Neuraxial Procedures for Pregnant COVID-19 Patients in Labor

BACKGROUND AND PURPOSE:

• Untreated viremia has the potential to lead to meningitis or encephalitis following neuraxial procedures
• Bauer et al. (Anesthesia & Analgesia, 2020) sought to determine outcomes in COVID-19 positive pregnant women undergoing spinal and epidural procedures

METHODS:

• Literature review
• Studies included
  • Confirmed COVID-19 cases at the time of delivery
  • Authors were contacted to obtain information about neuraxial procedures used and clinical follow-up

RESULTS:

• 4 publications (January 20, 2020 to February 6, 2020) | 14 cases | One combined spinal epidural and 13 epidural
  • Cesarean: 13 patients (93%)
  • Preterm (<37 weeks): 6 patients (43%)
  • Fever: 10 patients (71%)
  • Antiviral treatment: 2 patients (14%)
  • Evidence of pneumonia: All patients
• There were no reported neurologic sequelae after neuraxial procedures in any of the cases
• Clinical characteristics
  • WBC counts: Not elevated in 13 (86%) patients
    • One case: WBC was 8.7 x 106/L which increased to 22.9 x 106/L following daily methylprednisolone for inflammation
  • Thrombocytopenia was reported in 2 pregnant patients without preeclampsia
• In a follow-up review, there were 77 reported cases that likewise were uneventful and did not result in adverse maternal neurologic events (4 combined spinal-epidural, 27 epidurals, 46 spinal procedures)

CONCLUSION:

• The associated risk of causing meningitis or encephalitis in general is “extremely low” and while based on limited number of cases, does not seem to be elevated
• The authors suggest that general anesthesia still confers greater risk, even in patients with COVID-19
  • Neuraxial procedures reduce SARS-CoV-2 transmission risk that is associated with intubation
  • General anesthesia increases the risk for atelectasis and ICU admission due to decreased respiratory functional capacity
• Consider an in-situ catheter in case of emergency cesarean (to avoid general) for pregnant women with COVID-19
• Check platelet counts prior to anesthesia procedures because COVID-19 can be associated with thrombocytopenia
  • A platelet count of 70,000 x 106/L has a low risk for spinal epidural hematoma
• Mullington et al. (Anesthesia & Analgesia, 2020), in response to the review article makes the case that there may be some risk with early epidural during labor
  • Epidural is generally associated with an increased risk for intrapartum pyrexia (2.5x) and can therefore complicate the clinical picture and subsequent management | There may be risk to the infant from intrapartum pyrexia (e.g. CP)
  • The authors of this letter to the editor suggest that epidural should not be routinely placed earlier in labor for patients with COVID-19 but rather that the decision should be individualized

Learn More – Primary Sources:

Neuraxial procedures in COVID-19 positive parturients – A review of current reports

Obstetric Anesthesia During the Coronavirus Disease 2019 Pandemic (Review)

The Timing of Labor Epidurals in COVID-19 Parturients: A Balance of Risk and Benefit

Pregnant Women with COVID-19 and ICU Admissions

BACKGROUND AND PURPOSE:

• Blitz et al. (AJOG, 2020) assessed whether pregnant women are more likely to be admitted to the ICU than non-pregnant women

METHODS:

• Retrospective case series (March 2 to April 9, 2020)
• Setting
  • Large hospital system (New York State)
• Participants
  • Hospitalized pregnant women: 15 to 49 years of age
  • Confirmed COVID-19 (RT-PCR) on admission, during the hospital stay, or postpartum period
• Study design
  • Data analyzed
    • Age
    • Pregnancy status
    • Admission to an ICU, as determined by the critical care attending physician
• Primary outcome
  • Incidence of ICU admission, comparing pregnant vs non-pregnant women with COVID-19

RESULTS:

• 1,168 patients admitted with COVID-19
  • 64.6% male | 28.4% non-pregnant females | 7.0% pregnant females
• 2,971 pregnant patients were admitted | Most were admitted for delivery
• There was no significant difference in ICU admissions between pregnant and non-pregnant women with COVID-19 (p=0.22)
  • Pregnant: 9.8% (8 patients out of 82 diagnosed with COVID-19)
  • Non-pregnant: 15.1% (50 patients out of 332 diagnosed)
  • Outcome result not impacted by patient age

CONCLUSION:

• COVID-19 infection did not alter the ICU admission rate for pregnant women admitted to hospital
• The authors state

…our findings are reassuring, and indicate that pregnant women infected with COVID-19 may not experience more severe disease progression than non-pregnant women

Learn More – Primary Sources:

Intensive Care Unit Admissions for Pregnant and Non-Pregnant Women with COVID-19

COVID-19 Treatment RCT Results: Combination Interferon beta-1b, Lopinavir-Ritonavir and Ribavirin

PURPOSE:

• There are multiple trials underway to determine efficacy of various treatments for COVID-19
  • Lopinavir/ritonavir is a combination HIV protease inhibitor medication
  • Ribavirin is a nucleoside analogue
• Hung et al. (Lancet, 2020) sought to determine the efficacy and safety of adding interferon beta-1b to lopinavir–ritonavir, and ribavirin for the treatment of COVID-19

METHODS:

• Multicenter, prospective, open-label randomized phase 2 controlled trial (RCT)
  • 6 Hong Kong hospitals | Between February 10 and March 20, 2020
• Participants
  • Hospitalized
  • Confirmed COVID-19
• Study design
  • Randomization (2:1) for a 14 day course of the following
    • Combination group: Combination of lopinavir 400 mg and ritonavir 100 mg every 12 hours | Ribavirin 400 mg every 12 hours | 3 doses of 8 million IU of interferon beta-1b on alternate days
    • Control group: Lopinavir 400 mg and ritonavir 100 mg every 12 h (control group)
• Primary outcome
  • Time for nasopharyngeal swab to be negative for SARS-CoV-2 (using RT-PCR)

RESULTS:

• 127 patients were recruited
  • Combination group: 86
  • Control group: 41
• Median time to symptom onset to start of study treatment: 5 days (IQR 3–7)
• Combination group had a shorter time from treatment to negative swab result (p=0·0010)
  • Combination group: 7 days
  • Control group: 12 days
  • Hazard ratio (HR): 4·37 (95% CI, 1·86–10·24)
• Adverse events
  • No difference between groups
  • Main side effects included limited nausea and diarrhea | Discontinuation of lopinavir–ritonavir in one patient (control group) because of biochemical hepatitis
  • No deaths in either group

CONCLUSION:

• In this phase 2 study, the authors conclude that

…early triple antiviral therapy was safe and superior to lopinavir–ritonavir alone in alleviating symptoms and shortening the duration of viral shedding and hospital stay in patients with mild to moderate COVID-19

• Future clinical study of a double antiviral therapy with interferon beta-1b as a backbone is warranted

Learn More – Primary Sources:

Triple combination of interferon beta-1b, lopinavir–ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial

Infectious SARS-CoV-2 Detected in Ocular Fluids of a COVID-19 Patient

BACKGROUND AND PURPOSE:

• Conjunctivitis has been reported with SARS-CoV-2 infection
• As with SARS, unprotected ocular exposure may be a route of infection
• Colavita et al. (Annals of Internal Medicine, 2020) present their findings on the early detection of infectious SARS-CoV-2 in ocular fluids from a patient with the first confirmed case of COVID-19 in Italy

METHODS:

• Case report
• Setting
  • National Institute for Infectious Diseases (INMI), Rome
• Patient
  • A 65-year old woman who travelled from Wuhan, China, to Italy
  • Confirmed infection with SARS-CoV-2 (real-time RT-PCR sputum assay)
• To confirm infectivity of viral genome in ocular fluid samples
  • Ocular sample inoculated into Vero E6 cells (used to propagate and study viruses)

RESULTS:

• Patient
  • Travel from Wuhan to Italy: January 23, 2020
  • Hospitalized: January, 29 2020 (1 day after symptom onset)
• Presenting symptoms
  • Nonproductive cough
  • Sore throat
  • Rhinitis
  • Bilateral conjunctivitis
• Day 4: Additional symptoms
  • Fever 38°C
  • Nausea
  • Vomiting
• Conjunctivitis:
  • Improved at day 15 and was resolved at day 20
• Viral RNA presence in ocular samples (using real-time RT-PCR)
  • Day 3: Virus first detected
  • Subsequent (almost) daily samples: Positive up to day 21
  • Day 27: SARS-CoV-2 RNA was again detected
• SARS-CoV-2 RNA was detected in ocular swabs days after it was undetectable in nasal swabs (nasal swabs last positive on day 16)
  • Viral load in ocular samples were lower than in nasal swabs
  • Suggests sustained replication in conjunctiva
• To confirm that virus in eye sample was still infectious, cytopathic effect was still observed 5 days after cells were inoculated with the virus

CONCLUSION:

• Ocular fluids from COVID-19 can contain infectious SARS-CoV-2
  • Ocular involvement may occur early in the course of disease
• The authors suggest
  • Ophthalmologists use proper PPE when performing eye exams, as ocular fluids may be a source of contagion
  • Transmission control: Reinforce avoidance of touching face and eyes

Learn More – Primary Sources:

SARS-CoV-2 Isolation From Ocular Secretions of a Patient With COVID-19 in Italy With Prolonged Viral RNA Detection

The UKOSS COVID-19 Pregnancy Registry: Update on 427 Patients Admitted to Hospital

PURPOSE:

• The UK Obstetric Surveillance System (UKOSS) is a research registry system, funded by the National Institute for Health Research in 2012 to prepare in case of a pandemic
  • Due to COVID-19, UKOSS was activated in March 2020
• Researchers based at the University of Oxford, in collaboration with RCOG, the Universities of Leeds and Birmingham, Kings and Imperial Colleges London studied the current risk factors and outcomes among pregnant women with SARS-CoV-2 infection who were hospitalized on maternity units from all 194 hospitals in the UK

METHODS:

• UKOSS National prospective observational cohort study (March 1 to April 14, 2020)
• Participants (exposed group)
  • Pregnant women admitted to hospital with confirmed SARS-CoV-2 infection
• Comparison cohort
  • 2 women giving birth immediately prior to any woman with confirmed influenza (derived from a previous study that analyzed influenza in pregnancy between November 1, 2017 and October 30, 2018)
  • This comparison (control) cohort was used to avoid confusing ‘non-SARS-CoV-2’ patients with those who may be infected but were asymptomatic
• Primary outcome
  • Incidence of maternal hospitalization and infant infection
  • Rates of maternal death, level 3 critical care unit admission, preterm birth, stillbirth, early neonatal death, perinatal death
• Statistical analysis
  • Based on number of patients in study and comparison cohort: 80% power at p<0.05 could detect a ≥1.5 difference of a more common risk factor (with 25% prevalence in comparison group) and ≥2 difference for a risk factor with 5% prevalence

RESULTS:

• Study cohort: n=427 | Comparison group: n= 694 women
  • Most common presenting symptoms were fever, cough, and breathlessness
  • 247 (58%) gave birth or had a pregnancy loss | Remaining 180 (42%) of cases are ongoing
• Estimated incidence of hospitalization with confirmed SARS-CoV-2 in pregnancy: 4.9/1000 maternities (95% CI, 4.5 to 5.4)
• The median gestation at symptom onset: 34 weeks (IQR 29- 38)
  • Admission during 3rd trimester or peripartum: 81%
• Risk factors for admission during pregnancy
  • Black or other minority ethnicity: 46% | Adjusted odds ratio (aOR) 4.49 (95% CI, 3.37 to 6.00)
  • Older maternal age (>35 years): aOR 1.35 (95% CI, 1.01 to 1.81)
  • Overweight (BMI ≥25): aOR 1.91 (95% CI, 1.37 to 2.68)
  • Obesity (BMI ≥30): aOR 2.20 (95% CI, 1.56 to 3.10)
  • Preexisting Medical Condition: aOR 1.52 (95% CI, 1.12 to 2.06) | Included asthma, hypertension, cardiac disease and diabetes
  • Patients were less likely to be smokers
• Of patients giving birth during the study, 75% delivered at term
• Preterm: 66 patients
  • 80% were iatrogenic: 48% due to maternal COVID-19 | 14% due to fetal compromise | 18% for other obstetric conditions
• Cesarean: 59%
  • Maternal compromise: 27%
  • Fetal compromise: 24%
  • Failure to progress or failed induction: 19%
  • Other obstetrical reasons: 15%
  • Previous cesarean: 11%
  • Maternal request: 4%
• Mothers requiring respiratory support: 10% (41 women) | 4 women required ECMO
  • Maternal case fatality: 1.2% (95% CI, 0.4% to 2.7%)
  • 3 women died of COVID-19 related complications
• Infants testing positive for SARS-CoV-2: 5% (12 infants) | 6 within 12 hours after birth | 4 delivered by cesarean including 3 pre-labor
• Fetal and newborn loss
  • Miscarriage: 4 (0.9% of admitted patients) between 10 and 19 weeks
  • Stillbirth: 3 (1 stillbirth not related to COVID-19; 2 stillbirths unclear if COVID-19 related)
  • Neonatal deaths: 2 (definitely not related to COVID-19)
• Newborn ICU admission: 25% of liveborn infants
  • Preterm: 75%
• Newborn SARS-CoV-2 testing
  • Infants testing positive: 5% (n=12)
  • Early onset (within 12 hours): 6 infants
    • Vaginal delivery: 2
    • Cesarean: 4 (3 prelabor)
    • Admitted to NICU: 1
  • Later onset (>12 hours): 6 infants
    • Prelabor caesarean: 4
    • Vaginal delivery: 2
    • Admitted to NICU: 5

CONCLUSION:

• Most patients had good outcomes that generally tracked with general non-pregnant population
  • Clinical course: 10% required ventilatory support
  • Risk factors: Strong association with comorbidities
• Transmission uncommon but may occur
• Hospitalizations were in late second and third trimester
• >60% cesarean rate: Majority for indications other than maternal compromise due to COVID-19
• The authors emphasize the association between black or minority ethnicity groups and hospitalization for COVID-19
  • This association was not explained by geography and remained after adjusting for age, BMI and co-morbidities and “is of concern and requires further investigation”

Learn More – Primary Sources:

Characteristics and outcomes of pregnant women hospitalised with confirmed SARS-CoV-2 infection in the UK: a national cohort study using the UK Obstetric Surveillance System (UKOSS)

RCOG and RCM respond to UKOSS study of more than 400 pregnant women hospitalised with coronavirus

Clinical Characteristics of Mild COVID-19 Cases with Digestive Symptoms

BACKGROUND AND PURPOSE:

• Digestive symptoms are more commonly reported in milder COVID-19 cases
• Han et al. (American Journal of Gastroenterology, 2020) describe the clinical characteristics of COVID-19 patients with digestive symptoms and mild disease severity

METHODS:

• Cohort study
• Participants
  • COVID-19 patients with mild disease
• Study design
  • Mild COVID-19 patients with GI symptoms were matched with a second group of patients with respiratory symptoms only
    • ≥1 digestive symptom(s) with or without respiratory symptoms | Digestive symptoms: Diarrhea, nausea, vomiting
    • Respiratory symptoms only | Respiratory symptoms: Cough | Expectoration | Chest discomfort | Shortness of breath | Sore throat
  • All patients were followed up until they tested negative for SARS-CoV-2 with 2 subsequent tests collected ≥24 hours apart
  • Clinical features were compared between the two groups

RESULTS:

• 206 patients with mild COVID-19
  • Digestive symptom(s) only: 48 patients
  • Both digestive and respiratory symptoms: 69 patients
  • Respiratory symptoms only: 89 patients
• Digestive symptoms
  • Diarrhea: 67 patients
    • Diarrhea as the first symptom: 19.4%
  • Diarrhea lasted from 1 to 14 days
    • Mean duration of 5.4 ± 3.1 days
    • Frequency of 4.3 ± 2.2 bowel movements per day
• Association with fever
  • Overall, 62.4% of patients with a digestive symptom had a concurrent fever
  • If a patient had nausea and vomiting plus diarrhea, fever was more likely (P=0.024)
    • N&V and diarrhea: 94.4%
    • N&V alone: 57.1%
    • Diarrhea alone: 63.3%
• Patients with digestive symptoms presented for care later than those with respiratory symptoms (P <0.001)
  • With digestive symptoms: 16.0 days
  • No digestive symptoms: 11.6 days
• Patients with digestive symptoms had a longer duration between symptom onset and viral clearance (P <0.001)
  • Digestive only: 40.9 days
  • Digestive and Respiratory: 42.0 days
  • Respiratory only: 33.5 days
• Patients with digestive symptoms more likely to have positive fecal SARS-CoV-2 results than those with respiratory symptoms only (P = 0.033)
  • With digestive symptoms: 73.3%
  • No digestive symptoms: 14.3%

CONCLUSION:

• Compared to patients with respiratory symptoms only, COVID-19 patients with mild disease and who experience digestive symptoms
  • Were more likely to test viral positive in stool
  • Had a longer delay before viral clearance
  • Presented for care later
• The authors state that

…clinicians should recognize that new-onset, acute digestive symptoms in a patient with a possible COVID-19 contact should at least prompt consideration of the illness, particularly during the times of high COVID-19 incidence and prevalence.

Learn More – Primary Sources:

Digestive Symptoms in COVID-19 Patients With Mild Disease Severity – Clinical Presentation, Stool Viral RNA Testing, and Outcomes

Is There a Role for Vaginal Delivery if First Twin is in Breech Presentation?

BACKGROUND AND PURPOSE:

• American and British guidelines recommend cesarean delivery for twin pregnancies with the first twin in breech presentation
• However, there is a paucity of evidence that planned vaginal delivery for a first twin in breech presentation is associated with a greater incidence of neonatal adverse outcomes
• Korb et al. (Obstetrics & Gynecology, 2020) compared neonatal mortality and morbidity based on the planned mode of delivery when the first twin is in breech presentation

METHODS:

• Secondary analysis of population-based study
  • JUmeaux MODe d’Accouchement (JUMODA) cohort
  • National prospective population-based study of twin deliveries conducted in 176 French hospitals
• Included data
  • Pregnancies with first twin in breech presentation and the following
    • Both fetuses alive
    • Birth weight between 1,500 g and 4,000 g
    • Pregnancies ≥32w0d
• Data analysis
  • Multivariate Poisson regression models and propensity score analyses to control for potential confounders
• Primary outcome: Composite of neonatal mortality and morbidity included ≥1 or more of the following
  • 5-minute Apgar score <4 | Birth trauma | Injury of the phrenic or facial nerve present | Subdural or intracerebral hemorrhage | Encephalopathy | Endotracheal ventilation | Sepsis | BPD | Need for supplemental oxygen | IVH (grade III and IV | NEC (stage II and III)
• Statistical analysis: Based on number of women available for each group
  • Power of 80% to show relative risk (RR) ≥ 2.65 for associations between the planned mode of delivery and the primary outcome

RESULTS:

• Data from 1,467 women
  • Planned cesarean delivery: 79.7%
  • Planned vaginal delivery: 20.3%
• Women who delivered both twins vaginally among the planned vaginal birth group: 62.1%
• Planned vaginal delivery was not associated with neonatal adverse outcomes
  • Planned vaginal: 1.7% (5 births)
  • Planned cesarean: 1.9% (22 births)
  • Crude RR: 0.90 (95% CI, 0.34 to 2.34)
  • Adjusted RR: 0.71 (95% CI, 0.27 to 1.86)
  • Using propensity score or other statistical analyses to account for confounders also did not demonstrate any association
• Neonatal mortality and morbidity rates were similar for second twins as well

CONCLUSION:

• Study limitations
  • The authors acknowledge comparatively small number of women who underwent a planned vaginal delivery
  • Study not powered to identify small differences in outcomes
• Planned vaginal delivery where the first twin is in breech presentation was not associated with an increased risk for significant neonatal mortality or morbidity

Learn More – Primary Sources:

First Twin in Breech Presentation and Neonatal Mortality and Morbidity According to Planned Mode of Delivery

SARS-CoV-2: Is the Virus Present in the Female Genital Tract?

BACKGROUND AND PURPOSE:

• SARS-CoV-2 RNA has been identified in various tissues and fluids, including respiratory tract, digestive tract, urine and tears
• Male genital tract
  • Li et al. (JAMA, 2020) looked at whether SARS-CoV-2 could be detected in semen
  • Among 38 men with confirmed COVID-19 infection, 15.8% were positive for SARS-CoV-2 in semen specimens | 26.7% were at the acute stage of infection and 8.7% were recovering
  • Virus may persist during recovery although important to note that presence of virus does not equal ability to replicate or cause infection
  • Currently there is no evidence of sexual transmission for SARS-CoV-2
• Cui et al. (AJOG, 2020) investigated whether SARS-CoV-2 is present in the lower female genital tract

METHODS:

• Case series (January 28 to February 18, 2020)
• Setting
  • Wuhan, China
• Participants
  • Female COVID-19 patients, diagnosed by either
    • RT-PCR for viral presence
    • National Health Commission of China clinical guidance (based on epidemiological histories, symptoms and CT scans)
• Study design
  • Vaginal fluid, exfoliated cells, and anal swabs were collected from each patient
  • Samples were collected twice and processed at two different laboratories
• Specimen collection
  • Vaginal fluid: Using a speculum, posterior fornix was swabbed
  • Exfoliated cells: Cells were obtained from the cervix using a cytologic test protocol
  • Anal: Swabbed 3 cm into the canal

RESULTS:

• 35 patients were included
  • None of the patients were in the ICU or on mechanical ventilation
• Age range: 37 to 88 years | 50% had chronic diseases | 28 had entered menopause
• Interval between onset of symptoms and sampling was between 8 and 41 days
• One anal swab sample was positive
• All lower genital tract samples were negative

CONCLUSION:

• No SARS-CoV-2 viral presence was detected in any lower female genital tract samples in this study
  • The author hypothesize that this is due to the lack of ACE2 receptor expression in the vagina and cervix

Learn More – Primary Sources:

Severe acute respiratory syndrome coronavirus 2 detection in the female lower genital tract

Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019

Early Self-Proning of COVID-19 Patients in the ED Improves Oxygen Saturation

BACKGROUND AND PURPOSE:

• Proning is standard care when treating patients with ARDS who cannot achieve adequate oxygen saturation
• Caputo et al. (Academic Emergency Medicine 2020) describe the use of early proning of awake, non-intubated, suspected COVID-19 patients in the emergency department (ED)

METHODS:

• Pilot study
• Setting
  • A single ED in New York City
• Participants
  • Patients who arrived at the ED with hypoxia (SpO2 <90%) and could self-prone
  • Hypoxia did not resolve (SpO2 >93%) despite supplemental oxygen
• Study design
  • Patients asked to self-prone and change position
  • SpO2 was measured with a standard pulse oximeter and recorded at triage and after 5 minutes of proning
  • Supplemental oxygenation was in the form of non-rebreather mask (NRB) and nasal cannula
• Primary outcome
  • Change in SpO2 prior to proning, after application of supplemental oxygen and after 5 minutes of proning
• Secondary outcome
  • Intubation rate within 24 hours of arriving to the ED

RESULTS:

• 50 patients
  • All tested positive for SARS-CoV-2
  • Median age: 59 years | 60% male
  • 80% tachypneic on arrival (respiratory rate >20)
• Median SpO2
  • At triage: 80% (IQR 69 to 85)
  • After supplemental oxygen: 84% (IQR 75 to 90)
  • After 5 min of proning: 94% (IQR 90 to 95)
• Comparing pre to post-proning, SpO2 was significantly increased (p=0.001)
• 24% of patients (13 patients) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED

CONCLUSION:

• For COVID-19 patients in the ED, early self-proning while awake demonstrated improved oxygen saturation
• Further research is necessary to determine overall impact on disease course and mortality rates

Learn More – Primary Sources:

Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single EDs Experience during the COVID-19 Pandemic

COVID-19: The Impact of Asymptomatic Cases on the Pandemic Outbreak

BACKGROUND AND PURPOSE:

• Undocumented COVID-19 infections are likely to increase the spread and severity of the pandemic worldwide
  • Undocumented infections can be due to limited testing availability, and cases that are mild or asymptomatic
• Li et al. (Science, 2020) sought to estimate the contagiousness and proportion of undocumented SARS-CoV-2 infections in China during the weeks before and after the shutdown of travel in and out of Wuhan

METHODS:

• Mathematical modeling
  • Simulated infection spread throughout time and space across 375 Chinese cities before and after travel restrictions
  • Cases were classified as
    • Documented (confirmed) and undocumented
  • ‘Re’ (effective reproductive number): Number of people each infected person infects
    • If <1, cases will decrease

RESULTS:

Before Travel Restrictions Modeling

• Virus Characteristics
  • Re: 2.38 (95% CI 2.04 to 2.77)
  • SARS-CoV-2 has high capacity for sustained transmission
  • Median latent period: Approximately 3.69 days
  • Median infectious period: Approximately 3.48 days
• Undocumented cases
  • Only 14% (95% CI, 10 to 18%) of total infections in China were reported
• Impact of undocumented cases
  • An estimated 79% of individuals were infected by undocumented cases
  • The authors estimated that without infections from undocumented cases, the infection would have been substantially reduced
    • In Wuhan: 66.1%
    • Across all of China: 78.8%

After Travel Restrictions Modeling

• Virus characteristics
  • The Re decreased after travel restrictions were enacted
    • January 10 to 23 (before restrictions): 2.38
    • January 24 to February 8: 0.99 (95% CI: 0.76 to 1.33)
  • Estimates of both the latency and infectious periods were similar to those before travel restrictions
• Undocumented cases
  • The contagiousness of undocumented infections was reduced, likely due to increased testing and effective social distancing

CONCLUSION:

• Through mathematical modeling, the authors discovered that
  • Approximately 86% of COVID-19 cases prior to China restrictions were undocumented
  • These undocumented cases facilitated rapid spread throughout China
• In addition, cases have a period of pre-symptomatic shedding
• The authors assert that to control SARS-CoV-2 there needs to be
  • Major increase in testing
  • Effective isolation of asymptomatic or mild cases
• Unclear if
  • Re can be maintained at <1 for a sufficient length of time to eliminate the disease locally once containment measures are relaxed
  • International containment measures are required to allow opening of borders, while still preventing reintroduction of the virus

Learn More – Primary Sources:

Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2)

RCT Results: In Situ vs Uterine Exteriorization for Cesarean Repair

BACKGROUND AND PURPOSE:

• A frequently cited reason to avoid exteriorization for uterine repair following cesarean delivery relates to potential for nausea and vomiting
  • Phenylephrine infusion with spinal anesthesia decreases the risk of hypotension and nausea
• Mireault et al. compared exteriorization vs in situ repair using a standardized anesthetic protocol with the goal of assessing impact on patient nausea and vomiting

METHODS:

• Randomized double-blind controlled trial (RCT)
• Participants
  • Women undergoing elective cesarean delivery
  • Exclusion: Risk factors for uterine atony and PPH | Preoperative nausea and vomiting | BMI >35 kg/m2
• Standardized anesthetic protocol used for all patients
  • 1,000 mL of Lactated Ringer’s (over 5 to 10 minutes) then 300 mL/hour infusion
  • Spinal placed with patient in sitting position (hyperbaric bupivacaine, fentanyl and morphine)
  • Patient then placed in supine position with left uterine displacement
  • Phenylephrine perfusion: 0.5 micrograms/kg of lean body weight/min
• Interventions
  • Exteriorization
  • In situ uterine repair
• Statistical analysis
  • Power: 80 patients per group was needed to demonstrate a 50% reduction in intraoperative nausea and vomiting with in situ repair
• Primary outcome
  • Postdelivery intraoperative nausea and vomiting using a 4-point scale (0 to 3)
  • Patients asked to rate nausea at time of skin incision, hysterotomy, placental delivery, beginning of uterine repair, beginning of fascia repair (last 2 time points used to assess nausea related to repair)
  • Patient and data collector were blinded
• Additional data collected included
  • Hypotensive episodes | Tachycardia | Antiemetics | Vasopressor boluses | Length of surgery | Blood loss

RESULTS:

• 180 women randomized
  • Exteriorization: 90 women
  • In situ repair: 90 women
• Nausea and vomiting were more common in the exteriorization group (p=0.01)
  • Exteriorization: 39%
  • In situ repair: 22%
• The exteriorization group more commonly experienced
  • Hypotension (p<0.001)
    • Exteriorization: 80%
    • In situ repair: 50%
  • Tachycardia (p=0.02)
    • Exteriorization: 33%
    • In situ repair: 17%
• More phenylephrine boluses were administered to the exteriorization group (p<0.001)
  • Exteriorization: median 4 boluses
  • In situ repair: median 2 boluses
• No differences were found for the following
  • Duration of surgery
  • Blood loss
  • Postoperative hemoglobin decline

CONCLUSION:

• When using standard anesthesia protocols that includes phenylephrine, in situ uterine repair is associated with less postoperative nausea and vomiting, compared to exteriorization
• There was no difference in blood loss or surgery duration

Learn More – Primary Sources:

Uterine Exteriorization Compared With In Situ Repair of Hysterotomy After Cesarean Delivery: A Randomized Controlled Trial