Anaesthetic Management of Caesarean Section in Asymptomatic COVID-19 Positive Parturients with Abnormal Laboratory Findings: A Series of 15 Cases

1. Associate Professor, Department of Anaesthesia, Government Medical College, Palakkad, Kerala, India. 2. Assistant Professor, Department of Anaesthesia, Government Medical College, Palakkad, Kerala, India. 3. Assistant Professor, Department of Anaesthesia, Government Medical College, Palakkad, Kerala, India. 4. Assistant Professor, Department of Anaesthesia, Government Medical College, Palakkad, Kerala, India.

Abstract

During the Coronavirus Disease 2019 (COVID-19) pandemic, Caesarean Sections (CS) were prioritised over other elective surgeries, leading to the identification and management of asymptomatic COVID-19 positive parturients. The present case series aimed to explore the possibility of laboratory abnormalities and adverse events that can occur in asymptomatic COVID-19 positive cases in the post-pandemic era when routine screening is no longer in place. Out of 141 asymptomatic COVID-19 positive CS patients, 15 cases were selected based on specific criteria. Demographic characteristics and clinical indicators were analysed, including age, gravidity, indications for CS, laboratory values {such as D-dimer, C Reactive Protein (CRP), and platelet count}, blood transfusion requirements, and obstetric outcomes. Indications for CS were predominantly previous CS and failure to progress. Laboratory abnormalities included elevated D-dimer, CRP, leukocyte count, and thrombocytopenia in some cases. Haemodynamic stability was maintained in all patients. The use of prophylactic anticoagulation was noted, potentially offering protection against thrombosis. Asymptomatic COVID-19 positive parturients can exhibit significant laboratory abnormalities. Thromboprophylaxis may play a role in mitigating thrombotic risks. The significance of the present case series lies in the fact that the laboratory abnormalities could only be detected since all positive patients were investigated as per hospital protocol, which will be missed in the post-COVID-19 era where routine investigations are not performed on asymptomatic patients. Therefore, healthcare workers should be aware of this possibility.

Anaesthesia, C-reactive protein, D-dimer

Caesarean sections had to be performed without exception due to their inherent nature during the COVID-19 pandemic, even though many other elective cases were postponed. Routine screening, as per hospital protocol, allowed for the detection of many asymptomatic parturients who were managed according to guidelines. The primary anaesthetic technique employed was subarachnoid blockade, unless contraindicated. Despite being asymptomatic, significant laboratory abnormalities and untoward incidents could occur in such cases. These findings hold relevance in the post-COVID-19 era when routine screening and laboratory investigations are not conducted for asymptomatic patients. Guzey NA et al., have discovered that closely monitoring laboratory values will provide information about the clinical course in COVID-19 positive parturients (1). Therefore, healthcare workers must maintain a high degree of suspicion and vigilance regarding the possibility of abnormal laboratory findings.

Case Report

In this case series, patients were classified as symptomatic or asymptomatic based on the presence or absence of any of the following symptoms: fever, cough, rhinitis, breathlessness, headache, and palpitation (2). Out of a total of 157 COVID-19 positive caesarean sections performed at the institution between March 2020 and February 2022, only 16 patients were symptomatic. Among the remaining 141 asymptomatic patients, the authors selected 15 cases who met one or more of the following criteria. Routine investigations were conducted for all positive patients according to hospital protocol. The modified cut-off values were based on previous studies.

1. D-dimer >1500 ng/mL (3)
2. C-Reactive Protein (CRP) ≥3 mg/dL (4)
3. Platelet count <100,000/mm3 (5)
4. Requirement of blood transfusion (6)
5. Intrauterine death of the baby (7)

Subarachnoid blockade was administered to 14 patients, while general anaesthesia with endotracheal intubation was performed in one patient due to thrombocytopaenia. Preoperatively, all patients were kept in an isolation ward, and the cases were conducted in a dedicated operation theatre for COVID-19 cases using Personal Protective Equipment (PPE) kits. The majority of patients were between the ages of 20 and 30 years and were second gravidas. The most common indication for caesarean section was a previous caesarean section, followed by failure to progress (Table/Fig 1). Four patients had haemoglobin levels below 11 gm%. Other blood results are provided in (Table/Fig 2). Significant laboratory abnormalities are highlighted in (Table/Fig 3). All patients maintained haemodynamic stability with a Mean Blood Pressure (MBP) of atleast 70 mmHg or higher. Hypotension was prevented by administering intravenous fluid preloading with 5 mL/kg and co-loading with 10 mL/kg, along with a bolus dose of 5mg of intravenous Ephedrine. Except for one patient, all patients received prophylactic Enoxaparin/Heparin, which was discontinued preoperatively according to recommended guidelines. The patient with thrombocytopaenia received general anaesthesia for the caesarean section, while the others underwent subarachnoid blockade. This patient tested negative for dengue IgM. Postoperatively, this patient required transfusion of four units of Platelet Concentrate (PC), two units of Packed Red Blood Cells (PRBC), and two units of Fresh Frozen Plasma (FFP). One patient with a history of previous caesarean section experienced complications including abruptio placentae, uterine rupture, and intrauterine death of the baby. This patient also received two units of PRBC transfusion. The average duration of hospital stay was 8.2 days, with only three patients requiring more than 10 days (Table/Fig 4). There were no other major adverse incidents, and all patients were discharged safely.

Discussion

Asymptomatic COVID-19 positive parturients were only detected due to routine Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR)/Rapid Antigen Test (RAT) screening. The major indication for Caesarean Section (CS) in the present case series was a history of previous CS and failure to progress, which is consistent with the findings of Guzey N et al., who evaluated 254 CS patients with COVID-19 (1). Complications such as placental abruption, preterm labour, stillbirth, and anaemia were observed, in line with previous studies (5),(7),(8),(9). The occurrence of two cases of placental abruption and one case of intrauterine death in the present case series could potentially be attributed to COVID-19. Aghaamoo S et al., found a higher risk of abruption, preterm labour, and stillbirth in patients with COVID-19 (7). The occurrence of anaemia in COVID-19 is significant as it can impair oxygen-carrying capacity and potentially exacerbate hypoxia due to lung damage. Bergamaschi G et al., and Dakshnamurthy P et al., have reported the occurrence of anaemia in COVID-19 positive parturients [8,9]. One patient presented with a haemoglobin level of 7.5g%, which was corrected with packed red cells and oxygen was administered via mask to improve oxygen flux. Leukocytosis greater than 10,000/cmm was reported by Chen R et al., (10). Eight patients had a total leukocyte count higher than 10,000, and only one patient had a count lower than 5,000/cmm. Jamal S et al., found that thrombocytopenia can occur even in asymptomatic COVID-19 positive parturients (5). One patient had a platelet count of 70,000/cmm, negative dengue tests, and no other identifiable cause. Denizli R et al., noted in their study that elevated liver enzymes could occur in COVID-19 positive pregnant patients, but no such findings were seen in this case series (11). Zhang Y et al., reported the importance of highlighting the increased risk of hypotension related to neuraxial anaesthesia in COVID-19 positive parturients undergoing caesarean deliveries (12). However, in this study, all patients remained haemodynamically stable. The Royal College of Obstetricians and Gynaecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) have differing guidelines for administering prophylactic Low Molecular Weight Heparin (LMWH)/Unfractionated Heparin (UFH) in COVID-19 positive antepartum patients (13),(14). In this case series, except for one patient, all patients were administered prophylactic LMWH/UFH as per institutional guidelines. This may have had a protective effect against thrombosis, even in asymptomatic cases, which could indirectly reflect as reduced D-dimer values. García IG et al., demonstrated that throughout pregnancy, D-dimer levels progressively and significantly increased, reaching higher levels in the third trimester, with a reference value of 551-3333 ng/mL (15). Since the above reference values are for normal pregnancies and thromboprophylaxis was used, a D-dimer value higher than 1500 ng/mL was taken as an inclusion criterion in this case series. Watts DH et al., found that the median CRP value for women in labour at term was 1.3 mg/dL (16). The CRP values higher than six in six patients in this series could be attributed to COVID-19. According to Kinsey KE et al., COVID-19 can cause intraoperative coagulopathy and significantly more oozing (17). This may have contributed to the increased requirement of blood products in two patients, even though there were other obvious indications for blood transfusion.

In summary, all mothers in the present case series study had a safe and healthy postoperative period, with only two patients requiring admission to the intensive care unit for blood transfusion and monitoring. There was one case of intrauterine death, but all other newborns were healthy and without any symptoms. Anesthesiologists can play a crucial role in ensuring the safety of newborns by assessing the APGAR score and providing resuscitation if necessary (18). Anticoagulation therapy for postpartum patients may contribute to a good prognosis (19).

Conclusion

COVID-19 positive parturients, even if asymptomatic, can exhibit laboratory abnormalities such as thrombocytopaenia, high D-dimer, and CRP levels. In some cases, the D-dimer levels were higher than expected during pregnancy, even after administering thromboprophylaxis. Further studies are needed on a country or region-specific basis to determine whether routine thromboprophylaxis is necessary, as different strains of COVID-19 vary in their tendency to cause thrombosis. Timely recognition of these laboratory abnormalities can help prevent potential complications such as bleeding, thrombosis, or sepsis. Although anaesthesia and perioperative management could be performed safely in this case series, it would be advisable for healthcare providers to exercise caution in the post-COVID-19 era when routine screening for COVID-19 is not conducted, as many asymptomatic cases can easily be missed.

DOI and Others

DOI: 10.7860/JCDR/2023/66382.18709

Date of Submission: Jul 05, 2023
Date of Peer Review: Aug 24, 2023
Date of Acceptance: Oct 11, 2023
Date of Publishing: Nov 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

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ETYMOLOGY: Author Origin

EMENDATIONS: 6