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A 29-year-old pregnant woman presents to hospital in Irbid, Jordan, on March 28, 2020, after testing positive for COVID-19. This is her second pregnancy (G2P1) at 37+4 weeks of gestation. She was referred after testing positive for COVID-19. The test was performed following a 4-day history of rhinorrhea without fever, chills, dry cough, or shortness of breath.

She notes that she delivered her first child by cesarean section in 2017 because of fetal distress. Her last menstrual period was on September 7, 2019.

Clinicians order basic blood tests, an electrocardiogram, and a chest x-ray with abdominal shield.

Test results identify elevated erythrocyte sedimentation rate and C-reactive protein, but are otherwise unremarkable. The obstetrics team consults with the patient regarding the course of her pregnancy. She reports having experienced no watery leakage, abdominal pain, or vaginal bleeding, and physical exam shows good fetal movement.

On consultation regarding her preferred mode of delivery, the patient decides on an elective C-section. Nasal swabs for COVID-19 repeated on April 4 and April 7, 2020, are both positive.

The Delivery

On April 10, 2020, physicians administer spinal anesthesia and perform a C-section, and deliver a live baby girl weighing 2.6 kg. They note normal tubes and ovaries without adhesions.

Wearing their operating room scrubs, the anesthesia team heads to the isolation unit. Each member of the team puts on a white gown that covers the entire body apart from the head, hands, and feet; then a head cap, overshoes, and two pairs of gloves (double gloving), and finally an N95 respirator and a face shield.

The anesthesiology team is prepared with all equipment required to perform both spinal and general anesthesia. The team enters the operating room; the patient is lying on the operating table. The team wears surgical masks on top of their N95 respirators, and a blue gown over the white one.

After taking a full history, the team places an intravenous cannula and begins delivering IV fluids. The patient is fully monitored with an electrocardiogram, blood pressure monitor, and pulse oximeter. The team confirms that anticoagulant has not been used, and starts the patient on spinal anesthesia.

They place the patient in a seated position at the side of the table, and begin the procedure with sterile gloves worn under aseptic technique. Painting is completed, and the patient is given local anesthesia (3 mL of 2% lidocaine). The team inserts a 25-gauge introducer of the spinal needle, followed by the spinal needle.

Bloody fluid emerges on the initial attempt, so clinicians remove the introducer along with the spinal needle, to prevent blood from obstructing the needle and causing failure of the spinal anesthesia. When the team inserts a new introducer at the level of L4-L5, cerebrospinal fluid comes out, and 2.5 mL of heavy bupivacaine 0.5% is administered.

The patient is maintained in the sitting position for 30 seconds, and then placed in a supine position with her head raised. Monitoring reveals stable vital signs with no hypotension. Her oxygen saturation is 98%, pulse is around 80, and blood pressure is 125/56.

The obstetric team performs painting and full scrubbing. They test spinal anesthesia and find it fully effective. The obstetrician begins to perform the C-section. The patient's blood pressure remains stable throughout the procedure, and ephedrine is not required.

Following delivery of the baby, the team takes a specimen of the amniotic fluid. The infant is seen by the pediatrician, who performs the PCR COVID-19 swab. Clinicians estimate blood loss to be less than 600 mL; 2.5 L of IV fluid is given during the whole procedure. The operation lasts about 30 minutes.

The incision is closed, and the patient is moved to her bed and transferred to her isolation room, which has been fully equipped as a recovery room. The anesthesia team removes their surgical masks, first pair of gloves, and the blue gown, and exits the operating theatre.

The team then moves near the exit of the isolation unit to change their clothes. They begin by removing the N95 respirator, then the other protective gear in sequence: head cap, overshoes, white gown, and second pair of gloves. They then take a shower bath and leave the isolation unit.

Following the procedure, on April 12, 2020, the patient is given a nasal swab, which tests negative. The swab for the neonate is also negative. Clinicians note that there is no cross-infection from the medical staff in contact with the patient.

Discussion

Clinicians reporting this of a successful C-section performed for a pregnant woman diagnosed with COVID-19 note that available data suggest that neither pregnancy nor delivery increases the chance of acquiring the virus; furthermore, there is no evidence that COVID-19 infection is associated with a worse clinical picture compared with nonpregnant women of the same age group.

Given the absence of a verified protocol for the anesthetic aspect of providing care for pregnant women undergoing C-section, this case highlights the anesthetic aspects of the surgery.

While the risk of catching the virus does not appear to be increased in the setting of pregnancy or delivery, pregnant women who develop pneumonia due to infection with COVID-19 do appear to have an increased risk for obstetric complications; these include preterm labor, premature rupture of membranes, preeclampsia, and need for C-section.

Importantly, there is evidence linking COVID-19-related hyperthermia during the first trimester with an increased risk of congenital anomalies. The authors note that while the virus that causes COVID-19, SARS-CoV-2, has not been detect­ed in umbilical cord blood and there is no evidence suggesting vertical transmission, there are three reported cases of pneumonia developing in neonates despite implementation of strict infection-control measures.

Management of pregnant women with positive COVID-19 tests is determined according to the severity of illness. Women with mild cases require continuous fetal heart rate monitoring, as well as maintaining oxygen saturation levels greater than 95%. Those with more severe illness may be managed by intensive care unit teams, and the case authors advise that betamethasone (i.e., glucocorticoids) should not be used due to its potential to in­crease mortality risk and delay viral clearance (as is seen with influenza virus).

Treatment options for COVID-19 are continuously evolving. While numerous medications are being studied in vitro for treatment of COVID-19, further clinical research is needed.

In the case of pregnancy, the appropriate time for delivery is determined based primarily on the clinical severity of COVID-19 and gestational age. Women with mild illness whose pregnancy is still preterm can wait until their infection status is negative; in those with severe illness, the risks and benefits must be weighed.

In cases of pregnancies that are past 32 weeks, delivery should be considered if it is expected to help improve the mother's respiratory condition. Conversely, in situations of premature gestation or when there is a risk that the respiratory condition will worsen, delivery can be delayed with constant fetal and maternal monitoring.

Infection Control

The CDC recommends that all patients should inform hospitals in advance about their COVID-19 status. In addition, hospitals should screen for COVID-19 signs and symptoms in patients known to have had con­tact with confirmed or suspected cases of COVID-19.

The American College of Obstetricians and Gynecologists (ACOG) that pregnant women admitted with suspected COVID-19 or who develop symptoms suggestive of COVID-19 during admission should be prioritized for testing. ACOG, in conjunction with the Society for Maternal-Fetal Medicine, recently developed an to assist practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19.

Surgical masks should be worn by all health workers caring for pregnant patients, and pregnant women with positive or suspected COVID-19 status should be cared for in negative pres­sure rooms before, during, and after delivery.

Importantly, on its own, having an active COVID-19 infection is not a reason to perform a C-section; rather, each patient's individual obstetric indications should determine the mode of delivery.

Patients who are symptomatic should be tested for COVID-19, and the maternal and fetal status should be evaluated in order to balance the risks and benefits of delaying the delivery (i.e., C-section or induction of labor) until the test results are received.

C-Section Procedure

The case authors advise that clinicians delivering COVID-19 patients should use neuraxial blockade techniques, whether delivery is vaginal or by C-section. This is recommended because these techniques will decrease the cardiopulmonary compromise caused by the stress of labor.

Other advantages of spinal anesthesia over general anesthesia for C-section include lower rates of respiratory depression, and because it is not considered an aerosolizing procedure, it may decrease the chance of spread of the virus to healthcare workers in the operating room.

Patients undergoing C-section under spinal anesthesia should wear a regional mask during the procedure. The case authors also advise avoiding use of sedative drugs due to their respiratory depressive effects, but if sedation is used, it should be administered gradually until the desired effect is reached. If needed, supplemental oxygen should be given at the lowest flow possible.

While the presence of COVID-19 has not been reported to affect cerebrospinal fluid, anesthesiologists per­forming the spinal blockade should avoid contact with the patient's fluid as much as possible. Existing guidelines do not advise use of epidural blood patch and sphenopalatine block, and similarly, postoperative patient-controlled analgesia is best avoided to prevent respiratory depression.

Conclusions

Special precautions should be used when caring for pregnant women with confirmed or suspected COVID-19 who are undergoing C-section, and spinal anesthesia is preferred over general anesthesia.

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