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ORIGINAL ARTICLES
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 584-588  

Perioperative obstetric care in coronavirus infectious disease 2019: Anesthetic perspective


Department of Anesthesiology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India

Date of Submission07-Jan-2021
Date of Decision17-Jan-2021
Date of Acceptance16-Apr-2021
Date of Web Publication27-May-2021

Correspondence Address:
Dr. Amrita Panda
Department of Anesthesiology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_4_21

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   Abstract 

Background: The novel coronavirus infectious disease-2019 (COVID-19) is a global pandemic involving many countries and has affected more than seventy-nine million people worldwide, with greater than a million deaths in the current scenario. Aims: The aim of the study is to improvise perioperative obstetric healthcare in a tertiary healthcare center. Settings and Design: This is a retrospective case series of parturients infected with COVID-19. Materials and Methods: We present a case series of COVID-19–infected parturients. There is no evidence that pregnant women are more likely to become seriously affected by coronavirus, yet these groups of patients are vulnerable to infection. Hence, the objectives in the management of such patients which includes caring for the range of the asymptomatic to critically ill women in the peripartum period and protection of healthcare providers from exposure to the disease while treating them while treating them is of paramount importance. Results: There is limited literature available about the effect of this disease and the risk of complications in pregnancy. The variables affect the respiratory system and exacerbate the susceptibility to infections. This complicates or delays the diagnosis in COVID-19–infected parturients, which affect their clinical outcome. Thus, there is a need on focused and optimal management in a tertiary healthcare center. Of the total 109 lower segment cesarean section patients in our hospital, there were only two maternal and neonatal deaths among the 12 emergency cases performed. Conclusions: Collaborative efforts are imperative among experts such as anesthesiologists and obstetricians to tackle the impact of this disease. There must be surveillance systems in place for reporting maternal and fetal data during this pandemic.

Keywords: Global pandemic, healthcare providers, operation theatre, surgical scenario


How to cite this article:
Panda A, Das S, Satapathy G C. Perioperative obstetric care in coronavirus infectious disease 2019: Anesthetic perspective. Anesth Essays Res 2020;14:584-8

How to cite this URL:
Panda A, Das S, Satapathy G C. Perioperative obstetric care in coronavirus infectious disease 2019: Anesthetic perspective. Anesth Essays Res [serial online] 2020 [cited 2021 Jun 17];14:584-8. Available from: https://www.aeronline.org/text.asp?2020/14/4/584/316980


   Introduction Top


Coronavirus infectious disease-2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2), the seventh coronavirus with proven interhuman transmission.[1] At the end of December 2019, the virus spread rapidly from China to the entire world, with 191 countries affected worldwide. The World Health Organization (WHO) declared COVID-19 a global pandemic on March 11, 2020.[1] As of December 2020, the number of individuals infected had risen to a total of more than 64 million globally with 1.5 million people died of COVID-19.[2] Although the rate of infection is more in men than women, pregnant women have a higher risk and negative outcomes because of the inherent physiologic changes.[3] Inflammatory nature of COVID-19 during pregnancy exposes both mothers and their fetuses to a higher risk of obstetric complications and potentially to long-term multisystemic complications. Although several case reports have been published, little is known about the real impact of COVID-19 in pregnancy, with no clear evidence for vertical transmission.[4],[5] Therefore, decisions about the route of delivery and delivery timing should be individualized for any specific patient, based on her obstetrical indications and fetal status. Higher rates of cesarean section, performed mainly for fetal distress, have been reported for mothers testing positive for SARS-CoV-2. Induced preterm delivery, possibly due to COVID-19–associated respiratory failure in late pregnancies, has also been reported.[5] The initial load of viral inoculums, route of entry of virus, patient's immune status, age, and associated comorbidities of the patient are important factors for host responses.[6] The large majority of pregnant women experience only mild or moderate symptoms, but when associated with comorbidities are at enhanced risk for severe illness, more likely to be admitted to intensive care unit (ICU) for mechanical ventilation, and hence increased risk of mortality as compared to nonpregnant women.[7] Anesthesiologists, being perioperative physicians, are the frontline healthcare providers and need to develop stringent, strategic measures for safety, while performing interventions on patients suspected or confirmed with COVID-19 infection. This includes the use of personal protective equipment (PPE) that is protective clothing, facemasks, goggles, head shields, and gloves to be worn by all operation room theater personnel, as a measure to prevent the occupational hazards and the spread of cross-infection from COVID-19–infected parturients. Therefore, we present a case series of pregnant women infected with COVID-19 infection, with evidence-based practice for anesthesiologists, and focus on preparedness to deal with such patients. There is also scarce information regarding the possible consequences and perinatal outcome of neonates born to COVID-19 parturients.[4] In our hospital scenario, the neonates were roomed into a separate unit dedicated during this pandemic. They were advised separation from their mothers and were further managed by the treating neonatologist till discharge.


   Case Reports Top


After obtaining ethical clearance from our institute, informed consent was obtained from all the patients, for the purpose of publication.

Case 1

A 30-year-old primigravida who was a diagnosed case of severe aortic stenosis presented at term for lower segment cesarean section (LSCS). Invasive monitoring (invasive blood pressure, central venous pressure) was planned for the patient anticipating heart failure intraoperatively or postoperatively. Induction was done with injection etomidate and fentanyl, and trachea was intubated in a single attempt with rocuronium. She was extubated in a deep plane and shifted to ICU for monitoring.

Case 2

A 35-year-old primigravida at 35 weeks gestation COVID-19 positive presented to our tertiary care health center for safe confinement. She was a known case of sickle cell disease who presented in vaso-occlusive crisis for the last 10 days, with overlapping features of COVID-19 infection. She was planned for emergency LSCS under regional anesthesia. Combined spinal epidural anesthesia with epidural catheter in situ (Epidural Anesthesia Set, imported by B. Braun Medical [India] Pvt. Ltd, Spinocan, imported by B. Braun Medical [India] Pvt. Ltd.) was the technique of choice in view of normal arterial blood gas analysis, but deranged liver function tests (serum bilirubin - 7.2), and increased D-dimer (4.63) [Table 1]. Intraoperatively, Grade-2 placenta previa was managed conservatively with blood transfusion and drugs. The patient was shifted to postoperative ICU for further management. Postoperative pain was managed with local anesthetics and opioids through epidural catheter. All further management was continued with antibiotics, antivirals, anticoagulants, and steroids as per the COVID-19 protocol and was then discharged uneventfully after 10 days of surgery.
Table 1: The number of patients and the range of D-dimer values where most of them had values in the range 5-300

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Case 3

A 39-year-old female presented to the hospital with preterm contractions at 32 weeks. She had a previous history of LSCS and was a diagnosed case of gestational hypertension, controlled on oral antihypertensives. As blood pressure was 180/110 mm of Hg, she was started on loading dose of magnesium sulfate which had to be stopped due to oliguria. Her investigations revealed severe preeclampsia in hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Cardiotocography showed fetal distress, so the decision to terminate the pregnancy through LSCS was taken. As her platelet count was 30,000, 4 units of random donor plasma was transfused and 2 units of fresh whole blood was cross-matched for surgery. On examination, she had tachycardia (heart rate - 138/min), and her blood pressure was 180/110 mm of Hg which was controlled with 1 mg metoprolol intravenous. SpO2 on room air showed 89% which improved to 100% with 8 l/minute of oxygen with face mask. She complained of orthopnea and had productive cough. She also had anasarca with facial puffiness and bilateral petechial hemorrhages on the shin. Airway examination revealed anticipated difficult airway as she was morbidly obese and had a short neck, with Modified Mallampatti Grade-IV, large breasts. Hence, a plan of endotracheal intubation using videolaryngoscope and controlled ventilation was done. Ramp position had to be made to facilitate intubation and ventilation. The baby after delivery had poor APGAR but responded well to resuscitation. There was an episode of postpartum hemorrhage which was managed by uterine massage. The patient was shifted to ICU for elective ventilation and was extubated the next day after adequate surgical hemostasis.

Case 4

An elderly primigravida with 35 weeks of gestational age in severe pregnancy-induced hypertension (PIH), impending HELLP syndrome and very low platelet count of 18,000, was posted for emergency LSCS in view of fetal compromise. General anesthesia was planned in view of thrombocytopenia. Four units of random donor plasma was transfused and two units of fresh whole blood was cross-matched for surgery. The surgery was uneventful and both the mother and baby were discharged successfully.

Case 5

A primigravida with 34 weeks of gestational age in severe PIH, with a blood pressure of 200/120 mmHg, but with normal investigations and COVID positive, generalized anasarca was posted for emergency LSCS in view of fetal compromise. The case was conducted under regional anesthesia but was difficult due to edema and difficult interspinous spaces. The mother and baby were discharged successfully, but severe bouts of hypotension occurred intraoperatively. This continued into the postoperative period and vasopressor infusion was administered for the first 12 h.

Case 6

A 29-year-old morbidly obese hypothyroid, primigravida at 36 weeks of gestation was tested COVID positive and was admitted to hospital for safe confinement. She had twin pregnancy after in vitro fertilization conception presented with breech and was planned for elective surgery under regional anesthesia (subarachnoid block). All her investigations were under normal reference values except deranged liver function tests, D-dimer, and C-reactive protein (CRP) levels (D-dimer - 6.2, CRP - 6.18). Difficulty in regional anesthesia was encountered due to reduced interspinous spaces, but preoperative ultrasonogram assessment was done to locate space, and paramedian approach was used to advocate the block. Intraoperatively, the case was uneventful except for atonic hemorrhage which was managed conservatively. The patient remained positive for the infection for a total duration of 35 days which had a bad perinatal outcome and one loss of the neonate occurred.

Case 7

A 30-year-old female at gestation age of 37 weeks, being COVID positive, was admitted to ICU with a history of fever, respiratory illness, and ground-glass infiltrates on chest X-ray, with altered liver enzymes, deranged renal function tests, raised D-dimer levels, and altered mental sensorium, was on ventilator support and invasive monitoring, and was posted for emergency LSCS to save the baby. The baby survived but mother succumbed on the 2nd postoperative day [Figure 1].
Figure 1: The total number of lower segment cesarean sections, both elective and emergency done along with the number of maternal and neonatal deaths in our hospital

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   Discussion Top


Pregnant women who are affected with the COVID-19 infection suffer more likely from respiratory complications requiring intensive care management in a tertiary hospital according to the CDC.[8] Anesthesiologists have been involved in critical care and surgical cases in most of the COVID-19 hospitals during this pandemic. Hence, the chance of contamination and cross-infection is very high, and there is the need of special precautionary measures to deal with this infection. Common procedure like intubation is associated with the risk of environmental and personal contamination of the virus. The clinical outcomes of parturients during SARS epidemic in 2003 were worse compared to the nonpregnant, with a greater incidence of complications such as tracheal intubation, renal failure, and disseminated intravascular coagulation.[9] The physiologic changes in pregnancy predispose these patients to pneumonia and fetal outcomes of women with pneumonia in terms of growth restriction, and in utero demise was also worse during the influenza pandemic.[9],[10]

Reassuringly, early data emerging from COVID-19 experience suggest that most pregnant females with COVID-19 experience mild disease. The mortality rate is 1% in the data from western countries.[1] In a joint report of 147 cases in pregnancy, WHO-China have recorded 8% as suffering from severe respiratory disease with SpO2 <93% and only 1% required mechanical ventilation.[11] This is similar to our case series of patients with existing comorbidities where we recorded only one patient with severe disease and mortality. The risk factors for this population developing severe COVID-19 include the factors such as Asian origin, preexisting cardiac, respiratory comorbid conditions, age >35 years, and increased body mass index.[12] This study is similar to our case series of seven patients with existing comorbidities and associated COVID-19 infection, where we recorded the severity of the disease, the need for mechanical ventilation and mortality in one of the patients.

The SARS due to novel coronavirus (SARS-CoV-2) spike protein is predicted to have a strong binding affinity to human angiotensin-converting enzyme 2 (ACE-2).[13] As a result of higher ACE-2 expression, COVID-19 infection causes its downregulation, lowering angiotensin (1–7) levels, which can mimic and worsen the vasoconstriction, inflammation, and procoagulopathic effects that occur in preeclampsia.[13]

Preeclampsia may be more common during COVID-19 infection, which is a similar finding in our case series where all the three patients were severely preeclamptic.

In another study, a small case series of 13 patients by Lui et al., higher rates of preterm labor and emergency cesarean sections in view of fetal distress is similar to our case series of 7 patients where all patients underwent emergency LSCS in view of fetal compromise.[14]

Few reports suggest increased chances of preterm births and fetal distress, which is similar to our case series where all cases were done for the indication of fetal distress. Preterm birth is supposed to be a commonly observed as well as documented with COVID-19.[15] A cohort study in the U.K. also reports an incidence of 27% preterm births and 15% fetal distress, though it is merely an association and has no causal link to COVID-19.[7]

The impact of COVID-19 in pregnancy is associated with increased risk of preterm birth, growth retardation, and perinatal mortality.[16],[17] Pregnant women with COVID-19 are more likely to be delivered by LSCS. There are few studies, one of them being the United Kingdom Obstetric Society study which suggests that most of caesarean section were for fetal indications, rather than maternal compromise due to SARS-CoV-2 infection. The risk of perinatal transmission during breastfeeding and the risk of developing COVID-19 infection in the neonate during this timeframe are unknown.[12] Many guidelines have been provided by different medical societies; however, due to scarcity of clinical data, there is difference in recommendation and management strategies for mother infant dyads.[4]

Preoperative recommendations

Complete blood count, liver function tests, and renal function tests are some of the prerequisites for surgery. The need of chest X-ray arises as per the need for diagnosis of the patients, and abdominal aprons or shields are needed for protection of the fetus. Chest computed tomography scans can be used in selected cases and are not contraindicated completely. In some cases, lung ultrasound imaging is an alternative to X-ray images.[18] If respiratory support is indicated, then proper planning is needed to avoid crash intubations which have a greater risk of infection transmission.

There must be a multidisciplinary approach and coordination among frontline healthcare workers and hospital leaders to improvise preoperative strategic measures for interventions in patients with suspected COVID-19 infection.

Intraoperative recommendations

Patients should be shifted strictly to the designated operating room to minimize staff exposure. Patients not requiring general anesthesia should continue to wear the surgical mask. Use of PPE is the priority for all healthcare providers and proper donning and doffing is the key element. PPE impairs vision and communication, so closed loop communication should be followed and used meticulously as far as practicable. We planned for general anesthesia with endotracheal intubation, wherever required, avoidance of fiberoptic intubations, rather the use of videolaryngoscope is the current practice. Bag and mask ventilation before intubation can generate aerosols; hence, it is avoided and it is prudent to adequately preoxygenate for 5 min followed by rapid sequence induction with no means to auscultate.

The main advantage of regional anesthesia is that aerosol generation is minimized; hence, much lesser risk of transmission of infection to operation theater personnel engaged in patient care.[19] In case of the need of ultrasound probe, intraoperatively, the probe along with the cord should be covered with the disposable sheath. The patient must wear surgical mask to prevent droplet transmission, and the use of nasal prongs is recommended to prevent dispersion of exhaled air droplets. Severely, COVID-19–infected parturients should receive low-molecular-weight heparin, and it should be started and stopped according to current American Society of Regional Anesthesia guidelines for anticoagulants and neuraxial block. These women should continue to receive thromboprophylaxis for 6 weeks even after discharge due to high risk of deep venous thrombosis and pulmonary embolism.[20] Psychoprophylaxis is essential, and timely evaluation for any sign of mental health symptom is needed to combat COVID-19–induced depression and postpartum psychosis.[21] Postoperative considerations include that at the end of the surgery, patients should remain in the same operating room to prevent contamination of other clinical areas. Decontamination of all equipment and operating room is done with 0.1% sodium hypochlorite solution for large surfaces and 70% alcohol for small surfaces.

Even as anesthesiologists, it is quite stressful at job, and avoiding physical and mental stress is important in COVID-19 scenario. In our case series of totaling of seven patients, we have experienced uneventful neuraxial procedures such as spinal and combined spinal epidural anesthesia, with a good postoperative course similar to the case series in other studies. Thus, regional anesthesia is reasonably safer and preferred in this group of patients as compared to general anesthesia. Being frontline caregivers, of the first COVID hospital in Odisha, without having any prior experience of dealing with this novel virus and the hardships we faced, we have tried to give our best endeavors and provide for perioperative care of COVID-19 patients.

Limitations

Our shortcomings are that it is not a systematic analysis, but only a case series. Further, we could not collect the follow-up results of the neonates born to COVID-19–infected mothers. Although D-dimer values can act as a global indicator for coagulation and fibrinolytic pathways in COVID-19–infected parturients, yet we could not correlate cutoff values for assessing prognosis or mortality in such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key messages

  1. Although understanding this infection is still evolving in all fields, the authors found that healthcare providers and anesthesiologists, in particular, are at greater risk of acquiring the disease from the hospital
  2. The results of our study could help in creating appropriate management protocols in managing emergencies
  3. Though the management of an emergency does not change, the challenges to perform them in fully donned PPE cannot be overlooked
  4. Even the best of the hospitals were baffled by this pandemic, so implementation of robust strategies and coordination between hospital administrators and frontline healthcare providers can help in combating the effects of this deadly virus.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Qui H, Wu J, Hong L, Chen D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zheijang China: An observational Cohort Study. Lancet Infect Dis 2020;20:689-96.  Back to cited text no. 12
    
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Tang P, Wang J, Song Y. Characteristics and pregnancy outcomes of patients with severe pneumonia complicating pregnancy: A retrospective study of 12 cases and a literature review. BMC Pregnancy Childbirth 2018;18:434.  Back to cited text no. 17
    
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