Q&A: Maternal SARS-CoV-2 infection, disseminated intravascular coagulation linked
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Even in cases of mild or asymptomatic COVID-19, severe disseminated intravascular coagulation was a possibility for pregnant people, findings from a retrospective case series show.
“There is no standardized protocol for maternal-fetal surveillance after maternal COVID-19 diagnosis,” Jeanette Carpenter, MD, a maternal-fetal medicine specialist at Pediatrix Medical Group, and colleagues wrote in the American Journal of Obstetrics & Gynecology Global Reports. “Clinicians typically find it reassuring if patients are mildly symptomatic or asymptomatic. After pregnant patients test positive for SARS-CoV-2, routine visits for prenatal care, ultrasound examinations and fetal surveillance are often postponed to minimize potential exposure of noninfected persons.”
However, patients with mild or asymptomatic cases of COVID-19 who had disseminated intravascular coagulation often reported decreased fetal movement (56%) or nonreassuring fetal heart rate pattern (16%).
Healio spoke with Carpenter to learn more about the clinical and research implications for pregnant people with mild or asymptomatic disease.
Healio: What prompted this study?
Carpenter: Through discussions on a private maternal-fetal medicine clinical forum and a maternal-fetal medicine Facebook page, we discovered that many clinicians were seeing similar cases across the United States of pregnant patients with either asymptomatic or mild COVID, disseminated intravascular coagulation, and evidence of fetal compromise in the form of decreased fetal movement, nonreassuring fetal heart rate tracings and stillbirth. We sought to describe the clinical features and outcomes in 19 identified cases between October 2020 and December 2021 (pre-omicron surge).
Healio: What is the main message for clinicians?
Carpenter: Severe disseminated intravascular coagulation can occur even if maternal COVID appears mild. All of the patients included in this case series were in the third trimester. Most (95%) required blood product transfusion and most (82%) had abnormal placental histopathology with evidence of what has been termed SARS-CoV-2 placentitis — histiocytic intervillositis, intervillous fibrin deposition and necrosis. Our findings suggest a link between infection of the placenta with SARS-CoV-2 and the development of maternal disseminated intravascular coagulation.
Healio: Were any of the findings surprising?
Carpenter: Yes. Previous studies had found that adverse pregnancy outcomes with COVID were primarily seen in those patients with severe or critical disease. In contrast, the patients in this retrospective case series had mild or asymptomatic COVID but severe clinical outcomes.
Healio: What work needs to be done to address disseminated intravascular coagulation in pregnant patients with COVID-19?
Carpenter: Of the 19 women included in this cases series, 18 were unvaccinated and one had an unknown vaccination history. COVID vaccination for pregnant patients should continue to be encouraged. When a pregnant patient presents in the third trimester with a recent positive test for COVID and decreased fetal movement, they should have prompt fetal monitoring. If fetal status is not reassuring and cesarean delivery is needed, we recommend — if time allows — laboratory evaluation for evidence of disseminated intravascular coagulation (platelet count, fibrinogen and prothrombin time/partial thromboplastin time) and ordering of blood products for potential massive transfusion protocol prior to delivery.
Healio: What research on this topic would you like to conduct next?
Carpenter: Future research should focus on whether these patients have adverse outcomes in future pregnancies. The current study did not include patients during the omicron surge. It will be important to determine if SARS-CoV-2 placentitis and maternal disseminated intravascular coagulation are more or less common with particular variants.