ABC | Volume 115, Nº1, July 2020

Editorial COVID-19: A New Challenge in Pregnancy and Heart Disease Walkiria Samuel Avila 1 a nd Regina Coeli de Carvalho 2 Universidade de São Paulo Instituto do Coração, 1 São Paulo, SP - Brasil Hospital Geral de Fortaleza, secretária de Saúde do Estado do Ceará (SESA), 2 Fortaleza, CE - Brazil Mailing Address: Walkiria Samuel Avila • Rua Martiniano de Carvalho 864, cj 1107-1108 Bela vista - São Paulo Postal Code 01321-000 E-mail: val_walkiria@incor.usp.br Manuscript received May 22, 2020, revised manuscript May 27, 2020, accepted May 27, 2020 Keywords Coronavirus; COVID19; Pandemics; Pregnancy; Pregnancy, high-risk; Severe Acute Respiratory Syndrome; Pneumonia; Hypertension/prevention and control; Risk Factors; Morbidity; Mortality. The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization on March 11, 2020. 1 Although SARS-CoV-2 isolation, gene sequencing, and structural analysis have been completed , therapies for COVID-19. The first epidemiological data have pointed to a worse outcomes and higher mortality of COVID-19 in patients with chronic diseases, such as heart disease and arterial hypertension. Subsequently, the Brazilian Health Ministry included in the high-risk group pregnant, puerperal and post- abortion women . 2 Previous epidemiological evidence strongly suggests that pregnant women have an increased risk of serious illness and death from viral infections during pandemics, such as influenza. 3 Physiological changes in pregnant women not only increase susceptibility to the viral infection but also increase the severity of this disease ( Table 1) . 4-6 During pregnancy, the immune response predominates through T-helper 2 (Th2) cells, which protect the fetus but make the mother more vulnerable to viral infections, which are more effectively fought by Th1 cells. 7 Pregnant women infected with the H1N1 influenza virus and two other pathogenic coronaviruses [severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)] had high morbidity and mortality during pregnancy and the postpartum period. It was estimate that 90% of pregnant women with these viral infections progressed to severe respiratory failure, with obstetric complications, such as abortion, premature birth, and intrauterine growth restriction. Maternal mortality in pregnant women infected with SARS-CoV or MERS-CoV has been reported to reach 25%, and no transplacental vertical transmission has been recorded . 8 There are no data to inform whether pregnancy increases susceptibility to COVID-19. The evidence is still scarce, but COVID-19 during pregnancy appears to be less severe than infections by H1N1 influenza virus, SARS-CoV, and MERS-CoV. Studies in pregnant women infected with SARS-CoV-2 are limited to small series . A systematic review 9 of 108 pregnant women with COVID-19 has shown cough and fever as their main complaints, present in almost 80% of the women, while only 12% had dyspnea. No maternal death has been reported. Of the three critical patients who required mechanical ventilation, two had obesity (body mass index > 35) as a morbidity factor. Another study 10 assessing 116 pregnant women with COVID-19 pneumonia has concluded that clinical pneumonia characteristics of pregnant women were similar to those of the general population. Currently, there is no evidence that pregnant women with COVID-19 are more prone to develop severe pneumonia as compared to nonpregnant ones. Fortunately, there was neither increase in spontaneous abortion or in natural preterm birth, nor evidence of vertical transmission of SARS-CoV-2. Perinatal transmission of COVID-19: Should we be concerned? Of 75 newborns of mothers with COVID-19, only one tested positive for the virus and had a satisfactory clinical outcome with mild changes in liver enzymes. 9 However, some babies testing negative for COVID-19 developed lymphocytopenia and radiological findings of pneumonia, and one had disseminated intravascular coagulation. All babies had a full recovery. 11,12 Based on these findings, we can exclude neither the possibility of subclinical response from fetuses and newborns to the maternal infection, nor transplacental vertical transmission. Thus, close monitoring of newborns of mothers with COVID-19 is recommended. Should pregnant women with heart disease or arterial hypertension and SARS-CoV-2 infection be considered at greater mortality risk? Th e Brazilian Society of Cardiology Statement for the Management of Cardiac Diseases in Pregnancy, 13 which includes healthcare protocols, treatment, and prevention strategies for heart complications during pregnancy, has contributed to a reduction in maternal mortality in Brazil. However, we are facing the emergence of COVID-19, a disease that shakes that once improved situation. New clinical research and an integrated approach to the subgroup of pregnant women with heart disease or hypertension affected by SARS-CoV-2 are mandatory. The optimistic perspective on the outcomes of the association of pregnancy and SARS-CoV-2 infection becomes uncertain in women with heart disease or hypertensive disorders, because these two heart conditions alone represent the main causes of maternal and fetal mortality during pregnancy. It is important that clinical suspicion of COVID-19 in pregnant women with heart disease MUST be ruled out . DOI: https://doi.org/10.36660/abc.20200511 1