Clinical and pregnancy characteristics
In total, 24 cases were hospitalized with confirmed COVID-19. The mean age was 26.5 years (range: 17–39), most cases were in their third trimester (15 cases, 62.5%), 6 cases were in their second trimester (25%), and only 3 cases (12.5%) were under 14 weeks. Thirteen cases were nulliparous (54.2%), 10 cases were in their second pregnancy (41.7%), and one of them was in their fifth pregnancy. Regarding their COVID-19 diagnosis, all patients were referred with clinical symptoms and their diagnosis was confirmed with a PCR test (in 21 cases) and CT scans (in 3 cases). Three cases were positive for both (a CT scan was performed with very low-dose radiation for respiratory symptoms according to the Iranian health ministry COVID-19 guidelines). Clinical symptoms are shown in Table 1. The most common symptoms were fever and cough.
Most cases were type A blood group (58.3%) [12 cases were A+ (50%) and 2 were A− (8.3%)], 5 cases were O+ (20.8%), and 3 cases were B+ (12.5%); there were no blood groups of B−, AB−, or O− (Fig. 1). The SpO2 of 17 cases (70.8%) was in the normal range (over 93%), while 7 cases (29.2%) had lower SpO2.
The main laboratory changes are shown in Table 2. In all, almost half (45.8%) of cases showed lymphopenia. Of 13 normal cases, 3 cases had values between 1100 and 1200, and 4 cases had values between 1200 and 1300. The mean leucocyte count (WBC) was 10,380 (range: 3900–23,200) per microliter. One case had severe leukocytosis due to acute abdomen and bile vomiting (23200); by eliminating this case from the analysis, a mean WBC of 9800 (range: 3900–19,000) per microliter was the result. Considering pregnancy physiological leukocytosis, which makes up to 16,900 cells per microliter normal, only two cases had WBC of over 16,000. Of these two cases, one was a twin pregnancy (WBC = 19,000) which was referred at the 33th gestational week with the complaint of rupture of membranes and a decrease in the amniotic fluid index; in this case, a Caesarean section was performed on the fourth day of hospitalization, the patient developed fever, tachycardia, and cough on the day of the operation, and subsequent PCR test and CT scan were positive. The second case of leukocytosis was related to severe preeclampsia with HELLP syndrome.
Regarding neutrophils percentage, the mean was 80% (range: 57–97%), in which fact the obvious increase in neutrophils is evident. The mean platelet count was 198,000 (range: 102000–333,000) per microliter, which was in the normal range. The mean of blood hemoglobin was 11.37 (range: 8.9–13.7) g/dl. Due to physiological anemia in pregnancy, the minimum normal values of the first, second, and third trimesters are considered to be 11, 10.5, and 11, respectively, considering gestational age. There were 10 anemic cases (41.6%); 1 in the first, 2 in the second and 7 in the third trimester, while 59% had normal hemoglobin. The minimum value was related to a 37-week pregnancy with underlying cardiac disease.
Liver enzymes (ALT and AST) were assessed in 18 cases; according to research, ALT ≥45 units per liter and AST ≥ 35 were considered abnormal. Of 18 cases, ALT was in the normal range in 16 cases (88.9%) and increased in 2 cases. AST was also normal in 15 cases (83.3%), and was increased in 3 cases (16.7%); a great increase was observed in 1 case (ALT = 122 and AST = 130), who was referred at the 36th week of gestation with fever, dry cough, and myalgia, and underwent labor induction and vaginal delivery due to fetal bradycardia; in this case, the CT scan was positive, but the PCR test was negative. LDH was assessed in 19 cases, with a mean of 439 (range: 265–645) units per liter (SD = 110.5). According to research, LDH in the third trimester is considered normal up to 524. However, LDH is an important value in determining the severity of preeclampsia; one of the high LDH cases in this study was due to HELLP syndrome (LDH = 645), and this case underwent emergency Caesarean section due to severe preeclampsia and placental abruption at the 28th week where the neonate ad expired due to severe preeclampsia, IUGR and chronic abruption. ESR was increased in only one case (ESR = 95 mm/hr), the case with HELLP syndrome. According to the literature, ESR may increase normally up to 70 in the third trimester. Creatinine was assessed in 22 cases, with a mean of 0.76 (range: 0.5–1) milligrams per deciliter (SD = 0.121). Compared to normal values of pregnancies, this value was increased in just 1 case. BUN was assessed in 16 cases, mean was 16.5 (range: 8–39) mg/dl, SD = 8.4) which was increased in 9 cases (56.3%). CRP was assessed in 22 cases, which was increased in 81.2% of cases. The blood pH of 6 neonates was assessed; except for 1 case related to HELLP syndrome, all were in the normal range.
A total of 12 cases were under ongoing normal pregnancy care. Of the 12 remaining cases, 10 cases delivered, 9 through Caesarean section and 1 vaginally. Two cases underwent therapeutic abortion, one for fetal anomaly, while the other case was hospitalized for pregnancy termination because of embryo death with underlying disease of mother (cirrhosis and colitis). This case developed dyspnea on the third day after admission; a PCR test was conducted and was positive.
One case was referred after a Caesarean section; the Caesarean indication was premature rupture of membranes and failure to induce labor. This case developed cough, fever, tachycardia, and saturation loss in the recovery room and was referred to Al-Zahra hospital. At the neonatal follow-up, the baby tested negative for PCR with a good health status.
The leading cause of Caesarean section in 4 cases was preeclampsia; 2 of them developed HELLP syndrome and eclampsia, with a fever developing after Caesarean in the case of the patient with HELLP syndrome, while the other case had a history of open heart surgery in childhood.
The case of twin pregnancy underwent Caesarean section due to rupture of membranes and decreased amniotic fluid index at 32–33 weeks of gestation. The mother developed fever, tachycardia and cough prior to surgery, a Caesarean was done under general anesthesia, the mother’s PCR test was positive after surgery, her SpO2 was 98% without oxygen therapy, and blood values were in normal ranges. The two preterm neonates were a girl and a boy who were admitted to the NICU due to subcostal retraction and were discharged with good general health status and negative PCR tests and were recommended to continue home quarantine. The general characteristics of mothers and neonates are shown in Table 3.
Another case was suspicious acute abdomen with bile vomiting at 31–32 weeks of gestation which led to sudden intrauterine fetal death (IUFD) few hours after laparotomy and underwent Caesarean for labor induction failure. Therefore, in all cases, performing Caesarean was under obstetric indication and was not associated with COVID-19 infection. Out of 8 Caesarean cases, three cases underwent general anesthesia and 5 underwent spinal anesthesia; general anesthesia was used for emergency delivery.
Regarding underlying disease, preeclampsia (in 4 cases), GTT disorder (in 2 cases), HTN (in 1 case), hypothyroidism (in 2 cases), history of open heart surgery in childhood (in 1 case), history of cirrhosis and colitis (in 1 case) and liver enzyme disorder (in 1 case) were observed.
Two cases with A+ blood group were admitted to the ICU, and 1 was referred with positive PCR, protracted diarrhea, hypokalemia, and severe dehydration, Spo2 = 85% and D-Dimer = 5603, at 29 weeks of gestation; she was discharged with general good health waiting for delivery at term. The second case was a nulliparous in the 31st week of gestation without underlying disease who was referred with a stomachache and protracted biliary vomiting, severe acidosis, and GTT disorder, and a positive CT scan, high leukocytosis (WBC = 23,200), lymphopenia (lymph = 5%), neutrophilia (Neut = 91%), normal hepatic and renal tests, fasting blood sugar no more than 160; however, the clinical symptoms of diabetic acidosis were manifested. The patient underwent exploratory laparatomy with diagnosis of acute abdomen and acidosis, in which no specific clinical findings were achieved; after laparatomy, the fetus developed sudden IUFD, and the mother underwent a Caesarean because of failed labor induction. The outcome was a 2500 g dead male; there were no symptoms of placental abruption. According to the national protocol, PCR tests and/or any assessment of COVID-19 infection are not done for expired cases, therefore, a PCR test was not done for the neonate, and no information was available on neonatal COVID-19 infection. The cause of clinical symptoms, IUFD, and its association with COVID-19 remains controversial.
During admission 11 neonates were born through 10 deliveries (1 case was twins). In all, 20% of cases were term pregnancies and 80% were under 37 weeks, of which 50% were under 34 weeks, and the remaining were among 34–37 weeks.
Over 11 neonates there were 5 girls and 6 boys; PCRs of all live neonates were negative. Neonatal outcomes were good in 8 of 11 cases (72.7%) according to gestational age. Apgar scores were good except in 2 cases (severe IUGR at 28 weeks and preeclampsia at 31–32 weeks. Apgar scores and neonatal weights were affected by maternal underlying disease and gestational age. Neonatal weight of 2 cases were very low (680 and 950 g for 28 and 34 weeks, respectively); the total neonatal mean weight was not computable because of different birth ages.
There were 5 cases of NICU hospitalization, all of which were preterm (31 to 36 weeks and 5 days) and all of which were discharged with good general health. There were 2 mortality cases among 11 neonates. Blood pH was assessed in 6 neonates due to prematurity and NICU admission, which were in the normal range except for 1 case (related to HELLP syndrome). PCR tests were negative for all live neonates. At the follow up of the other 12 ongoing pregnancies, 11 delivered at term, 10 through Caesarean, mostly because of previous Caesarean section or maternal demand. One pregnancy ended in IUFD because of pregnancy hypertension and was induced for vaginal delivery. All live babies were healthy.