Anesthesia management in obstetric patients with positive COVID-19

Abstract

The COVID-19 pandemic, is an ongoing pandemic caused by corona virus.It can lead to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).As of 9 March 2021, more than 117 million cases have been confirmed, with more than 2.6 million deaths attributed to COVID-19, making it one of the deadliest pandemics in history. As the pandemic evolves rapidly, there are data emerging to suggest that pregnant women diagnosed as having coronavirus disease 2019 can have severe morbidities (up to 9%). The aim of this article is to bring attention to all steps that should be followed in obstetric patients with positive COVID-19. This is a litterature review, refering to international guidelines and international collegues experiences , especially from Wuhan and USA. In contrast to earlier data that showed good maternal and neonatal outcomes, the latest data suggest that pregnant woman can have severe morbidities. Exposure to virus predisposes both mother and fetus to an increased risk of infection and severe adverse maternal and perinatal outcomes. The anesthesia management of the patient with a suspected or confirmed COVID-19 infection presents a major challenge for anesthesia professionals because of the pathophysiologic and confirmed rapid human-to- human transmission of the virus through symptomatic and asymptomatic carriers. As with SARS and MERS, the most critical goal in the OR is to prevent cross-contamination by implementing stringent anesthesia guidelines and infection control strategies in the perioperative setting. Pregnant women with suspected or confirmed COVID-19 should be triaged and their condition categorized as mild, severe, or critical. Asymptomatic and mild cases should be isolated at home, and be taken care throw all the process until the day of the delivery. Severe and MOF patients should be taken care in the hospital by a multidisciplinary group. Vaginal delivery is recommended in stable patients because viral shedding and vertical transmission have not been reported. There are international recommendations starting to continuous CTG monitoring due to possible increased risk of fetal distress, monitor temperature, respiratory rate. Under normal labor progression, vaginal examinations should be minimized. Neuraxial analgesia is not contraindicated, and by providing good analgesia, it may reduce cardiopulmonary stress from pain and anxiety. Although evidence of mother-to-child transmission is lacking, early cord clamping may be discussed with the patient. The patient could informedly decide skin-to-skin contact with the newborn , ensuring precautions for respiratory droplets with the use of a mask as well as hand and skin hygiene. Caesarean section should follow usual obstetric indications. The potential risk of vertical transmission is not an indication for caesarean section. Because of pulmonary complication known in COVID-19, the regional anesthesia is recommended unless there are no contraindication. Before neuraxial anesthesia must be done blood count test, especially to asses the platelet count. If general anesthesia is required , the anesthesia machine must be prepared with an HMEF between the circuit and the patient’s airway. The most experienced anesthesia provider should be dedicated to the intubation. The anesthetist should manage the pain, preferably with NSAIDS, the PONV using antiemetics and VTE prophylaxis. COVID-19 is highly contagious, and this must be taken into consideration when planning intrapartum care. Rational use of personal protective equipment is key in preventing infection in attending professionals. The first of all is ’’ Primum non nocere’’, it should be done the best for the pregnant patient and for the newborn protecting the personnel. There are still limited data on the care and management of the parturient with COVID-19. It is paramount that our profession shares our experiences and practices to help guide our multidisciplinary approach in delivering the best care possible to these women.