Cesarean Delivery Tied to Worse Outcomes in Women With COVID-19

By Marilynn Larkin

June 16, 2020

NEW YORK (Reuters Health) - Cesarean delivery was associated with severe maternal outcomes and clinical deterioration compared to vaginal delivery among women infected with COVID-19 in Spain.

"We were really surprised by the high rate of cesarean section in (COVID-19 patients) in China," Dr. David Baud of Lausanne University Hospital in Switzerland, told Reuters Health by email. "We were not so surprised to discover (in our own study) that vaginal delivery is safer in (such) patients."

Dr. Baud and colleagues studied data on women in Spain with SARS-CoV-2 and singleton pregnancies between March 12 and April 6, 2020, and who delivered within the next 14 days.

As reported in JAMA, among the 82 participants, four presented with severe COVID-19 symptoms, including one with concomitant preeclampsia. All four underwent cesarean delivery and required ICU admission.

Seventy-eight women presented with no or mild COVID-19, including 11 who required oxygen supplementation. Forty-one (53%) delivered vaginally and 37 (47%) by cesarean delivery - 29 for obstetrical indications and eight for COVID-19 symptoms without other obstetrical indications.

Compared to those delivering vaginally, women who underwent cesarean deliveries were more likely to be multiparous, obese, require oxygen at admission, and have abnormal chest x-ray findings.

No severe adverse outcomes occurred in women who had a vaginal delivery. However, five (13.5%) who underwent a cesarean required ICU admission.

Two (4.9%) with a vaginal delivery experienced clinical deterioration after birth versus eight (21.6%) with cesarean delivery. After adjustment for potential confounders, cesarean birth was significantly associated with clinical deterioration (adjusted odds ratio, 13.4).

Eight newborns (19.5%) delivered vaginally and 11 (29.7%) born by cesarean delivery were admitted to the neonatal ICU. After adjustment, cesarean birth was significantly associated with an increased risk of NICU admission (aOR, 6.9).

Three newborns delivered vaginally tested within six hours after birth had a positive SARS-CoV-2 RT-PCR result. However, repeat testing at 48 hours was negative. None developed COVID-19 symptoms within 10 days.

Two other newborns, both cesarean deliveries at term, developed COVID-19 symptoms within 10 days. In this case, although initial testing at birth was negative, repeat testing was positive. Both newborns were in contact with their parents immediately after birth. Symptoms resolved within 48 hours.

Dr. Baud said, "Clinicians should not perform cesarean section just because the patient has COVID-19 or to prevent transmission of the virus to the baby. Cesarean section seems not to prevent infection of the newborn."

Dr. Matthew Blitz, maternal fetal medicine specialist at Northwell Health's Southside Hospital in Bayshore New York, commented by email, "Our health system has now cared for more than 500 pregnant women with positive SARS-CoV-2 test results and only about a dozen were admitted to the ICU, as we recently reported in the American Journal of Obstetrics and Gynecology."(https://www.ajog.org/article/S0002-9378(20)30528-7/pdf)

"In nearly all of those cases, the patients had severe or critical disease on presentation to the hospital," he told Reuters Health. "In our experience, significant clinical deterioration of patients presenting with mild or absent symptoms, regardless of mode of delivery, is exceedingly rare."

Like Dr. Baud, he said, "the decision to perform a cesarean section should be based on standard obstetrical indications. The presence or absence of COVID-19 should not be a factor. There is certainly much debate about mode of delivery and optimal delivery timing in severe COVID-19 cases, but larger studies will be needed to guide management."

Dr. Robert Atlas, Chair of the Department of Obstetrics and Gynecology at Mercy Medical Center in Baltimore, commented in an email to Reuters Health, "The patients undergoing cesarean section were in general sicker, heavier and earlier in gestation."

"I am a little surprised at the results," he said. "The total number is relatively small, and I would like to see an update to the data. I think this is helpful as we look at how we are dealing with delivery surrounding this disease and should attempt delivery, as we always should, weighing the risks and benefits of cesarean section versus vaginal delivery."

"If we can deliver these patients vaginally, in general, it will be better, as with all patients," he said. "However, there may be very ill individuals who just will not tolerate an induction of labor and will require a cesarean section."

SOURCE: https://bit.ly/2YBCLRk JAMA, online June 8, 2020.

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