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As the COVID-19 pandemic continues, now in its third year, we have learned and continue to learn much about the cardiovascular complications that arise as a result of the novel coronavirus infection.
At this point in the pandemic’s trajectory both macrovascular and microvascular sequelae of the virus have been identified including thromboembolism, heart muscle injury, heart failure, and arrhythmias.1 Historically it has been difficult to study pregnancy related complications due to the difficulty in enrolling pregnant participants.
In keeping with their mission to stay on the cutting edge of cardiovascular care, the American College of Cardiology (ACC) Cardiovascular Disease in Women Committee reviewed all the available data in an effort to determine the specific cardiovascular risks for pregnant women who are infected with the COVID-19 virus.
Building on evidence from the US Centers for Disease Control and Prevention (CDC) who found that pregnant women are at increased risk of adverse outcomes with COVID-19, the ACC committee found that infected pregnant women are at higher risk for pre-term birth and still birth when compared to pregnant women not infected with the virus.1 Further it was found that one third of infants born to women with COVID-19 required neonatal intensive care.1
It is well known that those with preexisting conditions are at higher risk for severe COVID-19 related disease, hospitalization, and death.1 Results of this current investigation indicate that pregnancy itself may be considered a preexisting condition putting women at much higher risk if infected by COVID-19. More specifically the ACC committee found that pregnant women infected with COVID-19 are at greater risk for intensive care unit admission, mechanical ventilation, and extracorporeal membrane oxygenation support when compared to nonpregnant women of reproductive age.1
With regards to cardiovascular complications in pregnant women with COVID-19, reports were found of myocardial damage, arrythmias, and heart failure, but more data will be required to determine if the prevalence of these complications differs between pregnant and non-pregnant women. Similarly, it remains unclear if the rates of preeclampsia, peripartum cardiomyopathy, and spontaneous coronary dissections can be distinguished from other COVID-19 CV complications.1
In addition to pregnancy specific complications, pregnant women with more traditional comorbidities associated with poor outcomes after COVID-19 infection are at even higher risk for complications including severe disease and death.1 Racial disparities were also found. Non-Hispanic Black women represented over one quarter of pregnancy associated deaths in one U.S. study while pregnant Hispanic women saw a 2.4-fold increase in death, Asian and Native Hawaiian/Pacific Islanders had the highest intensive care unit admissions.1
Although it is clear that pregnancy is responsible for a unique cardiovascular risk profile during COVID-19 infection it is unclear why. The authors propose that a key reason could be that pregnant women generally have lower vaccination rates compared to non-pregnant women.1 In fact, in one study cited by the committee, three quarters of pregnant women requiring hospitalization with COVID-19, the overwhelming majority of those requiring intensive care admission, and all of the fetal deaths occurred in unvaccinated women.1 With the COVID-19 pandemic showing no sign of retreat pregnant women need to know the facts.
“Pregnant people need to know that they are at increased risk of a severe COVID-19 infection, including ICU admissions, cardiac complications, need for critical care and death for the patient or fetus. Unfortunately, pregnant women have lagged behind other groups getting vaccinated,” wrote lead author Joan Briller, MD, of the University of Illionois.1
The authors of this report want women to know that all available data support vaccination for COVID-19 in pregnancy with both an excellent safety profile and protection for the infant once born.1 More research is needed to determine how to differentiate between COVID-19 complications and those attributable to pregnancy and COVID. The committee suggests that, in the meantime, “Pregnancy Heart Teams” should be created and responsive to presumed pregnant COVID-19 admissions.1
These teams should be multidisciplinary and include high risk obstetricians, obstetric anesthesia, cardiologists, and experts in adult and neonatal critical care.1 Armed with the knowledge that COVID-19 in pregnant women has its own unique considerations we can provide care tailored to this patient population in the hopes of saving the lives of mothers and babies through and hopefully after the pandemic.
1. Briller JE, Aggarwal NR, Davis MB, Hameed AB, Malhamé I, Mahmoud Z, McDonald EG, Moraes de Oliveira G, Quesada O, Scott NS, Sharma J; American College of Cardiology Cardiovascular Disease in Women Committee. Cardiovascular Complications of Pregnancy-Associated COVID-19 Infections. JACC Adv. 2022 Aug 10:100057. doi: 10.1016/j.jacadv.2022.100057. Epub ahead of print. PMID: 35967591; PMCID: PMC9364954.