Zika Virus: Obstetric and Pediatric Anesthesia Considerations

Jacqueline L. Tutiven, MD; Benjamin T. Pruden, MD; James S. Banks, MD; Mario Stevenson, PhD; David J. Birnbach, MD, MPH

Disclosures

Anesth Analg. 2017;124(6):1918-1929. 

In This Article

Abstract and Introduction

Abstract

As of November 2016, the Florida Department of Health (FDH) and the Centers for Disease Control and Prevention have confirmed more than 4000 travel-related Zika virus (ZIKV) infections in the United States with >700 of those in Florida. There have been 139 cases of locally acquired infection, all occurring in Miami, Florida. Within the US territories (eg, Puerto Rico, US Virgin Islands), >30,000 cases of ZIKV infection have been reported. The projected number of individuals at risk for ZIKV infection in the Caribbean and Latin America approximates 5 million. Similar to Dengue and Chikungunya viruses, ZIKV is spread to humans by infected Aedes aegypti mosquitoes, through travel-associated local transmission, via sexual contact, and through blood transfusions. South Florida is an epicenter for ZIKV infection in the United States and the year-round warm climate along with an abundance of mosquito vectors that can harbor the flavivirus raise health care concerns. ZIKV infection is generally mild with clinical manifestations of fever, rash, conjunctivitis, and arthralgia. Of greatest concern, however, is growing evidence for the relationship between ZIKV infection of pregnant women and increased incidence of abnormal pregnancies and congenital abnormalities in the newborn, now medically termed ZIKA Congenital Syndrome. Federal health officials are observing 899 confirmed Zika-positive pregnancies and the FDH is currently monitoring 110 pregnant women with evidence of Zika infection. The University of Miami/Jackson Memorial Hospital is uniquely positioned just north of downtown Miami and within the vicinity of Liberty City, Little Haiti, and Miami Beach, which are currently "hot spots" for Zika virus exposure and transmissions. As the FDH works fervently to prevent a Zika epidemic in the region, health care providers at the University of Miami and Jackson Memorial Hospital prepare for the clinical spectrum of ZIKV effects as well as the safe perioperative care of the parturients and their affected newborns. In an effort to meet anesthetic preparedness for the care of potential Zika-positive patients and perinatal management of babies born with ZIKA Congenital Syndrome, this review highlights the interim guidelines from the Centers for Disease Control and Prevention and also suggest anesthetic implications and recommendations. In addition, this article reviews guidance for the evaluation and anesthetic management of infants with congenital ZIKV infection. To better manage the perioperative care of affected newborns, this article also reviews the comparative anesthetic implications of babies born with related congenital malformations.

Introduction

Within the US territories, >30,000 cases of Zika virus (ZIKV) infection have been reported.[1] ZIKV and other flaviviruses, including Dengue, West Nile Virus as well as the alphavirus Chikungunya, are single-stranded ribonucleic acid (RNA) viruses that are transmitted by mosquito vectors and cause disease in humans.[2] Federal health officials are observing 899 confirmed Zika-positive pregnancies and the Florida Department of Health is currently monitoring 110 pregnant women with evidence of ZIKV infection.[3] After its initial discovery in the Zika forest in Uganda in 1947, ZIKV did not receive much early attention; up until 2007, only 14 cases of human disease were known. In the past 10 years, ZIKV outbreaks have affected populations in the Yap Island (where since 2007, three-fourths of the Island's residents have been infected), French Polynesia (2013), and Brazil (2015). As opposed to previous outbreaks, the latest outbreak has given rise to an epidemic that is sweeping across South and Central America and the Caribbean. The ZIKV has 2 lineages: African and Asian, with the Asian lineage being responsible for the recent outbreaks in the Americas.[4] Infection by ZIKV usually presents itself clinically with a mild exanthematous rash, conjunctivitis, arthralgia, and fever. However, many infected persons are asymptomatic. Although typically self-limiting, studies now suggest an association between ZIKV infection and Guillain–Barré syndrome. Researchers are finding that symptoms of Guillain–Barré syndrome may appear contiguous with an active ZIKV infection (parainfectious).[5,6] Documented modes of infection include transmission via sexual contact, mother to fetus, and blood. There have been no reports of transmission via breast milk, urine, or saliva.[2] Even more alarming, maternal–fetal transmission of ZIKV has causally been linked to babies born with microcephaly, cerebral calcifications, and intrauterine growth restriction.[7,8] There is no specific treatment for ZIKV infection. Rest, fluids, and acetaminophen are recommended for generalized symptoms and fever. However, because symptomatology from Zika is not distinct and can be seen with other flaviviruses including dengue, the use of nonsteroidal anti-inflammatory drugs and aspirin is generally contraindicated in these pregnant women until dengue is ruled out because of the high risk for hemorrhagic complications and the premature closure of the ductus arteriosus when >32 weeks' gestation.[9]

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