European Journal of Cardiovascular Medicine

Bangladesh ranked 9th in the world in terms of the greatest anticipated birthrate since COVID-19 outbreak. (UNICEF, 2020) COVID-19 had been emerged as a global pandemic, having the manifestation of respiratory tract infection with high rate of contamination, high rate of case fatality, which still doesn’t have any definitive cure. The first diagnosed case of COVID-19 found in Wuhan, China on December 2019.(World Health Organization, 2020) In Bangladesh, the first case was detected on 8th of March, 2020.(IEDCR, n.d.) Till date, 539 million infected cases with a total 6.32 million deaths have been attributed worldwide.(COVID Live - Coronavirus Statistics - World meter, 2022) In Bangladesh, due to this disease more than 2 million infected cases and approximately 30 thousand fatalities have been reported.(WHO, 2023) Varied rate of infection among different subgroup of population have been witnessed. Previous pandemic experiences indicated that, pregnant women remain susceptible to worsened outcomes compared to other population groups in terms of severity of infection and fatality.(Rasmussen et al., 2008) Despite the fact that, COVID 19 has not contributed in increased maternal or neonatal death, however, the illness severity of the pregnant women may surpass that of the non-pregnant women requiring for increased intensive care requisite.(Collin et al., 2020; Delahoy et al., 2020; Ellington, 2020; L et al., 2020) Corona virus infection reportedly increases the likelihood of spontaneous abortion, preeclampsia, stillbirth, preterm birth, caesarean deliveries.(Doré lien, 2019; Schwartz & Graham, 2020; Wei et al., 2021a) Along with physiological determinants, health system and health seeking factors also influence the pregnancy outcomes during this pandemic period. Restriction of movement, social distancing, fear of being infected resulted in low rate of maternal health checkups which can consequent in adverse pregnancy outcomes. (Ariani, 2022) Pregnancy specific clinical data on COVID-19 infection and consequences are scarce in our country. This research work thus attempted to evaluate pregnancy outcomes in pregnant women who tested positive with COVID at the time of delivery and compared the outcomes with non-COVID pregnancies to broaden the existing knowledge on this matter.

Subjects and methods: With a retrospective comparative observational study design, this research work has been conducted in Border Guard Hospital, Dhaka, Bangladesh among 68 randomly selected single tone non-complicated pregnancy cases who were admitted in the hospital in their third trimester to attain medical care for delivery purpose. The study has been carried out between the period of March 2023 to October 2023. Hospital records of patients who were admitted between July 2022 to February 2023 have been evaluated.

Sample selection: Pregnant women who tested with RT-PCR and diagnosed COVID positive or negative have been selected as sample who met the study selection criteria. Patients with history any significant morbidity remained excluded from the study.

Data collection and analysis: Data regarding maternal and perinatal outcomes have been inspected. Demographic data, clinical findings, reproductive characteristics and lab investigations have been compared among the COVID and non-COVID cases. IBM-SPSS software version 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp) has been used to analyse the data.

Ethical approval: Ethical clearance have been obtained from the respective hospital’s ethical review board before commencing the study.

The study sample comprised of 19 to 35 years old respondents, mostly aged between 21 to 25 years (58.8%) of respondents. Majority of the respondents have literacy level up to SSC and HSC level and all of the respondents were housewives. Followers of the Islam religion was predominant. In most cases gravida of the respondents was 2 were less (58.82% of the COVID 19 positive cases and 70.6% of the COVID 19 cases). Diabetic mellitus, gestational diabetes and pregnancy induced hypertension was evident among 5.9%, 5.9%, and 11.8% of the COVID 19 positive respondents and 5.9%, 23.53%, and 5.9% of the COVID 19 negative respondents (respectively). The sex of the newborn was male in 78.6% of the COVID 19 positive respondents and 52.9% of the COVID 19 negative respondents. The COVID cases were mostly asymptomatic and only 14.7% cases had mild symptoms (Table 1).

The evaluation of clinical presentation showed that, oxygen saturation and temperature were insignificantly lower and higher in COVID positive cases compared to COVID 19 negative cases (p>0.05). Pulse was significantly increased in COVID positive group and systolic blood pressure was significantly increased in COVID negative group in this study (p<0.05). Diastolic blood pressure was increased in COVID negative group but this difference was not statistically significant (p>0.05) (Table 2).

The mean difference of gestational age at delivery between the COVID 19 positive and negative cases showed statistically significant difference, where the mean was lower among COVID positive cases (p<0.05). The mean duration of hospital stay was statistically significantly higher among COVID positive cases compared to COVID 19 cases (p<0.05). Among the other maternal consequences, this study observed, prolonged labor was evident only among COVID positive cases (5.88%). Most of the deliveries conducted with LUCS where the proportion was higher among COVID positive cases. Preterm delivery was recorded in 35.29% of the COVID positive cases compared to 17.65% of the COVID negative cases. Additionally, ante-partum and post-partum complications were found in 35.29% and 5.88% of the COVID positive cases. Oxygen therapy and intensive care treatment were required by 52.94% and 29.41% of the COVID positive cases (p>0.05) (Table 3).

The fetal outcome and neonatal consequences were insignificantly different among COVID positive and negative cases (p>0.05). The mean birth weight found to be nearly similar in both groups. Although, fetal distress, oxygen therapy or NICU requirement found to be nil among the COVID negative cases. Less fetal movement recorded in 5.88% of the COVID negative cases. Breathing difficulties have been exhibited by 5.88% of the newborns from COVID mothers (Table 4).

The clinical data of 68 pregnancy outcomes of this study who contracted the COVID infection at their third trimester compared to infection-free pregnancy cases demonstrated that, COVID infections had a greater impact on maternal outcomes than on fetal or neonatal outcomes. The age range of 21 to 25 years is represented by about 60% of the study sample. Maternal outcomes include, significantly lower gestational age at delivery and significantly higher duration of hospital stay among COVID mothers (p<0.05). Most of the deliveries conducted with LUCS where the proportion was higher among COVID positive cases (p>0.05). Among other maternal consequences, prolonged labour, preterm delivery, ante-partum and post-partum complications, requirement of oxygen therapy and intensive care treatment were also found to be higher in proportion among COVID positive cases, though these findings were statistically insignificant (p>0.05).

Previous research on the effects of influenza infection during pregnancy indicated that late-pregnancy infections were associated with greater incidence of preterm birth (PTB) and caesarean delivery. (Doré lien, 2019) Several studies, evaluated COVID19 impact on pregnancy outcomes from multiple aspects. Wei et al. observed that, COVID19 infection in pregnancy was associated with 1.82 times heightened risk of preterm birth, and 4.78 times heightened risk of ICU admission.(Wei et al., 2021b) Moni et al. found similar observation as the present study about the comparison of gestational age at delivery among COVID and non-COVID pregnancies and showed that, gestational age at delivery was significantly lower among COVID mothers.(Moni et al., 2022) Binte et al. also found that, higher proportion of COVID positive mothers deliver their babies before due date compared to the COVID negative mothers.(Binte Masud et al., 2021) Studies evaluated impact of COVID19 infection on pregnancy outcome in terms of onset of infection by trimester found that, preterm birth risk is not elevated if the infection occurs in first or second trimesters. However, they found that, preterm birth rates were 2.76 times more frequent among women who got infected in their third trimester. They also found that, when infected after the gestational age of 34 weeks, the chances of preterm birth increase up to 7 times.(Falloch et al., 2022) Although, Piekos et al. showed that, COVID infection at any trimesters of pregnancy have increased incidence of preterm births.(Piekos et al., 2022) Studies also found that, COVID-19 pregnancies compared to non-COVID pregnancies are not associated with gestational diabetes, caesarean delivery, complication in the postpartum period or neonatal death.(Wei et al., 2021b) However some findings also suggested that, COVID mothers are significantly more prevalent with gestational diabetes.(Wei et al., 2021b)

Among the fetal and newborn consequences, fetal distress, requirement of oxygen therapy and NICU admission, breathing difficulties found to be evident only among COVID positive cases (p>0.05). Mean birth weight was nearly similar among both of the groups (p>0.05). Review studies also found that, NICU admission found to be more frequent among newborn born from COVID mothers than the non-COVID mothers. (Smith et al., 2020) Findings from the study of Verma et al. also depicted that, newborns of COVID mothers were more frequent with respiratory distress, requiring for NICU admission and mechanical ventilation. (Verma et al., 2020).

The evaluation of clinical presentation showed that, oxygen saturation and pulse readings were within normal range among all respondents, however, oxygen saturation and temperature were insignificantly lower and higher in COVID positive cases compared to COVID 19 negative cases (p>0.05). Though pulse and blood pressure were within normal range for all respondents, still pulse was significantly increased in COVID positive group and systolic blood pressure was significantly increased in COVID negative group in this study (p<0.05). Diastolic blood pressure was increased in COVID negative group but this difference was statistically insignificant (p>0.05). However, various studies have found that, COVID19 in pregnancy is associated with increased risk of preeclampsia, compared to that of non-COVID19 cases which is unlike what we have discovered. (Conde-Agudelo & Romero, 2022; Villar et al., 2021; Wei et al., 2021b)

This study comprised of asymptomatic or mild cases of COVID 19 pregnancy cases who showed higher prevalence of LUCS, prolonged labor, preterm delivery, ante-partum and post-partum complications, requirement of oxygen therapy and intensive care treatment compared to non-COVID pregnancy cases. Gestational age at delivery and duration of hospital stay was significantly impacted by COVID infection. Fetal distress, breathing difficulties, requirement of oxygen therapy and NICU admissions were manifested in fetus and newborns of COIVD infected mothers only.

1. Ariani, N. (2022). Antenatal care services utilization during COVID-19 second wave attack in Pasuruan, Indonesia. Journal of Medicine and Life, 15(1), 7–14. https://doi.org/10.25122/jml-2021-0238
2. Binte Masud, S., Zebeen, F., Alam, D. W., Hossian, M., Zaman, S., Begum, R. A., Nabi, M. H., & Hawlader, M. D. H. (2021). Adverse Birth Outcomes Among Pregnant Women With and Without COVID-19: A Comparative Study From Bangladesh. Journal of Preventive Medicine and Public Health, 54(6), 422–430. https://doi.org/10.3961/jpmph.21.432
3. Collin, J., Byström, E., Carnahan, A., & Ahrne, M. (2020). Public Health Agency of Sweden’s Brief Report: Pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 infection in intensive care in Sweden. Acta Obstetricia et Gynecologica Scandinavica, 99(7), 819–822. https://doi.org/10.1111/aogs.13901
4. Conde-Agudelo, A., & Romero, R. (2022). SARS-CoV-2 infection during pregnancy and risk of preeclampsia: A systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 226(1), 68-89.e3. https://doi.org/10.1016/j.ajog.2021.07.009
5. COVID Live—Coronavirus Statistics—Worldometer. (2022, June 20). https://www.worldometers.info/coronavirus/
6. Delahoy, M. J., Whitaker, M., O’Halloran, A., Chai, S. J., Kirley, P. D., Alden, N., Kawasaki, B., Meek, J., Yousey-Hindes, K., Anderson, E. J., Openo, K. P., Monroe, M. L., Ryan, P. A., Fox, K., Kim, S., Lynfield, R., Siebman, S., Davis, S. S., Sosin, D. M., … COVID-NET Surveillance Team. (2020). Characteristics and Maternal and Birth Outcomes of Hospitalized Pregnant Women with Laboratory-Confirmed COVID-19—COVID-NET, 13 States, March 1-August 22, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(38), 1347–1354. https://doi.org/10.15585/mmwr.mm6938e1
7. Dorélien, A. (2019). The Effects of In Utero Exposure to Influenza on Birth and Infant Outcomes in the US. Population and Development Review, 45(3), 489–523. https://doi.org/10.1111/padr.12232
8. Ellington, S. (2020). Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status—United States, January 22–June 7, 2020. MMWR. Morbidity and Mortality Weekly Report, 69. https://doi.org/10.15585/mmwr.mm6925a1
9. Fallach, N., Segal, Y., Agassy, J., Perez, G., Peretz, A., Chodick, G., Gazit, S., Patalon, T., Tov, A. B., & Goldshtein, I. (2022). Pregnancy outcomes after SARS-CoV-2 infection by trimester: A large, population-based cohort study. PLOS ONE, 17(7), e0270893. https://doi.org/10.1371/journal.pone.0270893
10. (n.d.). COVID-19 General Information. IEDCR. Retrieved June 7, 2022, from https://iedcr.gov.bd/covid-19/covid-19-general-information
11. L, P., Tr, M., J, G., Hs, L., Eo, K., Ds, R., Jtb, W., Al, N., Np, K., Sj, H., Sj, J., Jm, G., La, J., Tt, S., & Es, W. (2020). SARS-CoV-2 Infection Among Hospitalized Pregnant Women: Reasons for Admission and Pregnancy Characteristics - Eight U.S. Health Care Centers, March 1-May 30, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(38). https://doi.org/10.15585/mmwr.mm6938e2
12. Moni, S. C., Saha, J., Ahmed, Q. N., Jahan, I., Jahan, M. A., Sheela, F. A., Mannan, M. A., & Shahidullah, M. (2022). Impact of SARS-CoV-2 Infection during Pregnancy and Perinatal Outcome: Findings from Private Hospitals at Dhaka, Bangladesh. Journal of Bangladesh College of Physicians and Surgeons, 40(4), Article 4. https://doi.org/10.3329/jbcps.v40i4.61889
13. Piekos, S. N., Roper, R. T., Hwang, Y. M., Sorensen, T., Price, N. D., Hood, L., & Hadlock, J. J. (2022). The effect of maternal SARS-CoV-2 infection timing on birth outcomes: A retrospective multicentre cohort study. The Lancet Digital Health, 4(2), e95–e104. https://doi.org/10.1016/S2589-7500(21)00250-8
14. Rasmussen, S. A., Jamieson, D. J., & Bresee, J. S. (2008). Pandemic influenza and pregnant women. Emerging Infectious Diseases, 14(1), 95–100. https://doi.org/10.3201/eid1401.070667
15. Schwartz, D. A., & Graham, A. L. (2020). Potential Maternal and Infant Outcomes from Coronavirus 2019-nCoV (SARS-CoV-2) Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses, 12(2), 194. https://doi.org/10.3390/v12020194
16. Smith, V., Seo, D., Warty, R., Payne, O., Salih, M., Chin, K. L., Ofori-Asenso, R., Krishnan, S., da Silva Costa, F., Vollenhoven, B., & Wallace, E. (2020). Maternal and neonatal outcomes associated with COVID-19 infection: A systematic review. PloS One, 15(6), e0234187. https://doi.org/10.1371/journal.pone.0234187
17. (2020). Pregnant mothers and babies born during COVID-19 pandemic threatened by strained health systems and disruptions in services. https://www.unicef.org/bangladesh/en/press-releases/pregnant-mothers-and-babies-born-during-covid-19-pandemic-threatened-strained-health
18. Verma, S., Bradshaw, C., Auyeung, N. S. F., Lumba, R., Farkas, J. S., Sweeney, N. B., Wachtel, E. V., Bailey, S. M., Noor, A., Kunjumon, B., Cicalese, E., Hate, R., Lighter, J. L., Alessi, S., Schweizer, W. E., Hanna, N., Roman, A. S., Dreyer, B., & Mally, P. V. (2020). Outcomes of Maternal-Newborn Dyads After Maternal SARS-CoV-2. Pediatrics, 146(4), e2020005637. https://doi.org/10.1542/peds.2020-005637