ABSTRACT
The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.
Subject(s)
Anesthesia, Obstetrical , COVID-19 , Cesarean Section , Female , Humans , Practice Guidelines as Topic , Pregnancy , United StatesABSTRACT
PURPOSE OF REVIEW: To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19. RECENT FINDINGS: Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates. SUMMARY: Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.
Subject(s)
COVID-19 , Labor, Obstetric , Pregnancy Complications, Infectious , Anesthesiologists , Cesarean Section , Female , Humans , Pregnancy , SARS-CoV-2ABSTRACT
Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).
Subject(s)
Ambulatory Care , COVID-19/therapy , Cesarean Section , Hospitalization , Labor, Induced , Pregnancy Complications, Infectious/therapy , Adult , Anti-Bacterial Agents/therapeutic use , Asymptomatic Diseases , Azithromycin/therapeutic use , COVID-19/complications , COVID-19/diagnosis , COVID-19/physiopathology , COVID-19 Nucleic Acid Testing , Carrier State/diagnosis , Disease Management , Enzyme Inhibitors/therapeutic use , Female , Fluid Therapy , Gestational Age , Hospitals, Community , Hospitals, University , Humans , Hydroxychloroquine/therapeutic use , Infection Control/methods , Intensive Care Units , Labor, Obstetric , Multi-Institutional Systems , New York City , Obesity, Maternal/complications , Obstetric Labor, Premature , Oxygen Inhalation Therapy , Pregnancy , Pregnancy Complications, Infectious/diagnosis , Pregnancy Complications, Infectious/physiopathology , Retrospective Studies , SARS-CoV-2 , Telemedicine , Young AdultABSTRACT
The COVID-19 pandemic has prompted obstetric anesthesiologists to reconsider the ways in which basic anesthesia care is provided on the Labor and Delivery Unit. Suggested modifications include an added emphasis on avoiding general anesthesia, a strong encouragement to infected individuals to opt for early neuraxial analgesia, and the prevention of emergent cesarean delivery, whenever possible. Through team efforts, adopting these measures can have real effects on reducing the transmission of the viral illness and maintaining patient and caregiver safety in the labor room.
Subject(s)
Analgesia, Obstetrical/methods , Anesthesia, Obstetrical/methods , COVID-19/therapy , Cesarean Section/methods , Pregnancy Complications, Infectious/therapy , Administration, Inhalation , Analgesia, Epidural/methods , Analgesia, Patient-Controlled , Analgesics, Opioid , Anesthesia, Epidural/methods , Anesthesia, Spinal/methods , Anesthetics, Inhalation , Anticoagulants , COVID-19/diagnosis , COVID-19/prevention & control , COVID-19 Testing , Emergencies , Female , Humans , Masks , Nitrous Oxide , Pregnancy , Pregnancy Complications, Infectious/diagnosis , Pregnancy Complications, Infectious/prevention & control , SARS-CoV-2Subject(s)
COVID-19/therapy , Delivery of Health Care, Integrated/organization & administration , Health Services Needs and Demand/organization & administration , Intensive Care Units/organization & administration , Obstetrics and Gynecology Department, Hospital/organization & administration , Patient Care Team/organization & administration , Personnel Staffing and Scheduling/organization & administration , Pregnancy Complications, Infectious/therapy , Female , Humans , Models, Organizational , Needs Assessment/organization & administration , Pregnancy , Risk Management , WorkflowABSTRACT
With increasing numbers of coronavirus disease 2019 (COVID-19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID-19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.