Letter to the Editor

Reporting 12 Cases of Maternal Mortality Due to COVID-19; the Role of Termination of Pregnancy as a Double-Edged Sword

Cite this article as: Ghaemi M, Hantoushzadeh S, Ghanbari R, Heidary Z. Reporting 12 cases of maternal mortality due to COVID-19; the role of termination of pregnancy as a double-edged sword. Arch Iran Med. 2022;25(11):765-766. doi: 10.34172/aim.2022.121

Dear Editor,

After publishing our last article entitled “maternal and neonatal complications, outcomes and possibility of vertical transmission in Iranian women with COVID-19”¹ that was published in your valuable journal, we wanted to share our last experience of 12 cases of mortalities due to COVID-19 in pregnant women from January 2021 to July 2021 in a single referral hospital in Iran.

Pregnant women with COVID-19 are more likely than normal pregnancies to have preterm birth as well as cesarean section. The rate of neonatal intensive care unit (NICU) admission for their neonates is higher, a well.² The results of the previous studies have been contradictory. In some studies, the rates of hospitalization in the intensive care unit (ICU) and mechanical ventilation were higher, although the mortality rate did not increase in comparison with non-pregnant cases. Most women recover without undesirable outcomes, but severe maternal complications as well as maternal and prenatal mortalities have been also reported from COVID-19.³

Here, we report 12 maternal mortalities due to COVID-19 infection in pregnant women. Their vital signs, laboratory data and the delivery mode are listed in Table 1. All women required intensive care unit admission. Totally, 7/12 (58.3%) of the cases were in trimester 3 and the others were in the second trimester. No maternal death before 20 weeks was reported. Most terminations except one were via cesarean section. Half of the women died shortly after pregnancy termination due to fetal or maternal distress. Four newborns remained alive and all were preterm but no history of their COVID-19 test was available. In the other cases where the pregnancy did not terminate, most fetuses were expired due to maternal distress. A severe drop in oxygen saturation and hemoglobin decrease in these individuals can expose the fetus to hypoxia and death.

On the other hand, the effect of pregnancy on the general condition of mothers is also important. The Royal College of Obstetricians and Gynecologists recommended the mode of delivery to be primarily determined by the obstetric symptoms and mentions that mothers with COVID-19 and their infants should be separated.⁴ Other evidence suggests that cytokine storm is responsible for severe symptoms and mortality in patients with COVID-19 rather than the virus itself. Therefore, cytokine storms during delivery seem to worsen the condition of the mothers. It seems that delivery is like a double-edged sword for mothers. On the one hand, it worsens the condition of mothers, and on the other hand, the risk of fetal distress and demise would be inevitable.

References

1. Heidary Z, Kohandel Gargari O, Fathi H, Zaki-Dizaji M, Ghaemi M, Hossein Rashidi B. Maternal and neonatal complications, outcomes and possibility of vertical transmission in Iranian women with COVID-19. Arch Iran Med 2021; 24(9):713-21. doi: 10.34172/aim.2021.104 [Crossref] [ Google Scholar]
2. Smith V, Seo D, Warty R, Payne O, Salih M, Chin KL. Maternal and neonatal outcomes associated with COVID-19 infection: a systematic review. PLoS One 2020; 15(6):e0234187. doi: 10.1371/journal.pone.0234187 [Crossref] [ Google Scholar]
3. Hantoushzadeh S, Abdollah Shamshirsaz A, Aleyasin A, Seferovic MD, Kazemi Aski S, Arian SE, et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020;223(1):109.e1-109.e16. 10.1016/j.ajog.2020.04.030.
4. Royal College of Obstetricians and Gynaecologists (RCOG). Coronavirus (COVID-19) Infection and Pregnancy. RCOG; 2020. Accessed 2021.