key: cord-0939771-da3ql2u8 authors: Sun, Mingyang; Xu, Guoting; Yang, Yong; Tao, Yuan; Pian-Smith, May; Madhavan, Vandana; Xie, Zhongcong; Zhang, Jiaqiang title: Evidence of mother-newborn infection with COVID-19 date: 2020-04-28 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.04.066 sha: bc701aae2df89fac86f2f4aaba2349bb7c6f7eaf doc_id: 939771 cord_uid: da3ql2u8 nan tracheal tube tip were collected from the mothers and newborns with synthetic fibre swabs. The decision to perform Cesarean delivery was based on either a confirmed or suspected maternal diagnosis of COVID-19, and the obstetricians' desire to shorten the course of delivery. All three newborns were tested for COVID-19 in accordance with governmental policies requiring testing of newborns of mothers with confirmed or suspected COVID-19. In all three cases, the obstetricians, anesthesiologists, neonatologists and nurses wore full personal protection equipment (PPE) including an N-95 mask, eye goggles, face shield, and a top-to-bottom tight-fitting gown, entering the operating rooms ~5 five min before the patients. Notably, only obstetricians touched both the mothers and newborns during the time of Cesarean delivery, handing the newborns off to the neonatologists after delivery. The resuscitation tables for newborns were ~ 3 m away from the head of the mothers. The operating rooms in cases 2 and 3 were equipped with negative pressure to minimise virus spread. The environmental surfaces of operating and inpatient rooms were routinely decontaminated with chlorine 2000 mg L -1 disinfectant for 30 min after patients had exited operating rooms or were discharged from inpatient rooms. Medical staff followed PPE doffing procedures according to standard guidelines, which included spraying the surfaces of PPE with 75% ethanol before removal and washing hands after doffing. The first patient was a 28-yr-old nulliparous woman at 37 weeks gestation who had lived in Wuhan, and arrived in Xinyang, Henan Province the third week in January 2020. The next day she developed a fever, on day 4 she developed a productive cough, and on day 8 the mother tested positive for SARS-CoV-2 by RT-PCR assay. Additional laboratory evaluation showed marked abnormalities (Supplemental Table 1 ). The mother's course was notable for fever, tachypnoea and hypoxaemia. She had a Cesarean delivery under general anaesthesia with rapid sequence induction and easy intubation using videoassisted laryngoscopy on day 9, and delivered a male with Apgar scores of 9 and 9 at 1 and 5 min, respectively. The mother did not have regional anaesthesia due to abnormal liver function and coagulopathy. The anaesthesia circuit had an electrostatic filter to avoid contaminating the machine and gas scavenging system. The operating room was not a negative-pressure Airborne Infection Isolation Room (AIIR). The mother wore a face mask except during intubation and mechanical ventilation. The newborn was taken from the operating room before extubation of the mother. For the remainder of his hospitalization, he was in the parent's inpatient room, but was placed in a temperature-controlled isolator 3 m away from the mother's head. He was cared for by a nurse who was not in physical contact with the mother or other visitors after the delivery. Visitors wore masks in the mother's room but were not allowed to be in contact with the newborn. The mother wore a face mask at all times after the surgery, and the medical staff wore PPE in the inpatient room as they did in the operating room. The newborn was discharged home 11 h after birth and tested positive for SARS-CoV2 on postnatal day (PND) 6. Three days later, his caregiver (grandmother) also tested positive for SARS-CoV2. The mother recovered well and was discharged home on day 26; 19 days after delivery no caregivers had developed COVID-19. The hospital has since implemented a rooming policy to immediately isolate newborns from mothers with COVID-19. The second patient was a 30-yr-old pregnant (G3P2) woman at 30.5 weeks gestation, who also lived in Wuhan and arrived in Henan Province the third week in January 2020. She had a cough, fever, dyspnoea, abnormal clinical laboratory results (Supplemental Table 1 ) and tested positive for SARS-CoV-2 near the end of January, 2020. On day 4 of illness, the decision was made for urgent Cesarean delivery under spinal anaesthesia; the newborn boy had Apgar scores of 5 and 8 at 1 and 5 min, respectively. The mother wore a mask during the procedure and had mild coughing. The newborn was placed in an isolation room in the neonatal intensive care unit (ICU) shortly after delivery; he was intubated for 4 days due to prematurity and received surfactant treatment. The newborn tested negative for SARS-CoV2 on PND 3. The mother's clinical condition deteriorated and she passed away on day 35. The third patient was a 29-yr-old pregnant woman at 36 weeks gestation who had a fever and cough, relatively normal clinical laboratory results (Supplemental Table 1 Limitations in this case series include lack of testing of amniotic fluid and cord blood specimens in newborns, which may have detected the presence of SARS-CoV-2. We recommend consideration of routine testing from these sites when mothers have COVID-19 or are under investigation. Although the route of transmission in these newborns is not clear, it is important to maintain practices to minimise droplet and contact spread; we recommend isolating newborns from SARS-CoV-2 positive mothers immediately after birth and the use of PPE by visitors in the hospital and at home as long as community-based spread is considered a threat in a given geographical area. While there is a common belief that general anaesthesia, associated with more aerosol generation during intubation, may increase the risk of transmission of SARS-CoV-2, 8 our case series included a case of potential transmission under regional anaesthesia. The limited case number in this series precludes conclusions about the association between risk of newborn SARS-CoV-2 transmission and type of anesthesia such that it is not yet known whether general or neuraxial anaesthesia 9 for Cesarean delivery can lead to different outcomes. Authors' contributions MS, GX, YY and YT: collected clinical data; MS, ZX and JZ wrote the manuscript; MPS and VM critically revised the manuscript, with the final version approved by all authors. The authors claim no conflict of interest. Partially supported by Joint Research Project of Medical Science and Technology of Henan Province (2018020414) and Nature Science Foundation of China (NSFC: 81901110) to MS, and NSFC -Henan Joint Fund (U1704165) to JZ. A Novel Coronavirus from Patients with Pneumonia in China Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study A case report of neonatal COVID-19 infection in China Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes Novel Coronavirus Infection in Newborn Babies Under 28 Days in China The authors would like to thank the patients and medical staff who provided the information for this report.