CASE REPORT Maternal mortality in pregnant women

1. Hospital Regional Docente de with positive SARS-CoV-2 antibodies

and severe preeclampsia. Report of 3
Cajamarca, Perú
2. Complejo Hospitalario Dr. Arnulfo
Arias Madrid. Caja de Seguro Social,
Panamá, Panamá
3. NIAID-National Institutes of Health,
cases
Maryland, EEUU
a. Obstetrician-gynecologist,
Mortalidad materna en gestantes con
Department of Obstetrics
b. Neurologist, Department of
anticuerpos a SARS-CoV-2 positivos y
Neurology
c. Radiologist, Department of Radiology
preeclampsia severa. Reporte de 3 casos
d. Clinical Pharmacologist, Maryland
USA Jorge Arturo Collantes Cubas1,a, Segundo Alberto Pérez Ventura1,a, Paulino Vigil
- De Gracia2,a, Karla Esperanza Castañeda Bazán1,b, Juan Martín Tapia Saldaña1,c,
Declaration: The authors declare this Francisco Jose Leyva3d
publication is original and has not been
previously published by another institution
and/or scientific journal. The study was
DOI: [Link]
approved by the Institutional Ethics ABSTRACT
Committee and has the institutional Maternal mortality from COVID-19 is rare in developed countries, but its association
permission. with other obstetric complications increases the risk. It is also associated with fetal
death. Postpartum women are at risk of thrombosis that increases with COVID-19
Funding: The authors certify that they have coagulopathy. Comorbidities such as obesity, diabetes, and hypertension increase
not received specific financial support, the risk of death from COVID-19, and pregnant women have more complications
equipment or materials from private persons, during the third trimester than in the first trimester, with higher risk than non-
public and/or private institutions to perform pregnant women of entering the ICU and requiring mechanical ventilation. In this
this study. report, stroke, diabetes and intracerebral hemorrhage were the three causes of
death described, all within the context of stillbirth, severe preeclampsia, eclampsia
Conflicts of interest: The authors declare and/or HELLP syndrome.
they do not have conflict of interest with any Key words: Maternal mortality, Preeclampsia, Eclampsia, HELLP syndrome, COVID-19,
declaration, institution or private person. Stroke, Diabetes mellitus.

Received: 12 September 2020 RESUMEN

La mortalidad materna por COVID-19 es poco frecuente en países desarrollados,
Accepted: 15 September 2020 pero su asociación a otras complicaciones obstétricas aumenta el riesgo. Además,
Corresponding author: está asociada a muerte fetal. Las puérperas, tienen riesgo de trombosis que se
Jorge Arturo Collantes Cubas incrementa con la coagulopatía por COVID-19. Las comorbilidades como obesidad,
diabetes, hipertensión incrementan el riesgo de muerte asociada a COVID-19 y
, Av. Mario Urteaga 210, Cajamarca- las gestantes en el tercer trimestre se complican más que en el primero, teniendo
Perú.06000 más riesgo que las mujeres no gestantes de ingresar a UCI y requerir ventilación
 +51976390499 mecánica. En este reporte, el accidente cerebrovascular isquémico y hemorrágico
m jorgecollantesg@[Link] y la diabetes fueron las tres causas de muerte, todas en un contexto de óbito fetal,
preeclampsia severa, eclampsia y/o síndrome HELLP.
Cite as: Collantes Cubas JA, Pérez Ventura SA, Palabras clave. Mortalidad materna, Preeclampsia, Eclampsia, Síndrome HELLP,
Vigil - De Gracia P, Castañeda Bazán KE, Tapia COVID-19, Accidente cerebrovascular, Diabetes mellitus
Saldaña JM, Leyva FJ. Maternal mortality
in pregnant women with positive SARS-
CoV-2 antibodies and severe preeclampsia.
Report of 3 cases. Rev Peru Ginecol Obstet. Introduction
2020;66(4). DOI: [Link]
rpgo.v66i2279 The consequences of COVID-19 infection in the world, as of August 25,
2020, is around 832 000 deaths among 23 million cases, with 103 deaths
per million inhabitants and a fatality of 3.8%. Perú has a mortality of 826
deaths per million inhabitants, corresponding to a fatality of 4.8%, the
highest in America at the moment(1).

Global maternal mortality expressed as the world maternal death ratio

in 2017 was 211/100 000 live births, the main causes being hemorrhage
in 27%, preeclampsia in 14%, sepsis 11%, abortion 8%, embolism 3%,
other direct causes 10% e indirect 28%(2).

The majority of pregnant women with COVID-19 are asymptomatic, in

87.9%(3). As for pregnant women who have symptoms, 86% have mild
disease, 9.3% severe and 4.7% critical(4).

Rev Peru Ginecol Obstet. 2020;66(3) 1

 Jorge Arturo Collantes Cubas, Segundo Alberto Pérez Ventura, Paulino Vigil - De
Gracia, Karla Esperanza Castañeda Bazán, Juan Martín Tapia Saldaña, Francisco
Jose Leyva

The most severe complications from COVID-19 The results of the laboratory tests were: reactive
occur mostly in the third trimester of pregnancy, C protein: 96 mg/dL, complement 3: 289 mg/dL,
4.2% suffer of pneumonia(5). Obstetric complica- complement 4: 90 mg/dL, sedimentation rate: 50
tions are present in 45% (95% CI: 24.0% to 6.0%) mm/h, SARS-CoV-2: IgG/IgM (+).
of cases(6).
Brain multislice spiral tomography (MST) with
With respect to women of the same age, preg- coronal and sagittal reconstructions (Figure 1)
nant women with COVID-19 are more likely to showed extensive right cerebral infarction (in
enter intensive care (OR=5.4 (95% CI 95%: 2,89 the middle cerebral artery (MCA) and the ante-
to 10.08) and to need mechanical ventilation, rior cerebral artery (ACA) territory, with a large
OR=4,0 (95% CI: 1.75 to 9.14) (7). In addition, it is mass effect, conditioning deviation of the mid-
known that the greater the number of comor- line by 14 mm to the left and partial collapse of
bidities, the greater the risk of death (8). In a the supratentorial ventricles. Increase density
study in Brazil, it was found that 55% of preg- of the MCA was evidenced, probably related to
nant women deaths from COVID-19 had co- thrombus (Alberta Stroke Program Early CT
morbidities, 80% of deaths occurred during the Score (ASPECTS):0). Chest MST with coronal and
puerperium, in 10% associated with preeclamp- sagittal reconstructions showed typical signs of
sia (9). In another report, 7 maternal deaths from Covid-19 (“ground glass”, vascular thickening,
COVID-19 also had fetal death in 42.9% of cas- cobblestone pattern, parenchymal bands and
es (10). Other comorbidities found in maternal bilateral consolidations predominantly left). CO-
deaths are diabetes, obesity, asthma, advanced RADS: 5(13).
maternal age, hypothyroidism (11). One death
during pregnancy due to coagulopathy and Treatment (see Table) included mechanical venti-
basilar artery thrombosis has been described lation. During evolution, she presented seizures,
in the United Kingdom (12). auricular flutter, septic shock, kidney injury and
died.
The objective of this communication is to pres-
ent three cases of maternal death with SARS- Case 2: Comorbidities, HELLP syndrome,
CoV-2 IgG / IgM (+), of the 36 occurred in Peru, acute kidney injury
treated at the Cajamarca Regional Teaching Hos-
pital. They had severe preeclampsia and compli- The case was a 40-year-old woman two days af-
cations such as eclampsia and HELLP syndrome, ter a cesarean section in another hospital for se-
with ischemic stroke, acute kidney injury, and vere preeclampsia, stillbirth and COVID-19, with
hemorrhagic cerebrovascular disease. In addi- a history of diabetes, obesity, high blood pres-
tion, all had stillbirth. sure, and HELLP syndrome, G5P3021. She com-
plained of abdominal pain.
Presentation of cases
The diagnosis was two days post cesarean sec-
Case 1: Ischemic stroke, eclampsia tion, severe preeclampsia, HELLP syndrome,
obesity, diabetes, IgG/IgM (+) to SARS-CoV-2.
A 32-year-old woman, 10-day puerperal with a
35-week stillbirth, and presenting high blood Laboratory tests were reported as: hemoglobin
pressure and seizures, arrived from a distant 4.9 mg/dL, platelets 77 000, glucose 400 mg/dL,
health center in coma, with sepsis and pneumo- creatinine 2.1 mg/dL, LDH 456 U/L, TGP 15 U/L,
nia to COVID-19, As a background, she was G2 TGO 30 U/L. Ultrasound showed free fluid in the
P0301 (one twin pregnancy) and had a positive abdominal cavity.
contact with COVID-19 in her previous hospital-
ization 10 days before. She presented seizures, Treatment included mechanical ventilation (Ta-
coma and left hemiplegia. The diagnosis was pu- ble 1).
erperal for 10 days, COVID-19 pneumonia, sep-
sis, right cerebral infarction, severe preeclamp- In the evolution, a 4 liters hemoperitoneum was
sia, eclampsia. The neurological diagnosis was found with no apparent cause. She underwent
score 20 according to the stroke score of the US laparotomy and exploration of the liver and
Health Centers (NIH Stroke Scale- NIHSS). spleen, but the bleeding source was not found.

2 Rev Peru Ginecol Obstet. 2020;66(3)

 Maternal mortality in pregnant women with positive SARS-CoV-2 antibodies and
severe preeclampsia. Report of 3 cases

Figure 1. Case 1. Brain tomography without contrast (with coronal and sagittal reconstruction): extensive rigth cerebral infarction (in the
territory of the middle cerebral artery (MCA) and anterior cerebral artery (ACA)), with a large mass effect, conditioning a deviation of the
midline by 14 mm to the left and partial collapse of the supratentorial ventricles. Increased MCA density is evidenced, probably related to
thrombus (Alberta Stroke Program Early CT Score (ASPECTS):0).

She was poly-transfused, had mechanical venti- diagnosed of stillbirth, severe preeclampsia,
lation. She improved in ICU but decompensated HELLP syndrome, eclampsia, cerebrovascular
later and developed acute kidney injury, anasar- disease (possible stroke with NIHSS 33), IgG/IgM
ca, and pulmonary edema. positive to SARS-CoV-2.

Case 3: Eclampsia, cardiorespiratory ar- Laboratory tests were: white blood count 17 200,
rest, hemorrhagic cerebrovascular dis- hemoglobin 13.7 mg/dL, glucose 218 mg/dL, cre-
ease, HELLP syndrome atinine 1.1 mg/dL, LDH 4 704 U/L, TGO 302 U/L,
total bilirubin 4.3 mg/dL (Table 1). Ultrasound
A 37-year-old female patient was admitted with- showed fetal death.
out prenatal control, with history of severe head-
ache, abdominal pain, loss of consciousness and Treatment consisted in cesarean section, me-
seizures. The 35-week pregnant woman was chanical ventilation (Table 1)

Figure 2. Case 1. Non-contrast chest tomography (with coronal and sagittal reconstruction) shows typical signs of Covid-19 - ‘ground
glass’, vascular thickening, cobblestone pattern, parenchymal bands and bilateral consolidations, predominantly left. CO-RADS: 5(13).

Rev Peru Ginecol Obstet. 2020;66(3) 3

 Jorge Arturo Collantes Cubas, Segundo Alberto Pérez Ventura, Paulino Vigil - De
Gracia, Karla Esperanza Castañeda Bazán, Juan Martín Tapia Saldaña, Francisco
Jose Leyva

Table 1. Clinical characteristics of the 3 cases of maternal death by COVID-19.

Case 1 Case 2 Case 3
Date 19/6/2020 27/06/2020 21/08/2020
Age 32 40 37
Gestational age (weeks) Postpartum 10 days (35 ss) Postpartum 2 days Pregnancy 35 weeks
Gestations 2 5
Type of delivery Vaginal Cesarean section Cesarean section
Newborn status Stillbirth Stillbirth Stillbirth
Systolic blood pressure (mmHg) 160 137 68
Diastolic blood pressure (mmHg) 70 89 45
O2 saturation (%) 95 94 91
Temperature (°C) 38.5 36.5 36.7
Breathing frequency 22 18 21
Glasgow 6 15 8
Diagnosis IgG/IgM IgG/IgM IgM/IgG
Newborn weight (g) 3 000 2 500
Preeclampsia Yes Yes Yes
Eclampsia Yes No Yes
HELLP Sd. No Yes Yes
Diabetes Yes Yes No
Hypertension No Yes No
Obesity No Yes
DHL (U/L) 445 585 4 868
Platelets 316 000 85 000 36 000
Glucose (mg/dL) 146 252 218
TGO (U/L) 16 22 1 650
TGP (U/L) 28 17 2 810
Hemoglobin (mg/dL) 12.3 4.1 13.7
Creatinine (mg/dL) 1.1 2 1.1
Leukocytes 20 600 12 360 17 200
PCR (mg/dL) 96
Pneumonia COVID-19 Yes No No
ICU Yes Yes No
Death Postpartum Postpartum Postpartum
Hospitalization days 10 26 2
Ceftriaxone, fentanyl, vecuronium, Magnesium sulphate, nifedipine,
Mechanical ventilation, ceftriaxone,
Treatment dexamethasone, phenytoin, furose- methyldopa, insulin, ceftriaxone,
noradrenaline
mide, insulin, mechanical ventilation enoxaparin, mechanical ventilation

During evolution she presented cardiorespira- to SARS-CoV-2 and severe preeclampsia, two
tory arrest in the emergency room, from which with eclampsia and two with HELLP syndrome.
she recovered. She underwent a cesarean sec- The first maternal death presented ischemic
tion without anesthesia, no hemoperitoneum stroke (cerebral infarction). The second died of
was found. It was not possible to perform a to- diabetes, kidney injury and pulmonary edema.
mography or to admit her to the intensive care The third, with eclampsia, HELLP syndrome
unit. She died one day after cesarean section. and possible stroke. All three had a stillbirth of
around 35 weeks.
Discussion
One publication on maternal death in Brazil
Among the 36 maternal deaths in Peru due to states that 10% of them were associated with
COVID-19, we present three maternal deaths preeclampsia(9), which differs from our findings,
that occurred in Cajamarca, all with IgG/IgM (+) where all three had severe preeclampsia with

4 Rev Peru Ginecol Obstet. 2020;66(3)

 Maternal mortality in pregnant women with positive SARS-CoV-2 antibodies and
severe preeclampsia. Report of 3 cases

eclampsia and/or HELLP syndrome. There are Second, the possibility that preeclampsia be con-
publications that seek criteria to differentiate sidered a comorbidity associated with mortal-
the findings or HELLP syndrome and complica- ity from COVID-19. Third, stillbirth may be com-
tions typical of COVID-19 with similar manifesta- mon and should be considered and prevented.
tions(14). Fourth, severe preeclampsia in the presence of
symptomatic COVID-19 has high mortality, due
In a systematic review of COVID-19 and preg- to the severity of both. Fifth, brain tomography
nancy, stillbirth figures are around 45%(10). We is essential in early diagnosis and would help to
found death in the third trimester (35 weeks) in quickly initiate the management of postpartum
all three cases (100%). women with ischemic or hemorrhagic brain in-
volvement.
In all three cases we have found diabetes associ-
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 Jorge Arturo Collantes Cubas, Segundo Alberto Pérez Ventura, Paulino Vigil - De
Gracia, Karla Esperanza Castañeda Bazán, Juan Martín Tapia Saldaña, Francisco
Jose Leyva

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