Weekly Update, 4/20-4/26

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Further data on COVID-19 and pregnancy does not show excess maternal mortality or adverse fetal outcomes.

  • A study from China of 118 pregnant patients who were either COVID-19 PCR positive (71%) or who had CT findings + symptoms of COVID-19 (29%) found that 92% had mild disease (the overall population rate of mild disease is approximately 81%).  The other 8% had severe disease (defined in this study as hypoxia).  Of the nine patients with severe disease, development was post-partum among six patients and only one patient needed non-invasive ventilation; there were no deaths.  The baseline data of neonatal outcomes is not yet available, but the study authors do not raise any concerns about adverse neonatal outcomes (three spontaneous abortions, two ectopic pregnancies). 21% of deliveries (half of which were induced) were premature, but there was no neonatal asphyxia.
  • Editor Comment:  This is reassuring, and consistent with previous data showing that COVID-19 does not present more virulently in pregnancy.  More data will likely be forthcoming.

Chen L. et al. Clinical Characteristics of Pregnant Women with COVID-19 in Wuhan, China. NEJM: April 17, 2020 DOI: 10.1056/NEJMc2009226 available here.

ACEI/ARBs do not seem to increase mortality, and may have some protective effects in patients with COVID-19

  • The first study is an observational case series of 1178 hypertensive patients from China with COVID-19, 32% of which were taking an ACE or an ARB. The mortality rate in the patients with hypertension was 21% (for reference, these are select patients with hypertension and co-morbid illness) There was no mortality difference between hypertensive patients taking ARBs/ACEs and those not.
  • A second and statistically superior study confirms the findings of this first study. This is a retrospective, multi-center study of 1128 adult patients with hypertension.  Of these, 188 were taking an ACE/ARB. Overall mortality was lower in those on an ACEI/ARB (3.7% in those on an ACEI/ARB and 9.8% in those not on an ACEI/ARB). An analysis based on propensity score (designed to remove variables such as age, gender and comorbidities) confirmed that morality results still favored the ACEI/ARB group (adjusted HR, 0.37; 95% CI, 0.15-0.89; P = 0.03).
  • Editor Comment:  These results are reassuring, with one study suggesting that ACEI/ARB are at worst neutral in terms of mortality, and the other suggesting a statistically significant mortality benefit with both ACEI/ARB. More data will likely be forthcoming.

Li, J et al. Association of Renin-Angiotensin System Inhibitors With Severity or Risk of Death in Patients With Hypertension Hospitalized for Coronavirus Disease 2019 (COVID-19) Infection in Wuhan, China JAMA Cardiol. Published online April 23, 2020. doi:10.1001/jamacardio.2020.1624

Zhang, P. et al. Association of Inpatient Use of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers with Mortality Among Patients With Hypertension Hospitalized With COVID-19  Originally publishedhttps://doi.org/10.1161/CIRCRE... Circulation Research

Some COVID-19 patients are hypercoagulable, and may present with stroke even in the absence of other severe manifestations of COVID-19. The risk is not well quantitated.

  • A case series from Italy of patients admitted to an ICU with COVID-19 found increased levels of fibrinogen and an enhanced clot formation using thromboelastometry, including a shorter clot formation time. In keeping with normal enhanced clot formation, the d-dimer was also elevated. There have also been increasing reports of stroke in relatively young people, despite the absence of other severe manifestations of COVID-19, though there is not yet well-quantified data for this 
  • For admitted patients, The American Society of Hematology recommends prophylaxis with enoxaparin 40mg QD as standard with intermittent pneumatic compression stockings as an alternative. See the guidelines here.

Spiezia, L. et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure.  Thrombosis and Hemostasis 21 April 2020 DOI https://doi.org/10.1055/s-0040...





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