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SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review

      Abstract

      The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), has been associated with worse outcomes in several patient populations, including the elderly and those with chronic comorbidities. Data from previous pandemics and seasonal influenza suggest that pregnant women may be at increased risk for infection-associated morbidity and mortality. Physiologic changes in normal pregnancy and metabolic and vascular changes in high-risk pregnancies may affect the pathogenesis or exacerbate the clinical presentation of COVID-19. Specifically, SARS-CoV-2 enters the cell via the angiotensin-converting enzyme 2 (ACE2) receptor, which is upregulated in normal pregnancy. Upregulation of ACE2 mediates conversion of angiotensin II (vasoconstrictor) to angiotensin-(1-7) (vasodilator) and contributes to relatively low blood pressures, despite upregulation of other components of the renin-angiotensin-aldosterone system. As a result of higher ACE2 expression, pregnant women may be at elevated risk for complications from SARS-CoV-2 infection. Upon binding to ACE2, SARS-CoV-2 causes its downregulation, thus lowering angiotensin-(1-7) levels, which can mimic/worsen the vasoconstriction, inflammation, and pro-coagulopathic effects that occur in preeclampsia. Indeed, early reports suggest that, among other adverse outcomes, preeclampsia may be more common in pregnant women with COVID-19. Medical therapy, during pregnancy and breastfeeding, relies on medications with proven safety, but safety data are often missing for medications in the early stages of clinical trials. We summarize guidelines for medical/obstetric care and outline future directions for optimization of treatment and preventive strategies for pregnant patients with COVID-19 with the understanding that relevant data are limited and rapidly changing.

      Abbreviations and Acronyms:

      ACE2 (angiotensin-converting enzyme 2), ACOG (American College of Obstetricians and Gynecologists), Ang (angiotensin), ARDS (acute respiratory distress syndrome), CD (cesarean delivery), CDC (Centers for Disease Control and Prevention), CL (cervical length), COVID-19 (coronavirus disease 2019), CRP (C-reactive protein), CT (computed tomography), CVS (chorionic villus sampling), F2F (face to face), FDA (Food and Drug Administration), F/U (follow-up), GA (general anesthesia), GBS (group B streptococcus), HCQ (hydroxychloroquine), HCW (health care worker), HIV (human immunodeficiency virus), ICU (intensive care unit), IL (interleukin), IOL (induction of labor), ISUOG (International Society of Ultrasound in Obstetrics and Gynecology), NAFTNet (North American Fetal Therapy Network), NSAID (nonsteroidal anti-inflammatory drug), NST (nonstress test), PPE (personal protective equipment), qRT-PCR (quantitative reverse transcriptase polymerase chain reaction), RAAS (renin-angiotensin-aldosterone system), RCOG (Royal College of Obstetricians and Gynaecologists), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), SMFM (Society for Maternal-Fetal Medicine), TMPRSS2 (transmembrane serine protease 2), US (ultrasonography), VD (vaginal delivery), WHO (World Health Organization)
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