key: cord-0984382-vudzfkcz
authors: Mahajan, Niraj N.; Ansari, Munira; Gaikwad, Chaitanya; Jadhav, Priyanka; Tirkey, Deepika; Pophalkar, Madhura P.; Bhurke, Aishwarya V.; Modi, Deepak N.; Mahale, Smita D.; Gajbhiye, Rahul K.
title: Impact of SARS‐CoV‐2 on multiple gestation pregnancy
date: 2020-12-18
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13508
sha: 2d2c5df15227c37cbe534cba33c4e659ac2f4f1d
doc_id: 984382
cord_uid: vudzfkcz

OBJECTIVE: To assess clinical presentations, pregnancy complications, and maternal and neonatal outcomes among women with multiple gestation pregnancy (MGP) and confirmed SARS‐CoV‐2 (COVID‐19) infection and to compare the data with a pre‐pandemic period. METHODS: A retrospective study at a dedicated COVID‐19 Hospital in Mumbai, India. Data were obtained from the PregCovid Registry of pregnant and postpartum women with PCR‐confirmed SARS‐CoV‐2 infection from April to September, 2020. Data were also compared with a cohort of women with MGP attending the hospital pre‐pandemic (n = 63). RESULTS: Data from 879 women (singleton pregnancy, n = 859; MGP, n = 20) with COVID‐19 were assessed. The twinning rate was 34.2 per 1000 births. As compared with singleton pregnancies, a higher proportion of women with MGP and Covid‐19 delivered preterm (P = 0.001). Spontaneous abortions were also higher in the MGP group than in the singleton group (P = 0.055). The incidence of pre‐eclampsia/eclampsia was higher in the COVID‐19 MGP group than in both the COVID‐19 singleton (41.6% vs. 7.9%) and pre‐pandemic MGP (50.0% vs. 12.7%) groups. CONCLUSION: There was a higher risk of pre‐eclampsia among women with MGP and COVID‐19. Women with MGP and COVID‐19 infection should receive special attention with a multidisciplinary approach to both maternal and neonatal care during the pandemic.

special care. COVID-19 infection independently has adverse effects on pregnant women. 3, 4 However, there is limited information on the impact of infection on MGP.

The primary aim of the present was therefore to assess clinical presentations, and maternal and neonatal outcomes among women with COVID-19 infection and assess the impact of COVID-19 on MGP as compared with singleton pregnancy. A secondary aim was to compare pregnancy complications, and maternal and neonatal outcomes of women with MGP in the pre-pandemic and pandemic period.

The present retrospective study analyzed data from pregnant women who were treated in a dedicated COVID-19 hospital, 5 BYL Nair Charitable Hospital, Mumbai, India, one of the participating centers of the PregCovid registry network, 6 from April 4 to September 10, 2020. The study was approved by the Ethics Committees of TNMC (no. ECARP/2020/63; May 27, 2020) and ICMR-NIRRH (IEC no. D/ICEC/Sci-53/55/2020; June 4, 2020). A waiver of consent was granted because the study data were obtained from medical case records.

Information was retrieved on clinical presentations, and maternal and neonatal outcomes for all women with MGP or singleton pregnancies and COVID-19 infection confirmed by RT-PCR. Delivery outcomes were also obtained for a pre-pandemic cohort of pregnant women attending the hospital between April 1, 2019, and March 31, 2020.

Statistical analyses were performed by using Prism (GraphPad).

Categoric variables were recorded as number (percentage) and continuous variables were expressed as median (interquartile range).

Pearson χ 2 , Fisher exact, odds ratio and Mann-Whitney U tests were used to compare differences between the groups. A P value of <0.05 was considered statistically significant.

In total, data from 879 women (singleton pregnancy, n = 859; MGP, n = 20) with confirmed COVID-19 infection were included in the study. Fifteen (75.0%) women with COVID-19 and MGP were in their third trimester, and 5 (25.0%) had a gestation of less than 28 weeks. At the time of manuscript preparation, 12 women with MGP had delivered, and 8 had ongoing pregnancies. Of the 12 women, 11 women delivered twins and 1 delivered triplets. All neonates tested negative for COVID-19 in the nasopharyngeal swabs taken at birth.

The clinical presentations and laboratory parameters did not differ significantly between singleton pregnancy and MGP among women with COVID-19 infection. The proportion of symptomatic and asymptomatic pregnant women was similar in the two groups (P = 0.505) ( Table 1 ). The women with MGP were significantly older than those with singleton pregnancies (P = 0.023) and reported to the hospital at an earlier gestation. A significantly higher proportion of MGP women with COVID-19 delivered preterm (66.7%) as compared with their singleton counterparts (8.6%) (P = 0.001).

Anemia was found in high proportion of cases in both the singleton (40.5%) and MGP (45.0%) groups. The incidence of spontaneous abortion was higher in MGP than in singleton pregnancy (10.0% vs.

1.7%, P = 0.055) ( Table 1 ). The two cases of spontaneous abortion in the MGP group occurred in the second trimester: one woman was referred for retained placenta and the other woman had undergone cervical encerclage at 16 weeks, but developed preterm premature rupture of membranes (PPROM) at 22 gestational weeks.

Pre-eclampsia and eclampsia were higher in MGP as compared to singleton (41.6% vs. 7.9%).

At the study hospital, the twinning rate was (34.2 per 1000 births) during the COVID-19 pandemic study period and 37.6 per 1000 deliveries in pre-pandemic period ( Table 2 ). The women with MGP and COVID-19 were also older as compared with those without COVID-19 (P = 0.009). The proportion of preterm deliveries among women with MGP was similar in the pandemic and pre-pandemic groups (60.0% vs. 73.0%, P = 0.459). The incidence of pre-eclampsia and eclampsia was also higher in the COVID-19 group than in the pre-pandemic group (50.0% vs. 12.7%) ( Table 2 ). Admission to the neonatal intensive care unit (NICU) occurred significantly more frequently in the pre-pandemic period than in pandemic period (67.5% vs. 38.1%, P = 0.014; OR, 3.4; 95% confidence interval

[CI], 1.3-8.8).

One woman with triplets had pre-eclampsia and another had moderate anemia with deranged liver enzymes (she received a transfusion 

The present study reported a higher incidence of twinning (34%)

as compared with other studies from north and south India. 7 Women with COVID-19 infection are at a higher risk of delivering preterm. 9 In the present study, the rate of preterm delivery was almost 8-fold higher for MGP than for singleton pregnancies. However, the incidence of preterm delivery among women with MGP and COVID-19 during the 5-month study period was marginally lower than that among uninfected women with MGP TA B L E 2 Comparison of maternal and pregnancy characteristics and outcomes in MGP between women with confirmed COVID-19 and a pre-pandemic cohort a during the 12 months preceding the pandemic (60% vs. 73%). The proportion of pre-eclampsia and PROM among women with MGP during the 5-month study period was significantly higher than that among women with MGP in the pre-pandemic period (P = 0.023 and P = 0.015, respectively). Although the risk of pre-eclampsia is known to be higher in twin pregnancies than in singleton pregnancies, 10 SARS-CoV-2 infection might also be a risk factor for pre-eclampsia. 11 during the pre-pandemic period.

The study also observed that women with MGP and COVID-19 did not require any additional COVID-19-related management protocols as compared with women with singleton pregnancies.

We believe that early case detection with the help of universal testing 14 is the key to good outcomes when treating COVID-19 infection in MGP. The preparedness of the administration to manage the pandemic helped to efficiently establish a dedicated COVID-19 hospital. 5 Thus, based on this experience, we recommend that a multidisciplinary team should be assembled to manage such cases of COVID-19 in MGP and management options should be selected on a case-by-case basis.

In conclusion, COVID-19 infection was found to be associated with increased risk of pre-eclampsia and PROM among women with MGP. Among the MGP cohort, two women with severe COVID-19

were infected in the second trimester and showed good outcomes.

However, the study is limited by the sample size from a single center. Further studies are required to confirm the present observations.

We recommend that women with MGP and COVID-19 infection should receive special attention and require a multidisciplinary team approach to both maternal and neonatal care during the COVID-19

pandemic.

Twinning across the developing world

COVID-19) Situation Reports n.d. https:// www.who.int/emerg encie s/disea ses/novel -coron aviru s-2019/ situa tion-reports

Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study

Pregnancy outcomes, Newborn complications and Maternal-Fetal Transmission of SARS-CoV-2 in women with COVID-19: a systematic review of 441 cases

Preparedness, administrative challenges for establishing obstetric services, and experience of delivering over 400 women at a tertiary care COVID-19 hospital in India

National Registry of Pregnant Women with COVID-19. PregCovid Registry Network

The twinning rates and epidemiological characteristics of births in Southeast Uttar Pradesh

Twinning rates in Tamilnadu

High rates of stillbirth and preterm delivery in women with covid-19 and the efficacy of ECMO in pregnancy

Prevalence and risk of pre-eclampsia and gestational hypertension in twin pregnancies: a population-based register study

Pre-eclampsia-like syndrome induced by severe COVID-19: a prospective observational study

Postpartum psychosis in mothers with SARS-CoV-2 infection: a case series from India

Co-infection of malaria and dengue in pregnant women with SARS-CoV-2

Universal screening identifies asymptomatic carriers of SARS-CoV-2 among pregnant women in India

The authors acknowledge the Director General, ICMR, and Network The study was funded by an intramural grant from ICMR-NIRRH (ICMR-NIRRH/RA/986/10-2020).

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 study concept and design. PJ, CG, DT, MP, and AB acquired the data. All authors interpreted the data. AB, CG, and NM per-