key: cord-314404-tkhupnko
authors: Ashokka, Balakrishnan; Loh, May-Han; Tan, Cher Heng; SU, Lin Lin; Young, Barnaby Edward; Lye, David Chien; Biswas, Arijit; E Illanes, Sebastian; Choolani, Mahesh
title: 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
date: 2020-04-10
journal: Am J Obstet Gynecol
DOI: 10.1016/j.ajog.2020.04.005
sha: 
doc_id: 314404
cord_uid: tkhupnko

COVID-19 in pregnancy can cause severe maternal morbidity in up to 9% of affected gravidae. Chest imaging is helpful in pregnant women who have a high pretest probability of COVID-19, but are RT-PCR negative. Vertical transmission is unlikely, but active measures are needed to prevent neonatal infection. We present an algorithm of care for the acutely ill parturient. We present a protocol for intrapartum care of the pregnant woman in labor.

Confirmation of the disease is done using nucleic acid amplification tests (NAAT), such as real 153 time reverse transcriptase polymerized chain reaction (RT-PCR). 13 The average RT-PCR testing 154 needs up to 2 hours yet takes between six to ten hours for completion or even longer when batch In an epidemic setting, where there is very high pre-test probability of COVID-19 infection, a 172 positive result on chest CT may precede RT-PCR and may carry higher. 23 In a case series of 173 fifteen COVID-19 pregnant patients who were exposed to between 2.3-5.8 mGy of ionizing 174 radiation, all were found to have CT findings of mild disease, which did not worsen with in SARS, 26 but not from MERS. 27 When imaged by CT, the distribution seen in similar to that noted in other viral and coronaviral 20 pneumonias, such as influenza, parainfluenza, respiratory syncytial virus, and adenovirus. 28, 29 Even the multifocal GGO, 192 described in more than 80% of COVID-19 pneumonias 30 are common features of atypical (e.g. 193 Mycoplasma pneumoniae) and opportunistic (e.g. Pneumocystis jirovecii) pneumonias. 31, 32 As 194 with other viral pneumonias, lymphadenopathy and pleural effusions are uncommon associated 195 findings. 30 In the latter stages of COVID-19, confluent consolidation and interstitial thickening The spread of the infection has been reported from patients deemed asymptomatic, thereby 208 making the early detection and containment of the disease difficult. 36 There is a possibility of 209 dissemination of the virus when a patient is forcefully exhaling when in pain during active 210 labor. 25 Hence it is prudent to consider early epidural analgesia for optimal pain control, and 211 unmedicated natural labors should be cautioned against. In addition, all healthcare staff attending 212 to women in active labor need to don full personal protective equipment (PPE).

In a simulated aerosol generating experiment generated by 3-jet Collison nebulizer and fed into a 216 Goldberg drum, SARS-CoV-2 could survive on plastic and stainless-steel surfaces for 72 hours, 217 cardboard 24 hours and copper 4 hours. The median half-life of the virus in this simulated 218 aerosol was 2.7 hours with 95% credible interval 1. 65-7.24 hours. 34 In contrast, in a real-world 219 experiment in Singapore, three patients' rooms were sampled at multiple sites including air 220 samples, which revealed that bleach disinfection was highly effective in two rooms and fomite 221 contamination was common in the third room. Notably, air samples, protective equipment, 222 anteroom and corridor outside of anteroom were negative. 35 Additionally, a case report of 223 emergency intubation in an unsuspected COVID-19 patient subsequently found to be positive 224 showed that no healthcare workers on surgical or N95 masks were infected. 36 Safe and optimal care of the parturient in the peripartum period requires a multidisciplinary team 243 approach. 37 The healthcare professionals that provide this coordinated care include obstetricians, 244 neonatologists, anesthesiologists, midwives and support services at the delivery suite. Here, we 245 highlight the acute care perspectives of the parturient, summarize existing evidence, and propose 246 an algorithmic approach for the management of the acutely ill parturient. When a COVID-19 parturient with desaturation (oxygen saturation decreases to ≤93%) presents 256 for emergency cesarean delivery, general anesthesia needs to be administered. This is done with When the parturient's oxygen saturation is adequate (94% and above), 6, 10 regional anesthesia If there is absence of maternal and / or fetal compromise, and emergency cesarean delivery is not 295 indicated, further plans for management of the patient are then made ( Figure 3 ). When 296 parturients are acutely ill, it may be challenging to differentiate the etiologies based on the presence of tachypnea and tachycardia. The percentage saturation of hemoglobin with oxygen 298 (SpO 2 ) is non-invasive continuous monitoring that provides real time information on peripheral 299 oxygen saturation. It also provides indirect information on adequacy of pulmonary gas exchange, 300 cardiac function and intravascular volume status. There is correlation between oxygenation 301 measured by SpO 2 and invasive arterial blood gas. An arterial partial pressure of oxygen (PaO 2 ) 302 of less than 60mmHg corresponds to SpO 2 of less than 90%. 44 Delivery units need to be 303 equipped with, and use continuous SpO 2 monitoring. Disposable low cost SpO 2 finger probes are 304 commercially available and need to be considered when multi-parameter monitoring is not 305 available. Knowing the (P-F ratio) which is the ratio between PaO 2 and fraction of inspired 306 oxygen (FiO 2 ) is useful in predicting the degree of lung compromise. 6

When SpO 2 has decreased to less than 94%, rapid clinical decisions must be made in the context 308 of COVID-19. Patients with low SpO 2, and are hypotensive must be prioritized and 309 systematically managed at the earliest, considering cardiac, non-cardiac and septic causes. The process of segregation is simple when the newborn is healthy. However, when there is 403 perinatal asphyxia or need for ventilatory support, the process is more complicated. The number of cases of COVID-19 continue to rise exponentially in many parts of the world.

Pregnant women at all gestational ages will count among this increase, and greatest at risk would 419 be the gravida in labor, and the acutely ill parturient. Whether the woman in labor needs an 420 emergency cesarean delivery or the plan is to aim for achieving a vaginal birth, she and the team 421 supporting her face many unique challenges. We present here the best evidence available to 422 address many of these challenges, from making the diagnosis in symptomatic cases, to the debate 423 between nucleic acid testing and chest imaging, to the management of the unwell patient in 424 labor. There is reasonably good evidence that vertical transmission is unlikely, and efforts must 425 be taken to prevent infection of the neonate. Given the limited knowledge about this novel coronavirus, which has both similarities and differences to SARS and MERS, the management 427 strategies provided here are a general guide based upon current available evidence, and may 428 change as we continue to learn more about the effect of COVID-19 in the pregnant woman. Corresponding (1B) chest radiograph does not reveal significant abnormality other than for a small focus of consolidation in the medial right lower zone (arrow), which would have been easily missed due to projection adjacent to the right cardiophrenic angle and overlapping rib shadow.

CT pulmonary angiogram of a different patient with severe pneumonia in the (1C) axial and (1D) coronal planes showing extensive multilobar GGO (arrows) with areas of confluent consolidation (arrowheads) mostly distributed in the posterior and basal regions of the lower lobes. No pulmonary embolism was detected. These findings are not specific to COVID-19 and may be seen in other viral and atypical pneumonias. Legend: *A suspect case of COVID-19 is one who present with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had travelled to any listed countries requiring heightened vigilance, or had prolonged close contact with a confirmed COVID-19 patient. ¶ Negative RT-PCR tested twice on consecutive days, and at least 24 hours apart. ** Close monitoring includes social and physical distancing, monitoring of body temperature, and symptoms of acute respiratory illness. RT-PCR: reverse transcriptase polymerized chain reaction. Chest imaging includes chest X-ray, CT chest, and ultrasound lungs Corresponding (1B) chest radiograph does not reveal significant abnormality other than for a small focus of consolidation in the medial right lower zone (arrow), which would have been easily missed due to projection adjacent to the right cardiophrenic angle and overlapping rib shadow. If administration of steroids is considered, the decision will be made following joint discussion by Obstetrics, Neonatology and Infectious Disease teams.

The aim is for normal vaginal delivery Discuss with patient regarding the delivery process and postpartum care

To inform patient that baby will be separated immediately after delivery and will be admitted to PICU. COVID-19 testing will be carried out on the baby.

If the test result is positive for baby, baby will stay with mother. If the test result is negative for baby, baby will remain isolated.

Consent forms for normal vaginal delivery, assisted vaginal delivery and caesarean delivery to be signed.

Strongly recommend early epidural analgesia so as to minimise the need for general anaesthesia in the event of emergency caesarean delivery.

Informed consent for labour epidural analgesia to be pre-obtained; consent to be reverified at time of procedure.

Strictly NO use of Entonox due to the risk of aerosolisation.

Once labour starts, patient is to be transferred from Isolation Ward to the Isolation Room in the Delivery Suite. If the Isolation Room in Delivery Suite is not available, the patient will be transferred from Isolation Ward to Medical Intensive Care Unit for delivery.

Overall Designated nurse assigned to the patient. Nurse in Charge / Sister is the second assistant.

Medical staff to manage the case will be consultants and / or registrars and not junior residents.

Practices of delay cord clamping and skin to skin bonding between mother and newborn is not recommended.

Should an emergency caesarean delivery is needed, designated operating room should be used. There are 2 designated operating rooms (Operating room nurse in charge will inform the operating room upon being activated) Please refer to the routes from Delivery Suite or Medical ICU to Operating Theatre. Umbilical cordintravascular surface (1 swab, from inside UA or UV) -PCR Placentafull thickness biopsy (include fetal and maternal surfacesto put stitch in maternal surface) -for histology Umbilical cord at the insertion sitefull thickness segmentfor histology Disposal of placenta ----placenta is to be placed in triple BIOHAZARD bags before disposal. If Caesarean delivery is performed, placenta is to be disposed in the Operating Theatre.

After delivery:

Baby will be immediately transferred to Paediatric Intensive Care Unit.

Patient will be transferred back to Isolation ward.

Transfer will be as for hospital protocol.

Upon completion of transfer, medical and nursing staff to shower and change out to new set of scrub uniform for the next case.

Book cleaning team to disinfect the room as per infectious control protocol. (turnaround time: up to 3 hours for the next availability of bed.)

Angiotensin-converting enzyme 2 -the functional receptor of SARS-CoV-2 AFE: Amniotic fluid embolism ARDS: Acute respiratory distress syndrome CO: cardiac output measured by non-invasive pulse contour methodology from intra-arterial waveform analysis COVID-19: Coronavirus Disease

Extracorporeal membrane oxygenation EC50: Effective concentration 50 -concentration of a drug that gives half maximal response Emergency cesarean delivery: Operative delivery that is to be conducted within 30 minutes after the decision is made for the surgery FiO 2 : Fraction of inspired oxygen Functional residual capacity: Volume of air in the lungs at the end of expiration; it is the sum of residual volume and end expiratory

Middle East respiratory syndrome coronavirus -the virus that causes MERS MODS: Multi-organ dysfunction syndrome NAAT: nucleic acid amplification test Negative pressure room: Room that maintains a lower air pressure inside the treatment area than that of the surrounding environment NIV: Non-invasive ventilation N95 mask

Ratio between arterial pressure of oxygen (PaO 2 ) and fraction of inspired oxygen (FiO 2 ) PPE: Personal protective equipment RA: Regional anesthesia RNA: Ribonucleic acid RSI: Rapid sequence induction RT-PCR: Reverse transcription polymerase chain reaction RV: Right ventricle SARS: Severe Acute Respiratory Syndrome SARS-CoV: Severe acute respiratory syndrome coronavirus -virus

SpO 2 : Percentage saturation of hemoglobin with oxygen Suspect case of COVID-19: A patient who presents with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had travelled to any listed countries requiring heightened vigilance, or had prolonged close contact with a confirmed COVID-19 patient SVR: Systemic vascular resistance TNFα: Tumor necrosis factor alpha TTE: Transthoracic echocardiography WHO