E-ISSN:2320-8686
P-ISSN:2321-127X
RNI:MPENG/2017/74037

Case Report

Anaesthetic Management

International Journal of Medical Research and Review

2025 Volume 13 Number 2 Apr-Jun
Publisherwww.medresearch.in

Anaesthetic Management of a Patient With Varicella For Emergency Caesarean Section

Chanchal1*, Chugh P2
DOI:https://doi.org/10.17511/ijmrr.2025.i02.08

1* Chanchal, Assistant Professor, Department of Anaesthesia, Maulana Azad Medical College, Delhi, India.

2 Puneet Chugh, Assistant Professor, Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Delhi, India.

Varicella zoster (VZ) is a highly contagious virus, and it can cause two different diseases: chicken pox as the primary infection and later reactivation as shingles or herpes zoster. Approximately 5–10% of pregnant women lack antibodies to VZV and may acquire varicella during pregnancy. We present a case of a 20-year-old woman with herpes zoster who presented for emergency caesarean section because of foetal distress while discussing the anaesthetic issues related to varicella in pregnancy.

Keywords: Varicella, caesarean section, herpes zoster

Corresponding Author How to Cite this Article To Browse
Chanchal, Assistant Professor, Department of Anaesthesia, Maulana Azad Medical College, Delhi, , India.
Email: 		Chanchal, Chugh P, Anaesthetic Management of a Patient With Varicella For Emergency Caesarean Section. Int J Med Res Rev. 2025;13(2):37-40.
Available From
https://ijmrr.medresearch.in/index.php/ijmrr/article/view/1548

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2025-04-26 2025-05-01 2025-05-08 2025-05-17 2025-05-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.76

© 2025 by Chanchal, Chugh P and Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Int J Med Res Rev 2025;13(2)37
Download PDFBack To ArticleIntroductionCase reportDiscussionConclusionReferences
Chanchal et al. Anaesthetic Management of a Patient With Varicella

Introduction

Varicella is usually a mild and self-limiting disease, but severe complications like pneumonia, hepatitis, meningitis, encephalitis and bleeding diathesis can occur in adults and immunocompromised persons. We describe a case of 20 year 20-year-old woman with herpes zoster who presented for an emergency caesarean section, and discuss the anaesthetic issues related to varicella in pregnancy.

Case report

A 55 kg, 20‑year‑old primigravida at 34 weeks presented to the hospital with decreased fetal movement. The patient had raised blood pressure for the last 4 months and was on oral labetalol 100 mg daily. On evaluation, the patient had a fair general condition with a blood pressure of 134/100, for which injection of labetalol 20 mg IV bolus and magnesium sulphate therapy and induction of labour were initiated. Also, the patient had multiple papulo-vesicular rashes on the back and left side of the abdomen. (Figure 1&2)

ijmrr-1548-01.JPG
Figure 1: Varicella lesions on the back and left side of the abdomen

ijmrr-1548-02.JPG
Figure 2: Varicella lesions left side of the abdomen

On enquiry, the patient gave a history of lesions starting from the left side of the abdomen over the last 4 days and spreading to an area of T9-10 dermatomes. A dermatologist consultation was done, and T. acyclovir 800 mg 5 times a day was started for seven days. There was no history of previous immunisation, and there was no history of exposure to varicella. Preoperative investigations were Hb 9.7 gm/dl, and the rest investigations were normal.

The patient was shifted to the emergency operating room because of fetal distress. In the preoperative area, she was afebrile on touch. Examination of the oral cavity showed no lesions. Systemic examinations were unremarkable. On airway examination, the patient had an adequate mouth opening with adequate neck extension, and the Modified Mallampati class was II.

The patient was fasting for 6 hours. A high-risk consent foranaesthesiawas obtained. Ranitidine 50 mg and metoclopramide 10 mg were given intravenously.

An experienced team comprising an anesthesiologist, obstetrician, and neonatologist were in attendance. In the operating room, all routine monitors were applied and continuously monitored. Oxygen supplementation was initiated through a simple facemask at 5 L/min, and left uterine displacement was ensured. Her baseline blood pressure was 139/95 mmHg, her heart rate was 82 beats/min, and oxygen saturation was 99% on room air. 18G intravenous access was secured, and Ringer’s lactate was started. With the patient in the sitting position, a subarachnoid block was performed at the L4‑5 intervertebral space through the midline approach with the 25-G pencil‑point Quincke needle. After confirming the free flow of cerebrospinal fluid, 10mg hyperbaric bupivacaine (0.5%) with 10 μg fentanyl was injected intrathecally. The patient was placed in a supine position, maintaining left uterine displacement. Bilateral T4 sensory level to pinprick was obtained after 2 min. The surgery commenced through Pfannenstiel incision, and a 1.9 kg infant was delivered with the APGAR scores of 9 at both 1 and 5 minutes. 2 U bolus oxytocin was administered, followed by an infusion of 15 U oxytocin in 0.9% saline, 500 mL over 5 hours. The uterus was well contracted, and the rest intraoperative period was uneventful.


Int J Med Res Rev 2025;13(2)38
Chanchal et al. Anaesthetic Management of a Patient With Varicella

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]


Int J Med Res Rev 2025;13(2)39
Chanchal et al. Anaesthetic Management of a Patient With Varicella

2. N. W. Brown, A. P. R. Parsons and P. C. A. Kam. Anaesthetic considerations in a parturient with varicella presenting for Caesarean section. Anaesthesia 2003;58:1092–95. DOI: 10.1046/j.1365-2044.2003.03442.x [Crossref][PubMed][Google Scholar]

3. Nandini M, Dave, Sachin P, Sasane, H. R. , Iyer. Caesarean Section In A Patient With Varicella: Anaesthesia Considerations And Clinical Relevance. Indian Journal of Anaesthesia 51(2):p 140, Mar–Apr 2007 [Crossref][PubMed][Google Scholar]

Disclaimer / Publisher's Note The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of Journals and/or the editor(s). Journals and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.


Int J Med Res Rev 2025;13(2)40