Cesarean Deliveries Skyrocket in Pregnant Women With COVID-19

Regardless of whether they were symptomatic, pregnant women infected with COVID-19 at a Texas hospital had extraordinarily high rates of cesarean deliveries, and more than a third of their newborns were admitted to the neonatal intensive care unit (NICU), a researcher said.

From March to September 2020, 65.6% of 32 symptomatic patients and 60.9% of 69 asymptomatic patients underwent a cesarean delivery compared with a 2019 cesarean rate of 31.7% in the U.S., reported Kristine Lane, a medical student at the University of Texas Medical Branch at Galveston, during the American Society of Anesthesiologists annual meeting.

In addition, 59.4% of symptomatic patients and 44.9% of asymptomatic patients needed emergency treatment during deliveries compared with a normal hospital rate of 2%. NICU admission was required in 43.8% and 36.2%, respectively, and respiratory support for newborns was needed in 31.3% and 29.0%, respectively.

“COVID-positive women were more likely to have complications with the delivery process at a vastly increased rate compared to the average non-COVID patient,” Lane told MedPage Today. “The increase in the prevalence of emergent cesarean section with symptomatic infection could be caused by reduced oxygenation and endothelial cell dysfunction. This potential for poor oxygenation could also contribute to the difference in newborn outcomes.”

Research published early in the pandemic, including a systematic review and a Spanish study, linked COVID-19 infection in pregnant women to high rates of cesarean sections. However, a large U.S. study published in August found no increase in cesarean deliveries among women infected with COVID-19, though it did find “higher rates of mortality, intubation, ICU admission, and preterm birth” compared with women without COVID-19.

Infected pregnant women “may be more susceptible to severe respiratory infections and embolic complications,” co-author Rovnat Babazade, MD, also of the University of Texas Medical Branch at Galveston, told MedPage Today. “During pregnancy, the maternal immune system adapts to allow for the growth of the fetus. Because of an altered immune response modulation in pregnancy, severe disease may be more likely due to COVID infection, causing release of damage-related proteins and a precipitous pro-inflammatory response.”

Additionally, “maternal infection with COVID-19 has correlation with increased newborn complications, like increased hospitalization, lower birth weights, and increased respiratory distress requiring oxygen support. We still do not know the risk of vertical transmission, the long-term outcomes of children born to COVID-positive mothers, or the actual toll — physical and mental — on patients and healthcare providers of additional precautions during the delivery process.”

This retrospective study tracked women ages 16 to 45 and defined emergent deliveries as those with complications, such as non-progressing labor, fetal malpresentation, or preeclampsia, requiring induction or cesarean delivery.

Among the symptomatic women, 40.6% had fever, 37.5% had cough, and 28.1% had shortness of breath.

“There was one case of a newborn who tested positive for COVID after delivery, which was concerning for vertical COVID transmission in utero,” Babazade noted. “The infant was born at 35 weeks to a symptomatic mother with respiratory distress and required intensive care unit admission for 4 days and oxygen support. The repeat COVID PCR and the nucleic acid amplification testing (NAAT) nasopharyngeal swab at 48 hours were positive. Proper PPE protocols were followed during delivery, which was an emergent C-section due to severe maternal COVID symptoms, and the mother only visited the infant via the phone.”

These findings aren’t surprising, Brian Casey, MD, of the University of Alabama at Birmingham, told MedPage Today. “We too have observed a high rate of cesarean delivery in women with symptomatic COVID infection,” he said. “Often, acute deterioration in the maternal condition drives the decision to emergently deliver the baby before term. However, it is curious that the cesarean delivery rate in asymptomatic women is almost as high.”