<div>In this issue of BJOG, Mendoza and colleagues report in an observational
study the occurrence of a preeclampsia-like syndrome in six out of eight
pregnant patients with novel coronavirus disease (COVID-19) who were
admitted to the Intensive Care Unit (ICU) with severe pneumonia (Mendoza
M, et al. BJOG 2020). There were no symptoms of preeclampsia amongst the
34 pregnant women who had mild forms of COVID-19. Importantly, the
authors recorded not only routine laboratory test results, but also
measured biophysical and biochemical markers that are typically altered
in women with preeclampsia (uterine artery pulsatility index on Doppler
ultrasound, serum soluble fms-like tyrosine kinase-1 [sFLT-1] and
placental growth factor [PlGF]). Such markers were normal in five of
the six cases, in whom the symptoms of preeclampsia resolved after
improvement of the maternal clinical situation.</div><div>The intriguingly high cumulative incidence of preeclampsia symptoms in
women with severe coronavirus disease needs to be interpreted with
caution due to the observational nature of the study, the small number
of pregnant women with severe infection and the possible role of
confounding factors. The normal biomarker results in most cases,
nevertheless, suggest that severe coronavirus disease can lead to
symptoms that mimic those of preeclampsia in the absence of defective
placentation, which is further corroborated by the resolution of the
symptoms without the delivery of the placenta when overall clinical
improvement occurs. It is plausible that such manifestations are the
result of widespread inflammation and endothelial damage, in a process
that has been denominated “cytokine storm”, responsible for many of
the symptoms of the coronavirus-related organ injury (Mehta P, et al.
Lancet 2020;395:1033-34) This mechanism includes activation of
inflammation pathways that convert arachidonic acid to prostaglandins,
thromboxane and eicosanoids, ultimately provoking significant cytokine
release. The cascade of events, however, does not appear to influence
the levels of specific preeclampsia angiogenic and anti-angiogenic
markers such as sFLT-1 and PlGF.</div><div>A normal sFLT-1: PlGF ratio in women with clinically suspected
preeclampsia can be reliably used predict the short-term absence of
disease (Zeisler H, et al. N Engl J Med 2016;374:13-22). Although the
definition of preeclampsia has changed over the last 20 years to
incorporate less specific clinical features of end-organ damage,
biomarkers will likely become part of the disease definition in the
years to come or, at least, a valuable tool to select subgroups of women
at higher risk of preeclampsia-related morbidity and mortality who
require closer monitoring or immediate delivery.</div><div>While larger cohorts derived from national datasets or international
registries of coronavirus disease in pregnancy will be essential to
confirm or refute this association, the preliminary data published in
this study indicate that delivery during severe coronavirus disease
should not be based on preeclampsia symptoms alone, particularly at
early gestational ages, and that the use of ultrasound and serum
biomarkers such as the sFLT-1: PlGF ratio might help to guide clinical
management by distinguishing hypertension and endothelial dysfunction
caused by COVID-19-related inflammation from true preeclampsia.</div><div><b>No disclosures:</b> A completed disclosure of interest form is
available to view online as supporting information.</div>