Impact of COVID-19 on pregnant women with Rheumatic heart disease or Peripartum cardiomyopathy

Abstract

•Pregnancy with heart disease is considered a high risk pregnancy due to higher morbidity and mortality Heart disease (RHD/PPCM) was reported in 1% of pregnant and/ post-partum women infected with SARS-CoV-2.•Preterm delivery, PPROM, low birth weight, neonatal death was observed in women with heart disease and COVID-19.•Healthcare system should be strengthened for management of heart disease and COVID-19. We observed that there is a limited information on the impact of the SARS-CoV-2 infection on pregnant women with heart disease (HD). Aim of our study was to investigate the impact of COVID-19 on pregnancy and neonate retrospectively at BYL Nair Charitable Hospital (NH), a dedicated COVID-19 hospital [[1]Mahajan N.N. Pednekar R. Patil S.R. et al.Preparedness, administrative challenges for establishing obstetric services, and experience of delivering over 400 women at a tertiary care COVID-19 hospital in India.Int J Gynaecol Obstet. 2020; 151: 188-196https://doi.org/10.1002/ijgo.13338Crossref PubMed Scopus (18) Google Scholar] in women with HD in Mumbai, India. In the initial phase of COVID-19 pandemic of 6 months, NH received five RT-PCR confirmed COVID-19 pregnant women with heart disease [Rheumatic HD (RHD; n = 3), Peripartum Cardiomyopathy (PPCM; n = 2)], out of 879 COVID-19 pregnant and post-partum women (Table 1). To address if COVID-19 poses additional risk in pregnancy with HD, we compared outcomes in uninfected pregnant women with HD (n = 43) in pre-pandemic period from the same center (Table S1). We found around 1% of heart disease in pregnant women with COVID-19. Adverse outcomes such as preterm delivery, PPROM, low birth weight, neonatal death were observed in pregnant women with HD (RHD/PPCM) and COVID-19. Pre-term delivery was nearly three times higher in women with HD and COVID-19 (95 % CI 0.33–20.48). PPROM/PROM was observed 14 times higher in women with HD and SARS-CoV-2 infection (95 % CI 0.69–283.79). Preterm vaginal delivery was reported in one woman with RHD and COVID-19 (Case-2) and her new-born required neonatal intensive care due to low birth weight.Table 1Demographic, epidemiological, clinical characteristics and management of pregnant women with RHD or PPCM and COVID-19.ParametersRHD1RHD2RHD3PPCM1PPCM2Heart Disease historyRHD since childhoodRHD diagnosed during first pregnancyRHD since childhoodPPCMPPCMNo. of referrals before reaching NH21245DemographicAge in years2731262621Gravida (G) /Parity (P)PrimigravidaG3P2L2G4P2L2G3P2L2PrimigravidaBMI kg/m222.623.1Not available34.523Containment/Sealed zoneNoYesNoNoYesIndication for COVID-19 RT-PCR testingSymptomaticUniversal TestingUniversal TestingSymptomaticUniversal TestingClinicalAsymptomatic/Symptomatic (Mild/Moderate/Severe)SymptomaticMild cough with expectoration and breathlessness bIncreased in intensity since 5 days but she had similar complaints since long before pregnancy.AsymptomaticAsymptomaticSymptomaticMild (palpitations and dyspnoea)AsymptomaticFeverNoNoNoNoNoCoughYesNoNoYesNoBreathing DifficultyYesNoNoYesNoInvestigationsHemoglobin, g/dL (Reference range - >11.0)12.111.19.91210.6White blood cell count, /μL (Reference range - 3500−9500)730067009800109006000Platelet count, ×103/μL (Reference range - 125−350)1.211.201.33.094.11Serum Creatinine, mg/dL (Reference range - 0.84–1.21)2.31.00.90.40.9EchocardiogramModerate MS, moderate MR, mild TR, dilated LA with mildly dilated LV, Moderate PAH, MVOA 1.3 cm2 LVEF-65 %Severe MS, moderate MR, trivial AR Severe TRModerate MS severe PAH LVEF 60 %Dilated LV, severe generalised LV hypokinesia, LVEF 20 %, LV diastolic dysfunction, LV non-compaction, Mild MR, Mild PAH, Mild TR, RVSP 48mmhgGlobal LV Hypokinesia, LVEF of 30−35 %, LV non-compaction, Mild MR, Moderately Compromised LV Systolic FunctionBlood Pressure in mmHg100/70110/70100/70130/80110/70Oxygen Saturation %9599989699Chest X-ray changesYesNot doneNot doneNormalNot doneConsolidationYesNoNoNoNoARDSNoNoNoNoNoArterial blood gas analysisNormalNormalNormalNormalNormalRelevant UltrasoundUltrasound - bilateral bright kidney.–––Level-II ultrasound at 21 weeks - severe oligohydramnios, bilateral hydro-nephrosis, hydro-ureter, key-hole bladder, posterior urethral valves.Weeks of Gestation at delivery39 weeks36 weeks37 weeks at admission36weeks 5days38weeks 1dayMode of deliveryVaginal DeliveryVaginal DeliveryUndeliveredCesarean sectionVaginal Delivery aPresented in the labour suite with a fully dilated cervix and delivered vaginally immediately on arrival, on the stretcher.PROM/PPROMNoNo–YesNoPreterm labourNoYes–YesNoNeonatal OutcomeGoodNICU admission, Baby survived–GoodMultiple congenital anomalies, poor APGAR, NICU admission, NNDBirth Weight in Kg2.4701.790–2.2402.229Complications intrapartum & postpartumNoNo–NoNoTreatmentfrusemide, lacilactone (with-held) and metoprololspironolactone, frusemide, metoprolol, penicillinatenolol, frusemide, penicillinfrusemide, bisoprolol, isosorbide dinitrate, digoxincarvedilol, ramiprilHospital Stay14174135MortalityNoNoNoNoNoSARS-CoV-2, Severe Acute Respiratory Syndrome Corona virus 2; RT-PCR, Reverse Transcriptase Polymerase Chain Reaction; COVID-19, coronavirus disease 2019; PROM, premature rupture of membranes ; PPROM, preterm premature rupture of membranes; NICU, neonatal intensive care unit; NND, neonatal death; RHD, rheumatic heart disease ; PPCM, peripartum cardiomyopathy; MS, mitral stenosis; MR, mitral regurgitation; TR, tricuspid regurgitation; LA- Left Atrium, LV-Left ventricular; PAH, pulmonary artery hypertension; MVOA, Mitral Valve Orifice Area; LVEF, left ventricle ejection fraction; AR, aortic regurgitation; RVSP, right ventricular systolic pressure; ARDS, Acute Respiratory Distress Syndrome.a Presented in the labour suite with a fully dilated cervix and delivered vaginally immediately on arrival, on the stretcher.b Increased in intensity since 5 days but she had similar complaints since long before pregnancy. Open table in a new tab SARS-CoV-2, Severe Acute Respiratory Syndrome Corona virus 2; RT-PCR, Reverse Transcriptase Polymerase Chain Reaction; COVID-19, coronavirus disease 2019; PROM, premature rupture of membranes ; PPROM, preterm premature rupture of membranes; NICU, neonatal intensive care unit; NND, neonatal death; RHD, rheumatic heart disease ; PPCM, peripartum cardiomyopathy; MS, mitral stenosis; MR, mitral regurgitation; TR, tricuspid regurgitation; LA- Left Atrium, LV-Left ventricular; PAH, pulmonary artery hypertension; MVOA, Mitral Valve Orifice Area; LVEF, left ventricle ejection fraction; AR, aortic regurgitation; RVSP, right ventricular systolic pressure; ARDS, Acute Respiratory Distress Syndrome. Pregnant woman with RHD and COVID-19 presented with fever, cough with expectoration, breathlessness, tachycardia with normal oxygen saturation. This suggests some diagnostic overlap between SARS-CoV-2 infection and new or recurrent acute respiratory failure with HD [[2]Beaton A. Zühlke L. Mwangi J. Taubert K.A. Rheumatic heart disease and COVID-19.Eur Heart J. 2020; 41: 4085-4086https://doi.org/10.1093/eurheartj/ehaa660Crossref PubMed Scopus (6) Google Scholar]. Two women with RHD were on secondary prophylaxis with penicillin in our study group. During the period of lockdown when there were transportation restrictions, the pregnant women with RHD faced several challenges in accessing the healthcare. Therefore, secondary prophylaxis must be ensured to all patients with RHD and more specifically to pregnant women by the public and private healthcare providers. Pregnancy is a state that is particularly susceptible to respiratory diseases like COVID-19 due to a compensated respiratory alkalosis with metabolic acidosis [[3]Juusela A. Nazir M. Gimovsky M. Two cases of coronavirus 2019–related cardiomyopathy in pregnancy.Am J Obstetrics Gynecol MFM. 2020; 2100113https://doi.org/10.1016/j.ajogmf.2020.100113Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar]. Despite this, both the cases with PPCM described in this report did not have worsening of PPCM due to COVID -19. We faced multiple challenges because of COVID-19 status and comorbidities of the women presented in this report. During the early phase of pandemic, there was a delay in receiving appropriate treatment as all these women were denied treatment in multiple hospitals before being referred to our dedicated COVID-19 facility at NH. This observation suggested the significant challenges faced by these women, who are also likely to face difficulties in secondary prophylaxis and access to health care leading to additional risk for adverse pregnancy and neonatal outcomes. One woman with PPCM (Case-5) had multiple congenital anomalies in the fetus at 21-weeks pregnancy but was denied medical termination of pregnancy (MTP) in multiple hospitals. The MTP Act (1971) in India permits the pregnancy termination until 20-weeks. Although MTP amendment Bill (2020) was passed in March, 2020 in the Lok-Sabha, it is yet to become an Act. In the context of the COVID-19 pandemic, our study generated an evidence of impact of COVID-19 on pregnant women with RHD with COVID-19. Therefore, countries with endemic RHD with higher COVID-19 burden should make provision of cardiac assessment on ultrasound to improve RHD diagnosis and strengthen the healthcare system for multi-speciality management of pregnant women with RHD and COVID-19.