中英双语：Covid-19感染后的产科患者的麻醉管理-我们需要知道的

糖糖不次糖 · 发表于 2023-1-15 13:37:46

本帖最后由糖糖不次糖于 2023-1-15 13:39 编辑

翻译：张丽徐医2022级麻醉学研究生

审校：赵林林徐医附院麻醉科

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Anesthesia management in a post Covid-19 obstetric

patient-What we need to know

Covid-19感染后的产科患者的麻醉管理-我们需要知道的

Abstract

The outbreak of the coronavirus disease (COVID)‑19 pandemic has led to unprecedented challenges globally . At the outset of the receding second wave and third wave of COVID‑19, many patients who have recovered from the severe acute respiratory syndrome coronavirus‑2 (SARS‑CoV‑2) are coming for elective/emergency surgery . This demands a noteworthy emphasis on the post‑COVID‑19 obstetric patients. The administration of quality and safe obstetric anesthesia are quite challenging in this mentioned subset due to the overlap of signs and symptoms of COVID‑19 with the constitutional signs and symptoms of pregnancy . The physiological changes in normal pregnancy and vascular , metabolic alterations in high‑risk pregnancy may affect or exacerbate the pathogenesis or clinical presentation of COVID‑19, respectively . This article highlights the specific concerns in recovered COVID‑19 pregnant patients with associated comorbidity posted for surgery and their repercussions on anesthesia management.

2019冠状病毒(COVID - 19)大流行的爆发，给全球带来了前所未有的挑战。在第二波和第三波COVID - 19疫情退去之初，许多已从严重急性呼吸综合征冠状病毒2 (SARS - CoV - 2)中康复的患者前来接受择期或急诊手术。这需要特别重视COVID – 19康复后的产科患者。由于COVID - 19的体征和症状与妊娠的体质体征和症状重叠，在上述中，实施高质量和安全的产科麻醉是相当具有挑战性的。正常妊娠期的生理变化和高危妊娠期的血管代谢变化可能分别影响或加剧COVID - 19的发病机制或临床表现。本文强调了手术后伴有相关共病的康复COVID - 19妊娠患者的具体担忧及其对麻醉管理的影响。

Keywords:Anesthesia, neonate, obstetric, post‑COVID, pregnancy , SARS‑CoV‑2

关键词：麻醉，新生儿，产科，后冠状病毒感染，妊娠，SARS - CoV - 2

Introduction

The severe acute respiratory syndrome coronavirus (SARS‑CoV)‑2 pandemic has presented unprecedented challenges globally.[1] The viral infection presents with a constellation of symptoms varying from a mild flu‑like illness to life‑threatening pneumonia picture. No age group is immune to this deadly infection. Furthermore, as the pandemic is raging on, there is a shift of paradigm from the existing scenario of coronavirus disease (COVID)‑19, as more patients are COVID‑19 “recovered”. Globally, 210 million women become pregnant every year and give birth to 130 million babies. Obstetric patients are specifically vulnerable to severe pneumonia due to alteration in the immune and physiological response; increased oxygen consumption, decreased functional residual capacity (FRC), decreased chest compliance, and altered T‑lymphocyte immunity, overall contribute to increased maternal mortality and morbidity.[2] Noteworthy, pregnancy is a state of partial immune response which makes this particular cohort prone to viral infection. Therefore, post‑COVID‑19 pregnant patients may have a serious post‑viral sequel. Nevertheless, it has been reported that age and other underlying medical conditions can increase the severity of the COVID‑19 illness both during and for 42 days following delivery.[3] The post‑COVID‑19 era has given birth to various myths and fallacies regarding medical, surgical, and obstetrical procedures. In the coming time, we may rendezvous with a large number of post‑COVID obstetric patients requiring operative interventions. Anesthesia concerns in this vulnerable cohort will be challenging compared to non‑COVID obstetric patients. At present, there exist no concrete guidelines for the anesthetic management of this subset although a few suggested guidelines and advisories are available. The current clinical evidence suggests that pregnant patients with COVID‑19 infection having associated pneumonia have an increased menace of obstetric complications; cesarean section, premature rupture of membranes, preeclampsia, and preterm labor.[4,5] The W orld Health Organization (WHO) has also stated that pregnant patient with pre‑existing comorbidities including obesity, diabetes, heart disease, and hypertension may have the additional risk of developing severe COVID‑19.[6] Thus, obstetric anesthesiologists may encounter recovered COVID‑positive patients for elective/ emergency surgical procedures that may pose unique unaccustomed challenges. The present review aims to increase the insight into peri‑intraoperative anesthesia concerns, the effect of post‑viral infection on different organs in pregnancy, the associated comorbidities, and postoperative management of post‑COVID‑19 patients.

严重急性呼吸综合征冠状病毒(SARS - CoV) - 2大流行在全球范围内提出了前所未有的挑战，病毒感染表现出一系列症状，从轻微的流感样疾病到危及生命的肺炎。任何年龄组都无法对这种致命感染免疫。此外，随着大流行的肆虐，随着更多的患者COVID - 19“康复”，现有的冠状病毒疾病(COVID - 19)的模式发生了转变。全球每年有2.1亿妇女怀孕，生下1.3亿婴儿。由于免疫和生理反应的改变，产科病人特别容易患严重肺炎；耗氧量增加、功能残气量(FRC)下降、胸部顺应性下降和T淋巴细胞免疫改变，总体上导致孕产妇死亡率和发病率增加。值得注意的是，怀孕是一种部分免疫反应的状态，这使得这一特定人群容易受到病毒感染。因此，COVID - 19后怀孕的患者可能会有严重的病毒后后遗症。然而，据报道，年龄和其他潜在的医疗条件会在分娩期间和分娩后42天内增加COVID - 19疾病的严重程度，后COVID - 19时代催生了各种关于医学、外科手术和产科手术的“神话”和谬误。在未来的一段时间里，我们可能会遇到大量需要手术干预的COVID后产科患者。与非COVID - 19产科患者相比，这一弱势群体的麻醉问题将具有挑战性。目前，虽然有一些指南和建议，但对这一群体的麻醉管理没有具体的指导方针。目前的临床证据表明，感染COVID - 19并伴有肺炎的孕妇发生产科并发症的威胁增加，剖宫产，胎膜早破，先兆子痫，早产。世界卫生组织(世卫组织)还指出，先前存在包括肥胖、糖尿病、心脏病和高血压在内的合并症的孕妇可能有发展为严重COVID - 19的额外风险。因此，产科麻醉医师可能会在择期或急诊手术中遇到COVID阳性康复患者，这可能会带来不一样的挑战。本综述旨在提高对围术中麻醉问题的认识，怀孕期间病毒感染对不同器官的影响，相关的合并症，以及COVID - 19患者的术后管理。

Methodology

Keeping this research question in mind, we did a literature search using the keywords COVID‑19, SARS‑CoV2, SARS‑CoV‑1, pregnancy, obstetric, neonate, anesthesia management, and related terms in the medical databases including Google Scholar, MedARXiv, PubMed, Cochrane, and W eb of Science. In addition to these, references were spotted through a manual search of bibliographies and via the citations in the articles. Specific concerns in recovered COVID‑19 pregnant patients and the associated comorbidity posted for surgery, and their repercussions on anesthesia management are discussed extensively in this review.

牢记这一研究问题，我们使用关键词COVID - 19, SARS - CoV2, SARS - CoV - 1，妊娠，产科，新生儿，麻醉管理和相关术语在包括谷歌Scholar, MedARXiv, PubMed, Cochrane和W web of Science的医学数据库中进行了文献检索。除此之外，参考文献是通过手动搜索参考书目和文章中的引用来发现的。本综述广泛讨论了康复的COVID - 19怀孕患者和手术相关疾病的具体问题，以及它们对麻醉管理的影响。

Pathophysiology of COVID-19 and its implications in pregnancy

COVID-19的病理生理学及其在妊娠中的意义

COVID‑19 is a single‑stranded capsulated ribonucleic acid (RNA) virus.[7] The immunological response to COVID‑19 depends on the function of the immune system.[7] The modulations in immune response to allow growth of the allogeneic fetus during pregnancy may result in an altered immune response to infection.[8,9] SARS‑CoV‑2 enters the body and infects the respiratory system mainly via two mechanisms. First, there is a direct attachment of the angiotensin‑converting enzyme 2 (ACE2) to spike protein and release of the nucleocapsid protein and viral genome into the cell cytoplasm of the host.[10] Second, the alternative avenue is the direct plasma membrane route through transmembrane serine protease 2 (TMPRSS2), causing proteolytic cleavage of the spike protein and fusion with the cell membrane.[11] During pregnancy, there is upregulation of ACE 2 and renin‑angiotensin‑aldosterone system (RAAS). Furthermore, this normal hormonal profile in pregnancy favors SARS‑CoV‑2 entry, and raises the possibility of the increased risk of the pregnant patient acquiring this infection. The viral binding to ACE2 causes its downregulation and un‑proportionate increase in angiotensin‑2 (Ang) relative to Ang (1‑7), thereby, aiding vasoconstriction, preeclampsia, preterm labor, and fetal growth retardation [Figure 1].[12,13]

COVID - 19是一种单链囊状核糖核酸(RNA)病毒。COVID - 19的免疫反应取决于免疫系统的功能在怀孕期间允许异基因胎儿生长的免疫反应的调节可能导致对感染的免疫反应的改变。SARS - CoV - 2主要通过两种机制进入人体并感染呼吸系统。首先，血管紧张素转换酶2 (ACE2)直接附着在刺突蛋白上，并将核衣壳蛋白和病毒基因组释放到宿主的细胞质中。第二，另一种途径是通过跨膜丝氨酸蛋白酶2 (TMPRSS2)的直接质膜途径，引起刺突蛋白的蛋白水解裂解并与细胞膜融合。怀孕期间，ACE 2和肾素-血管紧张素-醛固酮系统(RAAS)上调。此外，怀孕期间的正常激素状况有利于SARS - CoV - 2的进入，并增加了孕妇感染的风险。病毒与ACE2结合导致其下调，血管紧张素- 2 (Ang)相对于Ang(1 - 7)不成比例地增加，从而导致血管收缩、子痫前期、早产和胎儿生长迟缓[图1]。

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The interplay of post-COVID-19 infection on physiological changes in pregnancy and its effects on different organs

covid -19感染后与妊娠生理变化的相互作用及其对不同器官的影响

Normal physiological alterations in pregnancy are considered essential for the development of the fetus, to increase the metabolic demand of the body, and for childbirth. These amendments start from the first trimester to labor, peak at term and return to the pre‑pregnancy level after delivery in the postpartum period.[14] Although these changes are well tolerated in a normal healthy pregnant patient, these can be magnified in the presence of COVID‑19‑related pathophysiological changes. Comprehensive knowledge of the physiological changes concerning post‑COVID‑19 infection is considered crucial for the successful management of obstetric patients. This conceptual understanding will further assist the anesthesiologists to tailor the anesthetic technique to manage the post‑COVID‑19 patients and critically ill pregnant patients with comorbidity.

怀孕期间的正常生理变化被认为是胎儿发育、增加身体代谢需求和分娩所必需的。这些变化从妊娠前三个月开始，在足月达到顶峰，产后分娩后恢复到孕前水平。尽管这些变化在正常健康的怀孕患者中可以很好地耐受，但在存在与COVID - 19相关的病理生理变化时，这些变化可能会被放大。全面了解COVID - 19感染后的生理变化被认为是成功管理产科患者的关键。这一概念上的理解将进一步帮助麻醉医生调整麻醉技术，以管理COVID - 19后患者和患有伴随疾病的危重妊娠患者。

Respiratory system呼吸系统

Recent evidence has revealed that the lung is the most affected organ in COVID‑19, and its pathogenesis includes capillary disruption, hyaline membrane formation, alveolar proliferation (fibrous), alveolar epithelium disruption, and pulmonary consolidation.[15,16]

Furthermore, pregnancy is a restrictive lung disease and various studies have inferred damaged lung in the post‑COVID‑19 recovered patient from SARS‑CoV‑2 pneumonia, leading to a restrictive lung pattern persisting up to 6 weeks post‑recovery, thereby, causing an exponentially increased risk of life‑threatening comorbidities.[17,18] The diffusing capacity for carbon monoxide (DLCO) was the most common abnormality followed by impaired total lung capacity (TLC), ranging from 15.5 to 43.6% and 5.2 to 10.9%, respectively, and a decline in the 6‑min walk distance (6‑MWD), indicating impaired intra‑alveolar diffusion capacity.[19‑21] Furthermore, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), TLC, increased ratio of FEV1/FVC, and DLCO were significantly lower in the patients after severe/ critical COVID‑19 [Table 1].[22]

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In conclusion, impaired respiratory muscle strength, decreased diffusion capacity, lung imaging abnormalities, decreased FRC, and decreased ability to clear pulmonary secretions postoperatively can be found in COVID‑19 recovered patients.[23] Despite adequate preoxygenation, increased oxygen consumption and decreased FRC may lead to rapid desaturation during apnea.[24] Apart from the post‑viral residual component, there can be an exacerbation of pre‑existing pulmonary complications, thereby, necessitating preoperative optimization and a thorough evaluation. As per a recent recommendation, a 6‑week respiratory rehabilitation can improve lung functions effectively.[25]

最近的证据表明，肺是COVID - 19最受影响的器官，其发病机制包括毛细血管破坏，透明膜形成，肺泡增生(纤维状)，肺泡上皮破坏，肺实变。

此外，怀孕是一种限制性肺部疾病，多项研究推断，在COVID - 19后康复的SARS - CoV - 2肺炎患者中，肺部受损，导致康复后持续6周的限制性肺部模式，从而导致危及生命的合并症风险呈指数级增加。一氧化碳弥散功能(DLCO)是最常见的异常变化，其次是总肺容量(TLC)受损，分别为15.5%到43.6%和5.2%到10.9%，6分钟步行距离(6 - MWD)下降，表明肺泡内扩散能力受损。此外，重/危重型COVID - 19患者的用力肺活量(FVC)、1 s用力呼气量(FEV1)、TLC、FEV1/FVC升高率和DLCO均显著降低[Table 1]。

总之，在COVID - 19康复患者中，可以发现呼吸肌力量受损、扩散能力下降、肺影像学异常、FRC下降以及术后清除肺分泌物能力下降。尽管有充分的预充氧，但增加的耗氧量和降低的FRC可能导致呼吸暂停期间快速去饱和。除了病毒后残留成分外，可能会加重原有的肺部并发症，因此，需要术前优化和完善的评估。根据最近的建议，6周的呼吸康复可以有效地改善肺功能。

Cardiovascular system (CVS)心血管系统

A high prevalence of cardiovascular disease has been observed in COVID‑19 illness.[26] T akotsubo cardiomyopathy, a stress‑induced secondary cardiomyopathy, is common in COVID‑19 due to pneumonia.[27] P erioperative complications may occur due to increased cardiac demand, decreased systemic oxygenation due to pneumonia, and concurrent electrolyte imbalance or immune dysregulation. F actors enhancing the imbalance between the myocardial oxygen demand (hypoxia, hypercarbia, hyperglycemia, and acidosis) should be avoided intraoperatively.

Alteration in the aortocaval compression compensatory mechanism may be observed in post‑SARS‑CoV‑2 infection due to variation in the renin‑angiotensin system to maintain blood pressure in the supine position, which may result in supine hypotension syndrome characterized by pallor, transient tachycardia followed by bradycardia, sweating, hypotension, and malaise.[28,29] Therefore, the pregnant patient should be preferably placed laterally with a wedge under the right buttock.

There is shortness of breath in 18% of the COVID‑19 recovered patients.[30] Moreover, there also exists physiological dyspnea due to increased maternal oxygen requirement, fetal oxygen consumption, and gestational anemia. Therefore, it should be distinguished from pathological breathlessness.[31] There can be other related changes in the CVS in post‑COVID‑19 pregnant patients [T able 2].

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在COVID - 19疾病中，心血管疾病的患病率很高。Takotsubo心肌病是一种应激性继发性心肌病，在COVID - 19中常见，由肺炎引起手术并发症可能是由于心脏需求增加、肺炎引起的全身氧合下降以及并发的电解质失衡或免疫失调。术中应避免增加心肌需氧量不平衡的因素(缺氧、高碳酸血症、高血糖和酸中毒)。

在SARS - CoV - 2感染后，由于维持仰卧位血压的肾素-血管紧张素系统发生变化，可观察到主动脉压代偿机制的改变，这可能导致仰卧位低血压综合征，其特征为脸色苍白、短暂性心动过速，随后出现心动过缓、出汗、低血压和不适。因此，妊娠患者最好躺下后在右侧臀部下方放置垫子。

18%的COVID - 19康复患者出现呼吸短促。此外，还存在因母体需氧量增加、胎儿耗氧量增加、妊娠期贫血引起的生理性呼吸困难。因此，应与病理性呼吸困难鉴别。COVID - 19后怀孕患者的CVS可能存在其他相关变化[Table 2]。

Immune response 免疫反应

• The modulations in maternal immune response favor T‑helper 2 (Th‑2; anti‑inflammator y, interleukin (IL)‑4,10,13, and transforming growth factor‑β (TGF‑β) than Th‑1 (proinflammatory, microbicidal, interferon‑γ (IFN‑γ), IL1α, IL‑1β, IL‑6, and IL‑12).[32]

•The COVID‑19 patients have both Th‑1 and Th‑2 activation; IFN‑γ, IL‑β, IL‑4,10, and predominantly IL‑6, and overall contribute to high mortality.[33,34]

• Although there is a dearth of data on the immune response of SARS‑CoV‑2 in pregnant patients, the available evidence suggests that overall, pregnancy increases the risk of infection and mortality compared to non‑pregnant patients.[35]

•It is imperative to know the timing of acquiring the COVID‑19 infection. The first and third trimesters are considered proinflammatory. Noteworthy, the SARS‑CoV‑2 infection acquired during this time has an exaggerated response to the virus, and thus, the patient may land up in a cytokine storm, thus, increasing the morbidity and mortality in the parturient.[36]

• Clinical evidence has suggested that post‑COVID‑19 parturients with mild residual symptoms may need intensive care unit admission for respiratory symptoms.[37,38]

• Lastly, there is a high level of stress and inflammation at the level of labor, further enhancing the poor outcome in post‑COVID‑19 recovered patients.[39]

•母体免疫应答的调节对T -辅助性2 (Th – 2；抗炎，白介素(IL) - 4,10,13和转化生长因子- β (TGF - β)比Th - 1(促炎，杀菌剂，干扰素- γ (IFN - γ)， IL - 1α， IL - 1β， IL - 6和IL - 12)有利。

•COVID - 19患者同时有Th - 1和Th - 2激活；IFN - γ， IL - β， IL - 4,10，主要是IL - 6，总体上导致高死亡率。

•尽管缺乏关于妊娠患者SARS - CoV - 2免疫反应的数据，但现有证据表明，总体而言，与非妊娠患者相比，妊娠会增加感染风险和死亡率。

•必须了解感染COVID - 19的时间。妊娠早期和晚期被认为是促炎期。值得注意的是，在此期间获得的SARS - CoV - 2感染对病毒有放大的反应，因此，患者可能陷入细胞因子风暴，从而增加产妇的发病率和死亡率。

•临床证据表明，有轻微残留症状的COVID - 19后产妇可能会因呼吸道症状进入重症监护病房。

•最后，分娩时的压力和炎症水平较高，进一步加剧了COVID - 19后康复患者的不良预后。

Thrombo-embolic phenomenon血栓栓塞现象

The net result of the post‑COVID‑19 changes and physiological changes in pregnancy is a hypercoagulable state [Table 3].[23]

COVID – 19感染后的改变和妊娠期生理改变的最终结果是高凝状态[Table 3].

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Endocrine system内分泌系统

SARS‑CoV‑2 enters the pancreas through the ACE2 receptors expressed in the endocrine pancreas. About 51% of the post‑COVID‑19 recovered patients may develop new‑onset diabetes with no history of diabetes or receiving any steroid treatment during the illness.[40] Overall, metabolic and hormonal perturbations caused by the involvement of the pancreas, thyroid, and adrenal gland have been noted. The post‑COVID‑19 trajectory consists of mainly primary hypothyroidism, hypothalamic‑pituitary‑adrenal axis damage, hypocortisolism, and secondary hypothyroidism.[23]

SARS - CoV - 2通过胰腺中表达的ACE2受体进入胰腺。约51%的COVID – 19感染后康复患者可能会发展为新发糖尿病，但没有糖尿病史或在患病期间接受过任何类固醇治疗。总的来说，已发现胰腺、甲状腺和肾上腺受累引起的代谢和激素紊乱。COVID - 19后的发展轨迹主要包括原发性甲状腺功能减退、下丘脑-垂体-肾上腺轴损伤、低皮质醇症和继发性甲状腺功能减退。

Neurological system神经系统

Cerebrovascular accidents are common neurological sequelae in post‑COVID‑19 patients. There can be a residual neuromuscular weakness, or headache (2–3% post‑COVID), that may lead to an excruciating spinal headache. Critical illness myopathy, fatigue, and muscle weakness can be observed in the recovering parturient and should be considered before employing regional anesthesia and perioperative risk stratification.

脑血管意外是COVID-19后常见的神经系统后遗症。可能会有残余的神经肌肉无力或头痛(2-3%)，这可能导致极度疼痛的脊柱痛。严重的肌肉病、疲劳、肌肉无力可在恢复期产妇中观察到，在采用区域麻醉和围手术期危险分层前应予以考虑。

Renal system

Acute kidney injury (AKI) after SARS‑CoV‑2 infection has proved to be an important risk factor for predicting mortality in critically ill patients. Due to AKI, approximately 35% of the patients recovered from SARS‑CoV‑2 may have a decreased glomerular filtration rate (GFR) for up to 6 months.[41] Also, in the perioperative period, further insults like hypovolemia due to blood loss, improper fluid management, hypotension, and use of nephrotoxic drugs can exacerbate kidney injury.[23] The aforementioned causes may increase the risk of intraoperative AKI and due precautions should be taken to prevent further injury.

SARS - CoV - 2感染后急性肾损伤(AKI)已被证明是预测危重患者死亡的重要危险因素。由于AKI，大约有35%从SARS - CoV - 2康复的患者在长达6个月的时间内肾小球滤过率(GFR)下降。此外，在围手术期，由于失血导致的低血容量、液体管理不当、低血压和使用肾毒性药物等进一步损害可加重肾损伤，上述原因可能会增加术中AKI的风险，应采取适当的预防措施，防止进一步损伤。

Gastrointestinal (GI) system

The most cardinal gastrointestinal symptoms in the post‑COVID‑19 state are lack of appetite, nausea, and vomiting.[42] All this can lead to Mendelson’s syndrome; a well‑recognized cause of lung injury and pulmonary edema, secondary to aspiration of gastric contents in the tracheobronchial tree.[43]

COVID – 19感染后最主要的胃肠道症状是食欲不振、恶心和呕吐。所有这些都会导致Mendelson综合症；一种公认的肺损伤和肺水肿的原因，继发于气管支气管的胃内容物误吸。

Preoperative considerations

• Anesthesia implications will be profound in the indexed subset, as the normal physiology of such patients will be impacted both by changes due to pregnancy and COVID‑19 post‑infection. Therefore, a thorough detailed preoperative evaluation is paramount.

麻醉的影响将是深远的，因为这类患者的正常生理将受到怀孕和感染COVID – 19后变化的影响。因此，术前全面详细的评估是至关重要的。

• The preoperative evaluation, history taking, functional status before surgery, and consent particularly to COVID‑19 status should be given utmost importance.

术前评估、病史采集、术前功能状态，特别是对COVID - 19状态的评估，应给予高度重视。

• Risk stratification should be done in the preoperative assessment; a.) Mild: stable vital signs with mild residual symptoms, b.) Severe: respiration rate ≥30/min, resting arterial oxygen saturation (SaO2 ≤93%), Critical: shock with organ failure, respiratory failure requiring mechanical ventilation, or refractory hypoxemia.[43] Based on the clinical evaluation, a multidisciplinary approach, along with an assessment of appropriate postoperative respiratory care is to be adopted.

术前评估应进行风险分层：a)轻度:生命体征稳定，残留症状轻微。b)重症:呼吸频率≥30/min，静息动脉氧饱和度(SaO2≤93%)，危重：休克伴器官衰竭，需要机械通气的呼吸衰竭，或难治性低氧血症。基于临床评估，多学科方法，以及适当的术后呼吸护理评估将被采用。

• History of duration and severity of COVID‑19, along with associated comorbidities should be noted along with their residual effects.[44]

应注意COVID - 19的病程和严重程度，以及相关的合并症及其残余影响

• Based on the indication of cesarean section, the severity of symptoms, presence of comorbidities (preeclampsia, cardiac, respiratory disease), obstetric history, and fetal condition, the timing of delivery can be individualized. In the absence of fetal distress and mild symptoms, pregnancy can be continued.[45]

根据剖宫产的指征、症状的严重程度、合并症的存在(子痫前期、心脏、呼吸系统疾病)、产科病史和胎儿状况，分娩时间可以因人而异。在没有胎儿窘迫和轻微症状的情况下，可以继续妊娠。

• Post-COVID syndrome: The Center for Disease Control (CDC) has coined the term post‑acute COVID‑19 syndrome for the patients who recovered from SARS‑CoV‑2 infection characterized by the persistence of clinical symptoms beyond 4 weeks from the onset of acute symptoms. It consists of a myriad of symptoms including tiredness, dyspnea, fatigue, brain fogginess, autonomic dysfunction, headache, persistent loss of smell or taste, cough, depression, low‑grade fevers, palpitations, dizziness, muscle pain, and joint pains. These further mandate the evaluation of the multiorgan effect of post‑COVID infection on various organ systems.[46]

新冠后综合征：疾控中心(CDC)创造了“新冠后急性综合征”一词，用于从SARS - CoV - 2感染中恢复的患者，其特征是从急性症状出现后持续4周以上的临床症状。它由无数的症状组成，包括疲劳、呼吸困难、困倦、脑雾、自主神经功能障碍、头痛、持续丧失嗅觉或味觉、咳嗽、抑郁、低烧、心悸、头晕、肌肉疼痛和关节疼痛。这进一步要求评估COVID感染后对各种器官系统的影响。

•Cardiovascular system: Cardiomyopathies, myocardial infarction, arrhythmias, and myocarditis are commonly associated complications with the recovered COVID‑19 patients, warranting cardiac evaluation in SARS‑CoV‑2‑recovered parturients.[47] Furthermore, cardiac and normal pregnancy symptoms including dyspnea on exertion, palpitations, tachycardia, and syncope are two sides of the same coin, thus, necessitating prompt differentiation between the two entities.

心血管系统：心肌病、心肌梗死、心律失常和心肌炎通常是COVID - 19康复患者的并发症，因此有必要对SARS - CoV - 2康复的孕产妇进行心脏评估。此外，心脏和正常妊娠症状，包括用力时呼吸困难、心悸、心动过速和晕厥是同一硬币的两面，因此，有必要立即区分这两个实体。

• Respiratory system: The evaluation of pulmonary sequelae after SARS‑CoV‑2 infection is cardinal. Effort tolerance after post‑COVID‑19 infection is subjective, albeit a 6‑min walk test and breath‑holding time are fairly objective. This aforementioned, non‑invasive test can be conducted at the time of a pre‑anesthesia checkup (P AC), if feasible.[48]

呼吸系统：SARS - CoV - 2感染后的肺部后遗症的评估是至关重要的。COVID - 19感染后的努力耐受是主观的，尽管6分钟的行走测试和屏气时间是相当客观的。如果可以的话，上述非侵入性检查可在麻醉前检查(pac)时进行。

•Neurological system: P ost‑viral symptoms are compiled under the parasol term of “post‑COVID‑19 syndrome.”[49] Symptoms including headache, neuromuscular weakness, depression, or any cerebrovascular accidents need to be properly evaluated at the time of P AC and properly documented, as they may have important implications during the intraoperative and postoperative period.[49]

神经系统：大多数病毒症状被归类为“新冠后综合征”，包括头痛、神经肌肉无力、抑郁或任何脑血管意外的症状需要在pac时进行适当评估并妥善记录，因为它们可能在术中和术后期间产生重要影响。[49]

• Anticoagulants: Obstetric patients who recovered from SARS‑CoV‑2 infection can be on antiplatelet or antithrombotic agents. A detailed history of the drug and clear instructions regarding the timing of stoppage and continuation should be given during the pre‑anesthetic checkup. Low dose aspirin (75–150 mg/day) can be continued safely, clopidogrel should be stopped 5 days before surgery and resumed 24 h postoperatively in high‑risk cardiac event patients.[23] Dual‑antiplatelet therapy can be discontinued 7–10 days before surgery and resumed 23 h postoperatively in the low‑risk of cardiac events parturients. Prophylactic and therapeutic doses of low molecular weight heparin (LMWH) should be stopped at 12 and 24 h, respectively, after the last dose.

抗凝血药物：从SARS - CoV - 2感染中恢复的产科患者可以使用抗血小板或抗血栓药物。在麻醉前检查时，应提供详细的用药史和关于停药和继续用药时间的明确说明。低剂量阿司匹林(75 - 150mg /天)可安全继续使用，高危心脏事件患者应在术前5天停用氯吡格雷，术后24小时恢复。在心脏事件风险低的产妇中，使用双抗血小板治疗可在术前7-10天停用，术后23小时恢复。预防和治疗剂量的低分子肝素(LMWH)应分别在最后一次剂量后12和24小时停止。

• Comorbidity: The history of comorbidity and preoperative optimization as far as possible is cardinal in these subsets as there can be worsening of comorbidities in the recovered COVID‑19 patients

伴随疾病：在这些亚组中，伴随疾病史和术前优化是最重要的，因为在康复的COVID - 19患者中，伴随疾病可能会恶化。

•Psychological counseling: P ost‑COVID‑19 recovered patients are in a state of post‑trauma stress with anxiety and depression. Nonetheless, they generally have increased anxiety and are worried about the neonatal outcome. Hence, they may require immediate psychological counseling from an expert.

心理咨询：大多数COVID - 19康复患者处于创伤后应激状态，伴有焦虑和抑郁。他们通常会增加焦虑，并担心对新生儿的影响。因此，他们可能需要立即向专家进行心理咨询。

• Vaccination history: The history of COVID‑19 vaccination should be elicited.

疫苗接种史：应了解COVID - 19疫苗接种史。

• Venous access: The propensity for venous thrombosis in the post‑COVID‑19 recovered patient may lead to difficulties in venous access. Therefore, veins need to be checked preoperatively and central venous cannulation can be considered, depending upon the overall assessment of the patient.

静脉通路：COVID - 19康复患者静脉血栓形成倾向可能导致静脉通路困难。因此，术前需要检查静脉，根据患者的整体评估，可以考虑中心静脉插管。

• Requirement of oxygenation: The shift of the diaphragm due to the growing uterus, reduction in FRC, and increased oxygen consumption result in the increased requirement of oxygen in pregnancy. Indeed, post‑COVID‑19 pulmonary fibrosis or other respiratory sequelae can further increase the oxygen requirement, and hence, functional assessment of oxygen requirement intra‑ and postoperatively is imperative. Also, the need for postoperative ventilation needs to be duly addressed preoperatively.

氧合需求：子宫生长引起的膈肌移位、FRC减少和耗氧量增加导致妊娠期对氧的需求增加。事实上，COVID - 19后肺纤维化或其他呼吸道后遗症可进一步增加需氧量，因此，对术中和术后需氧量进行功能评估是必要的。此外，术后通气需要在术前得到合理的解决。

• Drug allergy: History of old drug allergy or newly developed drug allergy due to anti‑COVID‑19 drugs or COVID‑19 vaccine should be asked, as ignorance may lead to anaphylaxis or any other catastrophic event intraoperatively.

药物过敏：应询问既往药物过敏史或因抗COVID - 19药物或COVID - 19疫苗引起的新发药物过敏史，因为可能导致术中过敏反应或任何其他灾难性事件。

Investigations

The goal of the investigations should be based on the evaluation of post‑COVID‑19 illness sequelae, functional evaluation of various organs, and associated comorbidities. Special investigations in a post‑COVID‑19 obstetric patient may vary from patient to patient and should be individualized depending upon the clinical scenario, presence of comorbidities, and institutional protocol. Any of the abnormal values in this battery of special investigations suggest that the disease sequelae are persisting and are not completely resolved, thereby, indicating a higher risk of intra/ perioperative complications [T able 4].

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调查的目标应基于对COVID - 19后遗症的评估、各种器官的功能评估以及相关的伴随疾病。COVID - 19后产科患者的特殊调查可能因患者而异，应根据临床情况、合并症的存在和机构方案进行个体化调查。这组特殊调查中的任何异常值都表明疾病后遗症持续存在且未完全消除，因此提示术中和围术期并发症的风险较高[Table 4]。

Perioperative concerns围手术期注意事项

1. Monitoring: Standard American Society of Anesthesiologists (ASA) monitoring including a pulse oximeter, electrocardiography (ECG), non‑invasive blood pressure, end‑tidal carbon dioxide (ETCO2), and temperature monitoring are to be done in all pregnant patients requiring surgical intervention.[50]

监测：美国麻醉医师协会(ASA)标准的监测包括脉搏氧饱和、心电图(ECG)、无创血压、呼气末二氧化碳(ETCO2)和体温监测将在所有需要手术干预的孕妇中进行。

2. The goal of oxygen therapy is to maintain oxygen saturation above 95–96% in a post‑COVID‑19 recovered obstetric patient.[50] It is noteworthy that recovered patients may have decreased saturation and anesthesia drugs may further cause desaturation, hence, warranting supplementar y oxygenation. Pregnancy is a state of increased oxygen consumption and decreased oxygen levels are not only detrimental to the mother but may cause fetal distress and enhance mortality and morbidity. Tools including modified early obstetric warning systems (MEOWS) can be helpful.[51] Also, an increased need for oxygen is a sign of deterioration.[52]

氧疗的目标是在COVID - 19康复的产科患者中维持95-96%以上的氧饱和度。值得注意的是，恢复后的患者可能饱和度降低，麻醉药物可能进一步导致饱和度降低，因此需要补充氧合。妊娠是一种耗氧增加的状态，氧水平下降不仅对母亲有害，而且可能导致胎儿窘迫，增加死亡率和发病率。包括改进的产科早期预警系统(MEOWS)在内的工具可能会有所帮助。此外，对氧气的需求增加是病情恶化的迹象。

3. Anti‑aspiration prophylaxis, H2 blocker, and/or metoclopramide for aspiration prophylaxis can be used to decrease the risk of aspiration due to reduced lower esophageal sphincter tone, particularly after 16 weeks of pregnancy.[53,54]

误吸预防、H2受体阻滞剂和/或胃复安用于误吸预防可用来降低因食管下括约肌张力降低而导致误吸的风险，特别是在怀孕16周后。

4. There is compression of inferior vena cava (IVC) due to the gravid uterus causing supine hypotension syndrome. Keeping a wedge under the right lower back or 10–15° left lateral table tilt can be useful for the same.[18]

妊娠子宫压迫下腔静脉，导致仰卧位低血压综合征。放一个垫子在右下背部或保持10-15°左侧倾斜度可以同样有用。

5. The choice of anesthesia depends upon the emergency/ urgency of the cesarean section and should be tailored based on the fetal, obstetric, and anesthesia risks involved.[23] Neuraxial anesthesia is recommended as first‑line in post‑COVID‑19 recovered patients both for elective and emergency cesarean section.[38]

麻醉的选择取决于剖宫产的紧急情况，并应根据所涉及的胎儿、产科和麻醉风险量身定制。无论是择期剖宫产还是急诊剖宫产，椎管内麻醉都被推荐作为COVID - 19康复后患者的一线麻醉方式。

6. If the patient is on anticoagulants, she should not receive regional anesthesia.[23]An early epidural to prevent the chance of an emergency cesarean section under general anesthesia, recent platelet count, keeping in mind the possibility of thrombocytopenia and other coagulation abnormalities due to antiplatelet or antithrombotic drugs are recommended for neuraxial blockade[55] in the post‑COVID‑19 state. The American Society of Regional Anesthesia (ASRA) institutional guidelines should be followed before administration of regional anesthesia, and there exists no strong evidence on any particular neuraxial technique more advantageous than others; hence, the decision depends on the discretion of the anesthesiologist.

如果病人正在使用抗凝剂，那么她不应该接受区域麻醉。在COVID - 19后状态下，建议早期硬膜外麻醉以防止全麻下紧急剖宫产的机会，近期血小板计数，牢记由于抗血小板或抗血栓药物导致血小板减少和其他凝血异常的可能性。在实施区域麻醉前应遵循美国区域麻醉学会(ASRA)的机构指南，并且没有强有力的证据表明任何特定的椎管内技术比其他技术更有利；因此，这个决定取决于麻醉医师的判断力。

7. Labor analgesia: Early labor analgesia is recommended to avoid general anesthesia in case of emergency and can also be used for postoperative pain relief. Patient‑controlled epidural analgesia (PCEA) can be used for giving labor analgesia.

分娩镇痛：建议早期分娩镇痛，避免急诊全麻，也可用于术后镇痛。病人自控硬膜外镇痛(PCEA)可用于分娩镇痛。

8. Goal‑directed fluid therapy can be instituted. Overzealous fluid overloading should be avoided. The COVID‑19 recovered parturient may become hypotensive (18%) during regional anesthesia or induction of anesthesia. Prophylactic vasopressors, namely phenylephrine/ ephedrine are preferred over fluid overloading. In a multicenter, retrospective, propensity score‑matched cohort study, the incidence of neuraxial anesthesia‑related hypotension was 57.4% in the COVID‑19 parturients and 41.9% in control parturients.[56] Another retrospective review of the patients with a history of COVID‑19 infection revealed abnormal cardiovagal function in 275 cases, orthostatic symptoms including postural orthostatic syndrome in 22% of the cases, and orthostatic intolerance in 11% of the cases between 0 and 122 days post‑infection. P ost‑COVID‑19 autonomic and small fiber neuropathy can occur.[57] Nevertheless, low cortisol levels and adrenal insufficiency have also been reported as post‑COVID ‑19 sequelae.[58]

可以制定目标导向的液体疗法。应避免过度的补液。COVID - 19康复产妇在区域麻醉或诱导麻醉期间可能出现低血压(18%)。预防性血管升压药，即去氧肾上腺素/麻黄碱优先于液体过量。在一项多中心、回顾性、倾向评分匹配的队列研究中，COVID – 19产妇椎管内麻醉相关低血压的发生率为57.4%，对照组为41.9%。另一项对有COVID - 19感染史的患者的回顾性研究显示，275例患者出现心血管功能异常，22%的病例出现直立姿势综合征，11%的病例在感染后0 - 122天出现直立姿势不耐受。可发生COVID – 19后自主神经病变和小纤维神经病变。然而，低皮质醇水平和肾上腺功能不全也被报告为COVID - 19后的后遗症。

9. Cross‑matching of blood and an adequate arrangement of blood and blood products should be ensured, depending on the requirement of the case.

应根据病例的需要，确保血液的交叉配型以及血液和血液制品的适当安排。

10. General anesthesia (GA) can be administered depending upon maternal emergency (severe pre‑eclampsia/eclampsia/ HELLP (hemolysis, elevated liver enzymes, low platelet count)), contraindication to regional anesthesia (severe thrombocytopenia, failed RA, coagulopathy), or fetal emergency (cord prolapse, severe fetal distress). GA should be preferred in patients with decreased cardio‑pulmonary reserve. Rapid sequence induction is employed and a higher fraction of inspired oxygen (FiO2) has to be maintained till fetal delivery to ensure adequate fetal oxygenation.[23]

全身麻醉(GA)可根据产妇紧急情况(严重子痫前期/子痫/ HELLP(溶血、肝酶升高、血小板计数低))、区域麻醉禁忌症(严重血小板减少、RA失败、凝血功能障碍)或胎儿紧急情况(脐带脱垂、严重胎儿窘迫)进行。对于心肺储备减少的患者应首选GA。采用快速诱导，在胎儿分娩前必须维持较高浓度的吸氧(FiO2)，以确保胎儿氧合充足。[

11. Patients receiving magnesium sulphate (MgSO4) should be carefully observed for any respiratory muscle weakness. This mandates its judicious use in patients with respiratory distress.

接受硫酸镁(MgSO4)治疗的患者应仔细观察有无呼吸肌无力。这要求在有呼吸窘迫的患者中明智地使用它。

12. Preoxygenation is recommended in COVID‑19 recovered parturients because of decreased FRC and an increased vulnerability to desaturation. Video laryngoscope‑aided intubation should be preferred due to the high chance of first‑pass success rate. A difficult airway cart has to be kept ready because of altered airway anatomy in a pregnant patient. According to the difficult airway algorithm, second‑generation supraglottic airway devices can be used as a part of the rescue plan in cannot intubate/ ventilate situation.

建议对COVID - 19康复的产妇进行预充氧，因为FRC降低，饱和度降低的脆弱性增加。首选可视喉镜辅助插管，因为首次插管成功率高。由于妊娠患者气道解剖结构的改变，必须随时准备一个困难气道推车。根据困难气道算法，在无法插管/通气的情况下，第二代声门上气道装置可作为抢救计划的一部分。

13. The post‑COVID‑19 recovered obstetric patients are prone to AKI intraoperatively, and hence, reno‑toxic drugs should be avoided and urine output should be maintained above 0.5–1 mL/h.

COVID-9康复后的产科患者术中容易发生AKI，应避免使用雷诺毒性药物，排尿量保持在0.5-1 mL/h以上。

14. In a diabetic parturient, perioperative perturbations in blood sugar levels should be avoided. Tight glycemic control is now being perceived as a perioperative goal in patients undergoing surgery.[59,60] Although there exist no robust guidelines for the target glycemic control intraoperatively, albeit blood glucose can be titrated to 80–120 mg/dL, and an institutional insulin infusion protocol can be followed.[61]

糖尿病产妇应避免围手术期血糖水平的波动。严格的血糖控制现在被认为是手术患者的围手术期目标。尽管术中血糖控制目标没有可靠的指导方针，但是血糖可以滴定至80-120 mg/dL，并且可以遵循胰岛素输注方案。

15. Although, there is a lack of evidence supporting the vertical transmission of the SARS‑CoV‑2 infection in the neonate from the mother, standard neonatal resuscitation guidelines are to be followed and an emergency cart including resuscitation drugs, suction, oxygen, and intubation trolley should be kept ready. Neonatologists are to be kept informed and available to assess the neonate’s well‑being.

尽管缺乏证据支持SARS - CoV - 2感染在新生儿中从母亲垂直传播，但仍应遵循标准的新生儿复苏指南，并应准备好包括复苏药物、吸盘、氧气和插管推车在内的急救车。新生儿专家应随时了解情况，并可随时评估新生儿的健康状况。

Postoperative concerns术后注意事项

1. Standard postoperative monitoring with a focus on continuous oxygen monitoring via pulse oximetry is mandatory.

必须进行标准的术后监测，重点是通过脉搏血氧仪进行持续的氧监测。

2. Multimodal analgesia can be used for enhanced recovery after cesarean section (postoperative pain relief),[62] and there exists no evidence against the use of non‑steroidal anti‑inflammatory drugs (NSAIDs) in the post‑COVID‑19 recovered patient. P ostoperative pain may worsen hypoxia, and tachycardia and produce an overall increase in the work of breathing.

多模式镇痛可用于改善剖宫产术后恢复(术后疼痛缓解)，并且尚无证据反对在COVID - 19后康复患者中使用非甾体类抗炎药(NSAIDs)。术中疼痛可加重缺氧和心动过速，并产生呼吸功的整体增加。

3. The following criteria denote intensive care unit (ICU) admission: Respiratory rate >30/min, desaturation (<92‑93%) at rest, FiO2 <300 mmHg. The Quick Sequential Organ F ailure Assessment Score (qSOF A) can also be used as an adjunct for making the final decision.

以下表示ICU入院标准：呼吸频率>30/min，休息时饱和度降低(<92 - 93%)，FiO2 <300 mmHg。快速顺序器官衰竭评估分数(qSOF A)也可以作为最终决定的辅助判断。

4. Post‑COVID‑19 recovered patients are prone to post‑dural puncture headache (PDPH) and should be managed promptly with adequate rest, judicious fluids, NSAIDs, and caffeine. Epidural saline is preferred over an autologous blood patch.

大多数COVID - 19康复患者容易出现硬膜后穿刺性头痛(PDPH)，应通过充分休息、适量饮水、非甾体抗炎药和咖啡因及时进行管理。硬膜外盐水优于自体血贴片。

5. Antiplatelet, anticoagulant, LMWH, and other drugs can be continued as per the recommended guidelines.

抗血小板、抗凝血、低分子肝素和其他药物可按照推荐指南继续使用。

6 Early mobilization should be encouraged, as both pregnancy and post‑COVID recovered states are considered hypercoagulable states, thereby, necessitating deep vein thrombosis (DVT) prophylaxis.

应鼓励早期活动，因为怀孕和COVID恢复后的状态都被认为是高凝状态，因此需要预防深静脉血栓形成(DVT)。

7. Psychological well‑being is very important in the COVID‑19 recovered patients, and the literature has reported severe post‑partum depression in SARS‑CoV‑2 ‑recovered patients. Prompt recognition and identification of depression and anxiety symptoms in a parturient along with proper psychological counseling and treatment are pivotal.

心理健康对COVID - 19康复患者非常重要，文献报道了SARS - CoV - 2康复患者严重的产后抑郁。及时认识和识别抑郁和焦虑症状以及适当的心理咨询和治疗是关键。

8. Breastfeeding can be encouraged.

可以鼓励母乳喂养。

Conclusion

Successful management of the post‑COVID‑19 recovered obstetric patient requires multidisciplinary teamwork and anesthesiologists form an integral part of the team. Neuraxial anesthesia and analgesia seem to be effective and safe in the recovered COVID‑19 obstetric patients. It is of utmost importance to establish standard care definitions in this important subset. The goal of anesthesia management should focus on the recognition of the sequelae of the COVID‑19 infection in the parturient with the aim of preoperative optimization, goal‑directed fluid therapy, protective intraoperative ventilatory strategies, adequate analgesia, and early ambulation.

成功管理新冠肺炎后康复的产科患者需要多学科合作，麻醉医生是团队不可或缺的一部分。椎管内麻醉和镇痛似乎对康复的COVID - 19产科患者是有效和安全的。在这个重要的团体中建立标准照护定义是至关重要的。麻醉管理的目标应集中在对产妇COVID - 19感染后遗症的认识，以优化术前、目标导向输液、术中保护性通气策略、充分镇痛和早期下床活动。

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中英双语：Covid-19感染后的产科患者的麻醉管理-我们需要知道的

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