COVID-19 and Risk for Stillbirth and Preterm Birth

PURPOSE:

Khalil et al. (JAMA, 2020) analyzed the association between COVID-19 and risk for stillbirth and preterm delivery

Retrospective cohort study
- St George’s University Hospital, London (UK)
Compared 2 time periods
- Prepandemic: October 1, 2019, to January 31, 2020
- Pandemic (following first reported cases in UK of COVID-19): February 1, 2020, to June 14, 2020
Outcomes
- Stillbirth | Preterm birth | Cesarean delivery | NICU admission
- Repeat analysis performed with exclusion of terminations for fetal anomalies (IN UK, stillbirth includes late termination ≥24 weeks)

Prepandemic
- 1681 births | 1631 singletons | 22 twins | 2 triplets
Pandemic period
- 1718 births: 1666 singleton | 26 twins
Nulliparity was less common during the pandemic period (P < .001)
- Prepandemic: 52.2%
- Pandemic: 45.6%
Fewer pregnancies were complicated by hypertension during the pandemic period (P = .005)
- Prepandemic: 5.7%
- Pandemic period: 3.7%
Stillbirth incidence was increased during the pandemic period
- Prepandemic: 2.38 per 1000 births (n=4)
- Pandemic: 9.31 per 1000 births (n=16)
- Difference: 6.93 per 1000 births (95% CI, 1.83-12.0; P = .01)
Stillbirth incidence remained elevated after exclusion of terminations for anomalies
- Prepandemic: 1.19 per 1000 births
- Pandemic: 6.98 per 1000 births
- Difference: 5.79 (95% CI, 1.54-10.1; P = .01)
There were no significant differences identified for the following outcomes
- Preterm deliveries (<37 weeks)
- NICU admission
No cases of stillbirth were associated with COVID-19
- None of the mothers had symptoms associated with COVID-19
- No placental or postmortem exams suggested of COVID-19
- Note: Universal testing for SARS-CoV-2 only began May 28, 2020

Stillbirth rates were increased during the pandemic vs prepandemic period
- One important limitation noted by authors is lack of data on cause of the stillbirth
Possible reasons for increase in stillbirth rate
- Increase may still be due to SARS-CoV-2 infection in asymptomatic women (who would not have been tested)
- Women may have deferred care due to COVID-19 concerns (e.g. delaying care to avoid infection)
- Possible change in practice resulting in fewer antenatal visits or ultrasound assessments
- Chance: Study time frame was short | If study was longer, difference perhaps would resolve
- Hospital may have received more referrals

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