Anesthetic management of emergent cesarean delivery in a parturient with coronavirus disease 2019 with rheumatic heart disease

Sir, The management of a coronavirus disease 2019 (COVID-19) positive mother is challenging due to various reasons. The virus can cause life-threatening severe acute respiratory tract infection in 5% patients, is extremely contagious, and can spread to other mothers and health-care personnel[1]. The clinical outcomes is worse in infected pregnant women than their nonpregnant counterparts. The prognosis might be worse if pregnant patients have cardiac disorders. Central neuraxial blockade should be the preferred technique to decrease the chances of aerosol generation in such situations[2]. Written and informed consent for publication was obtained from the patient. Here, we describe the management of a COVID-19 parturient having rheumatic heart disease, scheduled for an emergency cesarean section. The patient was a 28-year-old primigravida at 39 weeks of gestation having a history of RHD with multivalvular lesions (mild mitral stenosis, severe mitral regurgitation, and mild aortic regurgitation). The patient was COVID positive (RT-PCR) with cough and sore throat. Images in echocardiography showed an ejection fraction of 60%. In view of the fetal distress, an emergent lower segment cesarean section was planned. Investigations were normal (complete blood count and renal and liver function tests were normal). In the operating room standard American Society of Anaesthesiologists monitors were applied; two peripheral venous line (20 G, 18 G) was secured and anti-aspiration prophylaxis was given to the patient. In the sitting position, subarachnoid blockade was administered in the L3-4 interspace. A dose of 2 ml (10 mg) hyperbaric bupivacaine was given. In the intraoperative period, oxygen supplementation was given by nasal prongs (4 l/min). After delivery of the baby, injection oxytocin 20 mg slow intravenous infusion was given. The baby cried soon after birth with an APGAR score of 8. Since the liquor was meconium stained, the baby was shifted to the neonatal ICU. The surgery lasted for 75 min with an estimated blood loss of 500 ml. Total fluid volume of 1000 ml BSS was given. The postoperative recovery of the mother was unremarkable. The baby tested negative for COVID-19 by the RT-PCR test. Gradually the baby developed dyspnea on the second day and was subsequently put on mechanical ventilation. During pregnancy regurgitant valvular disease is well tolerated because of the increased plasma volume and lowered systemic vascular resistance which results in increased cardiac output. In regional anesthesia, there might be less chances of hemodynamic changes, although general anesthesia for the cesarean section can be equally safe. We planned for subarachnoid blockade to decrease the chances of aerosolization, which occurs during preoxygenation, face mask ventilation, endotracheal intubation, oral or tracheal suctioning, and extubation[1]. Bhakta et al.[3] used regional blocks for cesarean delivery in patients having severe peripartum cardiomyopathy. Recent publications have described the safety of central neuraxial blocks for COVID-positive obstetric patients requiring a caesarean section[4]. During the COVID-19 pandemic, we need to modify routine practices to ensure safety of the mother and the baby while judiciously using resources (PPEs, man power, designated areas) and techniques of anesthesia[5]. We suggest that after adequate preloading, low-dose spinal anesthesia is an acceptable option for emergent caesarean delivery in COVID-19 a patient with RHD. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgements Contributions: Dr Poonam Kumari: this author helped in conceptualization, writing-original draft. Dr Amarjeet Kumar: this author helped in conceptualization, writing-original draft. Dr Chandni Sinha: this author helped in supervision, writing-review, and editing. Dr Ajeet Kumar: this author helped in supervision. Dr V.P. Akhil: this author helped in supervision. Dr Rajnish Kumar: this author helped in supervision.