The pandemic spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has affected 188 countries and territories. Altered physiological status during pregnancy makes a mother vulnerable to severe SARS-CoV-2 infection. The virus may be transmitted from mother to baby during antenatal period or postnatal period. Although the primary mode of transmission of the virus is by respiratory droplets, there is emerging evidence of in utero transmission from mother to foetus. In this rare case report, we describe one such episode of probable vertical transmission. To the best of our knowledge, this is the second systematically investigated Indian case, indicating in utero transmission of SARS-CoV-2 from mother to foetus.
BACKGROUND Meconium stained amniotic fluid (MSAF) occurs in 12 - 15 % of all deliveries and is frequently associated with adverse outcome in pregnancy. The present study was carried out to find out the maternal and fetal outcome in pregnancy complicated by meconium stained liquor in labour METHODS This retrospective study was carried out at a tertiary care centre at Pune. A total of 340 cases who had meconium stained liquor during labour or was detected on amniotomy was analysed. RESULTS Out of 340 cases, 252 (74.1 %) had thin and 88 (25.9 %) had thick meconium. MSAF was detected more in early labour (244, 71.8 %), as compared to advanced labour (96, 28.2 %). 212 (84.13 %) patients with thin meconium delivered by vaginal route. 30 (34.09 %) patients with thick meconium delivered by vaginal route. 40 (15.87 %) patients with thin meconium delivered by LSCS and 58 (65.91 %) with thick meconium delivered by LSCS. This difference was statistically significant (< 0.001). Being multiparous was a protective factor both for mother and baby against the presence of MSAF. A majority of neonates, 199 (58.53 %) were asymptomatic at birth both in thin and thick MSAF group. Endotracheal suctioning was done in 101 (29.7 %) neonates in both groups. 40 neonates (11.77 %) were admitted to NICU for severe birth asphyxia. Meconium aspiration syndrome (MAS) was observed in 20 cases (5.88 %), out of which 18 (90 %) had thick meconium and 02 (10 %) had thin meconium. A total of 04 (1.18 %) neonatal deaths occurred due to MAS. They were born to primigravida, had induced onset of labour with detection of thick meconium and delivered vaginally. CONCLUSIONS Meconium stained amniotic fluid (MSAF) is associated with increased incidence of caesarean section, lower Apgar score, NICU admissions, development of meconium aspiration syndrome and neonatal death. Obstetrician should be more vigilant while dealing with cases of thick type of MSAF. A timely caesarean section improves the neonatal outcome. KEYWORDS Meconium Stained Amniotic Fluid (MSAF), Meconium Aspiration Syndrome (MAS)
A mniotic fluid embolism (AFE) is a relatively rare but potentially catastrophic obstetric emergency. Early studies revealed mortality rates as high as 61-86%, but more recent studies suggest a case fatality of 13-26% with adverse neonatal outcomes [1]. The incidence ranges from 1:8000 to 1:80,000 pregnancies [2]. Despite the reduction in mortality, it still accounts for a significant number of maternal deaths in the USA, the UK, and some other countries. Exact figures from India could not be found. There are no proven risk factors though age more than 35 years, cesarean section, placenta previa, and multiple pregnancies have been highlighted [3]. There are no proven mechanisms either though two theories have been propounded. Initially thought to be due to mechanical obstruction caused by fetal amniotic fluid contents, now it is proposed to be due to an anaphylactic reaction to fetal content in maternal circulation [2]. Despite advances in diagnostics, AFE still remains a clinical diagnosis and no specific tests are recommended, however, a multidisciplinary approach is important for favorable outcomes [4]. We present a case of AFE which manifested atypically with severe back pain and respiratory distress in OT before anesthesia induction for elective lower segment cesarean section (LSCS) which fortunately responded favorably to aggressive management. CASE REPORT A 27-year-old second gravid (post-LSCS) with 38 weeks of gestation, booked case, was posted for elective cesarean section. The patient was accepted in American Society of Anesthesiologists-II for pregnancy and the plan of anesthesia was sub-arachnoid block. A self-declaration for coronavirus disease (COVID)-19 before surgery was not contributory and she also underwent rapid polymerase chain reaction test for COVID-19 as per existing guidelines. On the day of surgery, just after transferring her on the operation table, she had a sudden, excruciating episode of back pain along with cough. The vital signs recorded at that time showed heart rate 126/min, SpO 2 98%, and blood pressure of 120/90 mmHg. Electrocardiography showed normal sinus rhythm. Fetal heart rate (FHR) monitored by Doppler suggested severe bradycardia with FHR <80/min. A quick spinal anesthetic was administered (as the patient positioning had already been done) with 2.20 ml of 0.5% hyperbaric bupivacaine between the L3 and L4 spines in the left lateral decubitus position. The quick cold sense check was performed with an alcohol swab to verify the sensory block level to the fourth thoracic spinal segment. A limp male baby (APGAR score of 02) was delivered and was successfully resuscitated by attending pediatrician. After delivering the baby, the patient suddenly developed tachycardia 150 bpm, hypotension 50/28 mm of Hg, and tachypnea 38/min with wheeze on auscultation. She complained
Ketamine combined with diazepam and pentazocine as a labour analgesia and obstetrical outcome.
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