|Year : 2013 | Volume
| Issue : 1 | Page : 44-46
Elective cesarean section in a parturient with post burn neck contracture: An anesthetic challenge!
Kamlesh Kumari, Vanita Ahuja, Satinder Gombar
Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||1-Jul-2013|
Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh
Source of Support: None, Conflict of Interest: None
The incidence of failed intubation in the pregnant population is 1 in 250-300 patients, which is 8 times higher than non-pregnant patients. Regional anesthesia is the technique of choice in a parturient with recognized potentially difficult airway for cesarean section; however, it may be controversial in the presence of anticipated intraoperative hemodynamic instability. We describe anesthetic management of 23-year-old female, gravida 2, para 1 admitted in the labor ward with central placenta previa and severe post burn contracture of neck for elective cesarean delivery.
Keywords: Difficult airway, elective cesarean delivery, parturient
|How to cite this article:|
Kumari K, Ahuja V, Gombar S. Elective cesarean section in a parturient with post burn neck contracture: An anesthetic challenge!. J Obstet Anaesth Crit Care 2013;3:44-6
|How to cite this URL:|
Kumari K, Ahuja V, Gombar S. Elective cesarean section in a parturient with post burn neck contracture: An anesthetic challenge!. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2020 Feb 20];3:44-6. Available from: http://www.joacc.com/text.asp?2013/3/1/44/114295
| Introduction|| |
The incidence of difficult intubation in the pregnant population is 8 times higher than in the non-pregnant population. , The incidence of thermal injuries in females of reproductive age varies from 0.6% to 15% in India which is very high.  Contracture of the neck is a sequel of burns and is a cause of difficult airway.  We describe anesthetic management of a parturient with central placenta previa with post burn contracture (PBC) of neck for elective cesarean delivery (CD) under general anesthesia (GA).
| Case Report|| |
A 23-year-old female, 55 kg, gravida 2, para 1 at 37 weeks of precious pregnancy with the central placenta previa and severe PBC of the neck was scheduled for elective CD. Patient had sustained 30% burns at 4 th month of this pregnancy and subsequently, she developed severe PBC of neck, chest, and arms. On airway examination, the patient had Mallampati grade IV with mouth opening of 2 cm, thyromental distance of 4.0 cm, inability to extend the neck, sternomental distance 8 cm, upper lip bite test  class III, mandibular protrusion was not possible and had a Wilson score  of 6/10 [Figure 1]. Systemic examination and routine investigations were unremarkable. Keeping the possibility of anticipated difficult airway and central placenta previa, we planned GA preceded by awake fiberoptic bronchoscope (FOB) guided endotracheal intubation (ETI). The same was explained to the patient and written consent was obtained.
|Figure 1: Anterior and lateral view of upper airway in the parturient showing Mallampati grade IV with mouth opening of 2 cm and inability to extend the neck|
Click here to view
Patient was premedicated with per oral (PO) ranitidine 150 mg and metoclopramide 10 mg the night before and on the morning of surgery. Intravenous (IV) access was secured with two peripheral cannula (18 guage and 16 gauge). IV glycopyrrolate 0.2 mg was given 45 min prior to the procedure. Minimum mandatory monitoring was started with multiparameter monitor (S/5 TM Datex Ohmeda, USA). Difficult airway cart was kept ready. Preparation for awake FOB intubation included gargles with 10 ml of 2% lignocaine, nebulization with 4% lignocaine (5 ml) and local application of 2% lignocaine jelly manually with fingers staring from tip to the base of tongue. Patient received 4 L/min oxygen through nasal prongs throughout the procedure till ETI. After achieving adequate local anesthesia of the airway, we decided to do a check laryngoscopy with Glidescope® (Saturn Biomedical Systems, Verathon, Canada) which revealed a Cormack and Lehane (CL) grade of 4. A berman's airway size 3 (Ningbo Greatcare Meditech Co., Ltd., China) was inserted to facilitate insertion of FOB (Fl-10P2, Pentax medical, Montvale, America). One milliliter of 4% lignocaine was instilled on visualization of vocal cords and trachea was intubated with 6.5 mm ID disposable, cuffed endotracheal tube (ETT). After correct placement of ETT, anesthesia was induced with propofol 100 mg, atracurium 25 mg and maintained with nitrous oxide in oxygen 50%, sevoflurane 1-2% and fentanyl 100 μg after delivery of the baby. APGAR score  at 1 and 5 min was 8/10 and 9/10.The intraoperative period was uneventful and patient's trachea was extubated over an airway exchange catheter with patient fully awake with intact protective airway reflexes. Intraoperative blood loss was 1L. Patient remained hemodynamic stable in the perioperative period and was discharged home after 1 week.
| Discussion|| |
Airway management in an obstetric patient is challenging as not only pregnancy itself, but also other factors (i.e., distorted anatomy of the airway, altered physiology) pose anesthetic challenges.  In addition, our patient developed thermal injury of 30% during 4 th month of pregnancy and the causes of difficult airway management were fixed flexion deformity, limited mouth opening, decreased pharyngeal space, decreased atlanto occipital extension and decreased submandibular compliance. This causes an inability to align the oral, pharyngeal and laryngeal axes. 
The Anesthesiologist should individualize the anesthetic approach in a parturient with difficult airway and must be fully prepared to administer GA if the need arises.  Epidural anesthesia is a useful technique to avoid major hemodynamic shifts or respiratory compromise, but it may not be beneficial in an event of intraoperative hemodynamic instability as failure to maintain oxygenation consequently has a high probability and a potential risk of impacting both mother and baby.  Moreover, it is known that the airway of the parturient changes from Mallampati class 2 pre-operatively to class 4 in the immediate post-operative period following hemorrhage and fluid administration. These changes in the airway may pre-dispose to subsequent difficult intubation, in the event that intraoperative GA is required during the regional anesthesia. 
We decided to use Glidescope® with dual purpose, so as to perform check laryngoscopy and if possible endotracheal intubation.  Glidescope® has an inherent unique curve of 60° at the midline, improved view of the glottis as it is able to "look round the corner," minimal manipulation and helps in intubation with rapid learning curve. However, we could not perform ETI with Glidescope® due to CL grade 4.  Hence, a GA technique with awake FOB was planned.
Awake FOB intubation remains the gold standard in patients with difficult airway.  Other options available for airway management in such cases are: supraglottic devices, blind nasal intubation, retrograde intubation, and tracheostmy. SGD's were not preferred as the first choice because the safety and oropharyngeal leak pressure of these devices have not been evaluated in a parturient with anatomically deformed or difficult airway in parturient. 
The key to successful management is a close loop communication between obstetrician and an experienced anesthesiologist with a careful anesthetic planning to ensure safe maternal and fetal outcome in a parturient with a difficult airway and anticipated intraoperative hemodynamic instability.
| References|| |
|1.||Kuczkowski KM, Reisner LS, Benumof JL. The difficult airway: Risk, prophylaxis, and management in chestnut DH. Obstetric Anesthesia: Principles and Practice. 3 rd ed.: Elsevier Mosby Inc, Philadelphia. PA, USA; 2004. p. 535-62. |
|2.||Ezri T, Szmuk P, Evron S, Geva D, Hagay Z, Katz J. Difficult airway in obstetric anesthesia: A review. Obstet Gynecol Surv 2001;56:631-41. |
|3.||Matthews RN. Obstetric implications of burns in pregnancy. Br J Obstet Gynaecol 1982;89:603-9. |
|4.||Stage AH. Severe burns in the pregnant patient. Obstet Gynecol 1973;42:259-62. |
|5.||Khan ZH, Mohammadi M, Rasouli MR, Farrokhnia F, Khan RH. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: A prospective study. Anesth Analg 2009;109:822-4. |
|6.||Gupta S, Pareek S, Dulara SC. Comparison of two methods for predicting difficult intubation in obstetric patients. Middle East J Anesthesiol 2003;17:275-85. |
|7.||Vahabi S, Haidari M, Akbari Torkamani S, Gorbani Vaghei A. New assessment of relationship between Apgar score and early neonatal mortality. Minerva Pediatr 2010;62:249-52. |
|8.||American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269-77. |
|9.||Bhavani-Shankar K, Lynch EP, Datta S. Airway changes during Cesarean hysterectomy. Can J Anaesth 2000;47:338-41. |
|10.||Ahuja V, Gombar S, Thapa D, Bagri K. Orotracheal intubation facilitated with a Glide Scope GVL® video laryngoscope in a patient with a large oronasopharyngeal rhinosporidiosis. Can J Anaesth 2012;59:327-9. |
|11.||Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: An analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011;114:34-41. |
|12.||Langeron O, Semjen F, Bourgain JL, Marsac A, Cros AM. Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management. Anesthesiology 2001;94:968-72. |