Maternal death due to COVID-19

Abstract

Background: Despite 2.5 million infections and 169,000 deaths worldwide (as of April 20, 2020), no maternal deaths and only a few pregnant women afflicted with severe respiratory morbidity have been reported to be related to COVID-19 disease. Given the disproportionate burden of severe and fatal respiratory disease previously documented among pregnant women following other coronavirus-related outbreaks (SARS-CoV in 2003 and MERS-CoV in 2012) and influenza pandemics over the last century, the absence of reported maternal morbidity and mortality with COVID-19 disease is unexpected.

Objective: To describe maternal and perinatal outcomes and death in a case series of pregnant women with COVID-19 disease.

Study design: We describe here a multiinstitution adjudicated case series from Iran that includes 9 pregnant women diagnosed with severe COVID-19 disease in their second or third trimester. All 9 pregnant women received a diagnosis of SARS-CoV-2 infection by reverse transcription polymerase chain reaction nucleic acid testing. Outcomes of these women were compared with their familial/household members with contact to the affected patient on or after their symptom onset. All data were reported at death or after a minimum of 14 days from date of admission with COVID-19 disease.

Results: Among 9 pregnant women with severe COVID-19 disease, at the time of reporting, 7 of 9 died, 1 of 9 remains critically ill and ventilator dependent, and 1 of 9 recovered after prolonged hospitalization. We obtained self-verified familial/household cohort data in all 9 cases, and in each and every instance, maternal outcomes were more severe compared with outcomes of other high- and low-risk familial/household members (n=33 members for comparison).

Conclusion: We report herein maternal deaths owing to COVID-19 disease. Until rigorously collected surveillance data emerge, it is prudent to be aware of the potential for maternal death among pregnant women diagnosed as having COVID-19 disease in their second or third trimester.

Keywords: COVID-19; SARS CoV-2 virus; coronavirus disease in pregnancy; lower respiratory infections in pregnancy; maternal death; maternal mortality; maternal respiratory morbidity; pregnancy; respiratory failure with COVID-19.

Figure 1

Summary timeline of patients’ events, procedures, and medications before death Narrative summaries are provided in the text, and further details are in Tables 1 and 2. The order of cases does not represent chronology or site of care. No patient was placed in prone position, either while pregnant or in the postpartum interval. Dosages of medications are provided in methods, timing is indicated by bars, and constituent drug therapies are detailed in each case report narrative. For all cases, anticoagulation therapy comprised enoxaparin (cases 1–7 and 9 at 40 mg subcutaneous daily) or heparin (case 8, heparin 5000 units subcutaneous twice daily). DCDA, dichorionic diamniotic; DFM, decreased fetal movement; IUFD, intrauterine fetal death; pos, positive; resp. distress, respiratory distress; RT-PCR NAT, reverse transcription polymerase chain reaction nucleic acid testing; SOB, shortness of breath. Hantoushzadeh et al. Maternal death due to coronavirus disease 2019. Am J Obstet Gynecol 2020.

Figure 2

Outcomes among familial and household members of the 7 pregnant patients who died following SARS-CoV-2 infection All of our pregnant patients had available self-reported data, and the only member who died was the pregnant patient. All occurrences of prolonged exposure occurred as a result of duration of symptoms before patient admission. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Hantoushzadeh et al. Maternal death due to coronavirus disease 2019. Am J Obstet Gynecol 2020.

Supplemental Figure 1

Summary data of cases of severe morbidity, but without death (as of April 20, 2020). A, Summary timeline of patients’ events, procedures, and medications in cases of severe morbidity but without death (as of April 20, 2020). Narrative summaries are provided in the text, and further details are in Supplemental Tables 1 and 2. The order of cases does not represent chronology or site of care. No patient was positioned in the prone position, either while pregnant or in the postpartum interval. Dosages of medications are provided in Methods, timing is indicated by bars, and constituent drug therapies are detailed in each case report narrative. For all cases, anticoagulation therapy comprised enoxaparin (case 9, at 40 mg subcutaneous daily) or heparin (case 8, heparin 5000 units subcutaneous twice daily). B, Outcomes among familial and household members of the 2 pregnant patients with severe morbidity but did not die (as of April 20, 2020). All of our pregnant patients had available self-reported data, and the only member with severe cardiopulmonary morbidity was the pregnant patient. All occurrences of prolonged exposure occurred as a result of duration of symptoms before patient admission. COV2, coronavirus 2, IUFD, intrauterine fetal death; neg, negative; pos, positive SOB, shortness of breath. Hantoushzadeh et al. Maternal death due to coronavirus disease 2019. Am J Obstet Gynecol 2020.