COVID-19 FAQs for Providers

 Question 1. What should be in an obstetric operating room "COVID starter kit?"

The following list is an example of items that could be included in a premade anesthesia “COVID starter kit” to help start a surgical case on a COVID-19 patient. Ideally this would be complemented with a full drug tray that contains the usual intraoperative anesthesia drugs. These “COVID starter kits” should be customized based on the needs and available resources at each facility/ obstetric unit.

Question 2. Can an Epidural Blood Patch be done in a COVID-19 positive patient or person under investigation (PUI) with a post-dural puncture headache?

• Management of post-dural puncture headache in a COVID-19 positive patient or PUI should rely on the usual considerations, since there is no available guidance. As per usual care, conservative management should initially be proposed.
• If the headache is severe and debilitating, the risk of neurological complications associated with severe untreated headache should be weighed against the theoretical risk of injecting viremic blood in the epidural space on a case by case basis. If the patient is clinically well (e.g. is without fever, pneumonia) and is not thrombocytopenic, consider proceeding with an epidural blood patch.
• The nasal sphenopalatine ganglion (SPG) block is potentially an aerosol-generating medical procedure, involving injection or insertion of local anesthetic into the nasal cavity. One must weigh the potential risks of this exposure to the possible benefit from SPG during the COVID-19 pandemic.

Question 3. How should nausea and vomiting be prevented during cesarean delivery?

• Vomiting is likely to increase the risk of COVID-19 transmission to adjacent healthcare providers and should therefore be prevented if possible.
• Proven antiemetic strategies include the administration of metoclopramide and ondansetron intraoperatively and maintaining blood pressure at baseline with a prophylactic phenylephrine infusion. Ask the surgeon to consider avoiding exteriorization of the uterus.1

1. Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JC. Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial. Obstet Gynecol. 2007;110(3):570-575.

Question 4. COVID-19 infection may be associated with a hypercoagulable state. Why may pregnant patients who are tested positive for COVID-19 receive thromboprophylaxis?

There is emerging data that critically ill non-pregnant patients with COVID-19 infection often develop a coagulopathy characterized by marked elevation of d-dimer, fibrinogen, and prolonged PT resulting in widespread microvascular thrombosis.

In one of several such reports in non-pregnant cases in Wuhan, autopsy findings of microthrombi in the pulmonary vasculature were described. Although the virus primarily affects the respiratory system, increased risk of cardiac arrest (cardiomyopathy) and neurologic complications (seizure and stroke) are reported. The RIETE registry from Europe has already reported 18 cases of non-pregnant patients with COVID-19 infection with venous thromboembolism (VTE).

Pregnant patients are in a hypercoagulable state at baseline and at increased risk of thromboembolic events.In some institutions, prophylactic anticoagulation of pregnant patients with COVID-19 infection has been suggested.

Drafted by Drs. Sharon Abramovitz and Klaus Kjaer (Anesthesiology) in collaboration with Drs. Corrina Oxford-Horrey (Obstetrics) and Maria DeSancho (Hematology) at Weill Cornell Medicine in New York.

1. Luo, W et al. Clinical Pathology of Critical Patient with Novel Coronavirus Pneumonia (COVID-19). Preprints. 2020, 2020020407
2. Xie Y, et al. COVID-19 Complicated by Acute Pulmonary Embolism. Radiology: Cardiothoracic Imaging. 2020.
3. Tang N, et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. Journal of Thrombosis and Haemostasis, March 27, 2020.
4. Sebaaly J et al. Enoxaparin Dosing at Extremes of Weight: Literature Review and Dosing Recommendations. Ann Pharmacother 2018; 52:898-909.
5. Leffert L, et al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-44.

Question 5. If your institution is considering prophylactic anticoagulation in pregnant women tested positive for COVID-19, what type of anticoagulant regimen should be given and how may this impact anesthesia care?

As anesthesiologists, it important to be aware of possible anticoagulation of obstetric patients.

In pregnant women tested positive for COVID-19, the timing and type of anticoagulation regimen should be carefully considered so that neuraxial anesthesia may be utilized and general anesthesia avoided, without unnecessarily increasing the risk of spinal epidural hematoma.

The necessity for general anesthesia, which poses significantly increased risk to the both the patient and the health care team, could be an undesired result of anticoagulation dosage and timing. Interdisciplinary discussion is important in determining the appropriate course of action for your institution.

Some specific considerations are listed here:

• Antepartum patients who are tested COVID-19 positive but have only mild to moderate symptoms and do not require admission to the hospital may be at low risk for VTE associated with COVID-19 infection. They may be considered for prophylaxis with heparin 5000 U SC BID/TID, especially if isolating at home with decreased mobility.
• Antepartum patients who are admitted to the hospital and tested COVID-19 positive may also be treated with up to heparin 5000 U SC BID/TID. This allows for neuraxial anesthesia 4 hours after the dose, without having to check the PTT value.
• If there is concern that the patient is not receiving adequate prophylaxis effect or that higher doses of heparin may be needed (e.g. obesity), a heparin infusion is an alternative. Patients on this regimen will be eligible for neuraxial anesthesia in as few as 4 hours after discontinuation of the infusion, but only upon confirmation of a normal PTT. Patients on prolonged heparin infusions should be evaluated for heparin-induced thrombocytopenia.
• LMWH prophylaxis is generally considered not to be ideal for pregnant patients who are at high risk for imminent delivery, since the treatment would preclude neuraxial anesthesia for at least 12 hours. This is particularly the case for pregnant women tested COVID-19 positive who are hospitalized antepartum. If LMWH is chosen, it can be helpful to have clear triggers for holding a dose, which should then prompt an obstetrical evaluation. Triggers may include:
• Painful uterine contractions
• Change in fetal status
• Increasing oxygen requirement
• Transfer from regular patient floor to ICU
• Critically ill pregnant patients who are in an ICU, intubated and on a ventilator may be managed with either LMWH or a heparin infusion, especially if a component of thrombotic lung disease is suspected. Efficacy may be monitored with anti-Xa levels to ensure desired effect in the setting of factors affecting heparin pharmacokinetics, such as obesity and/or renal failure. If Cesarean delivery is indicated in these patients, infusions have the advantage over LMWH that anticoagulation effect will usually wear off faster once discontinued, not to allow for neuraxial anesthesia but to decrease surgical bleeding.
• Post-partum patients with a COVID-19 infection may benefit from LMWH or heparin SC prophylaxis for up to 6 weeks postpartum.

Drafted by Drs. Sharon Abramovitz and Klaus Kjaer (Anesthesiology) in collaboration with Drs. Corrina Oxford-Horrey (Obstetrics) and Maria DeSancho (Hematology) at Weill Cornell Medicine in New York.

1. Luo, W et al. Clinical Pathology of Critical Patient with Novel Coronavirus Pneumonia (COVID-19). Preprints2020, 2020020407
2. Xie Y, et al. COVID-19 Complicated by Acute Pulmonary Embolism. Radiology: Cardiothoracic Imaging. 2020.
3. Tang N, et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. Journal of Thrombosis and Haemostasis, March 27, 2020.
4. Sebaaly J et al. Enoxaparin Dosing at Extremes of Weight: Literature Review and Dosing Recommendations. Ann Pharmacother 2018; 52:898-909.
5. Leffert L, et al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-44.

The educational materials presented here are the individual authors' opinions and not medical advice, are not intended to set out a legal standard of care, and do not replace medical care or the judgment of the responsible medical professional in light of all the circumstances presented by an individual patient. The materials are not intended to ensure a successful patient outcome in every situation and are not a guarantee of any specific outcome. Materials are subject to periodic revision as additional data becomes available. The opinions, beliefs and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs and viewpoints of SOAP or any of its members, employees or agents.