DOI: 10.1111/1471-0528.16583 BJOG Exchange www.bjog.org Authors’ reply re: Pre-eclampsia-like Although this hypothesis has biological 2 Mendoza M, Garcia-Ruiz I, Maiz N, Rodo C, syndrome induced by severe COVID- plausibility, previous studies have Garcia-Manau P, Serrano B, et al. Pre- eclampsia-like syndrome induced by severe 19: a prospective observational shown a correlation between placental COVID-19: a prospective observational study. study histological findings consistent with BJOG 2020;127:1374–80. maternal underperfusion and anti-an- 3 Dap M, Morel O. Proteinuria in Covid-19 giogenic status.5 By contrast, in our pregnant women: Preeclampsia or severe Sir, study we did not find increased soluble infection? Eur J Obstet Gynecol Reprod Biol 2020;252:612. Thank you for the opportunity to fms-like tyrosine kinase-1/placental 4 Shanes ED, Mithal LB, Otero S, Azad HA, respond to the letter from Leavitt and growth factor values in most of the Miller ES, Goldstein JA. Placental Pathology in colleagues.1 We would like to thank women with COVID-19 and signs and COVID-19. Am J Clin Pathol 2020;154:23–32. them for their interest in our study2 and symptoms of PE. For this reason, we 5 Soto E, Romero R, Kusanovic JP, Ogge G, their valuable observations. We agree believe that the placental malperfusion Hussein Y, Yeo L, et al. Late-onset preeclampsia is associated with an imbalance with Leavitt and colleagues that a sim- due to COVID-19 is unlikely to be the of angiogenic and anti-angiogenic factors in ilar underlying pathophysiology (en- main aetiology of the PE-like syndrome. patients with and without placental lesions dothelial damage) may exist in both Thus, we agree with Leavitt and col- consistent with maternal underperfusion. J pre-eclampsia (PE) and COVID-19, leagues that the shared pathophysiology Matern Fetal Neonatal Med 2012;25:498– which may explain most of their com- between COVID-19 and PE is probably 507. mon clinical manifestations. related to immunothrombosis and Other authors have suggested that the decreased alpha-1-antitrypsin (AAT) and M Mendoza, I Garcia-Ruiz, signs and symptoms of PE present in that further research is needed to better E Carreras, & A Suy some pregnant women with COVID-19 understand the causes of PE and PE-like Maternal-Fetal Medicine Unit, Department of could be a consequence of the placental syndrome in order to achieve appropriate Obstetrics, Hospital Universitari Vall dysfunction due to intravascular inflam- treatments for these conditions. & d’Hebron, Universitat Autonoma de mation associated with the infection, Barcelona, Barcelona, Spain leading to a prothrombotic state in the References Accepted 27 October 2020. placenta.3 This hypothesis is supported 1 Leavitt AO, Li Q, Chan ED. Re: Pre-eclampsia- DOI: 10.1111/1471-0528.16583 by the higher rates of maternal vascular like syndrome induced by severe COVID-19: a malperfusion features observed from prospective observational study. BJOG 2020; placentas of women with COVID-19.4 https://doi.org/10.1111/1471‐0528.16584. ª 2020 John Wiley & Sons Ltd. 1