All hemodynamic parameters were well‑preserved throughout the 50 minutes of surgery and blood loss of 500 ml. Urine output was 100 ml, and a total of 1200 ml of crystalloid was given. There were no varicella lesions on the baby. Both mother and baby were discharged on day 9 of delivery with no complications.
Discussion
Varicella is a disease caused by a DNA virus named varicella zoster virus (VZV), which belongs to the herpes virus family. This virus may lie inactive in the dorsal root ganglia for a long period and may get reactivated can result in localised skin lesions known as ‘herpes zoster’ (shingles). The VZV infection risk is about 95%. Only 2% of cases occur in adult life, but they still cause 25% of all VZV-related deaths. The effects of primary VZV in pregnancy for both mother and foetus vary with the gestational age. The baby is at the highest risk in the first and second trimesters, whereas the mother is in the third trimester. [2]
This virus can be transmitted by direct contact or via aerosolised respiratory droplets. The symptoms include rash with low-grade fever and malaise. The most common complication includes secondary bacterial superinfection caused by Streptococcus pyogenes or Staphylococcus aureus. The central nervous system is the most common extra-cutaneous site involved. Acute cerebellar ataxia, encephalitis, aseptic meningitis, and Guillain–Barré syndrome can also occur. The potential risks of varicella infection among adults are a concern and challenge to physicians and have important implications for susceptible pregnant women. Early recognition, evaluation and management are important in preventing serious maternal complications. A patient with signs of primary varicella needs to be evaluated for varicella pneumonia, and intravenous acyclovir should be given when varicella pneumonia is present. [2]
Foetal complications include congenital varicella syndrome, characterised by skin lesions, neurological & eye defects, limb hypoplasia, restricted intrauterine growth & developmental delay. [3] Choice of anaesthesia in obstetric patients with varicella depends on patient’s clinical condition. On review of literature, we found two similar cases of caesarean section of patients with varicella conducted under general anaesthesia.[2]
It has been seen that the response to immune function is diminished under general anaesthesia, which is mainly due to inhalational agents. However, we could not locate any case of a pregnant patient with varicella for emergency caesarean section under regional anaesthesia.
Performing subarachnoid block in pregnant patients with viral infections such as active herpes infections and human immunodeficiency virus (HIV) is controversial.2 One major concern of performing regional anaesthesia is injecting the virus into the CSF, which may lead to meningitis or encephalitis.
The other major concern is the protection of health professionals from getting exposed while conducting an infectious patient. Personnel with previous exposure to this virus may have some immunity. However, the anaesthesiologist conducting the case must be careful.[3]
We chose to administer a subarachnoid block to our patient as the patient was afebrile and had no signs or symptoms of pneumonia. Also, the patient had no lesions at the site of spinal needle insertion. A sitting position for the block was chosen as the patient was unable to lie supine because of widespread lesions on the abdomen. Subarachnoid block was proved successful in our case with no maternal and foetal complications.
Conclusion
Both regional and general anaesthesia can be administered in obstetric patients with varicella, depending on the patient’s clinical condition and the nature of surgery.
The risks and benefits of both types of anesthesia should be considered. Subarachnoid block proved safe and successful in our case. The complications of varicella, especially bleeding diathesis, myocarditis and hepatitis, must be remembered and ruled out before the anaesthesia.
References
1. Ohri R, Vyas V. Anaesthetic Implications in a Primigravida Posted for Cesarean Section with Varicella Zoster Infection. J South Asian Feder Obst Gynae 2018;10(4):291-292. . [Crossref][PubMed][Google Scholar]