The association between COVID-19 and preterm delivery
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The COVID-19 pandemic is continuing to cause huge social, economic, and health-related costs throughout the world, especially in Spain. Clinicians are still coming to terms with the range of health conditions wrought by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A new study shows that this infection results in fetal and maternal complications.

Adverse Outcomes in Pregnancy
Prior studies have shown that the cytokines found to be elevated to tremendously high levels in progressive COVID-19, like IL-6, are linked to a poor perinatal prognosis in pregnant patients. Therefore, the researchers tried to identify whether COVID-19 leads to adverse outcomes in pregnancy. They focused on indicators like preterm birth, premature rupture of membranes, and increased neonatal intensive care unit (NICU) admissions.

The study involved over 1,000 patients who gave birth between March 23 and May 31, 2020. Of these, about a were COVID-19-positive. Of the pregnant women with COVID-19, almost 90% were asymptomatic at the time of delivery, but 20% had reported symptoms earlier. That is, almost 80% of this group remained asymptomatic throughout.

Most Infected Pregnant Women are Asymptomatic
Among the pregnant women who were symptomatic during childbirth, the vast majority, almost 86%, had mild symptoms like cough and anosmia, tiredness, fever, and mild shortness of breath. About 7% developed mild or moderate pneumonia, and another 7% had severe pneumonia. Not a single pregnant woman died or went into septic shock.

Risk of Preterm Birth Doubled
The researchers found that despite the majority of infections being asymptomatic, there were twice as many preterm births among these women, at ~14% vs 7% in the healthy group. This difference was found even though prior screening by ultrasound and clinical examination had shown no significant variation in risk factors between the groups.

Iatrogenic Preterm Deliveries
Iatrogenic preterm deliveries that were not the result of premature rupture of membranes (PROM) were four times more common in this group, at 5% vs. 1%, but not spontaneous preterm deliveries, which had the same incidence in both groups. This could have been due to the presence of severe pre-eclampsia and pneumonia, leading to the induction of labor in order to end the pregnancies.

Symptomatic COVID-19 was observed to be present in over 40% of iatrogenic preterm deliveries, but only a fifth of spontaneous preterm births. Both PROM and preterm premature rupture of the membranes (PPROM) were found to be increased in the exposed group as compared to the unexposed group, by 70%. The researchers sum up, “We did find an increase in obstetric pathology in these patients, which in our opinion indicates that in the pregnant woman with asymptomatic COVID-19, there is a specific obstetric pathology that needs to be recognized.” The unique finding here is that PROM is associated with COVID-19, possibly due to the increased levels of cytokines like IL-6 that are already known to be common to both preterm delivery, PROM, and COVID-19. In fact, IL-6 is established to be a risk factor for preterm delivery.

Further work is required to trace the effect of genetic and ethnic susceptibility, as well as of socioeconomic deprivation impacting on obstetric care, on the demographic divide observed in this study.