COVID-19 INFECTION IN PREGNANCY: A DESCRIPTIVE CROSS-SECTIONAL STUDY

The RT-PCR infecon in up unl


INTRODUCTION
The coronavirus disease 2019 , caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly infec ous disease and has had a major impact 1 worldwide. It has affected almost every country including Nepal and has become a major global health threat. The World Health Organiza on (WHO) declared COVID-19 2 infec on as a global pandemic on March 11, 2020. Transmission occurs mainly through contact with respiratory 3 droplets produced by an infected person. Measures to control and prevent the infec on, such as adherence to universal precau ons, quaran ne, and mely diagnosis to 4 control the transmission of SARS-CoV-2. COVID-19 causes 5 common cold to severe Acute Respiratory Syndrome. Viral pneumonia is one of the leading cause for death during the 6 pregnancy worldwide. Pregnant women undergo physiological and immunologic changes to support and protect the developing foetus, which lead to altered immune systems, which result in an altered response to SARS-CoV-2 infec on in pregnancy, could poten ally affect the severity of COVID-19 during pregnancy. High heart rate, oxygen consump on, stroke volume, and reduc on in the lung capacity and func onal residual capacity are major physiological changes that affect the cardiovascular and respiratory systems at the me of the pregnancy leading to more chances of developing the complica ons due to SARS- 8,9 CoV-2 infec on in pregnancy than non-pregnant popula on. Most people with COVID-19 experience mild to moderate disease, COVID-19 can cause severe disease or death, par cularly in high-risk pa ents such as the elderly and 10 those with underlying co-morbidi es condi ons. The SARS-CoV-2 virus can be transmi ed from the mother to the [11][12][13] newborn, although this rarely occurs.
There have been rare reports of suspected ver cal transmission of SARS-CoV- 14,15 2 virus. Mother-to-child transmission typically occurs by postnatal exposure and infec on. Neonates with SARS-CoV- 16,17 2 virus infec on typically have a mild illness.
The health care facility should be well equipped for early detec on and managements of maternal course of illness and obstetric 18 complica ons e.g., preterm labour or other foetal compromise. Royal college of Obstetricians and Gynaecologists (RCOG) reports that pregnant women are no more likely to infected with SARS-CoV-2, clinical course and severity of COVID-19 in 19 pregnancy is similar to the general popula on, but the centers for disease control and preven on (CDC) report that pregnant women with COVID-19 manifest a more severe 20 disease when infected with SARS-CoV-2. Principles of management of COVID-19 in pregnancy include early isola on, aggressive infec on control, early iden fica on of complica ons and iden fica on of co-morbidi es condi ons. Oxygen therapy, prophylac c an bio cs for preven on of superimposed bacterial infec on and early intuba on should be considered if there is a respiratory failure. Planning of delivery should be based on obstetrics 21 indica on. There are limited studies available throughout the world regarding the outcomes of COVID-19 during pregnancy, differences in clinical course, and the poten al risks to the unborn child and no studies were done in Nepal. Therefore, this study was conducted with the aim to gather informa on regarding the clinical manifesta ons, various maternal, obstetric and neonatal outcomes of SARS-CoV-2 infec on in pregnancy.

METHODOLOGY
A descrip ve cross-sec onal study was conducted during the second wave of COVID-19 in the Department of Obstetrics and Gynaecology, antenatal ward of Birat Medical College Teaching Hospital from April 3 to July 3, 2021. Ethical clearance was taken from the Ins tu onal Review Commi ee of Birat Medical College Teaching Hospital. All pregnant women admi ed to antenatal ward were sent real-me reverse transcrip on polymerase chain reac on(RT-PCR) for SARS-CoV-2 infec on. The pregnant women with RT-PCR confirmed SARS-CoV-2 infec on cases were enrolled in the study and followed up ll discharged from the hospital. All pregnant women with confirmed SARS-CoV-2 infec on were shi ed immediately to Birat Medical College Teaching Hospital COVID ward, another COVID hospital designated by the Government of Nepal or advised for home quaran ne and self-isola on to prevent infec on to other pa ents and health care providers. The par cipants were explained about the aim of study and informed consent was taken prior to data collec on. Only those women who had given consent for study were enrolled in the study. Structured ques onnaires were used to gather informa on regarding the clinical manifesta ons, various maternal, obstetrics and fetal complica ons of COVID-19 in pregnancy. Face to face interview and pa ents inpa ents record file was used for data collec on by the researcher, using a preformed proforma. Confiden ality was maintained throughout the study. The collected data were entered in Microso Excel and analyzed by using SPSS version 22. Data were presented using descrip ve sta s cs in frequency, percentage, mean and standard devia ons.

RESULTS
During the study period, 411 pregnant women RT-PCR for SARS-CoV-2 infec on were sent. Among them, 74 (18.0%) of pregnant women were found to be infected with SARS-CoV-2 virus. The posi vity rate was 18.0%. The age of the pregnant women were in the range of 18 to 41 years, with mean age and standard devia on of 24.38 ± 5.10 years. The age distribu on of pa ents are shown in table 1.      23 second wave of COVID-19. This is because during the peak of the second wave of the SARS-CoV-2 infec on, infec on was spread all over Nepal. We found that 95.5% of pregnant women didn't give any history of contact with COVID-19 pa ents. This is because SARS-CoV-2 virus infec on had spread in the community, most people had asymptoma c SARS-CoV-2 infec on and most of the people SARS-CoV-2 infec on status was not known. SARS-CoV-2 infec on could be transmi ed even from the infected asymptoma c 24 individuals. In our finding the 82.4% infected women were between 21 to 30 years of age. This finding is similar to a 25 study done by Sharma et al. reported that the popula on of the age group 21 to 30 years is more infected with SARS-CoV-2 virus. The reason behind such distribu on of SARS-CoV-2 infec on is that, this is the age when most of the females become pregnant and this age group of females works outside the house so more chance of SARS-CoV-2 infec on. We found 79.7% of pregnant women with SARS-CoV-2 infec on were asymptoma c. Among symptoma c women 73.3% had fever and respiratory symptoms, 26.6% pregnant women with SARS-CoV-2 infec on had other symptoms like fa gue, myalgia, joint pain, loss of taste and smell. This was similar to RCOG guideline, Coronavirus infec on in pregnancy reported that more than two-thirds of pregnant women with SARS-CoV-2 infec on have no symptoms and the most common symptoms of SARS-CoV-2 19 infec on in pregnancy are cough and fever. Allotey et al.also reported that pregnant women with SARS-CoV-2 26 infec on are less likely to manifest symptoms. Sathian et al. et al also reported that the clinical presenta on of pregnant women with COVID-19 is comparable with the SARS-CoV-2 infected non-pregnant females, and the frequent symptoms were fever, cough, myalgia, sore throat 23 and malaise. Pregnant women were not found to be at higher risk for COVID-19 than women who are not pregnant. However pregnant people with symptoma c COVID-19 may experience more adverse outcomes compared to non- 27 pregnant people. Hazari et al.reported that pregnant women had a much more severe course of illness compared to non-pregnant women with the COVID-19. They had more ICU admissions and suffered more complica ons of COVID- 28 19, such as risk for miscarriage and preterm deliveries. In our study pregnant women require admission in hospital for 1 day to 29 days with mean days of hospital stay and standard devia on of 2.24 and 3.487 respec vely. Four pregnant women had severe COVID-19 infec on, required ICU admission and oxygen support while one required mechanical ven la on. There was one maternal mortality (1.4%). This was similar to study done by Joshi RK et al, case 29 fatality rate during second wave of COVID-19 was 1.5%. According toRCOG guideline overall risk of maternal death 19 remains very low in SARS-CoV-2 infec on in pregnancy. The case fatality rate is low in our study, this is because in our study most of the pregnant women (82.4%) were of age group 21 to 30 years, only one pregnant women had comorbidity and majority of pregnant women were asymptoma c (79.7%) SARS-CoV-2 infec on. Case fatality rate in COVID-19 varied considerably with age and case fatality sharply increase beyond 40 years of age and more than 18% beyond 60 years and is strongly associated with 30 comorbidi es. We found that COVID-19 in pregnancy increased the risk of pregnancy complica ons like preterm labour occurs in 12.2% of pregnancy followed by premature rupture of membranes occurs in 6.8% of pregnancy, foetal distress occurs in 5.4% of pregnancy, and s llbirth occurs in 2.7% of pregnancy. This finding is supported by several studies that COVID-19 in pregnancy increases the risk of preterm labour and premature rupture of membranes 28,[31][32][33] (PROM). In contrast to our finding, a study done by Murphy et al.reported COVID-19 in pregnancy does not 34 increase in the incidence of preterm birth. and byYu et al. has reported the maternal, foetal outcomes of COVID-19 in 35 pregnancy appeared very good. In our study caesarean sec on rate is 36.5 % which is comparable to caesarean sec on rate of non COVID-19 pregnancy at ter ary care 36 referral centre of eastern Nepal. But Overtoom et al.reported that COVID-19 infec on in pregnancy increased 37 risk of caesarean sec on and ICU admission. Allotey et al. reported that pregnant women with COVID-19 were associated with serious complica ons such as admission to intensive care unit, need of mechanical ven la on and maternal death than non-pregnant women of reproduc ve 26 age. A meta-analysis done by Wei SQ reported that COVID-19 in pregnancy was associated with preterm birth, s llbirth but not with increased risk of caesarean delivery compared 38 with non COVID-19 pregnancy. But Symptoma c COVID-19 in pregnancy was associated with an increased risk of caesarean delivery as compared with asymptoma c COVID- 38 19 in pregnancy.

CONCLUSION
Symptoma cally, clinical course and severity of COVID-19 in pregnancy is comparable to non-pregnant women with COVID-19 but associated with increased risk of pregnancy complica ons like Preterm labour, premature rupture of membranes, foetal distress and s llbirth.

RECOMMENDATIONS
The pregnant woman's health is very important and needs proper care during this rapidly increasing COVID-19 pandemic. Mul disciplinary care is necessary for proper management of pregnant women with COVID-19. The proper evalua on and treatment is necessary, considering both maternal and fetal outcomes in COVID-19 in pregnancy.

LIMITATIONS OF THE STUDY
The en re course of COVID-19 infec on in pregnant women could not be assessed as pa ents were discharged.