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 Table of Contents 
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 883-892  

COVID-19 in pregnancy: A preliminary 50-day review from India


1 Professor & Head, Department of Obstetrics & Gynecology, Critical Care & Sleep Medicine, New Delhi, India
2 Assistant Professor & COVID-19 Nodal Officer, Department of Obstetrics & Gynecology, Critical Care & Sleep Medicine, New Delhi, India
3 Post Graduate Student, Department of Obstetrics & Gynecology, Critical Care & Sleep Medicine, New Delhi, India
4 HAG & Associate Professor, Department of Obstetrics & Gynecology, Critical Care & Sleep Medicine, New Delhi, India
5 Assistant Professor & COVID-19 Nodal Officer Department of Pulmonary, Critical Care & Sleep Medicine, New Delhi, India
6 Professor & Medical Superintendent, VMMC & Safdarjung Hospital, New Delhi, India

Date of Submission18-Jul-2020
Date of Decision17-Sep-2020
Date of Acceptance04-Oct-2020
Date of Web Publication27-Feb-2021

Correspondence Address:
Dr. Sheeba Marwah
Assistant Professor & COVID-19 Nodal Officer, Department of Obstetrics & Gynecology, VMMC and Safdarjung Hospital, New Delhi - 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1471_20

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  Abstract 


Background: This retrospective review was done to gauge the preliminary experience of COVID-19 in pregnancy during first 50 days of lockdown in a tertiary care hospital of India. Methods: This was a single-centered study, wherein all the suspected women (as defined by ICMR guidelines) who were tested for SARS-CoV 2 infection by nasopharyngeal/oropharyngeal swabs, and rendered to RT-PCR, were included. Parallel evaluation was performed for women in both groups for sociodemographic and obstetric attributes, risk factors, clinical presentation and feto-maternal outcome. Categorical variables were presented in number and percentage. Qualitative variables were equated using Chi-Square test/Fisher's exact test. A P value of < 0.05 was counted as significant. Results: Amongst 112 suspected cases, seven (6.25%) were found to be positive for SARS COV2. Majority of COVID-19 positive women hailed from urban hotspot areas (57.7%) and were un-booked (57.1%). Most were mild cases, and symptomatic (85.7%), with fever (57.1%) being predominant feature in all suspects; no adverse effects seen on pregnancy and fetus, with uneventful postpartum period. Conclusion: No adverse outcome in mother and baby after acquiring SARS-COV2 infection was observed, with maximum cases being mild; fever was the predominant symptom in all suspects, with significantly higher percentage in COVID-19 positives.

Keywords: Clinical features, COVID-19 suspects, feto-maternal outcome, pregnancy, risk factors


How to cite this article:
Arora R, Marwah S, Dhama V, Dabral A, Gupta N, Arora B. COVID-19 in pregnancy: A preliminary 50-day review from India. J Family Med Prim Care 2021;10:883-92

How to cite this URL:
Arora R, Marwah S, Dhama V, Dabral A, Gupta N, Arora B. COVID-19 in pregnancy: A preliminary 50-day review from India. J Family Med Prim Care [serial online] 2021 [cited 2021 Apr 16];10:883-92. Available from: https://www.jfmpc.com/text.asp?2021/10/2/883/310267




  Introduction Top


Coronavirus disease 2019 (COVID-19) is an evolving infectious disease with a precipitous upsurge in cases and deaths, since being originally discovered in China, in December 2019.[1],[2],[3] Even before being declared a pandemic by WHO on 11.3.2020, this disease has been knocking the public health systems, eliciting unparalleled first time processes and actions by leaderships across the world, including lock-downs for putting a ceiling on movement and shelter-in-place directives.[4],[5],[6] India was no different, following reporting of its first case of the COVID-19 on 30 January 2020, where currently nationwide lockdown is in progress. Onlookers assert that though this stringent measure has decelerated the progression of the pandemic in India to the scale of increasing twofold every 6 days, but the phased exit strategy to end it soon forced by fiscal deficit steering resumption of commercial activities, the current infection rate of coronavirus (SARS-CoV2) in India of 1.7 would surely scale heights.[5],[6]

The increasing mortality rate with SARS-CoV2 necessitates recognizing and safeguarding vulnerable populations in society as a crucial constituent in its management. Gravid women are notorious to be inexplicably afflicted by respiratory ailments, with concomitant higher infectious morbidity and maternal mortality rates, owing to the specific cardiorespiratory and immunological changes occurring physiologically in pregnancy.[1],[4],[5] Also, a probable deferment in diagnosis and source control occurs in pregnant women, especially in women with only trivial upper respiratory tract symptoms like soreness and nasal congestion. With already 67,152 confirmed cases, and 2,206 deaths in the country, as on May 10 2020, number of antenatal women harboring SARS-CoV2 in India is also bound to increase with gradual un-lock-down.[7],[8]

Data on COVID-19 in pregnancy so far has been very sparse, with most being small-scale reviews/isolated case reports to comprehensively fathom risks attributable to COVID-19 infection.[1],[5],[6],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] Not many accounts have been narrated in India so far too.[20] In-fact, information on in pregnancy is still in its incipient stage, with plausible repercussions of the virus on mother and fetus still rapidly evolving. Thus, a novel attempt is made to notate the 50-day experience of COVID-19 suspect/positive cases in pregnancy from one of the largest tertiary care health facilities in Northern India, with an objective to appraise the current situation, besides augmenting preparedness of the maternity services for the long haul against this relatively unknown entity. This will also promulgate awareness of SARS-COV2 behavior both in Indian pregnant women, and primary care physicians encountering more antenatal women due to movement restrictions, with respect to fetal and maternal outcome, and clinical characteristics, in order to initiate optimal control measures and effective therapeutic decisions, outlining principles of management guided by multidisciplinary approach, to prevent its adverse upshots and long-term complications.


  Materials and Methods Top


This was a single centered retrospective study over 50 days to gauge and tabulate the preliminary experience of COVID-19 in pregnancy during lockdown from 23rd March-10th May2020, after taking due permission and approval in writing from the Medical Superintendent of the hospital and IEC clearance for conducting the 50 day appraisal. The review was done in accordance meeting the ethical norms, in compliance with the Helsinki Declaration of 1975, as revised in 2000.

All suspect/known COVID-19 positive women who had come to the department of obstetrics & gynecology for their maternity services were included. Suspect and cases were defined as per the existing ICMR guidelines.[23] Suspected women underwent RT PCR for SARS-CoV2 by nasopharyngeal and oropharyngeal swab after taking written informed consent, as per the institutional protocol. COVID-19 positive women were managed as per MOHFW guidelines and hospital SOPs, whereas negatives were given routine antenatal, intrapartum, and postnatal management.[1],[6] Parallel evaluation was performed for women in both groups with regards to sociodemographic and obstetric attributes, risk factors for acquiring COVID-19, clinical presentation and feto-maternal outcome. All data extracted on MS EXCEL spreadsheet, which was reviewed and analyzed using Statistical Package for Social Sciences (SPSS) version 21.0. Categorical variables were presented in number and percentage (%). Qualitative variables were rivaled using Chi-Square test/Fisher's exact test. A P value of <0.05 was counted as significant.


  Results Top


There were total 2013 births during the 50-day study period. In all, 112 suspected/known COVID-19 positive women came to obstetrics and gynecology department of Safdarjung for maternity care. Amongst these, 7 were COVID-19 positive, whereas other 105 came out to be negative, following sampling for SARS-CoV2. Amongst these 7 with corona virus infection, 6 were symptomatic suspects who turned out to be positive on testing, whereas one was known positive referred from another hospital for safe confinement.

Analyzing the sociodemographic and maternal characteristics of study populace, most of them were young, with all COVID-19 positive females being 20-30 years in age (P value = 0.186), hailing from lower socioeconomic strata (P value-.219). Around 57.7% of SARS CoV2 positive pregnant women were residing in urban hotspot areas of Delhi NCR (p of rural vs urban = 0.338/0.518). Maximum (2/3rd) females were Hindus. Around 60 percent of suspects were un-booked with no prior antenatal visits (P = 1). Half of the women were primigravidae, whereas positivity of SARS-CoV2 was seen in multigravidas mainly, though difference was insignificant (P = 0.292). Majority (98/112) of the women presented in third trimester of pregnancy in both groups (P = 0.5). All females with COVID-19 positive pregnancy were high risk women obstetrically, with presence of comorbidities like aplastic anemia, iron deficiency anemia, hypertensive disorders of pregnancy, hypothyroidism, uncontrolled DM, severe FGR.

Scrutinizing the risk factors for acquiring novel coronavirus infection, whilst only one woman gave history of definite close contact (husband) with COVID-19 positive person, three women with exposure to another positive Health care worker within the hospital premises were found negative subsequently on RTPCR assay (P = 0.230). [Table 1]
Table 1: Sociodemographic Factors, obstetrics characteristics and risk factors of study population

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Eighty five percent of COVID-19 positive gestational women were found to have at least one symptom suggestive of viral infection; with fever being the predominant presentation (P = 0.196). However, more than half of women who were negative on viral testing were asymptomatic suspects coming from containment zones without any other risk factor, when compared to asymptomatic positive (P = 0.045) [Table 2]
Table 2: Clinical presentation of the study population

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Amongst the women with active novel corona virus infection, 3 stayed undelivered at the end of this preliminary review (P = 0.026). Remaining four delivered live born babies, two by LSCS (failed induction; previous LSCS with gestational hypertension with impending rupture). In contrast, women who were negative for COVID-19, 7 underwent evacuation (including one molar pregnancy at 24 weeks POG), two were operated (laparotomy and proceed) for ruptured ectopic pregnancy, 74 delivered vaginally (with one patient having a preterm MSB baby) (P = 0.034); remaining 21 percent women underwent LSCS. Fortunately, all 4 COVID-19 positive parturient had relatively uneventful postnatal period. None of the suspects required ICU admission. Only one amongst the 4 live born babies was low birth weight (P = .234) All had good Apgar scores, with no early neonatal death. Upon COVID-19 testing of newborns, two babies tested positive (day 3) for SARS-CoV2 [Table 3].
Table 3: Feto-maternal Outcome of the study population

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  Discussion Top


An initial attempt was made over first fifty days, to review the effects of SARS-CoV2 infection on pregnancy in the extant study including all suspect/confirmed positive pregnant women for the first time in India. Seven women came to be COVID-19 positive. This can be attributed to stringent lockdown guidelines, restricting movement of patients, limited availability of testing kits in early days in India, causing less liberal testing protocols for pregnant women. Sampling of pregnant women gained momentum after issuing of ICMR guidelines of testing asymptomatic women residing in hotspots/evacuee camps/containment zones.[19]

[Table 4] depicts a comparative evaluation of studies done by past pollsters till date on COVID-19 in pregnancy, across the world, with the findings of present study.
Table 4: Comparative evaluation of present study with published reports of COVID-19 in pregnancy

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As opposed to previous systematic reviews, a relatively younger age (mean age = 27 years) in women in this analysis reverberates the concept of early age at marriage and conception prevalent in India.[1],[9],[10],[11],[12],[21],[22]

Just like most of the respiratory infections, sociodemographic factors play a vital role in transmission of this unique COVID-19 in pregnancy, as indicated by most of the study population belonging to lower socio-economic status. This is boosted by the fact that most of the antenatal women (confirmed cases or negative) were residing in areas declared as hotspots/containment areas for COVID-19 by Government of India to map the local transmission of the disease and prevent the contagion from dissemination.[6] It also emphasizes this consortium of women endorse most of the infectious morbidity, which can be further ascribed to poverty, illiteracy, poor sanitation, inadequate shelter and overcrowding in most of the families.[24],[25] This factor has not been examined by any investigators till date. It forms the basis of the notion of social distancing and practicing hand hygiene by all as a cornerstone to curtail the spread of SARS-CoV2, as advocated by WHO, and MOHFW guidelines in India.[4],[8]

Also, majority of women were un-booked, with no previous antenatal visits, which can be explained by the poor attitude of these women for seeking timely antenatal care, coming only at term or in labor for maternity services. Therefore, unlike other types of coronavirus infection (SARS, MERS), there was not much disparity in both groups in relation to trimester of pregnancy.[9],[10],[11] Safdarjung hospital, being the largest tertiary care center in Northern India, serves as the referral health facility for numerous nursing homes and hospitals of public and private sector across the North India. As such, all confirmed SARS CoV2 positive women in the present study, were high risk pregnancies having associated comorbidities, contributing towards making them even more susceptible to acquire the viral infection. In-fact the only known positive, asymptomatic COVID-19 women included was also a referral from another smaller non-COVID facility for further management. Ethnic variation in gestation age of babies holds true with mean gestational age of our women being 256 days, when opposed to the current available western data.[1],[25],[26],[27]

History of exposure to people with symptoms of COVID-19, coming from hot spot areas and women with Immunocompromised conditions/immunosuppressive drugs are those who are most prone for COVID-19 in pregnancy.[1],[2],[3],[9],[10],[11],[12],[26] A Meticulous breakdown of risk factors in the present study revealed a positive history of contact/exposure only in 4 cases, amongst which the only one with prolonged close contact (spouse) was COVID-19 positive. The other three had exposure of smaller duration at a distance to health care worker (using adequate PPE), averting them from acquiring SARS-CoV2. This emphasizes the need for use of mask and for following respiratory etiquettes by all, including patients, besides practicing social distancing to break the chain of coronavirus spread.

No significant difference was observed in symptomatology in women of both groups, with fever followed by dry cough being the most common clinical presentation.[9],[10],[11],[12] This is in accordance with noteworthy reviews on COVID-19 in pregnancy.[10],[11],[12] Other symptoms were less consistent in COVID-19 positive women. Hence, obstetricians and midwives at Prenatal clinics across various health facilities, should be directed to ascertain all pregnant women and their aides (as feasible) be scrutinized for increased temperature, and respirational signs; and all symptomatic must be isolated from others, with directives to wear a mask at all times.

Though case reports/series published so far have described mostly cesarean section as mode of delivery for gestational women, amongst the delivered women with COVID-19 positive status in the present research, LSCS was done only for obstetric indications.[17],[18] This is endorsed by the national guidelines, in absence of evidence favoring one mode of birth over another.[28],[29] But when contrasted with suspects who tested negative for SARS-CoV2, this uneven delivery bias towards LSCS can be attributed to lesser no of COVID-19 positive cases. Further continued longitudinal review for the same, with increasing number of COVID-19 positive parturient, would be able to give a better grasp on the effect on mode of delivery, if any.[6],[7],[8],[9],[10],[11],[12],[13],[15]

In line with most of the previous investigations, findings of this study also highlighted less virulence of SARS-CoV2, with respect to adverse effects in pregnancy and fetus. But these observations were in strike contrast with conclusions drawn by Mascio et al., Allott et al. or Khalul et al., that COVID-19 was allied with moderately greater preterm births, preeclampsia, other maternal morbidity and perinatal death That may be due to earlier gestational age upon acquiring SARS-CoV2, heterogeneity in clinical presentation and perinatal management amongst the included cases in that review.[6] All 4 live born neonates were healthy with good APGAR scores, with only two of them testing positive for infection, during the course of hospital stay. But vertical transmission cannot be commented upon accurately in these cases, since the mothers' reports were delayed, and received postpartum due to logistical challenges in these early days of COVID-19 in India. As per hospital norms, rooming in was practiced, and babies' breast fed; this could also have led to babies getting infected. However in subsequent analysis, both became negative. Ideally, if symptomatic, separation from mother should be done, But since benefits of breast feeding outweigh risks of transmitting SARS-CoV2 due to close contact, we recommend rooming in.[2],[17],[18] However, COVID-19 positive mothers must wear mask, and practice hand hygiene before each feed, maintaining 6 m distance when not feeding.

Strengths and limitations of this preliminary review

The fortes of this initial review of suspected women undergoing COVID-19 testing during pregnancy and further analysis, was an unfiltered biggest first-hand account of SARS- CoV2 antenatal cases in India till date, and managing confirmed cases after establishing a separate nearly ideal dedicated COVID-19 facility ; besides enthused and well-trained clinicians, along with much needed support from hospital administration. It has been a learning experience for all obstetricians involved in dispensing care to these women. Also, completeness and accuracy in data collection, with a predefined methodology, rules out selective reporting bias. This has provided much enhanced quality conclusions to be drawn unlike previous isolated case reports/series from other countries.

However, a smaller incidence of COVID-19 positive amongst suspects is just a tip of iceberg to actual incidence of SARS-CoV2 in pregnancy. This is in line with the current movement restrictions applied all over the region, where most of the women are not being able to report to hospital, unless indicated. Also, absence of widespread availability of cost-effective testing facilities across the nation prevents universal testing in pregnant women to avert morbidity and mortality in them.


  Conclusion and Recommendations Top


To summarize, 7 (6.25%) were positive for SARS-COV2; Majority women hailed from urban hotspot areas (57.7%) and were un-booked (57.1%). Most were mild cases, and symptomatic (85.7%), with fever (57.1%) being the predominant feature; with no adverse effects on pregnancy and fetus; vertical transmission cannot be ruled out at this initial stage.

The findings of the present study describe not much altered outcome in mother and baby after acquiring SARS-CoV2 infection, when parallel evaluation of confirmed positive was done with negatives; though almost all confirmed cases had preexisting comorbidities, posing a higher risk to their pregnancy. Leveraging this existing longitudinal pregnancy surveillance to seize quantifiable information for COVID-19, especially involving multiple centers across India, could help to facilitate rapid collaborative data collection across the nation for public health action, specifically on pregnancy outcome in early gestation, vertical transmission, and neonatal upshots. Also various strategies to tackle knowledge interludes encompassing the effect of COVID-19 in pregnancy ought to be deployed or instituted, including sentinel reconnaissance, sero-prevalence surveys, and socio-behavioral and psychosomatic exploration, involving participation of both public and private sector. Also, in light of rapidly evolving evidence, guidelines need to be modified accordingly, tailored to local needs of patients. Adept preparedness in terms of training of doctors and health care workers becomes the need of the hour for even smaller centers in low resource settings in India.

Besides the successful mantra to circumvent the chain of transmission of this SARS-Cov2 pathogen, and its deleterious effects remain implementation of preventive measures like regular hand hygiene, maintaining social distancing, following respiratory etiquettes, staying at home and disinfecting contaminated surfaces; for all this educational materials can also be developed and distributed.

Acknowledgements

We express heartfelt gratitude to Dr Rajiv Garg, 7Director General Health Services at Ministry of Health and Family welfare of India for all the support and guidance for setting up of COVID 19 dedicated facility at our hospital, besides inspiring us to report this initial experience of 50 days. Also we are thankful to all the suspected pregnant women included who fought the battle against COVID-19, and went through the ordeal, apart from the stressful process of parturition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None required

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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



 

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