Intepretation
Contrary to finding from a recent study in London United Kingdom that reported a significant increase in the incidence of stillbirth during COVID-19 pandemic vs the prepandemic period9, our study demonstrated no significant difference in adverse obstetric outcome between both periods. Although differences in study demography may have played a role in outcome differences, the significant increase in antenatal growth scans performed during the pandemic in our study may have contributed to a much reduced stillbirth rate. Furthermore, despite the significant reduction in antenatal in-patient admissions and face-to-face antenatal consultations during the pandemic which are established risk factors for adverse obstetric outcomes5,7, the obstetric outcomes (perinatal and maternal) prepandemic vs during the pandemic are comparable. The increase in antenatal scans during the pandemic may have played a significant role in mitigating the resultant adverse impacts from these risk factors.
The association between COVID-19 infection and poor maternal outcome in pregnant women with severe infection has been established from previous studies1,10, however, ongoing controversies abound about the risk to babies of infected mothers8. The evidence is conflicting, and while some studies have demonstrated the absence of coronavirus in amniotic fluid, nasopharyngeal, cord blood, and placental specimens1,10,11, others have reported an increased risk of vertical transmission12,13. In the national cohort study using the UK Obstetric Surveillance System (UKOSS), 2.5% of babies (n=6) had a positive nasopharyngeal swab within 12 hours of birth4. In our study, no case of vertical transmission was seen (all 9 women who tested positive to SARS-CoV-2 infection had good perinatal outcome and none of their babies tested positive to the virus).
It is unlikely that the trend towards adverse perinatal outcome seen in this study could have been due to the direct impact of coronavirus on pregnancy. A major risk factor for poor obstetric outcome is the failure to seek urgent care when necessary particularly in high risk women such as those with intrauterine growth restriction, hypertensive disorders, diabetes, or those with reduced fetal movements. This problem was particularly heightened in the early stages of the pandemic when women did not attend their routine appointments because of fear of contracting the virus or anxiety surrounding changes in obstetric care4.
The significant reduction in general anaesthesia as well as small increase in labour epidural during the pandemic are consistent with recommendations from several professional bodies including the Royal College of Anaesthetists-Obstetric Anaesthetists’ Association (RCOA-OAA), and the Royal College of Obstetricians and Gynaecologists (RCOG)8,14. General anaesthesia is an aerosol-generating procedure and associated with increased risk of transmission of SAR-CoV-2 infection. Consideration for early regional (epidural) analgesia for pain relief in labour is recommended to reduce the need for general anaesthesia in the event of a category 1 emergency caesarean section14. In this study, all the women who tested positive to SAR-CoV-2 infection and delivered by caesarean section had spinal anaesthesia.