At the Heart of the Discussion: COVID-19 Cardiovascular Complications in Pregnant Women

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Pregnancy is accompanied by cardiovascular changes, namely increased sympathetic drive, renin-angiotensin-aldosterone system (RAAS) activation for plasma volume expansion, as well as increased erythropoiesis for efficient oxygen and nutrient delivery; these altogether meet the metabolic and circulatory demands for maternal-foetal wellbeing.¹ The association between coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2 virus, and cardiovascular complications during pregnancy is less well studied — pregnant and lactating individuals are often excluded from clinical trials, owing to ethical concerns of potential foetal or neonatal harm due to drug-exposure in utero.^2,3There is also occasional lack of consensus for COVID-19 vaccination during pregnancy, accounting for vaccine hesitancy and the lower vaccination rate in pregnant individuals.^4,5 In the August 2022 issue of JACC: Advances, Briller et al explored the differences in cardiovascular complications between pregnant individuals and their non-pregnant counterparts.⁶

Pre-eclampsia, defined as gestational hypertension with proteinuria⁷, is a concerning cardiovascular condition unique to pregnant women; it is a result of excessive vasomotor sympathetic activity and reduced plasma volume expansion.¹Infection with SARS-CoV-2 invokes damage to the vascular endothelium, triggers inflammation, and limits plasma volume expansion due to RAAS disablement.⁶ Focusing on the effect of SARS-CoV-2 on the RAAS, COVID-19 infection can be seen as a risk factor of pre-eclampsia. Statistically, COVID-19-infected pregnant subjects had a higher likelihood of developing pre-eclampsia (relative risk 1.89; 95% CI, 1.17-3.05).⁶ Moreover, myocardial infarction (MI) and heart failure-like clinical imaging were observed in pregnant COVID-19-infected individuals. Heart failure, commonly manifesting as dyspnoea, is defined as failure to meet metabolic demands with cardiac output⁸; the increased effective circulating volume during pregnancy may prompt left ventricular remodelling, to the extent of reduced ejection fraction.⁶ Heart failure may also trigger arrhythmia such as atrial fibrillation, which was observed in 13.3% of pregnancy-associated symptomatic COVID-19 patients from a Dominican Republic study.⁶However, the exact incidence of MI and heart failure in pregnant women remains unknown due to the diagnostic challenges in delineating the major underlying aetiology — more of COVID-19 or pregnancy. Contrary to common understanding that pregnancy is a factor of hypercoagulability, existing studies do not show any increased thromboembolism risk in pregnant COVID-19 patients.⁶

It is essential to acknowledge the possible cardiovascular complications following COVID-19 infection, since they may urge pharmacological management and close assessment for potential emergency caesarean delivery.⁹ COVID-19 vaccination is by far the most effective way to avoid cardiovascular complications.¹⁰ Although vaccination does not completely prevent infections, it can reduce the risk of complications.¹¹Major factors of vaccine hesitancy currently include fear of harming the unborn child and lack of consensus in vaccination recommendations.^4,5 These obstacles will have to be addressed before an increase in vaccination rate among pregnant individuals is to be observed. Although vaccine manufacturers and health authorities have expressed mixed recommendations on COVID-19 vaccination during pregnancy — pregnancy was previously listed as a contraindication for the CZ02 vaccine and the United Kingdom Joint Committee on Vaccination and Immunisation once advised against vaccination in low-risk pregnant individuals. More recently, studies have demonstrated COVID-19 vaccine efficacy and safety, even for the pregnant population.^12,13Local health departments can thus disseminate these findings for reassurance.

Reference

Sanghavi M & Rutherford JD. Circulation. 2014;130:1003-8.

Rubin R. JAMA. 2021;325(11):1027-1028.

Smith DD, et al. Am J Perinatol. 2020;37:792-9.

Razzaghi H, et al. Public Health Rep. 2022;137(5):988-99.

Iacobucci G. BMJ. 2021;375:n2862.

Briller JE, et al. JACC Adv. 2022;1(3):1-11.

Children’s Hospital of Philadelphia. Available online. https://www.chop.edu/conditions-diseases/gestational-hypertension#:~:text=Gestational%20hypertension%20is%20diagnosed%20when,increased%20protein%20in%20her%20urine. Last accessed: 27 September 2022.

Puggia I, et al. Heart Failure in the Child and Young Adult: From Bench to Bedside. 2018; P.3-19.

Townsend R, et al. Integr Blood Press Control. 2016;9:79-94.

The Hong Kong College of Obstetricians and Gynaecologists. Available online. https://www.hkcog.org.hk/hkcog/news_4_65.html. Last accessed: 26 September 2022.

Centers of Disease Control and Prevention. Available online. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html. Last accessed: 27 September 2022.

Ellington S & Olson CK. Lancet Infect Dis. 2022. 10.1016/S1473-3099(22)00443-1.

Prasad S. Nat Commun. 2022;13:2414.

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Disclaimer

This article is not medical advice. Patients should seek personal assessment by a licenced specialist. Physicians are recommended to read the full publication(s) as cited in the article before making medical decisions. This article does not supersede nor replace the published article(s).