Pregnant pause

Experts fear that the more virulent strains of SARS-CoV-2 and inconclusive evidence around vaccines have left expectant mothers most vulnerable in the second wave, with miscarriages, premature births and even death a possibility in symptomatic cases

In mid-April, 28-year-old Disha Kumar (name changed on request) delivered a healthy baby girl at Wockhardt Hospital in Mira Road. Weighing almost 3 kg, the newborn was taken into care after a cesarean procedure. But, all was not well with the mother, who had been diagnosed with COVID-19, and was fighting for her life in the ICU ward. “Her fever was persistent. We tried to stabilise her oxygen levels before doing the delivery, but her SpO2 continued to drop thereafter. Despite giving her 100 per cent oxygen and doing a tracheostomy, her SpO2 remained below 84,” recalls Dr Mangala Patil, consultant obstetrician and gynaecologist, Wockhardt Hospital, Mira Road. A few days later, she succumbed to the infection.

Death due to COVID-19 among pregnant women is no longer a rarity in the second wave of the pandemic. The medical community has raised concerns over these women appearing to be at an increased risk of severe symptoms, complications and in some cases, even death this year.

A study published this April in the peer-reviewed journal, The Lancet, titled, Were pregnant women more affected by COVID-19 in the second wave of the pandemic?, states that initial data from the US had been “reassuring,” with “death from COVID-19 during pregnancy as low as (0.19 per cent) and consistent with that of non-pregnant women of childbearing age (0.25 per cent).” This was even lower than the 2009 H1N1 influenza pandemic. The influenza mortality in pregnant women in the US was 4.3 per cent. For Middle East respiratory syndrome (MERS), three maternal deaths were reported in “13 per cent and 40 per cent of published case reports, respectively”.

Amita Pitre and Dr Kuppulakshmi

The study, however, indicated that since September 2020, a second wave in the UK appeared to have had a marked impact on pregnant women, with many requiring admission to intensive care and being considered for extracorporeal membrane oxygenation (ECMO).

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The observed increase in pregnant women with severe COVID-19 in India could relate to the emergence of a more pathogenic strain of SARS-CoV-2. Dr Surabhi Siddhartha, consultant obstetrician and gynaecologist, Motherhood Hospital in Kharghar, explains, “This year, there has been mutation in the COVID-19 virus. It has become more virulent now. It is affecting people with low immunity. And it is a known fact that pregnant women have a weaker immunity, and have therefore appeared vulnerable in the second wave.”

A Centers for Disease Control (CDC) study also suggests that physiological changes in pregnancy, such as increased heart rate and oxygen consumption, decreased lung capacity, a shift away from cell-mediated immunity and increased risk for thromboembolic disease, make pregnant women more vulnerable to COVID-19. Dr Siddhartha adds, “Pregnant women are also showing more severe symptoms this time. They come to us with fever and breathlessness. I have personally seen 20 patients, who contracted COVID-19. Many of them have delivered recently. Last week, we got one patient, who had tested positive in March. She was 32 weeks into her pregnancy, and all of a sudden her water bag broke. Fortunately, we managed to treat her on time, and both she and her baby are fine. I’ve seen many premature deliveries this year.”

Dr Mangala Patil, consultant obstetrician and gynaecologist, Wockhardt Hospital

Doctors say that expectant women struggle during COVID-19, because the growing uterus pushes against the diaphragm, compressing the lungs and making it harder to breathe in a normal amount of air. There are high chances of women having miscarriages, and even stillbirths, also known as intrauterine fetal demise (IUFT). “There is a possibility of IUFT or miscarriages in the first or second trimester,” Dr Siddhartha adds.

In Dr Patil’s experience so far, asymptomatic pregnant women were treated and given a discharge from the hospital within five to seven days in the first wave of COVID-19. In the second wave, however, they required immediate ICU admission and a longer stay in the hospital. “I’ve admitted more than 15 COVID-positive pregnant women in the last three months. Out of these, five were near-term and have already delivered their babies. There were complications to mothers, who had problems of blood pressure and diabetes. They also required steroids, among other drugs needed for COVID-19 treatment.”

Speaking about Kumar’s case, Dr Patil says that the first-time mother had ignored her symptoms. “Kumar experienced fever just 15 days before her due date. She went to her gynaecologist, who suggested that she do an RT-PCR test and other blood investigations. The COVID-19 test came back negative, so she ruled that out. While her fever was persistent, she never went to a physician. Now, one needs to understand that a gynaecologist cannot check you like a physician would. Eight days later, she went back to her gynaecologist, who checked her oxygen level. Her SpO2 was 84 and temperature was 101. Finally, she did an antigen test, which came positive,” Dr Patil recalls.

Since it was the peak of the second wave, Kumar was admitted to a municipal facility. A few days later, she was accommodated at Wockhardt Hospital by Dr Patil. “People should stop ignoring symptoms and go to the doctor immediately.”
 
The Institute of Obstetrics and Gynaecology (IOG) in Chennai has admitted over 2,000 pregnant women spanning both the waves of the pandemic. Out of these, 250 were admitted in the second wave, all of whom were severely symptomatic expectant mothers. “Thankfully, there is no evidence of impact to the baby, if the mother is infected. It’s only when the oxygen carrying capacity reduces and O2 is unable to reach the baby, that there are chances of it being stillborn.  Since we don’t conduct autopsy on deceased newborns, we don’t have any more information to make deductions,” Dr Kuppulakshmi, professor of obstetrics at the institute says.

Dr Siddhartha feels that vertical transmission of the virus may be possible. The Lancet study suggests this, as well. “…It is a relatively common route of transmission for those neonates diagnosed with COVID-19 immediately after birth. Infection of this cohort appears to occur primarily through postnatal exposure (70.5 per cent), but a significant proportion of infections might be congenital (5.7 per cent). However, a consensus for the laboratory diagnosis of congenital infection and a mechanism for transmission are yet to be established,” states the study.

Doctors are still unsure of recommending a vaccine to expectant mothers in the absence of any clear data or studies. Covishield and Covaxin, the two jabs that India is currently administering, have not been tested on pregnant women.

Last month, Brazil suspended the India-made Covishield vaccine for pregnant women after a woman, who had taken the shot, died. As of now, countries that are vaccinating pregnant women include the US, UK, Australia, and those in the European Union.

Amita Pitre, lead specialist, gender justice at Oxfam India, has studied the issue of vaccination among pregnant women. “Because I work on gender and health issues, I am studying how pregnant women have been systematically left out of all clinical trials of vaccinations. This is almost routinely done in most clinical trials, though there are guidelines on how to work around the problem. Experts and guidelines say there should be presumed inclusion of pregnant women in all trials, unless there are specific reasons to exclude them,” Pitre shares.

So, should a pregnant woman take a jab? It depends on the risk-benefit analysis, she adds, saying, “Where COVID-19 cases are very high and the probability of pregnant women getting infected is high, then the  benefit of vaccinating pregnant women could weigh the risks”

The Federation of Obstetric and Gynaecological Societies of India has recommended that pregnant women get vaccinated. “Best would be to have transparent risk-benefit analysis as per the probability of infections. This has not been done. Also, the Oxford-AstraZeneca and Covaxin vaccines excluded pregnant women during clinical trials, so that data is not available. But, scientists can go back to the animal tests and do a risk-benefit analysis on the basis of that,” Pitre concludes.

250
No. of symptomatic pregnant women admitted to IOG in Chennai in the second wave

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