Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study

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..

Critical care, maternal and neonatal outcomes of pregnant women with COVID-19 admitted to eight intensive care units during the wildtype, alpha and delta waves of the pandemic across the North West of England-a retrospective review

INTRODUCTION

Few studies have described obstetric and critical care outcomes in pregnant women with COVID-19 needing intensive care unit (ICU) admission.

MATERIAL AND METHODS

Obstetric and critical care outcomes of COVID-19 women admitted to eight ICUs from April 1, 2020 to September 15, 2021, in the North West of England were retrospectively analyzed. Women admitted to ICU were assigned to three groups: antepartum women discharged from ICU prior to delivery (antepartum ICU-discharged group), antepartum women who had expedited delivery (antepartum ICU-delivered group) and a postpartum group. Our aims were to describe maternal characteristics and assess how delivery influenced the obstetric and critical care outcomes in these women.

RESULTS

During the study period, 615 women tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of whom 62 (10.1%) needed ICU admission due to symptomatic COVID-19. Pregnancy loss (3.2%) was recorded in two women. Detailed obstetric and critical outcomes from 60 women are reported. Nine antepartum women (15%) admitted to ICU were discharged and continued their pregnancy, 13 antepartum women (21.7%) had expedited delivery by cesarean birth after ICU admission and 38 (63.3%) women were admitted to ICU during the postpartum period. Antepartum ICU-discharged women contracted the SARS-CoV-2 at an earlier median gestational age (23 weeks; p = 0.0003) and needed ICU admission at an earlier median gestational age (28 weeks, p = 0.03) compared with antepartum ICU-delivered (28 and 32 weeks) and postpartum women (35.5 and 36 weeks). Antepartum ICU-discharged women had the lowest rate of mechanical ventilation receipt (11.1%) compared with antepartum ICU-delivered women (52.3%) and postpartum women (44.3%) but the difference was not statistically significant (p = 0.13). No significant differences were observed in the frequency and severity of critical care complications in the antepartum ICU-discharged, antepartum-ICU delivered and postpartum women.

CONCLUSIONS

Of the women admitted to ICU antepartum, 40% were discharged while remaining pregnant and 60% had expedited delivery. Antepartum women who were discharged from ICU without giving birth may receive lower rates of mechanical ventilation than those who delivered in ICU or admitted postpartum; however, further studies are needed to confirm or refute this association.

Safety of spinal anesthesia in pregnant vaccinated with one or two doses of the BNT162b2 vaccine: A retrospective observational cohort study

Purpose

To evaluate the safety of spinal anesthesia in pregnant women who underwent cesarean section during the Covid-19 pandemia and were immunized with the BNT162b2 vaccine.

Methods

Historical cohort study that included three groups: non-vaccinated pregnant with no history of acute or previous Covid-19 [NV (n = 70)], vaccinated with one dose [1D (n = 65)] or two doses of BNT162b2 [2D (n = 45)], who underwent cesarean section with spinal anesthesia. Variables with normal distribution were analyzed with ANOVA. When one or more groups had non-normal distribution, the Kruskal-Wallis test was used. For categorical variables, the chi-square test or Kruskal-Wallis test was performed. When any variable had a frequency of less than five, the two-tailed Fisher's exact test with the Freeman-Halton extension was used. The significance level considered was p < .05.

Results

Apparently there is no interaction between BNT162b2 and the drugs most commonly used in spinal anesthesia for cesarean delivery. Conclusion: Performing spinal anesthesia in patients immunized with BNT162b2 does not seem to result in significant differences in outcomes compared to those not vaccinated. Apparently there is no need to change the standards of performing spinal anesthesia in patients vaccinated with the BNT162b2 vaccine.

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.

Maternal collapse in pregnancy

Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.

The impact of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes

The rapidly evolving COVID-19 pandemic has resulted in an upsurge of scientific productivity to help address the global health crisis. One area of active research is the impact of COVID-19 on pregnancy. Here, we provide an epidemiological overview about what is known about the effects of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes, and identify gaps in knowledge. Pregnant people are at increased risk for severe COVID-19, and maternal SARS-CoV-2 infection increases the risk of negative maternal-fetal outcomes. Despite this elevated risk, there have been high rates of vaccine hesitancy, heightened by the initial lack of safety and efficacy data for COVID-19 vaccination in pregnancy. In response, retrospective cohort studies were performed to examine the impact of COVID-19 vaccination during pregnancy. Here, we report the vaccine's efficacy during pregnancy and its impact on maternal-fetal outcomes, as well as an overview of initial studies on booster shots in pregnancy. We found that pregnant people are at risk for more severe COVID-19 outcomes, maternal SARS-CoV-2 infection is associated with worse birth outcomes, COVID-19 vaccine hesitancy remains prevalent in the pregnant population, and COVID-19 vaccination and boosters promote better maternal-fetal outcomes. The results should help reduce vaccine hesitancy by alleviating concerns about the safety and efficacy of administering the COVID-19 vaccine during pregnancy. Overall, this review provides an introduction to COVID-19 during pregnancy. It is expected to help consolidate current knowledge, accelerate research of COVID-19 during pregnancy and inform clinical, policy, and research decisions regarding COVID-19 vaccination in pregnant people.

COVID-19 in Pregnancy

Coronavirus disease-2019 (COVID-19) infection during pregnancy is associated with severe complications and adverse effects for the mother, the fetus, and the neonate. The frequency of these outcomes varies according to the region, the gestational age, and the presence of comorbidities. Many COVID-19 interventions, including oxygen therapy, high-flow nasal cannula, and invasive mechanical ventilation, are challenging and require understanding physiologic adaptations of pregnancy. Vaccination is safe during pregnancy and lactation and constitutes the most important intervention to reduce severe disease and complications.