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KAVITA NARANG: Physiologic, metabolic, and vascular changes that occur during normal and high-risk pregnancies may affect the risk of SARS-CoV-2 infection and modify or exacerbate the clinical presentation of COVID-19 in pregnant patients. Based on data from prior pandemics, pregnant women may be at risk for worse outcomes. Worldwide population-based studies have identified age and comorbid conditions as predictors of poor outcomes. However, data on pregnant patients are currently still limited.

I'm Kavita Narang, a second-year fellow in the Division of Maternal and Fetal Medicine at Mayo Clinic. We recently published our paper, titled "SARS-CoV-2 Infection and COVID-19 in Pregnancy," which will be published in the August 2020 issue of Mayo Clinic Proceedings, and we will be focusing on a multidisciplinary review on the mechanistic pathway and management of COVID-19 in pregnancy.

SARS-CoV-2 enters the cell via the angiotensin-converting enzyme 2 receptor, also known as the ACE2 receptor, which is upregulated in normal pregnancies. Upregulation of ACE2 mediates the conversion of angiotensin II, which is a vasoconstrictor, to angiotensin 1 to 7, which is a vasodilator, resulting in overall decreased blood pressure in pregnancy. As a result of upregulation of ACE2 receptors in pregnancy, pregnant women may be at an elevated risk of complication from SARS-CoV-2.

Upon binding to ACE2, SARS-CoV-2 results in its downregulation and therefore, lower levels of angiotensin 1 to 7, which can mimic vasoconstriction, inflammation, and procoagulopathy, as seen in preeclampsia, a condition of high blood pressure in pregnancy. Due to these overlapping mechanical pathway and clinical features and lab abnormalities, including thrombocytopenia and liver function derangements that can be seen in both preeclampsia and COVID-19, that may make it a little bit more challenging to make the distinction between these two conditions.

Pharmacologic therapy in pregnancy is limited to those with proven clinical safety, which is often unavailable for medications early in the clinical trials. Larger multicenter studies are going to be a critical part in helping us to understand the pathophysiology and clinical features of COVID-19 in pregnancy and therefore optimizing our preventive and treatment strategies for COVID in normal and high-risk pregnancies.

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