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Evaluation of maternal and fetal outcomes in pregnant women with COVID-19 based on different trimesters
Minoo Movahedi1, Khadijeh M Siahafshari1, Maryam Hajhashemi1, Farzin Khorvash2, Milad Saeidi3, Zahra Allameh1
1 Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran
3 School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| Date of Submission | 25-May-2022 |
| Date of Acceptance | 16-Jul-2022 |
| Date of Web Publication | 30-Jun-2023 |
Correspondence Address:
Dr. Khadijeh M Siahafshari
School of Medicine, Hezar Jarib St., Isfahan
Iran
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/abr.abr_173_22
Background: COVID-19 is the leading cause of the recent pandemic in the globe. This disease might have different effects on the maternal and fetal outcomes in pregnancy. The aim of this study was to assess these outcomes in pregnant women with COVID-19 infections in different trimesters.
Materials and Methods: This is a prospective cohort study that was performed in February 2020 to August 2021 in Isfahan on 430 pregnant women with definite diagnosis of COVID-19 infection admitted to our medical centers. The included cases were followed based on the gestational age in which they were diagnosed with COVID-19 infection. Patients were divided into three groups (first, second, and third trimesters) based on COVID-19 infection.
Results: The frequency of requiring mechanical ventilation was higher in mothers with COVID-19 in the second trimester (P = 0.049) and the frequency of PIH was significantly higher in mothers with COVID-19 in the third trimester compared to other women (P = 0.009). Fetal growth restriction (FGR) was also observed in 22 patients (5.3%) that was mostly observed with COVID-19 in the third trimester (P = 0.012). Oligohydramnios and fetal distress leading to C/S were observed in 19 patients (4.6%) and 12 patients (2.9%), respectively. The majority of maternal mortality was among cases with COVID-19 infection in the third trimester (44.4%).
Conclusion: We observed higher maternal and fetal complications in women especially those in the third trimester. Our results were in line with the findings of previous studies. Women with COVID-19 infection in the third trimester had highest frequencies of preterm labor and FGR.
Keywords: COVID-19, neonate, outcomes, pregnancy
How to cite this article:
Movahedi M, Siahafshari KM, Hajhashemi M, Khorvash F, Saeidi M, Allameh Z. Evaluation of maternal and fetal outcomes in pregnant women with COVID-19 based on different trimesters. Adv Biomed Res 2023;12:165 |
How to cite this URL:
Movahedi M, Siahafshari KM, Hajhashemi M, Khorvash F, Saeidi M, Allameh Z. Evaluation of maternal and fetal outcomes in pregnant women with COVID-19 based on different trimesters. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:165. Available from: https://www.advbiores.net/text.asp?2023/12/1/165/379639 |
| Introduction | |  |
COVID-19 is a disease currently known as the coronavirus causing respiratory distress syndrome (SARS-Cov-2).[1] The virus was first discovered in Wuhan, China, and soon led to an epidemic around the world.[2],[3] The incubation period of the disease is reported to be between 2 and 14 days.[4]
Pregnancy increases the risk of side effects on mother and baby in many respiratory viral infections.[5] Physiological and immunological changes that occur as a natural component of pregnancy can increase the risk of complications from respiratory infections.[6] Changes in the oxygen consumption and decreased lung capacity, as well as the development of immunological adaptations that allow the mother to tolerate the fetus with different antigens.[7],[8]
Data from several studies have shown that influenza increases the morbidity and mortality of pregnant women compared to nonpregnant women.[9] This association has previously been seen in two older viruses of the corona family that cause Middle East Respiratory Syndrome (MERS).[10],[11]
At present we have very little information about the complications of COVID-19 pregnancy.[12] Limited information has been provided during studies conducted in Wuhan, China, regarding the pregnancy complications caused by a new virus in the COVID-19 epidemic.[13]
In a recent study, the polymerase chain reaction (PCR) result of the virus in samples were taken from maternal neonatal blood, and neonatal throat samples were all negative.[14] These results indicated that the probability of vertical transmission of this newly discovered virus during the third trimester of pregnancy was very low.[15] Regarding the importance and prevalence of COVID-19 and the possible maternal and fetal complications due to the infections, here in the present study we aimed to assess these complications.
| Materials and Methods | | |
This is a prospective cohort study that was performed in February 2020 to August 2021 in Al-Zahra and Amin hospitals affiliated to Isfahan University of Medical Sciences. The current study was conducted on all pregnant women with definite diagnosis of COVID-19 infection admitted to our medical centers. All of the pregnant mothers that were hospitalized with COVID-19 infection in our facilities were followed until termination. The study protocol was approved by the Research Committee of Isfahan University of Medical Sciences and the Ethics committee has confirmed it (Ethics code: IR.MUI.MED.REC.1399.717).
The inclusion criteria were pregnant women admitted to our medical centers, and definite COVID-19 infection by PCR test and/or CT scan findings. The exclusion criteria were previously diagnosed medical diseases including cardiovascular, renal or hepatic failures, vasculitis, antiphospholipid syndrome, history of pregnancy-induced hypertension (PIH), and history of neonatal problems in previous pregnancies including fetal growth restriction (FGR).
All pregnant women were included in February 2020 until August 2021 with the mentioned criteria that were admitted to the medical centers during the study period using census method. The included cases were followed based on the gestational age in which they were diagnosed with COVID-19 infection. As a result, we divided our data in to three groups (first, second, and third trimesters). Information of the study population were collected using a checklist by the means of interview and physical examinations. They were all followed until termination and the visits were repeated every month. After the termination of the pregnancy, we collected data of the neonates using a checklist.
The collected data related to the mothers were mother's age, gestational age, weight, body mass index (BMI), blood pressure, requiring mechanical ventilation, O2 saturation, ICU admission fetal weight, percentile of fetal weight and amniotic fluid index (AFI). The data regarding the neonates were birth weight, Apgar score in 1 and 5 min after birth, and gestational age, requiring NICU admission, mechanical ventilation, and neonatal mortality.
The obtained data were analyzed with SPSS software version 24. P value <0.05 was considered as significance threshold.
| Results | | |
In the present study, data of 509 pregnant women with COVID-19 infection were reviewed. 73 patients were excluded due to lack of follow up, and 6 cases were excluded due to history of FGR (2 cases) and previous diagnosis of hypertension (4 cases). Data of 430 cases were analyzed. 23 women (5.4%) were diagnosed with COVID-19 in the first trimester, 88 women (20.5%) in the second trimester, and 319 women (74.1%) in the third trimester. Initial analysis of demographic data showed that the mean age of the mothers was 31.62 ± 5.61 years. Totally, 138 women (32.1%) had normal vaginal delivery (NVD) and 292 women (67.9%) had cesarean section (C/S). 63 women (15.2%) were admitted to the ICU of the medical centers and 19 women (4.6%) required mechanical ventilation. Pregnancy-induced hypertension (PIH) occurred in 49 women (11.9%).
Data were compared between women with COVID-19 in different trimesters. These data showed that the frequency of requiring mechanical ventilation was higher in mothers with COVID-19 in the second trimester (P = 0.049) and the frequency of PIH was significantly higher in mothers with COVID-19 the third trimester compared to other women (P = 0.009). By comparing the other data between mothers with COVID-19 infections in different trimesters, we observed no significant differences regarding age (P = 0.188), delivery type (P = 0.864) and ICU admission (P = 0.291). These data are indicated in [Table 1] and [Figure 1]. | Table 1: Evaluation and comparison of data between mothers in different gestational ages
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Totally, 89 women (21.5%) had preterm labor with majority in women with COVID-19 in the third trimester [Table 2] and [Figure 2].
FGR was also observed in 22 patients (5.3%) that was mostly observed with COVID-19 in the third trimester (P = 0.012). Oligohydramnios and fetal distress leading to C/S were observed in 19 patients (4.6%) and 12 patients (2.9%), respectively. There were no significant differences between mothers with COVID-19 in different gestational ages regarding the preterm labor, oligohydramnios, and fetal distress (P > 0.05) [Table 3]. | Table 3: Evaluation and comparison of fetal complications in mothers with COVID-19 in different gestational age
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Based on our findings, the majority of maternal mortality was among cases with COVID-19 infection in the third trimester (44.4%). On the other hand, we observed higher mortality rates in cases with COVID-19 infection in the first trimester (8.7%) compared to other cases (P = 0.019). These data are shown in [Table 4] and [Figure 3].
We also assessed the data of nine deceased cases and outcome of their children. These data are shown in [Table 5].
Further evaluations showed that IUFD was observed more among women with COVID-19 in the second trimester (9.9%) (P = 0.001). No significant differences were observed between women regarding NICU admission (P = 0.182), newborn MV/CPAP (P = 0.334) and newborn death. These data are shown in [Table 6].
Furthermore, it was observed that the Apgar score in 1 and 5 min after birth were highest in patients with COVID-19 infection in the first trimester and women with COVID-19 infection in the third trimester had the lowest Apgar scores (P = 0.008 and P = 0.040, respectively) [Table 7] and [Figure 4].
| Discussion | | |
Based on our findings, by evaluating 430 women, the mortality rate was 2.1% in mothers with highest rate in mothers with COVID-19 in the third trimester, and 2.1% mortality and abortion in neonates. It was observed that 67.9% had C/S type of delivery and 15.2% were admitted to the ICU. The frequencies of mechanical ventilation and PIH were highest in mothers with COVID-19 in the second and third trimesters, respectively.
In addition, women with COVID-19 infection in the third trimester had highest frequencies of preterm labor and FGR.
These data indicate the importance of COVID-19 infection in pregnant women especially those in the third trimester. This highlights the role of prevention and proper treatments in pregnant women. It should be noted that despite high frequencies of infected cases, we did not have higher rates of mortality compared to other studies. As mentioned earlier, various research have been conducted on the effects of COVID-19 in pregnant women.
The prevalence of different pregnancy-related complications have been assessed among normal populations. Based on recent data, the prevalence of preeclampsia was accounted 4--5%, the prevalence of abortion was 11--12%, the prevalence of FGR was 3--7%, the prevalence of oligohydramnios was 1--2%, the prevalence of IUFD was 13.9 per 1,000 birth and the prevalence of preterm labor was 10%. It could be observed that the prevalence of these complications is higher among mothers with COVID-19 infection but the prevalence of FGR is similar to the general population.[16] Therefore, we state that currently, there are no hard evidence that COVID-19 infection during pregnancy could increase risks of FGR and this could be due to small sample size.
In 2020, a study was conducted by Zhang and colleagues in China on 16 pregnant women with COVID-19. It was shown that all cases underwent C/S delivery and 18.8% were admitted in the ICU.[17] Another study was performed by Pirjani and colleagues in Iran. They showed that 6.06% of women with COVID-19 were admitted to ICU, and 52.76% had C/S delivery.[18] These results were in line with the findings of our study. It was observed that 67.9% of women had C/S type of delivery and 15.2% were admitted to the ICU. This shows higher rates of C/S delivery and ICU admission.
In a study by Zaigham and Andersson, data of 108 pregnancies were evaluated. Based on their findings, 91% of the women were delivered by C/S. It was reported that 20% of women presented in earlier gestational weeks and were discharged, undelivered, without any major complications. The mortality rate for mothers and neonates were reported 0% and 1%, respectively.[19] It was indicated significantly higher C/S delivery in women compared to NVD and almost similar mortality rates were reported. Nevertheless, it was observed various maternal and fetal complications in women with COVID-19 infection in the first trimester. It is believed that lack of proper follow-up could be a limitation of the study by Zaigham and Andersson.
Another important point in our study was that we evaluated maternal mortality due to COVID-19 infection and found that the mortality rate in the first trimester was significantly higher than the other trimesters. These data could be due to the issue that women with COVID-19 infections in the first trimester often do not refer to medical centers until their disease progress to higher stages but in the second and third trimesters, women with signs of COVID-19 infection refer immediately to medical centers. Therefore, we observed lower mortality rates in the third trimester. The important points of our study were larger study population compared to most of the previous studies and comparing the pregnancy outcomes in women with COVID-19 infections during different gestational ages. By comparing these results, it was observed higher rates of different complications in pregnant women in their third gestational age.
In addition, different studies have been conducted on the pregnancy outcomes in COVID-19 infection. The most common complications were increased frequencies of C/S section, ICU admission, preterm labor, and fetal distress.[20],[21],[22]
Smith and colleagues also evaluated nine articles regarding the pregnancy outcomes in women with COVID-19 infection. By evaluating data of 92 patients, it was reported that 63.8% of women had preterm births, 61.1% had fetal distress, and 80% had a C/S.[23] These data are not consistent with our findings. It was observed preterm labor in 20% and NICU admission in 23% of cases. These differences could be due to the variations in the study populations. In the present study, data of 430 pregnant women were assessed that could increase the validity of our data.
The rates of maternal mortality due to COVID-19 infection could vary in different populations. Metz and colleagues reported that this rate could be up to 5%.[24] In another study by Nakamura-Pereira and others, it was stated that the mortality rates of pregnant women with COVID-19 could reach almost 4% in South American countries.[25] Therefore, it is believed that our mortality rate in this study is not higher than previous studies. We believe that special care should be provided for similar cases to minimize the mortality rates.
The limitations of our study were conducting this study in two centers. Therefore, different managements in these two centers could be a shortcoming of this study. It is believed that the multicentric studies with similar treatment guidelines should be conducted in this regard. However, our data could have high clinical importance. We emphasize that the preventive and therapeutic strategies against COVID-19 should be conducted with higher priorities in pregnant women in the third trimester.
| Conclusion | | |
Our data were indicative of higher maternal and fetal complications in women especially those in the third trimester. Women with COVID-19 infection in the third trimester had highest frequencies of preterm labor and FGR. The Apgar score in 1 and 5 min after birth were lowest in patients with COVID-19 infection in the third trimester. It is emphasized that the preventive and therapeutic strategies against COVID-19 should be conducted with higher priorities in pregnant women in the third trimester.
Financial support and sponsorship
This study was financially supported by Isfahan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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