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World J Virol. Sep 25, 2022; 11(5): 310-320
Published online Sep 25, 2022. doi: 10.5501/wjv.v11.i5.310
COVID-19 and hemolysis, elevated liver enzymes and thrombocytopenia syndrome in pregnant women - association or causation?
Prashant Nasa, Deven Juneja, Ravi Jain, Ruchi Nasa
Prashant Nasa, Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
Prashant Nasa, Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain 17666, Abu Dhabi, United Arab Emirates
Deven Juneja, Institute of Critical Care Medicine, Max Super Specialty Hospital Saket, New Delhi 110017, India
Ravi Jain, Department of Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302001, India
Ruchi Nasa, Department of Pathology, Fakeeh University Hospital, Dubai 00000, United Arab Emirates
Author contributions: Nasa P conceptualized and designed the article; Nasa P, Juneja D, Jain R, and Nasa R performed acquisition of data, analysis and interpretation of data, and drafted the article; Juneja D and Jain R revised the article; all authors have read and approve the final manuscript.
Conflict-of-interest statement: Prashant Nasa declared to be on the advisory board of Edwards life sciences. Other authors do not declare any conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Prashant Nasa, MD, Chief Doctor, Department of Critical Care Medicine, NMC Specialty Hospital, Amman Street, Al Nahda 2, Dubai 7832, United Arab Emirates. dr.prashantnasa@hotmail.com
Received: August 12, 2022
Peer-review started: August 12, 2022
First decision: August 29, 2022
Revised: September 7, 2022
Accepted: September 13, 2022
Article in press: September 13, 2022
Published online: September 25, 2022
Processing time: 42 Days and 20.1 Hours
Abstract

Pregnant women are among the high-risk population for severe coronavirus disease 2019 (COVID-19) with unfavorable peripartum outcomes and increased incidence of preterm births. Hemolysis, the elevation of liver enzymes, and low platelet count (HELLP) syndrome and severe preeclampsia are among the leading causes of maternal mortality. Evidence supports a higher odd of pre-eclampsia in women with COVID-19, given overlapping pathophysiology. Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system. The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation, which may be another common link between COVID-19 and HELLP syndrome. On PubMed search from January 1, 2020, to July 30, 2022, we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome. Most of these studies are case reports or series, did not perform histopathology analysis of the placenta, or measured biomarkers linked to pre-eclampsia/HELLP syndrome. Hence, the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies. We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation, and gaps in the current evidence and propose an area of future research.

Keywords: SARS-CoV-2; Preeclampsia; Hypertension; Pregnancy-induced; Liver dysfunction; Pregnancy-induced

Core Tip: Observational studies showed an increased prevalence of preeclampsia and hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome in pregnant women with coronavirus disease 2019 (COVID-19). Despite a possible pathophysiology linkage between COVID-19 and HELLP syndrome, the evidence on temporality to prove a causal association between infection with severe acute respiratory syndrome coronavirus 2 and HELLP syndrome is lacking.