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Table of Contents
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 40-44

Perioperative management in obstetric patients with suspected COVID-19 at Bali, Indonesia: Case series

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia

Date of Submission28-Jul-2020
Date of Decision16-Oct-2020
Date of Acceptance23-Oct-2020
Date of Web Publication8-Feb-2021

Correspondence Address:
Dr. Adinda Putra Pradhana
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana UniversityJl. PB Sudirman, Denpasar 80232, Bali
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_166_20

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The COVID-19 pandemic is a challenge for health practitioners, where there are many suspected and confirmed patients with COVID-19, including obstetric patients. Perioperative treatment of COVID-19 patients must be under applicable standards, for both patients and the medical personnel. Personal protective equipment is essential for health workers who treat patients with COVID-19 to prevent the transmission of the virus. The method of delivery ideally should be adapted to the clinical condition of the patient. At the same time, the management of anesthesia for patients with cesarean sections should also be adjusted to the patient's clinical condition by taking into consideration the availability of facilities and infrastructure that we have. Through this report, we want to show how we manage COVID-19 in obstetric cases using the available resources in a third-world country.

Keywords: Anesthesia technique, anesthesia, coronavirus, COVID-19, obstetric, perioperative

How to cite this article:
Katipana MV, Wiryana M, Tjahya Aryasa E M, Pradhana AP. Perioperative management in obstetric patients with suspected COVID-19 at Bali, Indonesia: Case series. Bali J Anaesthesiol 2021;5:40-4

How to cite this URL:
Katipana MV, Wiryana M, Tjahya Aryasa E M, Pradhana AP. Perioperative management in obstetric patients with suspected COVID-19 at Bali, Indonesia: Case series. Bali J Anaesthesiol [serial online] 2021 [cited 2022 Dec 5];5:40-4. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/40/308884

  Introduction Top

In early December 2019, a new infectious disease first appeared in Wuhan, China. On February 2020, the World Health Organization (WHO) proclaimed the disease as the coronavirus disease 2019 or COVID-19 caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2).[1] The WHO then was declared a COVID-19 pandemic on March 2020. The WHO reported more than 10 million cases globally, and more than 700,000 cases in South East Asia with more than 21,000 death cases.[2] In Indonesia alone until June 2020, more than 55,000 confirmed cases, more than 2000 death cases.[3],[4] This pandemic poses new challenges for the health-care system worldwide both in prevention and management. Anesthesiologists also have an essential role in this condition, for the handling of both suspected and confirmed patients who require anesthesia services for surgery and as well as for treating patients who are on critical conditions that require airway management.[5]

The mode of transmission of this virus from humans to humans through droplets, direct or indirect contact such as touching objects that are contaminated with droplets. Transmission through droplets occurs within a range of 6 feet between humans. Transmission through other objects is unclear, while the fecal-oral transmission may occur because SARS-CoV2 has been successfully identified in fecal specimens. [5,6] The incubation period of this virus is approximately 2–7 days up to 14 days, with an average period of 4–12 days.[5],[7],[8]

Perioperative management in cases with COVID-19 infection is a challenge, especially in handling obstetric cases. For this reason, during the April–May 2020 period, we collected obstetric cases of COVID-19 infection at Sanglah General Hospital Denpasar, Bali, Indonesia.

  Case Report Top

During April–May 2020, there were seven obstetric cases, of which six of them required anesthesia for cesarean section procedures, and one case underwent spontaneous delivery [Table 1]. In this report, we collected data retrospectively from our emergency department to evaluate the suggested or confirmed obstetric patients with COVID-19 infection. We used the obstetric and anesthetic management and guideline according to our hospital regulation for emergency procedures in obstetric patients with suspected or confirmed COVID-19 that was drafted by an expert meeting and formulated as a standard at Sanglah General Hospital Denpasar [Figure 1]. Of the six cases, there was only one case that had a history of contact with confirmed COVID-19 patients, and the others were patients who came from the red zone that was the result of local community transmission.
Table 1: Patient's characteristic

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Figure 1: Our hospital's flowchart for pregnancy presenting with COVID-19 infection

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Two confirmed patients referred from the prior hospital with mild symptoms such as dry cough, and one case had a fever history 1 week prior. One of them had preeclampsia with elevated liver enzymes and serum creatinine, and we take the patient to the isolation intensive care unit to evaluate. The obstetric team immediately initiated conservative preeclampsia therapy for that case.

Four cases came with suspected COVID-19 per rapid antibody test, and two cases came with confirmed COVID-19 per real-time polymerase chain reaction (RT-PCR) test. When the patient came, they were identified by our triage staff and diverted to a specific isolated room, and the patient should be using a surgical mask that we provided. All medical staff utilized personal protective equipment (PPE) including fit-tested disposable N95 respirator, goggles, face shield, gowns, double-layered gloves, and protective footwear to achieve maximum droplet/contact isolation precaution. Our medical staff completed personal hand hygiene before and after contact with the patient.

As an initial preoperative evaluation, we collected medical history and performed a physical examination, including blood pressure, temperature, oxygen saturation (SaO2), heart and respiratory rate, and urine output. We gave supplemental oxygen which aims to maintain SaO2 >94%, titrate oxygen therapy according to the conditions. The obstetric team performed the obstetric examination to the patient to confirm fetal viability or well-being. Preoperative investigations include blood count, kidney function including creatinine, urea, electrolyte panel, live profile, lactate dehydrogenase and C-reactive protein, and coagulation tests [Table 2].
Table 2: Clinical manifestation

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As per standard guidelines, we prefer regional anesthesia to general anesthesia in managing these cases. However, we performed general anesthesia in one case with a hemorrhagic shock. For postoperative care, we put the patient directly to the isolation ward until they confirmed negative with the RT-PCR test. Only one patient, we transferred to isolation intensive unit postoperatively because of the hemodynamic state caused by hemorrhagic shock. In our study, there was no patient who came to serious respiratory symptoms, either preoperative or postoperative.

APGAR scores of all neonates were eight or higher, and there were one of the neonatal deaths, due to obstetric complication of bleeding due to placental abruption. For postoperative pain management, all patients were given opioid without any adverse effect.

  Discussion Top

Pregnancy is a condition with a partial physiological status of immunosuppressant, which makes the mother more vulnerable to viral infections. Pregnant women are very susceptible to pathogens in the respiratory system such as pneumonia, this is due to physiological changes in the immune and cardiopulmonary systems that cause pregnant women to be intolerant of hypoxic conditions.[9],[10],[11] Respiratory system viruses posed a risk of miscarriage and premature labor in pregnant women.[12]

Most of COVID-19 manifestations in pregnancy patients are mild. The most common symptoms include fever, cough, fatigue, myalgia, and shortness of breath.[8],[13] Some patients experience severe symptoms such as severe pneumonia, which then develops into acute respiratory distress syndrome which requires intensive care.[11]

SARS-CoV2 transmitted through respiratory droplets to the mucous membrane of the respiratory tract when the patient coughs or sneezes. Airborne spread occurs due to inhalation of aerosol particles. The incubation period for this disease is estimated to be around 4–12 days, with a range of 2–14 days. The peak of transmission occurs in the 2nd week of illness. There is no evidence to show that patients with SARS-CoV2 infection can be transmitted before the onset of the symptoms.[5],[6]

In this report, there were two patients with positive preoperative RT-PCR tests. They had mild respiratory system symptoms, such as dry cough without fever. Moreover, the rest of the cases were asymptomatic. One patient was admitted to the intensive care after surgery due to intraoperative bleeding, without worsening of the respiratory symptoms.

Fever is the main symptom that is seen in patients where as many as 43.8% are the initial symptoms when coming to the hospital. As many as approximately 88.7% develop a fever during hospitalization. The second-most common symptoms that make patients come to the hospital are cough (67.8%), nausea and vomiting (5%), and diarrhea which are unusual symptoms (3.8%).[7]

Some studies postulate that changes in the hormonal milieu in pregnancy, which influence immunological responses to viral pathogens together with the physiological transition to a Th2 environment favoring the expression of anti-inflammatory cytokines (interleukin-4 [IL-4] and IL-10) and other unidentified immune adaptations, may serve as the predominant immune response to SARS-CoV-2, resulting in the lesser severity of COVID-19 compared to that in nonpregnant individuals.[14]

Chen et al.[15] reported nine women with COVID-19 in the third trimester of pregnancy had symptoms such as fever, cough, myalgia, sore throat, and malaise. On laboratory examination also found lymphocytopenia. All of the women had cesarean delivery with APGAR score of the neonates averaging 8–9 in the 1st min and 9–10 in the 5th min. It is still unclear whether COVID-19 infection can cross the transplacental route toward the fetus.[9]

Several studies found that leukocytes or red blood cells are normal or decreased at an early stage, and the number of lymphocytes can also be reduced, C-reactive protein could be an increase, thrombocytopenia, increased levels of liver enzymes and creatine phosphokinase.[7],[10] In our hospital, as an initial examination, we performed a full blood examination to assess leukocytes, lymphocytes, platelets, as well as rapid antibody tests. Three out of six cases had increased leukocyte values. Furthermore, three out of six cases experience lymphocytopenia. None experienced thrombocytopenia. Most of our cases had elevated neutrophil count and the normal value of monocytes, basophils, and eosinophils.

Radiological examination revealed pneumonia images on chest radiography, and computed tomography (CT) thoracic scan without contrast became the most useful investigation to confirm and exclude viral pneumonia. The most common imaging patterns found on chest CT scans are ground-glass opacity and patchy bilateral shadowing.[6],[7],[10] Ideally, radiology should be performed in all suspected cases, where radiation exposure to the fetus is minimal. In some case reports, it was found that the sensitivity of chest CT for diagnosis of COVID-19 is higher than RT-PCR.[10] Chest imaging is important but not replace molecular confirmation of COVID-19. The predominant findings are peripheral airspace shadowing on a plain chest radiograph and bilateral, multi-lobar ground-glass opacities, or consolidation on CT scan of the chest. These features are nonspecific and appear to be similar in pregnancy.[14]

All our patients underwent chest radiographic examination postoperatively. In one case, we found a specific infiltrate in upper lung that suspected pulmonary tuberculosis without any significant clinical manifestation and the others found normal. No CT scan was performed in this study, because according to clinical judgment, most patients are asymptomatic, with unspecific chest X-ray, and the quantitative results of RT-PCR for COVID-19 came back negative.

COVID-19 can be detected using RT-PCR, which is the standard test for COVID-19. Specimens were collected from saliva, upper respiratory tract (nasopharyngeal and oropharyngeal smears), lower respiratory tract (sputum, endotracheal aspiration, and bronchoalveolar lavage), as well as urine and feces. The repetition of this test needs to be done to confirm the diagnosis. If SARS-CoV2 nucleic acid is not detected in respiratory tract samples, then two consecutive examinations are needed at least 24-h intervals.[10] In this study, all patients had RT-PCR tests twice with intervals between 24-h examinations postoperatively. There were two cases with positive RT-PCR preoperatively.

According to our hospital regulation, if there are indications of labor induction in pregnant women with suspected or confirmed COVID-19, an urgency evaluation is performed. If possible, it is delayed until the infection is confirmed or the acute condition has been resolved. If the postponement of the procedure is considered unsafe, induction of labor is carried out in an isolation room including postpartum care. If there are indications of planned surgery for pregnant women with suspected or confirmed COVID-19, an urgency evaluation should be carried out, and if possible, postponed to reduce the risk of transmission until the infection is confirmed or the acute condition has been resolved. If the surgical procedure cannot be postponed, then the surgery is according to standard procedures with infection prevention according to the complete PPE standard.

All neonates from our cases had no respiratory symptoms, and the quantitative RT-PCR was negative. They were separated from their mother and handled in the neonatology ward in our hospital until the follow-up test revealed negative for RT-PCR. No case of neonatal asphyxia in our live birth was recorded. In a recent study, there have been no confirmed instances data of vertical transmission among the neonates born to COVID-19 infected mothers.[14]

  Conclusion Top

Perioperative management of obstetric patients with COVID-19 is a chawllenge. The management of the delivery of obstetric patients with COVID-19 can be done by induction for normal delivery or cesarean section delivery. The delivery of the cesarean section alone is not an indication for COVID-19 patients. Anesthesia management for obstetric patients with COVID-19 using the neuraxial anesthesia is preferred than general anesthesia. However, the challenges that we have today is the lack of facility, such as a negative pressure operating room for suspected or confirmed COVID-19 patients, especially in third-world countries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ryalino C. Covid-19: What we know so far. Bali J Anaesthesiol 2020;4:1-2.  Back to cited text no. 1
  [Full text]  
Ryalino C. How Indonesia copes with coronavirus disease 2019 so far (part one): The country, the government, and the society. Bali J Anaesthesiol 2020;4:33-4.  Back to cited text no. 2
  [Full text]  
Hartawan IG, Senapathi TG, Pradhana AP, Tanggono A. Perioperative management in an emergency operating theater in Bali during COVID-19 pandemic. Bali J Anaesthesiol 2020;4 Suppl S1:17-8.  Back to cited text no. 3
Senapathi TG, Ryalino C, Wiryana M, Hartawan IG, Pradhana AP. Perioperative safety during Covid-19 pandemic: A review article. Bali J Anaesthesiol 2020;4 Suppl S1:8-12.  Back to cited text no. 4
Zheng H, Hebert HL, Chatziperi A, Meng W, Smith BH, Yan J, et al. Perioperative management of patients with suspected or confirmed COVID-19: review and recommendations for perioperative management from a retrospective cohort study. British Journal of Anaesthesia 2020;125:895e911.  Back to cited text no. 5
Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: What obstetricians need to know. Am J Obstet Gynecol 2020;222:415-26.  Back to cited text no. 6
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1-13.  Back to cited text no. 7
Roy A, Singh A, Khanna P. Oxygen delivery devices in Covid-19 patients: Review and recommendation. Bali J Anaesthesiol 2020;4 Suppl S1:3-7.  Back to cited text no. 8
Senapathi TG, Ryalino C, Raju A, Winata IG, Hartawan IN, Hartawan IG. Perioperative management for cesarean section in COVID-19 patients. Bali J Anaesthesiol 2020;4 Suppl S1:13-6.  Back to cited text no. 9
Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? Acta Obstet Gynecol Scand 2020;99:439-42.  Back to cited text no. 10
Yan J, Guo J, Fan C, Juan J, Yu X, Li J, et al. Coronavirus disease 2019 in pregnant women: A report based on 116 cases. Am J Obstet Gynecol 2020;223:111.e1-14.  Back to cited text no. 11
Qiancheng X, Jian S, Lingling P, Lei H, Xiaogan J, Weihua L, et al. Coronavirus disease 2019 in pregnancy. Int J Infect Dis 2020;95:376-83.  Back to cited text no. 12
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 13
Dashraath P, Wong JL, Lim MX, Lim LM, Li S, Biswas A, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31.  Back to cited text no. 14
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;395:809-15.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]

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