Second Wave of SARS-CoV-2: Impact on Pregnant Women and Newborns–A Tertiary Care Experience in North India

Study Design and Participants

This was a single-center, retrospective study performed in a tertiary care hospital of North India with 24,000 deliveries per year. The hospital has a separate COVID-19 facility for Obstetrics and Gynecology and a level II intensive care unit (ICU). A total of 98 women were admitted from April 1, 2021, to June 30, 2021, among whom 4 women were admitted with gynecological conditions and hence were excluded from the study. Finally, 94 antenatal and postnatal women comprised the study population.

The testing strategy was according to Indian Council of Medical Research (ICMR) guidelines. All women were tested with rapid antigen test (RAT) kit on admission. Antenatal women who tested negative with RAT underwent quantitative reverse transcriptase polymerase chain reaction (qRTPCR). All RAT- and qRTPCR-positive women were admitted to COVID-19 block unless they were fit for home isolation. The guidelines of Ministry of Health and Family Welfare (MoHFW), Government of India (GOI), were followed for classification and management of these women.⁷ Women with mild and moderate symptoms were admitted to the isolation ward, whereas those with severe disease or those who deteriorated during hospital stay were transferred to the ICU. ICU care comprised oxygen therapy, antibiotics, antivirals, steroid, and thromboprophylaxis. In those women in whom chest imaging was indicated, chest X-ray (posteroanterior view) with abdominal shield for pregnant women was the modality of choice. Neither any pregnant female nor any postpartum female required computed tomography of chest. More of noninvasive oxygen therapy was used during ICU stay such as non-rebreathing mask and high-flow nasal cannula (which can deliver oxygen up to 6 0L/min). In antenatal women with early gestation prone positioning was implemented and in advanced gestation lateral tilt was implemented. Antibiotics (oral antibiotics: azithromycin; parenteral antibiotics: penicillin [ampicillin, piperacillin/tazobactam], cephalosporin [ceftriaxone], clindamycin to prevent secondary bacterial infection) were administered according to hospital policy. Antivirals such as remdesivir were used in severe cases after appropriate counselling and written consent due to unproven teratogenicity. Methylprednisolone (40 mg 12 hourly) was used during the second wave instead of dexamethasone. Low-molecular-weight heparin, 0.4 mL/day by subcutaneous route in women with body weight < 60 kg and 0.6 mL/day subcutaneous route in women with body weight > 60 kg, was used for thromboprophylaxis in all women. Women who were asymptomatic for 10 days after diagnosis, including 3 days after resolution of symptoms, were discharged. The test for SARS-CoV-2 was not repeated prior to discharge. All medical records regarding demographic characteristics, obstetric parameters, presence of comorbidities, disease severity, investigations, management, and fetal outcome were reviewed. The study was approved by the institutional ethics committee.

Statistical Analysis

Categorical variables are presented in number and percentage (%) and continuous variables are presented as mean ± standard deviation and median. The data were entered in MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.

Study Population Characteristics

Among 94 women, 54 (57.45%) were antenatal and 40 (42.55%) were postnatal. A majority (75.53%) of them were between 20 and 30 years of age. Among 54 antenatal women, 34 (62.96%) were multigravida, 9 (20.37%) women were discharged undelivered and in subsequent follow-up 1 woman had miscarriage within 2 weeks of discharge, 5 continued their pregnancy without any adverse outcome, and the remaining 3 women delivered healthy baby at follow-up (1 had term and the other 2 had preterm deliveries).

Severity of Infection and Comorbidity

A large number of women was asymptomatic (42.55%) during the second wave. Among the symptomatic population, most (32.98%) had mild symptoms such as fever, cough, loose stool, ageusia and anosmia, with fever being the most common symptom. Moderate disease was present in 9.58%, such as fever with either dyspnea (respiratory rate ≥ 24/min) or SpO₂ ≤ 93% on room air. Severe disease was present in 14.89% of women with breathlessness (respiratory rate > 30/min) or SpO₂ < 90% on room air; 14.89% required ICU admission and 24.46% needed oxygen therapy. Among the study population, 48.94% had some medical comorbidity, with hypertensive disorders being the most common (14.89%), followed by anemia (8.51%), diabetes, hypothyroidism, and intrahepatic cholestasis of pregnancy (6.38% each) (►Table 1). Three women succumbed to the disease: two became symptomatic in the postnatal period and were tested positive, and the third woman had severe COVID-19 disease at 34 weeks of gestation. One of them was overtly diabetic and another had rheumatic heart disease (►Table 2).

Women were discharged based on the government's (MoHFW) discharge policy. The average hospital stay was 14 ± 2 days.

Pregnancy Outcome

Among 43 antenatal women admitted to the facility, 20 (37%) had vaginal delivery and 23 (42.6%) underwent cesarean delivery while remaining 17 (20.4%) discharged undelivered. The indications for cesarean section in almost all cases were purely obstetric indications, with fetal distress with meconium-stained liquor being the most common indication. In one case, the mother presented with acute-onset desaturation and emergency cesarean section was performed to improve the outcome.

Among 20 women who delivered vaginally, 12 (60%) had term delivery and 8 (40%) women had preterm vaginal delivery. Among 23 cesarean deliveries, 16 (69.56%) were done for fetal distress and 7 (30.43%) had preterm emergency cesarean, with multiple pregnancy and antepartum hemorrhage being the common indications. Overall, the preterm delivery rate was 34.88%. Seven elective cesarean deliveries were done on maternal demand in term women with previous cesarean section as they did not give consent for trial of vaginal delivery after being explained regarding the risk of scar dehiscence or scar rupture. Health care workers are at additional risk and all appropriate COVID-19 protocols were followed.

Neonatal Outcome

A total of 40 women were admitted postpartum and another 43 antenatal women delivered during their stay. Among 83 women, 1 woman was admitted with sepsis. Also, 34.88% had preterm delivery and 13.95% (6 women) had intrauterine demise (IUD) and delivered a stillborn baby. Among the women who had IUD, two had severe COVID-19, resulting in hypoxia. Four of these had preterm vaginal delivery and two had diabetes, which may be the cause of intrauterine fetal demise. Two women with singleton pregnancy had an early neonatal death. One woman with twin pregnancy delivered by emergency preterm lower segment cesarean section at 32 weeks in view of both twin fetal growth restriction with one twin having reversed end diastolic flow but ultimately resulted in early neonatal death of both the twin babies. Two women with twin pregnancy had early neonatal death of one twin and another twin required nursery admission. Total neonatal deaths were 5 (11.62%). Among these, four had preterm vaginal delivery and three had twin pregnancy. Among 76 newborns, 6 (7.89%) babies had positive RTPCR report, but no mortality among them was observed. All babies were discharged in healthy state.

Follow-up

All women were contacted telephonically after 2 weeks of discharge; eight were lost to follow-up as they could not be contacted. One woman with rheumatic heart disease expired after 2 days of discharge at home; the cause was not known. Among 11 women who were antenatal during discharge, 3 had vaginal delivery within the next 2 weeks, 1 had spontaneous abortion, 2 could not be contacted, and the rest were continuing their pregnancy well at the time of writing this paper. Common complaints after discharge were malaise, body ache, and cough. Few had complaints of persistent two or three spikes of fever. Another group complained of palpitation and breathlessness on exertion.