key: cord-0948600-zkoan83w authors: Bhatia, K. title: Obstetric analgesia and anaesthesia in SARS‐CoV‐2‐positive parturients across 10 maternity units in the north‐west of England: a retrospective cohort study date: 2022-02-28 journal: Anaesthesia DOI: 10.1111/anae.15672 sha: 4807e9a794188977d516e7e719825106c6b751d4 doc_id: 948600 cord_uid: zkoan83w Since the start of the COVID‐19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS‐CoV‐2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS‐CoV‐2 across 10 hospitals in the north‐west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS‐CoV‐2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID‐19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64–1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6–96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19–2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04–2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47–3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16–2.12; p = 0.008); and a higher critical care utilisation rate both pre‐ (8% vs. 0%, p = 0.001) and post‐delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83–6.52; p = 0.001). Eight neonates tested positive for SARS‐CoV‐2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78–1.57; p = 0.55). In women with COVID‐19, non‐neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID‐19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission. COVID-19, caused by the SARS-CoV-2 virus, has spread rapidly around the globe since the first reported case in late 2019. Multiple reviews published on COVID-19 in pregnancy have now reported higher rates of emergency caesarean birth, pre-eclampsia, admission to the intensive care unit (ICU), preterm birth and adverse fetal outcomes, particularly in symptomatic parturients [1] [2] [3] [4] [5] [6] [7] [8] . At the start of the COVID-19 pandemic in 2020, recommendations from various national as well as international societies advocated the use of neuraxial labour analgesia and anaesthesia (where feasible) in parturients with SARS-CoV-2 infection [9] [10] [11] . These recommendations were based not only on decreasing the risks associated with general anaesthesia (GA) in parturients with acute respiratory illness, but also to minimise the exposure of healthcare staff to aerosol generating procedures potentially associated with infection. Our previous study in the north-west of England found that the rate of GA for caesarean birth declined markedly in the first wave of the pandemic from 7.7% to 3.7%, though these data included only a limited number of parturients with SARS-CoV-2 infection [12] . Paradoxically however, a recent registry-based study in the USA highlighted a lower rate of neuraxial labour analgesia in parturients with symptomatic COVID-19, and a higher rate of GA for emergency caesarean birth [13] . To date, there have been no largescale multicentre studies of labour analgesia and anaesthetic interventions in parturients who tested positive for SARS-CoV-2 before childbirth in the UK, though some single centres have reported anaesthetic outcomes in a small number of parturients affected by COVID-19 [14, 15] . Using data from 10 maternity units across the northwest of England, we conducted a retrospective cohort study to investigate the anaesthetic and analgesic techniques used, and maternal and neonatal outcomes, among parturients who tested positive for SARS-CoV-2 infection between 1 April 2020 and 31 May 2021. and neonatal outcomes, using a composite of adverse neonatal outcomes of Apgar score < 7 at 5 min, umbilical arterial pH < 7.20, SARS-CoV-2-positive rates, NICU admission rate, tracheal intubation, stillbirth and mortality. An overall comparison of caesarean birth rates in SARS-CoV-2 positive/negative parturients across the maternity units was also performed. Rates and effect sizes were estimated from the data as stratified by hospital to obtain pooled estimates with 95%CI. Multilevel linear, quantal and logistic mixed-effects regression models were used for analyses, stratified by hospital as random coefficients. Fisher's expanded exact p value was used to compare distributions in categories. Analyses were performed using Stata 16.1 (StataCorp Inc., College Station, TX, USA) and p < 0.05 (two-sided) was used to define statistical significance. Over the 1-y study period, 57,800 births were recorded at the 10 participating maternity units including 18,871 (32.65%) caesarean deliveries. A total of 836 parturients tested positive for SARS-CoV-2 antenatally. Of these, 263 (31.4%) were symptomatic while 573 (68.6%) were asymptomatic at the time of testing. Respiratory symptoms were reported in 134 parturients (51%). Cough was the most common respiratory symptom, reported in 125 parturients (47.5%), followed by shortness of breath in 91 (32.3%) and Information Table S2 ). To the best of our knowledge, this is one of the largest observational multicentre studies focusing specifically on analgesic and anaesthetic interventions in parturients who tested positive for SARS-CoV-2 antenatally [13, 20, 21] . We also believe it to be the first that investigates UK practice in parturients infected with SARS-CoV-2. Results are shown in a matrix format with the observed data on the diagonal. Odds ratios, 95%CI and p values were estimated using multilevel mixed-effects logistic regression, stratified by hospital, as appropriate. Figure 1 Effects of COVID-19 on caesarean birth rates. COVID-19-positive parturients (n = 836) are compared with non-exposed controls (n = 56,964 [26, 27] . We found similar rates of nitrous oxide usage and higher rates of parenteral opioid usage in our study, which may be reflective of the high incidence of asymptomatic infection. Further, delivery of nitrous oxide/oxygen by demand valve was not deemed to be an aerosol generating procedure as per the UK guidelines and this technique could be readily administered by midwifery staff without modification to the 'droplet precautions' personal protective equipment [9] . Remifentanil patient-controlled analgesia has been suggested as an alternative labour analgesic to neuraxial techniques in SARS-CoV-2-positive parturients, providing that maternal oxygen saturations are >95% [9] . To our knowledge, our study is one of the first to highlight a remifentanil patient-controlled analgesia utilisation rate of 3.8% for labour analgesia in this group. The regional anaesthesia rate of 94.2% for caesarean birth in our study is not surprising since most guidelines and societies encouraged the use of regional anaesthesia in this cohort [9] [10] [11] . Spinal anaesthesia was the most frequently utilised (85%) anaesthetic technique for caesarean delivery. The reasons for using a spinal anaesthetic over an epidural may include a lower-risk of conversion to a GA (and thus avoidance of an aerosol generating procedure) and a superior quality of sensory and motor block. The overall GA rate for caesarean birth in women who tested positive for SARS-CoV-2 was 5.8% in our study. This is lower than the mean GA rate of 8.75% reported prepandemic in the UK National Obstetric Anaesthesia Database analysis [22] , but higher than our previously reported rate of 3.7% in hospitals in north-west England in the early stages of the pandemic [12] . Our current data, collected over a longer time period and with more participating hospitals and over 10 times as many parturients, indicate that the GA rate increased in this cohort as the pandemic progressed. Factors that may have contributed to this finding may include a higher proportion of symptomatic parturients presenting for caesarean birth, a better understanding of the risks associated with so-called aerosol generating procedures [28, 29] and better availability of personal protective equipment allowing anaesthetists to take appropriate precautions during a GA. The most common indications for administering a GA among symptomatic parturients in our study were clinical urgency (e.g. category-1 caesarean), escalating oxygen requirements and thrombocytopenia. Failed neuraxial anaesthesia was a contributory factor for conversion to GA in asymptomatic parturients. Our findings indicate that parturients with symptomatic COVID-19 in this region are more likely to be of Asian [13, 20, 21] . In these regions, however, the usual uptake of epidural in women during labour (not affected by SARS-CoV-2) is 60-80%, much higher than the UK, so higher rates of labour epidural analgesia are unsurprising [13, 21, 22, 30] . Studies from Europe and the USA have reported that <2% of SARS-CoV-2-positive parturients utilised parenteral opioids for labour analgesia [13, 21] , and no parturients utilised nitrous oxide for pain relief in the study from the USA [13] ; however, nitrous oxide is uncommonly used for labour analgesia in the USA [26, 31] . The view that parenteral opioids may worsen respiratory symptoms in COVID-19 parturients may also have been a contributory factor to low parenteral opioid usage in these studies. The available literature suggests that labour analgesia regimens observed in SARS-CoV-2positive parturients across different countries may simply reflect the usual national and regional pre-pandemic trends. Our study findings seem to support this assumption when viewed in combination with pre-pandemic UK data [22] . The regional anaesthesia rate for caesarean birth in our study was higher than reported in studies from the USA (91.3%) [13] , Europe (75%) and France (72%) [20, 21] , and comparable with a small single-centre study from Turkey (95%) [32] . Accordingly, the GA rate for caesarean section was lower in our sample than in other studies [13, 20, 21] . Notably, parturients with symptomatic COVID-19 (primarily respiratory failure) were quoted to have a higher rate of GA for caesarean section in the studies from the USA [13, 20] . Data from our study emphasise that parturients with Our study has a number of limitations. The lack of SARS-CoV-2-negative controls limits the inferences that can be drawn. The findings in this study come from a limited number of consultant-led maternity units in the north-west of England and these may not necessarily be reflected nationally or in the community setting. The retrospective nature of the study makes it prone to selection and information bias. Routine testing was introduced into maternity units from May 2020, hence some women who were symptomatic but untested may have not been studied. Finally, our study did not examine maternal interventions such as the use of steroids, immunomodulatory therapies or vaccination in symptomatic or asymptomatic parturients, all of which might have influenced maternal outcomes. Overall, we conclude that, among parturients in the north-west of England who tested positive for the SARS-CoV-2 virus, non-neuraxial analgesic regimens were commonly utilised for labour. 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