COVID-19 Pregnancies with Heart Disease: Challenges of Delivery

INTRODUCTION

The unprecedent pandemic of SARS-CoV-2, since December 2019, affected pregnant and postpartum women adversely. They are poised at higher risk of COVID-19 outcomes, as seen with other viruses (H1N1, SARS, and MERS) of the respiratory tract.^[1] The risk of acquiring the novel coronavirus in pregnancy is similar to non-pregnant females. Asymptomatic or mild disease occurs in majority but the symptomatic ones are at a higher risk of landing in severe disease. Studies earlier in the pandemic painted an optimistic picture for the outcomes of pregnancies with SARS-CoV-2 infection where mortality rates are very low.^[2] A living systematic review and meta-analysis has reported that although pregnant women with COVID-19 as compared to non-pregnant counterparts have reported lesser symptoms of fever and myalgia, pregnant women are more likely to require admission to intensive care unit (ICU) and ventilation more often. Severity of COVID-19 in pregnancy is further increased with advanced maternal age, high body mass index, chronic hypertension, and pre-existing diabetes.^[1]

There is generally good fetal outcome with no increase in spontaneous abortion or intrauterine fetal deaths except in those pregnancies with very severe COVID. Pre-term birth rates are high in pregnant women with COVID-19 than in pregnant women without the disease.^[1]

Heart disease in pregnancy is high-risk conditions due to hemodynamic overload of pregnancy on the cardiovascular system added with the SARS-CoV-2 infection, deterioration of cardiac function is imminent.^[3] SARS-CoV-2 affects the respiratory, cardiac, and coagulation systems which have already been physiologically adapted to bear the pregnancy load. Hence, pregnant women having heart disease and SARS-CoV-2 infection can have a greatly increased maternal morbidity and mortality due to the overlapping of complications. The evidence of acute respiratory distress syndrome caused by COVID-19 causing 12.5% maternal deaths having a high prevalence of heart disease as a comorbidity has been reported by Brazilian Ministry of Health.^[4]

A heart disease unrecognized before pregnancy diagnosis is most likely to be missed as the presenting symptoms of heart diseases and COVID-19 such as shortness of breath, cough, and fatigue being common can confuse clinicians. Rheumatic heart disease is still the most common cause of heart disease in pregnancy in India when compared to developed nations where congenital heart disease is now more common. Maternal mortality for women with severe and moderate mitral stenosis was found to be 3% and 1% respectively, in the medium to higher Human Development Index countries, so the rates in developing countries are assumed to be much higher due to lack of early recognition and facilities.^[5]

However, the clinical outcomes of COVID-19 in pregnancy with heart disease are still under-reported, management difficult, and prognosis uncertain. Paucity of available reported outcomes of pregnancy in patients with heart disease and COVID-19 was found when a literature search was made for such cases. This case series reports on the management of delivery and complications in pregnancies of heart disease with COVID-19, high-lighting the presentation, severity, delivery concerns, and clinical management with the maternal and fetal outcomes.

CASE DETAILS

Out of 54 COVID-positive pregnancies delivered in a dedicated multispecialty COVID hospital from July to November 2020, four cases (7.4%) were of heart disease in pregnancy. All cases were confirmed SARS-CoV-2 tested on nasal and oropharyngeal swabs by the reverse transcription– polymerase chain reaction method. Out of the four cases of COVID-19 infection in cardiac disease, two were in the WHO Risk Class III (One Moderate MS and one Post-mitral Valve Replacement) and two in the WHO Risk Class IV (severe mitral stenosis). A multidisciplinary team of obstetricians, cardiologist, anesthesiologists, intensive care specialist and nursing teams of labor room, operation theater, and ICU were involved in care.

DISCUSSION

In India, rheumatic heart disease is the main etiology of heart diseases encountered during pregnancy, followed by congenital heart diseases and cardiomyopathies.^[6] The total prevalence of heart disease in pregnant women is 0.2–4%, half of which have a congenital anomaly in developed countries. About 56–89% are of rheumatic origin in the developing countries.^[7]

Prompt testing for SARS-CoV-2 and isolation should be done upon any new onset cough or anosmia in pregnant women with cardiac disease. Diagnosed positive cases require a multidisciplinary team of obstetricians, intensivists, obstetric anesthetists, microbiologists, and neonatologists at a higher center of care.^[4] The prognostic factors in cardiac disease are the pre-pregnancy functional status, ventricular ejection fraction, type and severity of cardiac lesions, and any previous adverse cardiac events.

A review comprising 80,000 COVID-19 pregnant women have reported lesser presentation by fever (OR 0.43) and myalgia (OR 0.48) but increased risk of requiring ICU admission (OR 1.62) and invasive ventilation (OR 1.88). Severe disease occurred more in elderly pregnancy, obesity, pre-existing hypertension, and diabetes.^[1] Cardiac disease in pregnancy was not addressed in this meta-analysis. Even CDC does not include valvular heart disease as a comorbidity that act as risk factor for severe COVID-19.^[8]

Asymptomatic pregnancies with heart disease testing positive for SARS-CoV-2 should be mandatorily given hospital or telemedicine care in early pregnancy for monitoring of symptoms and worsening parameters. Life-threatening medical emergencies such as heart failure can occur anytime pregnant women affected with cardiac disease, especially during 28–32 weeks and labor delivery.

Conflicting results of ICU admission (7%) in symptomatic COVID pregnant women with no 3–4% intubation rates have been cited.^[9,10] In this series, 50% of COVID pregnancies with heart disease required ICU care and 25% of mechanical ventilation (non-invasive) whereas among other than heart disease 6/50 (12%) required ICU admission.

Thirteen out of 50 deliveries in COVID-19-positive deliveries were pre-term (26%) in our center but none in this heart disease group. The increased risk of pre-term births in most COVID pregnancies was not found in this cohort.^[11] Another study from India has reported 3 times higher pre-term delivery in women with HD and COVID-19 (95% CI 0.33–20.48), along with higher rates (14 times) of pre-labor rupture of membranes.^{[ 12]}

For most cardiac patients, vaginal route is preferred for delivery and cesarean section reserved for obstetric indications as greater blood loss, increased thromboembolism, and infections risk for mother. Elective cesarean section is indicated for those on oral anticoagulants (because of risk of fetal intracranial bleeding), Marfan syndrome with ascending aorta diameter >45 mm, acute or chronic dissection, and acute heart failure.^[13] In critically ill antenatal mothers (with hypoxia, cardiovascular or neurological complications, or signs of progressive multiple organ failure), a cesarean section is the most appropriate route of birth.

Although urgent cesarean delivery is suggested for gravidas with advanced heart failure and hemodynamic instability despite treatment, the first patient of this case series who had heart failure and impending eclampsia was delivered by vaginal instrumental delivery as she was referred in the second stage of labor. Maternal vitals monitoring in labor for systemic arterial pressure and heart rate is mandatory. Pulse oximetry becomes important in care of laboring COVID parturient for detecting any fall in oxygen saturation. Electrocardiogram use is as indicated by the patient’s condition. Avoiding supine position in labor with a left lateral tilts and attend to any hemodynamic fluctuations occurring with uterine contractions. Continuous electronic fetal heart rate monitoring is recommended during labor. Descent of the fetal head to the perineum should be allowed with uterine contractions so that the circulatory overload due to maternal pushing is avoided. Low forceps or vacuum extraction can then be used to assist the delivery of head.

The hypercoagulable state of pregnancy increases the risk of thromboembolism in women with heart disease. The combination of COVID-19 and mechanical valve prosthesis or atrial fibrillation in rheumatic valve disease increases the risk of thromboembolic events in pregnant women. For postpartum women having heart disease and COVID-19 both, thromboembolism is a serious threat. All patients in this case series received thromboprophylaxis with LMWH which was continued till 6-week postpartum. They were also advised meticulous leg care, compression stockings and were allowed early ambulation for reduction of puerperal thromboembolic risks.^[13]

Antibiotic prophylaxis is a routine practice for all cesarean sections for reducing the risk of postpartum endometritis. In addition, endocarditis protection is also ensured.

Cardiomyopathy has been reported in pregnant COVID patients, but it is not known whether COVID-19 cardiomyopathy is exacerbated in pregnancy or not.^[14]

Pregnant women with MS are at risk for pulmonary edema and atrial arrhythmias. Hemodynamic changes in pregnancy cause an increase in the gradient across the stenotic mitral valve and could lead to pulmonary congestion. Even when pregnancy is not complicated by the development of pulmonary edema, some women with MS experience deterioration in their functional class or develop new cardiac symptoms. Moreover, COVID can be one of the factors for this as seen in this series of cases.

Monitoring post-delivery should be in a special care unit, such as an intensive care and coronary care where cardiac complications can be promptly diagnosed and treated. Monitoring should be for 24 h, as post-delivery fluid shifts may extend beyond delivery duration, if regional anesthesia was used.

The laboratory parameters studied in COVID for these pregnant women were ferritin, total leukocyte count (TLC), C-reactive protien (CRP), lactate dehydrogenase (LDH), D-dimer, and procalcitonin as they are related used for predicting COVID-19 infection severity. The recommended cutoffs for ferritin are 109.8 ng/mL, WBC is 14.9109/L, CRP 10.15 is mg/L, and LDH is 229.33 U/L as per a study in China.^[15,16] In this case series, only higher TLC predicted a COVID sepsis but other parameters were similar among all four cases but had severe disease.

The core members for managing these cases were cardiologist and the gynecologist, anesthetist, and neonatologist. Care of high-risk patients requires a team approach including a maternal-fetal medicine specialist, cardiologist, and obstetrical anesthesiologist. European Society of Cardiology guidelines for the management of grown-up congenital heart disease are modified for pregnant women with heart disease according to disease complexity and pregnancy risk.^[16] Level 1 represents care for highly complex and high-risk (WHO Class III or IV) lesions, for which exclusive care in a specialist unit is advisable, usually monthly or bimonthly. During pregnancy, standard cardiac follow-up for most women will consist of clinical assessment and echocardiography.

Pregnancy in a cardiac disease is a complex population of patients requiring protection from SARSCoV-2 and a proactive, tailored treatment in case of COVID-19 infection. All medical organizations recommend for COVID-19 vaccination in the unvaccinated pregnant or recently pregnant or those planning pregnancy, as reduction of risk of COVID-19 and disease severity occurs which will better the maternal outcomes in cardiac patients as well.

CONCLUSION

COVID-19 in pregnant women with cardiac disease has increased rates of complications, oxygen requirements, and ICU requirements than other COVID pregnancy patients. They require hospitalization, intensive monitoring and protocol-based treatment, and delivery for a good maternal and fetal outcome in COVID-19 with cardiac disease in pregnancy.