Protocolized approach to a COVID-19 parturient undergoing a cesarean section - A case report.

The health care workers working in the operation theater (OT) face many unique challenges to deal with the corona virus disease (COVID-19) patients undergoing surgery. We hereby report the management of a COVID-19 parturient undergoing cesarean section in the dedicated COVID health center. Patient care of this special and vulnerable subset of population with least exposure of COVID-19 to health care worker was the cornerstone of the management. We have summarized some of the important precautionary measures which were taken during cesarean section to minimize exposure and genuine use of resources in this pandemic. To conclude, despite Personal Protective Equipment (PPE), precautionary measures and strategies are of utmost importance and should be opted so as to lower the virus contagion risk. Copyright:

Introduction

As the world is crippling with corona virus disease 2019 (COVID-19) pandemic, surgery of immunocompromised COVID-19 parturient requires a closed loop communication and prior preparation among different medicine disciplines and the other health care workers (HCWs) with anesthesiologist serving as an architect. We hereby, report a protocolized approach to a COVID-19 parturient undergoing a cesarean section so as to maintain the maternal and fetal well-being with prevention of infection of this highly contagious disease among the HCW.

Case Report

A 27-year-old asymptomatic COVID-19 parturient, American Society of Anesthesiologist (ASA) grade 2, second gravida with pregnancy of 40 weeks 3 days was referred to our hospital for delivery after she was tested positive on real time polymerase chain reaction (RT-PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from the COVID care centre. She was admitted to isolation room of our hospital for continuous monitoring of vitals including oxygen saturation (SpO2). Isolation room consisted of a single bed with single door, dedicated bathroom and air conditioning. Her investigations including coagulation, renal and liver profile were within normal limits [Hemoglobin - 10.8 g/dl, total leucocyte count - 8000/cu.mm, platelet count - 182,000/cu.mm, prothrombin time – 12 sec , INR – 1.30, activated partial thromboplastin time – 38 sec, serum urea – 16 mg/dl, serum creatinine – 0.7 mg/dl, serum sodium – 135 mmol/L, serum potassium – 3.8 mmol/L, total bilirubin – 0.3 mg/dl and alkaline phosphatase – 135 IU/L]. Due to failed induction and Intra Uterine Growth Retardation (IUGR), she was posted for category 2 cesarean section in the designated COVID-19 operation theater (OT).[1] As per our hospital policy, designated OT personnel were notified in advance so that they could don level-3 personal protective equipment (PPE)[23] and prepare the OT accordingly. Patient was transported to COVID-19 OT with a surgical triple layer mask covering the face through the designated green corridor. The file was wrapped in plastic cover. Senior anesthesiologist wearing Level- 3 PPE evaluated the patient just outside OR (clear zone) and discussed regarding subarachnoid block (SAB) and back up strategy i.e., general anesthesia in case of SAB failure. Anesthesiologist after evaluation changed his outer gloves with the help of OR circulating nurse, thereby maintaining proper hand hygiene. Meanwhile, anesthesia technician (AT) prepared two trays as per our department standing operating procedure (SOP) of obstetric anesthesia for COVID-19 patient [Figure 1]. The tray that is wheeled inside the OR is called COVID-19 tray while the other is called backup tray that remains outside the OR but within the OT complex. It was the responsibility of OT runner to promptly provide requisite article from backup trolley. The individual air conditioner along with two exhaust fans were operational throughout the surgery. Using a separate entry, the patient was wheeled inside the OR in left lateral position and simultaneously another OR helper sprayed the sodium hypochlorite solution (1%) on the footprints of the trolley.

Figure 1

Summary of important precautionary measures which were taken during surgery in coronavirus disease (COVID-19) operation theater (OT)

Routine perioperative monitoring was instituted (electrocardiogram, noninvasive blood pressure (BP) and SpO2). Her preoperative vitals were Heart rate (HR) – 102/min, BP – 120/60 mm Hg and Spo2- 98% on room air. A peripheral venous access was secured and co-loading with 500 ml of ringer lactate was started. Injection ondansetron 4 mg and injection perinorm 10 mg was given intravenously to prevent intraoperative nausea and vomiting that may result in viral spread. Under all aseptic conditions, SAB was performed at L3-L4 level using a 26 G Quincke's spinal needle after infiltration of local anesthesia (Lignocaine 2%) in the sitting position. While aspirating the cerebrospinal fluid (CSF) using 5 ml syringe prefilled with 2 ml of 0.5% bupivacaine (Heavy), central CSF swirl could not be appreciated due to fogging of face shield and goggles. However, on aspirating more volume, the swirl was noticed and the drug was given. The parturient was then made to lie down supine with pillow kept under shoulders and a wedge to provide left lateral position. A low transverse incision was made after achieving T4 level of SAB, confirmed using modified Bromage scale, pinprick and cold sensation.

Immediately after delivery of female neonate, 3 IU of oxytocin was administered intravenously slowly over 30 sec followed by infusion oxytocin at the rate of 7.5 IU/hr. The neonate was immediately wrapped in the sterilized sheet by the circulating nurse. He handed over to the OT runner outside the OR and neonatologist further managed her in the especially prepared room in the same vicinity. The surgery went uneventful with estimated blood loss of 400 ml. Patient was monitored postoperatively on the same OT table. One gram of intravenous infusion of paracetamol was given for postoperative pain relief. The patient was shifted back to isolation room after the SAB level receded to T12 dermatome. As neonate was febrile, she was shifted to isolated neonatal care unit (NCU).

After this, the OR team (except AT) went for doffing one by one which was followed by shower in the respective changing room. The previous scrubs were dumped in separate bins kept in the changing rooms with 1% sodium hypochlorite solution. Simultaneously, the anesthesia workstation and all the monitoring cables were disinfected with 1% sodium hypochlorite by AT after discarding the disposables and covid tray articles. This was followed by disinfection of OT by OR helper and that OT was ready for next case in 1 hr.

The neonate and breast milk specimen both tested negative on RT-PCR test for SARS-CoV-2. Expressed breast feed was initiated and continued till 2 days in NCU and then the neonate was handed over to the family. The patient stayed in the isolation room. The baby was handed to the mother only for feeding and she used to breast fed the baby following infection prevention control (IPC) measures. The patient remained asymptomatic with normal postoperative investigations and was discharged from the hospital on 9th day.

Discussion

In our hospital, we have a dedicated COVID-19 OT complex which consist of two OR. It has good congruence with the standards laid by the perioperative recommendation issued during this pandemic.[2] Due to non-availability of negative pressure OR, the makeshift arrangements were done instead of central air conditioning.

COVID-19 is highly contagious disease and found notorious to infect HCWs despite of wearing PPE.[3] Along with providing the best clinical care for the COVID-19 pregnant patient, our aim is also to prevent the exposure of SARS- COV-2 to HCWs and the newborn by taking necessary IPC measures.[4] Therefore, we preferred to use Level 3 PPE in OT, mock drills for better coordination and transferred the newborn to the separate room immediately as a part of our effective IPC measures. Level 3 PPE included splash resistant whole body suit, N-95 mask, cap, goggles, face shield, shoe covers and 2 pairs of gloves. However, the patient was wearing surgical triple layer mask during transport as an IPC measure according to our hospital policy. It is also supported by Liew et al. for rational use of N-95 mask in this pandemic.[6] In OR, circulating nurse used to help other OR members to maintain hand hygiene. Different precautionary measures and strategies were opted in covid OT to prevent cross contamination and virus fomites formation at various places.[45] [Figures 1 and 2] Routine use of oxygen for fetal indications should also be avoided if the patient Spo2 >94% so as to prevent aerosolization.

Figure 2

Figure depicting the use of transparent, water resistant plastic sheet to cover monitors and anesthesia workstation to prevent cross contamination

We preferred spinal anesthesia in place of general and epidural anesthesia[478] Similarly, Bauer et al.[4] and Chen et al.[8] also concluded that regional anesthesia should be preferred over general anesthesia to prevent undue exposure of HCWs to aerosol generating procedure. However, involvement of angiotensin converting enzyme-II in SARS-CoV-2 infection can result in hypotensive episodes.[8] In our case, the patient did not require any vasopressor as SBP was maintained within 90% of baseline. Recommendations on breastfeeding, vertical transmission and neonate care are controversial.[457910] Groß et al. reported that neonate and breast milk samples from COVID-19mother for 4 consecutive days were tested positive for ribonucleic acid (RNA) of SARS-CoV-2 RNA.[9] In contrast, Yang et al. reported that the breast milk of COVID-19 parturient did not contain SARS-CoV-2.[10] Bauer et al. also reported that the incidence of the vertical transmission was low.[4]

Since the patient was also asymptomatic in postoperative period, no further testing including chest x ray and Computed Tomography (CT) scan was done.[5]

To conclude, despite the PPE, it is imperative to adopt certain precautionary measures and strategies to lower the virus contagion risk to HCWs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.