key: cord-0902043-hxedkja1
authors: Jakimiuk, Artur J.; Januszewski, Marcin; Santor-Zaczynska, Malgorzata; Jakimiuk, Alicja A.; Oleksik, Tomasz; Pokulniewicz, Marek; Wierzba, Waldemar
title: Absence of SARS-CoV-2 RNA in peritoneal fluid during surgery in COVID-19 positive pregnant women
date: 2021-06-15
journal: J Minim Invasive Gynecol
DOI: 10.1016/j.jmig.2021.06.006
sha: 9ae8d281edf61e70d4d43d3e35cf31ad571544cf
doc_id: 902043
cord_uid: hxedkja1

Study Objective: COVID-19 infection poses significant risks during surgical interventions. We investigated the intraperitoneal presence of SARS-CoV-2 in COVID-19 positive patients. Design: A prospective group study. Setting: Department of Obstetrics and Gynecology designated for COVID-19 patients, Central Clinical Hospital of the Ministry of Interior, Warsaw Patients: Overall, 65 pregnant women with COVID-19 infection underwent caesarian section. The diagnosis was confirmed either by positive antigen test or by positive RT-PCR assay performed within no more than 13 days prior to the operation. Interventions: On the day of the operation, a nasopharyngeal swab was taken, and peritoneal fluid was collected at the beginning of the operation. Both the nasopharyngeal swab and peritoneal fluid samples were tested for SARS-CoV-2. Measurements and Main Results: A total of 65 pregnant women with COVID-19 infection were enrolled in the study. The SARS-CoV-2 RNA test by nasopharyngeal swab produced positive results in 34 patients. In this group as well as in 31 non-confirmed patients all peritoneal fluid samples tested negative for SARS-CoV-2 RNA. Conclusion: These results suggest a low risk of COVID-19 transmission from the peritoneal cavity at the time of laparoscopy or laparotomy

The World Health Organisation declared a COVID-19 pandemic on 11 March 2020 and the unprepared health care systems were left struggling to mount an adequate response. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is primarily transmitted through respiratory droplets (droplet particles being > 5-10 μm in diameter) (1) . It can also be transmitted through surfaces contaminated with the secretions of an infected person (i.e., via direct contact). Airborne transmission (< 5 μm in diameter droplet nuclei) may take place in specific circumstances, where aerosol particles are produced (1) . The increasing number of positive cases reported daily challenged health care systems around the world and significantly impacted all areas of medicine. Infection with SARS-CoV-2 mainly affects the lower respiratory tract, causing mild to moderate respiratory symptoms in 85% of cases. Cardiovascular, renal, neurological, dermatological, and gastrointestinal manifestations have also been reported (2, 3, 4, 5) . Increasing age, male sex, obesity, and other comorbidities such as hypertension, diabetes, and cardiovascular diseases, all increase the frequency of disease progression towards greater clinical severity and ICU admission (2, 3, 4) .

Pathophysiological processes responsible for developing hypertension, diabetes, or cardiovascular diseases and physiologic immune adaptations to pregnancy (25) escalate during the 2 nd trimester and the beginning of the 3 rd trimester and may predispose pregnant women to a severe course of illness (6, 7) . Pregnancy enhances susceptibility to respiratory pathogens due to physiologic changes (higher diaphragm position, increased oxygen demand, and progesterone-related edema of the respiratory tract) (8) and predispose women towards complications from respiratory infections leading to maternal and fetal mortality and morbidity (9, 10) . In addition, an immunologic modulation occurs, from a pro-inflammatory state (favourable to the implantation and placentation process) during the first trimester, to an antiinflammatory condition (favourable for fetal growth) during the second trimester, and finally reaching a second pro-inflammatory state during the third trimester (in preparation for delivery) (11) . Previous studies have shown that the clinical characteristics of maternal COVID-19 infection are like those in nonpregnant adults. (12, 13, 14) . However, new data emerged in meta-analyses by Allotey et al., [15] Khali et al., [16] and Mazur-Bialy et al., (17) showing that pregnant women may have an increased risk of developing severe symptoms. Therefore, we can extrapolate that viral loads of SARS-CoV-2 in different body compartments in the population of pregnant women do not negatively deviate from those in non-pregnant women.

Laparoscopic surgery is a method which requires creating a pneumoperitoneum by inflating the abdominal compartment with carbon dioxide. In this process, as well as during open surgeries, such as cesarean section, using energy-based tools for cutting tissue or sealing blood vessels, there exists the potential for the aerosolization of viral particles and contamination of the operating theatre. (18) It has not yet been established whether mechanical insufflation and exsufflation during laparoscopy are aerosol-generating procedures (AGPs) (19) . Nevertheless, an absence of evidence is not the evidence of absence, and so long as there have been no thorough investigations made, the possibility of transmission cannot be excluded (20) . Due to the pandemic, all scheduled surgeries were initially postponed and special approaches for emergency and minimally invasive surgery such as the use of built-in-filter trocars or surgical smoke evacuators were introduced to reduce virus transmission to health personnel (21) . SARS CoV-2 is not only present in bronchoalveolar lavage fluid, sputum, and nasal and pharyngeal swabs, but also in feces, blood, and urine (22) . However, it is not yet known whether the SARS-COV-2 virus is present in the peritoneal cavity, and its excretory mechanism remains unclear. In this study we aimed to systematically assess the 

The study was conducted between May 15, 2020 and November 23, 2020 at the Department of Obstetrics 

Following Polish Association of Epidemiologists and Infectiologists (24) guidelines, patients were divided into 4 groups according to the severity of symptoms. Using the test results, we classified 4 groups of severity as mild (asymptomatic, or the presence of cough, fever, dyspnoea, fatigue, headache muscle pains, nausea, vomiting, diarrhoea), moderate (clinical and radiological features of lung occupation), severe (respiratory failure), and critical (ARDS, hypotensive shock, multiorgan failure, loss of consciousness).

Estimates of the incidence of COVID positivity during the study period were derived from official Polish government online data. Data were analysed using MS Excel. Table 1 . The study was conducted at a time when the community incidence rate of COVID infection in Poland was estimated to be 0.006% (25).

To our knowledge, this is the first prospective study to ascertain whether SARS-CoV-2 is present in the peritoneal cavities of a group of COVID-19 patients. Previously published studies reported on a limited number of cases and their methodologies differ significantly. Several series of cases report findings like our study, suggesting that the peritoneal cavity of COVID-19 patients is less likely to harbour the SARS CoV-2 virus. Seeliger B et al., (26) and Safari S. et al., (27) did not identify intraperitoneal viral RNA in patients who underwent surgical procedures in 5 and 4 cases, respectively. Similar observations were made in small groups of patients treated with acute peritoneal dialyses (28, 29, 30) and in several case studies (31, 32, 33) . We encountered 3 case reports indicating the presence of SARS-CoV-2 virus in ascites due to decompensated cirrhosis (34, 35) and bowel obstruction (36) may be suspected that surgical smoke harbour airborne contaminants such as blood fragments, cellular material, bacteria, or viruses (39) which rise a concern of SARS-CoV-2 transmission. Our study demonstrates that SARS-CoV-2 is below detectable levels in the peritoneal cavity in COVID-19 pregnant patients. As we failed to identify SARS-CoV-2 in the peritoneal cavity, it may indicate that both laparoscopic and open surgery in pregnant patients with COVID-19 is safer than previously assumed (40) . Therefore, as it has been suggested by Mintz Y. et al., (41) laparoscopic surgery should be considered as a first-choice method. However, the role of energy-based equipment such as electrosurgical coagulators or ultrasonic dissectors during laparoscopy or laparotomy in the spread of viral particles of blood origin is still a matter of conjecture, and more research is needed to confirm whether such methods are safe.

The main weaknesses of our investigation include the homogenic group of patients and the single-centre nature of our investigation.

The main strengths of our study are its prospective design and substantial sample size. Severe 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Critical 0 (0%) 0 (0%) 0 (0%) 0 (0%) Indication for caesarean section, No.

(%) Emergency 23 (67.6%) 29 (93.5%) 0 (0%) 52 (80%) Planned 11(32.4%) 2 (6.5%) 0 (0%) 13 (20%)

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