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\begin{document}

             \author[1]{Dr. Priya  Bulchandani}

             \author[2]{Dr. Tushar  palve}

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\date{\small \em Received: 15 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Background: There has been increased severity and susceptibility in pregnant females with previous viral illness outbreaks. The data of pregnancy outcomes with COVID-19 are lacking and available in few small number series. The objective of this study was to report the maternal and perinatal outcomes of COVID-19 during pregnancy.Methodology: Retrospective records of 185 pregnant women with laboratory confirmed COVID-19 disease in single center were reviewed from 1 st May to 31 st July 2020 and descriptive analysis of outcomes was done.Results: There were 185 laboratory confirmed COVID-19 pregnant females in this study with mean age of 27.3+ 5.33 years. The majority presented in third trimester with no sign and symptoms of disease activity (66%). Lymphocytopenia (34.81%) ,elevated levels of C-reactive protein 49.95% and chest X-ray abnormalities in 32.43% were observed. 72.51% of women were delivered vaginaly and 27.49% required caesarean section with major indication being previous LSCS. The rate of preterm delivery was 17.54% with PPROM in 11.70%. Three maternal intensive care unit admissions were noted but no maternal death. 4 neonatal death and 4 still birth were also noted.

\end{abstract}


\keywords{COVID-19, outcomes, delivery, pregnancy.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
? Since the first reports of cases from Wuhan, a city in the Hubei, Province of China, more than 20 million cases of COVID-19 have been reported \hyperref[b0]{(1)}. The emerging COVID-19 pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). This has led to turmoil in healthcare conduct. There is evolving understanding and hence, upcoming protocols with progressing pandemic. ? Pregnant females are at a heightened risk of contracting viral lower respiratory tract infections due to altered physiology with elevated diaphragm, increased oxygen consumption and mucosal edema of respiratory tract making them relatively intolerant to hypoxic environment. There are also alterations in immune response with pregnancy which may contribute further to this increased vulnerability \hyperref[b1]{(2,}\hyperref[b2]{3)}. It has been reported that viral pneumonia in pregnant women is associated with an increased risk of preterm birth, foetal growth restriction (FGR), and perinatal mortality (4).  
\section[{Material and Methods}]{Material and Methods}\par
We retrospectively reviewed the clinical records of 185 pregnant women with laboratory confirmed COVID-19 admitted in our center. The epidemiology, outcomes and challenges faced were analyzed. The impact of COVID 19 in ante and peri-partum period, neonatal and maternal sequelae of this disease were addressed in this study. Age (years) (Mean + SD) 
\section[{III.}]{III.} 
\section[{Results}]{Results} 
\section[{a) Clinical characteristics}]{a) Clinical characteristics}? <20 ? 20-25 ? 25-30 ? 30-35 ? >35 27.3 + ? 5\par
5.33? 75 ? 57 ? 37 ? 11\par
Gestational age at admission (weeks)? <14 ? 14-27 ? 28-36 ? 37-40 ? >40 ? ? 9 ? 5 ? 43 ? 105 ? 23 Parity - ? Primi-gravida ? Multi-gravida ? ? 75 ? 110\par
Symptoms -? Fatigue ? Fever ? Cough ? Myalgia ? Diarrhea ? Sore throat ? Dyspnea ? Asymptomatic ? 30 ? 25 ? 20 ? 20 ? 9 ? 5 ? 3 ? 66 Comorbidities - ? Hypertensive disorders ? Gestational diabetes mellitus ? Severe anemia ? Hypothyroidism ? Bronchial asthma ? Pulmonary Tuberculosis ? ? 20 ? 14 ? 9 ? 5 ? 4 ? 2 Treatment Received - ? Antibiotic therapy ? Antiviral therapy ? Use of corticosteroid Number of Patients ? 160 ? 3 ? 3 ICU admission - ? Non-invasive ventilation ? Invasive mechanical ventilation ? 3 ? 1 ? 2\par
Hospital Stay (days)  Mode of delivery-? Cesarean delivery ? Vaginal delivery ? Not delivered ? 47 ? 124 ? 14\par
Indication of cesarean delivery -? COVID-19 pneumonia ? Previous cesarean delivery ? Mal-presentation ? Cephalo-pelvic disproportion ? Placenta Previa ? Failure to progress ? Pre-eclampsia ? Others ? Fetal distress ? None ? 28 ? 5 ? 4 ? 3 ? 2 ? 2 ? 2 ? 1\par
Gestational age at delivery  ? 9 cases presented before 14 weeks of gestation of which 2cases were complicated with complete spontaneous abortion, 2 cases with ruptured ectopic and 1 case with missed abortion. ? The remaining 4 patients were discharged and kept on follow up. They have crossed 20 weeks of gestation with normal fetal growth and no anomaly observed in morphology scan. 5 patients with gestational age at presentation between 14 -27 weeks were discharged after an uneventful hospital stay and are maintaining fine at follow up.\par
? 43 cases presented between 28-37 weeks of gestation of which 30 cases had pre-term delivery and remaining 13 cases were delivered at term. Of the 30 cases who underwent pre-term delivery, 20 cases had PPROM. ? 124 cases were subjected to vaginal delivery while 47 cases required cesarean section with majority (59.57\%, 28/47) due to previous LSCS. The other indications for cesarean section are mentioned in Table  {\ref .} IV. 
\section[{Discussion}]{Discussion}\par
? This study reports observations of 185 pregnant females who were laboratory confirmed COVID-19 cases. The predominant symptom was observed to be fatigue in 16.22 \% (30/185) which was different from the past studies that reported fever as the commonest manifestation \hyperref[b9]{(9)}\hyperref[b10]{(10)}\hyperref[b11]{(11)}. ? The fatigue may also be present as manifestation of routine pregnancy and therefore could have been confounding with results. They were asymptomatic in 35.68 \% cases and were detected in routine testing done prior to hospital admission. In majority of these there was history of residence in containment zones or hotspots or contact with COVID-19 cases. This entails the high index of suspicion that needs to be kept with emphasis on history and routine screening of all before hospital admission to effectively curtail the spread to other patients and healthcare personnel. ? 3 patients (1.62\%) required ICU care with 2 of them requiring ventilatory support and one on noninvasive ventilation, however, they recovered and were transferred back to the ward. One of them had pre-term delivery and rest 2 delivered at term with no adverse foetal outcome. This suggests that effective oxygenation and critical care did not worsen the neonatal outcomes, although, the less number of these patients limit us in conclusively authenticating this observation. The ICU admission rates are similar to the study by Huntley et al which quoted 3 \% cases requiring ICU care \hyperref[b13]{(12)}. ? The laboratory parameters showed lymphocytopenia in 34.81 \% and leukopenia in 21.62\% which suggests that lymphocytes were reduced even in patients with normal leucocyte count which has also been demonstrated in other studies with striking differences. A study of 393 hospitalized patients in New York revealed lymphocytopenia in 90 \% whilst leukopenia in approximately 15 \% only \hyperref[b14]{(13)}. CRP elevations have been associated with inflammation and COVID-19 disease process in cytokine storm states. These were elevated in 45.95\% patients in this study corroborating the other studies in this regard. In other studies, CRP elevations have been found as high as 67 \% with COVID-19. \hyperref[b8]{(8,}\hyperref[b9]{9,}\hyperref[b10]{10)} ? The Chest X-ray showed abnormal findings predominantly consisting of ground glass opacities or patchy infiltrates in lung fields in 32.43\% cases (60/185). CT scan was not done in this study in majority of patients. ? The rates of spontaneous abortion was observed to be 23.08 \% cases (3/13, 13 cases presented at or before 20 weeks of gestational age). This rate has been found to be 12.5 \% in the study by Yan et al comprising of 116 patients \hyperref[b15]{(14)}.\par
? The rate of pre-term delivery was noted to be 17.54\% (30/171). Of these 30 patients, 20 (66.67\%) had PPROM. The overall incidence of PPROM was 11.70\% (20/171) which was higher than the study by Yan et al who observed 6.1 \% incidence of PPROM \hyperref[b15]{(14)}.\par
? Wong et al in their study of 12 pregnant females infected with SARS-CoV reported 3 cases of maternal demise, more than 50 \% of those who presented before 12 weeks were complicated with spontaneous abortion, 80 \% females presenting after 24 weeks had pre-term delivery and ongoing pregnancies were complicated with Intra-uterine growth restriction \hyperref[b16]{(15)}. This study, however, concludes reassuring data with COVID-19. V. 
\section[{Limitations}]{Limitations}\par
This study entails a single centre experience with limited patient subset. The non-carrying out of routine neonatal testing due to logistic and economic issues prevents in ascertaining vertical transmission risk. CT scan which has become an indispensable modality was not used in this study due to institutional logistic issues. This study also has the limitation in concluding vaginal mode of delivery and breastfeeding confer an additional risk of vertical transmission of COVID-19.\par
VI. 
\section[{Conclusion}]{Conclusion}\par
This study concludes that presently there is no evidence that pregnant women with COVID-19 are more prone to experience severe pneumonia than nonpregnant patients. The study suggests that one mode of delivery is not superior over the other as far as risk associated with COVID-19 disease. The risks of pregnancy related complications are not significantly increased due to COVID-19.The ongoing research and data collection may answer the questions in relation to the risk of congenital infection, intrapartum management, and vertical transmission. \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.7966996699669967\textwidth}P{0.053300330033003294\textwidth}}
\multicolumn{2}{l}{? 185 consecutive laboratory confirmed COVID-19}\\
\multicolumn{2}{l}{affected pregnant females were included in this}\\
study with a mean age of 27.3 +\tabcellsep 5.33years. Majority\\
\multicolumn{2}{l}{were in gestational ages of 37-40 weeks (56.76\%,}\\
105/185).\tabcellsep \\
\multicolumn{2}{l}{? There was history of residence in containment zone}\\
\multicolumn{2}{l}{in 110 cases (59.46\%), 12.97\% cases had contact}\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_3}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.6817708333333333\textwidth}P{0.16822916666666665\textwidth}}
\tabcellsep Number\\
? >37 weeks\tabcellsep ? 141\\
? < 37 weeks\tabcellsep ? 30\\
? Associated with PPROM\tabcellsep ? 20\\
d) Clinical Outcome In Neonates\tabcellsep \end{longtable} \par
 
\caption{\label{tab_4}}\end{figure}
 			\footnote{© 2020 Global Journals Obstetric Outcomes in Covid-19 Pandemic: Single Center Experience at Tertiary Level Institute} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{bibitemlist}
 			 		 	 
\end{document}
