Discussion:
In COVID-19 pandemic, pregnant woman and neonate were in need of special care. Keeping it in mind that pregnant lady and neonates are more vulnerable to SARS CoV-2 infection, Combined Military Hospital (CMH) Bogura prepared a COVID dedicated ward for antenatal patients. Patients were managed by a multidisciplinary team consisted of obstetrician, medicine specialist, anaesthetist, neonatologist, nurse and hospital authority support for logistics. We compared the COVID positive pregnant patients to non-pregnant COVID patients to compare the effect of COVID on fetomaternal outcome.
In the study, we have analysed the mean age, weight, and gestational week for both situations in case and in control where there were no significant difference between case and control group in terms of age, body weight and gestational weeks of delivery. This result is similar to Munir S 6 et al in their study conducted in Sir Gangaram Hospital in Pakistan where mean age was 29 ±4.17 years SD. In that study, mean gestational age was 29 ± 9.53 weeks. Another study conducted in Wuhan reported the mean age of the patients between 29 to 35 years, and the gestation ranged from 33 to 41 weeks.7
In current study, when analyzing the asymptomatic versus the noticeable symptoms, fever was most prevalent symptom in fifteen (25.9%) followed by weakness, sore throat, loss of smell, etc. These results are almost similar to results of a recent study by Chen et al8reported nine COVID positive women diagnosed in their third trimester of pregnancy. The common symptom was fever in seven, cough in four, myalgia in three, and sore throat and malaise each of two women. None of the patient required ventilator and none expired, these results are similar to the current study.
In this study, there was minimal investigations as most patients were either asymptomatic or had mild symptoms. Ultrasonography of pregnancy profile in each patient was done but not chest X-ray. Haemoglobin, WBC, Platelet count for both case and control can be seen in Table 6. Serum creatinine was 0.745±0.15 in cases and 0.67±0.12 in controls. No significant differences were there in blood parameters of two groups. It was quite different from the study conducted by Parul T9 et al where she showed increased leucocyte count during admission in COVID positive patients.
We found some comorbidities in our patients such as gestational diabetes mellitus was present in three (5.2%) patients in both groups. Pregnancy induced hypertension (PIH) was found in three (5.2%) in both groups. Two (3.4%) patients had hypothyroidism in control group. One (1.7%) had Bronchial asthma. Parul Shah et al 9 showed in her study, out of 125 cases, 6 (4.8%) GDM, 7 (5.6 %) PIH, and 2 (1.6%) pre-eclampsia cases were found. In a systematic review by Gajbhiye R. et al involving 441 pregnant women, the most common co-morbidities associated with women with COVID-19 were hypertensive disorders (10%), diabetes (9%), placental disorders (2%), co-infections (3%), and hypothyroidism (3%).10
Analysing the mode of termination in Table 7, we can see that LSCS is significantly higher in case group (P value < 0.05). Additionally, time of delivery in cases were 37.2- 40.4 weeks and in control was 34.3-40.4 weeks (Table 10). In the study of Yu et al11 of seven patients, all were delivered by caesarean section. A total of 97 pregnant women including 2 twins delivered their babies of whom 53.6% underwent caesarean delivery and 43.26% had vaginal delivery including 2 preterm vaginal delivery ,this I found in study by Shah PT 9 et al. Caesarean section is found to be significantly higher in all the studies.
In present study, both case and control group had one preterm labour. No preterm rupture of membrane was found in COVID-positive group. Three congenitally abnormal baby was found in COVID-19 positive group (Cleft lip and palate, synductyly, congenital meconium ileum).
Analysing the Neonatal ICU admission rate in Table 9, the reasons for admission in ICU in COVID positive mother’s babies were umbilical sepsis one, neonatal asphyxia two, transient tachypnea (TTN) of newborn in one and feeding difficulties in one neonate. Mean birth weight in case group was 3.1± 0.08 SD kg and in control group it was 3.0 ± .06 SD kg. No significant difference was found between two groups. No baby died in our study. All had good Apger Score but two of them later developed perinatal asphyxia.
It is known to all that any kind of viral pneumonia in pregnant women, put the patient in a higher risk of preterm birth, intrauterine fetal growth restriction (IFGR), and perinatal mortality by Madinger et al.12 It is reported by Chen et al that pregnant patients infected with viral pneumonia other than SARS-CoV-2 have increased risk of fetal growth restriction (FGR), preterm delivery, low birth weight and Apger score <7 at 5 minutes.13 This finding was quite dissimilar to our study. Entoun L. 14 et al showed in their study varies from 2.24 to 4.45 kg with mean of 3.139 kg ± 437 which is in a body with our study.
Each newborn was tested for COVID using nasopharyngeal sample immediately after birth. All were negative which is contrary to study by Yu et al.11 in which one out of three neonates was tested positive for COVID -19, but the RT-PCR test for COVID-19 virus of the placenta and cord blood in these cases were negative. Another study showed that Ninety-six (96.9%) of neonates were tested for COVID-19 viral nucleic acid on nasopharyngeal and pharyngeal samples and 16.67% (16 of 96) were positive9. So, possibilities of vertical transmission is still there. There are studies reported on 3 neonates born to confirmed COVID-19 women, who tested positive for immunoglobulin G and immunoglobulin M antibodies despite having a negative viral nucleic acid result, raising the possibility of vertical transmission. But it requires more data 15.
In present study, breastfeeding of neonates of COVID positive mother was significantly less than neonates of control group (Table 11). Artificial feeding was higher in cases than control 40.4 % in cases and 1.8% in control group which was statistically significant (P value <0.001 %). This was due to early isolation of baby from mother to prevent contact transmission. WHO guidelines states that ‘the benefits of skin-to-skin contact and breastfeeding substantially outweigh the potential risks of transmission and illness associated with COVID-19 infection’ while guidance from China states that ‘Infants shouldn’t be given feeding with the expressed breast milk from confirmed or suspected COVID-19 mothers’. 16
Mean duration of hospital stay was significantly higher in COVID positive patients with 13.79±6.0 days than control with 5.54± 5.0 days. This was due to post-operative observation and anti-coagulant administration.