Maternal and Neonatal Outcomes in Pregnant Women With SARS-CoV-2 Infection Complicated by Hepatic Dysfunction

Abstract

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has caused one of the most devastating healthcare crises in recent times and presented many diagnostic challenges and uncertainties. COVID-19 complicated by acute hepatic dysfunction is a well-described phenomenon, but its impact on maternal and perinatal outcomes is not well documented. In this study, we aimed to evaluate the maternal and neonatal outcomes in pregnant women with COVID-19 complicated by liver dysfunction and compare those with pregnant women with COVID-19 and normal liver function. Methodology This was a retrospective observational cohort study conducted at the Tata Main Hospital, Jamshedpur, a tertiary care hospital in eastern India. All COVID-19-positive pregnant women (n=249) admitted to the hospital from May 15, 2020, to August 15, 2021, were included in this study. Retrospective data collection was done using the medical records of these COVID-19-positive pregnant women and included the baseline characteristics, past medical history, obstetric history, clinical presentation, laboratory results, management modalities, and maternal and neonatal outcomes. Of note, 107 women were found to have acute liver function abnormality on admission and 142 women had normal liver function tests (LFTs). Pregnant women with normal LFTs were classified as group one and those with deranged LFTs as group two. Characteristics such as age, period of gestation, symptoms, associated comorbidities, laboratory results, management, and outcomes were compared across both groups. Results Out of the total 249 pregnant women with COVID-19 admitted during the study period, 42.97% (n=107) women had laboratory findings consistent with liver dysfunction and 142 women (57.03%) had a normal liver function. Significantly higher levels of lactate dehydrogenase (LDH), C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), alanine transaminase (ALT), aspartate aminotransferase (AST), and total bilirubin levels were seen in pregnant women with hepatic dysfunction when compared to those with normal liver function. Among the 249 patients, the majority were asymptomatic or had mild disease, 12 women had moderate disease, and six women had severe COVID-19. All women with severe COVID-19 had deranged LFTs. There was no statistical difference in terms of obstetric management between pregnant patients with and without liver dysfunction. Out of the 107 women with deranged liver function, 18 women had a preterm birth, four had intrauterine fetal death, and one had neonatal death. Complications such as postpartum hemorrhage, the need for blood transfusions, sepsis and multiorgan failure, and mortality were more commonly seen in the group of pregnant women with hepatic dysfunction associated with COVID-19. Conclusion COVID-19 in pregnancy may cause deranged LFTs in these women. Pregnant women with COVID-19 complicated by liver dysfunction have been reported to have worse inflammation...

COVID-19 associated liver injury: A general review with special consideration of pregnancy and obstetric outcomes

“…For example, in the case by Arslan et al [ 118 ], the patient’s proteinuria was concerning for pre-eclampsia and liver enzymes trended down as expected after cesarean delivery, though both maternal and neonatal outcomes were poor which complicates interpretation of the case. Similarly, in the case by Choudhary et al [ 111 ], hypoglycemia and elevated bilirubin were highly suspicious for AFLP, but liver enzymes remained elevated for multiple days after delivery.…”

“…A retrospective cohort study of 122 COVID-19 positive pregnant patients in Istanbul found acute liver injury conferred a 3.5-fold risk of becoming critically ill during hospitalization[ 112 ]. Maternal mortality is reportedly more common in pregnant patients who delivered while COVID-19 positive with acute liver injury than COVID-19 positive without liver injury[ 111 ].…”

“…The largest published study evaluating COVALI in pregnancy is a 249-patient prospective cohort study performed at large tertiary care hospital in eastern India[ 111 ]. Unlike in previous studies, patients with hypertensive disorders, diabetic disorders, or concern for intrahepatic cholestasis were not excluded.…”

“…While no associations between liver injury and mode of delivery or neonatal outcomes were identified, those with liver injury tended to deliver pre-term and/or require cesarean delivery more often, both of which increase morbidity. Their key finding was that obstetric complications were significantly higher in COVID-19 positive pregnant patients with liver injury, despite no differences in maternal or gestational age[ 111 ]. Specifically, pregnant persons with COVALI were less likely to have a normal vaginal delivery than those without liver injury (18.7% vs 30.3%).…”

“…Specifically, pregnant persons with COVALI were less likely to have a normal vaginal delivery than those without liver injury (18.7% vs 30.3%). Further, postpartum hemorrhage, sepsis, and death were more common in those who delivered while COVID-19 positive with acute liver injury[ 111 ].…”