Clinical outcomes and complications in pregnancies with
COVID-19
Participant 5 was diagnosed with SARS-CoV-2 at GA 29w1d. She presented
at the antenatal ward at GA 29w6d with reduced fetal movements and
vaginal bleeding. The neonate was delivered the same day by emergency
caesarean section due to a pathological cardiotocography (CTG) and was
born small for gestational age (birth weight 1235 g, Z-score -1.87).
APGAR was 8 after 5 minutes and umbilical cord blood with respiratory
compensated metabolic acidosis (arterial pH 7.23, Base Excess -10.4 and
venous pH 7.33, Base Excess -12.0). Microscopic examination of the
placenta showed severe acute and chronic intervillositis with necrosis
of the trophoblast (Figure S1). Swabs from the fetal side of the
placenta were positive for SARS-CoV-2. The results of the vaginal swabs
were inconclusive. The neonate was admitted to NICU for 40 days. The
mother had a complicated puerperal period with fever, fatigue, and
diarrhea. Yersinia enterocolitica was found in a maternal fecal sample.
Bacterial culture from the placenta was negative. SARS-CoV-2 antibodies
were not detected in either maternal or in cord blood. Eleven weeks
after delivery, anti-cardiolipin antibodies were found associated with
an increased risk of arterial and venous thrombosis. The findings could
be consistent with intrauterine SARS-CoV-2 infection, but bacterial
infection could not be ruled out.
Participant 6 tested
positive for SARS-CoV-2 at GA 31w2d. Her partner was tested positive the
same day. She presented at the antenatal ward at 32w0d with a reduction
in fetal movements but was discharged after a normal CTG. At 32w3d, she
presented with contractions. The neonate was delivered shortly after by
emergency caesarean section due to a preterminal CTG with APGAR 0 after
5 minutes and arterial pH 6.82, Base Excess -17.5 and venous pH 6.85,
Base Excess -17.2. Birth weight was 2000 g and Z-score -0.29. One hour
after delivery, the neonate was declared dead after a prolonged neonatal
resuscitation attempt. Autopsy of the neonate showed no malformations,
but signs of asphyxia from petechiae and meconium aspiration. In
addition, there was some histologic evidence of acute thymic involution
and adrenal stress-related changes, but no signs of prolonged
intrauterine stress or growth restriction. Microscopic examination of
the placenta showed severe abnormality with acute and chronic
intervillositis and abundant perivillous fibrin deposits comprising 70%
of the parenchyma (Figure S2). SARS-CoV-2 was detected in the vaginal
swab at delivery and in swabs from both the fetal and maternal side of
the placenta. Neonatal swabs were SARS-CoV-2 negative. The mother tested
positive for SARS-CoV-2 antibodies while umbilical cord blood tested
negative. Blood and urine culture at the time of delivery were negative.
The placental findings, potentially linked to intrauterine SARS-CoV-2
infection were likely to have caused the fatal fetal outcome.
Participant 27 was diagnosed with gestational diabetes mellitus at GA
13w0d. She tested positive for SARS-CoV-2 at GA 27w2d and was
hospitalized at GA 28w0d due to COVID-19. During the admission, she was
diagnosed with three segmental lung embolisms and a secondary pneumonia
was suspected. She was treated with Low Molecular Weight Heparins,
Remdesivir, antibiotics, and prednisolone. Vaginal swabs analysed for
SARS-CoV-2 were negative. She gave birth by an uncomplicated planned
caesarean section at GA 38w0d. During admission, no antibodies were
detected in maternal blood eight days after the SARS-CoV-2 positive
pharyngeal swab, whereas at delivery, 75 days after the initial
infection, SARS-CoV-2 antibodies were detectable in both maternal and
cord blood samples.
Participant 28 presented at the antenatal ward at GA 24w5d with vaginal
bleeding and at GA 25w1d with symptoms of deep vein thrombosis of the
femoral vein, which was confirmed by ultrasound. She started treatment
with Low Molecular Weight Heparin. The vaginal bleeding was derived from
a varicose vein in the left labium minor. Eleven days later (GA 26w5d),
she contacted the Emergency Department due to shortness of breath and
vomiting. There was no suspicion of pulmonary embolism or severe
COVID-19. She tested positive for SARS-CoV-2 by a pharyngeal swab and
was admitted for two days. At day one after the positive pharyngeal
swab, two vaginal swabs were positive for SARS-CoV-2, but no maternal
antibodies were detected. Blood culture and urine culture taken after
admission to the hospital with COVID-19 were negative. She gave birth by
an uncomplicated planned caesarean section at GA 38w5d. On day 16 and 37
after the positive swab and at delivery (day 84), SARS-CoV-2 antibodies
were detected in maternal blood samples. At delivery, antibodies were
also detected in cord blood.
Besides the abovementioned four severe cases, a few other complications
were found among participants during pregnancy and delivery (table 1).