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\begin{document}

\title{Maternal and perinatal outcomes of vaginal delivery of pregnant women
with COVID-19 in Wuhan}



\author[1]{Min Wu}%
\author[2]{Qingqing Luo}%
\author[3]{Dujuan Yao}%
\author[3]{Lin Xia}%
\author[3]{Qianqian Tang}%
\author[3]{Jianwen Zhu}%
\author[3]{Xiangzhi Zeng}%
\author[3]{Lan Chen}%
\author[3]{Hui Chen}%
\author[1]{Hillary Kizwi}%
\author[3]{Geqing Xia}%
\author[3]{Qingmiao Zhang}%
\affil[1]{Huazhong University of Science and Technology Tongji Medical College}%
\affil[2]{Huazhong University of Science and Technology}%
\affil[3]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: Most of the pregnant women with 2019 novel coronavirus
pneumonia are terminated by cesarean section because the risk of
mother-to-child transmission is not yet clear. The aim of this study was
to evaluate maternal and perinatal outcomes of vaginal delivery of
pregnant women with COVID-19 infection. Design: 8 pregnant women who
were suspected or confirmed with COVID-19 infection between 31 January
and 20 April,2020, gave birth vaginally in Wuhan Union hospital were
included. Clinical manifestations, laboratory test results, chest CT
scans and maternal and perinatal outcomes were recorded. Evidence of
perinatal infection of virus was assessed by using SARS-COV-2 associated
coronavirus reverse-transcriptase polymerase chain reaction in neonatal
throat and anal swab samples. Results: None of the 8 pregnant women
experienced dystocia and severe postpartum complications, 8 livebirths
were recorded, no fetal distress or asphyxia was observed. No newborn
infant had clinical COVID-19 and all investigations were negative for
SARS-COV-2. Conclusions: Our study showed that vaginal delivery does not
increase the probability of mother-to-child transmission of
SARS-COV-2,maternal and neonatal outcomes were not affected. We suggest
that pregnant women with COVID-19 pneumonia without severe systemic
complications and respiratory failure can be considered for vaginal
delivery.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Since the outbreak of the novel coronavirus pneumonia (COVID-19) in
Wuhan in December 2019\textsuperscript{{[}1{]}}, the epidemic has spread
rapidly throughout the world, especially in Europe and North America.
There have been almost 90 million cases
worldwide\textsuperscript{{[}2{]}}. It was declared to be a pandemic and
one of the most important public heathy issues worldwide. Till now,
there are many studies on the epidemiology, clinical characteristics and
treatment of novel coronavirus pneumonia \textsuperscript{{[}3-4{]}},
and the novel virus that caused the pneumonia was named severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2)\textsuperscript{{[}5{]}}
. Studies about pregnant women with COVID-19 were limited, and vaginal
delivery in such patients was not reported so far. We admitted 30
pregnant women in Union Hospital (Wuhan, China) between 31 January to 20
April 2020,eight of them delivered vaginally. This study
retrospectively analyzed the clinical features and maternal and fetal
outcomes of these 8 patients,with the aim of discussing the indications
of vaginal delivery and whether vaginal delivery increases the
probability of mother to child transmission of SARS-COV-2.

\textbf{Materials and methods}

Between 31 January to 20 April 2020, 8 pregnant women had experienced
vaginal delivery in Union Hospital affiliated hospital of Tongji Medical
College, Huazhong University of Science and Technology (Wuhan, China).
These patients fulfilled the diagnosis criteria for COVID-19 pneumonia
according to New Coronavirus Pneumonia Prevention and Control Program
(7th edition) which was published by the National Health Commission of
China\textsuperscript{{[}6{]}}. All the eight patients didn't have
contraindications for vaginal delivery. In accordance with patients'
wishes, all of them delivered in a negative pressure operating room
after fully communications with patients about the advantages and
disadvantages of vaginal delivery and cesarean section.

The clinical data including basic information, duration of labor,
whether there was an episiotomy or poor healing of episiotomy,
postpartum hemorrhage, clinical classification of pneumonia, lung CT
images and laboratory data were collected. All eight pregnant women with
COVID-19 pneumonia tested SARS-CoV-2 by using quantitative RT-PCR
(qRT-PCR) on samples from the respiratory tract. Pregnant women who were
admitted after March venous blood was collected and tested for
antibodies IgM/G by Enzyme linked immunosorbent assay. When the cervix
dilatation reached 4cm, pregnant women were sent to negative pressure
rooms for delivery. Pregnant women were advised to wear surgical mask
all the time, and newborns were prevented from touching their mothers.

The neonatal outcomes were recorded. Neonatal throat secretions and anal
swabs were taken immediately after birth to test SARS-COV-2 by using
quantitative RT-PCR (qRT-PCR), and then the newborns were sent to the
isolation ward. Two newborns were taken home instead of isolation ward
because their mothers' SARS-COV-2 PCR results came negative. We followed
up the mothers and babies for one month after delivery. Followed up
information included the maternal vaginal bleeding, clinical symptoms of
COVID-19 pneumonia such as fever, diarrhea and so on. We also recorded
the hospital stay of neonates, neonatal complications and weight of the
neonates after a month.

\textbf{Statistical analysis}

Statistical analysis was performed with SPSS, version 20.0. Categorical
variables were presented as numbers and percentages. Continuous
variables were presented as mean and standard deviation.

\textbf{Results}

Eight of the pregnant women aged at 25-31years, all of them were at the
third trimester, two of them were multipara, six of them were primipara.
The time from onset to delivery were 2-8 days. Case 3 complicated with
mild anemia and thrombocytopenia, the platelet count was 90G/L, case 8
complicated with premature rupture of membranes, case 2 and case 5
complicated with mild anemia(table 1). Three of the eight pregnant women
had pneumonia related symptoms, case 1 had dry cough, case 5 had
intermittent fever and general weakness on the third day before
delivery, the maximum body temperature was 38 degrees, the body
temperature was normal at the time of delivery, case 6 had fever and dry
cough from a week before delivery, the maximum body temperature was 39
degrees, and she was still febrile at the time of delivery. The oxygen
saturation of all eight prenatal pregnant women was higher than 93\% in
resting state, no one had shortness of breath. According to the 7th
edition of New Coronavirus Pneumonia Prevention and Control
Program\textsuperscript{{[}6{]}}, there was no pneumonia changes on lung
CT in case 3,7,8, they were mild cases, the rest five cases were normal
cases(table 1). Case 6 had a maximum body temperature to 40 degree, with
severe cough, needed high flow rate of oxygen to maintain oxygen
saturation, and the lowest oxygen saturation was 90\% at rest. Her
pneumonia aggravated after childbirth and became a severe case. Four
days after delivery, her pneumonia gradually started to improve, body
temperature and cough were getting relieved, oxygen saturation turned
normal at rest. Pneumonia in the rest seven puerperants was not getting
worse after childbirth. In laboratory examination, there were 6
cases(case1,2,4,5,6,7) of lymphocytopenia and 2 cases(case5,6) of
leukocytopenia. Pregnant women who were hospitalized before March 2020
were not able to carry out the detection of SARS-COV-2 IgM/G when they
were in hospital,case 3, case 7 and case 8 were positive for SARS-COV-2
IgM/G(table 1).

In all eight cases labor progressed smoothly. Postpartum hemorrhage was
defined as a cumulative blood loss of greater than or equal to 1,000 mL
or blood loss accompanied by signs or symptoms of hypovolemia within 24
hours after the birth process \textsuperscript{{[}7{]}}. The amount of
bleeding was evaluated by weighing method and comparison of hemoglobin
before and after delivery\textsuperscript{{[}8{]}}. No postpartum
hemorrhage occurred(table 2). In order to deliver the fetuses as soon as
possible to reduce the risk of mother to child transmission of the
SARS-COV-2, perineum lateral resection was performed in all the patients
except the multipara in the second stage of labor.

Case 6 experienced wound healing complication, the incision of perineum
was split after the suture was removed, and it healed one week later. To
other patients with lateral incisions, sutures were removed on the 5th
day postnatal, and healed well(table 2). Hospital discharge
standards\textsuperscript{{[}6{]}} included patients with no fever for 3
days or more, no obvious self-conscious symptoms, negative SARS-COV-2
PCR twice in a row, obvious absorption of pulmonary inflammation on CT.
The hospital stay of all eight patients were 4-23 days(table 2).

Eight livebirths were recorded, no perinatal death, no low birth weight
no fetal distress was observed, case 6 had Amniotic fluid stained with
feces. All eight livebirths had a 1-min Apgar score of 8 and a 5-min
Apgar score of 9 (table 3). Throat swabs and anal swabs of all the
newborns were negative for the presence of SARS-CoV-2. Six of the
newborns were sent to neonatology department for medical observation,
the length of stay were 3-15days. Newborn 5 and newborn 6 had pneumonia
during hospitalization(table 3).

Seven of the family accepted follow-up after a month since they gave
birth, case 3 accepted follow-up on call only. No maternal and newborn
deaths were recorded, case 6 reported to have dry cough occasionally, no
abnormal or vaginal bleedings were reported(table 4,5). Detection of
SARS-CoV-2 nucleic acid in throat swabs of all the seven parturient
women were negative. SARS-COV-2 IgM/G was positive in the venous blood
of case 5 and case 6. Case 7 and case 8 had positive results of
SARS-COV-2 IgG , the other five were negative(table 4). All the eight
infants were gaining weight and no infant was hospitalized again. All
the seven infants' throat swabs and anal swabs were negative for
SARS-COV-2 nucleic acid detection, and SARS-COV-2 IgM/G were all
negative in venous blood.

\textbf{Discussion}

COVID-19 is not yet under control globally, with the spread of
2019-ncov, the number of pregnant women with COVID-19 also increased. As
for the choice of delivery mode, expert's
consensus\textsuperscript{{[}9{]}} showed that COVID-19 pneumonia
couldn't not be used as an indication for cesarean section, but in fact,
most of the pregnant women with COVID-19 terminated pregnancy by
cesarean section in fear of additional risk of mother to child
transmissions\textsuperscript{{[}10-11{]}}. Therefore, there were few
studies on vaginal delivery in pregnancy women with COVID-19. It is
uncertain whether SARS-COV-2 is transmitted by mother-to-child
transmission during delivery.

Several studies\textsuperscript{{[}11-14{]}} had suggested that there is
a possibility of vertical transmission of SARS-COV-2, while the newborns
who were reported to have positive viral nuclear acid detection were all
delivered by cesarean section. The antibodies IgM /IgG of SARS-COV-2
were positive while the nucleic acid was negative in these newborns. In
this study, no definite evidence of SARS-COV-2 infection was found in
neonates who were delivered vaginally. Neonate 5 and neonate 6
experienced pneumonia after birth, which may be related to the fever of
their mothers before delivery, in addition, case 6 had meconium stained
amniotic fluid, which also increased the probability of neonatal
pneumonia and infection\textsuperscript{{[}15{]}}. Follow up results
showed that no serious complications had occurred in the newborns, the
antibody IgM /IgG and nuclear acid detection of SARS-COV-2 were negative
in seven neonates under follow up. In our patients,no SARS-CoV-2
transmission occurred. But it is important to note that all the pregnant
women in this study had a short course of COVID-19 pneumonia (2-8 days)
before birth, and it was possible that the virus had not yet affected
the fetus. However, what was clear was that vaginal delivery does not
increase the probability of SARS-COV-2 mother-to-child transmission
under strict protective measures (delivered in a negative pressure
operating room, pregnant women always wearing mask, avoiding contacting
between the newborns and their mother).

A case report\textsuperscript{{[}13{]}} showed that the SARS-COV-2
antibodies IgM and IgG of a newborn delivered by a pregnant woman at 34
weeks with COVID-19 were positive. SARS-COV-2 nucleic acid test for
mother's throat swabs were positive, while the nucleic acid test for
vaginal secretions was negative. Another
study\textsuperscript{{[}16{]}}included 35 females showed that no
positive SARS-COV-2 RT-PCR result was found in the vaginal environment
perhaps due to the lack of the receptor of SARS-CoV-2 in the vagina and
cervix tissues. It suggests that it would not increase the risk of
mother-child transmission when the fetus passed through the mother's
birth canal. Therefore, we believe that there was no relationship
between mother-child transmission and mode of delivery.

In this study, case 6's pneumonia worsened after childbirth, reviewing
the clinical features of the pregnant woman, we found that she had got a
high fever for a long period that continued to birth before delivery.
The results of laboratory examination indicated that her inflammatory
markers, C-reactive protein (CRP) and Procalcitonin (PCT), increased
progressively, it suggested that she may be in the acute stage of viral
infection. During labor, maternal breathing pattern was affected by
labor pain, in the second stage of labor, the need to hold their breath
to force the baby out, caused maternal oxygen consumption to increased.
Infection of SARS-CoV-2 mainly attacked body respiratory system, the
progressive exacerbation of lung lesions might lead to respiratory
distress especially in labor, and the fetus might experience fetal
distress or even fetal death. In this case, there was no maternal
respiratory distress or fetal distress during delivery, however the
patient who had a long term of high fever, oxygen saturation decreased,
and healing of the perineal incision was poor. Therefore, we suggest
that only after careful consideration we may decide to choose vaginal
delivery as a preferred mode of delivery to women who are in acute
inflammatory progress of COVID-19 pneumonia.

We suggest that pregnant women with SARS-COV-2 infection who do not have
respiratory failure or multi-functional organ dysfunction, and also,
when they are in a stable stage of pneumonia should be considered for
vaginal delivery if there is contraindications for vaginal delivery
trial and if the patient has an intention of vaginal delivery. However,
it should be noted that vaginal delivery should be carried out in the
negative pressure delivery room, and the medical staff and pregnant
women should be strictly protected, at the same time, newborns should be
avoided to have direct contact with their mothers.

The limitations of this study lie in the few patients and the limited
follow-up time. Long-term follow-up is needed to observe whether there
are long-term maternal and neonatal complications.

\textbf{Disclosure of interests}

We declare no competing interests.

\textbf{Contribution to authorship}

MW, HC and GQX conceived the study. WM drafted the manuscript and
contributed to data acquisition, analysis, and interpretation. HC and
GQX obtaining written consent from patients, obtaining ethical approval,
and participated in revising the final manuscript. XZZ, JWZ and LC were
the obstetricians of the pregnant women, and took responsibility for
collecting samples, and confirming data accuracy. LX, DJY,QMZ and QQT
were in charge of following up the mothers and the babies and collecting
the followed-up materials. QQL and HAK were in charge of the laboratory
tasks, including sample processing and detection.

\textbf{Funding}

This work was supported by grants from the Fundamental Research Funds
for the Central Universities (No.2020kfyXGYJ008) and the National
Natural Science Foundation of China (No. 81703242).

\textbf{Details of ethics approval}

The study was approved by the Ethics Committee of the Union hospital,
Tongji Medical College, Huazhong University of Science and Technology
(date of approval: 20 February 2020 and approval number: 2020(0047). All
the pregnant women provided written informed consent.

\par\null

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