Aris T. Papageorghiou, - and Philippe Deruelle, - and Robert B. Gunier, - and Stephen Rauch, - and Perla K. García-May, - and Mohak Mhatre, - and Mustapha Ado Usman, - and Sherief Abd-Elsalam, - and Saturday Etuk, - and Lavone E. Simmons, - and Raffaele Napolitano, - and Sonia Deantoni, - and Becky Liu, - and Federico Prefumo, - and Valeria Savasi, - and Marynéa Silva do Vale, - and Eric Baafi, - and Ghulam Zainab, - and Ricardo Nieto, - and Nerea Maiz, - and Muhammad Baffah Aminu, - and Jorge Arturo Cardona-Perez, - and Rachel Craik, - and Adele Winsey, - and Gabriela Tavchioska, - and Babagana Bako, - and Daniel Oros, - and Albertina Rego, - and Anne Carolina Benski, - and Fatimah Hassan-Hanga, - and Mónica Savorani, - and Francesca Guiliani, - and Loïc Sentilhes, - and Milagros Risso, - and Ken Takahashi, - and Carmen Vecchiarelli, - and Satoru Ikenoue, - and Ramachandran Thiruvengadam, - and Constanza P. Soto Conti, - and Enrico Ferrazi, - and Irene Cetin, - and Vincent Bizor Nachinab, - and Ernawati, - and Eduardo A. Duro, - and Roberto Casale, - and Alexey Kholin, - and Michelle L. Firlit, - and Sarah Rae Easter, - and Joanna Sichitiu, - and Abimbola Bowale, - and Rosa Maria Cerbo, - and Paolo Ivo Cavoretto, - and Brenda Eskenazi, - and Jim G. Thornton, - and Zulfiqar A. Bhutta, - and Stephen H. Kennedy, - and José Villar, - (2021) Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study. American Journal of Obstetrics and Gynecology, 225 (3). 289.e1-289.e17. ISSN 00029378

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Abstract

Background It is unclear whether the suggested link between COVID-19 during pregnancy and preeclampsia is an independent association or if these are caused by common risk factors. Objective This study aimed to quantify any independent association between COVID-19 during pregnancy and preeclampsia and to determine the effect of these variables on maternal and neonatal morbidity and mortality. Study Design This was a large, longitudinal, prospective, unmatched diagnosed and not-diagnosed observational study assessing the effect of COVID-19 during pregnancy on mothers and neonates. Two consecutive not-diagnosed women were concomitantly enrolled immediately after each diagnosed woman was identified, at any stage during pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed until hospital discharge using the standardized INTERGROWTH-21st protocols and electronic data management system. A total of 43 institutions in 18 countries contributed to the study sample. The independent association between the 2 entities was quantified with the risk factors known to be associated with preeclampsia analyzed in each group. The outcomes were compared among women with COVID-19 alone, preeclampsia alone, both conditions, and those without either of the 2 conditions. Results We enrolled 2184 pregnant women; of these, 725 (33.2%) were enrolled in the COVID-19 diagnosed and 1459 (66.8%) in the COVID-19 not-diagnosed groups. Of these women, 123 had preeclampsia of which 59 of 725 (8.1%) were in the COVID-19 diagnosed group and 64 of 1459 (4.4%) were in the not-diagnosed group (risk ratio, 1.86; 95% confidence interval, 1.32–2.61). After adjustment for sociodemographic factors and conditions associated with both COVID-19 and preeclampsia, the risk ratio for preeclampsia remained significant among all women (risk ratio, 1.77; 95% confidence interval, 1.25–2.52) and nulliparous women specifically (risk ratio, 1.89; 95% confidence interval, 1.17–3.05). There was a trend but no statistical significance among parous women (risk ratio, 1.64; 95% confidence interval, 0.99–2.73). The risk ratio for preterm birth for all women diagnosed with COVID-19 and preeclampsia was 4.05 (95% confidence interval, 2.99–5.49) and 6.26 (95% confidence interval, 4.35–9.00) for nulliparous women. Compared with women with neither condition diagnosed, the composite adverse perinatal outcome showed a stepwise increase in the risk ratio for COVID-19 without preeclampsia, preeclampsia without COVID-19, and COVID-19 with preeclampsia (risk ratio, 2.16; 95% confidence interval, 1.63–2.86; risk ratio, 2.53; 95% confidence interval, 1.44–4.45; and risk ratio, 2.84; 95% confidence interval, 1.67–4.82, respectively). Similar findings were found for the composite adverse maternal outcome with risk ratios of 1.76 (95% confidence interval, 1.32–2.35), 2.07 (95% confidence interval, 1.20–3.57), and 2.77 (95% confidence interval, 1.66–4.63). The association between COVID-19 and gestational hypertension and the direction of the effects on preterm birth and adverse perinatal and maternal outcomes, were similar to preeclampsia, but confined to nulliparous women with lower risk ratios. Conclusion COVID-19 during pregnancy is strongly associated with preeclampsia, especially among nulliparous women. This association is independent of any risk factors and preexisting conditions. COVID-19 severity does not seem to be a factor in this association. Both conditions are associated independently of and in an additive fashion with preterm birth, severe perinatal morbidity and mortality, and adverse maternal outcomes. Women with preeclampsia should be considered a particularly vulnerable group with regard to the risks posed by COVID-19.

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