Article Information

Ayman Albarrak¹, Mohammed Albattat¹, Ali Ibrahim Alshaqaqiq¹, Mohammed Al-Falah¹, Hussain Alshaqaqiq¹, Abdullah Alshakhs¹, Ahmed Al-Essa¹, Mustafa Alkathim¹, Muteb Alotaibi¹, Ali Alturaifi¹, Ali alsulaiman¹, Naif Alhamam², Khaled Yassen^3*

¹Internship physician 2019 group, College of Medicine, King Faisal University, Alhassa, Hofuf, Kingdom of Saudi Arabia

²Orthopaedic/Surgery Department, Vice Dean for clinical Affairs, College of Medicine, King Faisal University, Alhassa, Hofuf, Kingdom of Saudi Arabia

³Anaesthesia/Surgery Department, Associate Professor, College of Medicine, King Faisal University, Alhassa, Hofuf, Kingdom of Saudi Arabia

^*Corresponding Author: Dr. Khaled Yassen, Associate Professor Anaesthesia/ Surgery Department, College of Medicine, King Faisal University, Alhassa, Hofufu, Kingdom of Saudi Arabia

Received: 02 July 2020; Accepted: 17 July 2020; Published: 23 July 2020

Citation: Ayman Albarrak, Mohammed Albattat, Ali Ibrahim Alshaqaqiq, Mohammed Al-Falah, Hussain Alshaqaqiq, Abdullah Alshakhs, Ahmed Al-Essa, Mustafa Alkathim, Muteb Alotaibi, Ali Alturaifi, Ali alsulaiman, Naif Alhamam, Khaled Yassen. Anesthesia Consideration for a Pregnant with Positive COVID 19: A Narrative Review. Anesthesia and Critical Care 2 (2020): 070-074.

Abstract

Keywords

COVID-19; Pregnancy; Neonate; Delivery; Clinical

Article Details

1. Introduction

Coronavirus disease 2019 (COVID-19) is defined as an illness caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly called 2019-nCoV). This virus was first identified during an outbreak of respiratory illness in Wuhan City, Hubei Province, China. The illness was initially reported on December 31st 2019 by the WHO, but unfortunately on January 30th 2020, the WHO decided to declare it as an outbreak. On March 11th 2020, the WHO further declared COVID-19 as a global pandemic [1-2].

COVID 19 can develop into severe acute respiratory syndrome with multi-organ involvement. Precautions during pregnancy and labor to minimize the risk of viral transmission to the newborn and others will be the focus for this literature review. This will help to provide updates into this field from last few months pandemic published experience.

2. Methods

A literature review of the online database (PubMed, Google Scholar, MEDLINE) with the following keywords were used: COVID-19, 2019-nCoV and pregnancy. The review looked into scientific publications from February to June 2020 which focused on pregnancy and new born management during this COVID-19 pandemic.

All searches as well as title and abstract screening and study selection were performed by the investigators working independently. Search results included every published or accepted manuscripts and fast brief reports and communications in English language due to the limited time since the pandemic was announced.

3. Discussion

A pregnant woman can contract the COVID 19 virus mainly by droplet airborne transmission from a close contact or during hospital visits. Preventive measures and the organization of health care team work in the hospitals is necessary to reduce this risk. Wearing surgical masks, minimizing number of care givers, negative pressure isolation rooms for positive patients and infection control measures are essential recommendations [3]. Droplet airborne sharing can spread the SARS-CoV-2 to neonates if measures of social distancing are not implemented by the mothers, caregivers, visitors, or healthcare personnel [4-6]. Limited and contradictory evidence raise the concern about the utero transplacental vertical viral transmission to the neonates but cannot be confirmed yet [7, 8].

Early umbilical cord clamping during delivery is recommended and symptomatic mothers as mentioned above should keep the six feet distance from their newborns until recovery and the elapse of two weeks with symptoms free or twice negative testing in order to reduce the risk of viral transmission. Breastfeeding should only be allowed following mother recovery with special attention to frequent hands washing and breast hygiene. [9-11] Antiviral drugs transmission through breastfeeding is confirmed in rats, but not yet in humans. Any suspension of breastfeeding will require regular emptying of breasts to avoid infection.

COVID infection clinical course in pregnant are similar to non-pregnant adults and it is not associated with poor maternal or perinatal outcomes, despite few reported cases of maternal death during the second or third trimesters [11, 12]. The use of acetaminophen during pregnancy in the first trimester is considered safe and can reduce the effect of fever on the embryo [7]. Adopting the Telehealth technology encourages distance communication and reduces cross infection [13]. In labor and delivery wards, patients must be triaged on admission into low, moderate or high risk COVID-19 patients. Vaginal delivery in COVID-19-patients is not contraindicated, but in emergent delivery in a critically ill parturient, cesarean becomes the most appropriate approach. Delivery should be carried out with full personal protective equipment (PPE) for medical caregivers. A negative pressure isolation room with at least 6 air exchanges per hour as per infection control measures is ideally preferred [14]. Microbiological filters (pore size < 0.05 mm) must be inserted between the parturient mouth piece and the nitrous oxide -oxygen (Entonox) breathing systems to avoid cross infection [15].

Early epidural analgesia can reduce the need for general anesthesia if cesarean section is to be indicated. Technical difficulties were reported by anesthesiologists when performing neuroaxial blocks as a result of weaning the uncomfortable protective personal equipment (PPE) and the presence of thrombocytopenia. Recent coagulation studies are necessary prior to epidural catheter insertion in positive COVID 19 during labor [16,17]. The risk of meningitis or encephalitis with neuraxial procedures in patients untreated viremia are not known, but the risk of general anesthesia as an aerosol generating technique outweighs the theoretical risk of causing meningitis/encephalitis until otherwise proved [18].

Video laryngoscopy is the preferred method for endotracheal intubation by experienced anesthetist and with the minimal number of care givers in the room [19]. Post-partum care demands venous thromboembolism (VTE) prophylactic therapy and measures [20].

References

1. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march-2020
2. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72-314 Cases From the Chinese Center for Disease Control and Prevention. JAMA (2020).
3. Chen L, Li Q, Zheng D, et al. Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan, China. N Engl J Med 382 (2020): e100.
4. Della Gatta AN, Rizzo R, Pilu G, et al. Coronavirus disease 2019 during pregnancy: a systematic review of reported cases. Am J Obstet Gynecol 18 (2020): S0002-9378.
5. Li N, Han L, Peng M, et al. Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case-control study. Clin Infect Dis 30 (2020).
6. Juan J, Gil MM, Rong Z, et al. Effects of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcomes: a systematic review. Ultrasound Obstet Gynecol (2020): PMCID: PMC7276742.
7. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 395 (2020): 809-815.
8. Alzamora MC, Paredes T, Caceres D, et al. Severe COVID-19 during Pregnancy and Possible Vertical Transmission. Am J Perinatol (2020) PMID: 32305046.
9. Elshafeey F, Magdi R, Hindi N, et al. A systematic scoping review of COVID-19 during pregnancy and childbirth. Int J Gynaecol Obstet 150 (2020): 47-52.
10. Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol 22 (2020): 415-426.
11. Qiao J. What are the risks of COVID-19 infection in pregnant women? Lancet 395 (2020): 760-762.
12. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, et al. Maternal death due to COVID-19. Am J Obstet Gynecol 28 (2020): S0002-9378.
13. DeNicola N, Grossman D, Marko K, et al. Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review. Obstet Gynecol 135 (2020): 371-382.
14. Maxwell C, McGeer A, Tai KFY, et al. No. 225-Management Guidelines for Obstetric Patients and Neonates Born to Mothers With Suspected or Probable Severe Acute Respiratory Syndrome (SARS). J Obstet Gynaecol Can 39 (2017): e130-e137.
15. Chilvers RJ, Weisz M. Entonox equipment as a potential source of cross-infection. Anaesthesia 55 (2000): 176-179.
16. Gouez AL, Vivanti AJ, Benhamou D, et al. Thrombocytopenia in pregnant patients with mild COVID-19, International Journal of Obstetric Anesthesia (2020).
17. Kim JH, Shrestha N, Girshin M. Unexpected severe thrombocytopenia in the COVID-19 positive parturient. Anesth Analg (2020): PMCID: PMC7219858.
18. Bauer ME, Chiware R, Pancaro C. Neuraxial procedures in COVID-19 positive parturients: a review of current reports. Anesth Analg (2020): PMCID: PMC7172565.
19. Kranke P, Weibel S, Sitter M, et al. Geburtshilfliche Anästhesie während der SARS-CoV-2-Pandemie: Übersicht der Handlungsempfehlungen [Obstetric Anesthesia During the SARS-CoV-2 Pandemic - a Brief Overview of Published Recommendations for Action by National and International Specialist Societies and Committees]. Anasthesiol Intensivmed Notfallmed Schmerzther 55 (2020): 266-274.
20. Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis 50 (2020): 72-81.