The clinical characteristics and vertical transmission potential of COVID-19 in pregnant women and neonates are still unknown. Hence, research in this area is the need of the hour
The birth of a baby brings a lot of joy to a family. However, recent updates on the babies born at Mumbai’s Nair Hospital, Nanavati Hospital and Agra’s SN Medical College brought happiness and hope not only to their families, but also to Indian epidemiologists who are currently working to understand the pathogen’s transmission scope from mothers to their new-born babies. Wondering why?
On 18th May, 2020, the civic-run Nair hospital completed delivery of a healthy baby boy. His birth spread cheer to the entire hospital staff. The hospital informed that this little baby was among 100 other babies born out of a COVID-19 positive mother at the centre. Doctors reported that none of the babies had contracted the virus so far.
The first ray of hope came in when Express Healthcare got a news lead about a healthy baby born to a mother in Mumbai who was infected with COVID-19. The baby was born at Mumbai’s Nanavati Hospital and was tested negative for COVID twice. We further investigated on this lead and found that a similar case occurred at Agra’s SN Medical College where a 24-year-old COVID-19 patient gave birth to a healthy boy and this baby too tested negative for the disease, confirming that in both these cases there wasn’t any vertical transmission (mother-to-child) of the virus.
Our curiosity grew further and we decided to find out whether this piece of information could possibly be part of a larger study on the vertical transmission of COVID-19 and bring new hope to our researchers in India.
A baby that brought joy
We first spoke to the doctors at Nanavati to understand the relevance of this case. Dr Suruchi Desai, Senior Consultant, Obstetrics and Gynaecology; Dr Tushar Maniar, Head Of Department – Centre for Child Health; Dr Tejal Shetty, Consultant Neonatologist; Dr Harshad Limaye, Senior Consultant, Internal Medicine and Dr Rahul Tambe, Senior Consultant, Internal Medicine were in charge of this case.
According to Dr Desai, the mother was asymptomatic COVID-19 patient and was admitted to the hospital with high blood pressure and a history of previous caesarean delivery, along with positive COVID-19 status. Therefore, they had to be doubly careful with the patient. “Only a handful of such surgeries are performed in India so far, thus a special obstetrics unit, suitable to the infection control protocols was created. We kept the surgical staff number to a minimum and trained them for the use of Personal Protection Equipment (PPE). Special COVID corridors were created for safe transportation of the mother and baby. The surgical unit took additional care to ensure there was no contact between the mother and the child. Immediately, post the successful delivery of the baby girl, a team of neonatologists headed by Dr Tushar Maniar, Head of Paediatrics Unit and Dr Tejal Shetty, Consultant Neonatologist, Nanavati Hospital, shifted her to a special isolation Intensive Care Unit (ICU). After three days of her birth, her samples were sent for COVID-19 testing and her results turned out to be negative. Again, on the eighth day, her tests were conducted and results were negative,” Dr Desai heartily mentioned.
While speaking to Tambe, the infection control expert at the hospital, we understood that this case is certainly important for epidemiologists to go into the details of these pathogens and their transmission levels. “As you are aware that India has two or more such babies who are born healthy despite their mother contracting the infection, it still stands as a positive achievement; firstly, because we were able to avoid the transmission during the caesarean procedure and secondly, of course as the vertical transmission didn’t happen. We were much worried about this case because just as the HIV virus transmits from a mother to child, COVID could have similar transmission scope, even more, because we still do not have enough evidence on this.”
This is true, the clinical characteristics and vertical transmission potential of COVID-19 pneumonia in pregnant women are still unknown. While there are some studies ongoing in China, the US and some other countries, none show more proof. Therefore, urgent questions that need to be addressed promptly include whether pregnant women with COVID-19 pneumonia will develop distinct symptoms from non-pregnant adults, whether pregnant women who have confirmed COVID-19 pneumonia are more likely to die of the infection or to undergo preterm labour, and whether COVID-19 could spread vertically and pose risks to the foetus and neonate. Answers to these questions are essential for formulating the principles of obstetric treatment for pregnant women with COVID-19 infection, point out experts.
Covid-19 is an ongoing pandemic and therefore, the research part is more dynamic with new findings occurring rapidly, opines Dr GLory Alexander Thomas, Director, Asha Foundation. “There are about 18 studies done on pregnant women with proved COVID-19 infection from China, the USA, South Korea, Sweden and Honduras. The numbers in each of these studies are small and therefore cannot be extrapolated to the general pregnant population with COVID-19 infection. These studies account for 108 pregnant women between 8th December, 2019 and 1st April, 2020. Women in pregnancy experience immunological and physiological changes that make them susceptible to viral respiratory infections such as the flu. Even SARS and MERS had adverse pregnancy outcomes like abortions, premature births and small-for-age babies. Similar studies in COVID-19 and pregnancy are very few but preliminary studies suggest that generally, COVID-19 pregnant women might not be at increased risk of severe complications or adverse birth outcomes but more and larger cohort studies are needed,” she informs.
Chipping in Dr Neha Bothara, Consultant Gynaecologist and Obstetrician, Hiranandani Hospital, Vashi-A Fortis Network Hospital, says, “Early studies in China did not reveal any mother-to-child transmission. However, newer findings have shown mother-to-child transmission of the virus within the womb. Nevertheless, one must keep in mind that these are early times with new data coming in every hour and long-term analysis is required before any conclusions can be reached about the true nature of this disease. The principles of obstetric management of patients with COVID-19 are similar to non-COVID-19 patients, in the sense of concentrating on minimising contamination and transmission to surroundings. Newer information from studies will empower medical personnel from taking better precautions during birthing procedures. Separation of mother and child after birth is being followed until the mother is non-infective. Fortunately, infants and young children have been found to be largely resistant to the virus’s effects, though they are not necessarily non-infective to the people around them. Viruses inherently are mutative and ever-changing. Pending new data and clinical experience universal precautions are the best bet for preventing transmission to newborns.”
Adding more perspective to this, Dr Subramanian Swaminathan, Infectious Diseases Consultant, Global Hospital, Chennai/Bengaluru and Chair, Transplant ID subcommittee, CIDS and Scientific Chairman, CIDSCON 2020, shares, “In general, pregnant women form a high-risk category for any infection- examples being H1N1 and chickenpox. The risk is to both – themselves and the foetus. For example, the death of pregnant women during the flu pandemic of 1918 was extraordinary, ranging from 27-45 per cent in the US. Indian data is hard to come by, but is likely more, given that the maximum number of deaths overall was likely in India (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600164/). So, studies (obervational) will need to be done quickly to find risks to mother, to the newborn baby and risks of malformations in the baby. The good news is that, thus far, it seems very mild. All pregnant mothers seem to have a successful outcome (https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.13867 ).
As experts highlight that more evidence and studies are needed to better understand COVID-19 among pregnant women and its risk factors for neonates SOPs for patient care has been framed already. This is some good news!
“Dr Sanjeev Singh, Professor of Hospital Administration and Sr Medical Superintendent, Amrita Institute of Medical Sciences, Kochi, reveals, “There is an interim guidance note from WHO on the treatment SOP for patients of OBGYN. American College of OBGYN and Society for maternal-foetal medicine has drafted the algorithm for testing, diagnosis and treatment of COVID patients in OBGYN. FOGSI in India has also come out with a short-term advisory on treatment and handling protocol for labour and delivery, and gyneac patients. Data also has been deeply analysed from affected countries like China, Italy, Spain, the UK, the USA etc., and thorough crunching of data has been done leading to protocol generation. Moreover, ICMR has recommended testing of pregnant women who belong to red/containment zone and are likely to deliver within five days to be tested with RT-PCR even if they are asymptomatic. Neonatal care will be offered as standard service. If the mother is COVID-positive, then adequate care needs to be taken during breastfeeding and kangaroo care.”
So, as SOPs have already been framed now, the four can be on research and further investigations on transmission scope, as well as gathering lessons from previous outbreaks.
Learning from HIV or not
Dr Bothara further adds, “The HIV pandemic brought valuable lessons for the future but COVID-19 is different in terms of the nature of its illness as well as the nature of its transmission. Being a respiratory illness, having a far higher transmission rate makes it a different ball game altogether to deal with when curtailing transmission. Vertical transmission rates also are lower than HIV (as per current evidence). Nevertheless, the policy of universal precautions has been successfully extrapolated to the COVID-19 pandemic as well. Key areas of research may now concentrate on determining the extent of vertical transmission among COVID-19 patients, the nature of passive and active immunity received by the unborn foetus, passive immunity possibly received through breast milk, etc.”
Dr Thomas spells outs the difference between the HIV and COVID-19. “In many newborns tested for Covid-19 from the nose, amniotic fluid and cord blood, the results were negative. Three babies had IgM, and IgG antibodies in their blood. IgG antibodies can transmit from mother’s blood to baby’s but not IgM. So, there was a doubt whether this baby had in-utero infection, but the baby did well. One baby was COVID-19 positive 36 hours after birth; now, whether this baby got it in utero or after birth is not known. One important difference between HIV and COVID -19 is that HIV is not transmitted through droplet infection like COVID-19. COVID- 19 is highly infectious and a new-born baby can easily pick it up from the mother after birth if one is not extremely careful. Further, so far, the SARS-COV2 has not been isolated from breast milk – so the question of breastfeeding has to be individualised on case-to-case basis,” she explains.
Well, whether there is a vertical transmission or not, the risk of transmission from a mother to the baby still remains.
Risk after birth
“Personally, I feel that more than in-utero or vertical transmission, the risk for the baby is after birth when he/she is in contact with the mother who can infect the baby through droplet infection and close contact. Here is where adequate precautions need to be taken and each case has to be individualised based on mother’s as well as baby’s health conditions. Since so far SARs-COV 2 has not been isolated from breast milk, the baby should receive the advantages that breastmilk has to offer, especially in a country like India with adequate precautions taken by the mother during handling and breastfeeding,” Dr Thomas advises.
Dr Swaminathan reckons, “This is a new infection, and we need to learn from experiences and data. We just need to collect observational data and monitor for now. Given the overall low risk here, the cause for alarm is unnecessary, and is distracting the efforts to be taken for the high-risk category.”
So, if India needs to invest in research on COVID-19 pregnant women and the virus infection scope in newborn, what could be the key points to be covered?
Pre-requisites for research
“Whatever research is available was done on pregnant ladies who presented in the third trimester, and vertical transmission was ruled out in the third trimester. One case report from Beijing showing COVID-19 positive in one day neonate does not rule out the possibility though. Amniotic fluid, cord blood samples, and nasopharyngeal swabs of infants need to checked; some say even rectal swabs of the infant should be checked. Trials are definitely required to prove the same,” believes Dr Farah Ingale, Senior Consultant – Internal Medicine, Fortis Group.
Similarly, Dr Thomas puts forward her views and recommends, “Randomised controlled trials are also required to look at outcomes in mothers with co-morbidities like high blood pressure and diabetes with COVID-19 and without COVID-19. Some of the mothers who got sick among the 108 pregnant mothers also had co-morbidities. Finally, a global and country registry has to be maintained for COVID-19 pregnant patients and all data has to be entered uniformly so that outcomes can be measured.”
Going forward, protecting the newborns and their mothers from COVID-19 will be paramount as epidemiologists predict that the virus is here to stay at least for some more time. Research in this area is, therefore, significant to find appropriate treatment and prevention options.