|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 101-107 |
|
A prospective cohort study to evaluate the outcome of COVID-19 infection in pregnant women in a tertiary care hospital
Mili D Choudhury1, Sivaji S Ghose2, GD Maiti1
1 Department of Obstetrics and Gynaecology, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Surgery, INHS Asvini, Mumbai, Maharashtra, India
| Date of Submission | 04-Feb-2022 |
| Date of Decision | 22-May-2022 |
| Date of Acceptance | 13-Jun-2022 |
| Date of Web Publication | 23-Dec-2022 |
Correspondence Address:
Sivaji S Ghose
Department of Surgery, INHS Asvini, Mumbai - 400 005, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_8_22
Background: Worldwide COVID-19 infection has played havoc. The number of COVID-positive pregnant cases in this study was not far behind the National average. The present study was conducted to evaluate the outcome of COVID-19 infection in pregnant women during their antenatal, intrapartum, and postnatal periods.
Methodology: The study design was a prospective cohort study. The total number of COVID-19 pregnant patients admitted to this tertiary care hospital from March 2020 to June 2021 was 106 cases at various trimesters. This hospital caters to serving personnel, ex-servicemen, and dependents of the Indian Armed Forces. The community being studied were only the dependents and the serving female personnel. Proper history, presenting complaints, period of gestation, obstetric and systemic examination findings, the severity of symptoms, home isolation or hospital stay, and treatment were all recorded in the form of the questionnaire. Finally, the antenatal, intrapartum, postnatal, and neonatal outcomes of these COVID-positive pregnant patients were compiled and studied.
Results: The prevalence of COVID-positive pregnant women in the community being studied was 9.9%. About 43.39% of the cases were diagnosed in the third trimester. Ninety-three percent of the patients in the present study were asymptomatic or with very mild symptoms. The mode of delivery in the present study was mostly by cesarean section (69.56%).
Conclusion: In the present study, pregnancy-associated complications were within the range of 2.8%–3% and only two newborns were COVID positive.
Keywords: Community, comorbidities, COVID19, IUGR, mortality, neonates, prematurity, recurrence
How to cite this article:
Choudhury MD, Ghose SS, Maiti G D. A prospective cohort study to evaluate the outcome of COVID-19 infection in pregnant women in a tertiary care hospital. J Curr Res Sci Med 2022;8:101-7 |
How to cite this URL:
Choudhury MD, Ghose SS, Maiti G D. A prospective cohort study to evaluate the outcome of COVID-19 infection in pregnant women in a tertiary care hospital. J Curr Res Sci Med [serial online] 2022 [cited 2023 Mar 31];8:101-7. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/101/364506 |
| Introduction | |  |
The WHO was alerted on December 31, 2019, by Chinese authorities of a series of pneumonia-like cases in the city of Wuhan. The Chinese Centre for Disease Control and Prevention identified this infection as a coronavirus infection on January 7, 2020. On February 11, 2020, the WHO announced a new name for the pandemic disease “2019 new coronavirus disease.”[1] COVID-19 has played havoc worldwide and by March 2020, many countries have reported positive cases of infection.[2] It has been a rapidly evolving situation and there is limited data regarding its impact on pregnant women. Data from Middle East respiratory syndrome coronavirus and severe acute respiratory syndrome coronavirus indicated that infection in pregnancy tends to be severe and associated with adverse neonatal outcomes including miscarriages, fetal growth restriction, and preterm birth.[3] Data from the UK of more than 400 pregnant patients hospitalized with COVID-19 infection suggested that there is increased potential for adverse maternal outcomes in pregnant patients while the risk of intrauterine vertical transmission is inconclusive. The study aimed to provide additional emerging information after evaluating the outcome of COVID-19 infection in pregnant women during their antenatal, intrapartum, and postnatal periods. The majority of pregnant patients with COVID-19 infection presented with a mild or asymptomatic course of the disease. Some cases were hospitalized and a few needed intensive care unit (ICU) admission and mechanical ventilation. This study was designed to provide more evidence regarding the outcome in pregnant ladies and neonates.
Aim
To evaluate the outcome of COVID-19 infection in pregnant women and neonates during the pandemic.
Objectives
The present study was intended:
- To evaluate the outcome of COVID-19 infection in pregnant women during their antenatal, intrapartum and postnatal periods
- To evaluate the outcome in neonates.
| Materials and Methods | | |
A prospective cohort study was conducted at a tertiary care hospital, which caters for serving personnel, ex-servicemen, and dependents of the Indian Armed Forces. The average annual birth rate of this hospital is 1080 per annum. The Obstetrics and Gynecology department of this hospital provides tertiary healthcare to the dependents as well as female serving personnel. All pregnant women with COVID19 infection diagnosed by reverse transcription–polymerase chain reaction (RT-PCR) or by chip-based, battery-operated rapid molecular test (TrueNat) over 18 months from March 2020 to August 2021 were included in this study. The questionnaire-based data had been collected prospectively. The total COVID19 patients admitted to this hospital during the study period was 1100. The monthly average was 100–150 patients. Of which pregnant ladies at various trimesters were 8–10 per month. In these months, there were a total of 106 COVID-positive pregnant patients at various trimesters and of which 46 patients were at term. Peak incidence was in May–August 2020, followed by a plateau in the number of cases. From April to June 2021, there was a second peak. The International Federation of Gynecology and Obstetrics has provided guidelines to manage pregnant women with COVID-19 infection in four main settings, which is by ambulatory antenatal care in outpatient clinics, obstetrics triaging, intrapartum and postpartum management. The recommendations provided by The Indian Council of Medical Research (ICMR)[4] are similar and were followed in the present study. Permission from the Institutional Ethical Committee (approval number DGAFMS/DG3B letter no 15965/58th/9/2022) was obtained for this study.
All pregnant women who were positive for COVID-19 infection at any week of gestation attending the obstetrics and gynecology outpatient department, labor room, and acute respiratory infection clinic of this tertiary care hospital and who met the inclusion criteria were included in the present study.
Inclusion criteria
COVID19-positive pregnant women between 18 and 40 years, booked cases, singleton or multiple pregnancies, pregnancy in any trimester, comorbidities such as diabetes mellitus, anemia, hypertension, liver diseases, and thyroid disorders were included.
Exclusion criteria
Women <18 years, women with preexisting cardiac disorders such as congenital heart disease, rheumatic heart disease, stroke, intrauterine infection, congenital anomalies of the fetus detected by anomaly scan by the radiologist before COVID-19 infection.
Any pregnant patient needing admission was tested by RT-PCR, True NAT or by Gene expert method and was kept in isolation. Patients who tested negative were shifted to the clean zone and if positive were shifted to the COVID ward, COVID labor room or ICU depending on the severity of the COVID symptoms, the period of gestation, and stage of labor. An informed consent, demographic and clinical history for each patient were collected. Study participants were assessed for clinical symptoms of COVID19 infection such as shortness of breath, cough, fever, diarrhea, headache, body ache, and malaise. Usual antenatal care was provided by the gynecologist in a personal protective equipment kit and the patients were made to wear N95 masks as per the guidelines. The COVID-positive patients were managed by a team of health professionals (medical specialists, respiratory physicians, cardiologists, and anesthetists). The patients were categorized into three groups (mild, moderate, and severe) depending on the severity of the disease.
Study participants were assessed regularly for weight gain, pulse rate, respiratory rate, temperature, blood pressure, SPO2, complete blood count, blood sugar, blood urea, serum creatinine, uric acid, liver function test, serum lactate dehydrogenase, C-reactive protein, D dimer, Neutrophil: lymphocyte ratio. Once recruited in the study, fetal monitoring was done by daily fetal movement count and fetal heart rate monitoring. Weekly ultrasonography was done for fetal biometry, amniotic fluid index, and biophysical profile for the patients who were in the third trimester of pregnancy. Doppler study was done only in indicated cases such as growth retardation and preeclampsia.
Finally, the age of the patients, clinical symptoms related to COVID19 infection, ICU stay if any, mechanical ventilation, extracorporeal membrane oxygenation, comorbidities such as diabetes mellitus, asthma, preeclampsia, thyroid disorder, liver disorder, coagulation disorder, gestational age, an antenatal outcome such as threatened abortion, missed abortion, inevitable abortion, and preterm labor were recorded and compiled. The intrapartum outcome in the form of mode of delivery, indication for operative delivery, duration of labor, fetal heart rate abnormalities, meconium-stained liquor, postpartum hemorrhage (PPH), and thromboembolism were recorded. In neonates, Apgar scores, need for resuscitation, neonatal intensive care unit (NICU) stay, seizures, and neonatal encephalopathy if any were recorded. Neonatal nasopharyngeal swabs were sent within 24 hours and rooming-in was recommended. Immediate breastfeeding was encouraged in these patients.
| Results | | |
The prevalence of COVID-positive pregnant women in the present study is 9.9% [Figure 1]. In our study 46 cases (43.39%) were diagnosed at the third trimester, 39 cases (36.79%) at the second trimester and 21 cases (19.8%) were at the first trimester. In this study, 93% of the patients were asymptomatic or with very mild symptoms [Figure 2].
Management protocol:
- Home isolation: 37
- Hospitalization: 69
- ICU management: 04
- Oxygen support: 19
- Ventilation: 02.
Only 34.9% patient were kept in home isolation in the present study and rest all were admitted [Figure 3] and [Figure 4].
In the present study, 12 cases (11%) had abortions mostly missed and incomplete abortions. There were three cases (2.8%) of preeclampsia and 1 case of pulmonary embolism, 7 cases had emesis, 2.8% had preterm labor, 2.8% had growth retardation, and 1.8% had premature rupture of membrane (PROM) [Figure 5].
43.39% of the COVID19-positive patients were with comorbidities mostly thyroid disorders and diabetes mellitus [Figure 3].
Intrapartum outcome included mode of delivery was by cesarean section in 69.56% of cases (21 Elective and 11 Emergency LSCS) and vaginal birth in 30% of cases (14 cases), [Figure 6]. The obstetric indications of cesarean sections done were duration of labor less than 4 h, fetal heart rate abnormalities (02), meconium-stained liquor (01), PPH (01) and thromboembolism (01). [Table 1] shows the management of mild, moderate and severe Covid positive cases.
In the present study, there were no cases of sepsis, secondary PPH, or maternal mortality.
In the present study, only two neonates (4%) were COVID-positive and only 15% needed resuscitation and NICU stay due to prematurity, and meconium-stained liquor [Figure 7].
| Discussion | | |
Viral infection can pose serious consequences on maternal and neonatal health.[5] To date, studies in pregnant women with COVID-19 have shown few maternal and neonatal complications.
The prevalence of COVID 19 infection in this tertiary care hospital was 9.9% which is comparable to the prevalence shown in a study update conducted at the University of Birmingham,[6] which is 9% and that at Lokmanya Tilak Medical College, Mumbai which showed the prevalence of 14.43%,[7] Prevalence of the disease in our hospital was less than the prevalence at Lokmanya Tilak medical college because our hospital caters for only the serving population, ex-servicemen and their dependents.
Liu et al. reported that most pregnant women acquired the disease in the third trimester of pregnancy,[5] but in our study, 43.39%of the cases were diagnosed in the third trimester, 36.79% in the second trimester and 19.8% of the cases in the first trimester.
In the present study, 12 cases had abortions (missed and incomplete abortions). A prospective comparative study showed that 10.3% of the cases in the first trimester had greater obstetrical outcomes mainly abortions.[8] Our study has provided a similar result. All the patients who underwent abortions in our study had no other comorbidities such as hypertension, diabetes mellitus, and thyroid disorders. However, the placenta and the product of conceptus showed deposition of fibrin and villus infarcts at multiple sites on histopathological examination. Evidence of inflammation was also observed in a few of the cases. High fever, immune response, and thromboembolic phenomenon may have contributed to these sequelae.
There were 2.8% of cases of preeclampsia and 0.94% of cases of pulmonary embolism, 6.6% cases had emesis, 2.8% had preterm labor, 2.8% had intrauterine growth retardation and 1.8% had PROM. The three cases who had preeclampsia had moderate-to-severe COVID symptoms. Moreover, the patients with intrauterine growth retardation and PROM had a high fever. The InterCOVID multinational cohort study[9] and a national retrospective cohort study in France[10] showed a similar result. Women with COVID19 infection were at higher risk for preeclampsia/eclampsia (relative risk [RR] 1.76; 95% confidence interval [CI], 1.27–2.43) and preterm birth (RR, 1.59; 95% CI, 2.88–1.72). Guidelines on the operationalization of maternal health services during the COVID-19 pandemic[11] showed more chances of preterm delivery and an increased risk of maternal death and ICU admission in COVID-positive pregnant cases.
In our study, 93% of the patients were asymptomatic or with very mild symptoms and only 3.7% had severe disease of which three were diabetic and one had hypertensive disorders of pregnancy. The results are similar to the findings of ICMR guidelines for the management of pregnant women in COVID-19.[11] The adverse pregnancy outcome was higher, especially among those with associated diseases such as preeclampsia or other complications because respiratory syndrome may increase pulmonary edema and decrease oxygen saturation.[12] Even though pregnant women are not likely at greater risk to contract the infection more than the general population, pregnancy itself alters the immune system and the response to viral infection can produce more severe symptoms.
Royal College of Obstetricians and Gynecologists guidelines emphasized the risk of venous thromboembolism in pregnancy. In our study, all the cases with moderate and severe symptoms were treated with Inj low molecular weight heparin in different doses.
In the present study, the cesarean section rate was 69.56% and only 30% had a vaginal delivery. A review on the mode of delivery stated that 68.9% of the cases were delivered by cesarean section with COVID-19 status alone being a common indication.[13] Similar results were provided by a systematic review reported by Nayak et al.[14] The ICMR guidelines for the management of pregnant women in the COVID-19 pandemic stated that the mode of delivery should not be influenced by COVID-19 unless the respiratory condition demands urgent delivery.[7] The reasons for the higher rate of caesarian sections in the present study is the fear, anxiety, and limited knowledge about the disease progression among the health care professionals and the patients.
Initial screening, isolation, prioritization of the cases depending on symptoms and the period of gestation, obstetric management, and following the preventive measures both by the health-care providers and the patients can decrease the outbreak of the disease and thus can provide a favorable maternal and neonatal outcome.
In the present study, 34.9% of patients were kept in home isolation and the rest all were admitted.
There were no cases of sepsis, secondary PPH, or maternal mortality. There is no evidence currently available to confirm the vertical transmission or transfer through breast milk.[15] Immediate breastfeeding was encouraged in all our postnatal patients. Studies have shown no risk of perinatal vertical transmission and intrauterine vertical transmission in the second and third trimesters.
In the present study, only two neonates(4%) were COVID positive. Only 15% of the newborns needed resuscitation and NICU stay which was due to prematurity, meconium-stained liquor. Only 2 out of 46 delivered newborns had COVID19-positive swab test reports.
Limitations
The study was restricted to the Armed forces community of a single tertiary care hospital. The study population was limited and the study period was for 18 months only. We could not confirm that all the newborns admitted to NICU required critical care due to COVID-19 infection only and the reason for preterm birth remained unclear.
| Conclusion | | |
By March 2020, many countries started reporting COVID-positive cases. It was a rapidly evolving situation and there was limited data regarding its impact on pregnant women. The study aimed to provide additional emerging information after evaluating the outcome of COVID-19 infection in pregnant women. In the present study, most of the COVID-positive pregnant patients were asymptomatic or with mild illness (93%) and only 3.7% had severe disease of which 3 were diabetic and 1 had hypertensive disorders of pregnancy. The present study showed that 11% of abortions were mostly missed and incomplete abortions. There were 2.8% cases of preeclampsia. The rate of preterm delivery and premature rupture of the membrane in the present study was 1.8%–3%. There was only one case of pulmonary embolism in the present study. The mode of delivery in the present study was mostly by cesarean section (69.56%) and was slightly higher as compared to the available data to date. There were no cases of sepsis, secondary PPH or maternal mortality in the present study. Only two neonates were COVID positive, and hence vertical transmission cannot be justified. The present study supports the view that COVID-19 infection in pregnancy may result in adverse pregnancy outcomes both in the antenatal and postnatal period.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  |
| 2. | |
| 3. | Al-Tawfiq JA. Middle East respiratory syndrome coronavirus (MERS-CoV) and COVID-19 infection during pregnancy. Travel Med Infect Dis 2020;36:101641. |
| 4. | Indian Council of Medical Research. Guidance for Management of Pregnant Women in COVID-19 Pandemic. India: ICMR; 2020. Available from: https://www.icmr.gov.in. [Last accessed on 2020 Apr 12]. |
| 5. | Liu H, Liu F, Li J, Zhang T, Wang D, Lan W. Clinical and CT imaging features of the COVID-19 pneumonia: Focus on pregnant women and children. J Infect 2020;80:e7-13. |
| 6. | |
| 7. | Nayak AH, Kapote DS, Fonseca M, Chavan N, Mayekar R, Sarmalkar M, et al. Impact of the coronavirus infection in pregnancy: A preliminary study of 141 patients. J Obstet Gynaecol India 2020;70:256-61. |
| 8. | Cosma S, Carosso AR, Cusato J, Borella F, Bertero L, Bovetti M, et al. Obstetric and neonatal outcomes after SARS-CoV-2 infection in the first trimester of pregnancy: A prospective comparative study. J Obstet Gynaecol Res 2022;48:393-401. |
| 9. | Villar J, Ariff S, Gunier RB, Thiruvengadam R, Rauch S, Kholin A, et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: The INTERCOVID multinational cohort study. JAMA Pediatr 2021;175:817-26. |
| 10. | Epelboin S, Labrosse J, De Mouzon J, Fauque P, Gervoise-Boyer MJ, Levy R, et al. Obstetrical outcomes and maternal morbidities associated with COVID-19 in pregnant women in France: A national retrospective cohort study. PLoS Med 2021;18:e1003857. |
| 11. | Guidelines on the Operationalization of Maternal Health Services during COVID 19 Pandemic: Maternal Health Division; Ministry of Health& Family Welfare; September, 2021. |
| 12. | Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;395:809-15. |
| 13. | Debrabandere ML, Farabaugh DC, Giordano C. A review on mode of delivery during COVID-19 between December 2019 and April 2020. Am J Perinatol 2021;38:332-41. |
| 14. | Cai J, Tang M, Gao Y, Zhang H, Yang Y, Zhang D, et al. Cesarean section or vaginal delivery to prevent possible vertical transmission from a pregnant mother confirmed with COVID-19 to a neonate: A systematic review. Front Med (Lausanne) 2021;8:634949. |
| 15. | Khoiwal K, Kapur D, Gaurav A, Chaturvedi J. Management of pregnant women in times of Covid-19: A review of current literature. J Obstet Gynaecol India 2020;70:262-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1]
|
Search Pubmed for