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Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 611-614  

Elective cesarean section in obstetric COVID-19 patients under spinal anesthesia: A prospective study


Department of Anesthesia and Critical Care, SKIMS Medical College, Srinagar, Jammu and Kashmir, India

Date of Submission12-Mar-2021
Date of Acceptance17-Mar-2021
Date of Web Publication27-May-2021

Correspondence Address:
Dr. Wasim Mohammad Bhat
Department of Anesthesia and Critical Care, SKIMS Medical College, Bemina, Srinagar - 190 017, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_29_21

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   Abstract 

Background: Managing obstetric emergencies in COVID-19 pandemic is a real challenge as these patients need timely intervention to save the life of the mother and the baby. Hence, to avoid life-threatening challenges, all pregnant patients were electively admitted and tested for COVID-19 near term to anticipate the difficulties and prevent complications. Aim: Our aim was to assess the impact of COVID-19 infection on maternal morbidity and mortality as well as the effect on the neonate under spinal anesthesia. Settings and Design: This was a prospective observational study. Materials and Methods: One hundred and fifteen COVID-19-positive pregnant patients in the age group of 20–40 years from July 2020 to December 2020 were electively taken for cesarean section under spinal anesthesia. Patients who needed emergency cesarean delivery were excluded from the study. Emergency cesarean delivery was avoided to reduce the risk of aerosol generation under general anesthesia as endotracheal intubation of COVID-19 patients poses a significant risk of viral exposure to doctors and staff. Written informed consent was obtained from all patients. Spinal anesthesia was given at L4–L5 intervertebral space. Demographic parameters, anesthetic and surgical parameters, and neonatal parameters were observed. Any inadvertent event was noted. Statistical Analysis: Data were expressed as mean, median, percentage, or number. Results: All pregnancies were singleton. None of the patients was converted to general anesthesia. One hundred and ten were either mildly symptomatic or asymptomatic. Five of our patients had severe symptoms and needed intensive care unit care preoperatively and postoperatively. Seven patients developed spinal hypotension and were managed by vasopressors. No significant thrombocytopenia was noted in any of our patients. None of our patients developed symptomatic thromboembolism. Vertical transmission was not reported in any of the cases. All babies were born with weight >2500 g and good APGAR score. Conclusion: Spinal anesthesia for LSCS is safe and effective for obstetric anesthesia in COVID-19 both for the parturient and the newborn.

Keywords: COVID-19, elective caesarean, spinal anesthesia


How to cite this article:
Jan M, Bhat WM, Rashid M, Ahad B. Elective cesarean section in obstetric COVID-19 patients under spinal anesthesia: A prospective study. Anesth Essays Res 2020;14:611-4

How to cite this URL:
Jan M, Bhat WM, Rashid M, Ahad B. Elective cesarean section in obstetric COVID-19 patients under spinal anesthesia: A prospective study. Anesth Essays Res [serial online] 2020 [cited 2021 Jun 16];14:611-4. Available from: https://www.aeronline.org/text.asp?2020/14/4/611/316978


   Introduction Top


Severe acute respiratory syndrome coronavirus (SARS-Cov-2) has emerged as a new entity since December 2019. The outbreak is believed to be originated in Wuhan, China, before it spreads to other parts of the country and rest of the world.[1],[2] COVID 19 or SARS-Cov-2 is a contagious pulmonary infection. Its symptoms and signs are similar to those seen in the SARS epidemic in 2003.[3] Respiratory droplets are believed to be the main route of transmission. However, there is a possibility of aerosol transmission in a relatively close environment with a high degree of contamination for a protracted period of time.[4] Pregnant women are supposed to have relatively depressed immunity and on a theoretical basis can have a higher chance of contracting an infection.[5] However, current evidence suggests that pregnant women are no more at risk of COVID-19 than other adults nor is the condition thought to be more severe in them.[6] The clinical course of COVID-19 appears to be mild in pregnant patients in contrast to the SARS, Middle East respiratory syndrome, and influenza outbreaks.[7]

Peripartum services, in contrast to many other healthcare services, cannot be deferred or postponed with the view of redirecting resources toward the overload imposed by COVID-19.[8],[9] Managing obstetric emergencies in COVID-19 pandemic is a real challenge as these patients need timely care and intervention to save the life of the mother and the baby. Even at times, it is more difficult and impossible to wait for the test results as the challenge may be life-threatening. Hence, avoid the life-threatening challenges, all pregnant patients are electively admitted and tested for COVID-19 near term to anticipate the difficulties and prepare health-care working team for the upcoming challenges.

With this background in mind, we at our institution performed a study on elective cesarean section in COVID-19 patients under spinal anesthesia. Our aim was to assess the impact of COVID-19 infection on maternal morbidity and mortality as well as the effects on the neonate.


   Materials and Methods Top


After obtaining approval from the Institutional Ethics Committee, this prospective observational study was conducted in a tertiary care hospital which was a designated COVID-19 facility. COVID-19 pregnant patients in the age group of 20 to 40 years were taken for elective cesarean delivery. This study was conducted from July 2020 to December 2020 under spinal anesthesia. One hundred and eighty patients were admitted during this period, of which only 115 qualified for the study. Patients who needed emergency cesarean delivery were excluded from the study to reduce the risk of general anesthesia as putting patients on mechanical ventilation poses a significant risk of viral exposure to the health-care personnel. Written informed consent was obtained from all patients. The study was performed as per the Declaration of Helsinki.

Level-3 personal protective equipment comprising N 95 respirators, impervious body suits with hoods, goggles, visor, shoe covers, and double-layered medical gloves were donned by the entire team which included anesthesiologist, obstetricians, neonatologist, nursing staff, and assistants. The patients were shifted to the operating room wearing N 95 masks except five patients who were on high-flow oxygen. Monitor was attached with electrocardiography, Oxygen saturation (SpO2), and non invasive blood pressure. Baseline readings of each parameter were noted. 18 G IV cannula was secured on the dorsum of the left hand and infusion of Ringer's lactate was started. Spinal anesthesia was given at L4–L5 intervertebral space in a sitting position using 27 G spinal needles. Injection bupivacaine 0.5% heavy 2.8 ml was injected into subarachnoid space after proper barbotage of cerebrospinal fluid. The patient was laid down in a supine position with a head down of 10° to 15°. Heart rate, blood pressure, and SpO2 were recorded at an interval of 5 min till completion of surgery. Any inadvertent event was noted. Number of personnel in operating theater was kept minimal but with assistance readily available. Complete blood count including platelet counts on admission was done in all patients.

The mother was transferred to the recovery room and taken care of the same staff and the residents. The baby was breastfed. All the team members exited the recovery area after doffing under supervision. The newborn was handed over to the mother for nursing. The mother was instructed to wear N95 respirator and maintain hygiene. A SARS-Cov-2 reverse transcription–polymerase chain reaction (RT-PCR) viral test (nasal swab) for neonates was performed twice, first on the day of delivery and then again at the time of discharge.

All medical staff who were involved in the taking care of these patients were monitored for any symptoms and signs of infection. Data were presented as mean, median, or number.


   Results Top


One hundred and fifteen patients were included in our study. All were detected by routine screening by RT-PCR technique for COVID-19. All pregnancies were singleton and underwent cesarean delivery under spinal anesthesia. None of the patients were converted to general anesthesia. Most of the pregnant patients (110) were either mildly symptomatic or asymptomatic. Five of our patients had severe symptoms. All these five patients needed intensive care unit (ICU) care requiring high-flow oxygen via high-flow nasal cannula and/or noninvasive ventilation (NIV) and the same was continued during surgery. All these patients were shifted to the ICU in the postoperative period. Two of them improved on high-flow nasal canula (HFNC). Three patients become severely sick in the postoperative period. One was intubated and put on mechanical ventilation but expired after 7 days. Two patients with severe symptoms improved with NIV postsurgery and were discharged to the ward after improvement. Demographic data of patients are shown in [Table 1].
Table 1: Demographic data

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Mean operative time, blood loss, postoperative stay, and other critical anesthesia and surgical issues are shown in [Table 2]. Seven of our patients developed spinal hypotension and were managed by vasopressors. No significant thrombocytopenia was noted in any of our patients. None of our patients developed symptomatic thromboembolism. Vertical transmission was not reported in any of the cases. All babies except one were born with weight >2500 g and good APGAR scores [Table 3]. Anemia was the most common coexisting condition followed by diabetes and pregnancy-induced hypertension [Table 4]. Two of our resident doctors and four paramedical staff contracted COVID-19. All of them had mild symptoms and were managed without requiring oxygen except one who needed oxygen via facemask and recovered subsequently.
Table 2: Anesthesia management and surgery

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Table 3: Neonatal parameters

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Table 4: Co-existing conditions

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   Discussion Top


We report 115 parturients with COVID-19 having a cesarean delivery. All these patients presented with laboratory-confirmed SARS-Cov-2 positivity. Although both general anesthesia and neuraxial anesthesia have been safely administered in pregnancy, we used only spinal anesthesia in our patients.[10],[11] As lung is the main target organ of the virus, there may be chances of exacerbation of pulmonary complications due to intubation in these patients. Moreover, general anesthesia is an aerosol-generating procedure so every attempt was tried to avoid general anesthesia. An elective cesarean is considered to be the safest in these patients, but there is a paucity of data till date. However, we recommend elective cesarean delivery in these patients. The society of obstetric anesthesia and perinatology also recommends the same.[12] In addition, an elective cesarean would avoid an emergency lower segment cesarean section (LSCS) and for need general anesthesia and tracheal intubation. Moreover, there is an emerging evidence of vertical transmission by vaginal delivery.[13]

All babies were born with weight >2500 g and good APGAR scores [Table 3]. None of the babies tested positive on the swab on day 1 and day 5. However, long-term follow-up of these babies to see any delayed effects is required. Similar results were obtained by Nayak et al.[14]

Most of our patients were either asymptomatic or mildy symptomatic in contrast to the proportion of maternal critical illness due to SARS-Cov-2 infection in Wuhan.[15] This could be explained by the fact that these patients were screened late in the pregnancy and there is a tendency to limit outdoor activities during this period of pregnancy. We did not report any neonate with COVID-19 infection in our study. Studies have also shown that SARS-Cov-2 virus has not been detected in amniotic fluid, cord blood, or breast milk of pregnant women infected with COVID-19.[7],[16] This could explain our absence of neonatal COVID-2 infection despite breastfeeding of neonates. Our policy involved strict adherence to hand hygiene and droplet precautions. We did not mandate isolation of neonates, but follow-up and routine surveillance was strictly adhered to.

Five of our patients had severe symptoms before cesarean delivery and developed severe respiratory symptoms with tachypnea and hypoxemia in the postoperative period. One of them required mechanical ventilation but failed to improve and died. Rest of them required oxygen via HFNC and NIV in addition to other supportive treatments. They improved significantly and were discharged afterward. All these five patients had co-existing diabetes and pregnancy-induced hypertension.

We did not find hemodynamic instability as a significant problem in COVID-19-positive parturients. Spinal hypotension developed in seven of our patients which is comparable to non-COVID obstetric patients.[17],[18],[19] Thromboembolism was not seen in any of the patients.

Six to twelve high-flow air exchanges were done per hour in the operating room initially and sterilization was performed after every surgery. Later on, negative-pressure operating room was created; none of our patients in the study were operated under general anesthesia. Parturients always wore a surgical mask at all times unless they were on oxygen therapy. Despite effective biosafety precautions along with careful patient transfer, two of our doctors and four paramedical staff contracted SARS-COV-2 infection.


   Conclusion Top


Spinal anesthesia for LSCS is safe and effective for obstetric anesthesia in COVID-19 both for the parturient and the newborn. Elective cesarean is preferable to emergency surgery. High-risk groups should be identified and treated vigorously. Moreover, effective biosafety precautions are of utmost importance for the safety of medical and paramedical staff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 1
    
2.
Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: Retrospective case series. BMJ 2020;368:m792.  Back to cited text no. 2
    
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7.
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID 19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;395:809-15.  Back to cited text no. 7
    
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Bampoe S, Odor PM, Lucas DN. Novel coronavirus SARS-CoV-2 and COVID-19. Practice recommendations for obstetric anaesthesia: What we have learned thus far. Int J Obstet Anesth 2020;43:1-8.  Back to cited text no. 8
    
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England N. Critical care and anaesthesia service reorganisation 2020. Available from: https://www.england.nhs.uk/coronavirus/wpcontent/uploads/sites/52/2020/03/Specialty guideCritical care and anaesthesia service reorganisation_V1_17 March.pdf. [Last accessed on 2020 May 30].  Back to cited text no. 9
    
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Birnbach DJ, Bateman BT. Obstetric anesthesia: Leading the way in patient safety. Obstet Gynecol Clin North Am 2019;46:329-37.  Back to cited text no. 10
    
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Sorbello M, El-Boghdadly K, Di Giacinto I, Cataldo R, Esposito C, Falcetta S, et al. The Italian coronavirus disease 2019 outbreak: Recommendations from clinical practice. Anaesthesia 2020;75:724-32.  Back to cited text no. 11
    
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Podovei M, Bernstein K, George R, Habib A, Kacmar R, Bateman B, et al. Society for Obstetrics Anaesthesia & Perinatology (SOAP) Interim Considerations for Obstetric Anaesthesia Care related to COVID 19. Available from: https://www.wfsahq.org/images/SOAP_COVID-19_ObstetricAnesthesia_Care_031620 2_.pdf. [Last accessed on 2020 May 12].  Back to cited text no. 12
    
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Gagneur A, Dirson E, Audebert S, Vallet S, Quillien MC, Baron R, et al. Vertical transmission of human coronavirus. Prospective pilot study. Pathol Biol (Paris) 2007;55:525-30.  Back to cited text no. 13
    
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Nayak AH, Kapote DS, Fonseca M, Chavan N, Mayekar R, Sarmalkar M, et al. Impact of the coronavirus infection in pregnancy: A preliminary study of 141 patients. J Obstet and Gynecol India 2020;70:256-61.  Back to cited text no. 14
    
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Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 15
    
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Fornari F. Vertical transmission of Covid-19-A systematic review. J Pediatr Perinatol Child Health 2020;4:7-4:7  Back to cited text no. 16
    
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Klöhr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarean section: Literature search and application to parturients. Acta Anaesthesiol Scand 2010;54:909-21.  Back to cited text no. 17
    
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Burns SM, Cowan CM, Wilkes RG. Prevention and management of hypotension during spinal anaesthesia for elective Caesarean section: A survey of practice. Anaesthesia 2001;56:794-8.  Back to cited text no. 18
    
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