate diagnosis and management. In addition to routine measurements of D-dimers, prothrombin time, and platelet count in all patients presenting with COVID-19 as per International Society on Thrombosis and Haemostasis (ISTH) guidance, monitoring of activated partial thromboplastin time (APTT) and fibrinogen levels should be considered in pregnancy, as highlighted in this report. These investigations in SARS-CoV-2-positive pregnant women are vital, as their derangement may signal a more severe COVID-19 infection, and may warrant pre-emptive admission and consideration of delivery to achieve maternal stabilization.

Anemia and pregnancy outcomes: a longitudinal study.

OBJECTIVES: To determine the prevalence of anemia at the first antenatal visit and at 32-34 weeks gestational age, and to evaluate perinatal and maternal outcomes. METHODS: Venous blood samples were obtained for complete blood counts at both study visits. Maternal and perinatal morbidity and mortality were also recorded. The data were analyzed using SPSS (version 23). RESULTS: Two thousand pregnant women were recruited. The prevalence of anemia was 42.7% (n = 854/2000) at the first antenatal visit. Thirty-five percent had mild anemia and 68.9% had normocytic normochromic anemia. The prevalence of anemia in HIV infected women was higher than that in the noninfected group and 47.2% of the study population (n = 2000) was HIV infected. At the 32-34 weeks visit, hemoglobin (Hb) levels were available for 1433/2000 (71.7%) of the participants. The prevalence of anemia was 28.1% (n = 403/1433); 19.3% had mild anemia and 65.3% had normocytic normochromic anemia. There was a significant difference in Hb levels between that of the first visit and that at 32-34 weeks (42.7% vs. 28.1%; p = .001; 95% CI: 0.11-0.18). There were significant differences in prematurity, birth weight and hypertensive disorders of pregnancy between the anemic and nonanemic groups. CONCLUSION: The prevalence of anemia decreased from 42.7% (booking) to 28.1% (32 - 34 weeks). Normocytic normochromic anemia was the commonest type of anemia. Attention needs to be focused on detailed investigations to establish the exact cause of anemia.

Adherence in a pragmatic randomized controlled trial on prophylactic iron supplementation during pregnancy in Maputo, Mozambique.

OBJECTIVE: Assessing the level of adherence and its determinants is important in appraising the overall effectiveness of trials. The present study aimed to evaluate the extent of adherence and its determinants in a pragmatic randomized controlled trial of Fe prophylaxis during pregnancy in Maputo, Mozambique. DESIGN: A pragmatic randomized controlled trial. SETTING: Two health centres (1° de Maio and Machava) in Maputo, Mozambique. SUBJECTS: Pregnant women (≥12 weeks' gestation, ≥18 years old, non-high-risk pregnancy; n 4326) attending prenatal care consultations at two health centres were randomized to receive routine Fe (n 2184; 60 mg ferrous sulfate plus 400 µg folic acid daily throughout pregnancy) or selective Fe (n 2142; screening and treatment for anaemia and daily intake of 1 mg folic acid). RESULTS: The level of adherence was 79% for having two or more visits, 53% for adequate prenatal care and 67% for complete intake of Fe/folic acid tablets during the trial. The correlation between the adherence measures ranged between 0·151 and 0·739. Adherence did not differ by trial arm, but there were centre differences in adequate prenatal visits and intake of tablets. Older women (>20 years) and those with a history of abortion were more likely to achieve greater adherence, whereas an increased number of previous births decreased the likelihood of adherence. HIV positivity decreased the likelihood of adherence in one trial centre and increased it in the other. CONCLUSIONS: The variation in adherence by trial centre, women's characteristics and outcome measures suggests that adherence in trials fully depends on participants' behaviour and can be increased by paying attention to contextual factors.

Hepatitis C virus-associated thrombocytopenia in pregnancy: impact upon multidisciplinary care provision.

OBJECTIVE: Recent studies have implicated hepatitis C virus (HCV) in the pathogenesis of immune thrombocytopenia. In pregnancy-associated immune thrombocytopenia, multidisciplinary management is required due to a potential for bleeding complications. We performed a retrospective review of HCV-infected pregnant women and age-matched controls who were not infected with HCV. METHODS: One hundred and six women with a HCV viral load were identified from 2009 to 2011. RESULTS: Thrombocytopenia was identified in 10.3% of HCV-infected pregnant women and 1.6% of age-matched controls (P<0.001). Mean platelet count during pregnancy was 120 ± 23 × 109/L in HCV-infected women and at delivery was significantly lower in HCV-infected women than in controls (P=0.01). Despite the significant difference in platelet counts, there was no significant difference in estimated blood loss (EBL) at delivery. Regional anaesthesia was performed in 73% of thrombocytopenic HCV-infected women and no complications were recorded. There were no fetal bleeding complications. CONCLUSION: In the first study to date to investigate the impact of HCV on maternal platelet count we demonstrated a significantly higher frequency of thrombocytopenia and a significantly lower platelet count in HCV-infected pregnant women compared with controls. Interestingly, thrombocytopenia had no detectable impact on EBL at delivery.

[Correction of anaemia in HIV-positive pregnant women receiving antiretroviral therapy].

The analysis of 162 surgical deliveries cases in HIV-infected pregnant women was carried out. Anaemia type identification was based on blood analysis data and erythrocytes morphology. Ways of disease correction were defined. Recommendations for anemia prevention and treatment in HIV-infected patients receiving anti-retroviral drugs are presented.

[Haemostasis disorders and ways of its correction in HIV-positive pregnant women receiving chemopreventive antiretroviral therapy].

The analysis of 162 surgical deliveries cases in HIV-positive patients with antiretroviral therapy--induced haemostasis disturbances and thrombocytopenia was carried out. The article gives the perioperative management during surgical delivery.

Parvovirus and herpes simplex association with unexplained anemia in pregnancy: a prospective study.

Anemia in pregnancy is a health problem in developing countries. Unexplained anemia constitutes about one-third of anemia. The purpose of the present study is to evaluate the association of parvovirus B19 and herpes simplex virus in pregnant females with unexplained anemia. The study included 100 pregnant patients with anaemia. Nutritional and hemolytic anemia were excluded. In addition, 24 healthy pregnant control were included. Virological markers for parvovirus B19 and herpes simplex were evaluated by PCR and specific IgM. Eighty-four patients had parvovirus infection as determined by positive PCR or/and positive IgM. While 40 patients had positive herpes simplex infection by positive PCR or/and IgM. Patients with parvovirus and herpes simplex infections either separately or had combined infections had significantly lower level of hemoglobin compared to patients negative for viruses infections (p=0.03, p=0.034, p<0.005 respectively). It can be concluded that both parvovirus B19 and herpes simplex are common among pregnant patients. Screening for parvovirus B19 and herpes simplex may help to reach for the diagnosis of unexplained anemia during first trimester of pregnancy and allow appropriate treatment to be offered.