Advertisement

Maternal deaths with coronavirus disease 2019: a different outcome from low- to middle-resource countries?

Published:April 26, 2020DOI:https://doi.org/10.1016/j.ajog.2020.04.023
      To the Editors:
      Physiological adaptations in normal pregnancy increase the susceptibility of mothers to microorganisms (bacteria and viruses) and their products. In particular, activation of the innate limb of immune response is thought to increase generation of reactive oxygen radicals by granulocytes and monocytes
      • Naccasha N.
      • Gervasi M.T.
      • Chaiworapongsa T.
      • et al.
      Phenotypic and metabolic chacateristics of monocytes and granulocytes in normal pregnancy and maternal infection.
      and predisposes to a cytokine storm. This has been invoked to explain the increased fatality rate of pregnant women affected by severe acute respiratory syndrome (SARS), Middle East respiratory syndrome, ebola, influenza, and H1N1.
      • Rasmussen S.A.
      • Smulian J.C.
      • Lednicky J.A.
      • Wen T.S.
      • Jamieson D.J.
      Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.
      ,
      • Cirelli J.F.
      • Surita F.G.
      • Costa M.L.
      • Parpinelli M.A.
      • Haddad S.M.
      • Cecatti J.G.
      The burden of indirect causes of maternal morbidity and mortality in the process of obstetric transition: A cross-sectional multicenter study. A importâcia das causas indiretas da morbidade e mortalidade maternas no processo de transição obstétrica: um estudo multicêntrico transversal.
      During the H1N1 pandemic, pregnancy, childbirth, and the postpartum period were considered risk factors for disease worsening and maternal death. In Brazil, H1N1 influenza was the main cause of indirect maternal death in 2009–2010.
      • Cirelli J.F.
      • Surita F.G.
      • Costa M.L.
      • Parpinelli M.A.
      • Haddad S.M.
      • Cecatti J.G.
      The burden of indirect causes of maternal morbidity and mortality in the process of obstetric transition: A cross-sectional multicenter study. A importâcia das causas indiretas da morbidade e mortalidade maternas no processo de transição obstétrica: um estudo multicêntrico transversal.
      However, in the case of coronavirus disease 2019 (COVID-19) and on the basis of a few case series from China, Europe, and the United States, it is thought that pregnant women may not be more likely to experience severe symptoms from this disease than the general population and there were no reported maternal deaths.
      • Rasmussen S.A.
      • Smulian J.C.
      • Lednicky J.A.
      • Wen T.S.
      • Jamieson D.J.
      Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.
      A new picture may now be emerging from Brazil, Iran, and Mexico, raising the possibility of increased risk of maternal death from COVID-19; in Brazil there is evidence of 5 maternal deaths out of 1947 total deaths from COVID-19, in Iran 2 of 3800,
      • Karimi-Zarchi M.
      • Neamatzadeh H.
      • Dastgheib S.A.
      • et al.
      Vertical transmission of coronavirus Disease 19 (COVID-19) from infected pregnant mothers to neonates: a review.
      and in Mexico 2 of 486 (Table). It is therefore possible that in developing as opposed to developed countries, high birth rates and limited resources for healthcare provision will uncover the increased risk for maternal death because of COVID-19 and emphasize the need for appropriate measures for adequate prenatal and postnatal care. At the present time, professional organizations have not emphasized that pregnant women exposed to severe acute respiratory syndrome coronavirus 2 may be at an increased risk for adverse outcome; however, it is important that obstetricians and gynecologists be aware that data from countries other than the USA and Europe seem to suggest an increased risk to pregnant mothers. We hope that the scientific community remains open minded and vigilant about this.
      TableCoronavirus disease 2019-related maternal deaths worldwide until April 10, 2020
      CountryMaternal deathsSymptoms onsetMoment of deathComorbiditiesSource
      Iran2 of 3800 reported total deathsPregnancyPostpartumNot reportedKarimi-Zarchi et al 2020
      Brazil5 of 1947 reported total deathsNot reportedPostpartum
      Mode of delivery: elective cesarean delivery
      Not reportedBrazilian Ministry of Health
      Not reportedPostpartum
      Mode of delivery: elective cesarean delivery
      Not reportedBrazilian Ministry of Health
      Postpartum (6 days after elective cesarean delivery)Postpartum (7 days)AbsentLocal media
      https://www.folhadelondrina.com.br/geral/mulher-de-28-anos-morre-por-covid-19-sete-dias-apos-parto-na-bahia-2985448e.html
      Pregnancy (admitted 32 weeks, emergency CS 2 days later)Postpartum (2 days)AbsentLocal media
      https://epoca.globo.com/brasil/gravida-morre-de-covid-19-em-recife-bebe-sobrevive-24353787
      Pregnancy (admitted 32 weeks, emergency CS)PostpartumAbsentLocal media
      https://www.agazeta.com.br/brasil/no-rio-mulher-morre-de-covid-19-dez-dias-apos-dar-a-luz-prematuramente-0420
      Mexico2 of 486 reported total deathsPregnancy (35 weeks)PostpartumObesity, hypertensionLocal media
      López-Gatell: Desafortunadamente mueren dos embarazadas por covid-19 | CNN [Internet]. 2020 [cited 2020 Apr 10]. Available from: https://cnnespanol.cnn.com/video/mueren-mujeres-embarazadas-covid-coronavirus-mexico-gatell-informe-sot-perspectivas-mexico.
      Not reportedNot reportedObesity, gestational diabetesMexico Ministry of Health

      Acknowledgments

      The authors thank the members of the Brazilian group of COVID-19 and pregnancy for all efforts in searching this reliable information (Carla Betina Andreucci, MD, PhD; Mariane de Oliveira Menezes, CPM, MSc; Leila Katz, MD, PhD; Roxana Rnobel, MD, PhD; and Adriana Melo, MD, PhD).
      This communication has been published in the middle of the COVID-19 pandemic and is available via expedited publication to assist patients and healthcare providers.

      References

        • Naccasha N.
        • Gervasi M.T.
        • Chaiworapongsa T.
        • et al.
        Phenotypic and metabolic chacateristics of monocytes and granulocytes in normal pregnancy and maternal infection.
        Am J Obstet Gynecol. 2001; 185: 1118-1123
        • Rasmussen S.A.
        • Smulian J.C.
        • Lednicky J.A.
        • Wen T.S.
        • Jamieson D.J.
        Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.
        Am J Obstet Gynecol. 2020; ([Epub ahead of print])
        • Cirelli J.F.
        • Surita F.G.
        • Costa M.L.
        • Parpinelli M.A.
        • Haddad S.M.
        • Cecatti J.G.
        The burden of indirect causes of maternal morbidity and mortality in the process of obstetric transition: A cross-sectional multicenter study. A importâcia das causas indiretas da morbidade e mortalidade maternas no processo de transição obstétrica: um estudo multicêntrico transversal.
        Rev Bras Ginecol Obstet. 2018; 40: 106-114
        • Karimi-Zarchi M.
        • Neamatzadeh H.
        • Dastgheib S.A.
        • et al.
        Vertical transmission of coronavirus Disease 19 (COVID-19) from infected pregnant mothers to neonates: a review.
        Fetal Pediatr Pathol. 2020; 0 ([Epub ahead of print]): 1-5