Covid-19 in Pregnancy: Cases of Women Managed in the City of Douala-Cameroon ()
1. Introduction
The SARS-CoV-2 pandemic is one of the deadliest pandemics in existence. The first case was diagnosed in December of 2019 in Wuhan, China, followed by the diagnosis of similar cases worldwide [1]. COVID-19 leads to severe acute respiratory syndrome caused by SARS-CoV-2 infection. In Africa, the first case of SARS-CoV-2 infection in pregnancy was reported in Egypt in February 2020 [2]. In Cameroon, a study done at the Douala Gynaeco-Obstetric and Pediatric Hospital from March 24th to July 24th 2020 revealed a 6% prevalence of COVID-19 among pregnant women [3]. In the UK, between the 1st of March and 14th of April 2020, the incidence of COVID-19 in pregnant women was 4.9% [4].
There are various opinions about the clinical manifestations of COVID-19 in pregnant women compared to the general population [5]. At the Douala Gynaeco-Obstetric and Pediatric Hospital, the most frequent symptoms were fever (27.4%), cough (21.5%), dyspnea (15.7%), asthenia (11.8%) and polyarthralgia (9.8%) [3]. However, the clinical diagnosis must be confirmed by laboratory testing for the virus. The gold standard test is the reverse transcription polymerase chain reaction (RT-PCR) test on a nasopharyngeal swab [6]. Rapid diagnostic tests (RDT) were used for mass screening when the gold standard test was not available. Chest CT scans showed frosted glass opacities classified as mild (25% lung parenchyma involvement), moderate (50%) or severe (75%) [7]. Treatment modalities varied from one hospital to another, as there is still no consensus on the management and this has been the subject of several discussions. Some maternal-fetal complications were described such as premature delivery, premature rupture of membranes, acute fetal distress and the risk of caesarean section [8]. Most studies report minor forms in pregnant women that can be managed as an outpatient with symptomatic treatment [9]. To date, vertical transmission of this condition has not been established and no fetal pathology has been described in cases of covid-19 infection in pregnant women [10].
Also, taking into account the maternal-fetal risks of COVID-19 infection in pregnant women, the mutation of variants, the persistence of the pandemic and the low sample size of the first publication in Cameroon, we considered it important to carry out a much larger and in-depth study on the maternal and fetal prognosis of this condition in pregnant women in three reference hospitals in the city of Douala.
The goal of this study was to assess the maternal and foetal outcomes in COVID-19 infected pregnant women in three hospitals in the city of Douala.
2. Methods
2.1. Study Design
Cross sectional descriptive study with retrospective data collection.
2.2. Study Period
Two years, 1 month period from the 1st of March 2020 to the 30th of April 2022.
2.3. Study Framework
The study was multicentric in three hospitals in the city of Douala, two of which are Category I hospitals; Douala Gynaeco-Obstetric and Pediatric Hospital (DGOPH) and Douala General Hospital (DGH); and one category 2 hospital: Douala Laquintinie Hospital (DLH). These health facilities were chosen because of the large number of patients who use them (DGH and DLH). These hospitals have been designated as the main centers for the management of pregnant women infected with COVID-19 in the city of Douala.
2.4. Inclusion Criteria
All records of pregnant women who had confirmed COVID-19, confirmed by reverse transcription polymerase chain reaction (RT-PCR) test or COVID-19 rapid diagnostic test (COVID RDT).
2.5. Exclusion Criteria
All incomplete records of pregnant women with confirmed COVID-19.
2.6. Sampling
A consecutive and exhaustive sampling method was used. All files of pregnant women diagnosed positive to COVID-19 in the Obstetrics and Gynaecology units of the three study sites and eligible for the study were recruited.
2.7. Variables Studied
The survey form contained socio-demographic data, clinical and para-clinical characteristics, management and materno-foetal outcome. SPSS.26 and Microsoft Excel 2016 software were used to analyze data. A logistic regression model was used to look for associations between variables.
2.8. Data Collection Tool
A questionnaire was designed, pretested and validated for the collection of data from the patient files. This questionnaire had all the variables described above and these data were used to fill the excel spreadsheet before analyses and interpretations.
2.9. Ethical Considerations
Ethical clearance was obtained from the institutional ethical committee of the University of Douala, and research authorization was acquired from the managers of hospitals where the study was carried out.
3. Results
During the study period, we identified 96 complete files of COVID-19 positive pregnant women out of a total of 4500 files of pregnant women consulted in the three hospitals. A prevalence of 2.3% was found, with a recruitment rate of 92.3%.
The mean age of the infected women was 31.72 ± 5.08 years with a median of 30 years. The most represented age group was 30 - 39 years. A secondary level of education was the most represented with a proportion of 46.9% (45). In our study, the most represented occupation was that of the unemployed, including pupils, students and housewives (45.8%). This was followed by the informal sector (29.2%) and then the formal sector (25.0%) (Table 1).
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Table 1. Socio-demographic characteristics of our patients.
Monofoetal pregnancies were the most represented with 89 cases (92.7%), followed by twin pregnancies with 6 cases (6.3%). The women were mostly in their third trimester of pregnancy (54 cases). In this series, 81 patients had co morbidities, with the most common being diabetes, 22 (27.2%), followed by HIV, 18 (22.2%). Eighty seven (87) of the patients were symptomatic (90.1%) and the most represented symptoms were fever 69 (71.9%), cough 65 (67.7%), dyspnea 63(65.6%), poly arthralgia 59 (61.5%), and asthenia 58 (60.4%) (Table 2).
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Table 2. Clinical characteristics of our patients.
CRP was positive in 90 (93.8%) of the 96 patients. D-dimer and LDH were elevated in 19 and 32 patients respectively.
Chest CT scan was requested in 50 patients with 16 (32.0%) of them having mild, 21 (42.0%) moderate and 13 (26.0%) severe lesions (Table 3).
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Table 3. Biological and morphological characteristics of our patients.
A total of 62 patients were managed as outpatients (64.6%) and 34 (35.4%) as intensive care patients, with caesarean deliveries being the most common route of delivery (58.3%). In all, 50% (48) of the 96 patients had premature rupture of membranes, 32.3% (31) had placental bleeding, 17.7% (17) had postpartum hemorrhage and 8.3% (8) had severe anemia. Worth noting that 10 of the 17 patients with postpartum hemorrhage had Sheehan’s syndrome (58.8%) and 15 (15.6%) died. We found 30.2% (31) of premature babies, 32.3% of newborns had respiratory distress at birth and 23 newborns died (Table 4).
Diabetes; hyper leukocytosis with neutrophile and lymphocyte predominance; increased biological factors LDH and D Dimeres; 75% CT involvement as well as intensive care hospitalization were factors statistically and significantly associated with maternal death. A maternal oxygen saturation of >94% constituted a protective factor against fetal death (Table 5).
From Table 5, the following factors were significantly found associated with maternal death: Diabetes (OR x4), HIV infection, high LDH and D-dimer levels (OR x16), 75% lung involvement on chest CT scan (OR x6), C/S deliveries (OR 3x) and admission to the intensive care unit. On the contrary, Oxygen saturation > 94% on admission was found to be a protective factor against maternal mortality. On the other hand, factors associated with neonatal mortality were: temperature ≥ 38.5˚C.
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Table 4. Pregnancy and maternal-fetal outcomes.
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Table 5. Factors associated with maternal and fetal mortality.
4. Discussion
We found a prevalence of 2.3% of COVID-19 among pregnant women with a recruitment rate of 92.3%. This result is different from the 6% prevalence found by Ngalame et al. in 2020 at the Douala Gynaeco-Obstetric and Pediatric Hospital (DGOPH) in 2020 [3]. This difference can be explained by the lack of control of the pandemic in its early stages which subsequently improved over time, hence this decrease in positive cases. In our study, the age of the patients varied between 22 and 43 years with an average of 31.72 ± 5.08 years. This average age is similar to that of 34 years found in the United Kingdom by Knight et al. [4]. The most represented age group was 30 - 39 years. It is identical to that obtained by Ngalame et al. at the Douala Gynaeco-Obstetric and Pediatric Hospital in 2020 [3].
The most represented sector of activity was that of the unemployed including pupils, students and housewives (44.46%). We justify this result by data in the literature which lists precariousness and promiscuity as risk factors for Covid 19 infection in pregnant women [11]. We found that 92.7% (89) of cases were singleton pregnancies and 56.25% (54) of infected pregnant women were in the third trimester of pregnancy at the time of diagnosis. These results are similar with most available data which demonstrate that pregnant women are mostly diagnosed in the third trimester of pregnancy [12] [13]. Li et al. in China in 2020 found 88.2% of monofetal pregnancies [13]. In our study, most of the infected patients (81) had numerous co-morbidities, the most frequent being diabetes (27.2%). Ngalame et al. (2020) had also found diabetes as the first comorbidity in pregnant women. This result is different from findings in Senegal in 2020 by Diouf et al. [12] who did not find any comorbidity associated with Covid 19 in pregnant women. This can be explained by the low sample size (9 patients) at the time of their study.
Symptoms were found in 87 patients (90.1%). Fever was the most common symptom (71.9%) followed by cough (67.7%). These results are consistent with those found in two cohort studies conducted by Knight et al. in the UK and Zaigham et al. in Sweden [4] [14]. However, they differ from those found in Senegal by Diouf et al. who reported headache as the main symptom [12]. Patients with elevated D-dimer, LDH, PT and aPTT were all between the moderate and severe phases of the disease. This result is the same as those found by Ngalame et al., Yangli et al. and Dehan et al. in Cameroon and China [3] [15] [16].
Chest CT scans were requested in 50 patients and 16 (42.0%) of them showed mild lesions, 21 (42.0%) moderate lesions and 13 (26.0%) severe lesions. All 50 patients showed a CT image typical of COVID-19 pneumonia. These results give us the impression that pregnancy does not alter the appearance of CT scan lesions in COVID-19 and are similar to those found in two Chinese studies by Li et al. who found most patients with typical CT scan images [13].
Caesarean deliveries were the most common (58.3%) with maternal respiratory distress as the main indication. This result is similar to that found in a British multicentric study which found 59% of caesarean sections [14]. Ngalame et al. found 62% of caesarean sections at the Douala Gynaeco-Obstetric and Pediatric Hospital in Cameroon [3], while Dehan et al. in China found 66.7% of caesarean sections [16].
In our study, we found 15.6% of maternal deaths, mainly in patients admitted in intensive care. These deaths can be explained by the presence of associated factors including diabetes, elevated D-dimer, LDH, lymphocytes and neutrophiles. Our death rate is lower than that found in the United Kingdom by Knight et al. in 2020 who found 30% of maternal deaths in intensive care [6] but are different from zero deaths found by Zaigham and al [14], Li et al. [13] Yangli et al. [16] in Sweden and China. Their results can be explained by the small sample size at the time of the studies and the high level of care in their facilities. In our study, 50% (48) of the 96 patients had premature rupture of membranes and preterm labor. We obtained 24% of neonatal deaths with the main etiology being neonatal asphyxia (32.3%) and a high admission of patients to intensive care. This result is higher than the 22.8% of deaths found by Ngalame et al. in the Douala Gynaeco-Obstetric and Pediatric Hospital in 2020 [3]. Our result is different from those obtained by Li et al. and Dahan et al. in China who did not find any neonatal asphyxia or death [13] [15] in intensive care. Furthermore, we found 30.2% (29) of premature babies, which is higher than the 12% found by Li et al. in China in 2020 [13] and lower than the 44% reported by Chen et al. in China [17]. This high rate of prematurity was due to gestational complications such as premature rupture of membranes and placental bleeding. We found that an arterial oxygen saturation (SaO2) > 94% is a protective factor against the occurrence of fetal death.
Despite our interesting findings, there are however some limitations of this study, such as; 1) The relatively shorter period of the study might introduce a selection bias, and 2) Selecting cases only from the three tertiary hospitals of Douala, excludes patients managed at lower health facilities, which take care of the majority of cases. This makes it difficult to generalize our findings.
5. Conclusion
Our study compliments that of Ngalame et al. at DGOPH (Cameroon) in 2020. It has the advantage that it allowed us to make an inventory of the socio-demographic, clinical, para-clinical management and maternal-fetal characteristics of COVID-19 infection in pregnant women. It was conducted in three hospitals and had a larger sample size. It identifies factors associated with maternal and fetal death and also protective factors.