key: cord-0721745-oxkhy5a5 authors: Mahajan, Niraj N.; Pednekar, Rahi; Gaikwad, Chaitanya; More, Prajakta; Pophalkar, Madhura; Kesarwani, Shweta; Jnanananda, Bhargavi; Mahale, Smita D; Gajbhiye, Rahul K title: Increased spontaneous preterm births during the second wave of the coronavirus disease 2019 pandemic in India date: 2021-11-05 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.13991 sha: 24f0254b1608950295cbb019f4b75d4f222a79cd doc_id: 721745 cord_uid: oxkhy5a5 OBJECTIVE: To compare spontaneous preterm birth (SPTB) and iatrogenic preterm birth (IPTB) rates during both waves of the coronavirus disease 2019 (COVID‐19) pandemic. METHODS: Retrospective analysis of the PregCovid registry of pregnant women with COVID‐19 was performed at a dedicated COVID‐19 hospital in Mumbai, India. The data of 1630 women were analyzed for this study between April 4, 2020 and July 4, 2021. Prepandemic data were analyzed and compared with pandemic data. Main outcome measure was spontaneous preterm birth rate. RESULTS: Preterm deliveries were higher during the second wave (46/329; 14%) compared with the first wave (82/807; 10.2%) of the COVID‐19 pandemic (P = 0.065). Higher SPTBs were reported during the second wave than the first wave (12.5% versus 8.3%) (P = 0.03) as well as the prepandemic period (12.5% versus 10.5%) (P = 0.286). IPTBs were significantly lower in the pandemic period than in the prepandemic period (1.8 versus 3.3) (P = 0.012). CONCLUSION: In Mumbai, India, we found an unusual change in SPTBs during the 6 months of the second wave of COVID‐19 compared with the previous 10 months of the first wave of pandemic and 1 year of prepandemic. women during the second wave of the COVID-19 pandemic in India. 8 Therefore, we aimed to analyze preterm deliveries and compare the rates of spontaneous preterm births (SPTBs) and iatrogenic preterm births (IPTBs) during the first and second waves of COVID-19. The SPTBs and IPTBs during the pandemic were compared with those in the pre-pandemic period. We conducted a hospital-based, retrospective cohort study using data from the PregCovid registry database at BYL Nair Charitable Hospital (NH), Mumbai, India. The data of women with COVID-19 and PTB admitted to NH, Mumbai, India from April 4, 2020 to July 4, 2021. 9 Details of the PregCovid registry protocol and data collection methods are described elsewhere. 10 Data from 1630 pregnant and postpartum women with COVID-19 were analyzed for this study. PTB was defined as all births before 37 completed weeks of gestation. 11 PTBs were further classified as spontaneous (due to spontaneous preterm labor, or preterm prelabor rupture of membranes [PPROM]), or Iatrogenic (due to provider-initiated cesarean, or labor induction, for a maternal, or fetal indication). 12 Gestational age was calculated based on last menstrual period and obstetric ultrasound. PTBs were subcategorized based on gestational age: extremely preterm (less than 28 weeks); very preterm (28-32 weeks); and moderate to late preterm (32-37 weeks). The COVID-19 pandemic period was divided into two waves: a first wave from April 1, 2020 to January 31, 2021 and the second Table S1 ). The study demonstrates increased SPTB rates in the second wave compared with the first wave of the COVID-19 pandemic and the prepandemic period. In the present study, the SPTB rate during the first wave of the COVID-19 pandemic was 8.3%, higher than the SPTB rate reported during the first wave in the UK (4.9%) 2 and Spain (6.1%). 3 The majority of the SPTBs in the present study were due to preterm labor, as PPROM was reportedly low (12%) during the COVID-19 pandemic period. The etiology of SPTB during the COVID-19 pandemic is largely unclear and possibly multifactorial, hampering effective prevention. 12 The In the present study, the SPTB rate during the first wave of the COVID-19 pandemic was 8.3%, higher than the SPTB rates reported during the first wave in the UK (4.9%) 2 and Spain (6.1%). 3 This could be because of the higher number of women who were anemic (58%) contributing to PTB in our cohort. In contrast to other studies, from the UK 2 and Spain, 3 we did not find any increase in the occurrence of IPTB. Both studies reported a very high proportion of IPTB; 60% in the UK 2 and 32% in Spain 3 due to elective premature termination of pregnancy to improve the worsening maternal respiratory distress in severe COVID-19. The IPTB in our study cohort (1.8%) includes termination for obstetric and fetal indications only, and it is significantly less compared with studies from the UK (20.2%) 2 and Spain (7.7%). 3 The multidisciplinary team at our hospital decided on a case-to-case basis for emergency cesarean section or labor induction; either for facilitating maternal resuscitation or because of fetal health concerns. 17, 18 Therefore the PTB rate remained low in the present study throughout the COVID-19 pandemic and consistent with the global prepandemic PTB rate of 11%. 19 A study from Kuwait also described management similar to that in the present study where all IPTB were as a result of termination for obstetric or fetal indication only. 5 We believe that labor induction or operative delivery in patients who are already medically disease are now discouraged. 17, 18 The universal screening that was implemented in the present study for detection of SARS CoV-2 infection in pregnant women, showed that 20% of the infected population was symptomatic. This is similar to a study from Spain (29%), which also incorporated universal testing 3 To the best of our knowledge, the present study is the first to describe the effects of both the first and second waves of the COVID-19 pandemic on SPTB and it generated contradictory evidence about the rates of IPTB among women with COVID-19. Limitations of the present study include that it is a single-center study, lacks testing for vaginal cytokines for detection of intraamniotic inflammation, and lacks genome sequencing data on SARS-CoV-2 strains to definitively establish a direct relationship of SARS-CoV-2 infection with PTB. Preterm birth not only causes an increased risk of long-term negative consequences such as adverse cognitive and motor development, behavioral and mental health problems, respiratory disorders, adding increased mortality and morbidity in early childhood but also leads to an increased financial burden on public health care. 24 Considering the increased burden of PTBs during the ongoing COVID-19 pandemic, appropriate healthcare policies are to be developed for achieving the Sustainable Development Goals. The authors thank Dr. Periyasamy Kuppusamy, ICMR-NIRRH for assistance with the statistical analysis. The authors have no conflicts of interest. NM, and RG had full access to all data, and take responsibility for data integrity, and the accuracy of the analysis. RG and NM were responsible for the study concept, and design. RP, CG, PM, MP, SK, and BJ acquired the data. All authors interpreted the data. NM performed the statistical analysis. NM, SM, and RG provided administrative, technical, and material support. RP, NM, CG, and RG drafted the manuscript. NM, SM, and RG revised the manuscript. Major causes of death in preterm infants in selected hospitals in Ethiopia (SIP): a prospective, cross-sectional, observational study Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study The association between SARS-CoV-2 infection and preterm delivery: a prospective study with a multivariable analysis Clinical outcomes of maternal and neonate with COVID-19 infection -multicenter study in Saudi Arabia Maternal and perinatal characteristics and outcomes of pregnancies complicated with COVID-19 in Kuwait COVID-19 during pregnancy: an overview of maternal characteristics, clinical symptoms, maternal and neonatal outcomes of 10,996 cases described in 15 countries Differential impact of COVID-19 in pregnant women from high-income countries and lowto middle-income countries: a systematic review and meta-analysis COVID-19) in India Preparedness, administrative challenges for establishing obstetric services, and experience of delivering over 400 women at a tertiary care COVID-19 hospital in India Protocol for a prospective, hospital-based registry of pregnant women with SARS-CoV-2 infection in India: PregCovid Registry study WHO: recommended definitions, terminology and format for statistical tables related to the perinatal period and use of a new certificate for cause of perinatal deaths The preterm birth syndrome: issues to consider in creating a classification system Clinical Management Protocol for COVID-19 SARS-CoV-2 spike mutations, L452R, T478K, E484Q and P681R, in the second wave of COVID-19 in Maharashtra Is pregnancy an immunological contributor to severe or controlled COVID-19 disease? COVID-19: unmasking emerging SARS-CoV-2 variants, vaccines and therapeutic strategies Royal College of Obstetricians & Gynaecologists. Coronavirus (COVID-19) infection and pregnancy COVID-19 Clinical management: living guidance Global burden of preterm birth Is COVID-19 a risk factor for severe preeclampsia? Hospital experience in a developing country Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: the INTERCOVID multinational cohort study The relationship between maternal anemia during pregnancy with preterm birth: a systematic review and meta-analysis Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasi-experimental study Additional supporting information may be found in the online version of the article at the publisher's website.