AFJOG

ORIGINAL RESEARCH group (p=0.002). The common urinary pathogens identified were Acinetobacter Baumanii, Proteus Mirabilis, Klebsiella Pneumonia and E. Coli. Candida species were detected in 12 (24%) and 4(7.1%) of vaginal swabs submitted for MCS in the control and case groups respectively (p = 0.001) (Table 2). C-reactive protein (CRP) was raised in 26 women (46.4%) in the case group and 15 women (30%) in the control group (p=0.110) The white cell count (WCC) was raised in 18 (32.1%) in the case group and 9 (18%) in the control group (p=0.095) (Table 2). Table 2. Overall results of infectivemarkers Test Case (n/%) Control (n/%) Total (n/%) p- value COVID-19 Overall Negative 35 (85.4%) 46 (92%) 81 (89%) 0.503 Positive 6 (14.6%) 4 (8%) 10 (11%) Total 41 50 91 COVID-19 PCR* Negative 29 (96.7%) 48 (98.0%) 77 (97.5%) 1.000 Positive 1 (3.3%) 1 (2.0%) 2 (2.5%) Total 30 49 79 COVID-19 IgG* Negative 16 (76.2%) 28 (87.5%) 44 (83.0%) 0.456 Positive 5 (23.8%) 4 (12.5%) 9 (17.0%) Total 21 32 53 Urine MC&S* Growth 5 (8.9%) 1 (0.5%) 6 (5.6%) 0.002 Not repre- sentative 16 (28.6%) 23(46%) 39 (36.8%) Total 56 50 106 High Vaginal Swab Growth 4 (7.1%) 12 (24%) 16 (15%) 0.001 Total 56 50 106 Low Vaginal Swab Growth 2 (3.6%) 9 (18%) 11 (10.3%) 0.001 Total 56 50 106 C Reactive Protein >10 26(46.4%) 15(30%) 41(38.7%) 0.110 Total 56 50 106 White Cell Count >10.9 18 (32.1%) 9 (18%) 27 (25.5%) 0.095 Total 56 50 106 *PCR – Polymerase Chain Reaction *IgG- Immunoglobulin G *MC&S- Microscopy, Culture and Sensitivity DISCUSSION We assessed the prevalence and association of COVID-19 infection with PTL and PPROM early in the COVID-19 pandemic at a tertiary hospital in Kwa-Zulu Natal Province (KZN) from September 2020 to October 2021. We found an association between COVID-19 infection and PTL or PPROM, p=0.503. We describe statistically significant differences in the prevalence of TB and urinary tract infections in association with PTL and PPROM. A history of PTL in a prior pregnancy and coitus in the five days before presentation may be associated with PTL and PPROM (p= 0.456 and p = 0.070, respectively). HIV status (p = 0.505) was not associated with PTL and PPROM. The results of this study reveal an association between PTL and COVID-19 infection. Case series and observational studies reported at the start of the COVID-19 pandemic in early 2020 showed rates of PTL in COVID-19 positive patients, ranging from23% to 46%. 5–9 These studies did not differentiate between spontaneous and iatrogenic PTL. At the start of the pandemic, most deliveries (21-23 %), were in fact iatrogenic for maternal reasons due to severe disease. 9 The plausible explanation for this association is the release of proinflammatory cytokines associated with high fever and severe COVID-19 disease, which may have triggered preterm labour. A limitation of earlier studies however is probably the lack of inclusion of asymptomatically infected patients. 5,9 In contrast, retrospective cohort studies that assessed the impact of the COVID-19 pandemic on preterm birth-rates in California, Massachusetts and Canada, reported no difference in rates of preterm birth during the peaks of the COVID-19 infection as compared to pre-pandemic periods (7.4% vs 7.9%) (p=0.4). 10,11 The finding of a strong association between UTIs and PTL and PPROM is similar to findings in other prospective case control studies that evaluated the association between UTI and PTL.16 UTIs, much like PTL, may present with lower abdominal pain in late gestation, creating a diagnostic challenge. To avoid this confounder, only patients presenting in true labour with regular, palpable contractions or cervical changes were included as cases of PTL. The prevalence of HIV infection at 43.4% aligns to that of the general population in KZN and represents the highest prevalence of HIV infection globally. 17 However, HIV status did not affect the prevalence of PTL and PPROM as the incidence was similar in both groups due to high viral suppression (80.4%). An HIV viral load suppression of 80.4% is in keeping with a maturing HIV epidemic, as most women in low- and middle-income countries (LMICs) access health facilities during pregnancy, and are offered HIV testing and appropriate highly active antiretroviral therapy if positive to prevent mother to child transmission. Similarly, a chart review of all preterm births from January toMarch 2018 at King Edward VIII Hospital showed that there was no difference in any of the risk variables, including HIV-positive status [48.9% (n=23/47) vs 47.6% (n=90/189)], between PPROM and non- PPROM groups.18 These findings suggested that HIV-infected women who are virally suppressed on anti-retroviral therapy presenting with PPROM have similar birth outcomes compared to HIV-uninfected women. 18 The increased prevalence of TB in the case group compared to the control group is statistically significant (p=0.018). Published data regarding TB infection during the peripartum period are sparse. This may be due to the fact that most LMICs countries may not systematically collect data on TB infections occurring during pregnancy. The burden of TB in pregnant women appears to be substantial, estimated at 210 per 100 000 pregnant women globally in 2011. 19 In sub–Saharan Africa, KZN has the highest burden of TB infection. 20 The risk of maternal mortality and death in women living with TB is significant, with a twofold increase in preterm birth. 19 Similarly, a prospective study at two hospitals in KwaZulu Natal between 1996 and 2001 found an association between TB and PTB (40%, n= 2 out of 5) and a high incidence of foetal growth restriction. 20 Inflammatory markers are shown to have useful predictive value in the diagnosis and monitoring of PTL. The finding of an elevated CRP in 46.4%of cases and 30% in controls (OR=2.022; p=0.085) and a high WCC of 32.1% in cases and 18% in controls (OR= 2.158, p=0.099) is in keeping with other studies that have assessed the predictive role of inflammatory markers in PTL. 21,22 The monitoring of these biochemical parameters to assess the maternal and foetal condition has definite value in management, especially in PPROM, where delivery may be indicated based on high inflammatory values.2 3 The high rate of Candida growth found on vaginal swab testing in pregnant women is in keeping with findings frommost LMIC. Prevalence studies show a vaginal Candida colonisation rate of 30% during pregnancy. 24 During pregnancy, vaginal Candida is more common and difficult to eradicate because of the expected physiological changes in the genitourinary tract. 24 CONCLUSION An association between COVID-19 infection and spontaneous PTL or PPROM was found, but statistical significance was not African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 2 | 2023 | 22