Discussion
COVID-19 is not yet under control globally, with the spread of
2019-ncov, the number of pregnant women with COVID-19 also increased. As
for the choice of delivery mode, expert’s
consensus[9] showed that COVID-19 pneumonia
couldn’t not be used as an indication for cesarean section, but in fact,
most of the pregnant women with COVID-19 terminated pregnancy by
cesarean section in fear of additional risk of mother to child
transmissions[10-11]. Therefore, there were few
studies on vaginal delivery in pregnancy women with COVID-19. It is
uncertain whether SARS-COV-2 is transmitted by mother-to-child
transmission during delivery.
Several studies[11-14] had suggested that there is
a possibility of vertical transmission of SARS-COV-2, while the newborns
who were reported to have positive viral nuclear acid detection were all
delivered by cesarean section. The antibodies IgM /IgG of SARS-COV-2
were positive while the nucleic acid was negative in these newborns. In
this study, no definite evidence of SARS-COV-2 infection was found in
neonates who were delivered vaginally. Neonate 5 and neonate 6
experienced pneumonia after birth, which may be related to the fever of
their mothers before delivery, in addition, case 6 had meconium stained
amniotic fluid, which also increased the probability of neonatal
pneumonia and infection[15]. Follow up results
showed that no serious complications had occurred in the newborns, the
antibody IgM /IgG and nuclear acid detection of SARS-COV-2 were negative
in seven neonates under follow up. In our patients,no SARS-CoV-2
transmission occurred. But it is important to note that all the pregnant
women in this study had a short course of COVID-19 pneumonia (2-8 days)
before birth, and it was possible that the virus had not yet affected
the fetus. However, what was clear was that vaginal delivery does not
increase the probability of SARS-COV-2 mother-to-child transmission
under strict protective measures (delivered in a negative pressure
operating room, pregnant women always wearing mask, avoiding contacting
between the newborns and their mother).
A case report[13] showed that the SARS-COV-2
antibodies IgM and IgG of a newborn delivered by a pregnant woman at 34
weeks with COVID-19 were positive. SARS-COV-2 nucleic acid test for
mother’s throat swabs were positive, while the nucleic acid test for
vaginal secretions was negative. Another study[16]included 35 females showed that no positive SARS-COV-2 RT-PCR result was
found in the vaginal environment perhaps due to the lack of the receptor
of SARS-CoV-2 in the vagina and cervix tissues. It suggests that it
would not increase the risk of mother-child transmission when the fetus
passed through the mother’s birth canal. Therefore, we believe that
there was no relationship between mother-child transmission and mode of
delivery.
In this study, case 6’s pneumonia worsened after childbirth, reviewing
the clinical features of the pregnant woman, we found that she had got a
high fever for a long period that continued to birth before delivery.
The results of laboratory examination indicated that her inflammatory
markers, C-reactive protein (CRP) and Procalcitonin (PCT), increased
progressively, it suggested that she may be in the acute stage of viral
infection. During labor, maternal breathing pattern was affected by
labor pain, in the second stage of labor, the need to hold their breath
to force the baby out, caused maternal oxygen consumption to increased.
Infection of SARS-CoV-2 mainly attacked body respiratory system, the
progressive exacerbation of lung lesions might lead to respiratory
distress especially in labor, and the fetus might experience fetal
distress or even fetal death. In this case, there was no maternal
respiratory distress or fetal distress during delivery, however the
patient who had a long term of high fever, oxygen saturation decreased,
and healing of the perineal incision was poor. Therefore, we suggest
that only after careful consideration we may decide to choose vaginal
delivery as a preferred mode of delivery to women who are in acute
inflammatory progress of COVID-19 pneumonia.
We suggest that pregnant women with SARS-COV-2 infection who do not have
respiratory failure or multi-functional organ dysfunction, and also,
when they are in a stable stage of pneumonia should be considered for
vaginal delivery if there is contraindications for vaginal delivery
trial and if the patient has an intention of vaginal delivery. However,
it should be noted that vaginal delivery should be carried out in the
negative pressure delivery room, and the medical staff and pregnant
women should be strictly protected, at the same time, newborns should be
avoided to have direct contact with their mothers.
The limitations of this study lie in the few patients and the limited
follow-up time. Long-term follow-up is needed to observe whether there
are long-term maternal and neonatal complications.