Data were analyzed using SPSS version 23 (SPSS Inc., Chicago, Ill., USA). Frequency and percentage were used to describe qualitative variables and chart to compare patients' symptoms.
Over one year, from February 2020 to February 2021, 25 pregnant women with the mean age of 32 (19-48 years) infected by COVID-19 were registered in our database. COVID-19 PCR testing was reported positive in 24 (96%) patients.
Five mothers with mild illness, mostly less than 25 weeks of pregnancy, were treated as outpatients. Fifteen patients were admitted to C-Ward (66% > 30 weeks), and 5 were monitored in C-ICU, mostly (26-30weeks).
About 50% experienced their first pregnancy, 12% had one or two abortions in the past, and there was no history of IUFD or neonatal death. Two mothers had twin pregnancies, both with a history of infertility (IVF and ICSI).
Eleven patients (44%) had a contact history with infected patients. None of 25 infected pregnant women were vaccinated against flu before contracting COVID-19.
The five most common symptoms at the first visit were cough (72%), feeling feverish (68%), dyspnea (60%), sweating (52%), decrease or loss of taste or smell (52%) (Figure 1).
The vital signs of all outpatients were normal, and their O₂ saturation was above 95%.
Among twenty admitted patients, 17 women needed O₂ therapy, including 3 patients who were intubated in C-ICU with O₂ saturation ≤ 90 %( 86-90%). Six patients, had respiratory rate> 22 breath/min. Nine patients (45%) had the oral T >37.7°C, and 2 had blood pressure>140/90 mmHg. Ten patients (50%) were tachycardic.
The most common abnormal laboratory findings were related to CRP and ESR.
Chest CT scan was performed for 13 admitted pregnant women based on clinical necessity. The frequency of chest CT abnormality was not significantly different in 5 different lobes (77-92%). The majority of Chest CT scans demonstrated a ground glass appearance (77%) (Table 1). The highest severity of pulmonary involvement was related to intubated patients. Three patients had a CT severity score>13, all intubated in the C-ICU.
The Data of all 25 pregnant women with COVID-19 infections are listed in Table 2.

 
 Figure 1. The frequency of symptoms in infected women with COVID-19

 
Table 1. Chest CT scan report in 13 admitted pregnant patients with COVID-19 infection

Table 2. The Chief Complaints, Clinical Characteristics, Treatments, and Outcomes of 5 outpatients, 20 C-Ward and 5 C-ICU admitted Women with COVID-19 infections 

C-ICU Admission *                     C-Ward admission**                     outpatient ***  
Dx: diagnosis                             MR: Maternal request                    FOF: Feeling of fever                  H.Chl: Hydroxychloroquine    
Azi: Azithromycin                      DiPhen: Diphenhydramine            NL:  Normal                                 GA: gestational age
 

In 12 out of 20 admitted cases (44%), pregnancy terminated during hospitalization; 7 (58%) term pregnancies and 5 for obstetrical complications includ-ing fetal distress (28 W), IUFD (28 W), cholestasis (27 W), heart disease (34 W), and preterm labor (37 W). In this study, there were three maternal mortalities (12%) and overall low morbidity. Two patients died during the acute infection (in the C-ICU); both had twin pregnancies, a history of infertility, and died from cardiac arrest (one due to myocarditis). The third patient died due to hepatic failure five months after delivery.
Totally, there was 24 live birth from 23 mothers (1twin) and only two IUFD (twin). Thirteen neonates (from 12 mothers) were born during hospitalization. Three out of 13 neonates (23%) expired, who were all preterm (27-28 W). PCR was taken from all the rest neonates with only one positive result. The infected neonate was isolated and showed no symptoms of COVID-19 infection after birth.
In the 6-month follow-up of women discharged from the hospital, there was no readmission due to COVID-19 infection. Nearly all signs and symptoms ameliorated during the first 2 weeks after discharge; however, the dyspnea in three patients and cardiac status in one patient improved more slowly. The pregnancy and disease outcomes are summarized in Table 3.

Table 3. The pregnancy and disease outcome in 25 pregnant women diagnosed with COVID-19 infection

A 27-year-old woman, G1P0, with GA= 29w+6d, with a history of hypothyroidism during pregnancy, treated with levothyroxine, was referred to hospital. She complained of feeling feverish, rigors, sweating, myalgia, productive cough, fatigue, conjunctivitis, dry mouth, sore throat, sneezing, nasal and throat itching, dyspnea, palpitations, anorexia, headache, dizziness, depression, nervousness, vomiting, flank pain, sleep disorder and pruritus. Her COVID-19 PCR test was positive. Her vital signs were stable and laboratory tests were: WBC=7900, Lymph= 15%, Hb= 9.8 g/dL, PLT=214000, AST=15 U/L, ALT=20 U/L, ALP=575 U/L, LDH=634 U/L, Urea=18mg/dL, Cr=0.9 mg/dL, ESR=47 mm/h, CRP=16.3 mg/L. During her admission, she also had mild uterine contractions. Hyd-roxychloroquine, betamethasone, magnesium sulfate, and Indomethacin were commenced. After 6 days, she was transferred to the C-ICU due to severe dyspnea. Her contractions stopped after 1 day. Proteinuria (1386 grams) was detected in the 24-hour urine sample, and echocardiography showed severe eccentric mitral regurgitation (MR) to lateral wall, pulmonary artery pressure (PAP)= 58mmHg, mild left ventricle (LV) dilatation with dysfunction, raised LV filling, and pressure, with an ejection fraction (EF) of =25%. The patient was then admitted to the C-ICU. Due to severe dyspnea, the MDT suggested postponing delivery until 34 weeks of gestational age. Treatment for possible viral myocarditis (due to COVID-19 or peripartum cardiomyopathy) was initiated. She received digoxin, Isordil, and hydralazine. Finally, at 34 weeks of gestational age, CS was performed (due to maternal condition, threatened preterm labor, and breech presentation). A live male infant weighing 2410 grams was delivered, with an Apgar score of 9/10, and he was admitted to NICU. After delivery, the mother's respire-tory function improved, and her cough stopped. She was transferred to C-Ward and then discharged from the hospital. The infant was also intubated due to respiratory distress, and after extubation, he had one seizure episode treated with phenobarbital. The baby had no further seizures after discontinuation of treatment and was ultimately discharged in a good general condition. After 6 months of follow-up, the ejection fraction showed a modest improvement to just 40%. The echocardiography (at 6 months) was as follows: Moderate LV systolic dysfunction, Apico-septal hypokinesia, NL left atrium (LA) and right atrium (RA) size, NL right ventricle (RV) function, mild to moderate MR, mild tricuspid regurgitation (TR), NL PAP at rest systolic pulmonary artery pressure SPAP= 30mmHg, EF=40%). Clinically, the mother and baby remain in good condition.
 

In this case series, we reported 25 COVID-19 infected pregnant women with positive signs, symptoms, and positive PCR testing in 24 out of 25.
In our report, the symptoms, signs, lab data of infected pregnant women were similar to the other reports. Fever, cough, dyspnea as the predominant symptoms (11, 16, 17), the decreased oxygen saturation <95%, tachycardia, fever (45%) (16-19) as the most significant signs, and high CRP level as the most common abnormal laboratory data are revealed (2, 18). The most common finding on the Chest CT scan of 13 patients was a ground-glass appearance, which was similar to other data (8-10, 19). As expected, the trend of CT severity score was associated with disease severity, C-ICU hospitalization, and intubation.
Among these 25 pregnant women, the vertical transmission was very low (one out of 23 live neonates). Some other studies confirmed the rare vertical transmission (11-12, 20).
Similar to some other published articles (21-23), the maternal mortality rate in our report was 12% (3out of 25), all preterm (23-28weeks). Two of the expired mothers had twin pregnancies. This could be explained by the fact that all possible effects of the virus on host cells and vice versa, which deteriorate normal organ function, could get worst in pregnant women and that the immunological changes during pregnancy increase susceptibility to viral infections, in particular respiratory pathogens (24-26). Consequently, pregnant women are more intolerant to hypoxia, especially in twin pregnancy and in early third trimester when maximum cardiac output happens and make the mother more prone to develop severe pneumonia, which is predisposing to hypoxemic respiratory failure due to COVID‐19 pneumonia.
 

In this case series, among 25 women with confirmed COVID-19, maternal, fetal, and neonatal mortality happened mostly in the early third trimester and in twin pregnancy.

 

This study was funded and supported by the Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

 

Author’s Contributions

MS: supervision, collected the data. FF: Conceived and designed the analysis, drafting and revising the manuscripts in English. MM: wrote the paper contributed data or analysis tools. SMA, LA, SS, TJ, PP, SA, MY, BN, SZ, SH, MH, MMM, SPS, AM, DA: collected the data. TV. TV: Contributed data or analysis tools; performed the analysis.

 

The authors declared no conflict of interest.

 

The data set collected and analyzed during the current study is available from the corresponding author on reasonable request.

 

This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.RESEARCH.REC.1399.766).

 

Informed consent was obtained from all individual participants included in the study.

 

 Not applicable.