Neonatal surgery during Covid-19 pandemic: Our experience in a tertiary care hospital in Bangladesh

Tosaddeque H Siddiqui; Zeba Ahmed; Nazrul Islam; Noor Mahammad; Abu Mohammad Shahinoor; Shahinur Rahman; Mridul P Joshi

doi:10.4103/pnjb.pnjb_18_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 1 | Page : 10-12

Neonatal surgery during Covid-19 pandemic: Our experience in a tertiary care hospital in Bangladesh

Tosaddeque H Siddiqui¹, Zeba Ahmed², Nazrul Islam¹, Noor Mahammad¹, Abu Mohammad Shahinoor¹, Shahinur Rahman¹, Mridul P Joshi¹
¹ Department of Paediatric Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
² Department of Gynaecology and Obstetrics, Mugdha Medical College and Hospital, Dhaka, Bangladesh

Date of Submission	17-Oct-2022
Date of Acceptance	15-Dec-2021
Date of Web Publication	31-May-2022

Correspondence Address:
Prof. Dr. Tosaddeque H Siddiqui
Department of Paediatric Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka
Bangladesh

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pnjb.pnjb_18_21

Abstract

Background: The impact of Covid-19 on global health and especially on the low-resource countries’ health system has been serious. The lack of personal protective equipment, masks, sanitizers, and lack of testing has made the surgical delivery even more challenging. These delays in management of these surgical cases are going to stack up in the future and increase mortality and morbidity. However, the emergent nature of some of the neonatal surgical cases cannot be postponed. Materials and Methods: This is a retrospective observational study done from April 2020 to September 2020 in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Surgical neonates were tested for SARS-CoV-2 by using the real-time PCR on oropharyngeal swabs. The reports of the tests were received only 24 h later. Results: A total of 22 neonates with surgical conditions were admitted during the study period. Eighteen were tested for Covid-19, whereas 4 were tested but reports were not awaited for surgery. All the babies tested negative for Covid-19. There were a variety of cases admitted, predominately hydronephrosis, clubfoot, meningocele, intestinal obstruction, cleft lip, and palate. Among the 22 surgical neonates, 6 received the surgical management, whereas 16 were managed conservatively and kept on follow-up. Regarding the outcome, 17 patients (3 managed surgically and 14 nonemergent cases were managed conservatively) were discharged to home. Mortality were 5 in number (3 postoperative patient and 2 while managing conservatively). Conclusion: During the unprecedented times of Covid-19, extreme precaution and protocol must be followed to carry on neonatal surgeries to protect both health workers and children.

Keywords: Bangladesh, Covid-19, neonatal surgery

How to cite this article:
Siddiqui TH, Ahmed Z, Islam N, Mahammad N, Shahinoor AM, Rahman S, Joshi MP. Neonatal surgery during Covid-19 pandemic: Our experience in a tertiary care hospital in Bangladesh. Paediatr Nephrol J Bangladesh 2022;7:10-2

How to cite this URL:
Siddiqui TH, Ahmed Z, Islam N, Mahammad N, Shahinoor AM, Rahman S, Joshi MP. Neonatal surgery during Covid-19 pandemic: Our experience in a tertiary care hospital in Bangladesh. Paediatr Nephrol J Bangladesh [serial online] 2022 [cited 2023 Oct 4];7:10-2. Available from: http://www.pnjb-online.org/text.asp?2022/7/1/10/346343

Introduction

The impact of Covid-19 pandemic, which is caused by SARS-CoV-2 virus, on global health has been significant and well documented,^[1],[2] especially in low-income countries has been dire. The pandemic has brought the health service providers, authorities, and healthcare workers on its knees. The lack of personal protective equipment, masks, sanitizers, and testing for Covid-19 has made the healthcare delivery even more challenging in the resources-limited countries.^[3]

In Bangladesh, as of reporting of this article dated October 5, 2020, a total number of cases are 369,000 with 5348 deaths.^[4] In comparison to the global health situation, the impact of Covid-19 on children is worse. According to the Information of Epidemiology, Disease Control, and Research, Bangladesh, 11% of the total infected cases are children under the age of 20.^[5] UNICEF has also predicted that over 28,000 children under the age of 5 may die in 6 months directly or indirectly due to Covid-19.^[6] Different measures such as hand hygiene, social distancing, universal wearing of masks, identification and isolation of infected people, and tracing of contacts are effective to control transmission and alleviate the epidemic.^[7],[8]

The pandemic has affected every aspect of life around the world including children’s surgical condition.^{[9],[10],[11]} Due to this pandemic, all the neonatal and pediatric nonemergent surgical cases have been postponed. The delay in management of these surgical cases is going to stack up in the future and increase mortality and morbidity. However, the emergent nature of some of the neonatal surgical cases cannot be postponed.

We report our experience in the management of neonatal surgical cases in a tertiary care hospital in Bangladesh in the past 6 months during the times of Covid-19.

Materials and Methods

This is a retrospective observational study done from April 2020 to September 2020 in BSMMU. Surgical neonates were tested for SARS-CoV-2 by using the real-time PCR on oropharyngeal swabs. The reports of the tests were received only 24 h later. Hence, waiting for reports on some of the neonates requiring immediate management was not feasible.

We used the hospital records for diagnosis, associated prematurity, and its management and outcome. Results were reported in terms of frequency and percentage.

Results

A total of 22 neonates with surgical conditions were admitted during the study period. Of the 22 neonates, 13 cases were preterm and 9 were term [Figure 1]. Eighteen were tested for Covid-19, whereas 4 were tested but reports were not awaited for surgery. All the babies tested negative for Covid-19.

Figure 1: Maturity of surgical neonates

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There were a variety of cases admitted, predominately hydronephrosis, clubfoot, meningocele, intestinal obstruction, cleft lip, and palate, among some. Detailed diagnosis is shown in [Table 1].

Table 1: Diagnosis of surgical neonates

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Of the 22 surgical neonates, 6 received the surgical management, whereas 16 were managed conservatively and kept on follow-up [Table 2].

Table 2: Management of surgical neonates

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Regarding the outcome, 17 patients (3 managed surgically and 14 nonemergent cases were managed conservatively) were discharged to home. Mortality were 5 in number (3 postoperative patients and 2 while managing conservatively) [Figure 2].

Figure 2: Outcome of surgical neonates

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Discussion

The troublesome thing about Covid-19 is that new information regarding the virus is emerging weekly if not daily. The information regarding its incubation period, transmission routes, pathogenesis, etc. is still not fully understood. The halting of the elective and semi-elective cases will create a backlog of cases which in due time going to affect children in terms of morbidity and mortality and also create a workload on surgical teams in the future.

Also, it is made even more challenging in the resource-limited countries like Bangladesh, where there is still lack of testing or even when tested failure to provide the report on time, lack of personal protective equipment for the surgical teams, and other theater workers.^[5] There is also lack of testing for the surgical teams. Despite the challenges and limitations, emergent surgical cases cannot be postponed.

In BSMMU, during the Covid-19 pandemic, all the elective cases were halted for 5 months and only for the past 1 month (beginning of September), elective cases and day case surgeries have started resuming after proper testing. In neonatal surgery, the lack of knowledge about the mode of transmission from mother to child has made the need of testing of the child debatable. However, in our institute, it was made mandatory to test all the neonates admitted in NICU and also those undergoing surgical procedures. Of all the neonates tested, 4 neonates had their reports awaited before surgical procedure and hence extra precautions were taken during the surgical procedures of these patients. Four neonates were later reported negative. In our 6 months’ experience, we had no patients infected with Covid-19 due to which surgical teams could work stress-free.

Of the 22 surgical neonates in 6 months, there were a variety of surgical cases. It was predominately hydronephrosis (2), B/L hydronephrosis due to posterior urethral valve (2), cleft palate (3), clubfoot (1), ruptured meningocele (1), pneumothorax (1), ileal atresia (1), imperforate anus with meningocele (1), etc.

The surgical cases requiring immediate surgical management were ruptured meningocele, imperforate anus, ileal atresia, ileal perforation with peritonitis, pneumothorax, and one case of posterior urethral valves in which catheterization failed. Vesicostomy was done. Another patient of posterior urethral valve was discharged after catheterization. Two cases of hydronephrosis were unilateral and moderate, so patients were kept in follow-up. If indicated, Anderson–Hynes pyeloplasty is planned.

Among the other performed procedures were excision and repair of ruptured meningocele, resection and anastomosis of ileal atresia, repair of ileal perforation, colostomy for imperforate anus (ARM). Chest tube was also inserted for pneumothorax. Neonatal surgery is one of the pillars of pediatric surgery on which it stands upon. It is already a challenging field due to the vulnerability of the new born and the Covid-19 pandemic has compounded the risk even further.

We have tried to manage all the patients with certain guidelines. Minimum handling of the child by multiple staffs and OT gown were used as personal protective equipment, double masks, regular hand washing, and sanitizing the hands after handling of each patient. Limiting the visit by mother was also enforced. Testing by real-time PCR was done for all the surgical patients. This is debatable whether all the patients need to be tested; however, the tendency of the mother to hide the history of symptoms in our country adds further doubt in the minds of the doctors. Also less staffs were allowed in the OT to minimize the transmission.

Regarding the outcome, 17 cases (77%) were discharged to home and kept in regular follow-up. All the cases of nonemergent cases were postponed and kept in follow-up. Since the past 1 month, the elective cases were resumed and the postponed neonatal cases will be operated in the coming days taking extreme precautions. Mortality were 5 in number, of which 3 were postoperative and 2 were patients of necrotizing enterocolitis.

Conclusion

These unprecedented times of Covid-19 have thrown a major challenge to the global health, especially the surgical faculties. However, more challenging surgical specialties such as the neonatal surgery cannot be halted. So, extreme precautions and protocols must be made to handle these patients to protect the health workers as well as the child.

Authors’ contributions

MTHS and MPJ examined the infants and contributed to the design, data organization, analysis, discussion, main interpretation of results, and writing of the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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