key: cord-0724313-6ktc9nkd
authors: Mohini, M.; Ahmed, S.; Rath, S. K.
title: Interpreting COVID-19 Outcomes in Pregnancy Needs Knowledge of Prevalent Conditions in that Time-frame
date: 2021-10-23
journal: Am J Obstet Gynecol
DOI: 10.1016/j.ajog.2021.10.023
sha: f6f1dbfb119c83bbf5e9df21b62ccb8838f1cc0b
doc_id: 724313
cord_uid: 6ktc9nkd

nan

Dept of Obstetric and Gynaecology, 7

Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, India. We thank Sarkar and associates for their interest in our manuscript 1 . We had shown that worse 37 outcomes during parturition in COVID-19 positive mothers were associated with other confounding 38 risk factors for pregnancy 2 . The multivariate analysis did not reveal COVID-19 to be an independent 39 risk factor, and we hypothesized that patients with such other risk factors are more likely to be 40 referred to a specialized centre. 41

We would like to clarify that the data collected was during the first wave and not the second wave in 42

India. Our University was one of the first in the country to have a dedicated COVID-19 hospital. Again 43 this dedicated COVID-19 hospital was the first in the state to have full facilities for caesarean delivery. 44

Of all consecutive pregnancies, only those who were delivering in this hospital between June 2020 and 45

November 2020 were included. 46

Since it was a government-designated COVID-19 hospital, most patients were admitted by referral 47 from other health care facilities (facilities for caesarean delivery was not available in other COVID-19 48 hospitals. Parallelly, a non-COVID-19 hospital was running wherein the non-COVID-19 deliveries took 49 place. We do not have the exact data on how many were referral admission in each section but it 50 would be much more than in the COVID-19 than in the non-COVID-19 section. 51

Most hospitals around the world were stretched for resources including manpower at the peaks of 52 COVID-19 waves. Fortunately, we did not face any dire shortage and all resources were shared 53

proportionately between COVID-19 and non-COVID-19 sections. PPH was increased in univariate 54 analysis and not on multivariate analysis while caesarean deliveries were higher in the COVID-19 group 55 even on multivariate regression. There can be three reasons for this: first, in the initial stages, 56 caesarean deliveries were preferred to minimize the risk of neonatal transmission. Second, the other 57 (non-COVID-19) pre-existing risks factors were more in the COVID-19 group. Third, hypoxemia in the 58 mother might lead to more foetal distress (poor tocograms) in babies leading to more caesarean 59 deliveries in a minority of cases. 60

The higher proportions of referrals might account for the lower APGAR scores in the newborns. Any 61 other healthcare facility that detected foetal distress and the mother was positive for COVID-19, would 62 refer the patient to our centre. The time taken for transfer to our centre might lead to lower APGAR 63 scores but the quick operative delivery and a strong neonatal ICU backup ensured that this did not 64 translate into neonatal mortality. 65

We thank Sarkar and associates for bringing out this important message that it is imperative to 66

interpret COVID-19 outcomes in the light of the background at the time of the study. COVID-19 and 67

its management have evolved fast from emergence to the current status where post-vaccination 68 breakthrough infections is a major issue. 69

Letter to the Editor RE: Worse Outcomes of Pregnancy in COVID-71 19 Infection during Parturition may be due to Referral Bias: Analysis in a Prospective Cohort of 72 963 pregnancies

Worse outcomes of pregnancy in COVID-19 infection 74 during parturition may be due to referral bias: analysis in a prospective cohort of 963 75 pregnancies