Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), introduced major challenges to maternal, fetal, and neonatal care. Pregnancy involves physiological and immunological adaptations that can alter responses to respiratory infection, and early pandemic reports raised concern regarding maternal disease severity, preterm birth, fetal compromise, neonatal intensive-care admission, and possible mother-to-child transmission. Large observational cohorts and living systematic reviews subsequently demonstrated that SARS-CoV-2 infection in pregnancy is associated with increased risks of selected adverse maternal and perinatal outcomes, particularly preterm delivery and neonatal-unit admission, although the magnitude of risk varies with disease severity, timing of infection, population characteristics, and comparator groups [1,2]. Evidence concerning the direct effect of maternal infection on the fetus has remained more nuanced. Early systematic reviews reported that vertical transmission was uncommon and that most neonates born to infected mothers did not have virologically confirmed infection [3,4]. Multinational and population-based studies later showed increased frequencies of some neonatal morbidities among exposed pregnancies, but these outcomes were strongly influenced by prematurity, maternal illness, obstetric intervention, and thresholds for neonatal observation [5-7]. In parallel, the pandemic itself affected access to antenatal care, referral pathways, surgical scheduling, and neonatal intensive-care resources, creating indirect pathways through which neonatal outcomes could be altered [8]. Congenital surgical disorders constitute a clinically distinct group because many require urgent diagnosis, stabilization, and operative treatment soon after birth. Conditions such as anorectal malformations, intestinal atresias, oesophageal atresia with tracheoesophageal fistula, congenital diaphragmatic hernia, abdominal wall defects, Hirschsprung disease, malrotation, and complicated necrotizing enterocolitis contribute substantially to neonatal surgical workload. The possibility that maternal COVID-19 could influence congenital anomaly patterns generated particular interest because inflammation, fever, placental vascular injury, and COVID-19-associated hypercoagulability were biologically plausible concerns. However, registry data assessing first-trimester exposure have not demonstrated a consistent pattern of major congenital malformations, and studies examining vascular-associated defects such as intestinal atresia have not established an increased incidence attributable to maternal infection [9,10,12]. During the pandemic, pediatric surgical services also had to maintain emergency care while adapting infection-control pathways, theatre practices, and perioperative protocols [11]. Data from India describing the actual spectrum of neonatal conditions requiring surgery among infants born after maternal COVID-19 during pregnancy remain limited. Such descriptive information is useful for service planning and for generating hypotheses, provided that exposure is not interpreted as proof of causation. Therefore, the objective of the present study was to describe the demographic and perinatal profile, spectrum of surgical diagnoses, operative interventions, postoperative complications, length of hospital stay, and in-hospital outcomes among neonates born to mothers with documented COVID-19 during pregnancy who underwent surgical intervention at a tertiary government hospital in Andhra Pradesh, India.

Study design and setting This hospital-based observational study was conducted at Government Medical College and Government General Hospital, Ananthapuramu, Andhra Pradesh, India, a tertiary referral centre providing obstetric, neonatal, pediatric, intensive-care, and operative services. Neonates with surgical conditions are stabilized and managed according to clinical urgency. The study period extended from October 2020 to February 2022, when pediatric surgical services functioned under enhanced infection-control and perioperative precautions consistent with contemporary pandemic practice [11]. Study population and eligibility criteria The study population comprised neonates born to mothers with documented COVID-19 infection at any time during pregnancy who underwent surgical intervention during the neonatal period. Maternal exposure was identified from records documenting a positive SARS-CoV-2 test or clinician-confirmed COVID-19 during pregnancy. Inclusion required documented maternal infection, an established neonatal surgical diagnosis, and an operative procedure. Neonates treated conservatively, infants beyond the neonatal period at index surgery, cases with uncertain maternal infection status, and records missing essential diagnostic, operative, or outcome data were excluded. Forty neonates fulfilled the criteria. Because there was no unexposed control group, the study was not designed to estimate anomaly incidence or relative risk. Variables and data collection Data were abstracted with a structured proforma from maternal, neonatal, operative, anesthesia, and inpatient records. Maternal variables included trimester of SARS-CoV-2 infection and mode of delivery. Neonatal variables included sex, gestational age, prematurity, birth weight, and low-birth-weight status. Surgical variables comprised diagnosis, urgency and timing of intervention, and procedure performed. Postoperative variables included mechanical ventilation, sepsis, surgical-site infection, anastomotic or bowel complications, repeat intervention, postoperative stay, survival to discharge, and in-hospital mortality. Infection timing was categorized by trimester because gestational timing is relevant when evaluating fetal effects and congenital malformations [9]. Outcome measures The primary outcome was the distribution of neonatal surgical conditions. Secondary outcomes were operative type and timing, postoperative morbidity, ventilatory support, repeat surgery, postoperative hospitalization, and survival to discharge. Because vertical transmission is uncommon and neonatal outcomes are influenced by prematurity and maternal disease severity, the analysis described surgical phenotype and hospital course without attributing individual anomalies to SARS-CoV-2 exposure [4-7]. Statistical analysis Data were entered into a spreadsheet and analyzed using IBM SPSS Statistics, version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized as mean ± standard deviation; categorical variables were expressed as frequency and percentage. Percentages used 40 neonates as the denominator unless specified otherwise. Comparative hypothesis testing and causal modeling were not performed because the analysis involved a single surgically selected cohort without a non-exposed comparison group. Ethical considerations The study followed institutional ethical principles for research using clinical data. Necessary Permissions were obtained before starting the study. Patient identifiers were excluded from the analytic dataset, and confidentiality of maternal and neonatal records was maintained during data handling and reporting.

A total of 40 neonates born to mothers who had documented COVID-19 infection during pregnancy and who subsequently required surgical intervention were included in the final analysis. The cohort therefore represents only neonates undergoing operative management and should not be interpreted as reflecting the incidence of congenital or neonatal surgical disorders among all pregnancies affected by COVID-19. The mean gestational age at birth was 36.8 ± 2.4 weeks, and the mean birth weight was 2.48 ± 0.62 kg. Twenty-four (60.0%) neonates were male and 16 (40.0%) were female. Preterm birth (<37 weeks) was documented in 13 (32.5%) neonates, while 16 (40.0%) had a birth weight below 2.5 kg. Caesarean delivery accounted for 24 (60.0%) births. Regarding the timing of maternal COVID-19 infection, 7 (17.5%) mothers had infection during the first trimester, 13 (32.5%) during the second trimester, and 20 (50.0%) during the third trimester. The baseline maternal and neonatal characteristics are summarized in Table 1. Table 1. Maternal and neonatal characteristics of the operated neonates (n = 40) Characteristic n (%) / Mean ± SD Gestational age at birth, weeks 36.8 ± 2.4 Gestational age category Preterm (<37 weeks) 13 (32.5) Term (≥37 weeks) 27 (67.5) Birth weight, kg 2.48 ± 0.62 Low birth weight (<2.5 kg) 16 (40.0) Sex Male 24 (60.0) Female 16 (40.0) Mode of delivery Vaginal delivery 16 (40.0) Caesarean section 24 (60.0) Trimester of maternal COVID-19 infection First trimester 7 (17.5) Second trimester 13 (32.5) Third trimester 20 (50.0) Spectrum of neonatal surgical conditions Gastrointestinal and anorectal disorders constituted the major proportion of surgical conditions. Anorectal malformation was the most frequent diagnosis, observed in 8 (20.0%) neonates. Intestinal atresia was identified in 6 (15.0%), including duodenal and jejunoileal atresias. Congenital diaphragmatic hernia and oesophageal atresia with or without tracheoesophageal fistula were each present in 4 (10.0%) neonates. Hirschsprung disease was diagnosed in 4 (10.0%) cases. Gastroschisis, omphalocele, and necrotizing enterocolitis requiring operative management were observed in 3 (7.5%) neonates each. Two (5.0%) neonates underwent surgery for intestinal malrotation with volvulus. Hypertrophic pyloric stenosis, meconium ileus requiring surgery, and sacrococcygeal teratoma accounted for one case each (Table 2). Table 2. Spectrum of surgical conditions among the study neonates (n = 40) Surgical condition n (%) Anorectal malformation 8 (20.0) Intestinal atresia 6 (15.0) Congenital diaphragmatic hernia 4 (10.0) Oesophageal atresia ± tracheoesophageal fistula 4 (10.0) Hirschsprung disease 4 (10.0) Gastroschisis 3 (7.5) Omphalocele 3 (7.5) Necrotizing enterocolitis requiring surgery 3 (7.5) Intestinal malrotation with volvulus 2 (5.0) Hypertrophic pyloric stenosis 1 (2.5) Meconium ileus requiring surgical intervention 1 (2.5) Sacrococcygeal teratoma 1 (2.5) Total 40 (100.0) Surgical interventions Twenty-seven (67.5%) neonates required emergency or urgent surgical intervention, while 13 (32.5%) underwent surgery after initial stabilization and preoperative evaluation. Nineteen (47.5%) neonates were operated within the first 24 hours following recognition of the surgical condition, 13 (32.5%) underwent intervention between 24 and 72 hours, and the remaining 8 (20.0%) underwent surgery after 72 hours. Among neonates with anorectal malformation, 5 underwent diverting colostomy and 3 underwent primary perineal repair/anoplasty based on the anatomical subtype. All six neonates with intestinal atresia underwent laparotomy with resection of the affected segment and primary anastomosis where feasible. Primary repair was performed in all four cases of oesophageal atresia/tracheoesophageal fistula and in four neonates with congenital diaphragmatic hernia. Of the four neonates with Hirschsprung disease, three underwent initial leveling colostomy, while one underwent definitive primary pull-through surgery. Two neonates with gastroschisis underwent primary abdominal wall closure and one required staged reduction using a silo. Among the three cases of omphalocele, two underwent primary closure and one required staged management. Laparotomy with bowel resection and stoma formation was required in three neonates with advanced necrotizing enterocolitis. Both cases of malrotation underwent a Ladd procedure. The principal procedures are shown in Table 3. Table 3. Principal surgical interventions performed (n = 40) Surgical intervention n (%) Colostomy/anoplasty for anorectal malformation 8 (20.0) Resection and anastomosis for intestinal atresia 6 (15.0) Repair of congenital diaphragmatic hernia 4 (10.0) Primary repair of oesophageal atresia/TEF 4 (10.0) Colostomy/pull-through for Hirschsprung disease 4 (10.0) Primary/staged closure of gastroschisis 3 (7.5) Primary/staged closure of omphalocele 3 (7.5) Laparotomy, bowel resection ± stoma for NEC 3 (7.5) Ladd procedure for intestinal malrotation 2 (5.0) Ramstedt pyloromyotomy 1 (2.5) Surgical management of meconium ileus 1 (2.5) Excision of sacrococcygeal teratoma 1 (2.5) Total 40 (100.0) Postoperative course and outcomes Postoperative mechanical ventilatory support was required in 15 (37.5%) neonates, particularly following major thoracic and gastrointestinal procedures. Postoperative sepsis occurred in 8 (20.0%) neonates, surgical-site infection in 3 (7.5%), and anastomotic or bowel-related complications in 2 (5.0%). Three (7.5%) neonates required an additional surgical intervention during the same hospital admission. The mean postoperative hospital stay was 14.6 ± 8.7 days. Overall, 36 (90.0%) neonates survived to hospital discharge, whereas 4 (10.0%) died during the postoperative period. The postoperative outcomes are presented in Table 4. Table 4. Postoperative outcomes among operated neonates (n = 40) Outcome n (%) / Mean ± SD Required postoperative mechanical ventilation 15 (37.5) Postoperative sepsis 8 (20.0) Surgical-site infection 3 (7.5) Anastomotic/bowel-related complication 2 (5.0) Required repeat surgical intervention 3 (7.5) Postoperative hospital stay, days 14.6 ± 8.7 Survived to hospital discharge 36 (90.0) In-hospital mortality 4 (10.0) Overall, the findings demonstrated a heterogeneous spectrum of neonatal surgical disorders, with gastrointestinal, anorectal, and congenital thoracoabdominal abnormalities predominating. Anorectal malformations and intestinal atresias together accounted for 35.0% of all surgical interventions. Despite the substantial requirement for emergency surgery and postoperative intensive care, the majority of neonates had a favorable short-term outcome, with a hospital survival rate of 90.0%. Because all participants were selected on the basis of having undergone surgical intervention, these findings describe the pattern and outcomes of surgical disease among operated COVID-19-exposed neonates and do not establish that maternal COVID-19 caused these anomalies or increased their prevalence.

This study describes a selected cohort of 40 neonates born to mothers with documented COVID-19 during pregnancy who required operative management. Gastrointestinal, anorectal, and thoracoabdominal disorders predominated, with anorectal malformation and intestinal atresia accounting for more than one-third of the surgical diagnoses. Two-thirds of the cohort required emergency or urgent intervention, illustrating the time-sensitive nature of neonatal surgical disease even during periods of major health-system disruption. Contemporary pediatric surgical experience during the pandemic similarly emphasized that congenital neonatal emergencies could not be deferred and required protected pathways for operative care [11]. The cohort also had a substantial burden of prematurity and low birth weight. Nearly one-third were born preterm and 40% weighed less than 2.5 kg. These findings are directionally consistent with broader literature showing increased preterm birth, neonatal-unit admission, and selected neonatal morbidities among pregnancies complicated by SARS-CoV-2 infection [1,5-7,13,14]. Marchand et al. reported increased odds of premature delivery among infected pregnancies, while the INTERCOVID study demonstrated higher maternal and neonatal morbidity compared with contemporaneous non-infected pregnancies [5,9]. Nevertheless, the present study cannot determine whether prematurity or low birth weight resulted from maternal infection, the underlying fetal surgical condition, obstetric decision-making, or a combination of these factors. The distribution of congenital abnormalities requires particularly cautious interpretation. Early biological hypotheses proposed that maternal inflammation, fever, placental vascular changes, or COVID-19-associated hypercoagulability could influence embryogenesis or fetal vascular events. However, available evidence through 2023 does not demonstrate a reproducible teratogenic pattern. In the International Registry of Coronavirus Exposure in Pregnancy, first-trimester infection was not associated with a clear increase in major congenital malformations and no specific malformation pattern was identified [10]. Reppucci et al. specifically examined vascular-associated congenital complications, including intestinal atresia, and found no significant increase after the onset of the pandemic; only one intestinal atresia was observed among 194 pregnancies with documented maternal COVID-19 [12]. Thus, the surgical diagnoses in our cohort should be interpreted as a spectrum observed after exposure, not as disorders caused by SARS-CoV-2. Postoperative morbidity was clinically important: 37.5% required mechanical ventilation, 20.0% developed sepsis, and 7.5% underwent repeat intervention. These outcomes likely reflect the severity of the underlying surgical conditions, prematurity, low birth weight, and the physiological demands of major neonatal surgery. Despite this burden, 90.0% survived to discharge. Reports from neonatal COVID-19 registries indicate that direct neonatal SARS-CoV-2 infection is uncommon and that short-term neonatal outcomes are influenced substantially by prematurity and maternal clinical context [4,6,14]. The present study therefore contributes primarily a surgical-service perspective. Larger multicentre studies with well-defined non-exposed comparison groups, trimester-specific exposure information, maternal disease-severity data, and congenital anomaly surveillance are required to determine whether any specific neonatal surgical phenotype is truly associated with maternal SARS-CoV-2 infection. Limitations This study has several limitations. The sample was small, single-centre, and restricted to neonates who underwent surgery, creating strong selection bias. There was no non-COVID comparison group, so incidence, relative risk, or causal association cannot be estimated. Maternal disease severity, vaccination status, viral variant, placental findings, and neonatal SARS-CoV-2 testing were not analyzed. Retrospective record dependence also limits control of unmeasured confounding and incomplete documentation.

Among 40 neonates born to mothers with documented COVID-19 during pregnancy who required surgery, gastrointestinal, anorectal, and thoracoabdominal conditions formed the dominant clinical spectrum. Anorectal malformation and intestinal atresia were the most frequent diagnoses, while emergency or urgent surgery was required in approximately two-thirds of patients. Postoperative ventilation and sepsis were important contributors to morbidity, although 90% of neonates survived to hospital discharge. These findings provide a descriptive account of neonatal surgical workload during the pandemic and support the need for uninterrupted tertiary surgical and intensive-care services. They do not demonstrate that maternal SARS-CoV-2 infection causes congenital anomalies. Multicentre controlled studies with trimester-specific exposure and standardized anomaly surveillance are warranted.

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