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      Intrauterine fetal demise as a result of maternal COVID-19 infection in the third trimester of pregnancy: A case report

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          Abstract

          Introduction

          As the global pandemic continues, more information is being collected on the incidence and range of adverse maternal and fetal outcomes resulting from COVID-19 infection.

          Presentation of case

          We present a case of a 29-year-old unvaccinated patient at 36 weeks gestation with several days of mild symptoms after testing positive for COVID-19 who presented with a complaint of decreased fetal movement and was found to have an intrauterine fetal demise. This case was further notable for thrombocytopenia, acute postpartum hemorrhage and placental histologic findings showing morphologic changes consistent with previously reported pathology seen with maternal COVID-19 infection including marked perivillous fibrin deposition and marked acute and chronic intervillositis.

          Discussion

          This case, combined with other similar reports in the literature, supports the conclusion that COVID-19 infection in pregnancy can result in severe perinatal adverse consequences regardless of initial maternal symptomatology.

          Conclusion

          Pregnancies affected by COVID-19 may benefit from a higher level of surveillance and proactive care and further research is warranted.

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          Most cited references9

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          The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

          The SCARE Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case reports and are used and endorsed by authors, journal editors and reviewers, in order to increase robustness and transparency in reporting surgical cases. They must be kept up to date in order to drive forwards reporting quality. As such, we have updated these guidelines via a DELPHI consensus exercise.
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            Consistent localization of SARS-CoV-2 spike glycoprotein and ACE2 over TMPRSS2 predominance in placental villi of 15 COVID-19 positive maternal-fetal dyads

            Introduction While the COVID-19 pandemic continues to have a significant global health impact, rates of maternal to infant vertical transmission remain low (<5%). Parenchymal changes of placentas from COVID-19 infected mothers have been reported by several groups, but the localization and relative abundance of SARS-CoV-2 viral proteins and cellular entry machinery has not been fully characterized within larger placental tissue cohorts. Methods An extended placental tissue cohort including samples from 15 COVID-19 positive maternal-fetal dyads (with n = 5 cases with evidence of fetal transmission) in comparison with 10 contemporary COVID-19 negative controls. Using comparative immunofluorescence, we examined the localization and relative tissue abundance of SARS-CoV2 spike glycoprotein (CoV2 SP) along with the co-localization of two SARS-CoV2 viral entry proteins angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2). Results/conclusions CoV2 SP was present within the villous placenta in COVID-19 positive pregnancies with and without evidence of fetal transmission. We further identified the predominance of ACE2 expression in comparison with TMPRSS2. Importantly, both CoV2 SP and ACE2 expression consistently localized primarily within the outer syncytiotrophoblast layer placental villi, a key physiologic interface between mother and fetus. Overall this study provides an important basis for the ongoing evaluation of SARS-CoV-2 physiology in pregnancy and highlights the importance of the placenta as a key source of primary human tissue for ongoing diagnostic and therapeutic research efforts to reduce the global burden of COVID-19.
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              Defining Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Placentitis

              Context.— Case reports and rare case series have demonstrated variable placental pathology in the setting of maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In rare small studies demonstrating infection of the placental parenchyma, histologic manifestations have included variable degrees of histiocytic intervillositis, perivillous fibrin deposition, and syncytiotrophoblast necrosis. Objective.— To characterize the placental pathologic features of SARS-CoV-2–infected placentas, irrespective of fetal-maternal transmission, and to examine the frequency of C4d activation in such cases. Design.— A retrospective study of 7 placentas from mothers with active SARS-CoV-2 infection and placental infection as demonstrated by RNA in situ hybridization was conducted. Results.— There were 6 placentas from live-born neonates (5 singletons, 1 nonfused diamniotic-dichorionic twin placenta), and 1 was from a stillbirth. A total of 5 of the 8 neonates (including the stillbirth) tested negative for SARS-CoV-2, and all were negative for neonatal infection. The remaining 3 neonates were well at time of discharge. All placentas were positive for SARS-CoV-2 infection by RNA in situ hybridization and demonstrated variable degrees of histiocytic intervillositis, perivillous fibrin deposition, and trophoblast necrosis. Three cases demonstrated features of fetal vascular malperfusion. CD68 highlighted intervillous histiocytes. C4d expression was present along the villous borders in 6 of 7 cases. Conclusions.— SARS-CoV-2 placentitis is defined by the triad of histiocytic intervillositis, perivillous fibrin deposition, and trophoblast necrosis. The features may occur in cases without confirmed transplacental transmission. The damage caused by SARS-CoV-2 placentitis is likely mediated by complement activation.
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                Author and article information

                Journal
                Int J Surg Case Rep
                Int J Surg Case Rep
                International Journal of Surgery Case Reports
                The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
                2210-2612
                12 August 2022
                12 August 2022
                : 107492
                Affiliations
                [a ]OMS IV, Edward Via College of Osteopathic Medicine, United States of America
                [b ]Piedmont Columbus Regional Hospital, United States of America
                Author notes
                [* ]Corresponding author at: 910 S Donahue Dr., Auburn, AL 368632, United States of America.
                Article
                S2210-2612(22)00738-6 107492
                10.1016/j.ijscr.2022.107492
                9372023
                8e133955-548f-40ae-b6e3-e99d2200ed98
                © 2022 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 30 April 2022
                : 4 August 2022
                : 7 August 2022
                Categories
                Case Report

                placenta,covid-19,intervillousitis,placentitis,infection
                placenta, covid-19, intervillousitis, placentitis, infection

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