Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : QC01 - QC05 Full Version

Association of Maternal Nutritional Status with COVID-19 Infection and its Effects on Pregnancy Outcomes- A Retrospective Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56119.16391
Rehana Najam, Yugantika Tomar

1. Head of Department, Department of Obstetrics and Gynaecology, Teerthankar Mahaveer Medical College, Moradabad, Uttar Pradesh, India. 2. Postgraduate Resident, Department of Obstetrics and Gynaecology, Teerthankar Mahaveer Medical College, Moradabad, Uttar Pradesh, India.

Correspondence Address :
Dr. Yugantika Tomar,
Postgraduate Resident, Department of Obstetrics and Gynaecology, Teerthankar Mahaveer Medical College, Moradabad, Uttar Pradesh, India.
E-mail: yugantika2313@gmail.com

Abstract

Introduction: Need is felt to perform research for assessing the impact of maternal nutrition status on severity of Coronavirus Disease 2019 (COVID-19) in pregnancy and effect of COVID-19 on maternal outcomes as it has not been established.

Aim: To evaluate association of maternal nutritional status and pregnancy outcomes with COVID-19 infection in pregnancy.

Materials And Methods: A retrospective study was conducted among 260 antenatal patients admitted in COVID-19 level 3 hospital (Teerthanker Mahaveer Medical College and Research Centre), Moradabad, Uttar Pradesh, India, from April 2020 to May 2021 with COVID-19 infection. Records were studied for the effect of maternal nutrition status along with COVID-19 and outcome of pregnancy in terms of anthropometric markers (body mass index), nutritional markers (haemoglobin, total serum proteins) and biochemical markers (oral glucose tolerance test, vitamin D). Pregnancy outcomes were assessed in terms of severity of symptoms, Intensive Care Unit (ICU) admission, labor outcome and obstetric complications . Data were tabulated and examined using the Statistical Package for Social Sciences (SPSS) version 20.0.

Results: Mean age of the patients enrolled was 21.4±5.6 years. A statistically significant association was seen with high body mass index (88.24%), hyperglycaemia (82.35%), hypoproteinaemia (6.01±0.47) and hypoalbuminaemia (0.93±0.24). Statistically significant association between adverse pregnancy outcomes in terms of bleeding per vaginum (11.76%) , preterm labour (54.92%), gestational diabetes mellitus (82.35%), hypertension (29.41%), Intrauterine Device (IUD) baby (35.29%) with increasing severity of COVID-19 infections.

Conclusion: COVID-19 adversely affects the maternal obstetric outcome. Maternal nutrition status factors associated with severity of COVID-19 were body mass index, deranged blood sugar levels and protein levels.

Keywords

Antenatal, Body mass index, Coronavirus disease 2019, Heamoglobin, Pregnancy outcomes, Total serum proteins

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes the Coronavirus Disease 2019 (COVID-19), a global public health disaster (1). Most cohort studies have concentrated on examining COVID-19's effects on the general population, and there is a lack of evidence on its impact on vulnerable populations around the world, such as pregnant women (2),(3). Preliminary studies have shown that COVID-19 infection has minimal effects on pregnancy outcomes. There is very limited data that can conclude the consequence of coronavirus disease in pregnant females and neonatal outcomes in India (4),(5).

The state of maternal nutrition is one of the important environmental factors which alter the course of pregnancy. The growth of foetal tissues and other products of conception, as well as the metabolic changes that occur throughout pregnancy, put the pregnant mother under a lot of stress and raise her nutritional needs. Workers in the fields of nutrition and maternal and child health from around the world have occasionally pointed out the close relationship between maternal nutritional status on the one hand and the health of the pregnant woman and her offspring on the other (6).

Being a developing country, majority of the females in India belong to the poverty stricken areas of the country and deal with nutritional deficiencies such as anaemia, vitamin D deficiency, hypoproteinaemia and diabetes. These conditions lead to increased propensity to infections in the patient (7),(8),(9).

Pregnancy being a state of special immune tolerance predisposes the woman to various viral infections (10). It leads to various changes in the immune and cardiopulmonary systems of a woman's body, which put her at an increased risk of getting viral infections and developing severe pneumonia. Extensive population-based cohort studies have shown that seasonal influenza epidemics increase the risk of severe complications in pregnant women (11),(12),(13). Although negative outcomes such as Intensive Care Unit (ICU) admission or patient death can occur, recent systematic reviews and meta-analyses reveal that the clinical course of COVID-19 in most women is not severe, and the infection has no major impact on pregnancy (14). Thus, there is contradictory data available with respect to effect of coronavirus in pregnant females and neonatal outcomes.
The nutritional status of pregnant females during the coronavirus pandemic and its effect on the neonate has not been established yet. There might be interplay of various variables related to maternal nutrition which affect the immunological responses, innate and adaptive, leading to increased degree of severity of illness in the pregnant female which should be looked into. Hence, a need was felt to perform a study for assessing the impact of the maternal nutrition status on severity of COVID-19 in pregnancy and its effect on maternal outcomes.

Material and Methods

This retrospective study was conducted among patients admitted in Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India, from April 2020 to May 2021. The records of 260 antenatal females admitted from April 2020 to May 2021, aged between 18-45 years with a positive Reverse Transcription Polymerase Chain Reaction (RT-PCR) report for COVID-19 was studied. The study was approved by the Institutional Research and Ethics Committee (Ref No. TMMC&RC/IEC/19-20/037).

Inclusion and Exclusion critera: All antenatal females with gestational age >6 weeks with cardiac activity on ultrasound and well defined gestational sac with positive COVID-19 report by RT-PCR attending COVID-19 level 3 hospital were included in the study. Any pregnant COVID-19 positive patients without investigations or records as per the study protocol were excluded from the study.

Maternal nutritional status was assessed using anthropometrical, nutritional and biochemical markers.

Anthropometrical marker: Pre-pregnancy weight of the patients was noted from the records brought by each patient and her Pre-pregnancy Body Mass Index (BMI) was calculated by dividing the pre-pregnancy weight (in kg) with square of height (in metre). Patients were classified into underweight (less than 18.5), normal BMI (18.5-24.9) and overweight (25-29.9) according to World Health Organization (WHO) classification (15).

Nutritional markers: Haemoglobin, total protein levels and albumin globulin ratio were the nutritional markers for assessment of maternal nutritional status in the present study. Total protein levels were divided into normal (6-8.3 g/dL) and decreased (<6 g/dL) and normal albumin globulin ratio was taken as 1-2 (16). Total protein levels and albumin globulin ratio levels were measured using Turbochem 100 auto analyser marketed by CPC. Patients with decreased haemoglobin values were classified into mild (10-10.9 mg/dL), moderate (7-10 mg/dL), severe (<7 mg/dL) and very severe anaemia (<4 mg/dL) according to the Indian Council of Medical research (ICMR) Classification of anaemia (17).

Biochemical marker: Vitamin D levels and Oral Glucose Tolerance Test (OGTT) were Biochemical markers used to assess maternal nutritional status in the present study. Blood sugar assessment in the study was done according to DIPSI guidelines using OGTT wherein a single blood sugar test 2 hours after 75 gm glucose ingestion was used to assess the blood sugar status of the patient (18). Value of more than 140 mg/dL was considered as significant. On the basis of multiple guidelines serum 25(OH) D level of <20 ng/mL has been defined as vitamin D deficiency (19). Vitamin D levels were estimated by automated immunoassays using Architecti1000sr Make 2015.

Detailed evaluation of all patients fulfilling the inclusion and exclusion criteria were collected from case sheets in the record room regarding their age, gestational age, socio-demographic factors. Socio-economic class of the patients was calculated on the basis of Modified Kuppuswamy Scale (20). The patient’s pre-pregnancy weight was noted from the records and BMI was calculated. Patient's baseline details like blood pressure, temperature and pulse rate were recorded. Examination findings, routine and specific investigations were noted and the patient’s progress till she was admitted in the hospital was followed.

Patients were classified into asymptomatic, mild symptomatic, moderately symptomatic and severe symptomatic according to Centre for Disease Control Guidelines (21). Individuals who tested positive for COVID-19, but had no symptoms consistent with the disease were classified as asymptomatic. Patients with positive report for COVID-19 and generalized symptoms such as fever, cough, sore throat, malaise, loss of taste/ smell but no shortness of breath/ dyspnea were classified as mild symptomatic. Patients with evidence of lower respiratory tract infection on clinical assessment or imaging and oxygen saturation ≥94% at room air were moderately symptomatic. All of the patients with increased respiratory rate (≥30 breaths per min), decreased oxygen saturation at rest (≤93%), PaO2/FiO2 ratio <300 mmHg or critical disease were classified into severe symptomatic category. All the patients in the severe symptomatic category had severe pneumonia, required Invasive mechanical ventilation and were admitted in the ICU. The course of hospital stay was recorded and various laboratory investigations of interest to the present study such as haemoglobin, total protein, Albumin/Globulin (A/G) ratio, vitamin D level, OGTT were studied for the purpose of maternal nutrition status. The ICU admission if any was recorded along with any condition like respiratory complications, foetal distress, antepartum haemorrhage, intrauterine death of baby, disseminated intravascular coagulation.

Statistical Analysis

Data were tabulated and examined using the Statistical Package for Social Sciences Version 20.0 (IBM SPSS Statistics for Mac, Armonk, NY: IBM Corp, USA). Descriptive statistical analysis had been carried out in the present study. Results on continuous measurements are presented as Mean±SD. The results on categorical data were tabulated as frequency distribution. The statistical power calculation was based on the assumption that the data were normally distributed. Chi-square test and Analysis of Variance (ANOVA) test were applied and significant difference between the groups and level of significance p-value was set at <0.05.

Results

Mean age of the patients enrolled was 21.4±5.6 years. It was observed that 66.92% (n=174) were booked patients with complete antenatal visits as per WHO (Table/Fig 1).

Out of 260 patients enrolled in this study 237 belonged to asymptomatic/mild symptomatic group, six were moderately symptomatic and 17 patients were severely symptomatic. A statistically significant relationship was seen between BMI and severity of COVID-19 infection. Out of the severe symptomatic patients 88.24% (n=15) were overweight and had BMI between 25-29.9. A significant relation was also seen between OGTT, total protein, A/G Ratio with severity of COVID-19 infection (Table/Fig 2).

A statistically significant relation was observed between adverse pregnancy outcomes in terms of bleeding per vaginum, preterm labour, gestational diabetes mellitus, gestational hypertension, IUD with increasing severity of COVID-19 infections (Table/Fig 3).

It was observed that nine out of 17 (52.94%) patients in the severe symptomatic group had preterm labour in the present study. Total six out of nine (66.66%) patients went into spontaneous preterm labour, three patients (33.33%) were induced due to obstetric reasons (two patients had foetal distress and one had abnormal doppler findings on ultrasound).

Discussion

Pregnant women are at a high risk of developing severe pneumonia due to altered cell-mediated immunity and changes in pulmonary function (22),(23). This has been demonstrated in the past during outbreaks involving viruses from the same family of COVID-19 such as SARS and Middle East Respiratory Syndrome (MERS) (24).

The mean age of patients enrolled in the present study was 21.4 years. A study assessing Coronavirus disease in pregnant women conducted by Yan J et al., (25) in China found the mean age of patients at admission to be 30.8 years, this discrepancy could be attributed to the culture of early marriage and childbirth of rural women in India. The same study found the mean gestational age on admission to be 38 weeks which was in concurrence with the present study.

As our hospital is located in the outskirts of the city most of the participants were in the lower socio-economic status in the present study. A study conducted by Little C et al., investigated the impact of socioeconomic status on COVID-19 and found no significant difference in hospital admission rates between low and high poverty groups in COVID-19 afflicted patients (26). Since our hospital is located in the outskirts of the main city, most of the patients coming to our hospital belong to the nearby villages and hence to the poorer strata of the society.

Only 6.53 % patients in the present study required ICU admission as they were severely symptomatic. Villar J et al., in their study found that out of 706 COVID-19 infected pregnant women enrolled in his study 44% were asymptomatic and 18.9% were severely symptomatic and required ICU admission. The difference in severely symptomatic patients can be attributed to larger sample size in Villar J et al., study as compared to the current study. This difference can also be because most of the patients enrolled in the current study were young (mean age 21.4 years) as compared to Villar J et al., study (mean age was 30.2 years), so they had better immunity and hence better outcomes (27).

Authors found increased severity of symptoms and higher morbidity and mortality in patients with raised BMI. The 88.24% of the severe symptomatic COVID-19 participants were overweight (p-value=0.00001). Mohseni H et al., conducted a study wherein they found that mean BMI of groups increased with severity symptoms. The BMI of moderate symptomatic (27.57 kg/m2), severe symptomatic (29.70 kg/m2) and death persons (28.13 kg/m2), was significantly higher than healthy (26.70 kg/m2) and mild symptoms (26.57 kg/m2) groups (p-value=0.001) (28). Obesity is linked to an increase in the production of inflammatory cytokines such as tumour necrosis Factor- alpha, interleukins, and interferons. This leads to a state of chronic inflammation and compromised immunological responses. This causes the symptoms to become more severe and is linked to an increased risk of deep vein thrombosis, pulmonary embolism, cardiovascular disease and stroke, and myocardial infarction (29).

Out of the 17 severe symptomatic patients enrolled in the present study, 17.65% had severe aneamia. The present study depicts increased severity of symptoms, higher rate of co-morbidities and increased mortality in the patients with decreased haemoglobin values. But due to lower number of patients in the severe symptomatic group no statistically significant association could be elicited between severity of aneamia and COVID-19 infection (p-value >0.05) in the current study.

A study conducted by Tao Z et al., in August 2020 demonstrated that anaemic patients with COVID-19 had an increased rate of comorbidities, more severe inflammatory responses, and organ damage when compared with the nonanaemic controls (30). Out of the 222 patients enrolled in the study, only 20 were severely symptomatic and 24.2 % of the patients with severe aneamia were moderate to severely symptomatic for COVID-19. However, the study subjects were non pregnant population (30). Lower number of subjects in the moderate and severe symptomatic COVID-19 inflicted groups could be the reason for the difference of findings in the present study and the study by Tao Z et al., (30). From the present study authors recommend further studies with higher sample sizes on this topic to assess the impact of aneamia on severity of COVID-19 infection

Around 82.35% of the severe symptomatic COVID-19 participants had >140 mg/dL OGTT and there was a statistically significant association found between COVID-19 status with deranged blood sugar values (p-value=0.00001). These findings were concurrent with the study conducted by Collin J et al., in Sweden in 2020 who found that pregnant women should exercise caution due to the potentially severe implications of SARS-CoV-2 infection, particularly those with additional risk factors such as obesity, hypertension, or gestational diabetes mellitus (31). Hence, the present study shows a positive association between severity of symptoms of COVID-19 and deranged blood sugar values. A meta-analysis conducted by Huag I et al., in August 2020 found that patients with diabetes mellitus had more severe disease, poorer outcome and higher mortality in COVID-19 (32).

The present study revealed that 76.47% of the severe symptomatic COVID-19 participants had vitamin D deficiency and there was no statistically significant association found between COVID-19 status with vitamin D deficiency. Jain A et al., in their study refuted the results presented in the study as they depicted a strong difference in vitamin D levels and severity of the COVID-19 symptoms. But the study population included non pregnant patients. No studies assessing the impact of vitamin D deficiency on severity of COVID-19 have been performed in pregnant population as yet. Hence, the author recommends further research on this topic (33).

A statistically significant association was found between COVID-19 status with health determinant parameters like Total protein and A/G ratio. Hypoproteinaemia is related with elevated inflammatory cytokines, prolonged Activated Partial Thromboplastin Time (APTT) and prothrombin time and deranged D-dimer values as a result of liver damage caused by hypercytokinaemia. These findings are in concurrence with the findings of Huang J et al., study where they compared the outcome of COVID-19 in patients with and without hypoalbuminaemia and found that patients with hypoalbuminaemia had a higher mortality rate (13.2%) as compared to patients with normal albumin (1%) (34).

A statistically significant relation was found between adverse pregnancy outcomes and severity of COVID-19. 11.76% severe symptomatic patients presented to us miscarriage. In patients with COVID-19 infection, Villar J et al., observed increased rates of pregnancy-induced hypertension, preeclampsia/eclampsia, sepsis as well increased admission to ICU (27). Wong SF et al., in the case series on pregnant women with COVID-19 reported an overall case fatality rate of 25% and 57% patients who presented to him in the first trimester had spontaneous miscarriage (35).

Preterm delivery was attributed to both obstetric reasons (abnormal Cardiotocography (CTG), doppler changes, Oligohydramnios) and due to COVID-19 infection. Wong SF et al., in the study on pregnancy and perinatal outcomes in women with severe acute respiratory syndrome found that out of five pregnant women with SARS with period of gestation more than 24 weeks, four underwent preterm delivery, and intrauterine growth restriction was observed in them despite their recovery before delivery (36).

Total 14 out of 260 (5.38%) patients enrolled in the present study, developed Multi Organ Dysfunction Syndrome (MODS) and ultimately died. A study conducted by Takemoto MLS et al., reported that pregnant women who had COVID-19 were 22 times more likely to die than pregnant women who did not have COVID-19 infection. Total 11 out of 706 (1.6%) women with COVID-19 diagnosis died in his study. Four of these women had severe preeclampsia, out of these four, three had respiratory failure and the fourth developed pulmonary embolism. Five women developed severe respiratory failure antenatally, two of whom had caesarean deliveries and died despite extensive respiratory assistance. The remaining two women's symptoms worsened within 7 days of an uncomplicated delivery and they died soon after, despite ICU care (37).

From present study it is clearly obvious that maternal obesity with impaired glucose tolerance, hypoproteinaemia could directly impair the maternal defence system thereby leading to severe COVID-19 infection. The severity of COVID-19 may lead to increased rate of abortions, IUDs, more chances of hypertension in pregnancy, Preterm delivery and high chances of ICU admissions. This research brings new insight into association between maternal nutritional status and adverse pregnancy outcomes with COVID-19 infection.

Limitation(s)

In present study factors such as Heamoglobin and Vitamin D levels could not be assessed in detail. due to lower sample size.

Conclusion

Hence, the study shows that maternal nutrition status affects the severity of symptoms in COVID-19 and adversely affects the maternal obstetric outcome in pregnancy. The factors positively affecting the maternal nutrition status were BMI, deranged blood sugar levels and protein levels of the patient.

Acknowledgement

Authors would like to thank Mr Vikram for helping with the statistical analysis in the present study.

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DOI and Others

DOI: 10.7860/JCDR/2022/56119.16391

Date of Submission: Mar 09, 2022
Date of Peer Review: Mar 30, 2022
Date of Acceptance: Apr 29, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 14, 2022
• Manual Googling: Mar 31, 2022
• iThenticate Software: Apr 28, 2022 (6%)

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