In a review of articles by researchers, the existing relationships between both pathological conditions were recorded, with the identification of biomarkers that can help in the differential diagnosis.
FAPESP/DICYT AGENCY – During the COVID-19 pandemic, especially before vaccines were available, alarm bells were raised about a possible correlation between severe cases of COVID-19 in pregnant women and preeclampsia, a pathological condition characterized by persistent increase in maternal blood pressure during pregnancy and which can cause serious complications for the mother and the baby. Pregnant women infected with SARS-CoV-2 tended to develop preeclampsia more frequently, in addition to being subject to a higher risk of complications and death.
One of the clinical challenges at that time lay in making the differential diagnosis. It happens that preeclampsia, which has a greater prevalence during the third trimester of pregnancy, is a disease that goes beyond blood pressure alterations, as it increases the risk of suffering from kidney failure, liver failure and placental dysfunction, conditions that a patient with severe COVID-19 may also suffer as a result of the exacerbated inflammation that the coronavirus induces.
And the care protocol for both situations is generally different: while the recommendation for preeclampsia consists of anticipating labor by interrupting the pregnancy, in the case of COVID-19, the pregnancy can be maintained with clinical support until the infection improves. . In other words, especially in the most severe cases of preeclampsia (called HELLP syndrome) and early cases (before 34 weeks of gestation) it is even more important to ensure the proper diagnosis.
Three years after the deadliest period of the pandemic, a review of studies conducted with the FAPESP support y published in it American Journal of Reproductive Immunology suggests the existence of a relationship between the pathophysiology of preeclampsia and that of COVID-19.
In the aforementioned work, carried out by researchers from the University of Campinas (Unicamp), in Brazil, and the Baylor College of Medicine, in the United States, the relationships between both pathological conditions were pointed out, with common pathways referring to the renin-angiotensin system ( the set of molecules involved in the regulation of blood pressure) and the ACE2 receptor (the acronym in English for angiotensin converting enzyme type 2), to which the SARS-CoV-2 virus binds to infect human cells. In another study, the same group of scientists identified biomarkers capable of distinguishing between preeclampsia and severe COVID-19 in pregnant women.
“There is indeed a very great similarity in the evolution of both conditions. In both COVID-19 and severe preeclampsia there can be multiple organ dysfunction and high blood pressure. There are also similarities in relation to the mechanism, since the ACE2 receptor plays a key role in the pressure regulation system. Therefore, it is possible that the infection generates an increased risk of preeclampsia, as demonstrated in the framework of various studies in which the existence of a higher frequency of preeclampsia in cases of COVID-19 was verified,” he explains. Maria Laura Costa do Nascimentoprofessor of obstetrics at Unicamp and author of the review.
In Brazil, more than 300 pregnant women die annually from preeclampsia. Costa do Nascimento affirms that high-income countries have practically eliminated these deaths thanks to investments in actions for timely diagnosis of this condition, which makes it possible to offer better treatment to pregnant women.
During the pandemic, cases of maternal deaths skyrocketed. Data from the Brazilian Ministry of Health shows that in 2020 there were 1,965 women who died during pregnancy, childbirth or the postpartum period in the country. In 2021, that number rose to 3,030 deaths.
The epidemiological bulletin also indicates a high-risk condition for preeclampsia. “Our goal for the year 2030 in terms of maternal deaths is to reach fewer than 30 deaths per 100,000 live births. At the moment[[datos de 2023]we are at 70 deaths per 100,000 live births. In the pandemic, in 2021, that number reached 120 deaths on the national average, with states and regions with even higher numbers. COVID-19 put a magnifying glass on what was already happening and showed the impact of the adverse outcome in these conditions,” says the researcher.
According to Costa do Nascimento, it is not possible to associate the increase in maternal mortality during the pandemic with the increase in cases of preeclampsia. “We do not have monitoring data or an adequate diagnosis of this condition. What can be said – based on a multicenter study that we carried out during the pandemic in 16 maternity hospitals in Brazil – is that when there is an increased risk of death or worsening of the patient’s health condition, both conditions were present. And our review work shows that the prevalence of preeclampsia increases among cases of infection.”
The biomarkers
another study led by the Costa do Nascimento group showed the existence of biomarkers capable of differentiating between preeclampsia and COVID-19 in pregnant women. “They are classic markers for preeclampsia[[las proteínas sFlt-1 y PlGF]that help control vasoconstriction and vasodilation. These proteins are made throughout gestation in the cells of the placenta. In cases of preeclampsia there is an imbalance: a decrease in proangiogenic proteins[[PlGF]and an increase in antiangiogenics[[sFlt-1]. We observed that these biomarkers are specific for preeclampsia. They do not suffer alterations in COVID, which could help make the differential diagnosis,” he comments.
As the researcher highlights, there are very well-defined risk factors for preeclampsia: women who suffer from chronic high blood pressure, who had preeclampsia during a previous pregnancy, a twin pregnancy, diabetes or some autoimmune disease. “There are various factors that define how the follow-up of this pregnant woman should be, and it is possible that COVID-19 should enter that list in the future,” he maintains.
Questions for the interview:
1. As a professional in the field of pregnancy and maternal health, can you talk about the potential correlation between severe cases of COVID-19 and preeclampsia? How does the pathophysiology of these two conditions overlap?
2. What are some of the challenges in making the differential diagnosis between preeclampsia and severe COVID-19 during pregnancy, and how can healthcare providers ensure accurate diagnosis for optimal care?
3. In your research, you identified biomarkers that can differentiate between these two conditions. Can you explain the significance of these findings and how they might impact clinical practice?
4. Are there any particular risk factors that make pregnant women more vulnerable to developing both preeclampsia and severe COVID-19? How can healthcare providers address these concerns proactively?
5. Given the increased prevalence of both conditions during the pandemic, what lessons have we learned about pregnancy and maternal health that can inform future policies and interventions?
