Anesthetic management of cesarean sections in coronavirus disease 2019 patients at our coronavirus disease center: a case series

Chandni Sinha; Poonam Kumari; Umesh K Bhadani; Monika Anant; Arun Shettru Kotresh

doi:10.4103/roaic.roaic_6_22

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 4 | Page : 370-372

Anesthetic management of cesarean sections in coronavirus disease 2019 patients at our coronavirus disease center: a case series

Chandni Sinha¹, Poonam Kumari¹, Umesh K Bhadani¹, Monika Anant², Arun Shettru Kotresh¹
¹ Department of Anaesthesia, AIIMS, Patna, Bihar, India
² Department of Obs & Gynae, AIIMS, Patna, Bihar, India

Date of Submission	21-Jan-2022
Date of Decision	06-Apr-2022
Date of Acceptance	10-Jul-2022
Date of Web Publication	29-Dec-2022

Correspondence Address:
MD Poonam Kumari
Department of Anaesthesia, Room No. 506, B-Block, OT Complex, All India Institute of Medical Sciences, Patna 801507, Bihar
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/roaic.roaic_6_22

Abstract

Coronavirus disease 2019 (COVID-19) is a contagious pulmonary infectious disease with respiratory symptoms. The virus, SARS-CoV-2 has shown 85% resemblance to SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). The management of a COVID-19 positive mother is challenging as the virus is extremely contagious and can be life threatening to mothers and health-care personnel. Here, we describe the successful anesthetic management of 20 pregnant women with confirmed COVID-19 infection undergoing cesarean section in our hospital. A dedicated operating room was used for cesarean delivery of a parturient with COVID-19. This dedicated operating room was located in the secluded area of our hospital, away from the rest of the operating rooms. The first choice of anesthesia was a single-shot subarachnoid block with 0.5% heavy bupivacaine.

Keywords: cesarean delivery, coronavirus disease 2019, pregnancy

How to cite this article:
Sinha C, Kumari P, Bhadani UK, Anant M, Shettru Kotresh A. Anesthetic management of cesarean sections in coronavirus disease 2019 patients at our coronavirus disease center: a case series. Res Opin Anesth Intensive Care 2022;9:370-2

How to cite this URL:
Sinha C, Kumari P, Bhadani UK, Anant M, Shettru Kotresh A. Anesthetic management of cesarean sections in coronavirus disease 2019 patients at our coronavirus disease center: a case series. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:370-2. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/370/365797

Introduction

Coronavirus disease 2019 (COVID-19) is a contagious pulmonary infectious disease with respiratory symptoms. The virus, SARS-CoV-2 has shown 85% resemblance to SARS coronavirus (SARS-CoV) and MERS coronavirus (MERS-CoV). Both the SARS and MERS epidemics had significant adverse effects on pregnant women including preterm deliveries, stillbirths, respiratory complications, and maternal mortality [1]. Preexisting physiological factors such as basal atelectasis from a gravid uterus, lower lung reserves (reduced functional residual capacity), and increased oxygen consumption (30%) might predispose the parturient to poor outcomes during respiratory illnesses. The management of a COVID-19 positive mother is challenging as the virus is extremely contagious and can cause a life-threatening condition. Anesthesiologists have high exposure risk to SARS-COV-2 when conducting a cesarean section on pregnant women with pneumonia.

Here, we describe the successful anesthetic management of 20 pregnant women with confirmed COVID-19 infection undergoing cesarean sections in our hospital. The aim is to provide additional data on the management of such patients in the current scenario. Medical records of pregnant women who underwent cesarean sections (elective or emergency) during the period from May to October 2020 were assessed. All these patients were confirmed to be COVID-19 positive by an RT-PCR test. This case report have been prepared in accordance with CARE guidelines. Written and informed consent for surgery was obtained from the patient. All clinical data were independently collected by two investigators.

Anesthestic management: operating room (OR) preparedness: a dedicated OR was used for cesarean delivery of a parturient with COVID-19. This dedicated OR was located in the secluded area of our hospital, away from the rest of the ORs. All the health-care personnel entered the dedicated OR after donning the full set of personal protection equipment: N-95 respirator, fluid-resistant protective gown, gloves, full face shield, and goggles. The patients were transferred to this facility with face covered with an N-95 respirator through a preplanned route in which all other patients and personnel movement was stopped to minimize contamination. Health-care personnel handling the patients wore a full set of personal protection equipment at every level. A separate entry and exit path was followed in the OT. Due importance was given to hand hygiene.

Minimal equipment required for anesthesia or surgery were kept in the OR. Two anesthesiologists, OT technician, two obstetricians, one scrub nurse, and one floor nurse were present for the surgeries. Drugs required for neuraxial blockade and general anesthesia were packed in separate plastic bags and carried in the OR for surgery. The anesthesia workstation was covered with a plastic sheet during the surgery. After the surgery all disposable items were packed in disposable sheets and sent to the biomedical waste disposal department.

Perioperative management: a written and informed consent was taken from all the patients and their relatives according to the institutional protocol. In all, 20 patients underwent a cesarean section out of which 18 completed a full term. Two patients had a preterm delivery. Nine patients had comorbidity in which three patients had diabetes mellitus, four had hypothyroidism, one pregnancy-induced hypertension, one had rheumatic heart disease as shown in [Table 1].

Table 1 Demographic data, clinical parameter, and anesthestic management and surgery

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All the patients were on preoperative low molecular weight heparin. Preoperative investigations such as hemoglobin and platelet were asked. It was normal in all patients except one who had a count of 85 000 as shown in [Table 1]. Majority of the patients were asymptomatic at the time of presentation, except two (fever and cough) and were referred to the hospital after being diagnosed as COVID in other hospitals.

The first choice of anesthesia was a single-shot subarachnoid block with 0.5% heavy bupivacaine. The volume ranged from 1.8 to 2.2 ml in all the patients. L2–L3 space/L3–L4 space was chosen for all the patients. In two patients, we encountered failure of the subarachnoid block due to technical difficulties. In these patients, general anesthesia was administered. Monitoring included: peripheral oxygen saturation, noninvasive blood pressure, and EEG and ETCO₂.

Patients in whom general anesthesia had to be given, rapid sequence induction with propofol was used after four maximal capacity breaths with 100% oxygen. Cricoid pressure was continuously applied till the position of the endotracheal tube was confirmed on ETCO₂. Fentanyl 1–2 μg/kg and succinylcholine 1–2 mg/kg were given at the time of induction. Sevoflurane in oxygen was used for maintenance of anesthesia. Lignocaine 1.5 mg/kg was administered to all patients before intubation. Extubation was given equal importance as intubation as chances of aerosol dispersion is high during this time. Intraoperative period was uneventful in all the patients with mean blood loss being around 550 ml. None of them required blood transfusion or postoperative ICU care. Patients were directly shifted to the isolation room after complete recovery.

All the newborns were normal. The neonates were transferred to the neonatal ICU for observation. Expressed breastfeeding was encouraged. Two RT-PCR samples were sent: one within 24 h and the other after 24 h. All the patients were followed up till 48 h postoperatively. They were put on analgesics: intravenous paracetamol 6 hourly till they started taking orally. NSAIDs were used if required. All the patients had an uneventful recovery. The mean days of discharge was 9 days. The patients were discharged when they met the following criteria: (a) 10 days from the onset of symptom, (b) no fever since last 3 days, (c) no breathlessness. RT-PCR was not repeated for any of the patients.

Discussion

Herein, we report 20 cases of parturients with COVID-19 who underwent cesarean sections under central neuraxial blockade or general anesthesia successfully. This is the first case series in context to the Indian subpopulations.

COVID-19 is a highly contagious disease with significant adverse effects. Vulnerable population including parturients need special attention and should be considered in response plans. The predominant sign and symptoms these patients present with are fever, cough, myalgia, fatigue, and pneumonia. Gastrointestinal symptoms like diarrhea and abdominal pain have also been reported. Majority of the patients infected with COVID-19 have mild presentation, unlike the patients infected with MERS or SARS. All the patients presenting to our hospital had mild disease with fever and cough being the only symptoms. Gestational diabetes and hypertension are the most common coexisting disorders with a prevalence of 9.6 and 8.5% [2]. In our case series, hypertension was the most common coexisting disorder.

In a recent cohort study of 1099 patients, Guan et al. [3] found that 36% of the patients had decreased platelet counts. We did not encounter decreased platelets except in one patient. Both neuraxial and general anesthesia have been safely reported in pregnancy. The main target for the virus is the lung; hence, it is preferable to avoid general anesthesia in such patients. It also avoids aerosol generation and cross infection. Single-shot subarachnoid blockade was the anesthesia of choice in our patients. Two patients who had to be given general anesthesia, recovered uneventfully.

Few authors have recommended rapid sequence spinal anesthesia and have compared its surgical readiness to general anesthesia [4]. A case series from Wuhan highlighted intraoperative hypotension in 86% of the patients undergoing cesarean section under epidural anesthesia [5]. They attributed the high susceptibility of circulatory system to SARS-COV-2 infection. We did not encounter such a thing in our patient. The onset time of sensory and motor block, the degree of motor block, the height of sensation, and the quality of anesthesia seemed to be the same as those of noninfected pregnant women. The intraoperative blood loss was similar to non-COVID parturients.Studies have shown absence of virus in the amniotic fluid, placenta, and breast milk hence ruling out vertical transmission [6]. None of the babies tested positive for COVID in our series. The babies were kept separately from their mothers to prevent infection after delivery. Administration of expressed breast milk was encouraged [7]. We concluded that our experience is that both spinal and general anesthesia are safe and effective for pregnant women and newborns. A separate operating room, proper patient transfer, training of medical staff, and effective biosafety precautions are important. Our experience may be helpful in planning for further obstetric anesthetic management of COVID-19 patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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