Research Article

Consequences of Maternal, Neonatal, And Prognostic Factors for Severity of Covid-19 in Pregnant Women

Mitra Darbandi¹, Kamyar Mansori², Badieh Pakdin¹, Farid Najafi¹, Ebrahim Shakiba¹ and Fatemeh Khosravi Shadmani^1*

¹Research Center for Environmental Determinants of Health (RCEDH), Kermanshah University of Medical Sciences, Iran

²Department of Biostatistics and Epidemiology, Zanjan University of Medical Sciences, Iran

Submission: June 06, 2022;Published: June 14, 2022

*Corresponding author: Fatemeh Khosravi Shadmani, Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

How to cite this article: Mitra Darbandi, Kamyar Mansori, Badieh Pakdin, Farid Najafi, Ebrahim Shakiba, Fatemeh Khosravi Shadmani. Consequences of Maternal, Neonatal, And Prognostic Factors for Severity of Covid-19 in Pregnant Women. J Gynecol Women’s Health 2022: 23(4): 556117. DOI: 10.19080/JGWH.2022.23.556117

Abstract

Background: The aim of this study was to evaluate the consequences of pregnancy, neonatal, and prognostic factors of the severity of pregnant women with COVID-19 in Kermanshah province, west of Iran.

Methods: This historical cohort study was conducted on all pregnant women with COVID-19 in Kermanshah province from April 2020 to April 202. The data collection tool was a checklist including demographic, epidemiological, clinical, laboratory, radiological, and therapeutic variables that were extracted through interviews with patients and their medical records. Univariate and Multivariable Logistic Regression model were used to data analysis by STATA 14 software.

Results: In this study, 375 pregnant women were evaluated with COVID-19 infection, severity of the disease was mild in 54.4% (204 women) and severe in 45.6% (171 women). A total of 21 pregnant women were hospitalized that 5 of whom were admitted to the ICU. Also, the most common neonatal events including low birth weight (4.8%) and spontaneous abortion (4.0%) was the most common consequence of pregnancy complications. Hospitalization (7.1 (1.6-32.0)) and distress (8.5 (4.0-17.8)) were the most important risk factors of the severity.

Conclusion: COVID-19 infection in pregnant women can increase preterm delivery, low birth weight, vertical transmission, cesarean delivery and spontaneous abortion. In addition, the clinical manifestations of pregnant women with COVID-19 were similar to those of general COVID-19 patients. Is necessary to increase the care of pregnant women during the COVID-19 epidemic and to receive specialized care in case of infection covid-19.

Keywords: COVID 19; Pregnant woman; Neonatal; Complication; Spontaneous abortion

Abbreviations: SD: Standard Deviation; OR: Odds Ratio; CI: Confidence Interval; LBW: Low Birth Weight; SARS: Severe Acute Respiratory Syndrome; MGP: Multiple Gestation Pregnancy

Introduction

The novel coronavirus epidemic called COVID-19 started in late 2019 in China and quickly spread to other parts of the world and turned to a pandemic [1-3]. This highly contagious virus infects all population strata. According to the WHO, on November 16, 2021, the new case and deaths were 254631818 and 5123367 in the world and 6045212 and 128272 in Iran, respectively [4] One of the most sensitive groups at risk during the COVID-19 pandemic is pregnant women and their fetuses [5-8]. In recent decades, epidemics of infectious diseases have incurred harmful effects of the viruses on pregnant women and their fetuses [9,10]. The H1N1 flu and the Z1KA epidemics are examples with severe complications in pregnant women and their fetuses [10-14].

Studies have shown pregnancy does not increase the risk of developing COVID-19, but the complications can be more severe and COVID-19 can take longer as compared with non-pregnant individuals [15,16]. It is not clear whether the trend of natural immunological changes in women during pregnancy can increase the incidence and exacerbation of COVID-19 signs and symptoms. Studies have reported that developing COVID-19 in pregnant women increases the risk of ICU admission, especially in mothers who develop kidney failure and sepsis in the third trimester [15,17,18]. Other complications reported in pregnant women with COVID-19 include increased rates of preterm childbirth and cesarean section. Fever and hypoxemia may increase the risk of preterm childbirth, premature rupture of membranes, and abnormal fetal heart patterns. Preterm childbirth also occurs in cases without severe respiratory disease [6,19].

The spread of the coronavirus has raised concerns about its intrauterine transmission from mother to fetus in pregnant women [1,20,21]. However, a number of studies rule out this possibility [22,23]. Viral pneumonia caused by any infectious agent is one of the leading causes of death during pregnancy worldwide and is the most common infection (excluding obstetric infections) in pregnant women [24]. Currently, the following questions are raised regarding COVID-19 in pregnant women: what are the signs and symptoms of COVID-19 and how severe are they in pregnant women? What are the odds of vertical transmission? And what is the status of the pregnant mother and her fetus after 40 days? Accordingly, the present study was conducted to evaluating the consequences of maternal, neonatal, and prognostic factors for severity of COVID-19 in pregnant women Kermanshah Province, west of Iran.

Materials and Methods

Study design and Subjects

TThe present research was a cohort study which designed and performed to determine the outcomes of pregnancy and neonatal in pregnant women with COVID-19 and the factors affecting its severity. The study population was all pregnant women with COVID-19 who were confirmed by RT-PCR test or CT scan test in Kermanshah province from April 2020 to April 2021.Considering all pregnant women with COVID-19 were examined during the above-mentioned period, the sampling method was census and there was no need to calculate the sample size. The main criteria for inclusion in the study included a pregnant woman with COVID-19 approved by RT-PCR test or CT scan test. To conduct the study, pregnant women with COVID-19 were included in the study from the time of diagnosis to three months after delivery and then examined monthly. It should be noted that the study was open cohort and pregnant women with COVID-19 could enter the study during the study.

Data collection

A researcher-made checklist was used to collect data from pregnant mothers. The checklist variables included demographic, epidemiological, clinical, laboratory, radiological, and therapeutic data which was preceded by relevant studies and consultation with experts. Demographic and clinical data were collected through interviews with the patient or her companion and the rest of the information was extracted from the patient’s medical record. Data were collected from the time of diagnosis to three months after delivery.

Statistical analysis

Data were analyzed using Stata software version 14.0 (Stata Corp, College Station, TX, USA). For descriptive analyses, the mean, standard deviation (SD), and number (%) were used. Then, univariate and multivariate logistic regression model was used to determine the predictors of the severity of COVID-19 in pregnant women and finally crude and adjusted odds ratio (OR) with 95% confidence interval (CI) were estimated. P-value <0.05 was considered as a significant level.

Ethics considerations

This study was performed according to the principles expressed in the Declaration of Helsinki and was approved by the Deputy of Research and Ethics Committee of Kermanshah University of Medical Sciences (Iran) (ID: IR.KUMS. REC.1399.718).

Result

In this research, carried out in the Iranian province of Kermanshah, 375 pregnant women with COVID-19 infection were studied. The subjects were diagnosed using RT-PCR test. Also, the consequences of maternal, neonatal, and prognostic factors for severity of COVID-19 in pregnant women were investigated. It worth mentioning that the pregnant women were studied at all gestational ages. (Table 1) has shown the characteristics of the pregnant women. The total number of 204 (54.4%) and 171 (45.6%) women in the study were diagnosed with mild and severe cases of covid-19 infection respectively. Plus, the mean age of pregnant women was 36.6±7.2. Although women with milder illnesses were younger, there was no statistically significant difference between the two groups of patients in terms of age (p=0.147).

A total of 21 pregnant women were hospitalized, out of whom 4 were diagnosed with mild cases of Covid 19 which revealed a significant difference between the groups (0.001) in terms of hospitalization. Of the hospitalized patients, 5 had severe COVID-19 infections and were admitted to the ICU. The median of ICU stay for these patients was calculated to be 3 (0- 5) days. Also, 72.5% of the patients had a history of exposure to the patient with Covid-19 which showed a significant difference between severe and mild case groups (p<0.001). Plus, in 33 (8.8%) patients, lung involvement was observed via CT scan; of these cases, 25 had severe disease and were significantly different from patients with mild cases (p <0.001). The most common presenting symptoms were loss of smell (59.7%), muscular pain (44.8%), and loss of taste (41.6%). These symptoms were significantly different between the severe and mild groups (Table 1). (Table 2) has indicated the results of the study; showing that 121 (32.3%) women had a cesarean delivery.

Also, neonatal related complications including low birth weight (LBW) (4.8%), preterm delivery (0.5%) and vertical transmission (0.5%) were significantly higher in women with severe cases compared to those with mild COVID-19 cases. In addition, spontaneous abortion (4.0%) was the most common pregnancy complications in the two groups. (Table 3) has indicated the prognostic factors for severity in patients infected with Covid 19. Hospitalization (7.1 (1.6-32.0)), loss of smell (2.3 (1.1-4.7)), muscular pain (3.6 (2.1-6.2)), fever (3.2 (1.8-5.7),headache (3.3 (1.8-6.1)), distress (8.5 (4.0-17.8)), and cough(2.8 (1.5-5.3)) were counted as the risk factors. According to the finding, for instance, women with muscular pain are 3.6 times more likely to be diagnosed with a severe case of COVID-19 (Table 3).

Discussion

The aim of this study was to determine the consequences of pregnancy, neonatal and prognostic factors of the severity of pregnant women with COVID-19 in Kermanshah province, west of Iran. In this study, 375 pregnant women were evaluated with COVID-19 infection, severity of the disease was mild in 54.4% (204 women) and severe in 45.6% (171 women). In addition, the results of this study demonstrated that neonatal events including LBW, preterm delivery and vertical transmission of COVID-19 were significantly higher in women with sever disease compared to the mild type. In addition, severe cases were significantly higher in participant who were in close contact with patient Covid-19. Previous studies have shown that pregnant women with COVID-19 infection are associated with increased preterm delivery and LBW.

A study in Wuhan-China has shown that compared to pregnant women without COVID-19, pregnant women with a confirmed COVID-19 diagnosis had an increased risk of preterm birth (OR 3.34, 95% CI 1.60-7.00) [18]. A study by Wong SF et al. have been showed that %80 pregnant women with severe acute respiratory syndrome (SARS) had preterm delivery [25]. It was reported in the study by Lee et al. that the prevalence of preterm delivery increased in women with COVID-19 infection [6]. In a systematic review, preterm delivery was calculated about 25% [26]. As well as the LBW in infants born to pregnant mothers with COVID-19 has been reported in the Lassi et al. study 16.6% and in the Abedzadeh-Kalahroudi et al. study 34.6% [27,28]. Therefore, preterm delivery and LBW are adverse outcomes in pregnant women with COVID-19 infection and these two consequences can cause other side effects for the infant.

In this study, vertical transmission was observed in two pregnant women confirmed COVID-19 diagnosis. The vertical transfer rate in the study of Chi J et al. was reported to be 3.91% by SARS-CoV-2 nucleic acid tests [26]. Although, some studies show that there is no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy [29,30]. However, the possibility of vertical transmission cannot be ruled out. In a study, the laboratory findings displaying inflammation and liver damage in a neonate indirectly support this possibility of vertical transmission [30]. Studies that have examined this association have often been cross-sectional, case-report or based on medical records. Therefore, the results should be reported with caution and further investigation is needed.

In this study, the percent of caesarean section was higher than vaginal delivery (25.3% vs. 32.3%).

Although, the mode of delivery was not significantly different in patients with severe and mild of COVID-19 infection. Studies on pregnant women with Covid-19 infection have shown that cesarean section is more common than vaginal delivery [26,31]. In addition, a population-based cohort study in Wuhan on 1,1078 participants, show that compared to pregnant women without COVID-19, pregnant women with a confirmed COVID-19 diagnosis had an increased risk of cesarean section (OR 3.63, 95% CI 1.95-6.76) [18]. However, caesarean section is not a recommended method of childbirth in pregnant women with COVID-19 infection. A systematic review study by Cai J et. al. has reported the rate of neonatal COVID-19 infection, neonatal deaths, and maternal deaths is no greater when the mother gave birth through vaginal delivery [32]. Our findings show that 15 women pregnant (4%) with COVID-19 infection had spontaneous abortion, this outcome 6.1% was reported in Russia [33].

A study in India showed spontaneous abortion in singleton pregnancy 1.7% and in multiple gestation pregnancy (MGP) 10% [34]. Therefore, it is necessary to increase the care of pregnant women during the COVID-19 epidemic and to receive specialized care in case of infection covid-19. The findings of this study showed that the clinical manifestations of pregnant women with COVID-19 were similar to those of general COVID-19 patients [35,36]. In pregnant women with sever Covid-19 infection, symptoms of the disease including cough, fever, loss of smell, muscular pain, headache and distress were more than patients with mild severity. According to the importance of vertical transfer, the lack of sufficient information on vertical transfer to infants was a limitation in this study. The absence of a control group was another limitation of the present study. Large sample size and number of significant variables were the strengths of the study.

Conclusion

The findings of this study demonstrated that COVID-19 infection in pregnant women can increase preterm delivery, LBW, vertical transmission, cesarean section and spontaneous abortion. In addition, severe cases were significantly higher in participant who were in close contact with patient COVID-19. The clinical manifestations of pregnant women with COVID-19 were similar to those of general COVID-19 patients.

Acknowledgements

We thank the colleagues of the Deputy Minister of Health and the Deputy Minister of Treatment at Kermanshah University of Medical Sciences.

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