|Year : 2007 | Volume
| Issue : 2 | Page : 140
Caesarean section in a patient with varicella: Anaesthesia considerations and clinical relevance
Nandini M Dave1, Sachin P Sasane2, HR Iyer3
1 M.D., D.N.B., MNAMS, Asso. Prof., Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India
2 M.B.B.S., Resident, Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India
3 M.D., D.A., Prof. & Head, Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India
|Date of Acceptance||04-Mar-2007|
|Date of Web Publication||20-Mar-2010|
Nandini M Dave
C-303, Presidential Towers, L B S Marg, Ghatkopar -West, Mumbai-400 086
A primigravida with chicken pox was posted for an emergency caesarean section. General anaesthesia was administered. Key issues in anaesthesia management and the clinical implications are discussed.
Keywords: Varicella zoster, Chicken pox, Caesarean section, Anaesthesia
|How to cite this article:|
Dave NM, Sasane SP, Iyer H R. Caesarean section in a patient with varicella: Anaesthesia considerations and clinical relevance. Indian J Anaesth 2007;51:140
|How to cite this URL:|
Dave NM, Sasane SP, Iyer H R. Caesarean section in a patient with varicella: Anaesthesia considerations and clinical relevance. Indian J Anaesth [serial online] 2007 [cited 2015 Mar 3];51:140. Available from: http://www.ijaweb.org/text.asp?2007/51/2/140/61131
| Introduction|| |
Varicella zoster virus infection (chicken pox) is usually a mild, self-limiting disease of childhood. Infection in adults is usually more severe. In this report, we present the case of a primigravida with varicella who was posted for an emergency Caesarean Section. Key issues regarding choice of anaesthesia and complications are discussed.
| Case report|| |
A 23 year old primigravida was admitted to the Infectious diseases hospital, Mumbai city at 39 weeks gestation. She presented herself to the outpatient department with an 8 day history of fever, malaise followed by development of a rash. Lesions first began as macules and papules on the face and then progressed to the trunk and abdomen, becoming pustular. Crusting of lesions began on day 5 after appearance. She had not been previously immunized and did not give a history of exposure to varicella. She had received acyclovir therapy from a private practitioner.She also gave a history of childhood poliomyelitis with mild residual weakness of left upper and lower extremity.
On admission, she was afebrile, pulse rate was 88 per minute and blood pressure 150/90 mmHg. Extremities, face, trunk and abdomen were covered with lesions that were mostly crusted but in various stages of healing. Examination of the oral cavity revealed no lesions. Chest was clear on auscultation and heart sounds were normal. She was started on cap. nifedipine 5 mg QID and kept under observation. Ultrasonography confirmed the presence of a single live fetus in vertex presentation. Laboratory tests conducted during confinement included complete haemogram, liver and renal function tests, coagulation profile which were all normal. X-Ray chest showed no evidence of varicella pneumonia. Three days following admission, she went into spontaneous labour. PV examination during the course of labour showed a foetus with brow presentation and hence the patient had to be taken up for an emergency Caesarean section.
On examination just prior to the anaesthetic, there was a vesiculopapular rash all over the body including the back in various stages of crusting, with a few uncrusted lesions. Because of the extensive skin lesions, we decided to administer general anaesthesia. Patient was fasting for 6 hours. A high risk consent for anaesthesia was obtained. IV ranitidine 50mg and IV metoclopramide 10 mg was administered as premedication 15 minutes prior to induction. General anaesthesia was induced using IV thiopentone 5mgkg-1 and endotracheal intubation was performed after administering succinylcholine 1.5 mgkg-1 using cricoid pressure. Patient was maintained on controlled ventilation using 100% oxygen and a muscle relaxant. A healthy female infant, with good APGAR scores, weighing 3 kg was delivered. There were no varicella lesions on the baby. Following baby delivery, IV midazolam 1mg and IV fentanyl 80 microgram was administered and oxytocin infusion was started. At the end of surgery, the patient was reversed with IV atropine and IV neostigmine and extubated. Both mother and baby were discharged on day 5 of delivery with no complications.
| Discussion|| |
Chicken pox or varicella is an acute, highly infectious disease caused by Varicella- Zoster virus characterized by a vesicular rash that is accompanied by fever and malaise, in most cases it is a mild, self-limiting disease. Severe complications, however, can occur especially in immunecompromised patients and adults.
The commonest complication is secondary bacterial superinfection of skin generally by Streptococcus pyogenes phylococcus aureus. The commonest extracutaneous site in children is the CNS. Aseptic meningitis, encephalitis, transverse myelitis, GBS and Reye's syndrome can occur. Varicella pneumonia is the commonest complication following infection in adults. Other complications include myocarditis, corneal lesions, nephritis, arthritis, bleeding diathesis, acute glomerulonephritis and hepatitis. 
Varicella in pregnancy has several implications for the mother and the foetus depending on the period of gestation. In general, the lesions tend to be numerous and there is an increased risk of maternal complications especially pneumonia in the third trimester. For the foetus the risk is greatest in the first and second trimesters. Congenital varicella syndrome characterized by skin lesions, neurological and eye defects, limb hypoplasia, intra uterine growth retardation, internal organ defects and developmental delay can occur due to direct viral damage during development. 
Perinatal varicella is associated with an increased foetal mortality when the disease develops within 5 days before delivery or within 48 hours thereafter. Since the newborn does not receive protective transplacental antibodies and has an immature immune system, the disease may be unusually severe.Mortality rate may be as high as 30%. 
In these newborns at high risk of developing varicella, passive immunization with zoster immunoglobulin is recommended. Acyclovir therapy is administered if varicella occurs. 
A live attenuated vaccine for prevention of varicella is available. For unimmunised subjects, prophylactic administration of zoster immunoglobulin within 72 hours of exposure can prevent or reduce the severity of illness. In the patients beyond 96 hours window after contact or in those with complications, antiviral therapy with acyclovir is recommended.
Maternal varicella has several implications for the anaesthetist. The optimal technique of anaesthesia has been the subject of debate. Spinal or epidural block may introduce the virus into the CNS with resultant meningitis or encephalitis. Camann and Toumala advised against regional block for atleast 2 weeks after onset of varicella symptoms.  However, regional anaesthesia has been the choice in parturients with acute varicella because of the high risk of pneumonia  . Also, spinal anaesthesia has been used safely in parturients with HIV infection.  Brown et al reported a case where spinal anaesthesia was administered to a parturient with varicella for a planned caesarean section. They suggested that the use of pencil point needle may reduce the risk of introduction of viral material into the CNS. 
Sites et al reported a case where extensive vulvar and vaginal lesions necessitated abdominal delivery. In this patient spinal anaesthesia was avoided due to extensive lesions on the back and caesarean section was performed under general anaesthesia. 
The main concern with use of general anaesthesia is postoperative pneumonia. There is evidence that general anaesthesia produces a decrease in the immune function response. Nitrous oxide, inhalational agents e.g. isoflurane, sevoflurane, desflurane have all been implicated.  Risk factors for varicella pneumonia include maternal smoking, women in third trimester, skin lesions greater than 100 and presence of pharyngeal lesions. If general anaesthesia has to be used it may be prudent to avoid inhalation agents by use of opioids, muscle relaxants and 100% oxygen.
Exposure of medical personnel to the infectious patient is a matter of concern. Previous exposure to the varicella zoster virus may confer immunity. However, the anaesthesiologist handling the case must exercise caution. A study to determine age related prevalence of varicella zoster virus antibodies concluded that a significant proportion of adolescents and adults in India are susceptible to varicella  . There are data to indicate that varicella vaccine is effective in preventing illness or modifying severity if used within 3-5 days of exposure  . Vaccination is routinely recommended for all susceptible health workers and is the preferred method for preventing varicella in health care settings. 
| Conclusion|| |
Regional as well as general anaesthesia have been used for Caesarean section in parturients with varicella. When choosing a technique for anaesthesia, the risks and benefits of general anaesthesia and central neuraxial block have to be carefully considered. The complications of varicella, especially bleeding diathesis, myocarditis and hepatitis must be borne in mind and ruled out prior to the anaesthetic. Prophylactic administration of zoster immunoglobulin to susceptible medical personnel is strongly recommended.
| References|| |
|1.||Whitley RJ. Varicella-zoster virus infections. In: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL editors Harrison's Principles of Internal Medicine 16th edition. Mc Graw- Hill Medical Publishing Division Ch164: 1042-45. |
|2.||Enders G, Miller E, Cradock - Watson J, Bolley I, Ridehalgh M. Consequences of varicella and herpes zoster in pregnancy: Prospective study of 1739 cases. Lancet 1994; 343: 1548- 51. |
|3.||Sauerbnei A, Wutzler P. Neonatal varicella. Journal of Perinatology 2001; 21: 545-49. |
|4.||Datta S. Anaesthesia and Obstetric management of high risk pregnancy, 2nd edn. St Louis: Mosby 1996: 476-78. |
|5.||Gambling D, Douglas M. Obstetric anaesthesia and uncommon disorders. W B Philadelphia: Saunders 1998: 366-67. |
|6.||Avidan M S, Groves P, Blott M et al. Low complication rate associated with Caesarean section under spinal anaesthesia for HIV-1 infected women on anti-retroviral therapy. Anesthesiology 2002; 97: 320-24. |
|7.||Brown NW, Parsons APR, Kam PCA. Anaesthetic considerations in a parturient with varicella presenting for Caesarean section. Anaesthesia 2003; 58: 1092-95. |
|8.||Sites C K, Sherer D M, Gandell D L et al. Extensive vulvar and vaginal varicella necessitating abdominal delivery. Am J Obstet Gynecol 1990; 163; 1630-31. |
|9.||Ashok Kumar, Sadhasivam S, Sethi AK. Anaesthesia- Immune system interactions: Implications for anaesthesiologists and current perspectives. Indian J Anaesth 2002; 46(1): 8-20. |
|10.||Lokeshwar MR, Agrawal A, Subbarao SD, Chakraborty MS, Ram Prasad AV, Weil J et al. Age related seroprevalence of antibodies to varicella in India. Indian Pediatr. 2000 Jul; 37 (7): 714-19. |
|11.||Salzman MB, Garcia C. Postexposure varicella vaccination in siblings of children with active varicella. Pediatr Infect Dis J 1998; 17(3): 256-57. |
|12.||CDC. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1997; 46 (No. RR-18). |