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Coronavirus disease 2019 in pregnancy: consider thromboembolic disorders and thromboprophylaxis

Published:April 22, 2020DOI:https://doi.org/10.1016/j.ajog.2020.04.017
      To the Editors:
      Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory distress syndrome coronavirus 2. This syndrome generally begins with respiratory symptoms that may progress to single-organ dysfunction (ie, respiratory failure) and then to multiorgan failure and death. In nonpregnant patients admitted to the intensive care unit with COVID-19 pneumonia, the frequency of venous thromboembolic disorders is 25% (20 of 81) detected by ultrasound examination of the lower extremities.
      • Cui S.
      • Chen S.
      • Li X.
      • Liu S.
      • Wang F.
      Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia.
      In another series of 184 patients with confirmed COVID-19 pneumonia, 31% of patients had venous or arterial thromboembolism (defined as acute pulmonary embolism, ischemic stroke, deep vein thrombosis, or myocardial infarction).
      • Klok F.A.
      • Kruip M.J.H.A.
      • van der Meer N.J.M.
      • et al.
      Incidence of thrombotic complications in critically ill ICU patients with COVID-19.
      The mechanism whereby viral infection causes multiorgan dysfunction is believed to involve the release of inflammatory cytokines
      • Qin C.
      • Zhou L.
      • Hu Z.
      • et al.
      Dysregulation of immune response in patients with COVID-19 in Wuhan, China.
      that induce the production of tissue factor and activate thrombin. Elevated concentration of D-dimer (>1 μg/mL) is considered indirect evidence of increased thrombin generation and is associated with an increased risk of death (odds ratio, 18.4; 95% confidence interval, 2.6–128).
      • Zhou F.
      • Yu T.
      • Du R.
      • et al.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
      Anticoagulant treatment with low-molecular-weight heparin has been associated with improved prognosis in patients with severe COVID-19 infection, stratified by sepsis-induced coagulopathy score or D-dimer results.
      • Tang N.
      • Bai H.
      • Chen X.
      • Gong J.
      • Li D.
      • Sun Z.
      Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy.
      The optimal management of pregnant women with COVID-19 poses multiple challenges, ranging from screening for the virus on admission to labor and delivery, to management of the acutely ill parturient, anesthesia, and protection of healthcare personnel.
      • Ashokka B.
      • Loh M.H.
      • Tan C.H.
      • et al.
      Care of the pregnant woman with COVID-19 in Labor and Delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel.
      Although it was originally thought that pregnant women with COVID-19 were no more likely to develop severe morbidity or die, recent reports suggest that a subset may develop multiorgan failure and even die. Given that healthy pregnant women have evidence of increased generation of thrombin and a prothrombotic state, as well as increased intravascular inflammation that is exaggerated in the context of infection, such patients may be at an increased risk for thrombosis when affected by COVID-19. The International Society of Thrombosis and Haemostasis has generated a simple algorithm for the management of COVID-19 coagulopathy.
      • Thachil J.
      • Tang N.
      • Gando S.
      • et al.
      ISTH interim guidance on recognition and management of coagulopathy in COVID-19.
      The recommendation has been made that low-molecular-weight heparin be considered in all such patients. This body of evidence should be considered by obstetricians caring for pregnant women with COVID-19. A coagulation profile to detect the presence of subclinical disseminated intravascular coagulation and the use of low-molecular-weight heparin for the prevention of thromboembolic disorders should be considered and discussed with physicians and patients.

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