The obstetric patient in the Covid pandemic: anaesthesia and perioperative care

Neuraxial Anesthesia during the COVID-19 Pandemic: Report from a Large Academic Medical Center

OBJECTIVE

 Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19.

STUDY DESIGN

 A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache.

RESULTS

 Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures.

CONCLUSION

 The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period.

KEY POINTS

· Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change..

Managing Labour in Women with COVID-19

Since first reported in December 2019 in Wuhan, China, COVID-19 caused by Severe Acute Respiratory Syndrome (SARS) Corona virus2 (SARS CoV-2) quickly spread to become a pandemic that has caused significant morbidity and mortality. The rapidity of the spread of the virus and the high mortality at the outset threatened to overwhelm health systems worldwide, and, indeed, this significantly impacted maternal health, especially since there was minimal experience to draw from. Experience with Covid 19 has grown exponentially as the unique needs of pregnant and labouring women with COVID-19 infection have become more evident. Managing COVID-19 parturients requires a multidisciplinary team consisting of anaesthesiologists, obstetricians, neonatologists, nursing staff, critical care staff, infectious disease and infection control experts. There should be a clear policy on triaging patients depending on the severity of their condition and the stage of labour. Those at high risk of respiratory failure should be managed in a tertiary referral centre with facilities for intensive care and assisted respiration. Staff and patients in delivery suites and operating rooms should be protected by enforcing infection protection principles such as offering dedicated rooms and theatres to SARS CoV-2 positive patients and using personal protective equipment. All hospital staff must be trained in infection control measures which should be updated regularly. Breastfeeding and care of the new-born must be part of the healthcare package offered to COVID-19 parturient mothers.

Can Fetal Heart Lie? Intrapartum CTG Changes in COVID-19 Mothers

Background

COVID-19 infection has raised multiple concerns in pregnant mothers; many questioned the risk of vertical transmission and the implication on the feto-maternal outcome. Cardiotocogrm (CTG) is the principal method to observe intrapartum fetal well-being. This paper aims to verify intrapartum CTG changes seen in seropositive COVID-19 mothers versus healthy controls and looks into their relation to subsequent delivery mode and neonatal outcome.

Methods

A case-control study recruited 90 pregnant women at the labor word of AL Yarmouk Teaching Hospital. All were term pregnancy admitted for delivery. They were grouped into 2: seropositive COVID-19 confirmed by real-time RT-PCR test (30/90) and healthy controls (60/90). We recorded their demographic criteria, laboratory results, CTG changes, delivery mode, and indication.

Results

COVID-19 cases showed significantly higher pulse rate, temperature, and leukocyte counts. Cesarian deliveries (CS) were higher in cases versus healthy controls (70 % vs. 53.3 %) and P = 0.45. Analysis of the CS indications showed that abnormal fetal heart tracing accounts for 33.3 % versus 15.6 % (P-value = 0.015) for cases versus healthy controls. 60 % of COVID-19 cases exhibited abnormal CTG changes versus 19.4 % in healthy controls. These changes were primarily fetal tachycardia and reduced variabilities.

Conclusions

The higher incidence of abnormal CTG in COVID-19 cases, alongside infection signs and symptoms, underlies the exaggerated inflammatory reactions inside the pregnant mother. These inflammatory reactions are the main causes of CTG changes and higher CS rates. Therefore, obstetricians are advised to optimize the maternal condition to rectify reactive CTG changes rather than proceeding into urgent CS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-022-01663-6.