Maternal deaths with coronavirus disease 2019: a different outcome from low- to middle-resource countries?

To the Editors:

Physiological adaptations in normal pregnancy increase the susceptibility of mothers to microorganisms (bacteria and viruses) and their products. In particular, activation of the innate limb of immune response is thought to increase generation of reactive oxygen radicals by granulocytes and monocytes and predisposes to a cytokine storm. This has been invoked to explain the increased fatality rate of pregnant women affected by severe acute respiratory syndrome (SARS), Middle East respiratory syndrome, ebola, influenza, and H1N1. , During the H1N1 pandemic, pregnancy, childbirth, and the postpartum period were considered risk factors for disease worsening and maternal death. In Brazil, H1N1 influenza was the main cause of indirect maternal death in 2009–2010. However, in the case of coronavirus disease 2019 (COVID-19) and on the basis of a few case series from China, Europe, and the United States, it is thought that pregnant women may not be more likely to experience severe symptoms from this disease than the general population and there were no reported maternal deaths. A new picture may now be emerging from Brazil, Iran, and Mexico, raising the possibility of increased risk of maternal death from COVID-19; in Brazil there is evidence of 5 maternal deaths out of 1947 total deaths from COVID-19, in Iran 2 of 3800, and in Mexico 2 of 486 (Table ). It is therefore possible that in developing as opposed to developed countries, high birth rates and limited resources for healthcare provision will uncover the increased risk for maternal death because of COVID-19 and emphasize the need for appropriate measures for adequate prenatal and postnatal care. At the present time, professional organizations have not emphasized that pregnant women exposed to severe acute respiratory syndrome coronavirus 2 may be at an increased risk for adverse outcome; however, it is important that obstetricians and gynecologists be aware that data from countries other than the USA and Europe seem to suggest an increased risk to pregnant mothers. We hope that the scientific community remains open minded and vigilant about this.

Table

Coronavirus disease 2019-related maternal deaths worldwide until April 10, 2020

Country	Maternal deaths	Symptoms onset	Moment of death	Comorbidities	Source
Iran	2 of 3800 reported total deaths	Pregnancy	Postpartum	Not reported	Karimi-Zarchi et al 2020
Brazil	5 of 1947 reported total deaths	Not reported	Postpartuma	Not reported	Brazilian Ministry of Health
		Not reported	Postpartuma	Not reported	Brazilian Ministry of Health
		Postpartum (6 days after elective cesarean delivery)	Postpartum (7 days)	Absent	Local mediab
		Pregnancy (admitted 32 weeks, emergency CS 2 days later)	Postpartum (2 days)	Absent	Local mediac
		Pregnancy (admitted 32 weeks, emergency CS)	Postpartum	Absent	Local mediad
Mexico	2 of 486 reported total deaths	Pregnancy (35 weeks)	Postpartum	Obesity, hypertension	Local mediae
		Not reported	Not reported	Obesity, gestational diabetes	Mexico Ministry of Health

Amorim. Maternal deaths with COVID-19. Am J Obstet Gynecol 2020.

Mode of delivery: elective cesarean delivery

https://www.folhadelondrina.com.br/geral/mulher-de-28-anos-morre-por-covid-19-sete-dias-apos-parto-na-bahia-2985448e.html

https://epoca.globo.com/brasil/gravida-morre-de-covid-19-em-recife-bebe-sobrevive-24353787

https://www.agazeta.com.br/brasil/no-rio-mulher-morre-de-covid-19-dez-dias-apos-dar-a-luz-prematuramente-0420

López-Gatell: Desafortunadamente mueren dos embarazadas por covid-19 | CNN [Internet]. 2020 [cited 2020 Apr 10]. Available from: https://cnnespanol.cnn.com/video/mueren-mujeres-embarazadas-covid-coronavirus-mexico-gatell-informe-sot-perspectivas-mexico.