|Year : 2013 | Volume
| Issue : 2 | Page : 114-119
Selected abstracts of the papers presented as poster presentations during the 6 th National Conference of Association of Obstetric Anaesthesiologists held in Mangalore 2013
|Date of Web Publication||19-Dec-2013|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Selected abstracts of the papers presented as poster presentations during the 6 th National Conference of Association of Obstetric Anaesthesiologists held in Mangalore 2013. J Obstet Anaesth Crit Care 2013;3:114-9
|How to cite this URL:|
. Selected abstracts of the papers presented as poster presentations during the 6 th National Conference of Association of Obstetric Anaesthesiologists held in Mangalore 2013. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Dec 13];3:114-9. Available from: http://www.joacc.com/text.asp?2013/3/2/114/123314
Obstetric anesthesia "Dashboard": A novel method of enhancing patient safety and quality assurance
Akshay Bahe, Sunil T. Pandya, Shanti Y, Sailaja K, Kousalya C, Aparna Reddy, Aanchal B
Fernandez Hospital, Prerna Anesthesia and Critical Care Services, Hyderabad, Andhra Pradesh, India
Introduction: The Obstetric anesthesia dashboard is the visual presentation of patient data with color coding. Red indicates alert - immediate corrective measure, amber indicates introspection and correction and green indicates, acceptable standards. We developed a unique "Anesthesia dashboard" to analyze the obstetric anesthesia related adverse events either for labor analgesia or operative procedures.
Objective: To develop an Obstetric anaesthesia dashboard that provides effective audit of the cases done over an year on a monthly basis and gives a quick access to the complications occurred and the insight to the effective management, thus improving standards and maternal satisfaction.
Materials and Methods: The audit was conducted prospectively on 10,920 cases which included Labor Epidurals; Obstetric surgeries in patients admitted between Jan 2012 to July 2013 at Fernandez Hospital Hyderabad, a tertiary care centre for Obstetrics and Perinatology.
Results: The compilation of data in the Dashboard gave us an instant insight into the areas where immediate improvement was needed as it would be shown eg. Catheter fall out [red and amber zones] and areas for raising the standards eg. Wet taps [continuous green zone], thus ensuring quality assurance and effectively decreasing the complications.
Conclusion: Anesthesia dashboard is a real-time actionable and efficient method of analyzing perioperative and procedural events. Besides providing 'at a glance audit', the visual indicators flagging problems and their consequences, helps timely introspection and corrective measures thus improving the standards of anesthesia care.
A comparative study between the effect of 0.5% hyperbaric bupivacaine and 0.5% hyperbaric bupivacaine with 25 μg fentanyl in spinal anaesthesia for obstetric patients undergoing LSCS surgeries
Harshavardhan, AV Abhinav, Shilpa SN
Father Muller Medical College, Kankanady , 0 Mangalore, Karnataka, India
Background: Intrathecal fentanyl prolongs spinal anesthesia but the optimum dose to be used in cesarean delivery is not yet known. We evaluated the effect of addition of intrathecal fentanyl to hyperbaric bupivacaine intra operatively, on postoperative pain and duration of action for lower segment caesarean section.
Aim: To compare the durataion of action and post operative analgesia between 0.5% Hyperbaric Bupivacaine and 0.5% Hyperbaric Bupivacaine with 25 μg fentanyl in Spinal Anaesthesia for Obstetric patients undergoing LSCS.
Materials and Methods: A total of 60 parturients carrying a singleton fetus at term, scheduled to undergo elective LSCS under spinal anesthesia were randomized in a double blind fashion into 2 groups of 30 each. Group A received 2 ml of 0.5% hyperbaric bupivacaine while Group B received 2 ml of 0.5% hyperbaric bupivacaine + 25 μg fentanyl.
Result: The duration of action and postoperative analgesia was 184.73 ± 68.64 min in group A, 360.71 ± 86.51 min in group B. The incidence of hypotension was more common in Group B, while nausea and pruritis was relatively lower in group A. No other side effects of intrathecal fentanyl were detected. Neonatal outcome was similar in both the groups.
Conclusion: Addition of 25 μg fentanyl to hyperbaric bupivacaine in spinal anesthesia for LSCS significantly prolongs the duration of action and postoperative analgesia without any maternal and neonatal side effects.
Postpartum seizures with posterior reversible encephalopathy syndrome following cesarean delivery for triplets
Anita Chhabra, Sheetal Jagtap
Dr. D.Y. Patil Medical College, Hospital and Research Centre, Nerul, Navi Mumbai, Maharashtra, India
Seizures in pregnant patient are generally assumed to be caused by eclampsia until proven otherwise. Posterior Reversible Encephalopathy Syndrome (PRES) is a cliniconeuroradiologic diagnosis associated with several medical conditions including hypertensive encephalopathy and eclampsia.
We present a case of 23 year old 2 nd gravida, para 1, posted for elective LSCS for triplets delivery. She suffered tonic-clonic convulsions in the immediate post-op period. Her antenatal course was without any prodromi suggestive of pre-eclampsia. LSCS performed under subarachnoid block was uneventful with triplets delivery, save for a single episode of high BP 160/100 which responded to Midazolam 1 mg. Following convulsions she was transferred to ICU and managed on ventilatory support with neurophysician's consultation. She was discharged on day 8 after confirming normal sensorium and without residual neurological deficit.
MRI findings revealed bilateral extensive of T2 and FLAIR hyperintensity involving frontoparietal, occipital, cortical and subcortical white matter with increased ADC values in these regions suggestive of vasogenic edema. The findings were suggestive of Posterior Reversible Encephalopathy Syndrome (PRES).
PRES is usually reversible with appropriate treatment. However, it is important to recognize and treat the etiology responsible as it has been shown to progress to irreversible ischaemic damage that can cause permanent neurologic sequelae including death.
Anaesthetic management of a ruptured ectopic pregnanacy in a patient with severe mitral stenosis and atrial fibrillation on anticoagulation
Archana Nankar, Jyoti Gadre, Sarojini Bobde, Shubhada Aphale
Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
Background: When a patient of severe mitral stenosis (0.6cm 2 ) with pulmonary hypertension lands up with ruptured ectopic pregnancy, tachycardia secondary to sudden blood loss and pain can be detrimental to patient's life. Loss of atrial systole and increase in ventricular rate results in decreased cardiac output and increased risk of pulmonary edema. Anticoagulation with warfarin furthur complicates the picture making fluid replacement more difficult.
Aim: To study anaesthetic management in an obstetric case with severe mitral stenosis and atrial fibrillation on anticoagulation having ruptured ectopic pregnancy.
Materials and Methods: A 35 year old patient of ruptured ectopic pregnancy with severe mitral stenosis (0.6 cm 2 ), pulmonary hypertension, appendymal clot was posted for emergency exploratory laparotomy. ECG showed atrial fibrillation and ventricular ectopic with heart rate of 156 bpm. Patient was on tab Digoxin 0.25 mg, tab Lasix 10mg and tab warfarin 5 mg that was started 1 month back. Coagulation profile was derranged, with PT/INR 150 sec/ 11.2. Fluid replacement with crystalloids(ringer's lactate)was started immediately in view of oliguria and signs of dehydration. Preoxygenation with 100% O 2 , titrated dose of iv opioids and benzodiazepins brought heart rate down to 120 bpm with sinus rhythm, and further management of anaesthesia was uneventful.
Conclusion: Management of emergency cases with severe mitral stenosis is directed towards avoiding cardiac decompensation with simultaneous assessment for volume overload and pulmonary edema. Cellular hydration with good urine output is equally important. Clinical signs are more to be relied on.
Comparison of intravenous phenylephrine, ephedrine and mephentermine for management of post spinal hypotension in cases of cesarean section and effects of these drugs on neonate
Vnkatesh Nutangi, W.S. Thatte, PM Velankar
Dr. DY Patil Medical College and Hospital, Pimpri, Pune, Maharashtra, India
Background and Aims: Maternal hemodynamic changes are common during spinal anaesthesia for caesarean section. This study was aimed at comparing the efficacy of intravenous Phenylephrine, Ephedrine and Mephentermine for management of hypotension during spinal anaesthesia in caesarean section and their effects on neonatal outcome.
Materials and Methods: A total of 60 (ASA) GRADE 1 and 2 patients undergoing elective and emergency caesarean section under spinal anaesthesia were randomly allocated into three groups of 20 each to receive group P-Phenylephrine 100 microgram, group E-Ephedrine 6mg and group M-Mephentermine 6 mg in 1 ml intravenously. The vasopressors were given whenever there is fall of blood pressure more than 20% of baseline values. Neonatal outcome was assessed using umbilical cord blood PH values.
Results: In Ephedrine and Mephentermine group there was no significant differences observed between changes in systolic and diastolic blood pressure. Whereas in phenylephrine group there was significant elevation of systolic and diastolic blood pressure compared to other two groups for first 4 minutes (P < 0.05). Thereafter differences narrowed off. The differences in umbilical cord blood PH between the three groups were found statistically insignificant.
Conclusion: Phenylephrine, Ephedrine and Mephentermine are equally efficient in managing hypotension during spinal anaesthesia for caesarean delivery. Neonatal outcome remains equally good in all the three groups.
Postpartum progressive reversible encephalopathy syndrome (PRES): A case report
Triveni B.V, Sheikh Mohammed Salman, Prashanth Mallya, Deepak Shedde
Yenepoya Medical College, Mangalore, Karnataka, India
Introduction: Posterior Reversible Encephalopathy Syndrome (PRES) is a clinicopathological syndrome associated with various clinical conditions presenting with headache, encephalopathy, seizure and cortical visual disturbances. Radiological findings in PRES are thought to be due to vasogenic edema predominantly in posterior cerebral hemispheres and are reversible with appropriate management.
We present a case of post partum PRES, A 29 year old primigravida of 33 weeks 3 days period of gestation who presented to our hospital with painless bleeding per vagina and breathlessness. A provisional diagnosis of Ante partum Haemorrhage due to Marginal Placenta Previa admitted for safe confinement. Caesarean section was performed for APH under subarachnoid block which was uneventful. On the fourth post operative day patient developed headache and generalised tonic clonic seizures. The provisional diagnosis of Postpartum PRES was made and confirmed with MRI. The differential diagnosis for postpartum seizures was ruled out. Patient was successfully treated with anticonvulsants, corticosteroids and supportive treatment.
Conclusion: Postpartum PRES is a rare clinical condition mostly associated with hypertension, Preeclampsia and vasculitis. Early recognition and treatment can lead to complete recovery of the condition.
Comparison of efficacy of Intrathecal hyperbaric bupivacaine with adjuvants (Fentanyl / Buprenorphine) in caesarean section
Syed Abu Sayeed, Nidhish Shetty, Nikhil M. P, Gayathri Bhat
K.S. Hegde Medical Academy, Mangalore, Karnataka, India
Introduction: The addition of intrathecal opioids to local anaesthetics has been found to improve the quality and duration of sensory and motor blockade, providing post operative pain relief for a longer period.
Materials and Methods: 60 parturients of ASA grade I and II scheduled for elective LSCS under subarachnoid block were randomly allocated into 3 groups. Group F received 15 μg fentanyl + 2 ml 0.5% hyperbaric bupivacaine, Group B received 90 μg buprenorphine + 2 ml of 0.5% hyperbaric bupivacaine and Group P received 0.3 ml normal saline + 2 ml of 0.5% hyperbaric bupivacaine. Efficacy of buprenorphine and fentanyl as adjuvants in terms of haemodynamic variables, duration of sensory block and motor block along with side effects were recorded.
Results: Mean duration of analgesia was significantly prolonged in group F (300 ± 29.2 min) and Group B (315.33 ± 8.90 min) than the placebo group P (120.9 ± 29.1 min). There was a significant fall in systolic blood pressure in Group F and B. There was no significant effect on Apgar score of the neonate.
Conclusion: Intrathecal hyperbaric bupivacaine with adjuvants opioids are well tolerated by the parturient and neonate during caesearian section with quality analgesia and increased duration of post operative analgesia.
Placenta percreta in a parturient with uncorrected tetralogy of fallot: An anaesthetic challenge
Suman Arora, Nidhi Bhatia
Post Graduate Institute of Medical Education and Research, Chandigarh, India
Background: The perioperative management of the parturient, with cyanotic congenital heart disease, is extremely challenging for the anaesthesiologist. The presence of placenta percreta in such high risk parturient further compounds the challenges and increases the incidence of perioperative complications, maternal morbidity and mortality.
Aim: To discuss the perioperative management of a parturient with uncorrected TOF and placenta percreta.
Materials and Methods: We report a case of 37 year old parturient with uncorrected TOF pathology posted for lower segment cesarean section. Intraoperatively she was found to have placenta percreta and suffered massive blood loss, episodes of severe hypotension, desaturation and ventricular tachycardia which were managed successfully. At the end of surgery haemostasis was not satisfactory so abdominal packing was done and abdomen was closed in layers. Patient shifted to ICU for further management. On the third postoperative day, abdominal packs were removed uneventfully. Her subsequent stay in the ICU was uneventful and was gradually weaned off the ventilator and ionotropic support.
Conclusion: For a successful outcome, such patients need aggressive management in the perioperative period by a multidisciplinary team of experts consisting of obstetrician, anaesthetist, intensivist, cardiologist and surgeon.
The effect and utility of opioid mediated spinal analgesia on progress of labor, maternal pain relief and fetal well being
Shravya, Rakesh Karnawat
S.N Medical College, Jaipur, Rajasthan, India
Background: Regional block has been a popular method to ensure painless labor. Opoid mediated spinal analgesia is an approach which provides excellent analgesia to laboring mother.
Aims: To provide Analgesia to patients in labor, its progress in labor, effects of fetal outcome and level of satisfaction in parturients and any complications.
Materials and Methods: Carried out on 50 parturients divided into 2 subgroups of 25 each; primigravida and multigravida, who were in active phase of labor. Spinal anesthesia was performed in sitting position at the level of L3-4 space and 2.5 mg (0.25% bupivacine), 15 microgram fentanyl and 100 microgram morphine was injected with 25G spinal needle.
Results: Procedure shortened the first stage of labor in both subgroups and did not prolong the labor. Mean VAPS score for 25 primigravida was 43.6-painful but bearable and in multigravida was 26-no pain. Satisfaction level was higher in multigravida. The mean APGAR score was 9.6 at birth to 10 at 10mins of birth. No major complications noted.
Conclusion: Opioid mediated spinal analgesia is an effective, low cost and safe technique of labor analgesia with no harmful effect on mother and fetus.
Rare non-obsteretric cause for obteretric emergency: Acute mitral regurgitation
Shehla Shakooh, S.S. Aphale, J. Gadre, S. Ladi, M. Mane
Department of Anaesthesiology, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
Acute mitral regurgitation is a rare condition especially in the reproductive age group. Such patients rarely present for anaesthesia for non cardiac surgeries. Though chronic mitral regurgitation typically is well tolerated in pregnancy, anaesthetic management of pregnant female with acute mitral regurgitation due to chordae tendineae rupture can be very challenging. In acute mitral regurgitation sudden development of severe insufficiency in a setting of relatively non compliant left atrium results in dramatic increase in left atrial, pulmonary venous and pulmonary arterial pressures.
We present a case of 31 year old female with 36 weeks of gestation diagnosed to have acute mitral regurgitation due to chordae tendineae rupture posted for LSCS. Towards the end of surgery the patient presented with signs of impending pulmonary oedema which were successfully managed and the patient was extubated on table. We discuss the anaesthetic management in such a case and how it is different from the more frequently seen chronic mitral regurgitation cases in pregnancy.
Caesarean section of a patient with viral hepatitis under local field block technique: A case report
Saurabh Aa. More, PV Bhale
Department of Anaesthesiology, MGM Medical College, Aurangabad, Maharashtra, India
Background: Viral hepatitis associated with pregnancy increases the risk of morbidity and mortality. Liver function derangements, abnormal coagulation profile, fluid status imbalances are few of the many challenges in such a scenario. General anesthesia and central neuraxial blockade may cause reduced liver blood flow leading to necrosis and long term damage of liver. Local infiltration technique has been described as an effective but rarely used option for caesarean section.
A 21 yr old multigravida with 34weeks gestation having viral hepatitis was posted for emergency caesarean section. Lab reports showed grossly elevated bilirubin levels, hypoalbuminemia, deranged creatinine. Due to coaugulopathy 4 units of FFP were transfused preoperatively. USG report showed mild hepato-splenomegaly, ascitis, bilateral pleural effusion. Caesarean section was done under local anaesthesia with field block technique (bilateral intercoastal and pararectal block) with I.V. supplementation (inj.fentanyl).
The patient had excellent intraoperative and postoperative analgesia with good heamodynamic stability and uneventful recovery.
Conclusion: This case highlights the effectives of local field block in cases of caesarean section in high risk patients.
Pregnancy with bilateral temporo-mandibular joint ankylosis for emergency lower segment caesarean section
Rupali Patil, Ajay Pal, Urvi Desai, Bharati Tendolkar
Department of Anaesthesiology, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
Introduction: Difficult airway in Temporo-mandibular joint (TMJ) ankylosis can be further compromised in pregnancy. Failure to control the airway and ventilate the patient would worsen hypoxemia and endanger both the mother and fetus.
Case: 32 yrs Primi-gravida with pre-eclampsia with abruption with Fetal distress. She had restricted mouth opening since childhood. Mouth opening-1 cm. Bilateral TMJ movement restricted and slux-(-1), Mal-occluded teeth, Thyromental distance-5 cm, Retrognathia, Mandibular hypoplasia, Bird facies, Neck movement - normal. Patient had severe respiratory distress with saturation 75-85 %. Elective surgical airway secured with tracheostomy tube no 6.5. Anaesthesia induced with inj. thiopentone sodium + suxamethonium. Patient ventilated through tracheostomy tube. Anaesthesia maintained on O2 + nitrous oxide (50:50) + isoflurane and atracurium. Analgesia achieved with fentanyl and i.v. paracetamol. Patient was reversed out of muscle relaxant. Elective ventilation done in I.C.U. Ventilatory support weaned - off, over 24 hrs and. Tracheostomy closed on 15 th postoperative day.
Conclusion: With difficult airway of TMJ ankylosis in pregnancy with PIH, safety and well being of mother and baby are most important and was achieved well. Morbidity in the form of tracheostomy and ventilatory support could have been prevented by early consultation and elective surgery for the same.
A comparison of spinal anesthesia with levobupivacaine and hyperbaric bupivacaine for cesarean sections: A randomized controlled Trial
Shahla haleem, Rahul joshi, Nabil ghani, Manazir Athar
Department of Anaesthesiology and Critical Care, JNMCH, Aligarh Muslim University, Uttar Pradesh, India
Purpose: Levobupivacaine showed a lower risk of cardiovascular and central nervous system (CNS) toxicity than bupivacaine which is the most popular local anesthetic agent in obstetric practice. The aim of this study was to investigate the clinical efficacy of levobupivacaine compared with hyperbaric bupivacaine for spinal anesthesia for cesarean section.
Materials and Methods: 40 pregnant women in ASA I-II group scheduled for elective cesarean were randomly allocated into two equal study groups. For intrathecal administration, in Group LF 10 mg levobupivacaine (0.5%) was combined with fentanyl (25 μcg). In group BF, the 10 mg hyperbaric bupivacaine (0.5%) was added with fentanyl (25 μcg). Sensory motor block characteristics of the groups were assessed with pinprick and Bromage scale; observed hemodynamic changes and side effects were recorded.
Results: Time to reach maximum dermatome for the sensory block, time to regression by two dermatomes and time to regress to T12 dermatome was found to be significantly long in Group BF. Whereas hypotension, bradycardia and nausea were less in Group LF, the need for ephedrine was higher in Group BF (P < 0.05).
Conclusion: The combination of levobupivacaine + fentanyl can be a good alternative in cesarean sections.
Anaesthetic management in a case of achondroplasia for emergency caesarean section
Pravin Thorat, Abhishek Bhuva, Nagesh Wasmatkar
Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra, India
Background: Achondroplasia, the commonest form of short-limb dwarfism, associated with several bony changes in face, neck, spine, and can also have neurological and cardiopulmonary complications. There are more than 100 different types of dwarfism, inherited as an autosomal dominant condition, 80% of cases result from spontaneous mutation. Achodroplasia is caused by mutation of fibroblast growth factor receptor 3 (FGFR 3). The clinical features includes a large tongue, saddle nose, large mandible, short limbs, short maxilla, limited neck extension, foramen magnum stenosis, severe kyphosis, scoliosis, lumbar lordosis, atlantoaxial instability. These features contributes to difficulty during intubation and maintaining general anaesthesia, and poses really anaesthetic challenges.
Case Report: In our case general anesthesia was used for emergency Caesarean section in an achondroplastic woman, 109 cm tall and weighing 43 kg, with 37-week pregnancy presenting with cephalopelvic disproportion and fetal distress with mild lumbar lordosis. General anaesthesia was induced with due cautions of airway stability and avoiding atlantoaxial subluxation and limiting the neck movements.
Conclusion: The risks of both general anesthesia and regional anesthesia in achondroplastic patients are known. A complete history and physical examination before administration of anesthesia can help to reduce risks. The anesthesia plan should be based on each individual case and the potential risks must be discussed with the patient.
A study to evaluate efficacy of single dose intrathecal bupivacaine with fentanyl and morphine for labour analgesia
Savita Saini, Nikita Jain, Ggeeta Ahalawat
Department of Anaesthesiology and Critical Care, PT. B.D. Sharma PGIMS, Rohtak, Haryana, India
Background: For labour analgesia, Epidural has been the prevalant technique provided to majority of primigravidae and is not readily available in our country. Multigravid women though have shorter duration of labor but have same intensity of pain. So to cater those and to provide a technique which is fast acting and less technically demanding we chose intrathecal analgesia using a single shot technique.
Aims: To evaluate efficacy of single dose intrathecal labou ranalgesia with respect to duration of analgesia, motor power, progress of labour, FHR and Apgar score in neonate.
Materials and Methods: Thirty multigravid women with uncomplicated full-term pregnancies in spontaneous labour having cervical dilation 3 to 5 cm were given Intrathecal analgesia using 2 mg 0.5% bupivacaine heavy with 25 μg fentanyl and 225 μg morphine.
Result: Onset of analgesia was 4.6 ± 1.9 minutes. Median VAS score after 5, 15, 30, 60, 90, 120 and 150minutes were 0. Mean delivery time was 145.1 minutes. Two parturients had vomiting. Motor block, sedation and nausea were rare. Pruritus was seen in 13% of the cases. Ceasarean section was performed in one case. Oxytocin augmentation was needed in 23% of the parturients. No neonate had Apgar <7.
Conclusion: Intrathecal analgesia is an effective option to consider for women in labour especially those whose labor progress rapidly. Also, ITN will have particular appeal for facilities that do not have readily available 24/7 epidural service.
Identification of epidural space in antenatal patients by loss of resistance: A comparison of three techniques
Shahla Haleem, NaziaTauheed, Aftab Ahmad, Nigar Bari
Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
Background: Epidural anaesthesia is a most frequently used procedure for labour analgesia. The definitive identification of epidural space and catheter placement warrants the most sensitive technique for diagnosis and identification of this space for successful epidural anaesthesia.
Aim: The present study aims at evaluating the technique of loss of resistance using saline or air-saline combination in comparison to the much widely practised LOR to air.
Materials and Methods: 75 ASA I/II patients being administered continuous epidural analgesia were divided into three groups of 25 each on the basis of the technique for loss of resistance employed, The groups were designated as Group A (air), Group S (saline) and Group M (air-saline combination) and compared for quality of analgesia, catheter insertion score (blood on needle/catheter insertion) and complications.
Results: Ease of catheter insertion was also similar in all groups. Blood on needle insertion was more common with air while blood on catheter insertion was similar in all the groups. Unblocked segments were more common in the air group, although statistically not significant.
Conclusion: It can be concluded from this study that air-saline technique was superior though statistically comparable to saline technique scoring over LOR to air for identification of epidural space.
Comparison of analgesic efficacy of paracetamol and tramadol for pain relief in early labour: A randomized double blind study
Nidhi Bhatia, Jeetinder Kaur Makkar, Kajal Jain, Vanita Jain
Department of Anaesthesia, PGIMER, Chandigarh, India
Background: Paracetamol is being increasingly used as an antipyretic and an analgesic with a well established efficacy, tolerability and a favourable safety profile. However, there are limited studies assessing its efficacy as analgesic in laboring patients.
Aims: This study was conducted with the aim of evaluating the analgesic efficacy and safety of paracetamol in comparison with tramadol in decreasing labour pain.
Materials and Methods: After institutional ethics committee approval and obtaining written informed consent, 65 labouring, primiparous, 18-40 year old parturients with uncomplicated singleton term pregnancy were included in the study at spontaneous onset of labour and cervical dilatation of 3-5 cm. Parturients were randomized into two groups with group P (n = 30) patients receiving 1gm of paracetamol intravenously in 100 ml of normal saline over 15 minutes and group T (n = 30) patients receiving 1 mg/kg of tramadol intramuscularly. Same doses of the drugs were repeated after 4 hours of initial dose. Primary outcome of the study was to assess the analgesic efficacy of intravenous infusion of paracetamol in comparison with intramuscular tramadol as measured by the difference in VAS score. Secondary outcome recorded were duration of labor and presence of any maternal or foetal adverse events during the study.
Results and Discussion: The mean VAS score was lower than the baseline scores upto 120 minutes in group T and upto 240 minutes in group P. There was no significant difference in the mean VAS scores between the two groups. The duration of first stage of labour was shorter in group P (248.00 ± 98.171 vs 340.63 ± 111.592 min, P = .003). There was no difference in 2 nd stage labor between the two groups. Cesarean delivery was done in 5 patients in group T and 4 in group P. In the tramadol group one patient developed vomiting and sedation was observed in three patients. There was no statistically significant difference in mean Apgar scores at 1 and 5 min when two groups were compared.
Anaesthetic management of emergency LSCS with dengue fever
Mohamed Mohseen, Anil Kumar, P N Viswanathan
JSS Medical College, Mysore, Karnataka, India
Introduction: In the most recent outbreak of dengue fever in Mysore, we encountered at least six cases of fever with thrombocytopenia in pregnancy but only one sero-positive for dengue. Dengue infection in pregnancy carries the risk of haemorrhage for both the mother and the newborn.
Case Report: A primigravida with term gestation with Dengue fever with thrombocytopenia with 39 weeks of gestation with high grade fever (102 F) with chills for two days, associated with malaise and epigastric pain. There were no bleeding manifestations. At the time of examination, patient was febrile (100 F) with stable vitals. HR-108/min, BP -128/74mmHg, SpO 2 -97% in Room Air. The laboratory investigations showed Haemoglobin 9.8gm%, total leukocyte count 9400/cu.mm and a platelet count of 80,000/cu.mm on the day of presentation, with platelet count of 1.42 lakhs/cu.mm, one day earlier. PT INR -1.34 and PT 17.4sec. Urine protein was measured trace, ECG - WNL. Patient's dengue serology was positive (IgM). Her liver and renal function tests were well within normal limits. The patient received two pints of Ringer Lactate and one pint of normal saline with three pints of platelet concentrate. Emergency LSCS was done. The case was managed successfully with sub-arachnoid block. Procedure was uneventful. Alive term female baby was delivered at 3:20pm (30/06/2013). The baby cried after resuscitation. Intra-operative and post - operative period was uneventful.
Conclusion: A WHO definition of dengue haemorrhage for diagnosis has been in use since 1975 which states that all four of the following criteria must be fulfilled: Fever, haemorrhagic tendency, thrombocytopenia and evidence of plasma leak as evidenced by hematocrit 20% higher than expected or a drop in hematocrit of 20% or more from the baseline following IV fluid, pleural effusion or ascitis. Adequate pre-operative preparation with meticulous anaesthetic management and good post-operative care led to an uneventful course in the hospital.
Anaesthetic management in emergency lscs in a patient with severe kyphoscoliosis
Manish Jha, Pooja Bhosle, Shubhada Aphale
Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India
Kyphoscoliosis or the hunch back is the deformity of costovertebral skeletal structure, characterized by anterior flexion and lateral curvature of vertebral column. It can be idiopathic or secondary kyphoscoliosis. Majority of individuals (80%) with kyphoscoliosis fall in the idiopathic group with a female predominance of 4:1. Severe scoliosis is rare in parturients, which varies from 1 in 1500 to 1 in 12000 pregnancies. Cardiorespiratory derangements with restrictive type of lung disease are usually associated with scoliosis. Sequelae include pulmonary hypertension, right heart failure and cor pulmonale. Considering female predominance, chances of pregnant patients presenting with kyphoscoliosis for LSCS is likely. Preoperative evaluation of these patients with pulmonary function tests and arterial blood gases to rule out unrecognized hypoxia is mandatory and may not be possible in emergency situation.
Aim: To assess the anaesthetic concerns in emergency LSCS in a patient with severe kyphoscoliosis.
Materials and Methods: A 32 year old primigravida with severe kyphoscoliosis with 37 weeks gestation with cervical dystocia posted for emergency lower segment caesarean section (LSCS). Being an emergency, we had no option but to rely entirely on clinical assessment. Weighing risks and benefits, we planned LSCS under regional anaesthesia preparing for its obvious difficulty and anticipated complications.
Result and Conclusion: The case was conducted uneventfully under spinal anaesthesia with adequate level of analgesia and vigilant monitoring. We investigated this gross kyphoscoliotic abnormality postoperative for correlations.
A randomised study to compare 0.5% hyperbaric bupivacaine and 0.75% isobaric ropivacaine with fentanyl in caesarean section
Shahla Haleem, Manazir Athar, M.M.H Siddiqi, Rahul Joshi
Department of Anaesthesiology and Critical Care, JNMCH, Aligarh Muslim University, Uttar Pradesh, India
Background and Objective: Bupivacaine is a highly cardiotoxic drug and also produces prolonged motor blockade. The newer drug ropivacaine being comparatively less cardiotoxic, also produces minimal motor blockade of shorter duration which relieves the psychological distress of patient being immobile for a longer period of time after Caesarean section. So We conducted this prospective, randomized double blind study with an aim of comparing the efficacy and characteristics of hyperbaric bupivacaine-fentanyl and isobaric ropivacaine-fentanyl in Caesarean section.
Material and Methods: Forty ASA physical status I and II parturient posted for elective Caesarean section were randomly given either 10 mg hyperbaric bupivacaine(0.5%)+ 25 μg fentanyl (BF) or 15 mg isobaric ropivacaine (0.75%) + 25 μg fentanyl (RF). The sensory and motor block characteristics, hemodynamic parameters as well as time to first analgesic requirement were recorded.
Results: Onset of motor block was significantly faster in the group BF while duration of motor blockade was shorter in group RF. Sensory block onset time and time to achieve T7 dermatomal level was shorter in group BF. L1 segment regression time and time to first analgesic requirement were more in group BF. Group RF showed more stable haemodynamic parameters as compared to group BF.
Conclusion: Intrathecal Ropivacaine with fentanyl is more suitable as it provides early motor recovery leading to faster patient ambulation, adequate sensory block along with good haemodynamic stability.
A randomised trial comparing prophylactic phenylephrine and ephedrine infusion during spinal anesthesia for emergency cesarean delivery in cases of acute fetal compromise
Kajal Jain, Jeetinder Kaur Makkar, Siva Subramani VP, Shalini Gainder
Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
Background: Maintenance of maternal blood pressure using phenylephrine is associated with higher umbilical artery pH (UApH) following elective low risk cesarean delivery (CD) than ephedrine. Data is limited about the effects of phenylephrine and ephedrine on fetal acid base status in cases of acute fetal compromise.
Methods: Ninety two pregnant women undergoing spinal anesthesia for emergency cesarean delivery indicated due to acute fetal compromise (category 2) were randomized to receive a prophylactic infusion of ephedrine @ 2.5 mg/minute or phenylephrine @ 30 μg/minute. Systolic blood pressure was targeted at/above 100 mmHg. Incidence of fetal acidosis defined as umbilical artery pH <7.2 and/ or base deficit >12 mmol/l was recorded. Other parameters of cord blood gases, Apgar score, need for immediate resuscitation, maternal hemodynamics and intra-operative nausea/vomiting were also compared.
Results: Umbilical artery pH and base excess were comparable in both the groups. Acidosis was observed in 14 neonates with ephedrine use and 9 with phenylephrine (P = 0.22). Low 1-min Apgar scores were noted in 15 of these acidotic newborns. UA pO2 was significantly higher in group E (P = 0.03). Incidence of intraoperative nausea and vomiting (4.4% vs 22.2%, P = 0.02) was less in phenylephrine group than in ephedrine group despite similar minimum recorded SBP. Maternal bradycardia was higher in phenylephrine. [P = 0.02].
Conclusion: Phenylephrine infusion caused dose dependent bradycardia. More mothers complained of nausea and vomiting and required treatment with use of ephedrine.
A prospective study comparing preemptive intramuscular ephedrine versus intravenous ephedrine to prevent hypotensionduring spinal anaesthesia for caesarean delivery-
Jaimy Raichel John
Department of Anaesthesiology and Critical Care, Padmashree Dr. D.Y. Patil Medical College and Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
Background and Aims: T compare the effects of preemptive intramuscular ephedrine versus intravenous ephedrine on maternal blood pressure and heart rate following spinal anesthesia in caesarean delivery.
Materials and Methods: A total of 60 patients, received either intramuscular ephedrine 45 mg 10 min prior to spinal anesthesia (Group I) or intravenous ephedrine 10 mg at the time of spinal anesthesia (Group II) with 0.5% hyperbaric bupivacaine 2.2 ml (11 mg). Baseline maternal heart rate and arterial blood pressure were recorded before induction, and every 1 minute for 10minutes and there after every 5 minutes and 2 hrs in recovery. Further rescue boluses of ephedrine 6 mg were given if systolic blood pressure decreased to less than 30 mm Hg from baseline value, or if symptoms suggestive of hypotension were reported. The presence of any complications was noted.
Results: There was no significant incidence of hypotension in Group I as compared to Group II.
Conclusion: Prophylactic bolus of ephedrine 10 mg intravenously given at the time of intrathecal block compared to prophylactic intramuscular 45 mg 10 minutes prior to intrathecal block, leads to a lower incidence of hypotension following spinal anesthesia for elective Caesarean section.
Anaesthetic management of a patient for emergency caserean section with takasayu's disease
H Radhesh, Jameela, Mahima, Vikas, Malkajayya
Department of Anaesthesiology and Critical Care, Father Muller Medical College, Hospital Kankannady, Mangalore, Karnataka, India
Takayasu's arteritis is a rare, chronic progressive panendarteritis involving the aorta and its main branches. Almost 80% of the patients are patients of child bearing age. It preferentially affects large arteries such as aorta and its branches and hence its alternative names of pulseless disease, obliterative thromboarthropathy or aortic arch syndrome The cardiovascular complications attributed to the disease are exaggerated during pregnancy and delivery. We present the case of 26 yr old primi at 32 weeks of gestation with Rh negative Aorto arteritis underwent successful emergency caesarean section under general anaesthesia.