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ORIGINAL ARTICLE
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Maternal and perinatal outcome in covid-19 complicated pregnancies in a level-3 covid facility of North India


 Department of Obstetrics and Gynecology, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India

Date of Submission23-Oct-2021
Date of Decision10-Jan-2022
Date of Acceptance19-Feb-2022

Correspondence Address:
Neelima Agarwal,
R 2/156 Rajnagar, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_846_21

  Abstract 


Background: Due to its physiologic immune suppression, pregnancy is a vulnerable time for severe respiratory infections including COVID-19. However, information regarding the effect of COVID-19 during pregnancy is limited. Objectives: To study the clinical profile of patients suffering from coronavirus disease-2019 (COVID-19) during pregnancy and to evaluate the effect of COVID-19 on maternal, perinatal, and neonatal outcomes. Methodology: This is a cross-sectional observational study over a period of one year from June 2020 to May 2021, in Level-3 Covid facility in Ghaziabad. All pregnant females with confirmed positive for Corona virus infection admitted to the covid ward under the department of Obstetrics & Gynecology were included in the study. Results: A total of 233 pregnant women were included in the study. Maximum patients were from age group 21-30 years (53.2), multigravida (62.7%), and presented in the third trimester (80.7%). On admission, 198 patients (85%) had no covid related symptoms and only three patients had severe symptoms requiring ICU care. Total 102 patients delivered (43.77%), out of whom 40 had a normal vaginal delivery and 62 had a cesarean section. The incidence of preterm birth was 22.5% and maternal death was in three patients (1.3%). Conclusion: The common presentation of COVID-19 during pregnancy is either a mild disease or even asymptomatic. The maternal outcomes observed in late pregnancy and fetal and neonatal outcomes appear good in most cases. Further studies are required to know long-term outcomes and potential intrauterine vertical transmission.

Keywords: Clinical profile, COVID-19 in pregnancy, maternal outcome, perinatal outcome



How to cite this URL:
Agarwal N, Gupta M, Agrawal A. Maternal and perinatal outcome in covid-19 complicated pregnancies in a level-3 covid facility of North India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=343057




  Introduction Top


The global coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been growing at an accelerating rate. Due to the increasing mortality rate, it becomes essential to identify and protect especially the vulnerable populations in society. The knowledge gained from previous human coronavirus outbreaks, namely, the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), suggests that pregnancy is particularly a susceptible condition to poor outcomes.[1],[2]

The physiological changes occurring during pregnancy make the mother more vulnerable to severe infections. There is an increase in the transverse diameter of the thoracic cage during pregnancy and also an elevated level of the diaphragm. These anatomical changes decrease maternal tolerance to hypoxia. Lung volume changes and vasodilatation can lead to mucosal edema and increased secretions in the upper respiratory tract. In addition, alterations in cell-mediated immunity contribute to the increased susceptibility of pregnant women to be infected by intracellular organisms such as viruses.[3]

Previous data on SARS and MERS suggest a wide range of clinical findings during pregnancy, from being asymptomatic to severe disease or even death. The most common symptoms of COVID-19 are fever and cough, with more than 80% of hospitalized patients presenting with these symptoms. However, pregnant women are more susceptible to adverse outcomes, including the need for admission to an intensive care unit (ICU), endotracheal intubation, and death.[4]

This study aimed to provide useful information to enhance our existing knowledge about COVID-19 infection in pregnancy and help in the development of management protocols to achieve a safe and favorable maternal and neonatal outcome.


  Material and Methods Top


Study design- Cross-sectional observational study

Study Place: Department of Obstetrics & Gynecology, in a designated Level-3 COVID-19 facility, running the largest COVID-19 labor room and emergency services in the city.

Study Duration: 1.6.2020- 31.5.2021 (12 months)

Study Population: All pregnant females with Corona virus infection admitted to the Department of Obstetrics & Gynecology.

Clearance was taken from the institutional ethical committee.

Inclusion criteria

  1. All pregnant females in any trimester of pregnancy.
  2. Presence of corona virus infection, as confirmed on RT-PCR or Rapid Antigen


Exclusion criteria

  1. Cases with suspected COVID-19 that are not confirmed by a laboratory test


Methodology

All pregnant Covid-19 Positive females who were admitted to fulfilling the inclusion and exclusion criteria were thoroughly analyzed. A detailed history was taken including obstetric history, menstrual history, past and personal history, and complaints if any. A thorough physical examination including general physical and obstetric examination was performed.

Baseline investigations in the form of complete hemogram, urine analysis, blood grouping and Rh typing, random blood sugar, viral markers (HIV, HCV, HBsAg), VDRL, and obstetric ultrasound were sent for all patients.

Complications in terms of medical complications (anemia, hypertension, hypothyroidism or diabetes mellitus), obstetric complications (malpresentations, contracted pelvis, previous low segment cesarean section [LSCS], prolonged leaking, fetal distress, etc.), or complications related to Covid-19 infection (fever, cough, breathing difficulty, heaviness in chest, etc.) were noted.

Patient's pregnancy and labor were managed accordingly. Neonatal outcome was noted by APGAR Score. Babies were handed over to relatives immediately after birth to prevent the spread of corona infection from the mother.

Patients were discharged in accordance with government guidelines after getting RTPCR report negative. Mother and baby were followed up for at least six weeks following delivery. Patients who were managed conservatively and discharged before delivery were also followed closely to know the development of any complications.

Statistical analysis

In the statistical analysis, percentages (frequencies) of various parameters were calculated and subjected to statistical tests using the Chi-square test. The computation was done using Microsoft Excel 2007.


  Results Top


A total of 249 Covid- positive women were admitted to the Obstetrics and Gynecology Department from June 1, 2020 to May 31, 2021. Out of these, 16 women had gynecological complaints and 233 were antenatal. Maximum pregnant patients were admitted in the month of July 2020, followed by another peak in September-October 2020 probably because of the festival season in India. Thereafter, there was a decline until the second wave of Covid infection hit North India, with a steep rise in cases in the month of April 2021 [Figure 1].
Figure 1: Month-wise admissions of Covid-positive pregnant females

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[Table 1] describes the baseline characteristic of the study participants. The mean age of the patients was 26.5 ± 3.2 years, with a range from 18 to 39 years. Maximum patients were from the age group 21-30 years (61.8%). The majority of them were urban by residence (54.9%) and belonged to the joint family (63.9%) [Table 1].
Table 1: Socio-demographic profile of covid-positive pregnant females

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The majority of the patients were multigravida (62.7%) and presented in the third trimester (80.7%). On admission, 198 patients (85%) had no covid related symptoms; 32 patients (13.7%) had mild symptoms of cough, shortness of breath, fever, rhinitis, myalgia, or fatigue, and 3 patients had severe symptoms with low SpO2 and required ICU care.

A very common association found in our study was the presence of moderate to severe anemia in 83 patients (35.6%) out of whom 51 patients (21.9%) required one or more blood transfusions. This figure was higher when compared to antenatal cases in non-covid times in our population where approximately 20-25% of females have anemia.

Other co-morbidities seen were mild to severe hypertensive disorders in 40 patients (17.2%) and hypothyroidism in 23 patients (9.85%). Diabetes was present in four patients (1.7%) [Table 2].
Table 2: Clinical profile of covid-positive pregnant females

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There were no maternal complications in 137 patients (58.7%) during their stay in hospital. Two patients had an antepartum hemorrhage and three had post-partum hemorrhage, requiring blood transfusion. One patient had an inversion of the uterus following normal vaginal delivery and had to be taken up for laparotomy. Mild to moderate Covid 19 pneumonia was present in seven patients and severe pneumonia in three patients requiring ICU care. There were 3 maternal deaths in our hospital. One presented at 25 weeks with eclampsia and cerebral edema, not responding to verbal stimuli, and loss of sensorium. She expired while she was being prepared for emergency hysterotomy. The other two patients were admitted in the second trimester with acute breathlessness and severe pneumonia and were admitted to ICU. One of them developed Multi-Organ Dysfunction Syndrome. Both of them could not be saved despite the best efforts by the ICU team [Table 3].
Table 3: Maternal complications during stay in hos

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Out of the total 233 covid-positive pregnant patients, 102 were delivered, 128 were managed conservatively and had ongoing pregnancy at the time of discharge and three patients expired. Of 102 patients who delivered, 40 had a normal vaginal delivery and 62 had a cesarean section [Figure 2].
Figure 2: Pregnancy outcome

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Out of the 102 patients who delivered, the majority had a normal vaginal delivery and cesarean section beyond 37 weeks (34.3% and 43.2%, respectively). The incidence of preterm birth (both NVD and LSCS included) in our study was 22.5% with 23 patients delivering before 37 weeks [Table 4]. This rate was higher than the similar population in non-covid times at our institution where 13-15% of patients have a preterm birth.
Table 4: Outcome of delivered patients

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The common indications of LSCS in our study were previous cesarean section and intrauterine growth retardation with oligohydramnios in 19.4% cases each. This was followed by non-progress of labor, postdated pregnancy, and PROM. Other indications were fetal distress, CPD, severe hypertension, and fetal malpresentations [Table 5].
Table 5: Indication for LSCS

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Among the 102 pregnant patients who delivered, one had twin delivery, making the total births 103 babies. Out of these, one patient had diagnosed preterm intrauterine death on admission. This patient had uncontrolled hypertension. The average birth weight of babies was 2.63 ± 1.2 kg with a range from 0.9 to 4.1 kg. The majority of the babies born were between 2-2.9 kg (n = 66, 64.1%). Two babies were more than 4 kg at birth [Table 6].
Table 6: Birth weight of newborns

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Out of the total 233 covid-positive pregnant patients, 230 patients (98.7%) were discharged in healthy condition whereas there was maternal death in three patients (1.3%) [Figure 3].
Figure 3: Discharge disposition

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  Discussion Top


Due to its physiologic immune suppression, pregnancy is a vulnerable time for severe respiratory infections including COVID-19.

In our study, the majority of the patients were asymptomatic (85%), 13.7% had mild symptoms and only three patients (1.3%) had severe covid symptoms. Similar findings were seen in the study by Singh et al.[5] in 132 covid positive pregnant females, where 65.15% were asymptomatic, 34.09% had a mild form of the disease, and only one presented with severe disease requiring intensive care. Also, in the study of 141 patients by Nayak, most of their patients (97%) were asymptomatic or had mild symptoms.[6] The presentation of mild symptoms of COVID-19 in pregnant patients may be due to fact that the average age of these patients is younger as compared to the general population affected by COVID-19 infection. This was confirmed in our as well as other studies. In our study, 68.2% of patients were young, less than 30 years of age. Similarly, in the studies by Singh et al.[5] and Gupta et al.,[7] 79.5% and 75.4% of patients were less than 30 years of age, respectively.

In our study, 84.7% of patients presented in the third trimester and above, and in fact, nine patients (3.8%) reported after 40 weeks. In a similar study by Singh et al.[5] the majority (94.69%) of patients were in the third trimester. This could be because of the fact that pregnant females were avoiding routine antenatal visits due to the fear of contracting covid infection, and visited their treating doctors near term only. As the universal screening of COVID was followed near term, most of these women were detected positive in the third trimester and asymptomatic positive women in early pregnancy were likely to be missed.

A very common association found in our study was the presence of moderate to severe anemia in 35.6% of patients, out of whom 21.9% required one or more blood transfusions. Other co-morbidities seen were mild to severe hypertensive disorders in 17.2%, hypothyroidism in 9.85%, and diabetes in 1.7% of patients. In the study by Singh et al.,[5] hypertensive disorders (13.28%), diabetic disorders (10.15%), and anemia (10.15%) were the most commonly seen co-morbidities. Nayak et al.[6] and Gajbhiye et al.[8] also reported hypertensive and diabetic disorders as the most commonly associated co-morbidities. Although present, the comorbidities were much fewer as compared to the general population affected by the covid infection. This could be another reason for less profound symptoms in the pregnant population.

In our study, 102 patients delivered out of the total 233 covid-positive pregnant patients admitted. From 102 patients who delivered, 39.2% (n = 40) had normal vaginal delivery and 60.8% (n = 62) had caesarean section. The patients who delivered vaginally either came in labor on admission or went in spontaneous labor during the stay. The high rate of cesarean section in our study was comparable to other studies, where 63.93% and 50% cesarean section rate was observed respectively.[5],[6] Few other studies on COVID-19-positive pregnant women also report very high cesarean sections rates, where the majority of LSCS were done in maternal interest, due to concern for respiratory function.[9],[10],[11],[12] However, COVID-19-positive as a sole indication for cesarean section was not followed in our study, and all the cesarean sections were done for obstetric indications only. The reporting of patients with obstetric complications like previous cesarean section, intrauterine growth retardation with oligohydramnios postdated pregnancy, PROM, severe hypertension, and fetal malpresentation supported the fact that patients avoided going to the doctor unless in an emergency due to the fear of Covid infection.

Preterm birth was another significant finding in our study where the incidence of preterm birth was 22.5% (23/102). The majority of these were during the second wave of covid infection (April-May 2021) when covid related symptoms were more pronounced in pregnant females. Spontaneous preterm birth was seen in 16.7% patients (17/102), out of whom, 10 patients had features of fever of varying degrees and other chest symptoms. Preterm cesarean section was done in five patients- three for severe hypertension, one for eclampsia, and one for preterm premature rupture of membranes. One was a diagnosed intrauterine fetal demise at thirty weeks and pregnancy was terminated. Other studies have also reported high rates of preterm births among COVID-19-affected pregnant women ranging from 28.69% to 47%.[5],[12] Although the cause for the high preterm births remains unclear in these studies, the possible correlation could be febrile illness associated with covid-19 symptomatic patients or iatrogenic termination of pregnancy for maternal interest. At present, there is insufficient evidence to determine any correlation between spontaneous preterm labor and COVID-19 infection in pregnancy.

The overall discharge disposition was very good in our study where 98.7% were discharged in healthy condition and there was maternal death in only three patients (1.3%). Out of these, one patient had an obstetric reason for mortality (eclampsia) and two patients came with severe covid related infections, who succumbed in ICU. In the study by Villar et al.,[13] the risk of maternal mortality was1.6%. However, these deaths were seen in institutions that were less developed, suggesting that COVID-19 in pregnancy could be fatal if proper ICU facilities are not available. Reassuringly, they also found that asymptomatic women with COVID-19 diagnosis had similar outcomes to women without COVID-19 diagnosis, except for preeclampsia.[13] In another systematicreview[14] the mortality rate of COVID-19 in pregnant and postpartum women was 1.30%, where all of the patients had a severe covid illness and were admitted to ICU. Unlike the current study, in some studies, the mortality rate of COVID-19-infected pregnant women was not higher than nonpregnant women of reproductive age.[5],[15],[16] This could be because it has been seen that the mortality rate in COVID-19 patients is more in older individuals, whereas the patients presenting during pregnancy are of younger age.


  Conclusions Top


The risk of developing Covid-19 infection and clinical characteristics during pregnancy are the same as in non-pregnant women of the same age, provided similar covid protocols are followed. However, their management in general can get affected due to patients staying away from scheduled antenatal care and also sometimes arriving late to the hospital out of panic of COVID 19. The favorable maternal, fetal, and neonatal outcomes observed in most patients affected by COVID-19 in late pregnancy are very convincing. As the disease is new, long-term follow-up is required to study any residual or delayed effects on the new-born and potential intrauterine vertical transmission.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Alfaraj SH, Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome coronavirus (MERS-CoV) infection during pregnancy: Report of two cases and review of the literature. J Microbiol Immunol Infect 2019;52:501-3.  Back to cited text no. 2
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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



 

 
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