key: cord-0733908-krf2a98u authors: Magoon, Rohan; Choudhary, Nitin; Saxena, Kirti.Nath title: Labour analgesia in COVID-19 positive parturients: points to ponder! date: 2021-02-09 journal: nan DOI: 10.1016/j.tacc.2021.01.004 sha: e075ce693941cfc69243e72c1591f5de0e18de77 doc_id: 733908 cord_uid: krf2a98u nan To the Editor, Amid the range of theoretical-to-practical concerns of varying significances, most of the working obstetric-guidelines propose the safety of neuraxial anaesthesia in COVID-19 positive parturients, particularly at the bet of avoiding higher risk of aerosol generation associated with general anaesthesia in the context of emergency caesarean-sections [1] [2] [3] . Nevertheless, these patients additionally classify as potential candidates for labour analgesia for safe conduct of normal vaginal delivery. While an epidural registers as the gold-standard of labour analgesia, the circumstantial decision-making on the relative risk-benefit profile of labour epidural in a COVID-19 patient can be precarious in view of the peculiarities such as: 1. Thrombocytopenia, initially reported in almost one-third COVID-19 patients and associated with thrice the risk of a severe underlying infection in accordance with a recent meta-analysis [1] [2] [3] . Despite the limited data on thrombocytopenia in pregnancy, a declining platelet-count poses a certain obstetric anaesthesiologist's dilemma. infection [4, 5] can potentially aggravate the pregnancy-associated hypercoagulable state. Anticoagulants being administered in such circumstances, present obvious 3. Epidural-associated pyrexia, manifests with an elevated incidence of two and a half times with labour epidural analgesia. Quite interestingly, Mullington et al red-flag a heightened possibility of the aforementioned with the institution of early labour epidurals as proposed by Bauer and colleagues [1, 6] . Needless to say, an ongoing COVID-19 related systemic inflammatory state predisposes to greater temperature surges in the parturients [4, 6, 7] . While the causal association of such pyrexic responses with the subsequent poor neonatal neurological outcome continues to be ardently debated [8] , the possible links should not be overlooked particularly in face of an exasperated pyrexia resulting from COVID-19 [1, 6] . 4 . Timing of epidural catheter placement, if significantly prefixed increases the odds of intrapartum pyrexia, furthermore. This counters the commonly cited advantage of respiratory-exacerbation avoidance owing to an early labour epidural [6] . J o u r n a l P r e -p r o o f 5. Technical issues, emanate while wearing personal protective equipment, presenting challenges to the best in business. To add to it, there is always a theoretical possibility of viremic-blood seeding the epidural/subarachnoid space, to result in meningitis/encephalitis [1] [2] [3] . It is noteworthy that the constellation of the abovementioned concerns in the most highrisk patients can even preclude a safe neuraxial analgesic approach. While the alternatives such as an inhalational Entonox-based labour analgesia are limited by aerosol generation risk, the other pharmacological modalities like opioids and non-steroidal antiinflammatory drugs (NSAIDs) are not without their risks of respiratory depression and accentuation of the COVID-19 disease process, respectively [1] [2] [3] . Moreover, the compounding factors including metabolic derangements and COVID-19 related endorgan dysfunction make the matter even worse [4, 5, 7, 9] . Such circumstances constitute enterprises for the consideration of the nonpharmacological labour analgesic modalities. The non-pharmacological analgesic techniques may be used include: psychotherapy, acupuncture, water bath, transcutaneous electrical nerve stimulation, continuous support, massage and intradermal sterile water block (ISBW) combined with pudendal nerve block (for second stage of labour) [10, 11] . Therefore, the attending obstetric anaesthesiologist needs to meticulously gauge the context to reach an appropriate case-based decision on the suitability of the performance and timing of labour epidural analgesia in COVID-19 positive parturients [6, 10, 11] . In the situations ill-suited to labour epidural, resorting to the safer non-pharmacological options can be instrumental in ensuring an uninterrupted provision of labour analgesic services even to the highest risk COVID-19 parturients. This is aligned with the highest priority goal to err on the side of caution while battling the intriguing viral enemy. On a positive note, the adaptations we endorse during these desperate times may eventually turn out much to the welfare of the obstetric population well beyond the pandemic. Obstetric Anesthesia During the COVID-19 Pandemic Considerations and recommendations for obstetric anesthesia care during COVID-19 pandemic -Saudi Anesthesia Society guidelines Management of pregnant laboring women during COVID-19 pandemic COVID-19 and congenital heart disease: Cardiopulmonary interactions for the worse! Left-ventricular diastolic dysfunction in COVID-19: Opening the Pandora's Box! [ahead of print The Timing of Labor Epidurals in COVID-19 Parturients: A Balance of Risk and Benefit Pulmonary vasculature in COVID-19: mechanism to monitoring! [ahead of print Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring Impending cognitive and functional decline in COVID-19 survivors. Comment on Labour analgesia in cardiac parturients: A personalised approach Labor analgesia with intradermal sterile water block in a patient with dilated cardiomyopathy This is to apprise you that the manuscript entitled "Labour analgesia in COVID-19 positive parturients: points to ponder!" submitted in your respective journal does not have any conflict of interest.We request you to kindly process the manuscript submitted in your esteemed journal.