Fetal deaths in pregnancies with SARS-CoV-2 infection in Brazil: A case series

Abstract

Background: There are few reports of miscarriages or stillbirths in women infected with SARS-CoV-2. We present five consecutive cases of fetal death (≥12 weeks) without other putative causes in women with laboratory-confirmed (RT-PCR) COVID-19 managed in a single Brazilian institution.

Case series: All five women were outpatients with mild or moderate forms of COVID-19 and were not taking any medication. Four were nulliparous, all were overweight or obese, and none had any comorbidities or pregnancy complications that could contribute to fetal demise. Fetal death occurred at 21-38 weeks of gestation, on COVID-days 1-22. SARS-Cov-2 was detected by RT-PCR in amniotic fluid in one case and in placental specimens in two cases. All five women had acute chorioamnionitis on placental histology, massive deposition of fibrin, mixed intervillitis/villitis, and intense neutrophil and lymphocyte infiltration. One fetus had neutrophils inside alveolar spaces, suggestive of fetal infection.

Conclusions: These five cases of fetal demise in women with confirmed COVID-19 without any other significant clinical or obstetric disorders suggest that fetal death can be an outcome of SARS-CoV-2 infection in pregnancy. The intense placental inflammatory reaction in all five cases raises the possibility of a direct effect of SARS-CoV-2 on the placenta.

Keywords: AF, Amniotic fluid; Abortion; BMI, Body mass index; BP, Blood pressure; COVID-19; CS, Cesarean section; ED, Emergency department; FHR, Fetal heart rate; Fetal death; GA, Gestational age; HR, Heart rate; Infectious disease transmission; RR, respiratory rate; SpO2, Oxygen saturation; Spontaneous; Stillbirth; US, Ultrasound; Vertical; Z-STORCH, Zika, syphillis, toxoplasmosis, rubella, cytomegalovirus, herpes.

Fig. 1

Placental histology Case 1. A. Low resolution: acute chorioamnionitis with extensive deposition of perivillous fibrin. B. High resolution: Mixed villitis and intervillitis.

Fig. 2

Histological findings Case 2. A. Placenta, low resolution: Extensive deposition of perivillous fibrin. B. Placenta, high resolution: Mixed villitis and intervillitis. C. Fetal lung: neutrophils inside alveolar spaces.