Stillborn Birth Linked to Maternal SARS-CoV-2 Infection

By Marilynn Larkin

November 05, 2021

NEW YORK (Reuters Health) - A case study in Italy suggests that maternal SARS-CoV-2 infection may be responsible for a stillbirth, mediated by fetal vascular malperfusion associated with the infection.

"The possible consequences of placentotropic SARS-CoV-2 (infection) include the occurrence of vertical transmission and/or stillbirth, as in our case," Dr. Fabrizio Zullo of Sapienza University of Rome told Reuters Health by email. "This latter possibility may be triggered by a hampered maternal and/or fetal perfusion of the placenta."

"The diffuse thrombosis and subsequent ischemia of fetal capillaries induced by COVID-19 cannot be predicted by standard clinical surveillance nor prevented by anticoagulants and represent a severe burden of SARS-CoV-2 infection," he said.

Dr. Zullo's case report, published in the American Journal of Obstetrics and Gynecology, involved a 33-year-old white woman, gravida 3 para 2 at 36 weeks + 1 day of gestation, with preterm labor and asymptomatic COVID-19 infection. Her vitals were normal on admission, and her past medical history was unremarkable.

An ultrasonographic assessment showed no fetal movement or heartbeat. Shortly after admission, a dead male fetus was delivered vaginally, with meconium-stained amniotic fluid. Autoptic findings showed that neonatal death occurred between 24 hours and five days before delivery.

Swabs from the fetal right and left main bronchus, small intestine and rectum were negative for SARS-CoV-2 RNA by RT-PCR assay. At gross examination, the placenta showed a diffuse marbled appearance and a focal hemorrhagic area.

Multiple areas of hemorrhagic/ischemic necrosis were observed, with central and peripheral villous infarctions and thrombosis of several maternal and fetal vessels with luminal fibrin and platelet deposition. All lesions appeared to be synchronous.

Virus particles were identified by electron microscopy (EM) within the cytoplasm of endothelial cells and SARS-CoV-2 RNA was detected in placental tissue by rRT-PCR assay.

"We confirmed that syncytiotrophoblast is the major target cell type for SARS-CoV-2 infection of the placenta," the authors state. "In this case, fetal vascular malperfusion was likely causally associated with the infection; indeed, our EM images clearly showed that the marked SARS-CoV-2 endotheliotropism involved the intravillous fetal capillaries."

Dr. Stephanie Zeszutek, Associate Professor in the Department of Primary Care at Touro College of Osteopathic Medicine in New York City, commented by email to Reuters Health, "Pulmonary infections (during pregnancy) may result in premature rupture of membranes, stillbirth, intrauterine growth restriction and preterm birth. Some adverse outcomes have occurred in infected pregnant patients, such as hospitalization, ICU admission and demise of the fetus or the mother."

"Changes in the blood flow of the placenta have been noted with SARS-CoV-2 infections; however, there is mixed evidence about the effect this infection has on pregnancies," she said. "At this time, many studies are unable to identify an association between stillbirth and COVID-19 infection and have found that there is no change in the rate of stillbirths in the third trimester compared to periods immediately prior to the COVID-19 pandemic."

"Management options for pregnant patients infected with SARS-CoV-2 infection include supportive care, corticosteroids, and extracorporeal membrane oxygenation along with multidisciplinary consultation," she added.

Dr. Kecia Gaither, Director of Perinatal Services at NYC Health + Hospitals/Lincoln in New York City, told Reuters Health by email, "There should be a discussion with all pregnant patients stricken with COVID that one can't predict outcomes. With that being said, the discussion should be tempered by the clinical symptoms that the mother exhibits--with severe COVID symptoms resulting in hospitalization/ICU care, risks of adverse outcomes are, of course, higher."

"All pregnant women are advised to obtain the COVID vaccination to mitigate the risk of contacting COVID," she said, "but certainly to decrease the likelihood of having severe complications from the virus."

SOURCE: American Journal of Obstetrics and Gynecology, online October 23, 2021.