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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 144-149

Retrospective analysis of the outcome of the anaesthetic procedures in COVID-19 parturient undergoing cesarean delivery in a tertiary care hospital in Delhi, India


1 Department of Anaesthesia and Intensive Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
2 Department of Anaesthesia and Intensive Care, Vardhaman Mahavir Medical College, New Delhi, India

Date of Submission07-Oct-2021
Date of Acceptance21-Apr-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Mousumi Saha
Department of Anaesthesia and Intensive Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_93_21

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  Abstract 


Context: The effect of coronavirus disease 2019 (COVID-19) on a parturient undergoing cesarean delivery (CD) is not fully understood. Aims: To evaluate anesthetic management of a COVID parturient undergoing CD. Settings and Design: Tertiary care hospital, retrospective analysis. Methodology: Hospital case record files of COVID-19 parturients who underwent CD were reviewed with respect to clinical presentation, anesthetic technique, peri-operative course, and maternal-fetal outcome. Data Analysis: Continuous variables are reported as mean ± SD or median (range) and categorical variables as numbers (percentages). Results: Hundred COVID-19 parturients underwent CD: Ninety-eight parturients had asymptomatic to mild clinical presentation, whereas two had a severe presentation. Raised liver enzymes, raised D-dimer, and thrombocytopenia were observed in 65, 34, and 11 parturients, respectively. Combined spinal-epidural anesthesia (CSEA), subarachnoid block (SAB), and general anesthesia were administered in 72, 26, and 2 parturients, respectively. Meantime to administration of SAB and CSEA were 23.5 ± 3.2 min and 28.4 ± 2.8 min, respectively. Adequate block height for CD was achieved in all parturients. Post-spinal hypotension that responded promptly to fluids and vasopressors was reported in six parturients. Postoperatively, two parturients required intensive care unit (ICU) care with one maternal mortality. None of the neonates tested positive for COVID-19. Three neonates had a low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) at 5 min with one neonatal mortality. Conclusions: Neuraxial anesthesia seems to be a safe and preferred anesthetic technique for CD in a COVID-19 parturient. The incidence of post-spinal hypotension is low and responds promptly to treatment. The course of neuraxial anesthesia and the neonatal outcome is unaffected by the COVID-19 status of the patient.

Keywords: Anesthesia, COVID-19, neonate, parturient, post-spinal hypotension


How to cite this article:
Wadhwa B, Gaba P, Chaudhary K, Saxena KN, Sharma KR, Saha M, Gaur S, Doda P. Retrospective analysis of the outcome of the anaesthetic procedures in COVID-19 parturient undergoing cesarean delivery in a tertiary care hospital in Delhi, India. J Obstet Anaesth Crit Care 2022;12:144-9

How to cite this URL:
Wadhwa B, Gaba P, Chaudhary K, Saxena KN, Sharma KR, Saha M, Gaur S, Doda P. Retrospective analysis of the outcome of the anaesthetic procedures in COVID-19 parturient undergoing cesarean delivery in a tertiary care hospital in Delhi, India. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2022 Oct 3];12:144-9. Available from: https://www.joacc.com/text.asp?2022/12/2/144/355356




  Introduction Top


An increased incidence of cesarean delivery (CD) has been reported in COVID-19 parturients.[1] COVID-19 infection along with the unique considerations of obstetric anesthesia poses a challenge to the anesthesiologist. These include concerns of aerosol-generating procedures with general anesthesia, post-spinal hypotension, and the risk of meningitis/encephalitis with neuraxial anesthesia as well as the impact of preoperative multi-system involvement on the anesthetic management. This retrospective study describes the clinical presentation, anesthetic technique, perioperative course, and maternal-neonatal outcomes of hundred COVID-19 positive parturients who presented for CD at a tertiary care hospital in Delhi, India during the study duration.


  Materials and Methods Top


The retrospective analysis was conducted after approval of the institutional ethics committee (IEC No F.1/IEC/MAMC/80/08/2020/No 215; principal investigator BW).

Patient population

Parturients with COVID-19 infection, confirmed by nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) assay who underwent cesarean delivery under anesthesia from 15th April to 25th August 2020 at a tertiary care hospital in Delhi, India were included in this study.

Data collection

Information required for the data collection forms [Annexure 1] was retrieved from the hospital case files by two investigators. The data collected included demographics, preoperative clinical status, laboratory findings, anesthetic management, and maternal-fetal outcomes. Demographic data included age and associated comorbid conditions. The indication of CD and the severity of the disease were noted. Disease severity was graded as asymptomatic, mild, moderate, severe, and critical as per National Institutes of Health (NIH) COVID-19 treatment guidelines.[2] The requirement and the mode of oxygen supplementation at the time of CD were noted. Laboratory investigations observed included complete blood count, liver function tests, bleeding time, prothrombin time, and D-dimer levels in the selected parturients. Anaesthetic management details regarding the anesthetic technique, achievement of adequate block height for CD, perioperative course, and complications were noted. The block height was considered adequate if sensory level up to T6 to pinprick was achieved bilaterally. The maternal outcome in terms of the need for intensive care unit (ICU) care and mortality was noted. Also, a note was made of neonatal outcome in terms of Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score at 5 min, need for neonatal ICU care, and mortality. The data collected was then reviewed by two independent investigators.



Data analysis

The analysis of data was performed using Microsoft Excel. The values of continuous variables are reported as mean ± SD or median (range). Categorical variables are reported as numbers and percentages.


  Results Top


Hundred COVID-19 positive parturients underwent CD under anesthesia during the study period. The mean age of the parturients was 28 ± 2.1 yrs.

Preoperative clinical status

Ninety-eight parturients had mild to asymptomatic clinical presentation, whereas two had a severe presentation with the requirement of oxygen supplementation through a nonrebreathing mask in one and noninvasive ventilation (NIV) in the other at the time of CD.

Collected data revealed associated comorbid conditions ranging from gestational diabetes mellitus, hypertensive disorders of pregnancy, and hypothyroidism to the less commonly seen conditions like antiphospholipid antibody syndrome and triplet pregnancy [Table 1].
Table 1: Associated Comorbid conditions

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Twenty-nine parturients underwent elective CD, whereas 71 underwent emergency CD.

Laboratory investigations

The complete blood count was unremarkable in the study parturients except for thrombocytopenia (< 1 lakh/mm3) in 11 parturients (11/100; 11%). Out of these 11, 4 parturients had platelet counts <50,000/mm3. The bleeding time was normal in all the study parturients irrespective of the platelet count.

The bilirubin levels were mildly raised in only three parturients (3/100; 3%) who had intrahepatic cholestasis of pregnancy. Raised liver enzymes [aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH)] were observed in 68.3% (65/95) of the parturients. The liver enzymes were more than three times the upper normal limit in 11 parturients (11/95; 11.57%). However, the prothrombin time (PT) was normal in all the parturients. D dimer levels were raised in 34 parturients. None of the parturients was administered heparin prophylaxis for raised D-dimer levels.

Anaesthetic management

Out of the hundred studied parturients, 72 received combined spinal-epidural anesthesia (CSEA), 26 received subarachnoid block (SAB), whereas two parturients were administered general anesthesia (GA). The mean time to administration of SAB and CSEA were 23.5 ± 3.2 min and 28.4 ± 2.8 min, respectively where time to administration of SAB and CSEA was defined as the time from the start of part preparation till the administration of intrathecal drug.

CSEA

Seventy-two parturients received CSEA. CSEA was administered using two space technique. SAB was administered in L3–4/L4–5 space, and 1.6–2.2 mL hyperbaric bupivacaine was administered, and an 18-G epidural catheter was inserted at a space above in all the cases. The median sensory level achieved was T5 (T4 –T6). Eight cases required intraoperative epidural supplementation, due to the prolonged duration of the surgery, with 0.5% plain bupivacaine after block regression. Fifty-three parturients were administered 6–8 mL of 0.25% plain bupivacaine with or without adjuvants [Table 2] after the completion of surgery for postoperative analgesia, whereas no drug was given through the epidural catheter in 11 parturients. Paracetamol infusion was administered postoperatively for postoperative analgesia in these patients. The epidural catheter was removed postoperatively after 6 h in all the parturients.
Table 2: Postoperative epidural activation drug doses

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SAB

In twenty-six parturients who received only SAB for CD, fentanyl (15–20 μg) was added as an adjuvant to 1.6–2.2 mL 0.5% hyperbaric bupivacaine. The median sensory level achieved was T5 (T4 –T6) dermatome level, and the meantime to regression to T10 ermatomal level was 146 ± 20 min. A single-shot 27-G Whitacre needle was used to administer SAB in four parturients with platelet count <50,000/mm3 after preoperative platelet transfusion.

Complications of neuraxial anesthesia

Post-spinal hypotension was observed in six parturients (6/110; 6%). This promptly responded to fluid bolus in three parturients, whereas three needed an additional single dose of 3 mg mephentermine. Bloody tap was observed in six parturients, but none of these had thrombocytopenia or deranged liver function tests. Neuraxial hematoma and neurological complications like meningitis/encephalitis or postdural puncture headache were not observed in any of the parturients. None of the parturients administered neuraxial opioids complained of sedation, itching, or postoperative nausea and vomiting.

General anesthesia

GA was administered in only two parturients; one with preoperative respiratory compromise on oxygen supplementation through noninvasive ventilation (NIV) at the time of CD and the other with placenta accrete, which obviated neuraxial block. Thiopentone and succinylcholine were used for rapid sequence intubation after preoxygenation. Both were intubated using a 7-mm internal diameter (ID) endotracheal tube in a single attempt using a Tuorenvideo laryngoscope (Tuoren Medical device India Ltd. Gurgaon, India) with a disposable blade within a transparent intubation box by the senior most member of the team. The intraoperative period was uneventful, and no episode of hypotension or desaturation was noted. Both the patients were subsequently managed in the ICU. The parturient with severe clinical presentation had a worsening course in the ICU and expired after 4 days of surgery, whereas the parturient with an indication of placenta accreta and mild clinical presentation was successfully weaned off and discharged after becoming COVID negative in 5 days.

Duration of urgery

The mean duration of surgery was 114 ± 08 min (110–190 min). A significantly longer duration was observed in the first eight surgeries (140–190 min).

Maternal outcome

One maternal mortality was noted. Rest all parturients recovered uneventfully.

Neonatal outcome

Three neonates had a low APGAR score at 5 min. None of the neonates required ICU care. One neonatal mortality was observed in emergency CD for fetal distress with grade III meconium-stained liquor. None of the neonates tested positive for COVID-19.


  Discussion Top


The study observed neuraxial block to be a safe and effective mode for achieving satisfactory obstetrical anesthesia. The incidence of post-spinal hypotension following subarachnoid block is low and responds promptly to treatment. Coexisting COVID-19 infection did not appear to affect the level or duration of block and maternal-fetal outcome. Neurological complications like meningitis or encephalitis were not observed in any of the parturients.

Multisystem involvement, high infectivity, changing treatment protocols, and an absence of a verified protocol for the anesthetic management in the COVID-19 parturient present a challenge for the anesthesiologist.

The clinical manifestations as compared to nonpregnant individuals of the same age are similar, and most infected mothers usually recover before delivery of the baby as observed in our study.[3],[4],[5] Only two parturients required ICU care with supplemental oxygen, with one parturient on preoperative NIV.

Preoperative raised liver enzymes were noted in 68.3% of the parturients similar to other studies.[6],[7] No deterioration or progression to severe pneumonia was observed in these patients in contrast to the findings of other authors.[6],[7] The raised liver enzymes appeared to be part of the viral pathology and had no impact on the coagulation. The interplay between inflammation and coagulation (thrombo-inflammation) is well established in the COVID-19 patients, but consumptive disseminated intravascular coagulation (DIC) with bleeding diathesis has not been reported, and most patients have normal prothrombin time as also observed in our study.[8]

Although thrombocytopenia was observed in 11 parturients with platelet count even less than 50,000/mm3 in 4 parturients; bleeding time was normal in all. SAB was administered in all these parturients without any complaints of neuraxial hematoma or other neurological complications similar to the observations by other authors.[9],[10] Thrombocytopenia has been observed to be a marker of severity in patients with COVID-19;[11] however, it was not associated with any worsening of clinical status in our series.

None of the parturients received heparin despite raised D-dimer in 34 parturients. Although elevated D-dimer levels are predictive of disease severity in the general population, D-dimer levels can be elevated during normal pregnancy and therefore may have a limited prognostic value of morbidity in COVID-19 parturients.[12],[13] Contraindication to neuraxial block and the risk of excessive hemorrhage in the event of administration of anticoagulation near delivery presumably precluded heparin prophylaxis in these parturients.

There is a general apprehension that the use of general anesthesia in a COVID parturient may increase respiratory compromise and worsen the clinical condition. Furthermore, aerosol generation during preoxygenation, facemask ventilation, endotracheal intubation, oral or tracheal suctioning, and extubation can place the health care workers at the risk of infection.[14] Neuraxial block is, therefore, considered the anesthesia of choice for CD in the COVID-positive parturient.[15]

Traditionally, SAB is the preferred neuraxial block in the parturient; however, performing surgery while wearing personal protective equipment (PPE) is likely to reduce skill sets and prolong the duration of surgery outlasting the effect of SAB. After working in the ICU while wearing PPE, we realized that the dexterity and skills get greatly compromised. This was the first time anyone from the team had worked while wearing PPE and keeping this in mind, we anticipated that there could be a delay in both the administration of the block and the completion of surgery. Thus, the decision to go for CSEA was made. Our decision proved to be a wise one as the first few cases conducted lasted 190 minu. As the team got adjusted to working with PPE, the mean duration of surgery and administration of block become lesser. In search of the literature, we were not able to find any study that compared CSEA with SAB in COVID CD. Only two case reports by Paramanathan et al.[16] and Du et al.[17] applied CSE anesthesia in emergency COVID CD, to avoid the risk of airway management, in case of insufficient spinal anesthesia.

Though PPE is necessary for the protection of front-line health care workers, it may lead to considerable physical and mental distress to the users like headaches, skin changes, somnolence, anxiety, depression, difficulty in communication, diminished visibility due to fogging, triple layers of gloves hindering tactile perception, and its overall negative impact on decision making and surgical performance, which leads to unexpected prolongation of surgery.

Similar observations were observed regarding the increased duration of surgery in the first half of the study period and presumably keeping this consideration in mind, CSEA was administered in 72% of the parturients. CSEA provided rapid, reliable onset of the block with prolongation of block and postoperative analgesia as and when required. In search of the literature, we were not able to find any study that compared the duration of CDs in non-COVID with COVID parturients.

Concerns over the complications of neuraxial block in COVID-19 patients include meningitis, encephalitis, bloody tap. and post-spinal hypotension. The bloody tap observed in six parturients was presumably due to minor vascular trauma as a result of the technically difficult procedure while wearing PPE. No other neurological complication was noted in any of the parturients. Our analysis is in agreement with other authors that the concerns with general anesthesia outweigh the theoretical risk of meningitis/encephalitis with a neuraxial block in the COVID-19 parturient.[18]

Excessive hypotension after spinal anesthesia has been reported by Chen et al.[14] in their case series on COVID parturients posted for CD. However, only six parturients in our study reported post-spinal hypotension, which could be rapidly corrected with IV fluids and a single dose of mephentermine injection. The incidence of post-spinal hypotension in our series was not higher than that seen in the non-COVID parturient and our analysis confirms the experience of other authors that spinal anesthesia is well tolerated in the COVID-positive parturient.[19],[20]

COVID 19-has had a profound impact on the mental health of patients with a high incidence of anxiety and depression.[21] However, preoperative sedative drugs are usually avoided for the fear of respiratory compromise and unpredictable effects in the COVID-19 parturient. Similar apprehension is prevalent with neuraxial opioids. In our study, four parturients received preoperative 0.5 mg midazolam, and forty-two were administered neuraxial opioids. None reported any adverse respiratory effects.

None of the neonates in our series tested positive for COVID-19. The results are in corroboration with the current evidence that supports the minimal risk of vertical transmission during delivery.[22] Low APGAR scores observed in three neonates were consistent with obstetrical considerations.

Delay in the administration of anesthesia and surgical readiness is of significant concern in the COVID-positive parturient presenting for emergency CD.[23],[24] Donning and doffing of PPE is a time-consuming process. The decreased visibility due to fogging of the face shield and reduced tactile perception while wearing triple gloves reduce the skillsets for technical procedures such as neuraxial blocks. The mean time to administration of SAB and CSEA was observed to be longer than the time usually taken for administration of blocks at our institution and can be attributed to the above factors. The performance of the procedure by the most experienced anesthesia provider in the team and the preparation of drugs and necessary equipment before donning may decrease the time to induction of anesthesia.

Limitations

Firstly, the study has inherent limitations of retrospective analysis. Secondly, it is likely to represent the characteristics of patients residing in districts catered by the hospital. However, the hospital caters to a large region of northern India. There are only a few case reports of COVID-19 parturients presenting for CD in the literature, and a large number of COVID-19 parturients in this study adds to its strength. The need for subsequent multicentric larger studies cannot be overemphasized.


  Conclusion Top


Neuraxial anesthesia seems to be a safe, effective, and preferred anesthetic technique for CD in COVID-19 parturients. Keeping in mind the high transmissibility of COVID-19 and the apprehension with the administration of GA in these patients, we recommend that CSEA is a better alternative as it can obviate the need for GA in case of inadequate level or prolonged surgery, which can occur due to the attrition of skills when operating in PPE. Additionally, CSEA also provides postoperative analgesia in the COVID- parturient. The incidence of post-spinal hypotension is low and responds promptly to treatment. The course of neuraxial anesthesia and the neonatal outcome is unaffected by the COVID status of the patient. The conduct of anesthesia and duration of surgery is prolonged due to a reduction in skill sets while wearing PPE.

Acknowledgement

To the residents of the Department of Anaesthesia and Department of Obstetric and Gynaecology and technical OT staff.

Key message

  • Neuraxial anesthesia seems a safe anesthetic mode for COVID-19 cesarean delivery.
  • Combined spinal-epidural anesthesia is the preferred neuraxial technique.
  • COVID-19 status does not affect the course of neuraxial anesthesia.
  • Neonatal outcome is unaffected by the COVID status of the mother.
  • The conduct of anesthesia is prolonged while wearing personal protective equipment.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mullins E, Evans D, Viner RM, O'Brien P, Morris E. Coronavirus in pregnancy and delivery: Rapid review. Ultrasound Obstet Gynecol 2020;55:586-92.  Back to cited text no. 1
    
2.
COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available from: https://www.covid19treatmentguidelines.nih.gov/. [Last accessed on 2021 Jul 29].  Back to cited text no. 2
    
3.
Elshafeey F, Magdi R, Hindi N, Elshebiny M, Farrag N, Mahdy S, et al. A systematic scoping review of COVID-19 during pregnancy and childbirth. Int J Gynaecol Obstet 2020;150:47-52.  Back to cited text no. 3
    
4.
Breslin N, Baptiste C, Gyamfi-Bannerman C, Miller R, Martinez R, Bernstein K, et al. COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM 2020;2:100118. doi: 10.1016/j.ajogmf. 2020.100162.  Back to cited text no. 4
    
5.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.  Back to cited text no. 5
    
6.
Cai Q, Huang D, Yu H, Zhu Z, Xia Z, Su Y. COVID-19: Abnormal liver function tests. J Hepatol 2020;73:566-74.  Back to cited text no. 6
    
7.
Fan Z, Chen L, Li J, Cheng X, Yang J, Tian C, et al. Clinical features of COVID-19-related liver functional abnormality. Clin Gastroenterol Hepatol 2020;18:1561-6.  Back to cited text no. 7
    
8.
Xu P, Zhou Q, Xu J. Mechanism of thrombocytopenia in COVID-19 patients. Ann Hematol 2020;99:1205-8.  Back to cited text no. 8
    
9.
Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost 2020;18:1559-61.  Back to cited text no. 9
    
10.
Lee LO, Bateman BT, Kheterpal S, Klumpner TT, Housey M, Aziz MF, et al. Risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturient: A report from the multicenter perioperative outcomes group. Anaesthesiology 2017;126:1053-63.  Back to cited text no. 10
    
11.
Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta 2020;506:145-8.  Back to cited text no. 11
    
12.
Dashraath P, Wong JLJ, Lim MXK, Lim LM, Li S, Biswas A, Choolani M, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31.  Back to cited text no. 12
    
13.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 13
    
14.
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anaesthetic regimens for parturient with COVID-19 undergoing Caesarean delivery: A case series of 17 patients. Can J Anaesth 2020;67:655-63.  Back to cited text no. 14
    
15.
Interim Considerations for Obstetric Anaesthesia Care Related to COVID-19.Society for Obstetric Anaesthesia and Perinatology. Available from: https://soap.org/education/provider-education/expert-summaries/interim-considerations-for-obstetric-anesthesia-care-related-to-covid19/. [Last accessed on 2021 Jul 29].  Back to cited text no. 15
    
16.
Paramanathan S, Kyng KJ, Laursen AL, Jensen LD, Grejs AM, Jain D. COVID-19 with severe acute respiratory distress in a pregnant woman leading to preterm caesarean section: A case report. Case Rep Womens Health 2021;30:e00304. doi: 10.1016/j.crwh. 2021.e00304.  Back to cited text no. 16
    
17.
Du Y, Wang L, Wu G, Lei X, Li W, Lv J. Anesthesia and protection in an emergency caesarean section for pregnant woman infected with a novel coronavirus: Case report and literature review. J Anesth 2020;34:613-8.  Back to cited text no. 17
    
18.
Bauer ME, Chiware R, Pancaro C. Neuraxial procedures in COVID-19-positive parturient: A review of current reports. Anesth Analg 2020;131:e22-4.  Back to cited text no. 18
    
19.
Xia H, Zhao S, Wu Z, Luo H, Zhou C, Chen X. Emergency caesarean delivery in a patient with confirmed COVID-19 under spinal anaesthesia. Br J Anaesth 2020;124:e216-8.  Back to cited text no. 19
    
20.
Zhong Q, Liu YY, Luo Q. Spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: Retrospective, single-centre, observational cohort study. Br J Anaesth 2020;124:670-5.  Back to cited text no. 20
    
21.
Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27.  Back to cited text no. 21
    
22.
Yuan J, Qian H, Cao S, Dong B, Yan X, Luo S, et al. Is there possibility of vertical transmission of COVID-19: A systematic review. Transl Pediatr 2021;10:423-34.  Back to cited text no. 22
    
23.
Yánez Benítez C, Güemes A, Aranda J, Ribeiro M, Ottolino P, Saverio SD, et al. Impact of personal protective equipment on surgical performance during the COVID-19 pandemic. World J Surg 2020;44:2842-7.  Back to cited text no. 23
    
24.
Alarfaj MA, Foula MS, Alshammary S, Nwesar FA, Eldamati AM, Alomar A, et al. Impact of wearing personal protective equipment on the performance and decision making of surgeons during the COVID-19 pandemic: An observational cross sectional study. Medicine 2021;100:e27240.  Back to cited text no. 24
    



 
 
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