Proteinuria in Covid-19 pregnant women: Preeclampsia or severe infection?

Abstract

We report the case of a severe COVID-19 infection in which the diagnosis of preeclampsia (PE) was wrongly assumed because of proteinuria. This case raises both the question of the predictive value of proteinuria and the differential diagnosis between preeclampsia and the severe form of COVID-19 in pregnant women. Despite numerous publications related to the pandemic, data remain limited regarding COVID-19 infections in pregnant women. The reported rates of severe infections range between 14 % (severe pneumonia) to 5% (severe acute respiratory syndrome/SARS) [1]. There are no clear maternal risk factors predicting severe infection in pregnant woman. A 26-year old woman (gravida 4, para 2) was admitted at 37 weeks of gestation with a 24-hs history of dry cough and headache. One of her relatives was infected by Covid-19. Until then the pregnancy was uneventful. At the time of hospital admission to the Covid-19 unit, her temperature was 37.9 C, her cardiac heart rate 112 beats per minute, her blood pressure 148/83 mm/Hg, her respiratory rate 22 breaths per minute and her oxygen saturation 98 % (ambient air breathing). Fetal heart rate was normal. Covid-19 nasopharyngeal tests were positive. On day 2, the 24-h urine protein test (performed due to arterial pressure >140/90 mmHg) was positive (1,2 g/24 h) and a suspected PE diagnosis was verified accordingly. On day 3 labour was induced on this indication in accordance with our national guidelines [2]. A C-section was performed because of arrested labor. A healthy 2700 g baby boy was born, with negative Covid-19 nasopharyngeal tests. In the post-partum period, the patient developed a respiratory distress syndrome requiring her transfer to the Intensive Care Unit (ICU) on day 5. From day 7 to day 17, she needed invasive ventilation and extracorporeal membrane oxygenation. She fully recovered on day 22. This case describes a complicated post-partum period in a woman with Covid-19. We suspected preeclampsia in this patient, which is a common disorder in pregnancy with hypertension and proteinuria related to placental dysfunction [2]. In their recent publication, Liu et al. highlighted the fact that proteinuria is more pronounced in non-pregnant Covid-19 patients than in healthy controls (28.57 % Vs 11.11 %; p < 0.05) [3]. Proteinuria seems to be associated with Covid-19 severity [3]. Di Mascio et al. observed a 16.2 % rate of preeclampsia in pregnancies affected by Coronavirus [4]. This is much more common than the 2-8 % rate in the general population [2]. The first hypothesis that might be put forward is that of false positive diagnosis of PE, with the proteinuria in fact being linked to infection itself (as suggested by Mendoza et al. [5]). The second hypothesis that

Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study

“…In other words, it may be difficult to clinically distinguish this syndrome from “true” preeclampsia because they both share characteristics of the severe endothelial dysfunction seen in nonpregnant patients. 7 , 30 …”

Body Localization of ACE-2: On the Trail of the Keyhole of SARS-CoV-2

“…Despite the clinical manifestation in COVID-19 pregnant women seems to remain the same as in non-pregnant patients, several studies suggest that pregnant women infected with COVID-19 may be at risk for preterm delivery (294)(295)(296). Recent papers also reported cases of pre-eclampsia and manifested gestational hypertension in COVID-19 pregnant women (297)(298)(299). An analysis of the WAPM study on COVID-19 reported that early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection (300).…”

Empfehlungen zu SARS-CoV-2/COVID-19 in Schwangerschaft, Geburt und Wochenbett – Update November 2021 (Langfassung)

“…Herzerkrankungen und COVID-19 haben ebenfalls gemeinsame Symptome, die in der Schwangerschaft zu einer Fehldiagnose führen können [354]. Geburtshilfliche Differentialdiagnosen sollten in jeder Abklärung einer vermuteten COVID-19-Erkrankung berücksichtigt werden [355]. Es wurde über eine Koinzidenz von PRES [356] und COVID-19-Krankheit berichtet, sodass die Differentialdiagnostik eines PRES besonders wichtig ist [357].…”