P.140 Emergency caesarean section for a parturient in acute respiratory distress due to COVID-19

Abstract

Introduction: Studies in the early pandemic have shown that 1 in 10 pregnant women admitted to hospital in UK with SARS- Cov 2 infection needed respiratory support.[1]Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-COV- 2 infection in UK: national population based cohort study. BMJ 2020 :369;m2107Google Scholar The risk is increased with other co-morbidities. Hence multi-disciplinary decision making and timely delivery are crucial. We describe the anaesthetic management of an emergency caesarean section (CS) of a morbidly obese parturient with cerebral palsy and TRAPS (Tumor necrosis factor receptor associated periodic syndrome) who presented with respiratory distress during the third trimester. Case Report: A 34-year-old woman booked for an elective CS was admitted with a 2-day history of increasing shortness of breath and fever at 33 weeks. She had tested positive for Covid-19, 9 days previously. She had a background history of cerebral palsy, a raised BMI of 46 kg/m 2and a genetic disorder TRAPS. She was also known to be difficult for lumbar puncture. On admission her respiratory rate was 40 breaths/min and her saturation 94% on 2 L/min of oxygen. She was started on co-amoxiclav and hydrocortisone. A multidisciplinary decision involving physicians, obstetricians, an intensivist and anaesthetist was to deliver if her condition worsened to facilitate maternal stabilisation. Her condition deteriorated overnight with increasing oxygen requirement to maintain saturation 94%. and PO2 of 8 kPa. The decision was made to deliver her the following morning. Dexamethasone and magnesium sulphate were administered for fetal lung maturation and brain protection. The anaesthetic technique was a single-shot spinal. Standard monitoring was used in theatre. Lumbar puncture in the sitting position at L3-4 was successful at second attempt. 0.5% hyperbaric bupivacaine 2.3 mL with diamorphine 250 μg was administered. Nasal Optiflow was available in case of significant hypoxia. Cardiovascular stability was maintained with a phenylephrine infusion. Maternal saturation was maintained at 94% with facemask oxygen at 8 L/min. She tolerated the supine position on an Oxford pillow for the duration of operation. The baby was delivered in good condition. Post-operatively, she was transferred to the high dependency unit where she required high-flow nasal oxygen with AIRVO2 50 L/min She was treated with remdesivir for 5 days and dexamethasone for 10 days. She responded to treatment and was stepped down to the ward after 5 days. Discussion: Covid-19 infection in a high-risk pregnancy can result in severe respiratory failure requiring ventilatory support. Multidisciplinary care is essential for management of such cases as timely delivery is essential to provide optimal ventilatory strategy for the mother. Non-invasive ventilation may be beneficial to patients in the initial phase and may prevent deterioration. Our aim was to avoid general anaesthesia. Spinal was preferred over CSE to minimise the time to administer block as patient has history of difficult lumbar puncture, difficulty in sitting up even with support due to cerebral palsy and significant scoliosis.