More on Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan, China

July 9, 2020 steven

To the Editor

Chen and colleagues (June 18 issue)¹ reported data, obtained from the reporting system of the National Health Commission of China, regarding 118 pregnant women with coronavirus disease 2019 (Covid-19) at 50 hospitals in Wuhan, China, from December 8, 2019, through March 20, 2020. Since January 2020, an additional 27 publications have described pregnancy outcomes among women with Covid-19 at one or more of the same hospitals in Wuhan, with dates that overlap with those covered in the report by Chen et al. If we count all the patients described in these reports as separate patients, then the reports include data on 446 pregnant women with Covid-19 (of whom 45 are still pregnant), as well as 401 births and 293 throat or nasopharyngeal swabs from infants (see the table in the Supplementary Appendix, available with the full text of this letter at NEJM.org). Of the infant swabs, 10 were reported as positive for the virus, with the infant’s age at testing ranging from less than 24 hours to 2 days. Chen et al. reported that only 8 of 70 newborns were tested, with no positive results. We assume that the report by Chen et al. encompasses data from previous reports and are concerned about this discrepancy regarding infant test results, given the 10 positive tests reported in previous publications. Greater clarity is needed regarding overlap and inconsistencies with respect to other reports.

Lynne M. Mofenson, M.D.
Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
[email protected]

Andrea Ciaranello, M.D., M.P.H.
Nicole LaHood, M.D.
Massachusetts General Hospital, Boston, MA

No potential conflict of interest relevant to this letter was reported.

This letter was published on July 8, 2020, at NEJM.org.

1. Chen L, Li Q, Zheng D, et al. Clinical characteristics of pregnant women with Covid-19 in Wuhan, China. N Engl J Med 2020;382(25):e100–e100.

To the Editor

Chen et al. describe maternal outcomes among 118 patients with Covid-19. We were surprised not only by the number of cesarean deliveries that were performed among women with nonsevere disease (58 of 61 deliveries [95%]) but also by the fact that 61% of the cesarean deliveries were performed without obstetrical indications.

Cesarean delivery is associated with an increased morbidity in the immediate postpartum period because of the increased risks of thromboembolic disease, blood loss, and infections; it is also associated with increased risks in future pregnancies.¹ Cesarean delivery may substantially affect recovery in patients who are already sick, particularly patients with Covid-19, given the reports that those with Covid-19 are at an increased risk for thromboembolism.² Professional societies recommend vaginal delivery for women with respiratory diseases to minimize postpartum complications.³ Even for patients in whom respiratory work should be limited, adequate analgesia and instrumental delivery may be sufficient.

There is currently no evidence that delivery by cesarean section improves outcomes among patients with Covid-19.⁴ We advise that cesarean delivery be performed in women with Covid-19 only after a careful evaluation of the disease severity and obstetrical indications.

Manon Vouga, M.D., Ph.D.
Lausanne University Hospital, Lausanne, Switzerland

William A. Grobman, M.D., M.B.A.
Northwestern University Feinberg School of Medicine, Chicago, IL

David Baud, M.D., Ph.D.
Lausanne University Hospital, Lausanne, Switzerland
[email protected]

No potential conflict of interest relevant to this letter was reported.

This letter was published on July 8, 2020, at NEJM.org.

1. Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018;392:1349–1357.
2. Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. April 19, 2020 (https://www.preprints.org/manuscript/202004.0345/v1). preprint.
3. Middleton PG, Gade EJ, Aguilera C, et al. ERS/TSANZ Task Force statement on the management of reproduction and pregnancy in women with airways diseases. Eur Respir J 2020;55:19012908–19012908.
4. Zaigham M, Andersson O. Maternal and perinatal outcomes with COVID-19: a systematic review of 108 pregnancies. Acta Obstet Gynecol Scand 2020;99:823–829.

Response

The authors reply: Mofenson and colleagues note that there are many reports describing pregnant women with Covid-19 and their neonates who received care in Wuhan hospitals. Researchers in various fields and from various institutions have reported features of pregnant women with Covid-19 from different perspectives, with the aim of disseminating clinical information as quickly as possible; unfortunately, as a result, several cases have been reported in more than one article.¹ Interhospital referrals and participation in multicenter research may have contributed to the overlap. To summarize the clinical characteristics of pregnant women with Covid-19, we systematically sorted out the obstetrical medical records of pregnant women with confirmed Covid-19 that had been uploaded by the 50 designated hospitals in Wuhan through the epidemic reporting system of the National Health Commission and described the data in our previous correspondence.

To the best of our knowledge, our report covered all confirmed cases of Covid-19 identified in pregnant women in Wuhan during the study period; we excluded postpartum cases. We reported that nucleic acid testing of eight neonatal throat swabs and three breast-milk samples had been negative. These test results were all obtained from the mothers’ medical records. Newborns who were delivered by women with Covid-19 were transferred to the neonatology department or to a designated children’s hospital within approximately 1 day after birth, and we did not have information on testing performed after transfer. Thus, some positive results of testing of neonatal swabs that have been reported by others were not included in our study.^2,3 We have assessed the health status of newborns through telephone follow-up, and none of the 70 newborns died within 28 days after birth.

Vouga et al. note concern about the high rate of cesarean delivery in our cohort. On the basis of discussions with local obstetricians, we think that the high rate of cesarean section was mainly related to an inadequate understanding of Covid-19 in the early stage of the pandemic and concern that excessive ventilation during vaginal delivery might aggravate the condition. Shortages in protective equipment and personnel also contributed to some decisions to pursue cesarean delivery. Now, with a better understanding of Covid-19, we agree that the disease is not an indication for operation, except in cases in which severe disease would make it difficult for a woman to undergo vaginal delivery.

Lian Chen, M.D.
Yangyu Zhao, M.D., Ph.D.
Jie Qiao, M.D., Ph.D.
Peking University Third Hospital, Beijing, China
[email protected]

Since publication of their letter, the authors report no further potential conflict of interest.

This letter was published on July 8, 2020, at NEJM.org.

Drs. Zhao and Qiao contributed equally to this letter.

1. Bauchner H, Golub RM, Zylke J. Editorial concern — possible reporting of the same patients with COVID-19 in different reports. JAMA 2020 March 16 (Epub ahead of print).
2. Zeng L, Xia S, Yuan W, et al. Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China. JAMA Pediatr 2020 March 26 (Epub ahead of print).
3. Wang S, Guo L, Chen L, et al. A case report of neonatal COVID-19 infection in China. Clin Infect Dis 2020 March 12 (Epub ahead of print).