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$able 0. Infectious Disorders in the arturient with Anesthetic Im%lications

1S+ 2 her%es sim%le3 virus' 1I+ 2 human immunodeficiency virus.

$he ris4 to the mother and the fetus is greatly increased in %regnancy that is com%licated

by infection and fever. $he diverse clinical manifestations of various infectious disorders,

combined with the uni5ue anesthetic im%lications of %regnancy, may result in life*threatening com%lications, significantly im%acting the %ractice of obstetrical anesthesia.

6egional anesthesia has become a hallmar4 of modern obstetric anesthesia %ractice and a

%aramount techni5ue for labor analgesia. $he diagnosis of infection in %regnancy oftenraises 5uestions about the safety of regional anesthesia in febrile %atients. Des%ite this

concern, and lac4 of universal guidelines, it has now been well established that the

%resence of infection and fever in labor does not always %reclude the administration of

neura3ial anesthesia."# $he decision to administer regional anesthesia in a febrile%arturient should be based on an individual ris4*to*benefit ratio. $he 4nowledge of the

underlying infectious %rocess, available treatment modality, and anesthetic im%lications

of both are im%ortant for o%timal anesthetic management.

Fever: definition and pathophysiology

7ormal body function de%ends on a relatively constant body tem%erature (with normal

diurnal variations), which is regulated by the hy%othalamus and determined by the

balance between heat %roduction and heat loss to the environment.0# $he coretem%erature (rectal, eso%hageal) is usually 8.9:C higher than the oral tem%erature. $here

is a circadian fluctuation in tem%erature with the nadir at ; A and the %ea4 at < . Infemales there is a monthly cycle during which the tem%erature increases at the time of

ovulation and falls bac4 to baseline at the onset of menstruation. $he normal core bodytem%erature in adults ranges from 0;.9:C to 0

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rarely e3ceeds >!:C. 7ormal circadian fluctuation in body tem%erature with increase in

the evening and decrease in the morning continues, even in febrile %atients. ;# Under

normal circumstances, core body tem%erature is tightly regulated, with a variation ofa%%ro3imately 8.9:C. Although the benefits of fever are uncertain, it has been suggested

that the increased body tem%erature aids in the activation of the host immune res%onse,

with augmentation of bactericidal, %hagocytic, and chemotactic %ro%erties of%olymor%honuclear leu4ocytes. $he negative as%ects of fever include increased basal

metabolic rate and increased cardiac demand.

Interaction with pregnancy

regnancy is associated with an increase in the maternal basal metabolic rate.?# $he %ainof labor causes the %arturient to hy%erventilate, which, along with accom%anying

%ers%iration, leads to com%ensatory heat dissi%ation. aternal body tem%erature in labor

is also significantly affected by the degree of %hysical activity. 1igher tem%eratures havebeen re%orted in laboring %arturients who remained calm and inactive.

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+iruses most commonly encountered in %arturients include influena virus, her%es

sim%le3 virus (1S+), he%atitis viruses, cytomegalovirus (C+), %a%illomavirus, and1I+ (Table 1). Additionally, febrile diseases caused by measles, rubella, and chic4en%o3

viruses may a%%ear during %regnancy.

Herpes simplex virus

General considerations

1er%es sim%le3 virus is a double*stranded deo3yribonucleic acid (D7A) virus. It belongsto a large grou% of double*stranded D7A viruses, which also encom%asses varicella*

oster virus, C+, and -%stein*/arr virus. $wo ty%es of 1S+ have been identified.

1er%es sim%le3 virus ty%e ! is generally associated with oral lesions (cold sores) and

transmission occurs through oral secretions. 1er%es sim%le3 virus ty%e " is associatedwith %ainful vesicular or %a%ular lesions on mucous membranes or s4in of the genital

tract. Se3ual contact remains the %redominant mode of 1S+ ty%e " transmission. /oth

ty%es of 1S+ share the %ro%erty of asym%tomatic %eriods of latency interru%ted bye%isodes of reactivation. During %eriods of latency the virus resides in the sensory neural

ganglia.!!# $wo cases of %ost%artum 1S+ endometritis have been re%orted in the

literature. /oth infants died from disseminated 1S+ infection. !"#

Anesthetic management

Differentiation between the %rimary (initial) and secondary (recurring) infection is of

critical im%ortance before the administration of anesthesia. Unfortunately, such a

distinction often %roves very difficult in clinical settings.!0# $he administration ofregional anesthesia often raises concerns about neura3ial s%read of the virus and%ossibility of a disseminated disease. Such concern seems more li4ely in %rimary

infections with transient %resence of the virus in the systemic circulation. !0#

$he transient viremia of %rimary infection is followed by %ermanent antibody %roduction> to ; wee4s later. $he coe3istence of ty%ical genital lesions with systemic sym%toms

(fever, myalgia, and headache) usually suggests a %rimary infection' however,

a%%ro3imately 08 of these %atients remain asym%tomatic. $he lac4 of sym%toms mayadditionally cloud the differential diagnosis.!># When %rimary infection is ac5uired in

the %eri%artum %eriod, the ris4 of vertical transmission to the neonate is very high

because of the %resence of viremia. !9# $o date, the safety of regional anesthesia in

%rimary infection with 1S+ has not been established. In contrast, viremia is rarely%resent in %atients with secondary, recurrent 1S+ ty%e " infection, and several

investigators have documented safety of regional anesthesia in these %atients. !;,!? and

!

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reactivation remains obscure, although %ruritus, scratching, and activation of the nucleus

of the fifth cranial nerve by o%ioid binding, have been %ostulated."!and ""# $his

association, however, has not been confirmed by other researchers and remainscontroversial. "0# It is noteworthy that no such association has been re%orted between

neura3ial o%ioids and recurrence of 1S+ ty%e " infections.

Hepatitis

General considerations

+iral he%atitis results from infection by a s%ectrum of viruses, which may vary in the

mode of transmission and clinical e3%ression. 1e%atitis viruses ty%e A, /, C, D, and -have been identified. $he onset of the disease may be gradual or fulminant. $he

incubation %eriod and seroconversion may vary from " to "> wee4s."># $he clinical

sym%tomatology may include fever, anore3ia, fatigue, nausea, vomiting, abdominaldiscomfort, and =aundice. $here is little sur%rise that some of these sym%toms might draw

insufficient attention since their occurrence in otherwise normal %regnancy is common."9#

Anesthetic managementAlthough mild he%atitis does not significantly alter anesthetic management and%regnancy outcome, careful %reanesthetic evaluation should determine the degree of

he%atic im%airment. Laboratory evaluation should include serum electrolytes, creatinine,

blood urea nitrogen, bilirubin, transaminases, al4aline %hos%hatase, albumin, and

%rothrombin time. Whenever %ossible, maternal serum should be chec4ed for the%resence of he%atitis / surface antigen (1bsAg). If a %regnant %atient with acute viral

he%atitis must undergo emergency delivery, %rom%t correction of electrolyte

abnormalities and dehydration is recommended."and "9#If general anesthesia is selected, anesthetic drugs with 4nown e3trahe%atic metabolism

are recommended. Standard doses of intravenous (I+) induction drugs are generally used

because their action is terminated by redistribution rather than metabolism or e3cretion.Isoflurane remains the %otent inhaled volatile anesthetic of choice because it has the least

effect on he%atic blood flow. &actors such as hy%otension, e3cessive sym%athetic

stimulation, and high airway %ressure should be avoided because they are causes ofreduced he%atic blood flow.

6egional anesthesia may be safely em%loyed in febrile %arturients with viral he%atitis

%rovided thrombocyto%enia is absent, coagulation studies remain normal, and

hy%otension is avoided. /ecause history of I+ drug abuse and coe3isting 1I+ infection

are common, combative behavior, widely fluctuating mood level, and altered %ain%erce%tion may be encountered when regional anesthesia is selected for these %atients.

";# $he ris4 of vertical transmission of he%atitis C to the fetus is significantly increased%eri%artum. "?# Universal safety %recautions are recommended when handling blood and

bodily fluids from these %atients.

Human immunodeficiency virus

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General considerations

$he ac5uired immune deficiency syndrome (AIDS) has grown from negligible numbers

in !@

Frganiation as of !@@?."

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Involvement of the res%iratory system with oro%haryngeal and eso%hageal %athology may

render 1I+*infected %atients increasingly %rone to regurgitation, difficult intubation, and

as%iration. F%%ortunistic %ulmonary infections may necessitate %rolonged mechanicalventilation in the %osto%erative %eriod. Careful e3aminations of the cardiovascular

(subclinical cardiomyo%athy), renal (ne%hro%athy), and hematological (neutro%enia,

thrombocyto%enia) systems are indicated in %reanesthetic assessment of these %atients.atients with AIDS may e3hibit electrolyte disturbances, such as hy%onatremia, which

may be due to adrenal infection by C+ or mycobacteria. If severe, these disturbances

should be corrected before induction of anesthesia. Although thrombocyto%enia mayoccur in the 1I+*%ositive %atient, it is rare for the %latelet count to be low enough as to

im%act on the choice of anesthetic. 1owever, if the %latelet count decreases below

98,888mm, the ris4s of bleeding and e%idural hematoma may increase.>!# $reatment of

com%lications of neura3ial anesthesia, including management of %ostdural %unctureheadache (D1) should not differ from the standards of care for healthy %atients.

S%ecifically, if D1 occurs, an e%idural blood %atch with autologous blood is safe and

effective treatment in the 1I+*infected %atient >"#

If general anesthesia is selected, dose ad=ustments for history of drug abuse (acute vs.chronic), com%romised he%atic and renal function, or generalied muscle wasting are

necessary. 1I+*related %ulmonary %athology may re5uire a higher fraction of ins%iredo3ygen concentration."and 00#

$he ris4 of occu%ational e3%osure to infected blood and bodily fluids should never be

underestimated when caring for these %atients. 7ecessary safety measures

(universalstandard %recautions) must be em%loyed when handling blood and blood%roducts of all %atients, not =ust those who are 4nown to be 1I+*%ositive., >># $here is a

Kwindow of time between the %rimary 1I+ infection and seroconversion, during which

the diagnosis can be delayed, yet viral transmission occur. $he use of gloves %revents@># $he

ris4 of 1I+ transmission from a needle stic4 in=ury with 1I+*infected blood is

a%%ro3imately 8.0". >9#

Bacterial infections in pregnancy

$he most common bacterial infections in %regnancy include U$Is, chorioamnionitis,

res%iratory tract infections, and %ost%artum endometritis (Table 2). Systemic bacterial

illness regardless of its origin may lead to serious maternal and fetal conse5uences if left

untreated. $he incidence of maternal infection in labor is estimated to be 0.!. ,MSe%ticemia has been re%orted in 8.8? of %regnant %atients. $he most common etiology

is gram*negative organisms (@9), with the remaining being caused by gram*%ositiveand other bacteria.>;#

rinary tract infections

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General considerations

Infections of the urinary tract are the most common bacterial infections encountered

during %regnancy. Urinary tract infections include a s%ectrum of disorders ranging from

asym%tomatic bacteriuria to %yelone%hritis. Asym%tomatic bacteriuria is diagnosed in

a%%ro3imately !8 of %regnant women.",>?and >8 cases of neonatal se%sis and neonatalres%iratory tract infections.9;# With %rolonged chorioamnionitis, neonatal morbidity is

substantially increased. 9?# Nrether et al.9

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$here is no evidence that neura3ial bloc4s are contraindicated in a febrile %arturient with

intra*amniotic infection."# /ecause most obstetricians administer %arenteral antibiotics

once the diagnosis of chorioamnionitis has been established, it is =ustified to delayadministration of labor analgesia until after the %arturient has received antibiotics. 9@#

1owever, administration of regional anesthesia before antibiotic thera%y in %arturients

with intraamniotic infection and %roven bacteremia has not %roven deleterious. ;8and;!#

Pneumonia

General considerations

/acterial %neumonia is uncommon in healthy %arturients because of efficient host

defense mechanisms. In contrast, alcoholism or drug abuse in %regnancy may im%air

consciousness and %redis%ose to inhalation of bacteria*containing secretions leading to

%neumonia. /acterial %neumonia is characteried by develo%ment of transient chills,followed by a ra%id increase in body core tem%erature. A%%ro3imately ;; of cases of

%neumonia in %regnancy are bacterial in origin.;"# $he etiology of %neumonia in%regnancy is no different from the non%regnant state. "and;"# Streptococcus

pneumoniaeis the most commonly isolated %athogen' however,Haemophilusand

Mycoplasmaalso have been im%licated.

Anesthetic management

$he %hysiologic changes of %regnancy, such as decreased functional residual ca%acity,

increased o3ygen consum%tion, ca%illary engorgement, hy%ersecretion of res%iratory tract

mucosa, and decreased cellular immunity, may %redis%ose to the develo%ment of%neumonia. A chest radiogra%h should be %erformed to confirm the diagnosis. $he%arturient with %neumonia is susce%tible to the develo%ment of %ulmonary edema.;"#

Su%%lemental o3ygen administration should maintain o3ygen saturation (S%F") above

@9 and arterial o3ygen tension (aF") above ?8 to

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ris4 for %ost%artum endometritis when com%ared with %arturients who delivered

vaginally. hr) is characteried by hy%otension,

hy%o%erfusion, low systemic vascular resistance, and increased cardiac out%ut (CF).rogression to the late %hase is associated with significant fluid losses and decreased CF.

eri%heral vascular resistance is increased and manifested clinically by cold and cyanotic

e3tremities. Fliguria and myocardial de%ression are characteristically %resent. Increasedconcentrations of fibrin degradation %roducts mirror the %resence of disseminated

intravascular coagulation (DIC). Adult res%iratory distress syndrome also may develo%.

$he diagnosis of se%tic shoc4 is usually established by the develo%ment of %ronouncedhy%otension in the %resence of %eri%heral vasodilation. 6a%id and aggressive treatment

with I+ fluids, vaso%ressors, and antibiotics is re5uired.

Anesthetic management

Se%tic shoc4 thera%y includes I+ administration of broad*s%ectrum antibiotics and

intensive fluid resuscitation, guided by cardiovascular monitoring. If abdominal deliveryis indicated, the need for emergent delivery must be often weighed against the need for

insertion of invasive monitors and resuscitative efforts aimed at restoring o%timal

maternal condition for delivery. $he late %hase of se%tic shoc4 is associated with low CF,intravascular fluid deficits, hy%otension, and coagulo%athy, a combination that usually

%recludes the administration of regional anesthesia.

aternal hemodynamic stability and maintenance of uterine %erfusion should determine

the choice of anesthetic drugs for induction and maintenance of general anesthesia.rolonged induction of anesthesia should be avoided so as to %revent neonatal de%ression

at delivery. $he selection of induction drugs should be based on their %redicted

cardiovascular res%onse, and drugs that su%%ort the cardiovascular system, such asetomidate or 4etamine, should be selected.

$egional anesthesia for the fe%rile parturient

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib8%23bib8http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib55%23bib55http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib8%23bib8http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib46%23bib46http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib64%23bib64http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib46%23bib46http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib8%23bib8http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib55%23bib55http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib8%23bib8http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib46%23bib46http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib64%23bib64http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T83-4B3KN62-H&_user=4429&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000059602&_version=1&_urlVersion=0&_userid=4429&md5=d5a796268aff8255f35135d62f8dad20#bib46%23bib46

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and maternal intra%artum Kfever.

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Nlosten et al.@># evaluated the effect of e%idural analgesia on sweating in non%regnant

volunteers. A higher core tem%erature was needed to induce sweating in%atients who

received e%idural analgesia. Additionally, decreased sweating was re%orted below thelevel of sensory bloc4, most li4ely resulting from the bloc4ade of sym%athetic nerve

fibers. aner et al.@9# showed that many %arturients do not %ers%ire, even in the

%resence of fever. Shivering was fre5uently not related to hy%othermia, and sweating wasnot triggered by hy%othermia in the studied sub=ects. Simultaneous sweating and

shivering were re%orted. im et al.@;# re%orted that shivering associated with e%idural

analgesia was %rimarily caused by normal, %hysiologic, thermoregulatory mechanisms. Incontrast, other investigators concluded that shivering was %rimarily caused by a

nonthermoregulatory mechanism. @?and @ of neonates born to febrile mothers in

the e%idural grou%, com%ared with @.

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association between labor e%idural analgesia and neonatal se%sis evaluation (wor4u%) is

less clear. any factors other than maternal fever are involved in the decision*ma4ing

%rocess leading to initiation of a neonatal se%sis evaluation.&inally, most randomied studies com%ared tem%erature changes in%atients who received

e%idural analgesia with control grou%s who received %arenteral me%eridine.!88#

e%eridine is 4nown to selectively decrease the shivering threshold, and it is used widelyas a treatment of %osto%erative shivering. $herefore, its selection as a control grou%

remains 5uestionable, and further investigations are needed.

"ummary

$he administration of e%idural anesthesia in healthy %arturients in labor has beenassociated with a modest increase in maternal core tem%erature. 1owever, there is lac4 of

evidence to suggest that this transient increase in maternal tem%erature adversely affects

the fetus.$here are many anesthetic challenges in the management of the infected %regnant %atient

(both in elective manner and emergency situations). A com%lete understanding of%hysiology of %regnancy, combined with the 4nowledge of etiology and %atho%hysiologyof the coe3isting disease %rocess is therefore essential in contem%orary anesthesia

%ractice. $he anesthesiologist may safely administer regional anesthesia to the ma=ority

of %atients with established infection, %rovided that se%sis is not %resent. 1owever, itseems %rudent to determine the etiology of infection and initiate a%%ro%riate thera%y with

antibiotics before induction of anesthesia.

Ac#nowledgement

$he author would li4e to than4 Dr. rystof . uc4ows4i for his 4ind %ermission to

use this article for the summary of the Anesthetic anagement of the arturient with&ever and Infection.

$eferences!.6.. Stoelting and S.&. Dierdorf, Infectious diseases. InO 6.. Stoelting and S.&. Dierdorf, -ditors,Anesthesia and Co!"isting

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;.-. At4ins, &ever Q new %ers%ectives on an old %henomenon.+ !ngl - Med-./(!@

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