Re: Novel Coronavirus COVID 19 in late pregnancy: outcomes of first nine cases in an inner city London hospital

We would like to share our experience of nine laboratory-proven COVID-19 mothers delivered at a London inner-city hospital between 7th of March and 22nd April 2020. In all cases, positive diagnosis was based on real time reverse transcriptase polymerase chain reaction (RT-PCR) of maternal nasopharygeal swabs. The median age and gestation at delivery were 31 years (range 18–39) and 39 weeks (range 27–39) respectively and two of the nine women were delivered by emergency caesarean section (CS) for COVID-19 pneumonia and deteriorating maternal respiratory function. Of the remaining seven, one mother had a normal vaginal delivery, six underwent elective CS for obstetric indications while an emergency CS was performed in one woman for suboptimal cardiotocography (Table 1). Seven of our nine women (78 %) had mild to moderate prodromal symptoms not requiring admission (such as fever, cough, myalgia, sore throat, anosmia): these women were only screened due to a high index of suspicion rather than severity of complaints. The infants were immediately isolated from the mothers at birth and had RT-PCR for SARS-Cov-2 nucleic acid nasal pharyngeal swabs performed. Only one of the nine babies was subsequently confirmed as COVID-19 positive (patient 1) based on nasopharyngeal RT-PCR.Table 1showing maternal and fetal outcomes (n = 9).PatientAge (yrs)ParityCXRGestation (wks)Mode of deliveryIndicationPMHFeverCoughMyalgia and joint painsRunny noseSore throatLethargyDyspnoeaAnosmiaFetal weight (g)Fetal COVID statusFetal outcome1362 + 0Consolidation38Em CSMaternal pneumonia and respiratory distressGestational diabetesYYNNYYYN4165PositiveViral pneumonia day 6 but recovered wellApgars 5, 92292 + 1Consolidation27Em CSMaternal pneumonia and respiratory distressNoneYYNNNNYY1200NegativeVentilated for 10 daysApgars 2, 63312 + 3Normal35Em CSPathological CTG not in labourNoneYYYNYYYY2700NegativeObservation only due to poor feedingApgars 6, 84310 + 1Consolidation39El CSBreechAsthmaYNNNYNNY3370NegativeTalipesApgars 9, 95221 + 0Consolidation38NVDN/ANoneNYYNNYNN4300NegativeWellApgars 9, 96394 + 1Not done37El CS3 previous CSInsulin dependent diabetes hypertensionNYNNNYNY2500NegativeWellApgars 8, 97181 + 0Not done39El CSPrevious CS and maternal requestNoneNYYNNNNY3060NegativeWellApgars 9, 98383 + 1Not done39El CS3 previous CSNoneNYYNYYYY3540NegativeWellApgars 9, 99340 + 0Not done39El CSMaternal requestNoneNYYNNYNY3560NegativeWellApgars 9, 9 Open table in a new tab We would like to focus on the first two mothers who were delivered by emergency CS due to inability to maintain oxygen saturation and to highlight the accompanying lymphopenia that were previously described in the cases reported by Sutton [[1]Sutton D. Fuchs K. D’Alton M. Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery.N Engl J Med. 2020; ([Epub ahead of print]): 13https://doi.org/10.1056/NEJMc2009316Crossref PubMed Scopus (746) Google Scholar] and Zheng [[2]Zeng L. Xia S. Yuan W. Yan K. Xiao F. Shao J. et al.Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China.JAMA Pediatr. 2020; : 26https://doi.org/10.1001/jamapediatrics.2020.0878Crossref Scopus (722) Google Scholar]. Patient 1: A 33 year old woman with diet controlled gestational diabetes mellitus was admitted at 39 weeks gestation with flu-like symptoms and productive cough. A provisional diagnosis of pneumonia was made but she developed chest pain and became tachypnoeic. Chest Xray revealed right basal consolidation and lymphopenia was noted (0.92 × 109/l; normal: 1.2–3.6). Maternal nasopharygeal swabs were positive for SARS-CoV-2 RT-PCR and she underwent an emergency CS for sudden deterioration of respiratory function, requiring 15 L/min of oxygen to maintain saturation of >95 %. A live infant 4.165 kgs was delivered with Apgar scores of 51minute and 95 minutes and was immediately separated from the mother. Following delivery, the patient continued to desaturate (80–85 %) on 100 % of oxygen and was transferred to a tertiary centre for extracorporeal membrane oxygenation (ECMO). The baby, subsequently confirmed as COVID-19 positive, developed pyrexia and exhibited signs of pneumonia on the sixth day but settled with benzylpenicillin and gentamycin. Patient 2: A 29 year old lady was admitted at 27 weeks gestation with myalgia, cough, pyrexia >38.4 °C and dyspnoea. SARS-CoV-2 was diagnosed on basis of nasopharyngeal RT-PCR and chest Xray showed basal consolidation (Fig. 1). She was commenced on intravenous clarithromycin and cefuroxime but became tachypnoeic and was unable to maintain oxygen saturation. Lymphopenia (1.05 × 109 /l; normal: 1.2–3.6) was noted and an emergency CS was performed for deteriorating maternal respiratory function. She required mechanical ventilation for four days post-delivery before being “stepped down”. The baby weighing 1.2 kgs with Apgars of 21minute and 65 minutes and required intubation because of prematurity. The baby was negative for nasopharyngeal, amniotic fluid and placental swabs RT-PCR for SARS-CoV-2 and was weaned off ventilation after 10 days. Table 1 shows that maternal symptoms can be variable and of interest is that cough (8/9) and anosmia (7/9) appear to be the commonest presentations in this small series. We had initially followed advice from Chinese literature which recommended isolation of the infected woman and her baby for 14 days [[2]Zeng L. Xia S. Yuan W. Yan K. Xiao F. Shao J. et al.Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China.JAMA Pediatr. 2020; : 26https://doi.org/10.1001/jamapediatrics.2020.0878Crossref Scopus (722) Google Scholar]. However, given the limited data and considering the potential detrimental effects on feeding and bonding, the Royal Colleges of Midwifery and Obstetricians and Gynaecologists have now jointly issued a guideline [[3]Corona virus infection in pregnancy. Information for healthcare professionals. V8 17/4/. Royal College of Midwives. Royal College of Obstetricians and Gynaecologists, 2020https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdfGoogle Scholar] that COVID-19 women and their healthy babies should be kept together in the postpartum period. Similarly, breast milk of affected mothers [[4]Chen H. Guo J. Wang C. et al.Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.Lancet. 2020; https://doi.org/10.1016/S0140-6736(20)30360-3Abstract Full Text Full Text PDF Scopus (2526) Google Scholar] has tested negative for COVID-19 and current evidence suggest that breast feeding is not contraindicated [[3]Corona virus infection in pregnancy. Information for healthcare professionals. V8 17/4/. Royal College of Midwives. Royal College of Obstetricians and Gynaecologists, 2020https://www.rcog.org.uk/globalassets/documents/guidelines/2020-04-17-coronavirus-covid-19-infection-in-pregnancy.pdfGoogle Scholar]. The most recent systemic review of six studies involving 48 delivered women indicates low likelihood of vertical transmission [[5]Della Gatta A.N. Rizzo R. Pilu G. Simonazzi G. COVID19 during pregnancy: a systematic review of reported cases.Am J Obstet Gynecol. 2020; 17 (pii: S0002-9378(20)30438-5.[Epub ahead of print])https://doi.org/10.1016/j.ajog.2020.04.013Abstract Full Text Full Text PDF Scopus (206) Google Scholar], although transplacental maternal-fetal transmission have been reported [[1]Sutton D. Fuchs K. D’Alton M. Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery.N Engl J Med. 2020; ([Epub ahead of print]): 13https://doi.org/10.1056/NEJMc2009316Crossref PubMed Scopus (746) Google Scholar,[2]Zeng L. Xia S. Yuan W. Yan K. Xiao F. Shao J. et al.Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China.JAMA Pediatr. 2020; : 26https://doi.org/10.1001/jamapediatrics.2020.0878Crossref Scopus (722) Google Scholar] including in our first case (where mother and baby were immediately separated and membranes had remained intact until CS). We can postulate that there may be a relationship between vertical transmission with maternal viral load as this was our most respiratory-compromised patient. The same systemic review [[5]Della Gatta A.N. Rizzo R. Pilu G. Simonazzi G. COVID19 during pregnancy: a systematic review of reported cases.Am J Obstet Gynecol. 2020; 17 (pii: S0002-9378(20)30438-5.[Epub ahead of print])https://doi.org/10.1016/j.ajog.2020.04.013Abstract Full Text Full Text PDF Scopus (206) Google Scholar] noted that 96 % of COVID-19 women were delivered by CS; however, we suspect that these were likely to be elective procedures for obstetric indications, like the last four women in our series, where COVID-19 had been detected several weeks prior to delivery in relatively stable patients. We end this letter by reminding clinicians that many pregnant women with COVID-19 present with mild or even no symptoms. In the United Kingdom, we currently do not have the capacity or funds to screen all pregnant women as recommended by Sutton et al. [[1]Sutton D. Fuchs K. D’Alton M. Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery.N Engl J Med. 2020; ([Epub ahead of print]): 13https://doi.org/10.1056/NEJMc2009316Crossref PubMed Scopus (746) Google Scholar] but any recent onset of cough and anosmia warrants a high level of suspicion for screening. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.