On May 8, Dr P Shanmugapriya, an eight-month pregnant medical officer, died due to COVID-19 in Madurai. She passed away at the Government Rajaji Hospital in Madurai about a week after she tested positive for the SARS-CoV-2 virus that causes COVID-19. Neither Dr Shanmugapriya, who worked as a medical officer at the Anuppanadi Primary Health Centre, nor her foetus could be saved. Ten days after Shanmugapriya’s death, Shamili, a probationary police sub-inspector who was seven months pregnant, died due to COVID-19 in Kolar. Shamili was 24. Shanmugapriya and Shamili’s deaths, however, are no longer a rarity in India’s COVID-19 second wave, raising concerns among the medical community over pregnant women appearing to be at increased risk of severe infection and deaths in 2021.
TNM spoke to doctors from south India to understand the risks and complications for pregnant women who have tested positive for the novel coronavirus. Doctors say that they are seeing a far higher number of pregnant women being infected by the coronavirus in the second wave compared to last year, with most presenting with symptoms. The number of severe cases is also on the rise, they say.
Dr Kuppulakshmi, Professor of Obstetrics at the Institute of Obstetrics and Gynaecology in Chennai, says the sheer number of symptomatic cases among pregnant women is very high in this wave. “Last time we rarely saw patients who were symptomatic. All the patients now are symptomatic. They first have fever, then cough and then breathlessness. They come only when there is breathlessness,” says Dr Kuppulakshmi, adding that pregnant women must consult with their doctors when they get a fever.
“Any fever in this pandemic, unless disproved, is COVID-19. So they have to come at the fever stage itself,” she explains.
The Kasturba Gandhi Hospital for Women and Children (KGH) in Chennai has seen at least 80 pregnant women with COVID-19 in the last few months. Putting into perspective the increase in infections, Dr Kalaivani, Director of KGH, recalls that the Government Raja Sir Ramaswamy Mudaliar (RSRM) Lying-in Hospital, where she had earlier been posted, had seen only 10% of pregnant women testing positive for the virus out of the 1,000 patients that had been admitted last year. “There is definitely an increase now,” she says, adding that KGH sees a number of referral cases from private hospitals. “Once their condition becomes severe, they are referred. So we see cases mostly with 40% lung involvement and upto 75%-80% lung involvement.”
Dr VP Paily, a senior obstetrician in Kochi’s Rajagiri Hospitals, says, “In the first wave, we found that pregnant women with COVID-19 were carrying on just like others. But now the number of those who are seriously ill is on the rise.”
The scenario isn’t very different in other cities as well. But is the high number of COVID-19 cases among pregnant women merely a consequence of the scale of infections in the second wave?
Dr Paily explains that the high caseloads is the main factor for more pregnant women being infected this time. “In addition, we believe the behaviour of the virus is different. We have nothing to substantiate it, but the behaviour seems to be different. But perhaps more than that, it may be the caseload,” he says.
A lack of adherence to COVID-19 appropriate behaviour is another factor. Dr Gayathri Karthik Nagesh, HOD & Consultant – Obstetrics and Gynaecology, Manipal Hospitals Old Airport Road, Bengaluru, says, “After the first wave, people became very lax thinking that the pandemic has come to an end. I have had patients coming in with fever and are symptomatic (for COVID-19), refusing to get an RT-PCR because they think that this is the latest ‘craze’.”
Dr Kuppulakshmi also notes, “Pregnant women are sheltering but their family members go out, don’t adhere to COVID-19 protocols and come back and pass it on to them.”
The United States had last November added pregnancy to its list of underlying medical conditions associated with high risk for severe COVID-19. This was based on a study by the Centres for Disease Control and Prevention (CDC) that found that pregnant women with COVID-19 were at significantly higher risk for severe outcomes than non-pregnant women. The findings revealed that pregnant women were at an increased risk for ICU admission, more likely to require invasive ventilation and ECMO (a heart-lung bypass machine) compared to non-pregnant women who were symptomatic. But more worryingly, there was a 70% increased risk of death associated with pregnancy, compared to women who were not pregnant.
So why are pregnant women with COVID-19 more at risk than their non-pregnant counterparts?
“Physiologically, pregnancy is an immunosuppressed state and a pregnant woman is more prone to infections. Also, in advanced pregnancy, the lung capacity is reduced, because the pregnant uterus tends to push the diaphragm upwards. So the respiratory compromise tends to be greater in pregnant women,” explains Dr Gayathri of Manipal Hospitals.
The CDC study also suggests that physiological changes in pregnancy such as increased heart rate and oxygen consumption, decreased lung capacity, a shift away from cell-mediated immunity and increased risk for thromboembolic disease make pregnant women more vulnerable to COVID-19.
In addition to this, Dr Gayathri says, “Whatever disease the pregnant patient may have peculiar to pregnancy- like gestational diabetes, hypertension etc make COVID-19 more difficult to treat. We have had our share of these kinds of problems.”
Doctors say that there are also some limitations in treating pregnant women who have COVID-19. “Pharmacologically, we are restricted in usage of various medications. Radiologically, high resolution CT may not be used freely, but if required we may need to do it with an abdominal shield to protect the fetus,” points out Dr Gayathri, adding that while intensivists and pulmonologists recommend proning for COVID-19 patients whose oxygen saturations levels have dropped, obstetricians find this physically difficult with pregnant women.
Dr Paily, however, says that although there are limiting factors, they tend not to hold back on steroids since it’s proven to improve lung function in the case of gestational diabetes. He says, “If the sugar goes up we counter it with insulin, so that’s the plan. So that doesn’t hold us back from using steroids. And the other drug that is available is Remdesivir — as a compassionate grounds it is being used although there is a discussion on whether it is useful. As such, because it is pregnancy we don’t withhold a drug which we are sure will help. In other words, we are not holding back steroids. We are not holding back anticoagulation medicines like Heparin either.”
Despite the best efforts of treating doctors, however, there has been a number of fatalities reported among pregnant women due to COVID-19.
Dr Paily, who is also the state coordinator of a maternal death audit by the Kerala Federation of Obstetrics and Gynaecology (KFOG), says at least 19 pregnant women have died due to COVID-19 in Kerala in the last three months. “It’s mainly the respiratory problem that kills them and you know that COVID-19 can affect (a person) in different waves. There is blood clotting as well, and because this is a pandemic we are not able to come to a final conclusion without an autopsy. So, we have to just go by clinical impressions. It may be respiratory problems and pulmonary embolism along with it. We are only guessing, as you can imagine investigations are not all that complete in these deaths,” he says.
Chennai’s Kasturba Gandhi Hospital has seen five pregnant women die in the last 15 days, says its Director Dr Kalaivani, “They are coming with very severe lung involvement, and we are giving them everything. But after four-five days, the lungs are not able to recuperate.” She adds that most of the deaths that have taken place at KGH are referral cases.
The maternal death audit in Kerala found that most of the pregnant women had died in the third trimester. Dr Paily says, “But this time the peculiarity is that there are deaths — two or three in the second trimester. No one as far as I know has died in the first trimester.”
Dr Gayathri says when the mother’s life is at risk, their biggest challenge is often deciding when to deliver the patient. “As obstetricians, we are faced with the task of handling both the vulnerable lives: the sick mother and the baby. We are faced with the challenge of deciding when to deliver, sometimes having to decide whether an early delivery will help the sick mother survive,” says the doctor from Bengaluru.
Dr Kalaivani also says they have been trying to deliver pregnant women with COVID-19 who are at term early. In addition, she says the government hospital is trying to screen pregnant women for COVID-19 as many of them have due dates in the next two months. “We have a system where we get the due dates of all women. So we ask them to come and screen them,” she says. Despite this, she says that there are now many more cases of pregnant women in their second trimester testing positive for the coronavirus.
While there have reportedly been cases of birth asphyxia in babies of mothers with moderate to severe COVID-19 in Delhi, doctors TNM spoke to say that in their experience, newborns have largely not been affected. Dr Kuppulakshmi says, “The baby is not affected. We are not seeing low birth weight, or intrauterine growth restriction (IUGR).”
Despite pregnant women facing a heightened risk of severe disease and death, they are not permitted to receive the COVID-19 vaccine by the Union government. Several countries including the US and the UK have advised pregnant women to get the COVID-19 vaccine, with data showing no health issues among those who have had the injection. The Government of India had recently changed its earlier guidelines, and has now allowed lactating mothers to take the vaccination. Doctors hope that pregnant women will soon be allowed as well, with the Federation of Obstetricians and Gynaecologists Society of India (FOGSI) recommending the same.
Until then, doctors advise pregnant women to strictly adhere to COVID-19 appropriate behaviour. Several doctors are also advising women to delay their pregnancies in the wake of the present surge. “Infertility cases can postpone their treatment for two-three months until the pandemic declines,” advises Dr Kuppulakshmi.
Dr Kalaivani also says, “If they come for pre-conception counselling, we ask them to postpone pregnancy for another six months. But once they are pregnant, we continue with our antenatal checkups.”