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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 17-21

Electrocardiographic changes in pregnant women with COVID-19

1 Center of Clinical Research Development, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
2 Center of Clinical Research Development, Nekouei-Hedayati-Forghani Hospital, Qom University of Medical Sciences, Qom, Iran
3 Department of Obstetrics and Gynecology, Faculty of Medicine, Qom University of Medical Sciences, Qom, Iran
4 Department of Social Medicine, Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran

Date of Submission08-Feb-2022
Date of Decision21-Mar-2022
Date of Acceptance25-Mar-2022
Date of Web Publication26-Apr-2022

Correspondence Address:
Monireh Mirzaie
Clinical Research Development Center, Nekouei-Hedayati-Forghani Hospital, Qom University of Medical Sciences, Qom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_9_22

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Introduction: One of the unique challenges for obstetricians in pregnancy is cardiovascular changes. This study aimed to evaluate electrocardiographic (ECG) changes in mothers with COVID-19. Materials and Methods: In a retrospective study, 89 pregnant women with positive reverse transcription-polymerase chain reaction for COVID-19, between 19 and 44 years old, were selected for the study, and 12 lead ECGs were extracted and recorded from the medical documents for all cases and all parameters analyzed. Results: Of the 89 patients that met inclusion criteria, only eight patients were admitted to intensive care unit. Of all, 64 cases (71.9%) had normal ECG, three patients showed atrioventricular (AV) block (3.4%), and three patients had first-degree AV block type (PR interval >200 ms). The mean QTC interval was 428.6 ± 37.4 ms and 15 (17%) patients had long QTC intervals (QTC ≥460 ms). There was a significant relationship between antivirus treatment (P = 0.027), as well as hydroxychloroquine (HCQ) with PR interval (P = 0.002). A significant relationship was found between corticosteroids with QTC (P = 0.019) and antibiotics with QTC (P = 0.018). Conclusion: A significant association between corticosteroids usage and QTC interval as well as antiviral and HCQ treatment with PR interval. These changes during pregnancy and COVID-19 should be interpreted with caution by physicians. Understanding changes in electrocardiography can help in better and early diagnosis and management of pregnant mothers to prevent adverse outcomes.

Keywords: COVID-19, electrocardiographic, pregnancy

How to cite this article:
Yousefzadeh M, Asgarian A, Ahangari R, Vahedian M, Mirzaie M. Electrocardiographic changes in pregnant women with COVID-19. J Pract Cardiovasc Sci 2022;8:17-21

How to cite this URL:
Yousefzadeh M, Asgarian A, Ahangari R, Vahedian M, Mirzaie M. Electrocardiographic changes in pregnant women with COVID-19. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Mar 30];8:17-21. Available from: https://www.j-pcs.org/text.asp?2022/8/1/17/344140

  Introduction Top

One of the unique challenges for obstetricians in pregnancy is cardiovascular changes that put mothers at risk.[1] The new coronavirus originated in December 2019 and quickly became a pandemic with a high mortality rate and is associated with a variety of cardiovascular manifestations such as acute coronary syndrome, cardiac arrhythmia, myocarditis, stress cardiomyopathy, and thromboembolism, as well as evidence of significant cardiac damage.[2],[3] Electrocardiographic (ECG) can be used as a valuable diagnostic tool for cardiac changes in patients with COVID-19 for early detection of infection and prevention from computed tomography (CT) scan.[4],[5]

Acute coronavirus (COVID-19) is predictive of adverse consequences in pregnant women and infants.[6],[7] The virus enhances histological changes and affects many nonrespiratory organs such as the heart, liver, kidneys, brain, or male reproductive system.[8],[9],[10] In studies, cardiovascular symptoms are seen in 30% of hospitalized patients, while pulmonary involvement has the most common clinical manifestations.[11],[12] Clinical outcomes in pregnant women with coronavirus are worse than in nonpregnant women due to physiological changes including behavioral changes (brain), cardiovascular (heart and blood vessels), hematological, metabolic, renal, immune, and cardiorespiratory system as well as intolerance to hypoxia.[13],[14]

Studies have reported that there are currently more than 17.5 million confirmed cases worldwide of COVID-19,[15] including the cardiovascular system.[16] COVID-19-related cardiomyopathy, viral myocarditis, myocardial infarction, and arrhythmia are some of the complications reported in the general adult population.[17] Almost 30% of patients with confirmed COVID-19 were found to have evidence of myocardial injury and COVID-19 related cardiomyopathy, cardiovascular, or respiratory diseases such as palpitations and shortness of breath have been observed in pregnant women.[18],[19] In addition, patients with preeclampsia are more prone to cardiovascular complications. Therefore, physicians should pay more attention to heart involvement in patients with COVID-19. This study aimed to evaluate ECG changes in mothers with COVID-19.

  Materials and Methods Top

Study setting

In a cross-sectional study, 200 pregnant women who were admitted for delivery were evaluated retrospectively. The pregnant women were referred to the delivery block of Qom referral hospital with COVID-19 symptoms including fever, cough, sore throat, body pain, lethargy, and fatigue. The eligible pregnant women were selected based on the inclusion and exclusion criteria and data of patients were extracted from the medical documents and entered into the study checklist. Finally, data of 89 eligible cases were evaluated and entered into the study from January 2019 to December 2020.

Inclusion criteria were including women in the third trimester of pregnancy period, with adequate clinical and laboratory data, single and normal fetuses admitted to the delivery unit. Nevertheless, cases with trauma, mothers under 18 and upper 45 years of age, those with coronary artery disease and high blood pressure were excluded from the study.

Data collection

At the beginning of the hospitalization for patients, samples for polymerase chain reaction (PCR) tests were sent to the laboratory for examination of COVID-19. In addition, a CT scan of the lungs was performed to determine the extent of the involvement; positive people were treated appropriately based on the national and WHO guidelines.[20],[21] The collected information including age, gestational age, number of pregnancies, previous deliveries and abortions, clinical signs, consequences of pregnancy and childbirth (rupture of the bladder, vaginal bleeding, preeclampsia, and renal failure), patient symptoms at the hospital (fever, cough, dyspnea, respiratory distress, muscle pain, diarrhea, and vomiting), blood oxygen level, type of delivery, hospitalization in intensive care unit (ICU), neonatal profile, ECG information and echocardiography, maternal COVID-19 test results, and CT scan results. ECG information and echocardiography data were interpreted by an expert cardiologist. Data obtained from mothers diagnosed with clinical or laboratory manifestations were entered into the information form. The severity of COVID-19 classification based on clinical parameters (mild, moderate, and severe) was done according to the WHO guideline.[20],[22] The patients with severe COVID-19 were admitted to ICU.

Ethical consideration

The present study was performed after obtaining the ethical code from the Ethical Committee of Qom University of Medical Sciences (IR.MUQ.REC.1399.130). Informed consent was taken from all patients or their families for entering this research. In addition, the results were reported overall and the patients' information was considered confidential without reporting any identical and personal details.

Statistical analysis

After collecting the forms, the data were analyzed using SPSS version 20 (SPSS Inc., Chicago, IL, USA). The results were expressed as the mean standard deviation for continuous data and the number and percentage for nominal data. A Chi-square test was used for assessing the relationship between treatment and ECG interval. P ≤ 0.05 was considered statistically significant.

  Results Top

Patient characteristics

Clinical characteristics of the study population are presented in [Table 1]. Of the 200 patients initially enrolled in the study, 89 met inclusion criteria and 111 were excluded due to incomplete data in ECG, laboratory, or clinical data. Hypothyroidism (29. 5%) and valvular heart disease (10.2%) were the most common comorbidities in studied patients. Out of the total number of patients, only eight patients were admitted to ICU. Of the 200 COVID-19 patients, one died and others were discharged with recovery. In this study, all patients were had positive PCR, and the CT scans only conducted in 20 moderate that severe patients, and in 17 cases (85%) lung involvement was observed. Furthermore, 93.2% of the participants in the study were Iranian.
Table 1: Clinical characteristics of all patients in study

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The distribution of 89 pregnant mothers' blood types diagnosed with COVID-19 showed that there were 16 (28.6%) patients with blood types of A+ and O+, 13 (23.2%) patients with blood types of B+, 7 (12.5%) patients with blood types of AB+, 3 (5.4%) patients with blood types of O−, 1 (1.8%) patient with the blood type of A−. There were no mothers diagnosed with a blood type of B − and AB−. Based on our results, the A+ and O+ were the most common blood types in studied cases.

The mean age of mothers was 31 ± 6.4 years (range19–44 years) and 29.59 ± 0.8.22 weeks (range 25–38) of gestational age. The maternal characteristics of all patients in the study are shown in [Table 2].
Table 2: The Mean and standard deviation of demographic variables in study patients

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A12-lead ECG was obtained from all patients admitted to the hospital. ECG characteristics are summarized in [Table 3]. Many patients (71.9%) had normal ECG, but T wave change was observed in 25 cases (28%) and three patients had atrioventricular (AV) block (3.4%). As shown in [Table 4], the mean QTC interval was 428.6 ± 37.4 ms and the QT interval was 348 ± 55.7 ms. As shown in [Table 5], a long QTC interval (QTC ≥460 ms) was observed in 15 (17%) patients, first-degree AV block type (PR interval >200 ms) in three patients and QTC interval >460 was observed in 15 cases (17%). Moreover, the PR interval >200 and QRS width >100 was detected in 3 cases (3.3%) and 4 cases (4.5%), respectively.
Table 3: Electrocardiographic characteristics of all studied patients

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Table 4: The mean and standard deviation of electrocardiographic characteristics in the study

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Table 5: Electrocardiographic variables of hospitalized patients

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Out of the total number of patients, 4 patients (4.4%) developed bundle branch block (QRS >100 msec), of which three patients were right bundle branch block (RBBB) and one was left bundle branch block patient (LBBB). There is a significant relationship [Table 6] between antivirus (P = 0.026) and hydroxychloroquine (HCQ) with PR interval (P = 0.004). In addition, a significant relationship was found between corticosteroids with QTC (P = 0.019) and antibiotics with QTC (P = 0.010). There is no significant relationship between antivirus (P = 0.08), corticosteroids (P = 0.15), antibiotics (P = 0.06), HCQ (P = 0.27), and nonsteroidal anti-inflammatory drugs (P = 0.6) and sinus rate. In four cases, the QRS prolongation did not seem to have a significant relationship with the involvement of COVID-19 patients. Moreover, there was no significant relationship between different drugs and the duration of QRS.
Table 6: The relationship between electrocardiographic changes and the received treatment

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  Discussion Top

This is a descriptive study that provides information on ECG parameters in pregnancy with COVID-19. Based on the results of the study performed on 89 patients, most of the people in study 66 (75%) had a normal heart rate (60–100 b/min). Eighteen patients (20.5%) had a tachycardia or heart rate of more than 100 b/min, for a variety of reasons. Studies have shown that the heart rate increases by about 20% compared to the baseline during a normal pregnancy, of course, other causes for tachycardia in these patients include fever, dehydration, shortness of breath, and stress.[19] A heart rate of <60, which was observed in 4 patients (4.5%), is normally less than expected however, mechanisms such as inflammation and possible involvement of the conduction tissue of the heart of the effect of drugs used in the treatment of COVID-19 patients can be considered. The same possible mechanism can justify the increase in interval PR with grade 1 AV in three cases. Cardiac arrhythmias increase in pregnant women due to physiological changes in the body.[23] Arrhythmias may also get worse with pregnancy.[24] There is numerous evidence that SARS-COV2 infection is presented with all spectrum of cardiovascular disease.[25] COVID-19-associated heart damage is referred to as cytokine storm, viral myocarditis, and ischemia.[26],[27] The same mechanism in addition to electrolyte disturbance and drug sides effects is responsible for cardiac arrhythmia.[28] Increased risk of thromboembolism during COVID-19, especially in acutely ill patients with acute respiratory distress syndrome (ARDS) is confirmed.[29] Hyper coagulation state during COVID-19 is attributed to systemic inflammation, immobility, and hypoxemia.[25] As shown in the results of the study, a significant relationship was observed between prolongation of PRI (PR interval) and the use of antiviral drugs lopinavir–ritonavir and the use of HCQ. One study found that lopinavir–ritonavir treatment did not significantly accelerate clinical improvement, reduce mortality, or significantly reduce the ability of the throat to detect viral RNA in patients with COVID-19.[30]

In a study by Haghjoo et al., the QTC >500 ms was observed in 11.2% of patients with COVID-19.[5] QT interval represents the time from the onset of ventricular depolarization to the completion of repolarization. Since it varies with heart rate, QTC interval is usually used.[31] Our study show in four cases, the increase in QRS, of which three were RBBB and one was LBBB, did not seem to have a significant relationship with COVID-19 involvements and based on our study, no significant relationship was observed between different drugs and QRS duration. In our study, 15 (17%) pregnant women with COVID-19 had prolonged QTC. There was a significant relationship between antibiotic use azithromycin (AZM) and prolonged QTC.[5] AZM could act on SARS-CoV-2 binding to respiratory cells. Its intracellular accumulation led to an increase in the pH that may impair the trans-Golgi network and lysosome functions.[32] Another study reported that treatment with AZM alone significantly decreased the mortality hazard ratio by 66% and combination therapy with HCQ + AZM decreased the mortality hazard ratio by 71%.[33] Based on a systematic review, ECG findings are related to COVID-19 infection. There were some worse consequences due to COVID-19 infection including ST-segment changes, T wave inversions, QT prolongation, and atrial fibrillation as early indicators of cardiac involvement.[4] These consequences are very important in pregnancy and delivery outcomes including higher sever infection, preterm delivery, PPROM, low birth weight, and neonatal death.[9],[34],[35],[36]

In the present study, a significant relationship was observed between prolongation QTC and corticosteroid use for treatment. In addition to reducing inflammation, taking corticosteroids can be effective in preventing prolongation QTC and reducing the chance of cardiac arrhythmias in the treatment of COVID 19. The effects of corticosteroids are not yet known in COVID-19, but evidence suggests that corticosteroids are beneficial in ARDS.

Limitations and recommendations

The sample size of this study was small and there was no control group in this study. Therefore, the conclusion for ECG change was conducted based on the results of other studies. Due to the spread and epidemic of COVID-19 and the impact on various organs of the body, especially in pregnant mothers, a larger study is needed. Participants in the study were a heterogeneous group of pregnant women. It was necessary to study the consequences of women about heart diseases with high accuracy.

  Conclusion Top

The results showed a significant association between corticosteroids usage and QTC interval as well as antiviral and HCQ treatment with PR interval. These changes during pregnancy and COVID-19 should be interpreted with caution by physicians. Understanding changes in electrocardiography can help in better and early diagnosis and management of pregnant mothers to prevent worse outcomes.

Ethics clearance

The present study was performed after obtaining the ethical code from ethical committee of Qom University of Medical Sciences (IR.MUQ.REC.1399.130).

Financial support and sponsorship

This study was supported financially by Qom University of Medical Sciences, Iran.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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