|Year : 2012 | Volume
| Issue : 2 | Page : 105-108
Anesthesia for cesarean section in a parturient with acute varicella: Is general anesthesia better than neuraxial anesthesia?
Bikash R Ray, Deepak Singhal, Anil Kumar, Anuradha Borle, Dalim K Baidya
Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||17-Dec-2012|
Dalim K Baidya
Department of Anesthesia, Room No - 507, 5th Floor, Academic Wing, CDER, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
The incidence of varicella infection during pregnancy is low. However, it is associated with a significant risk of morbidity and mortality, both to the mother and the fetus. The risk for any complication is highest for the mother during the third trimester and pneumonia is the leading cause of maternal mortality. Anesthetic management in these patients depends upon the extent of involvement of the disease, associated complications of varicella, duration of antiviral therapy and natural course if the disease. We present the anesthetic management of a case of cesarean section in a patient with acute varicella infection, and discuss the various concerns regarding the choice of anesthesia.
Keywords: Anesthesia, cesarean section, pregnancy, varicella (chicken pox)
|How to cite this article:|
Ray BR, Singhal D, Kumar A, Borle A, Baidya DK. Anesthesia for cesarean section in a parturient with acute varicella: Is general anesthesia better than neuraxial anesthesia?. J Obstet Anaesth Crit Care 2012;2:105-8
|How to cite this URL:|
Ray BR, Singhal D, Kumar A, Borle A, Baidya DK. Anesthesia for cesarean section in a parturient with acute varicella: Is general anesthesia better than neuraxial anesthesia?. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2020 Sep 18];2:105-8. Available from: http://www.joacc.com/text.asp?2012/2/2/105/104737
| Introduction|| |
Varicella or chickenpox is an extremely contagious infection caused by the varicella zoster virus (VZV). It is usually a benign illness of the childhood and is characterized by an exanthematous rash.  However it has a higher rate of complications in adults and pregnant women are more susceptible for complications.  Pregnant women with active varicella infection for cesarean section have several issues regarding the choice of anesthetic technique. Here we present the anesthetic management of cesarean section in a parturient with varicella and discuss the various anesthesia related concerns.
| Case Report|| |
A 27-year-old (50 kg weight, 154 cm height) primigravida with Rh isoimmunized pregnancy reported to our hospital at 32 weeks of pregnancy for conduction of safe confinement. She was diagnosed as a case of Rh-isoimmunization during her first antenatal visit after which she was lost follow up. At the time of presentation, she produced a history of fever, productive cough and malaise since last three days followed by development of maculopapular rash. Lesions first began as macules and papules on the face and then progressed to the trunk and abdomen, becoming pustular since two days. She was started on Acyclovir therapy by a private practitioner. She had not been previously immunized and did not give any history of exposure to varicella. She was evaluated and found to have intrauterine growth retardation (IUGR) of the fetus. Her medical history was not suggestive of any other associated illness and her blood investigations were within normal limits. On examination she was afebrile, had stable vitals (heart rate of 88/min, blood pressure of 128/72 mm of Hg, respiratory rate of 16/min, and room air saturation of 97 %) but auscultation of her chest revealed conducted sounds in the base of both the lungs. The fetus had recurrent episodes of reversible bradycardia. In view of severe IUGR and recurrent bradycardia urgent cesarean section was planned.
She received antiaspiration prophylaxis and prophylactic antibiotic (cefotaxim and metronidazole) prior to surgery. In the operation theater her bladder was catheterized and a large bore intravenous line was secured. The patient was not willing for general anesthesia; central neuraxial block was planned after discussing with the obstetrician. She was positioned in the left lateral position and the lumbar area, which was free from the maculopapular rash, was prepared with antiseptic solutions. 10 mg hyperbaric bupivacaine and 20 mcg fentanyl was injected intrathecally using a 25 G pencil point spinal needle.
A female child was delivered after 12 minutes of neuraxial block with birth weight of 1.9 kg and Apgar score of 7 and 8 at 1 and 5 minute respectively. The baby was shifted to neonatal intensive care unit for monitoring and further management. Blood loss was 800ml and she received 2 liter of Ringer's lactate throughout the surgery. She received 15 units oxytocin through infusion during the surgery. At the end of the surgery, she was shifted to post anesthesia recovery room for monitoring.
In recovery all monitors was attached and she received intravenous paracetamol 1gm six hourly for postoperative pain. Injection tramadol 50 mg intravenously was used as rescue analgesia as and when required. She was hemodynamically stable throughout the stay in the recovery room. Antiviral (tab acyclovir 800 mg by mouth five times daily) and antibacterial medications were continued in the postoperative period for 5 days. Her rash gradually disappeared in next five days and her post-operative hospital stay was uneventful. The child was kept in the neonatal intensive care unit for 10 days. She was discharged on post-operative day twelve and followed up in medicine clinic.
| Discussion|| |
Varicella (chickenpox) is caused by the varicella- zoster virus, of which humans are the only reservoirs. It is a highly contagious disease, with an attack rate of at least 90% among susceptible (sero-negative) individuals. Incubation period ranges from 14 to 17 days, after which it presents with rash, low-grade fever and malaise with prodromal symptoms. The skin lesions include maculopapules, vesicles, and scab in various stages of the disease. Patients remain infectious from 48 hours before the onset of rash till the crusting of all vesicles. It is self-limiting in milder form but complications can occur, particularly in immunocompromised patients. 
Commonest complication is secondary bacterial infection of the skin lesions caused by streptococcus pyogenes or staphylococcus aureus. Most common extracutaneous site of involvement is CNS in children and lungs in adults. Varicella infection may be associated with aseptic meningitis, encephalitis, transverse myelitis, and Guillain-Barrι syndrome. Other complications may include myocarditis, corneal lesions, nephritis, arthritis, bleeding diatheses, acute glomerulonephritis and hepatitis. 
Varicella during pregnancy is not uncommon. The risk for maternal complications is highest during the third trimester whereas the fetus is maximally affected during the first trimester.  The neonatal varicella is usually severe if the maternal infection has an onset between 4 to 7 days before delivery and till 48 hours after delivery, due to direct transplacental transfer of the virus and lack of antibodies against the virus. 
A pregnant patient with active varicella for cesarean section poses several concerns to the anesthesiologist. The most important dilemma is regarding the choice of anesthesia technique. Gambling and Douglas recommended regional anesthesia in pregnant women with varicella due to high risk of varicella pneumonia,  whereas Camann and Toumals suggested to avoid regional anesthesia for two week after onset of symptoms due to the presence of viremia.  There are no recommendations or strong level of evidence regarding the choice of anesthesia technique, due to lack of randomized controlled studies in these patients. In the present case, spinal anesthesia was chosen for the fear of potential risk of varicella pneumonia. Moreover, the patient was not willing for general anesthesia.
Use of neuraxial anesthetic techniques is debated due to the possibility of introducing the virus into the central nervous system (CNS) during the placement of the block. The probability is even higher during the primary infection when viraemia is present. Another concern is the difficulty in differentiating between the post dural puncture headache and headache due to CNS infection. Similar argument is justified in parturients with HIV infection. However, there is no evidence of spread of HIV to the central nervous system through neuraxial blockade in parturient with HIV infection.  Neuraxial anesthesia has been found to be safe and the preferred method of choice in parturients with HIV infection.  Use of pencil point spinal is advocated by Brown et al, as it will prevent tissue coring and will reduce the potential risk of introducing infective viral material into the central nervous system.  However the neuraxial involvement of the virus can occur naturally and independently of the block, as the dorsal root ganglion is infected during systemic varicella infection, where the virus remains latent until reactivated, producing zoster.  Furthermore our patient received acyclovir therapy for 2 days prior to surgery. Acyclovir inhibits replication of the varicella zoster virus (VZV) and viral activity cannot be detected in peripheral blood 24 hours after initiation of acyclovir therapy.  Hence, appropriate antiviral treatment for at least 24 hours can theoretically reduce the risk of infection. Martin et al have described successful placement of epidural blood patch in a woman in the context of acute varicella under antiviral coverage.  In this case successful spinal block was possible as the interspinous space in the lumbar region was spared from the rash. In patients with extensive skin involvement at the site of placement of the block, general anesthesia would be the anesthesia technique of choice. In our opinion, neuraxial block is safe and should be the preferred in parturients with varicella, in whom the site of placement of block is not involved and have received antiviral therapy for more than 24 hours. However, neurological monitoring and antiviral therapy should be considered in the postoperative period.
The major concern with the use of general anesthesia technique is potential risk of viral pneumonia which has a high morbidity and mortality.  Our patient had history of fever and cough for two days and had conducted sounds at lung bases, which made us choose regional anesthesia over general anesthesia.
Varicella pneumonia, the most serious complication following chickenpox, develops more commonly in adults (up to 20% of cases) than in children and is more common and severe in pregnant women than in adult immunocompetent population. Primary varicella infections occur in as few as l-5 in 10,000 pregnancies,  but the mortality from untreated varicella pneumonia in pregnancy may be as high as 45% because of high incidence of respiratory failure.  Clinical features of varicella pneumonia appear 3-5 days after the onset of the disease and include fever, tachypnea, dyspnea, cough, pleuritic chest pain and haemoptysis. Intubation and mechanical ventilation are required in 10% of adult patients with varicella infections. Pregnancy, in the third trimester, increases maternal risk of pulmonary complications two to three-fold due to secondary immunosuppression and changes in pulmonary compliance. Harger and coworkers found that maternal smoking; presence of skin lesions >100 and pharyngeal lesions as the risk factors for pneumonia in paturients.  Acyclovir should be started for varicella pneumonia as soon as possible irrespective of the stage of disease but if started within 72 hours of dyspnea it decreases the maternal mortality from 45% to less than 20%. As varicella pneumonia has high mortality and morbidity during pregnancy, all pregnant women with varicella should be closely monitored. If general anesthesia is used in these patients it may increase the chance of pneumonia due to change in pulmonary mechanics and decrease in immune response. Dave and coworkers suggested that if general anesthetic technique is used for cesarean section in parturient with varicella, it should be devoid of inhalational anesthetic and nitrous oxide, as they are known to decrease the immune response.  In our opinion, general anesthesia should be preferably avoided in pregnant women with active varicella who have symptoms suggestive of onset of pneumonia or have any of the risk factors for development of varicella pneumonia. If general anesthesia is used for cesarean section in pregnant women with varicella, intensive surveillance for detection of pneumonia and aggressive antiviral therapy will decrease the complications due to varicella pneumonia.
Neonate born from a mother who had varicella infection should receive zoster immunoglobulin as soon as possible. Though routine acyclovir therapy is not recommended for prophylaxis in these infants, it should be started promptly when varicella infection occurs. 
Although exposure or infection with VZV provides immunity, a second infection can occur.  Hence all medical personal should execute caution and minimize exposure to infectious patient. Prophylactic administration of zoster immunoglobulin within 72 hours can prevent or reduce the severity of varicella infection in unimmunized subjects.  A vaccine is available for prevention of varicella, which provides >70% protection against infection and reduces severity in >90% subjects for 7 to 10 years. Routine vaccination is recommended for all health care providers for prevention of the infection. Also all susceptible women of childbearing age should be vaccinated to reduce the severity of infection. However vaccination is not recommended during pregnancy. 
To conclude, central neuraxial block is safe and should be preferred in pregnant women with active varicella infection, when performed after appropriate antiviral therapy has been initiated. Postoperatively, antiviral therapy should be continued and neurological monitoring should be considered if neuraxial technique was used. General anesthesia, though have been used in these patients, should preferably be avoided in patients having risk factors for development of varicella pneumonia. All patients should be monitored for development of varicella pneumonia in the perioperative period, which should be treated aggressively with appropriate antiviral therapy. Medical personnel should be aware of the prophylactic and preventive measures against varicella infection.
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