Cardiovascular Complications of COVID-19 among Pregnant Women and Their Fetuses: A Systematic Review

Abstract

Background: COVID-19 is a viral infectious disease leading to a spectrum of clinical complications, especially cardiovascular. Evidence shows that this infection can potentially accompany a worse outcome in pregnant women. Cardiovascular complications in mothers and their fetuses are reported by previous studies.

Objective: In this systematic review, we aim to investigate the cardiovascular complications of COVID-19 during pregnancy in the mothers and fetus, according to the published literature.

Method: We systematically searched the online databases of PubMed, Scopus, Web of Science, and Google Scholar, using relevant keywords up to April 2022. We included all observational studies reporting cardiovascular complications among COVID-19-affected pregnant women and their fetuses.

Results: We included 74 studies containing 47582 pregnant COVID-19 cases. Pre-eclampsia, hypertensive disorders, cardiomyopathy, heart failure, myocardial infarction, thrombosis formation, alterations in maternal-fetal Doppler patterns, and maternal and fetal arrhythmia were reported as cardiovascular complications. The highest incidences of pre-eclampsia/eclampsia among COVID-19 pregnant cases, reported by studies, were 69% and 62%, and the lowest were 0.5% and 3%. The highest and lowest incidences of fetal bradycardia were 20% and 3%, and regarding fetal tachycardia, 5.4% and 1%, respectively.

Conclusion: SARS-CoV-2 infection during pregnancy can potentially be associated with cardiovascular complications in the mother, particularly pre-eclampsia and heart failure. Moreover, SARS-CoV-2 infection during pregnancy can potentially cause cardiovascular complications in the fetus, particularly arrhythmia.

Keywords: COVID-19; SARS-CoV-2; cardiovascular complications; pre-eclampsia; pregnancy.

Figure 1

PRISMA flow diagram.

Figure 2

Association of SARS-CoV-2 with hypertensive disorders and pre-eclampsia. SARS-CoV-2 binds to ACE-2 and reduces ACE-2 and ANG-(1–7) levels. Reduced ANG-(1–7) decreases its vasodilatory effect and, therefore, enhances vasoconstriction. Endothelial cells also express ACE2 receptors and SARS-CoV-2 infection can cause immune cell-mediated endothelial damage, which is a hallmark of pre-eclampsia. Additionally, the virus invades the cells, activating the inflammatory response by increasing TNF-, IL-6, IL-1. This cytokine hyperproduction increases the risk of vascular hyperpermeability, which can lead to hypertensive diseases. These mechanisms could explain the hypertension problems seen in COVID-19 individuals who are pregnant. (ACE2= Angiotensin-converting enzyme 2, ANG = angiotensin, IL = interleukin, TNF-a = tumor necrosis factor α).