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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 164-171

Characteristics and outcomes of pregnant women with confirmed COVID-19 infection posted for cesarean section. A retrospective, Cohort study


Department of Anaesthesia, Sri Venkateswara Medical College (SVMC), Chittor, Andhra Pradesh, India

Date of Submission08-Mar-2021
Date of Acceptance18-Jun-2021
Date of Web Publication17-Mar-2022

Correspondence Address:
Dr. K G Sreehari
Assistant professor, Department of Anaesthesia, Sri Venkateswara Medical College (SVMC), Tirupati, Chittor - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_30_21

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  Abstract 


Background and Aim of the Study: Clinical and epidemiological features of COVID-19 infection have been widely reported. However, clinical studies on maternal and neonatal outcomes of pregnant women with COVID-19 infection remain sparse. The aim of this study was to describe the characteristics and outcome of pregnant women with confirmed COVID-19 infection posted for cesarean section.
Objectives: To describe demographic and clinical characteristics of pregnant women with confirmed COVID-19 infection. To analyze the data regarding indications for cesarean section, type of anesthesia administered, and incidence of perioperative complications. To document and analyze the data regarding maternal and neonatal outcomes.
Method: Study Design: A cohort retrospective study was conducted in the Department of Anesthesiology, Institute of pregnant woman (IPW), Sri Venkateswara Medical College (SVMC), Tirupati. Retrospective review of medical records of pregnant women with confirmed COVID-19 infection posted for cesarean section admitted in IPW/SVMC, tertiary care teaching hospital in Tirupati during May 2020 to January 2021 (9 months) was done, and the data regarding maternal demographic and clinical characteristics, type of anesthesia administered, the incidence of perioperative complications, and outcomes were collected and analyzed.
Results: A total of 197 patients had undergone cesarean section in our IPW/SVMC, tertiary care Teaching Hospital, Tirupati, AP, INDIA. Most of the women werere aged in the range of 20 to 30 years – 138 cases (70%). A total of 104 pregnant women (52%) were without co-morbidities. A total of 163 pregnant women (83%) were asymptomatic on admission. Most of the cesarean births occurred for indications other than maternal compromise due to COVID-19 infection. A total of 186 women (94%) gave birth at term and 5% gave birth at preterm. Outcomes of pregnant women with confirmed COVID-19 infection posted for cesarean section are as follows: the number of live births (including twins) was 197 (99%), 1 case of IUD, and 1 stillbirth occurred (1%). Out of 197 live births, 180 neonates (91%) were born with a birth weight of more than 2.5 kg, and 8% of them were low birth weight (< 2.5 kg) babies. Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score at 1 min and 5 min after birth (mean ± SD) were 9 ± 0. 5 and 10 ± 0.0, respectively. The type of anesthesia administered was spinal anesthesia in all the cases (100%), and there was no significant incidence of perioperative complications when compared to the general population. Most of the pregnant women were discharged well to home (n = 196), one patient needed COVID- ICU admission, and one patient died due to acute respiratory failure. Most of the neonates were discharged well to home.
Conclusion: Most of the pregnant women with confirmed COVID-19 infection posted for cesarean section do not have severe illness, and there is no significant maternal morbidity and mortality related to SARS-CoV-2 (COVID-19) infection. Spinal anesthesia is the safest anesthesia procedure in pregnant women with confirmed COVID-19 infection posted for caesarean section.

Keywords: COVID-19, neonatal outcome, pregnant women, spinal anesthesia


How to cite this article:
Sreehari K G, Jamuna T, Balasubramanyam V, Ramesh M N, Yedoti VK, Radha J. Characteristics and outcomes of pregnant women with confirmed COVID-19 infection posted for cesarean section. A retrospective, Cohort study. J NTR Univ Health Sci 2021;10:164-71

How to cite this URL:
Sreehari K G, Jamuna T, Balasubramanyam V, Ramesh M N, Yedoti VK, Radha J. Characteristics and outcomes of pregnant women with confirmed COVID-19 infection posted for cesarean section. A retrospective, Cohort study. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Nov 30];10:164-71. Available from: https://www.jdrntruhs.org/text.asp?2021/10/3/164/339804




  Introduction Top


The W.H.O declared coronavirus disease 2019 (COVID- 19) a global pandemic. The disease is caused by the severe acute respiratory syndrome coronavirus (SARS -CoV-2) in March 2020.[1] As the number of confirmed cases increases, evidence of the transmission, incidence, and effect of COVID-19 infection in mothers and their babies remains limited. Pregnant women are not thought to be more susceptible to infection than the general population. [2,3] However, changes to the immune system mean that pregnant women may be more vulnerable to severe infection.[4] Evidence from other similar viral illnesses, such as influence A/H1,[5],[6],[7],[8] severe acute respiratory syndrome (SARS),[9] and middle east respiratory syndrome (MERS), [10,11] suggests that pregnant women are at a greater risk of severe maternal and neonatal morbidity and mortality.

The epidemiological data in China have shown that most cases have mild symptoms, with an overall case fatality rate of 2.3%. Although SARS-CoV-2 appears to be less virulent than the previous two zoonotic corona viruses, SARS-CoV and MERS-CoV, it is far more efficient in transmission among close contacts. Clinical and epidemiological features of COVID-19 infection have been widely reported. However, clinical studies on maternal and neonatal outcomes of pregnant women with SARS- CoV 2 infection remain sparse.


  Methodology Top


Study Design: A cohort retrospective study. The cohort consisted of pregnant woman with confirmed COVID-19 infection and posted for cesarean section from May 2020 to January 2021 (9 months duration). The study was conducted in the Department of Anesthesiology, Institute of pregnant woman, Sri Venkateswara Medical College (SVMC), Tirupati, Andhra Pradesh, INDIA.

Inclusion criteria

  1. Pregnant women aged between 20 and 40 years.
  2. Pregnant women with confirmed COVID-19 infection by positive reverse transcription-polymerase chain reaction (RTPCR) tests and posted for cesarean section from May 2020 to January 2021 (9 months).


Exclusion criteria

Pregnant women with confirmed COVID-19 infection who had undergone normal vaginal delivery.

After obtaining institutional ethical committee (IEC) approval, we retrospectively reviewed medical records of pregnant women with confirmed COVID-19 infection posted for cesarean section admitted in IPW/SVMC, tertiary care teaching hospital in Tirupati, during the period of May 2020 to January 2021.

For the purpose of this study, we defined confirmed maternal infection as detection of viral RNA on RTPCR of throat/nasopharyngeal swab. During our study period, due to limited resources, neonates were tested only if they had symptoms or who needed admission in NICU for COVID-19 infection. We defined neonatal infection as detection of the viral RNA on polymerase chain reaction testing of blood/nasopharyngeal swab or aspirate.

To reduce the contact transmission, all COVID-19-positive pregnant women were immediately moved to the isolation ward (COVID ward) after diagnosis. Pregnant women posted for cesarean section were admitted in two dedicated COVID operation theaters (OT) in our hospital. All health care workers in close contact strictly adhered to contact and airborne precautions in addition to standard precautions. In our institute, we had taken the following perioperative precautions.

Perioperative anesthesia care

Regional anesthesia is the safest anesthesia technique for cesarean section because it is not an aerosol-generating procedure (AGP), which significantly decreases the risk of coronavirus transmission to the attending OT staff.

PERSONAL PROTECTION EQUIPMENT (PPE):

Wearing the PPE correctly will protect the health care workers from contamination. Before wearing the PPE, proper hand hygiene should be performed.

STEPS OF DONNING:

  1. The gown should be donned first
  2. The mask and respirator should be kept next and adjusted to fit.
  3. Goggles or face shields should be donned next.
  4. Gloves are donned last.


STEPS OF DOFFING:

The removal of PPE is a critical and important step that needs to be carefully carried out in order to avoid self-contamination because the PPE could by now be contaminated.

  1. The gloves are removed first, because they are a heavily contaminated item, after the removal of the gloves, hand hygiene should be performed, and a new pair of gloves should be worn to further continue the doffing procedure.
  2. After the removal of the gown, goggles should be removed.
  3. Mask/respirator should be removed.
  4. New pair of gloves that were worn should be removed at last and disposed of in a biohazard bin.
  5. Followed by proper hand hygiene.


After preanesthetic checkup, all patients received antibiotic prophylaxis 1 h before the surgery. All pregnant patients are provided with surgical masks in the perioperative period.

Standard monitoring was done with electrocardiography (ECG), saturated oxygen (SPO2), and noninvasive blood pressure (NIBP). An 18-gauge IV cannula was secured.

Under strict aseptic precautions, 7.5 to 10 mg of 0.5% hyperbaric bupivacaine was given intrathecally in the L3–L4 space or L4–L5 space with 23 G/25 G Quincke's spinal needle.

After the delivery of the baby, all patients received 10 to 15 IU oxytocin IV infusion in 500 mL normal saline for a period of 1 to 2 h. Hemodynamic monitoring was done intraoperatively and postoperatively for 24 h in recovery room.

To reduce contact transmission, all the COVID-19 patients were immediately shifted to isolation wards after cesarean delivery, and their newborns were cared for by other family members. Postnatal management of infants born to mothers with COVID-19 infection was to keep mother and infant together to encourage early breastfeeding with consideration of using a fluid-resistant surgical face mask to the mother. These findings emphasize the importance of infection control measures around the time of birth and support the advice given by the W.H.O around precautions to take while breastfeeding. All the neonates were observed for any signs/symptoms of respiratory distress for the first 48 h.

Statistical analysis

Computer analysis of statistical data was done utilizing Statistical Package of Social Sciences (SPSS), version 23. Demographic, clinical characteristics of pregnant women, type of anesthesia administered, and incidence of perioperative complications, maternal and neonatal outcomes were collected from medical records and reviewed independently by two investigators. We presented the data in numbers and percentages. APGAR score at 1 min and 5 min after birth are represented as mean ± SD.

Data analysis

We collected data from all the case sheets of pregnant women with confirmed COVID-19 infection posted for cesarean section from May 2020 to January 2021. Demographic and clinical characteristics of pregnant women with confirmed COVID-19 infection posted for cesarean section 8 are shown in [Table 1] and [Table 2], respectively.
Table 1: Demographic Characteristics of Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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Table 2: Clinical Characteristics of Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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Out of 327 total cases, 197 (100%) patients had undergone cesarean section in our IPW/SVMC tertiary care Teaching Hospital, Tirupati.

A total of 138 cases (70%) were aged between 20 and 30 years. Maternal comorbidities on admission were as follows: A total of 104 pregnant women (52%) were without comorbidities. Aanemia (21%), gestational hypertension (9%), hypothyroidism (8%), diabetes (4%), asthma (2%), hepatitis B (1.5%), and retrovirus positive (1%) were the comorbidities present in the rest of the patients.

A total of 105 pregnant women (53%) were multigravida, and two women (1%) had multiple pregnancies (twins).

A total of 163 pregnant women (83%) were asymptomatic on admission, the most common symptom reported by the women were fever (5%), cough and cold (4%), sore throat (3%), gastrointestinal symptoms (2%), and anosmia (0.5%).

Most of the cesarean births were planned for indications other than maternal compromise due to SARS-CoV-2 infection [Table 2]. The common indications for cesarean section were previous lower segment cesarean section (LSCS) (47%), malpresentation (14%), failed progression (12%), obstruction (9%), pre-eclampsia/eclampsia (8%), premature rupture of membranes (PROM) (4%), fetal distress (4.5%), and antepartum hemorrhage (APH) (1.5%).

The type of anesthesia administered was spinal anesthesia in all (100%) the cases [Table 3]. The incidence of perioperative complications is as follows [Table 4].
Table 3: Type of Anesthesia Administered For Cesarean Section

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Table 4: Incidence of Perioperative Complications in Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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During the intraoperative period, one patient had failed spinal (after 10 min, Bromage score was 0 and no sensory loss), so planned for second spinal which was successful. Her recovery was uneventful.

During the early postoperative period (up to 24 h after surgery), one patient developed mild postpartum hemorrhage (PPH), which was controlled by uterotonic agents, and her hemodynamics were stabilized after transfusion of one unit of compatible whole blood. She was discharged on the postoperative day 8.

During the late postoperative period, one patient on the postoperative day 2 developed breathlessness, so she was immediately shifted to COVID ICU for intensive care management. On the basis of clinical examination and laboratory investigations, she was diagnosed with severe COVID pneumonia. She was treated with ventilatory support and antiviral agents (Inj. remdesivir). In spite of all the efforts, she died due to acute respiratory failure on the postoperative day 4.

Pregnancy outcomes of women with confirmed COVID-19 infection and posted for cesarean section are as follows: The number of live births (including twins) was 197 (99%). One case of intra-uterine death (IUD) and one stillbirth occurred (1%) [Table 5]. A total of 186 women (94%) gave birth at term, and 5% gave birth at preterm. Out of 197 live births, 91% of neonates were born with a birth weight of more than 2.5 kg, 8% of them were low birth weight babies (< 2.5 kg). APGAR scores at 1 min and 5 min after birth (mean ± SD) were 9 ± 0. 5 and 10 ± 0.0, respectively [Table 6].
Table 5: Pregnancy Outcomes Among Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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Table 6: Clinical Characteristics of Newborn (Live Births)

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Final maternal outcomes of women with confirmed COVID-19 infection posted for cesarean section were that most of them were discharged well to home (n = 196) and one patient needed COVID-ICU admission, who died due to acute respiratory failure [Table 7].
Table 7: Final Outcomes of Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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Outcomes of the neonates of pregnant women with confirmed COVID-19 infection posted for cesarean section are the number of neonates discharged well to home was 197. Four neonates needed NICU admission. Out of four neonates, two were admitted for respiratory distress, one for birth asphyxia, and one for neonatal jaundice. All four neonates admitted in NICU tested COVID-19 negative via RTPCR and were discharged well to home [Table 8].
Table 8: Outcomes of Neonates Born to Pregnant Women With Confirmed COVID-19 Infection Posted For Cesarean Section

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Most neonates born to the mother with confirmed COVID-19 infection were asymptomatic and discharged home well. A small number of neonates had symptoms with a minority needing admission to neonatal Intensive Care Unit. So, the significance of vertical transmission remains unknown.


  Discussion Top


To the best of our best knowledge, this is the first cohort retrospective study to describe the characteristics and outcomes of 197 pregnant women with confirmed COVID-19 infection posted for cesarean section. We found that most of the pregnant women were asymptomatic (83%) on admission. Most of the cesarean birth occurred for an indication other than maternal compromise due to COVID-19 infection. Spinal anesthesia is the safest, rapid onset, and reliable method to anesthetize pregnant women with confirmed COVID-19 infection posted for cesarean section because it is not an aerosol-generating procedure. A total of 94% of the women gave birth at term, 91% of the neonate's birth weight was more than 2.5 kg. Most of the neonates were asymptomatic and discharged well to home.

Comparison with other studies

An earlier clinical descriptive study by Chen et al.,[8] reported the clinical features of nine pregnant women with laboratory-confirmed COVID-19 infection cases, all of whom underwent cesarean delivery in one tertiary hospital in Wuhan.

In a case-control study by Na Li et al.,[12] in addition to 14 cesarean delivery patients, they also reported two pregnant women who had a full-term vaginal delivery and were confirmed with COVID-19 pneumonia on the day of delivery. A higher incidence rate of premature delivery was observed in confirmed cases (18.8%), but none was due to severe maternal respiratory failure. This rate was higher than in suspected patients (16.7%) and in the two control groups (~ 5%) of their study, but lower than the rate of 44% in confirmed COVID- 19 pneumonia patients reported by Chen et al.[8] All these events of preterm delivery were triggered by gestational complications such as premature rupture of membranes and placental bleeding, which might not be directly related to COVID-19 pneumonia. They did not observe any deaths or events of severe complications associated with COVID-19 pneumonia that required critical care in pregnant women and newborns.

Hence, the adverse effects of COVID-19 pneumonia on pregnancy appear to be less severe than those of SARS-CoV and MERS-CoV. Three pregnant women died during the 2003 SARS outbreak in Hong Kong, and preterm delivery was as high as 80%.[13] Although no maternal deaths were recorded in the MERS-CoV outbreak, more than half of their newborns required critical care, and nearly 30% eventually died.[14]

Zhu et al.,[15] reported 10 newborns born to mothers with COVID-19 pneumonia in Wuhan; one newborn died from multiple organ failure and disseminated intravascular coagulation (DIC), and another had DIC but recovered. However, none of these 10 newborns tested positive for SARS-CoV-2. A previous study also reported that SARS-CoV infection could increase the risk of preterm delivery in the second trimester and spontaneous abortion in the first trimester.[16] Because all of the patients in our study and others were in the third trimester, the potential adverse effect of SARS-CoV-2 infection in the first and second trimesters remains to be investigated.

Health care workers need to stay vigilant against COVID-19 infection when there is an epidemic in the neighborhood or when pregnant women have a travel history to an epidemic area within 14 days. As suggested by Favre et al.,[17] vaginal delivery could be considered for the benefit of patients, when there is a labor room properly equipped for airborne precautions. All health care workers in close contact should strictly adhere to contact and airborne precautions in addition to standard precautions.

Similar to two previous reports of pregnant women with confirmed COVID-19 infection, [8,18] we did not find any evidence to support the vertical transmission of SARS-CoV-2 from mother to fetus via placenta or during cesarean delivery. Therefore, there is limited evidence of vertical transmission via the placenta or during cesarean delivery.

A prospective national population-based cohort study using the UK Obstetric Surveillance System (UKOSS) done by Knight M et al.,[19] estimated the incidence of admission to hospital with confirmed SARS-CoV-2 infection in pregnancy was 4.9 (95% confidence interval 4.5 to 5.4) per 1000 maternities. A total of 233 (56%) pregnant women admitted to hospital with SARS-CoV-2 infection in pregnancy were from black or other ethnic minority groups, 281 (69%) were overweight or obese, 175 (41%) were aged 35 or over, and 145 (34%) had pre-existing comorbidities. A total of 266 (62%) women gave birth or had a pregnancy loss; 196 (73%) gave birth at term. Forty-one (10%) women admitted to the hospital needed respiratory support, and five (1%) women died. Twelve (5%) of 265 infants tested positive for SARS-CoV-2 RNA, six of them within the first 12 h after birth. Most pregnant women admitted to hospital with SARS-CoV-2 infection were in the late second or third trimester, supporting guidance for continued social distancing measures in later pregnancy. Most had good outcomes, and transmission of SARS-CoV-2 to infants was uncommon. The high proportion of women from black or minority ethnic groups admitted with an infection needs urgent investigation and explanation.

A living systematic review and meta-analysis done by John Allotey et al.,[20] concluded that pregnant and recently pregnant women are less likely to manifest COVID-19 related symptoms of fever and myalgia than nonpregnant women of reproductive age and are potentially more likely to need intensive care treatment for COVID-19. Pre-existing co-morbidities, high maternal age, and high body mass index seem to be risk factors for severe COVID-19. Preterm birth rates are high in pregnant women with COVID-19 than in pregnant women without the disease. An increase in rates of preterm birth in pregnant women with COVID-19 compared with those without the disease was observed. These preterm births could be medically indicated, as the overall rates of spontaneous preterm births in pregnant women with COVID-19 were broadly similar to those observed in the prepandemic period. Although more than 60% of pregnant women underwent cesarean section in the noncomparative studies, we did not find a statistically significant difference in comparative studies of pregnant women with and without COVID-19. The precision of the estimates is expected to improve with the publication of more data in the future.

Limitations of our study

  1. We do not yet have complete maternal and neonatal outcomes for the women who were admitted for safe institutional delivery. Because no follow-up was done after being discharged well to home. So, long term/delayed effects of COVID-19 infection remain unknown.
  2. The potential adverse effects of COVID-19 infection in the first and third trimester remain to be investigated because all of the patients in our study were in the third trimester.
  3. Due to limited resources, COVID-19 testing was done for only symptomatic neonates and those who needed NICU admission. So, the significance of vertical transmission remains unknown.



  Conclusion Top


In the context of the COVID-19 pandemic, ongoing collection of data on the outcomes of the infections during pregnancy will remain important. Nevertheless, these data suggest that most of the pregnant women with confirmed COVID-19 infection posted for cesarean section do not have severe illness, and there is no significant maternal morbidity and mortality related to COVID-19 infection. Spinal anesthesia is the safest anesthesia technique for cesarean section in pregnant women with confirmed COVID-19 infection because it is not an aerosol-generating procedure (AGP), which significantly decreases the risk of corona virus transmission to the attending OT staff. Most of the cesarean births occurred for indications other than maternal compromise due to COVID-19 infection, and there was no significant incidence of perioperative complications when compared to the general population. Most of the neonates were discharged well to home.

Acknowledgement

We acknowledge the help and support of all the faculty and postgraduates in the Department of Anesthesiology & Critical Care, without whose support this research would not have been possible: Dr. Srinivas M, Dr. Jeevan, Dr. Srinivas S, Dr. Ravishankar, Dr. Mydhili, Dr. sreenivasulu B, Dr. Jagadeesh N, Dr. Satyanarayana, Dr. Chiranjeevi, Dr. Vijay, Dr. Kumar, Dr. Harikrishna, Dr. Sunil N, Dr. Gnapika, Dr. Sumiya, Dr. Mohan Krishna, and Dr. Poornachandrika.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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