Gurol-Urganci I, Jardine JE, Carroll F, Draycott T, Dunn G, Fremeaux A, Harris T, Hawdon J, Morris E, Muller P, Waite L, Webster K, VAN DER Meulen J, Khalil A. Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection at the time of birth in England: national cohort study. Am J Obstet Gynecol. 2021 May 20:S0002-9378(21)00565-2. doi: 10.1016/j.ajog.2021.05.016. Epub ahead of print. PMID: 34023315; PMCID: PMC8135190.

Objective: The aim of this study was to determine the association between SARS-CoV-2 infection at the time of birth and maternal and perinatal outcomes.

Methods: This is a population-based cohort study in England. The inclusion criteria were women with a recorded singleton birth between 29^th May 2020 and 31^st January 2021 in a national database of hospital admissions. Maternal and perinatal outcomes were compared between pregnant women with a laboratory-confirmed SARS-CoV-2 infection recorded in the birth episode and those without. Study outcomes were fetal death at or beyond 24 weeks’ gestation (stillbirth), preterm birth (<37 weeks gestation), small for gestational age infant (SGA; birthweight <10^thcentile), preeclampsia/eclampsia, induction of labor, mode of birth, specialist neonatal care, composite neonatal adverse outcome indicator, maternal and neonatal length of hospital stay following birth (3 days or more), 28-day neonatal and 42-day maternal hospital readmission. Adjusted odds ratios (aOR) and their 95% confidence interval (CI) for the association between SARS-CoV-2 infection status and outcomes were calculated using logistic regression, adjusting for maternal age, ethnicity, parity, pre-existing diabetes, pre-existing hypertension and socioeconomic deprivation measured using Index of Multiple Deprivation 2019. Models were fitted with robust standard errors to account for hospital-level clustering. The analysis of the neonatal outcomes was repeated for those born at term (≥ 37 weeks’ gestation) since preterm birth has been reported to be more common in pregnant women with SARS-CoV-2 infection.

Results: The analysis included 342,080 women, of whom 3,527 had laboratory-confirmed SARS-CoV-2 infection. Laboratory-confirmed SARS-CoV-2 infection was more common in women who were younger, of non-white ethnicity, primiparous, residing in the most deprived areas, or had comorbidities. Fetal death (aOR, 2.21, 95% CI 1.58-3.11; P<0.001) and preterm birth (aOR 2.17, 95% CI 1.96-2.42; P<0.001) occurred more frequently in women with SARS-CoV-2 infection than those without. Risk of preeclampsia/eclampsia (aOR 1.55, 95% CI 1.29-1.85; P<0.001), birth by emergency Cesarean delivery (aOR 1.63, 95% CI 1.51-1.76; P<0.001) and prolonged admission following birth (aOR 1.57, 95%CI 1.44-1.72; P<0.001) were significantly higher for women with SARS-CoV-2 infection than those without. There were no significant differences in the rate of other maternal outcomes. Risk of neonatal adverse outcome (aOR 1.45, 95% CI 1.27-1.66; P<0.001), need for specialist neonatal care (aOR 1.24, 95% CI 1.02-1.51; P=0.03), and prolonged neonatal admission following birth (aOR 1.61, 95% CI 1.49-1.75; P<0.001) were all significantly higher for infants with mothers with laboratory-confirmed SARS-CoV-2 infection. When the analysis was restricted to pregnancies delivered at term (≥37 weeks), there were no significant differences in neonatal adverse outcome (P=0.78), need for specialist neonatal care after birth (P=0.22) or neonatal readmission within four weeks of birth (P=0.05). Neonates born at term to mothers with laboratory-confirmed SARS-CoV-2 infection were more likely to have prolonged admission following birth (21.1% compared to 14.6%, aOR 1.61, 95% CI 1.49-1.75; P<0.001).

Conclusions: SARS-CoV-2 infection at the time of birth is associated with higher rates of fetal death, preterm birth, preeclampsia and emergency Cesarean delivery. There were no additional adverse neonatal outcomes, other than those related to preterm delivery. Pregnant women should be counseled regarding risks of SARS-COV-2 infection and should be considered a priority for vaccination.