The Maternal Outcome of Patients with COVID-19 and their babies in the first 24 hours of Birth

1. INTRODUCTION

Human health has always been one of the most important issues of society, researchers are increasingly trying to provide solutions to improve health by using science and technology [1-3]. In this regard, viruses have been considered as one of the viruses that can cause respiratory infections ranging from the common cold to more severe illnesses such as SARS and MERS [4, 5].

COVID-19 caused acute respiratory syndrome that was detected in Wuhan, China at the end of 2019, and quickly spread as a pandemic in different countries. The common symptoms include fever, headache, fatigue, muscle pain, and cough [6, 7]. In case of severe complications, it includes respiratory, heart, and gastrointestinal problems [8-10].

The pandemic of COVID-19 around the world is also very worrying, and researchers and doctors are trying to find solutions to control and prevention [11]. The entry of COVID-19 into the world community has had wide consequences for the medical community, economy, and human society. This virus causes different symptoms in the human body, from mild to severe, and may even lead to death [12-14].

With the increasing prevalence of this disease, the incidence of COVID-19 in pregnant mothers is also increasing [15]. Therefore, the prevention and control of this disease in pregnant women and the potential risk of vertical transmission to the child have become a major concern [15, 16].

COVID-19 as one of the biggest health and medical challenges in the world, continues to have an impact on human society [17]. Pregnant women also have their concerns as one of the most vulnerable groups so it is necessary to carefully examine the benefits of interventions for the mother and the fetus in terms of possible risks [15, 17].

Some studies show that the impact of infection on pregnant women is not higher than others. Although in some cases, pregnant women may be more at risk due to the lack of an immune system, with strict adherence to health protocols, possible risks can be avoided [18, 19]. Pregnancy is one of the most important life stages for every woman, it is associated with significant physiological changes that make pregnant women more susceptible to infectious diseases than other people [20, 21].

Compared to the general population, pregnant women are more sensitive to respiratory diseases and have a low immune system. In addition, physiological changes during pregnancy cause hypoxia intolerance and decrease functional residual capacity and residual volume during pregnancy, so they are susceptible to infectious diseases and serious risks [22, 23]. Physiological changes during pregnancy reduce acute inflammatory immune responses to prevent fetal rejection, which makes pregnant women more vulnerable to severe illness after exposure to viruses, especially respiratory viruses [24-26].

Considering the possible risks, the necessary measures should be taken to protect the health of pregnant women and their fetuses and babies, especially during the epidemic of infectious diseases [26].

In a study, Nikpour et al. examined pregnancy outcomes and clinical manifestations of the disease of COVID-19 in pregnant women. Their results showed that the common manifestations of COVID-19 in pregnant women included fever, cough, and muscle pain. The most common laboratory results are a decrease in blood lymphocytes and an increase in blood CRP. Complications of pregnancy and childbirth in pregnant women included an increase in premature birth and an increase in the rate of cesarean section [27].

In research, Darvishi et al investigated COVID-19 and pregnancy and showed that the most common clinical manifestations of patients are fever, cough, and muscle pain. In the laboratory tests of these patients, lymphocytes and CRP increase and also increase the rate of premature birth and an increase in the rate of cesarean section [28].

Considering that during the outbreak of infectious diseases, pregnant women and their fetuses constitute a high-risk population and limited information is available about the effects of the COVID-19 disease on the mother and the baby. Moreover, the importance of the health of mothers and their babies at all times, especially in the special conditions of the COVID-19 pandemic. This study was conducted to investigate the impact of COVID-19 on pregnant mothers and their babies to help prevent hospitalization policies in this field with a better understanding of the disease and its consequences.

2. MATERIALS AND METHODS

This is a cross-sectional (descriptive-analytical) study that population study included all pregnant women infected with COVID-19 in one year. Data was collected using the checklist prepared by the researcher with studying the medical records of the patients. In this research, 81 pregnant women suffering from COVID-19 referred to Ayatollah Kashani Hospital in Jiroft in 2021 were examined. Data collection tools according to the expected outcomes of mothers including maternal mortality, the need to be transferred to the ICU and the need for early termination of pregnancy, and the outcome of babies including mortality after birth, Apgar scores at 0 and 5 minutes after birth, and the need to be transferred to NICU. The first part of the checklist form of demographic variables included demographic variables and the second part was information about epidemiological, clinical, laboratory, radiological, and treatment characteristics. The inclusion criteria included pregnancy confirmed by ultrasound, getting infected with COVID-19 confirmed PCR test, and pregnancy over 34 weeks.

After collecting information, the data were analyzed with SPSS-V25 statistical software. Quantitative data were reported as “standard deviation ± mean” and qualitative data were reported as “number (percent)”.

3. RESULTS

In this study, 81 pregnant women infected with COVID-19 were examined in 2021. The average age of patients was 29.16 ± 6.7 years. (Table 2) shows the information about mothers with COVID-19, out of 81 people examined, 6 people (7.3%) were in the age group of 15-20 years, and 34 people (42%) were in the age group of 20-30 years. 35 people (43.2%) were in the age group of 30-40 years and 6 people (7.3%) were in the age group of 40-50 years. 12 people (14.8%) gave birth by cesarean section and 69 people (85.2%) had birth naturally. 34 people (42%) were pregnant for the first time, 24 people (29.6%) were pregnant for the second time, 17 people (21%) were pregnant for the third time, 4 people (4.9%) were pregnant for the fourth time, and 2 people (2.5%) were pregnant for the fifth time. Out of 81 people examined, only 10 people (12.3%) were using drugs.

Table 2 shows the information related to the medical history of mothers with COVID-19, 6 people (7.4%) had heart disease, 5 people (6.2%) had hyperthyroidism, 1 person (1.2%) had Convulsions, 12 people (1.2%) had anemia, 2 people (2.5%) had asthma and 4 people (4.9%) had pregnancy diabetes, as well as 8 people (9.9%) had blood pressure and 15 people (18.5%) were diagnosed with diabetes during pregnancy.

Out of the 81 people examined, 14 babies (17.3%) were transferred to NICU and 67 babies (82.7%) were not transferred to NICU. The information about the mortality of mothers with COVID-19 transferred to the ICU shows that, out of 15 patients transferred to ICU, 3 people died and out of 81 people investigated, 78 people (96.3%) were alive.

It shows information about the Apgar score at minutes 0 and 5, at minute 0, 1 person (1.2%) had a score of 7, 5 people (6.2%) had a score of 8, and 75 people (92.5%) had a score of 8. Their APGAR score was 9. Furthermore, at the 5th minute, all the babies had an Apgar score of 10.

The information about the babies who needed oxygen therapy in the NICU shows that, of the 81 patients examined, 10 (3.12%) needed oxygen therapy and 71 (7.87%) did not need oxygen therapy. None of the patients had uterine atony. Also, 6 (7.4%) needed a vacuum and 75 (92.6%) did not need a vacuum.

Information about lung involvement in the CT scan of mothers with COVID-19 shows that, out of 81 people studied, 24 people (29.6%) had lung involvement and 57 people (70.4%) had no lung involvement. Moreover, 53 people (65.4%) had shortness of breath, and the rest did not have any symptoms of shortness of breath.

4. DISCUSSION

The aim of this study was to consider the maternal outcome of patients with COVID-19 and their babies in the first 24 hours of birth in 2021 at Ayatollah Kashani Hospital in Jiroft. In this study, 81 pregnant women were investigated. The prevalence of death in mothers with COVID-19 was found to be 3.7%, in some studies, maternal death due to COVID-19 was not reported, although severe symptoms were observed in 5% of cases [29]. In a study conducted in Shiraz, among 16 cases of mothers infected with COVID-19, one case of maternal death (6.25%) was observed [30]. Compared to the deaths of mothers in non-corona conditions that were reported in 2017, 0.76% occurred around the time of childbirth [24]. It should be noted that the prevalence of death due to COVID-19 in the general population has been reported at 3.4% [31]. which is somewhat consistent with the findings of the present study. Also, the results of studies on similar viral infections caused by the coronavirus, such as influenza and SARS in 2002 and Middle East respiratory syndrome in 2012, indicate an increase in the percentage of deaths and deaths in pregnant women and the appearance of fetal complications [7].

In the present study, there was no more cesarean section in these people, in the same way, in the study of Moia et al., 2 babies were born by cesarean section [indication = 1 case of decollement and 1 case of non-progress of labor] and 5 babies were born naturally [25], contrary with the results of the present study in other countries, we can refer to Chen et al.'s study that all mothers underwent cesarean section [18], in Zhu et al.'s study, 7 women out of 9 women studied underwent cesarean section [22]. In a systematic review of Scoping Review, Al-Shafaei et al. showed that 33 studies were conducted on 385 pregnant women (369 with mild type, 14 with severe type, and 3 with critical condition) reported that 69.4% of the cases had been delivered by cesarean section, which could be caused by the fear of the treatment team for the natural delivery of these people [9].

14.8% of pregnant women infected with COVID-19 had a premature birth. Regarding preterm delivery, different numbers have been reported in other countries. For example, Mullins reported that 42% of mothers with COVID-19 had preterm delivery [32]. Chen et al. reported that 9 mothers in 2 weeks, week 36 pregnancies were delivered by cesarean section and [18], Zhu et al., reported that 9.5% of women had preterm delivery [22]. Wang et al. reported that one woman had preterm delivery due to fetal distress [33]. Also, in the study of Sarna et al., it has been shown that infection with COVID-19 is associated with an increase in preterm delivery. The cause of preterm delivery in two recent studies is the use of retroviral drugs for mothers, which induce labor [34].

The Apgar score of the examined infants at minute 0 was higher than 7, and the death of the infant was not found. In this regard, in the study of Chen et al., all babies had an Apgar score above 8 in 1 to 5 minutes after delivery, and none of the babies had neonatal asphyxia or death [18]. In a study by LIU et al., they reported the results of their study about neonatal outcomes in China. The Apgar score was 8 or higher at minute 5 and no infant had asphyxia and no infant death was found [5]. The results of the study by YU et al. showed that out of 7 babies born to mothers infected with COVID-19, all were healthy with Apgar ≥9, and none of them had infant asphyxia [23]. In Yang et al.'s study, in connection with 9 women with COVID-19 who were in their third trimester of pregnancy, no fetal death, infant death, or asphyxia was reported, and none of these cases occurred in four infants. It was not observed due to the COVID-19 infection. It is worth noting that the 5-minute Apgar score of all infants was 9 or more than 5 [35].

18.5% of women with COVID-19 were transferred to the ICU, in the study by Zaghim et al., which was conducted on 108 pregnant women with COVID-19 infection, 91% of them had a cesarean section and 20% were in the intensive care unit. Mothers were hospitalized, but no maternal deaths were observed [36]. It was also reported in a study that about 30% of pregnant women were infected with SARS-COV-2, were hospitalized in the intensive care unit, and about 22% of them needed mechanical ventilation, and the death rate in these women was 25 percent [37].

Most pregnant women had shortness of breath. In pregnant women, due to the weakness of the immune system and physiological changes in the respiratory system [decrease in the height of the diaphragm, increase in oxygen consumption, edema of the mucous membrane of the respiratory tract], their tolerance to hypoxia decreases. Respiratory problems will increase in pregnant women infected with COVID-19 [38]. In Chen et al.'s study, the clinical symptoms are such that 44% experienced cough, and 33% experienced shortness of breath [18]. During pregnancy, lung volume, including functional residual capacity, expiratory volume, residual volume, and the total capacity of the lungs decreases with the enlargement of the uterus, in addition, pregnancy leads to an increase in oxygen consumption. Accordingly, pregnant women are susceptible to respiratory failure due to the infection caused by COVID-19 [38]. In a study, they also concluded that acute respiratory syndrome and Middle East respiratory syndrome during pregnancy cause severe complications such as the need for chip placement, ICU care, kidney failure, and death [7].

In the present study, 29.6% had lung involvement, which was obtained in different studies, this percentage was higher than in the present study, which may be due to geographical conditions and differences in sample size. Here we will refer to some of these studies, in a study they reported the results of radiographs of mothers infected with the coronavirus as follows, 88.8% of pregnant mothers had lung involvement, and 5 out of 9 infected pregnant mothers showed it in their lungs. Double-sided frosted glass, 3 pregnant mothers' lungs contained a piece of solidification, but in one pregnant woman, no problems were observed and her lung was clean and without infusion [18]. Liu et al. used a 5-point scale to evaluate pulmonary involvement with CT scans. The classification of pulmonary involvement was as follows: 0: no involvement, 1: involvement less than 5%, 2: involvement less than 25%, 3: involvement between 25 and 49%, 4: involvement between 50 and 75%, and 5: more than 75 percent. In this study, 12 pregnant mothers were in Classification 4, 5 pregnant mothers were in Classification 3, and 4 were in Classification 2. The CT scan images obtained before and after delivery did not show any signs of aggravation of pneumonia after delivery [5]. In Zhu et al.'s study, before treatment, the CT scan of the pregnant women in the study showed typical changes in viral pneumonia, such as bilateral diffuse ground-glass opacities, stained lungs, and patchy margins. As the disease progressed, lung lesions increased, but after treatment, the lesions disappeared [23].

One of the advantages of this study is the research on the target group at risk and sensitive (pregnant women and babies), which are at greater risk of getting involved with COVID-19 and its complications. So until this study was done, there was not enough research in this field. Considering that pregnancy and childbirth may cause more risks for this group of patients, further study in this field can help us find better strategies to prevent and manage this disease in pregnant women and infants. Furthermore, research in this field can help doctors and specialists to be trained for better management and more effective treatment for this group of patients.

CONCLUSION AND RECOMMENDATIONS

This study showed that maternal complications, especially maternal death, were higher than expected in the study group, even considering the statistics of non-infected pregnant people. In other words, pregnant women with COVID-19 have a higher risk of death and maternal problems.

Regarding the results of neonatal symptoms, this research showed that there was no significant increase in the studied neonatal symptoms. Also, in this study death of the baby was not reported. However, it should be noted that the complications of COVID-19 in infants can also be serious, therefore more research on the complications of COVID-19 in pregnant women and infants will give us a better understanding of the risks and diseases associated with them and can help improve the health of this group of patients.

The most important strategy to prevent the infection and complications of COVID-19 in mothers and babies is to take preventive measures to prevent the infection of pregnant mothers and to minimize the possibility of infection of babies. Therefore, mothers and babies should be monitored according to the guidelines for the management of isolation before delivery, during delivery, and after delivery.

LIMITATIONS OF THE STUDY

One of the limitations of this study is the error percentage of the PCR test of COVID-19, which currently does not have a preferred method to reduce the error. Considering maternal and newborn complications in pregnant women with COVID-19 seems that reducing the risk of infection in mothers and babies is one of the important ways to prevent these complications. Therefore, it is suggested that high-risk mothers and babies use pre-delivery, delivery, and post-delivery isolation guidelines. In addition, the need to conduct longitudinal studies with a larger sample size in Iran can be helpful.

REFERENCES