Aim and primary objective: To study the clinical presentations, maternal and neonatal outcomes in pregnant women with coronavirus disease 2019 (COVID-19) infection. Secondary objective: To compare the clinical profile between the first and the second waves and to determine the risk factors associated with the maternal outcomes. Materials and methods: This retrospective cohort study was carried out in pregnant women with confirmed COVID-19 infection who delivered from May 2020 to Dec 2021 in six hospitals in South India. Data on maternal demographics, severity of disease, and maternal and neonatal outcomes were collected from the medical records. Women who tested positive for COVID-19 infection were grouped into two cohorts, those who tested positive in the first wave between April and September 2020 and those who tested positive in the second wave between March and September 2021. A comparison was made between the two waves and risk factors for the outcomes were also analyzed. Results: There were 471 COVID-positive pregnant women in the study, 252 in the first wave and 219 in the second. Demographic characteristics did not differ significantly between the two waves. The common symptoms of COVID-19 were cold/cough (50%) and fever (40%) and were similar in both the waves. Compared to the first wave, more women were symptomatic in the second wave (58.9% vs 24.21%) and needed hospitalization (55.71% vs 44.84%). Maternal morbidity/mortality (hospitalization for COVID treatment, oxygen administration, and maternal deaths) was significantly more in the second wave. Obstetric complications, cesarean section rates, preterm delivery, low birth weight babies, and neonatal intensive care unit admissions were not different between the two waves. There were six maternal deaths and three neonatal deaths in the second wave and none in the first. Symptomatic COVID was associated with increased maternal morbidity and mortality. Cesarean section rates were higher in those symptomatic after 34 weeks of gestation. Conclusion: This study demonstrated that the severity of COVID and maternal and neonatal outcomes was significantly worse in the second wave. Symptomatic women were more affected though there were no identifiable risk factors. Clinical significance: This study shows that different variants of the virus may cause different severity of presentation. The significant morbidity and mortality of the second wave reinforces the need for vaccination in reproductive age women.