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LETTERS TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 6  |  Page : 501-503  

Chicken pox in pregnancy: Choice of anaesthetic technique


Department of Anaesthesiology and Critical Care, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi, India

Date of Web Publication11-Jun-2019

Correspondence Address:
Dr. Mukundan Ramanujam
22C, Pocket B, Dilshad Garden, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_53_19

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How to cite this article:
Ramanujam M, Tyagi A, Garg D. Chicken pox in pregnancy: Choice of anaesthetic technique. Indian J Anaesth 2019;63:501-3

How to cite this URL:
Ramanujam M, Tyagi A, Garg D. Chicken pox in pregnancy: Choice of anaesthetic technique. Indian J Anaesth [serial online] 2019 [cited 2019 Aug 20];63:501-3. Available from: http://www.ijaweb.org/text.asp?2019/63/6/501/259946



Sir,

Chicken pox is typically a disease of childhood and is uncommon in adults. For an anaesthesiologist it is exceedingly rare to encounter a parturient suffering with chicken pox, since she would require an operative procedure. Also, there is a lack of concurrent evidence to guide the choice of anaesthetic technique in such patients.[1]

24-year-old patient with 37-week pregnancy presented to obstetric emergency following pain in abdomen. She was a known case of hypothyroidism controlled on eltroxin 25 μg daily, and was diagnosed to be suffering with chicken pox since 4 days. Acyclovir was administered orally, 800 mg five times a day. On ninth day after the onset of chickenpox, emergency caesarean section was planned due to foetal distress. Patient still had extensive lesions of chicken pox, but was afebrile.

After shifting to the operating room, routine monitoring was instituted and general anaesthesia planned due to extensive lesions on the back [Figure 1]. Rapid-sequence induction was followed by endotracheal intubation. Haemodynamic and respiratory parameters were stable intraoperatively and trachea was extubated at end of surgery. After an uneventful stay in post anaesthesia care unit, she was transferred back to obstetrics ward and subsequently discharged uneventfully after 7 days.
Figure 1: Lesions of chicken pox in the back of the patient on the 1st post-operative day, with the patient in slight rightward tilt

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The occurrence of chicken pox in pregnancy is estimated to be only 0.4–0.7 per 1000 live births.[2] Delivery during the period of rash is presumed to increase risk of foetal transmission, and hence it is recommended to have minimum 7 days interval between onset of rash and delivery.[1] In our case, the delivery was necessitated due to foetal distress on day 9 of onset.

Anaesthetic concerns in such a mother include increased risk of varicella pneumonia following endotracheal intubation; and risk of seeding of virus into the CNS with neuraxial block. There is no sufficient evidence on anaesthetic technique for such cases.[1]

During pregnancy, varicella pneumonia was presumed to be a common complication of chicken pox, with high mortality.[3] General anaesthesia, specifically inhalation agents and opioids, are speculated to have immunosuppressive effects. This prompted several authors[3],[4],[5] to suggest avoidance of general anaesthesia for these patients. However, acyclovir reduces viral replication and with its use the risk of pneumonia is essentially reduced to the same level as of general population.[3] In addition, immunosuppressive effects were suggested to be more of an effect of surgical trauma and consequent endocrine responses rather than anaesthesia per se.[6] In such a scenario, it may be safe to presume that general anaesthesia possess no additional risk, especially in patients receiving acyclovir. We also administered general anaesthesia without any viral sequelae in the patient postoperatively.

Neuraxial blocks could risk direct inoculation of virus into CNS as well. Additionally as the skin lesions of chicken pox are prone to secondary bacterial infections; it may lead to bacterial seeding of CNS. However, neuraxial blocks have also been used safely when performed at site free of lesions.[3],[4],[5]

We searched for all cases pertaining to anaesthetic management of parturient with chicken pox presenting for caesarean section.[3],[4],[5],[7] Of a total of four cases, three had been conducted under neuraxial block.[3],[4],[5] The use of general anaesthesia has been very scarce in these patients.[7] This would probably be a result of preference for neuraxial block during caesarean section per se, as well as avoidance of intubation for fear of varicella pneumonitis. We wish to add to the rare instances of using general anaesthesia safely in these patients, and its uncomplicated postoperative course. Our experience could help in adding to evidence showing lack of viral pneumonitis following general anaesthesia, when acyclovir was being used for treatment of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chickenpox in Pregnancy (Green-top Guideline No. 13). 2015. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg13/. [Last cited on 2019 Jan 22].  Back to cited text no. 1
    
2.
Tsens LC, Norwitz ER. Infectious disease. In: Dutta S, editor. Anesthetic and Obstetric Managemant of High Risk Pregnency. 3rd ed. New York: Springer; 2004. p. 381-402.  Back to cited text no. 2
    
3.
Brown NW, Parsons APR, Kam PCA. Anaesthetic considerations in a parturient with varicella presenting for caesarean section. Anaesthesia 2003;58:1092-5.  Back to cited text no. 3
    
4.
Baidya D, Borle A, Kumar A, Ray B, Singhal D. 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.  Back to cited text no. 4
  [Full text]  
5.
Janardhan AL, Gupta N, Prakash S, Gogna RL. Anesthetic management of a parturient with varicella presenting for cesarean delivery. Int J Obstet Anesth 2016;28:92-4.  Back to cited text no. 5
    
6.
Stevenson GW, Hall SC, Rudnick S, Seleny FL, Stevenson HC. The effect of anesthetic agents on the human immune response. Anesthesiology 1990;72:542-52.  Back to cited text no. 6
    
7.
Dave NM, Sasane SP, Iyer H. Caesarean section in a patient with varicella: Anaesthesia considerations and clinical relevance. Indian J Anaesth 2007;51:140.  Back to cited text no. 7
  [Full text]  


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