Cardiovascular Complications of Pregnancy-Associated COVID-19 Infections

Abstract

Cardiovascular complications are frequently present in coronavirus-2019 (COVID-19) infection. These include microvascular and macrovascular thrombotic complications such as arterial and venous thromboembolism, myocardial injury or inflammation resulting in infarction, heart failure, and arrhythmias. Data suggest increased risk of adverse outcomes in pregnant compared with nonpregnant women of reproductive age with COVID-19 infection, including need for intensive care unit admission, mechanical ventilation, and extracorporeal membrane oxygenation utilization. Current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that may mimic COVID-19 complications such as peripartum cardiomyopathy, spontaneous coronary artery dissection, and preeclampsia. Unique to pregnancy, COVID-19 complications can result in preterm delivery and modify management of the pregnancy. Moreover, pregnancy has often been an exclusion criterion for enrollment in research studies. In this review, we summarize what is known about pregnancy-associated COVID-19 cardiovascular complications.

Keywords: CDC, Centers for Disease Control; COVID-19, coronavirus-2019; ECG, electrocardiogram; ECMO, extracorporeal membrane oxygenation; LV, left ventricular; MI, myocardial injury; PASC, postacute sequelae of SARS-CoV-2 infection; PPCM, peripartum cardiomyopathy; SCAD, spontaneous coronary artery dissection; Tn, cardiac troponin; arrhythmias; cardio-obstetrics; peripartum cardiomyopathy; preeclampsia; thromboembolic disease; vaccine induced thrombocytopenia.

Graphical abstract

Central Illustration

Spectrum of Cardiovascular Complications in Pregnancy-Associated COVID-19 Infection COVID-19 = coronavirus-2019; ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit.

Figure 1

Suggested Approach to Chest Discomfort in Pregnancy-Associated COVID-19 With Suspected Acute Coronary Syndrome The cardiovascular differential diagnosis of chest discomfort includes demand ischemia, myocarditis, stress cardiomyopathy, and acute coronary syndromes. Urgent angiography is reasonable if the ECG suggests ST-segment elevation myocardial infarction especially with classic symptoms. Equivocal symptoms or ECG findings can prompt evaluation with a focused or full TTE. Presence of wall motion abnormalities will help guide decision to proceed to coronary angiography, computed tomographic angiography, or medical therapy. CT angiography is an option for stable patients or patients with divergent findings to rule out ACS or point to an alternative diagnosis. See further discussion in text. ACS = acute coronary syndrome; CAD = coronary artery disease; CCTA = coronary computed tomographic angiography; CT = computed tomography; ECG = electrocardiography; MI = myocardial injury; PCI = percutaneous coronary intervention; SCAD = spontaneous coronary artery dissection; STEMI = ST-segment elevation myocardial infarction; TTE = transthoracic echocardiography.

Figure 2

Considerations in Women Symptoms of Heart Failure Distinguishing the etiology of heart failure in COVID-19 patients without ACS can be challenging as multiple features overlap. Echocardiography, coronary CT angiography, and CMR testing can be considered as diagnostic tools. Timing of presentation is also helpful. COVID-19 infection can occur throughout pregnancy although it may be most severe in the third trimester. Peripartum cardiomyopathy usually presents toward the end of pregnancy or in the months following delivery. See further discussion in the text. ACS = acute coronary syndrome; CAD = coronary atherosclerosis; CHD = congenital heart disease; CMP = cardiomyopathy; CMR = cardiac magnetic resonance imaging; CT = computed tomography; CT-PE = CT pulmonary angiography; CVD = cardiovascular disease; HFpEF = heart failure with preserved ejection fraction; LGE = late gadolinium enhancement; LV = left ventricle; PPCM = peripartum cardiomyopathy; Tn = troponin; VHD = valvular heart disease.