|Year : 2020 | Volume
| Issue : 5 | Page : 13-16
Perioperative management for cesarean section in COVID-19 patients
Tjokorda Gde Agung Senapathi1, Christopher Ryalino1, Anu Raju2, I Gde Sastra Winata3, I Nyoman Budi Hartawan4, I Gusti Agung Utara Hartawan1
1 Department of Anesthesiology and Intensive Care, Udayana University, Denpasar, Indonesia
2 Department of Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia
3 Department of Obstetrics and Gynaecologic, Udayana University, Denpasar, Indonesia
4 Department of Pediatrics, Faculty of Medicine, Udayana University, Denpasar, Indonesia
|Date of Submission||29-May-2020|
|Date of Decision||07-Jun-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||13-Jul-2020|
Dr. Christopher Ryalino
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Indonesia
Source of Support: None, Conflict of Interest: None
Background: Pregnant women and neonates are susceptible populations in many infections. Health-care workers are facing a new challenge as only few data are available on the effect of coronavirus disease 2019 (COVID-19) on pregnancy. The aim of this review was to see the current recommendations regarding the perioperative management of the cesarean section in COVID-19 patients. Methods: We used the keywords of (((((coronavirus [Title/Abstract]) OR (covid-19 [Title/Abstract])) OR (ncov-19 [Title/Abstract])) OR (SARS-cov-2 [Title/Abstract]))) AND (Cesarean [Title/Abstract] or Pregnancy [Title/Abstract]) in the PubMed database to find eligible reports. We studied all titles and abstracts from the search results and removed irrelevant studies that did not comply with our research question. Two authors were assigned to assess the validity and reliability of the studies using the Joanna Briggs Institute's critical appraisal tool. The cutoff point for inclusion was 50% of the total checkmarks in each critical appraisal checklist. Results: We found 16 articles from the PubMed database based on keywords described earlier. After eligibility screening, we found seven eligible articles describing perioperative management of the cesarean section during the COVID-19 pandemic. Conclusion: There is no solid evidence that the cesarean section is protective against the transmission of COVID-19. The use of an appropriate biosafety level-3 protective suits is imperative in managing patients presenting for cesarean section with COVID-19 in an operating room. A negative-pressure environment, both in the operating room and incubator, should be prepared for such cases. Regional anesthesia is the recommended technique, but general anesthesia is preferable in specific maternity conditions.
Keywords: Cesarean section, neonatal care, novel coronavirus, parturient, pregnancy, severe acute respiratory syndrome-CoV-2
|How to cite this article:|
Agung Senapathi TG, Ryalino C, Raju A, Sastra Winata I G, Budi Hartawan I N, Agung Utara Hartawan I G. Perioperative management for cesarean section in COVID-19 patients. Bali J Anaesthesiol 2020;4, Suppl S1:13-6
|How to cite this URL:|
Agung Senapathi TG, Ryalino C, Raju A, Sastra Winata I G, Budi Hartawan I N, Agung Utara Hartawan I G. Perioperative management for cesarean section in COVID-19 patients. Bali J Anaesthesiol [serial online] 2020 [cited 2022 Aug 18];4, Suppl S1:13-6. Available from: https://www.bjoaonline.com/text.asp?2020/4/5/13/289545
| Introduction|| |
On March 11, 2020, the World Health Organization declared the novel coronavirus disease 2019 (COVID-19) outbreak as a global pandemic., Dr. Tedros Adhanom Ghebreyesus, the WHO Director-General, stated that the organization is deeply concerned by the alarming spread and severity and called on countries to take action now to contain the virus.
Due to its shared traits, most of our early knowledge of COVID-19 is originated from what we know about severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS)., However, COVID-19 shows a lower mortality rate than MERS (3% vs. 40%) but with a higher reproduction rate (1.4–5.5 vs. <1). Clinical care protocols are currently developing as evidence becomes accessible about the nature of the disease.
Most COVID-19 patients present with fever, dry cough, dyspnea, and with bilateral ground-glass opacities on chest computed tomography scan. Those with severe illness rapidly developed acute respiratory distress syndrome and required intensive care unit admission. A report showed that COVID-19 targets other organs such as the kidney and testicles.
Both pregnant women and neonates are susceptible populations in many infections. Health-care workers are facing a new challenge as only a few data are available on the effect of COVID-19 on pregnancy. We know now that there is no solid evidence on the timing of delivery and the safety of vaginal or cesarean delivery. Both timing and method of delivery should be personalized based on the maternal–fetal status, as well as obstetric indication.,
The cesarean section is the most common major surgery in the world. In this review, we sum up several perioperative recommendations regarding the management of the cesarean section in the COVID-19 pandemic setting.
| Methods|| |
This review includes studies and reports describing perioperative recommendations on the cesarean section during COVID-19 pandemic. There were no restrictions regarding the language of the publication where non-English articles were translated using Google translate to review the content of the article. We entered the keywords of (((((coronavirus [Title/Abstract]) OR (covid-19[Title/Abstract])) OR (ncov-19 [Title/Abstract])) OR (SARS-cov-2 [Title/Abstract]))) AND (Cesarean [Title/Abstract] or Pregnancy [Title/Abstract]) in the PubMed database to find eligible reports. The designed research question was: “What are the current recommendations regarding the perioperative management of Cesarean section in COVID-19 patients?”
Two authors reviewed each article to minimize the discard of relevant reports. Whenever a discrepancy arose, we employed a verdict by the third author. We studied all titles and abstracts from the search results and removed irrelevant studies that did not comply with our research question. We further assessed the reports for quality before including them in this review. We utilized the Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. to merge and manage the collected data.
Data collection and analysis
Two authors were assigned independently to each article to assess the validity and reliability of the studies using the Joanna Briggs Institute's critical appraisal tool. Again, the verdict of the third author was used in a discrepancy. The cutoff point for inclusion was 50% of the total checkmarks in each critical appraisal checklist. The result was synthesized as a narrative report.
| Results and Discussion|| |
We found 16 articles from the PubMed database based on keywords described earlier. After eligibility screening, we found seven eligible articles describing perioperative management of the cesarean section during the COVID-19 pandemic [Table 1]. We analyzed all eligible articles and present the recommendations as per the following topic: delivery mode, preoperative management, intraoperative management, and postoperative management. Due to its importance, we decided to present the neonatal care section as well in this report.
There is no convincing indication that the cesarean section is protective against the transmission of COVID-19. Vaginal delivery is not contraindicated in patients with COVID-19., Usual obstetric indications should be employed as there is no clear benefit of cesarean delivery in women with COVID-19 infection. This means that obstetric and maternofetal indications are still valid to use. Both regional or general anesthesia can be performed in pregnant women with pneumonia due to COVID-19. However, regional anesthesia should be chosen whenever possible to reduce the risk of transmission. In poor maternal status, general endotracheal anesthesia should be used for cesarean delivery.
Patients with COVID-19 should be prevented transmitting the virus right from the hospital entrance. They should be transferred to a designated operating theater equipped with negative-pressure ventilation.,,, There are no effective drugs or vaccines so far targeting COVID-19. Protection devices, hand hygiene, and personal isolation are keys to controlling further infection and viral spread. It is important to prevent health workers from being exposed and provide a safe environment. Limitations to the entrance/exit movements of the operating crews prior to and during the procedure should be applied to minimize exposure and conserve valuable personal protective equipment.
All personnel must use an appropriate biosafety level-3 (BSL-3) protective suits during the surgery, including protective suits, N95 masks, disposable caps, goggles, and rubber gloves., Trainings regarding infection control procedures and a thorough understanding of nosocomial COVID-19 infection must be held regularly in hospitals.
An emergency cesarean section requires a systematic plan and preparedness for minimizing cross-contaminations. Special attention must be given to the fasting time due to the nature of insufficient fasting in emergency patients. Postoperative nausea and vomiting prophylaxis has to be administrated to avoid nausea and vomiting, with regard to its potential to produce aerosol and cause transmission. Regional anesthesia is suggested in COVID-19 patients because it is safer than general anesthesia.,, Both anesthesia and surgery should be performed by experts to ensure reduced exposure time. Regional anesthesia reduces the need for aerosol-producing conditions (i.e., intubation and extubation) and avoids the use of mechanical ventilation.
If general anesthesia is indicated, rapid sequence induction without positive pressure mask ventilation is recommended. During the surgery, a designated personnel must be stationed outside the operating room just in case if any additional equipment or medications are needed. COVID-19 may result in rapid deterioration of lung fun personnel ction. Although both neuraxial and general anesthesia have been safely reported in pregnancy, neuraxial anesthesia will reduce the possibility of exacerbating respiratory complications due to intubation.
The use of high-flow nasal cannula should also be employed with cautions due to its aerosol-producing nature. The use of masks for the patient and the employment of negative pressure ventilation are intended to control the spread of airborne pathogens, which have been proven to avoid cross-contamination during the SARS epidemic.,,
Rapid sequence spinal anesthesia,, is an emergency cesarean section where patients are transferred in a left lateral position with supplemental oxygen, and a single shot subarachnoid block is provided by the most experienced, available anesthetist. The time required is comparable to general anesthesia and neonatal outcomes are better.
General anesthesia should be chosen when a COVID-19 parturient presents with desaturation (≤93%) or when clinically indicated by maternofetal reasons. The general anesthesia should be carried out with rapid sequence induction with a cuffed tube. The presence of systemic complications of COVID-19 such as renal failure and disseminated intravascular coagulation might warrant the use of invasive monitoring (intra-arterial blood pressure and central venous pressure). Extubation after general anesthesia should be performed with similar precautions as with intubation. Patients with COVID-19 tend be more agitated during emergence. This may result in a higher incidence of coughing compared to the intubation.
Transferring COVID-19 patients to the postanesthesia care unit after a cesarean delivery may compromise and contaminate other postoperative patients. Suspected and confirmed patients should be monitored in the operating room where the cesarean section was carried out and subsequently transferred directly to isolation wards upon full recovery.
Reusable medical and surgical instruments should be disinfected and sealed into a double-layer disposable waste bags and sent to the designated disinfection department. All medical staff who were involved in the cesarean section and neonatal care are recommended to have a COVID-19 tests at least once in the following 2 weeks or accordingly based on the local hospital guidelines.
Not all neonates born from mother with COVID-19 require intensive monitoring. If the neonate is stable and does not require neonatal intensive care unit (NICU) admission, the neonate should be placed in the isolation nursery to avoid exposure risk to other babies. The transfer of the neonate from the operating complex to the NICU should be employed in a negative-pressured incubator.
Delayed cord clamping for neonates born to pregnant women infected with COVID-19 is not recommended.,, Limited data on pregnancy with SARS-CoV infection showed a low probability of vertical transmission.,,, Two cases of COVID-19 infection were reported in neonates., Therefore, newborns of mothers with suspected or diagnosed COVID-19 infection should be isolated separately for 14 days after birth and closely monitored for clinical manifestations of infection. Current evidence shows that there is no vertical transmission during pregnancy.,,,,,
As it is unstipulated if COVID-19 virus exists in breast milk, breastfeeding is not recommended. The evidence regarding the safety of breastfeeding is still limited.,, Isolated room for newborns from COVID-19 patients should be selected in advance, and the team managing the newborn should also be trained on the workflow and infection control.
| Conclusion|| |
There is no solid evidence that the cesarean section is protective against the transmission of COVID-19. The use of an appropriate BSL-3 protective suits is imperative in managing patients presenting for the cesarean section with COVID-19 in the operating room. A negative-pressure environment, both in the operating room and incubator, should be prepared for such cases. Regional anesthesia is the recommended technique, but general anesthesia is preferable in specific maternofetal conditions. Current evidence shows there is no vertical transmission during pregnancy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ryalino C. Covid-19: What we know so far. Bali J Anesthesiol 2020;4:1-2.
Ryalino C. How Indonesia copes with coronavirus disease 2019 so far (part one): The country, the government, and the society. Bali J Anesthesiol 2020;4:33-4.
Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.
Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al
. A major outbreak of severe acute respiratory syndrome in Hong Kong. N
Engl J Med 2003;348:1986-94.
Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al
. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: A descriptive study. Lancet Infect Dis 2013;13:752-61.
Chen J. Pathogenicity and transmissibility of 2019-nCoV–A quick overview and comparison with other emerging viruses. Microbes Infect 2020;22:69-71. [doi: 10.1016/j.micinf. 2020.01.004].
Gonzalez-Brown VM, Reno J, Lortz H, Fiorini K, Costantine MM. Operating room guide for confirmed or suspected COVID-19 pregnant patients requiring cesarean delivery. Am J Perinatol 2020. [doi:10.1055/s-0040-1709683].
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.
Fan C, Li K, Ding Y, Lu WL, Wang J. ACE2 Expression in Kidney and Testis May Cause Kidney and Testis Damage After 2019-nCoV Infection. medRxiv; 2020. [doi: 10.1101/2020.02.12.20022418].
Parazzini F, Bortolus R, Mauri PA, Favilli A, Gerli S, Ferrazzi E. Delivery in pregnant women infected with SARS-CoV-2: A fast review. Int J Gynaecol Obstet 2020;150:41-6.
Boerma T, Ronsmans C, Melesse DY, Barros AJ, Barros FC, Juan L, et al
. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392:1341-8.
Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol 2020. [doi: 10.1055/s-0040-1710050].
Zaigham M, Andersson O. Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies. Acta Obstet Gynecol Scand 2020;99:823-9.
Dashraath P, Wong JL, Lim MX, Lim LM, Li S, Biswas A,et al
. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31.
Chen D, Yang H, Cao Y, Cheng W, Duan T, Fan C, et al
. Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection. Int J Gynaecol Obstet 2020;149:130-6.
Lie SA, Wong SW, Wong LT, Wong TGL, Chong SY. Practical considerations for performing regional anesthesia: Lessons learned from the COVID-19 pandemic. Can J Anaesth 2020;67:885-92.
Lee DH, Lee J, Kim E, Woo K, Park HY, An J. Emergency cesarean section on severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) confirmed patient. Korean J Anesthesiol 2020. 2020;[doi: 10.4097/kja.20116].
Chen X, Liu Y, Gong Y, Guo X, Zuo M, Li J, et al
. Perioperative management of patients infected with the novel coronavirus. Anesthesiology 2020;132:1307-16.
Ti LK, Ang LS, Foong TW, Ng BS. What we do when a COVID-19 patient needs an operation: Operating room preparation and guidance. Can J Anaesth 2020;67:756-8.
Birnbach DJ, Bateman BT. Obstetric anesthesia: Leading the way in patient safety. Obstet Gynecol Clin North Am 2019;46:329-37.
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.
Park J, Yoo SY, Ko JH, Lee SM, Chung YJ, Lee JH, et al
. Infection prevention measures for surgical procedures during a middle east respiratory syndrome outbreak in a tertiary care hospital in South Korea. Sci Rep 2020;10:325.
Roberge RJ, Kim JH, Powell JB. N95 respirator use during advanced pregnancy. Am J Infect Control 2014;42:1097-100.
Krom AJ, Cohen Y, Miller JP, Ezri T, Halpern SH, Ginosar Y. Choice of anaesthesia for category-1 caesarean section in women with anticipated difficult tracheal intubation: The use of decision analysis. Anaesthesia 2017;72:156-71.
Kinsella SM, Girgirah K, Scrutton MJ. Rapid sequence spinal anaesthesia for category-1 urgency caesarean section: A case series. Anaesthesia 2010;65:664-9.
Devroe S, Van De Velde M, Rex S. General anesthesia for caesarean section. Curr Opin Anaesthesiol 2015;28:240-6.
Lim G, Facco FL, Nathan N, Waters JH, Wong CA, Eltzschig HK. A review of the impact of obstetric anesthesia on maternal and neonatal outcomes. Anesthesiology 2018;129:192-215.
Ashokka B, Loh MH, Tan CH, Su LL, Young BE, Lye DC,et al
. Care of the pregnant woman with COVID-19 in labor and delivery: Anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. Am J Obstet Gynecol 2020. pii: S0002-9378(20)30430-0.
Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67:568-76.
Chan MT, Chow BK, Lo T, Ko FW, Ng SS, Gin T, et al
. Exhaled air dispersion during bag-mask ventilation and sputum suctioning – Implications for infection control. Sci Rep 2018;8:198.
Wang L, Shi Y, Xiao T, Fu J, Feng X, Mu D, et al
. Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (First edition). Ann Transl Med 2020;8:47.
Madinger NE, Greenspoon JS, Ellrodt AG. Pneumonia during pregnancy: Has modern technology improved maternal and fetal outcome? Am J Obstet Gynecol 1989;161:657-62.
Li Y, Zhao R, Zheng S, Chen X, Wang J, Sheng X, et al
. Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, China. Emerg Infect Dis 2020;26:1335-6.
Robertson CA, Lowther SA, Birch T, Tan C, Sorhage F, Stockman L, et al
. SARS and pregnancy: A case report. Emerg Infect Dis 2004;10:345-8.
Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, et al
. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol 2004;191:292-7.
Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G,et al
. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9:51-60.
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al
. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al
. Perinatal transmission of COVID-19 associated SARS-CoV-2: Should we worry? Clin Infect Dis 2020. pii: ciaa226.
Yang H, Wang C, Poon LC. Novel coronavirus infection and pregnancy. Ultrasound Obstet Gynecol 2020;55:435-7.