Intravenous immunoglobulin in COVID-19 associated Guillain-Barré syndrome in pregnancy

Efficacy of intravenous immunoglobulin (IVIg) on COVID-19-related neurological disorders over the last 2 years: an up-to-date narrative review

Introduction

Among the clinical manifestations of SARS-CoV-2 infection, neurological features have been commonly reported and the state-of-the-art technique suggests several mechanisms of action providing a pathophysiological rationale for central and peripheral neurological system involvement. However, during the 1st months of the pandemic, clinicians were challenged to find the best therapeutic options to treat COVID-19-related neurological conditions.

Methods

We explored the indexed medical literature in order to answer the question of whether IVIg could be included as a valid weapon in the therapeutic arsenal against COVID-19-induced neurological disorders.

Results

Virtually, all reviewed studies were in agreement of detecting an acceptable to great efficacy upon IVIg employment in neurological diseases, with no or mild adverse effects. In the first part of this narrative review, the interaction of SARS-CoV-2 with the nervous system has been discussed and the IVIg mechanisms of action were reviewed. In the second part, we collected scientific literature data over the last 2 years to discuss the use of IVIg therapy in different neuro-COVID conditions, thus providing a summary of the treatment strategies and key findings.

Discussion

Intravenous immunoglobulin (IVIg) therapy is a versatile tool with multiple molecular targets and mechanisms of action that might respond to some of the suggested effects of infection through inflammatory and autoimmune responses. As such, IVIg therapy has been used in several COVID-19-related neurological diseases, including polyneuropathies, encephalitis, and status epilepticus, and results have often shown improvement of symptoms, thus suggesting IVIg treatment to be safe and effective.

An atypical presentation of pre-eclampsia (PET) in a patient diagnosed with Guillain-Barré syndrome: A case report

Guillain-Barré syndrome (GBS) is an autoimmune neurological disorder with unknown aetiology. Given the incidence of GBS is between 1.2 and 1.9 cases per 100,000 people annually [1], it is extremely rare in pregnancy. We report a case with a challenging diagnosis of pre-eclampsia (PET) in a 34-year-old diabetic primigravida who was diagnosed with GBS at 30 weeks of gestation. At her initial presentation, she complained of progressive weakness of her limbs and facial muscles. This was associated with difficulty swallowing. The diagnosis of GBS was made based on electromyography (EMG) and clinical findings. She was managed conservatively with supportive management and was delivered by lower segment caesarean section at 34 weeks of gestation due to rapidly deteriorating liver function tests (LFTs) in the likely setting of PET.

Clinical Outcomes of COVID-19 Infection in Pregnant and Nonpregnant Women: Results from The Philippine CORONA Study

OBJECTIVE

Our study determined the association of pregnancy with various clinical outcomes among women with COVID-19 infection.

METHODS

We conducted a retrospective, cohort, subgroup analysis of the Philippine CORONA Study datasets comparing the clinical/neurological manifestations and outcomes of pregnant and nonpregnant women admitted in 37 Philippine hospitals for COVID-19 infection.

RESULTS

We included 2448 women in the analyses (322 pregnant and 2.126 nonpregnant). Logistic regression models showed that crude odds ratio (OR) for mortality (OR 0.26 [95% CI 0.11, 0.66]), respiratory failure [OR 0.37 [95% CI 0.17, 0.80]), need for intensive care (OR 0.39 [95% CI 0.19, 0.80]), and prolonged length of hospital stay (OR 1.73 [95% CI 1.36, 2.19]) among pregnant women were significant. After adjusting for age, disease severity, and new-onset neurological symptoms, only the length of hospital stay remained significant (adjusted OR 1.99 [95% CI 1.56,2.54]). Cox regression models revealed that the unadjusted hazard ratio (HR) for mortality (HR 0.22 [95% CI 0.09, 0.55]) among pregnant women was statistically significant; however, after adjustment, the HR for mortality became nonsignificant.

CONCLUSION

We did not find a significantly increased risk of mortality, respiratory failure, and need for ICU admission in pregnant women compared with nonpregnant women with COVID-19. However, the likelihood of hospital confinement beyond 14 days was twice more likely among pregnant women than nonpregnant women with COVID-19.

Pregnancy and neurologic complications of COVID-19: A scoping review

While neurologic complications are frequently reported among patients with COVID‐19 in the general population, they are unknown in pregnant women. This paper summarizes the case reports of pregnant women with confirmed SARS‐CoV‐2 infection plus a specified neurologic diagnosis. Until November 2021, 18 case reports were found. Both the central and peripheral nervous systems were equally affected: delirium (n = 1), posterior reversible encephalopathy syndrome (n = 4), cerebrovascular disease (n = 2), acute cerebral demyelinating disease (n = 1), acute necrotizing encephalopathy (n = 1), Guillain–Barré syndrome (n = 5), including one patient who also had vestibular neuritis, Bell's palsy (n = 3), and rhabdomyolysis (n = 1). The median maternal age was 32.5 (25—35) years, the median gestational age was 34 (30—36.5) weeks, and 38.9% presented previous medical conditions. Respiratory symptoms were reported in 76.5%, and 76.5% received immunotherapies to treat the COVID‐19 or the neurologic complications. Half the women required admission to ICU and, more often, were those with central nervous system involvement (77.8% vs. 22.2%; Chi‐square test, p = .018). For 64.7% of women, the most common method of delivery was surgical, although just one case was due to the neurologic complication. There were reports of one spontaneous abortion, two fetal deaths, and no maternal deaths. Only one case presented a poor neurologic outcome. It is possible that our findings are underestimated, considering that there are thousands of reports regarding neurologic complications in the general population with COVID‐19.

The Current Evidence Regarding COVID-19 and Pregnancy: Where Are We Now and Where Should We Head to Next?

Despite the volume of publications dedicated to unraveling the biological characteristics and clinical manifestations of SARS-CoV-2, available data on pregnant patients are limited. In the current review of literature, we present an overview on the developmental course, complications, and adverse effects of COVID-19 on pregnancy. A comprehensive review of the literature was performed in PubMed/Medline, Embase, and Cochrane Central databases up to June 2021. This article collectively presents what has been so far reported on the identified critical aspects, namely complications during pregnancy, delivery challenges, neonatal health care, potential routes of viral transmission, including vertical transmission or breastfeeding, along with the risks involved in the vaccination strategy during pregnancy. Despite the fact that we are still largely navigating uncharted territory, the observed publication explosion in the field is unprecedented. The overwhelming need for data is undoubtable, and this serves as the driver for the plethora of publications witnessed. Nonetheless, the quality of data sourced is variable. In the midst of the frenzy for reporting on SARS-CoV-2 data, monitoring this informational overload is where we should head to next, considering that poor quality research may in fact hamper our attempts to prevail against this unparalleled pandemic outbreak.