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.