CME INDIA Presentation by Dr Richa Manaswita, MBBS, DGO, DNB (Obs & Gynae), Jr. Consultant, Coccon Hospital, Jaipur; Dr Vaibhav Agnihotri, MBBS, DCH, DNB(Paediatrics), IAP Fellowship Neonatology, PGPN, Boston University, PCBD John Hopkins University.

Course is mild but prolonged

Recent two papers, one Meta-Analysis published in BMJ and other data of PRIORITY is enough to alter physicians for a unique pattern of COVID19 in pregnancy.

• ICMR researcher highlighted that in Mumbai one in 10 pregnant women did not show any symptoms of COVID-19 at the time of presenting in a hospital. Maharashtra state data shows 12.3% pregnant women were infected with COVID19. (Small data on 1140 pregnant women.)
• So far, we do not have reliable data in INDIA about status of symptoms and course in pregnant women in outdoor care. This knowledge gap does not allow us to predict the ways of proper care and prediction. Although potential increased risk of COVID19 on pregnancy outcome is grave.
• PRIORITY (largest longitudinal cohort of ambulatory patients in the United States) is an ongoing prospective cohort study of pregnant or recently pregnant patients with known or suspected SARS-CoV-2 infection. Participants included in this study were enrolled in PRIORITY from March 22, 2020, until July 10, 2020. This date recently published throws light on longitudinal changes in symptoms over time and total duration of the disease among pregnant population.

Most common 3 important symptoms from PRIORITY data

Symptoms Resolution Pattern

The median time from any symptom onset to complete resolution of symptoms was 37 days (95% CI 35–39).

Difference between Pregnant vs Non-Pregnant cases

• Non-pregnant population–based cohort of 1,099 patients in China the most common presenting symptoms were fever (43.8% on hospital admission) and cough (67.8%), compared with cough (20%) and sore throat (16%) as the most common first symptoms in PRIORITY cohort, with fever present in only 12% of the population.
• One week after symptom onset among PRIORITY participants who tested positive for SARS-CoV-2 infection, cough (41%) and fatigue (33%) were prevalent but fever remained uncommon (5%)

PRIORITY Cohort

• 60% white
• 31% are Latina
• 9% are Black.

Another recent meta-analysis from BMJ shows

• Pregnant women with COVID-19 are less likely than non-pregnant women with COVID-19 to have symptoms like fever or muscle pain but more likely to need intensive care (BMJ reports, new study).
• It shows that pregnant or recently pregnant women with COVID-19 were more likely to give birth prematurely. 
• This also shows that 1 in 4 of all babies born to women with COVID-19, were admitted to a neonatal unit but data on causes of preterm births or indications for admission to neonatal units among these babies is lacking.
• Stillbirth and new-born death rates however were low.

CME INDIA Learning Points:

• Coronavirus disease 2019 (COVID-19) has a prolonged and nonspecific disease course during pregnancy and in the 6 weeks after pregnancy.
• Majority of the symptomatic women may have mild disease and might not be hospitalised, the median time to symptom resolution could be 37 days, and for some, even longer as per PRIORITY data.
• There remains significant gaps in knowledge on the clinical course of disease and the overall prognosis in this population.
• It has been suspected that pregnant patients have a different clinical presentation of symptoms and morbidity from COVID-19 compared with the nonpregnant population.
• Lower prevalence of fever and higher rates of fatigue, body aches, and headache, as per PRIORITY data alerts us to keep watch.
• Pregnancy also confers a prolonged course of disease for patients with COVID-19.
• Pregnant or recently pregnant women with COVID-19 seem to be at increased risk of requiring admission to an intensive care unit or invasive ventilation.
• Increased maternal age, high body mass index, and pre-existing comorbidities might be associated with severe disease.
• Pregnant women with COVID-19 are at increased risk of delivering preterm and their babies being admitted to the neonatal unit. But overall rates of spontaneous preterm births are not high.
• Stillbirth and neonatal death rates are low in women with suspected or confirmed COVID-19.
• ICMR has recommended universal testing for COVID19 in pregnant women including those women not showing any symptoms.

Source:

• BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3320 (Published 01 September 2020) Cite this as: BMJ 2020;370:m3320
• Reference: https://journals.lww.com/greenjournal/Fulltext/9900/Clinical_Presentation_of_Coronavirus_Disease_2019.2.aspx Obstetrics & Gynecology.

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