|Year : 2016 | Volume
| Issue : 1 | Page : 41-63
Selected abstracts of the papers presented as poster presentation during the 8 th national conference of association of obstetric anesthesiologists and 1 st world obstetric anesthesia congress at Hyderabad in September 2013
|Date of Web Publication||22-Apr-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Selected abstracts of the papers presented as poster presentation during the 8 th national conference of association of obstetric anesthesiologists and 1 st world obstetric anesthesia congress at Hyderabad in September 2013. J Obstet Anaesth Crit Care 2016;6:41-63
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. Selected abstracts of the papers presented as poster presentation during the 8 th national conference of association of obstetric anesthesiologists and 1 st world obstetric anesthesia congress at Hyderabad in September 2013. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Dec 11];6:41-63. Available from: http://www.joacc.com/text.asp?2016/6/1/41/181079
Epidural labor analgesia for caesarean section-proper handover makes difference
Abdulvahab TT, Annu Anna Suresh, Santhosh Gopalakrishnan
Department of Anaesthesiology, Hamad Medical Corporation, Doha, Qatar
Background: Women's Hospital, HMC, Qataris a high volume obstetric hospital with around 20,000 deliveries each year. We have separate Anesthesia team for Labor rooms and Operating rooms working in 3 shifts a day. We have a paperless electronic clinical information system implemented recently. Many patients on Epidural Labor Analgesia in Labor room coming to Operating Room for Caesarean section for various indications. But we lack a proper standardized safe handover from Labor room Anesthetist/Midwife to the Operating room Anesthetist. These vital informations are very important in deciding the technique of anesthesia and providing quality care. Otherwise we would be compromising patent safety.
Aims: To achieve a safe standardised handover of 80% of epidural labour analgesia patient coming for Caesarean section which is 0% now by the end of April 2015.
Materials and Methods: We conducted a prospective survey among OR Anesthetist who is providing Anesthesia for patients coming from LR on Epidural Labor Analgesia for Caesarean section for fifteen days by giving questionnaire. The survey was asking for the details of information on the patient's epidural he received. None of them got the complete information. We prepared a checklist with essential information which is initiated by the performing Anesthetist in LR and later to be completed and handed over by the midwife to the OR Anesthetist. We conducted Re-survey after that. Survey during next fifteen days showed 93% patients were handed over by using standardized check list.
Conclusion: Implementation of a safe Standardized check list enhanced the safe handover of patients on epidural labor analgesia coming for Cesarean section. This will help the Anesthetist to plan appropriate Anesthesia which will facilitate safe and effective delivery of care.
Evaluation of Hemodynamic changes after leg wrapping in elective LSCS under Spinal anaesthesia
Adithya Vishnu, Aparna Bagle, Girwalkar Aparna
Department of Anaesthesiology, Dr Dy Patil Medical College, Pune, Maharashtra, India
Background: Hypotension after spinal anaesthesia is a common adverse effect that is commonly experienced in patients undergoing Cesarean section. However spinal blockade provides excellent anaesthesia for patients undergoing cesarean section. In our study the aim is to analyse if a simple technique like leg wrapping with elastic crepe bandage would be effective in controlling post spinal hypotension.
Materials and Methods: 60 full term patients who were posted for elective cesarean section belonging to ASA I and II were divided into two groups. Patients in Group A had their legs wrapped with elastic crepe bandage and in the other group N leg wrapping was not done. Also the patients were pre loaded with Ringer lactate at 10 ml/kg prior to the Spinal anaesthesia. The hemodynamic parameters were monitored every 3 minutes until the delivery of the baby and every 5 minutes after that until the end of surgery. If hypotension occurred, then along with crystalloid loading a bolus dose of inj Mephentermine 6 mg was given.
Result: Frequency of hypotension in Group A (6.66 %) was significantly less compared to group N (46.66%). Vasopressor requirement was significantly less in group A, P < 0.01. That was highly significant.
Conclusion: Wrapping of lower extremities was the simple, easiest and effective method of controlling post spinal hypotension in Caesarean Patients and needs to be practiced routinely.
Anaesthesia for a 1 st trimester primigravida posted for emergency laparoscopic appendicectomy
S Amita, Hemalatha S, Archana, Nalini Kotekar
Department of Anaesthesiology, JSS Medical College, Mysore, Karnataka, India
Introduction: It is estimated that anaesthesia for non-obstetric surgery occurs in approximately 2% of pregnant women. Between the 15 th and 56 th days of gestation, the human embryo is most vulnerable to the teratogenicity. Chances of miscarriages are high.
Case Report: A 25 year primigravida, 13 weeks gestatioin, presented with pain abdomen in right lower quadrant, ultrasound revealed retrocaecal appendicitis. Posted for laproscopic appendicectomy. Accepted under ASA grade 2 with special consent in the event of misscarriage with due asepsis sabarachnoid block given with 3.2 ml 0.5% bupivacaine + 30 mcg clonidine. Inj. paracetamol at 10 mg/kg was given to alleivate referred pain due to diaghphramatic irritation due to pneumoperitoneum. Perioperative hemodynamics were stable and an uneventful course.
Discussion: The advantages of laproscopic surgery include less exposure of the fetus to toxic agents, smaller incisions, decreased pain, less need for analgesics, and more rapid recovery and mobilization. Carbon dioxide pneumoperitoneum is associated with an increased risk of hypoxaemia, hypercarbia and hypotension because of the physiological and anatomical changes of pregnancy. During laparoscopy-use open technique to enter abdomen, compensate fetal acidosis, use lower pneumoperitoneum pressures, limit trendlenburg and reverse trendelenburg position, monitor FHS and uterine activity.
Goals of anaesthesia:
- Optimize and maintain
- normal maternal physiological function
- utero-placental blood flow,
- oxygen delivery;
- unwanted drug effects on the fetus;
- myometrial stimulation;
- awareness during general anaesthesia;
- Regional anaesthesia preferable
Emergency surgery must proceed regardless of gestational age and the primary goal is to preserve the life of the mother. Nonurgent surgeries postponed until second trimester.
Conclusion: In an emergency surgery like our case SAB can be a suitable alternative to GA to avoid polypharmacy, its consequences, shoulder pain managed with paracetamol infusion. Follow up (one week) uneventful, fetal status on repeat pelvic scan normal.
Role of intramuscular injections of vasopressors in combating spinal hypotension during caesarean section: A prospective randomized double blinded controlled clinical trial
Ananth Srikrishna Somayaji, Gayatri Bhat, Ananda Bangera
Department of Anaesthesiology, KS Hegde Medical Academy, Mangalore, Karnataka, India
Background: Hypotension is a common problem encountered by an anaesthesiologist following spinal anaesthesia. Vasopressors have important role in managing this hypotension. The common approach to their use in routine clinical setting is reactive rather than preventive. The incidences of maternal hypotension prompts the pre-emptive administration. There have been studies comparing bolus and IV infusion in the past. A comparative study testing the efficacy of IM vasopressors are scarce. Hence this study has been contemplated in elective caesarean deliveries.
Aims: To compare the efficacy of phenylephrine, ephedrine and mephentermine by IM route for maintenance of arterial pressure during spinal anaesthesia in parturient.
Materials and Methods: 120 Parturients of age ranging between 20-32 years, undergoing elective caesarean section under spinal anaesthesia belonging to ASA I and II were selected. They were randomly included in to four groups. Group 1 received preemptive phenylephrine 4 mg IM, Group 2 received ephedrine 45 mg IM, Group 3 received mephentermine 30 mg IM and Group 4 received normal saline 0.9% 2 ml IM as placebo, immediately following spinal anaesthesia. Mean arterial pressure and heart rate were primarily evaluated and any other complications were noted down. Rescue doses of IV Ephedrine were given in necessary cases and its total requirement was noted. Maternal nausea, vomiting and Apgar score were also documented.
Results: The incidence of hypotension in Phenylephrine group was found to be 30%, in the Ephedrine group 40%, 46.6% in the Mephentermine group, and 73.3% in the Placebo group. The results of the study point towards significantly decreased incidence of hypotension in Phenylephrine group compared to the control group (P = 0.034) The incidence of rescue IV Ephedrine requirement was maximum with placebo group, least with Mephentermine compared to Ephedrine and Placebo group. However, there was no statistical difference between the groups with respect to doses of IV ephedrine used for rescue (P = 0.08). Maternal nausea, vomiting and newborn Apgar score were also comparable.
Conclusion: All the vasopressors are effective in reducing the severity of hypotension, though Phenylephrine was found to be the better drug for prevention of hypotension in parturients.
Perioperative hemodynamic response and vasopressor requirement during spinal anesthesia for cesarean section in healthy and severe preeclamptic parturients: A prospective cohort comparison
Anil Kumar, Aparna Bagle, Girwalkar Aparna
Department of Anaesthesiology, Dr DY Patil Medical College, Pune, Maharashtra, India
Background: Spinal anesthesia is the technique of choice in cesarean sections, but it is not widely accepted in severe pre-eclampsia due to fear of sudden and extensive sympathetic blockade. This study was conducted to compare the heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), vasopressor requirement and neonatal outcome between normotensive and preeclamptic women undergoing caesarean section under spinal anaesthesia.
Materials and Methods: We selected a total of 30 healthy (Group C) and 30 Preeclampsia (BP >140/90 mmHg) parturients (Group P) above 18 years of age, undergoing elective cesarean section in the study. After preloading with 10 ml/kg of ringer lactate solution spinal anesthesia will be given with 10 mg of hyperbaric bupivacaine. SBP, DBP, MAP and HR were recorded before spinal anesthesia and at every 3 min intervals after spinal anesthesia for the first 30 min and then after every 5 min till completion of surgery. Mephentermine administered in 5 mg bolus dose when MAP decreased more than 30% of baseline.
Results: SBP, DBP, and MAP were lower in normotensive group compared to preeclamptic group and the difference between two groups was statistically significant. Mephentermine requirement in the normotensive group was significantly greater (P < 0.05) than that of pre-eclamptic group. Apgar scores at 1 and 5 min after birth were comparable in both the groups.
Conclusion: Pre-eclamptics experienced less hypotension following subarachnoid block (SAB) than normotensives and required less Mephentermine with comparable fetal Apgar scores.
Multiple gestations after assisted reproductive technology (ART): A new challenge in modern obstetric anaesthesia
Anis Kangani, Sarojini Bobde, Abhay Sancheti, Sushma Ladi, Shubhada Aphale
Department of Anaesthesiology, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
Introduction: Even though physiological changes of pregnancy are considered physiological when, art is used in elderly gravida changes don't remain physiological and anaesthesia management becomes challenging due to multiple co-morbid conditions in mother and baby.
Case Report: A 52 years multiparous menopausal lady (g6p5l2d3), known chronic hypertensive and hypothyroid since 10 years was managed with art because of advanced age. She presented with twin pragnancy with placenta previa with iud of one fetus at 21 weeks of gestation. She was admitted to Bharati Hospital Pune at 24 weeks, was evaluated and investigated, prescribed with antihypertensives. Her pregnancy was continued till 29 weeks and as soon as the other baby attained 1 kg of weight, caesarean section was done under spinal anaesthesia.
Discussion: Maternal age is the dominant factor in determinimg the likelihood of succesful pregnancy after assisted reproductive techniques like ivf, by transfering a greater number of embroyos the probabilty of live birth and likelihood of multifetal pregnancy increases in this case also six emroyos were implanted of which four were reduced. At 21 weeks fetal death occurred by continuing the pregnancy multiple life threatening complications like dic, pph can occur. Pre-term delivery, low birth weight, small for gestation and co-existing iud made survival of the living fetus more difficult. Placenta previa, chronic hypertension and hypothyroidism added to the risk.
Conclusion: Anaesthesiologists should be prepared to face complicated scenarios with art obstetric cases and preoperative screening of these patients should involve specialised investigations like ecg, 2d echo and other screening tests in view of incresing incidence of elderly mothers.
Left ventricular non-compaction and pregnancy: A rare co-existence, favourable outcome
Anisha Gala, S Tarakeswari, K Sailaja
Department of Anaesthesiology, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy. Non-compaction of left ventricle is a form of familial cardiomyopathy due to arrest of compaction of loose interwoven myocardium during embryogenesis. The clinical presentation is varied, from symptomatic patient to severe cardiac failure and sudden cardiac death. The classic triad of complications is heart failure, arrhythmias and systemic embolic events. The paucity of data of LVNC in pregnancy makes it difficult to optimise management plan.
Case Report: This case reviews a primigravida, who presented in emergency room as a referral for preterm labour, at Fernandez Hospital, a tertiary perinatal care institute with about 8,000. She had been treated with tocolytics and was given Betamethasone for fetal lung maturity. She came in a state of cardiovascular collapse. A perimortem Caesarean section was done, and she was resuscitated as per ACLS protocol, and the mother and the baby survived. Later, echocardiography revealed non-compaction of left ventricle. She was discharged on ninth post-operative day.
Conclusion: Cardiomayopathies of varied etiologies are encountered in pregnancy, and LVNC is one of the rare causes. The management of pregnant patients with any inherited cardiomyopathy is directed to the usual treatment of heart failure with diuretics (with or without digoxin) or alternatively hydralazine and nitrates. Standard heart failure treatment with ACE and aldosterone inhibition together with diuretics and beta-blockers post-delivery is likely to promote recovery of ventricular function once the baby is delivered. Lactation is an additional stressor which may exacerbate heart failure post-delivery. Concentrated efforts of a team comprising of an Obstetrician, Anaesthesiologist, Physician and Cardiologist optimizes the outcome.
Liver disorders lead the list! Disease specific morbidity and mortality in pregnancy Anisha Gala, Pallavi Reddy, Nuzhat Aziz and Prerna. Anaesthesia and critical care services Fernandez Hospital, Hyderabad, Telangana, India
Anisha Gala, Pallavi Reddy, Nuzhat Aziz
Departments of Anaesthesiology and Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: Approximately, 800 women die daily from preventable causes related to pregnancy and childbirth. Most of these deaths (99%) are in the developing world. The leading causes of maternal death have been reported to be haemorrhage, hypertension, sepsis and complications related to unsafe abortions. Disease specific morbidity and mortality allows us to study the complications and fatality that can occur in a particular condition. It also enables risk categorization and timely transfer in pregnancy.
Aims: The aim was to evaluate disease specific maternal morbidity and mortality in our pregnant population.
Materials and Methods: This was a retrospective analysis of the deliveries from January 2011 to December 2014 at Fernandez Hospital, a tertiary perinatal centre with about 8,000 deliveries per year. The data was retrieved from electronic medical records and maternal morbidity was determined by using the WHO criteria for severe acute maternal morbidity termed as Maternal Near-Miss (MNM). The maternal deaths during this period were used to calculate the disease specific mortality.
Results: We had 28,819 deliveries during this time period, with 22 maternal deaths, giving a maternal mortality of 76.3/100,000 births. Liver disorders (portal hypertension, acute fatty liver of pregnancy and viral hepatitis) had the highest maternal morbidity and mortality -with 1 in 2 becoming a MNM and 1 in 15 ending up in a maternal death. The incidence of near-miss in hypertensive disorders, post-partum hemorrhage and sepsis was 1 in 352, 1 in 23 and 1 in 4, while the maternal mortality in this group was 1 in 3226, 1 in 2912 and 1 in 27 deliveries.
Conclusion: While the commonest causes of maternal death are hypertension, haemorrhage and sepsis, when we calculate disease-specific rates, liver disorders have the highest morbidity and mortality and should be managed in a tertiary care centre only.
Assisted vaginal delivery rates in group 1 robsons classification
Anisha Gala, Aparna G, Manokanth M
Department of Anaesthesiology, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: Epidural analgesia is one of the most effective modality to offer pain relief in labour. The outcomes of labour in those mothers taking epidural labour analgesia are subject to plenty of confounding variables like induced labour, medical risk factors, previous cesarean section, etc. Robsons classification is a 10 group classification for deliveries wherein they are divided based on labour characteristics, presentation, previous and prematurity. The group 1 Robsons lends itself to evaluation of interventions since it has nulliparous women, with cephalic presentation, at term in spontaneous labour. Labour analgesia outcomes have not been evaluated in this specific group and compared.
Aim: To compare delivery outcomes and focus on assisted vaginal delivery rates in Group 1 Robson's class with epidural labour analgesia and those without.
Materials and Methods: We analysed deliveries that occurred during January 2013 to December 2014 at Fernandez Hospital, a tertiary perinatal care institute in Hyderabad, India with about 8,000 deliveries per year. The data was collected from electronic records. All the deliveries were classified using the ten group Robsons classification. The Group 1 Robson was divided into two groups - with and without epidural labour analgesia and outcomes compared.
Results: We had 3,493 mothers belonging to group 1 Robsons out of 15,751 deliveries during this study period - with 2317 opting to have epidural labour analgesia (uptake rate 66%). The vaginal delivery rate was 77.3% vs 77.6% in epidural and non epidural group. The cesarean section rate was similar at 22% across the groups. The intrumental vaginal delivery rate was 21.96% in epidural group in comparison to 11.05% in non epidural group.
Conclusion: Instrumental delivery rate is double in women opting for epidural labour analgesia in nulliparous, term, cephalic pregnancies in spontaneous labour.
Life threatening adverse reaction following prostaglandin analogue use in obstetric and gynaecological practice
Department of Anaesthesiology, Fortis Hospitals, BG Road, Bengaluru, Karnataka, India
Introduction: Prostaglandin analogues are the most commonly used drugs by the obstetricians because of its favourable actions on the uterus and cervix. Although considered safe it is associated with adverse effects. Here we report two cases who had severe hypertensive crises after administration of this drug.
Case Report 1: 24 year old primigravida, received prostaglandin analogue twice prophylactically to prevent PPH and later inspite of this when she developed PPH a second dose dose was administered. She adversely reacted to this medication with hyperpyrexia, absent peripheral pulses but invasive blood pressure readings were high.
Case Report 2: 32 year old lady, for hysteroscopic resection of submucosal fibroids received 200 mcg of misoprostol vaginally 30 minutes prior to the procedure. During resection of the second fibroid there was profuse hemorrhage (loss of about 800 ml). And emergency laparotomy was planned. Second dose of 600mcg misoprostol was administered per rectally. After sometime her pulses were not felt, invasive monitoring showed systemic hypertension, she developedpulmonary edema which resolved gradually. Both our cases had a few things in common; both suffered from significant blood loss, both received prostaglandin analogues twice via different routes, in both the patients, peripheral pulses were absent and systemic hypertension was noted. Although these reactions have not been observed in the past many adverse reactions to misoprostol have been reported.
Conclusion: Prostaglandin analogues are generally considered safe and used widely in obstetrics and gynecology practice, but, adverse events are known to occur. Though sweeping remarks cannot be made based on two cases, it may be reasonable to conclude that when misoprostol is administered in a hypovolemic patient, severe vasoconstriction and hypertensive crisis might occur and hence to minimize the side effects, minimum effective dose may be administered.
Intrathecal dexmedetomidine versus morphine as adjuvants to Bupivacaine in elective LSCS cases. A comparative study
Ankita Mohta, Niranjan Swain, Ranjita Baksi
Department of Anaesthesiology, Institute of Medical Sciences and SUM Hospital, Bhuvaneshwar, Odisha, India
Background: Addition of Various adjuvants with local anesthetics in a subarachnoid block has improved the quality and prolonged the duration of analgesia to avoid intraoperative visceral and somatic pain and to provide prolonged postoperative analgesia. It is the moral responsibility of anesthesiologist to provide pain free post-operative period and early ambulation for mother so as to take care of her newborn.
Aim of the Study: To compare the onset, duration of sensory and motor block, post-operative analgesia and adverse effects of demedetomidine and morphine when given intra thecally with 0.5% hyper-baric bupivacaine in elective LSCS mothers.
Materials and Methods: 58 patients classified in American Society of Anesthesiologists classes I and II scheduled for elective LSCS. Patients were randomly allocated to receive either 12 mg hyperbaric bupivacaine plus 5 μg dexmedetomidine (group D, n = 31) or 12 mg hyperbaric bupivacaine plus 125 μg morphine (group M, n = 27) intrathecal.
Results: Patients in dexmedetomidine group (D) had comparitively longer sensory and motor block time than patients in morphine group (M). The mean time of sensory regression to S1 was 410 ± 23 min in group D and 375 ± 12 min in group M. The onset times to reach T6 dermatome were not significantly different between the groups. Both the group showed significantly less and delayed requirement of rescue analgesic.
Conclusion: Intrathecal dexmedetomidine is associated with prolonged motor and sensory block. Both group showed hemodynamic stability, and reduced demand for rescue analgesics in 24 hours. Morphine was associated with adverse effects like nausea, vomiting and pruritus.
An outcome analysis of speed of local anaesthetic injection on hypotension during spinal anaesthesia in caesarean section
Ankita Mohta, Debasish Kaunar, Ranjita Baksi
Department of Anaesthesiology, Institute of Medical Sciences and SUM Hospital, Bhuvaneshwar, Odisha, India
Maternal hypotension is a common problem during cesarean section under spinal anesthesia. We evaluated the influence of injection speed of local anesthetic to subarachnoid space on maternal hypotension and level of sensory block.
Materials and Methods: 40 ASA I and II term parturients scheduled for Cesarean delivery were given Bupivacaine (0.5%) 10 mg with butrephenol 0.5 mg was injected to subarachnoid space either quickly (over 20 seconds, n = 20) or slowly (over 60 seconds, n = 20) in parturients scheduled for elective cesarean section. The onset and level of sensory block was checked and heart rate and blood pressure was checked by 2 minutes during 20 minutes. Hypotension (systolic blood pressure <100 mmHg or <30% of baseline) were treated with ephedrine and were recorded.
Results: Hypotension occurred 80% of parturients with spinal anesthesia. Slow injection didn't influence on the onset and level of sensory block and didn't reduce the incidence of hypotension. But onset of hypotension was delayed.
Conclusion: Slow injection (during 60 seconds) of local anesthetic delayed onset of hypotension and required less amount of ephedrine. Slow injection of local anesthetic can be considered as one of the effective methods for the cardiovascular stability during cesarean section under spinal anesthesia.
Pregnancy with swineflu with known case of hypothyroidism and PIH and obesity
Barkha Agrawal, Pushpa Agrawal, Vaishnavi Kulkarni
Department of Anaesthesiology, Dr VM Government Medical College, Solpaur, Maharashtra, India
Background: Pregnant women are more susceptible to influenza and pregnancy may enhance the severity of the illness. We reported a 28 year old pregnant woman with swine flu and other comorbid conditions. Patient was known case of hypothyroidism with mild PIH and obesity. All these conditions made it a very high risk case and increased complications.
Aim: In this case we aimed to assess clinical characteristic obstetric and perinatal outcome of pregnant woman with H1N1 infection and all the comorbid conditions posted for emergency caesarean section.
Materials and Methods: After studying the present condition of the patient, taking tablet thyronom for hypothyroidism since 11 months, also diagnosed as mild PIH on tablet nicardia 10 mg tds with history of cough, cold, fever since 4 days. It was epidemic of swine flu, so patient was tested for same and swine flu positive report was found. Patient was posted for emergency caesarean section for cephalopelvic disproportion. After assessing pros and cons we preferred to go with regional anesthesia without causing any insult to airway of the patient, but at the same time prepared for intubation and mechanical intubation.
Result: Patient tolerated procedure well and was stable throughout and was then shifted to swine flu ward for monitoring and isolation.
Conclusion: The presenting symptoms of pregnant woman with HIN1 were similar to that of general population. Acquiring infection in late trimester, late initiation of antiviral treatment and presence of comorbid illness were high risk factors for developing critical illness. Also management of parturient with H1N1 is best carried out in tertiary care centre with icu facilities.
Peripartum hysterectomy: A near miss obstetric event in a tertiary care hospital
Bharti Sharma, Pooja Sikka, Kajal Jain, Vanita Jain
Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
Background: Peripartum hysterectomy is the last resort to save the life of a mother in case of severe postpartum hemorrhage, a life threatening condition; thus plays a vital role in reduction of maternal mortality. Emergency peripartum hysterectomy is an unequivocal marker of severe maternal morbidity and near miss mortality. We have analysed all cases of peripartum hysterectomy in one year in our institute as described.
Objectives: To find out the incidence and study management issues during peripartum hysterectomy (a near miss event) in a tertiary care hospital.
Materials and Methods: A retrospective study of all case records of patients who underwent peripartum hysterectomy between April 2014 and March 2015.
Results: The incidence of peripartum hysterectomy was 7.46 per 1000 deliveries during the period of evaluation. Of these, only 2 women were hospital supervised whereas the majority of patients were referrals. The main indications of peripartum hysterectomies were placenta accreta (60%), atonic PPH (27.5%) and uterine rupture (7.5%). Intensive care management was deemed necessary in 35% of women postoperatively. Most common maternal complications were febrile morbidity, bladder injury, disseminated intravascular coagulation and wound infection. There were four maternal deaths (10%) following peripartum hysterectomy.
Conclusion: The most common cause of Peripartum hysterectomy a 'near miss' event in our institute comprised of patients with diagnosis of placenta accreta. This was found to be associated with a high incidence of maternal morbidity. However, maternal mortality occurred with atonic post partum hemorrhage.
Anaesthetic management of a patient for caesarean section with confirmed H1N1 influenza with acute respiratory distress syndrome (ARDS) under central neuraxial blockade
Bhavik Bhuva, Amruta Bedekar, Bhagyasjree Shivde
Department of Anaesthesia, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
Background: Since last few years a new strain of influenza virus -H1N1 has infected people of all age groups and caused significant morbidity and mortality. Pregnant patients are at increased risk due to impaired immune function. We report successful use of spinal anaesthesia for Caesarean section of a patient already on non-invasive ventilation for ARDS due to confirmed H1N1.
Aim: To assess the feasibility of Central Neuraxial blockade in a pregnant patient with ARDS, with a view to avoid General Anaesthesia and its attendant risks.
Materials and Methods: A 24 year old (G3A2) patient with 32 weeks gestation presented to hospital with respiratory distress. She was diagnosed as H1N1 influenza with bilateral pulmonary infiltrates on chest x ray (ARDS). Medical management including oral Oseltamivir was started. Non invasive ventilation (NIV) was instituted and respiratory parameters (Respiratory rate, oxygen saturation, ABG) were stabilised. On ultrasound examination, there was severe oligohydramnios with mild IUGR. After multidisciplinary team discussion, it was decided to proceed with Caesarean section for both maternal and fetal well-being. Detailed pre-anaesthetic check was conducted. She had no previous comorbidities. Her biochemical and haematological investigations were unremarkable. After considering the perioperative risks and benefits of GA vs Spinal for both mother and fetus, it was decided to proceed with spinal anaesthesia with continued use of NIV intraoperatively. Preoperatively, aspiration prophylaxis was given. She was preloaded with IV Ringers Lactate and was monitored using ECG, NIBP, Pulse rate, Spo2 and Respiration. Under all aseptic precautions Subarachnoid block was given using 27 G Whitacre needle at vertebral level L3-L4 in sitting position. 1.68 Kg baby was delivered and shifted to NICU. Patient remained haemodynamically stable and respiration remained adequate and comfortable with NIV intraoperatively. She was shifted back to ICU with portable NIV.
Result and Conclusion: General anaesthesia for Caesarean section carries more risks for mother and fetus even in normal pregnant patients. Risks further aggravates in a patient with pre-existing respiratory distress. In such scenario, when the clinical condition of the patient does not require ventilatory supports, central neuraxial blockade remains a safer option for anaesthesia in Caesarean section.
Effective post operative analgesia for cesarean deliveries: A double blind randomized clinical study with diclofenac and tramadol suppositories
Chella Rao K, Gayatri Bhat, Ananda Bangera
Department of Anaesthesiology, K S Hegde Medical Academy, Mangalore, Karnataka, India
Background: Pain has always been a major concern to mankind. Post-caesarean section pain complicates recovery by impending the bondage between mother and newborn. Usually strong opioids are used to combat this. NSAIDs are equally beneficial and reduce opioid induced side effects. Due to inadequately trained manpower along with regulatory supply blocks of narcotics, pain is less treated at rural centers.
Aim of the Study: Comparing analgesic effects of Diclofenac and Tramadol suppositories, regarding duration of action, complications and side effects in post-cesarean section patients.
Materials and Methods: In this study 60 parturients were randomly selected under 2 groups, Diclofenac suppository 100mg (Group A, n = 30) and Tramadol suppository 100mg (Group B, n = 30). Drugs were administered twice dialy after surgery for 24 hr. The visual analogue scale (VAS) at rest and with movements, duration of post operative analgesia is evaluated every 2 hr for over 24 hr.
Results: Patient demographic characteristics are statistically insignificant between 2 groups. Duration of analgesia is more with Group A (218.5 min) with P value (0.000, < 0.05) compared to Group B (116.5 min). VAS score of 4 attained in 23.3% in Group A compared to 63.3% in Group B with a statistically significant P of 0.0002. Incidence of the side effects like nausea, vomiting, and pruritus are more with Group B.
Conclusion: Diclofenac suppository devoid of adverse effects caused by Tramadol seems appropriate in management of pain after caesarean section. It prolongs duration and quality of analgesia with fewer incidences of side effects and ease of administration through rectal route, which can be used in any small hospital set ups also.
Severe mitral and aortic stenosis in a parturient: An anaesthesiologist's nightmare!
Deepika Jain, Nidhi Bhatia, Suman Arora
Department of Anaesthesiology, Rainbow Hospital, Hyderabad and PGIMER, Chandigarh, Punjab and Haryana, India
Background: 60 to 90% of the cardiovascular diseases complicating pregnancy are of rheumatic etiology in India, causing significant feto-maternal morbidity and mortality owing to the intrapartum and (immediate) postpartum exacerbation of the antenatal physiological alterations.
Objective: This case study intends to demonstrate efficient intra and postpartum management of such cases by supplementing general anaesthesia with an epidural for an elective caesarian section.
Case Description: A 26 year old primigravida presented with increasing shortness of breath on exertion at 32 weeks of gestation. Clinical Examination revealed dyspnoea in supine posture (NYHA III), a palpable tapping apex, a mid-diastolic murmur in the mitral area, a heart rate of 100 bpm and blood pressure of 122/75 mmHg. The CXR showed left atrial enlargement and 2D Echo was diagnostic of severe mitral (MVA .5 cm 2 ) and aortic stenosis (mean gradient 45 mmHg) with mild pulmonary arterial hypertension. The ejection fraction was 62% with no evidence of a clot or vegetation.
Materials and Methods: The plan of anesthesia was general anesthesia with an epidural adjunct. After securing adequate venous access and an radial artery cannula, an epidural catheter was placed. The patient was induced using fentanyl, thiopentone and suxamethonium and airway secured with 7.0 mm cuffed ETT and epidural activated using 10 ml 0.25% bupivacaine. Anesthesia was maintained using O2-N2O/40-60 and isoflurane at a MAC of 0.8. At the end of surgery after return of adequate spontaneous ventilation the patient was extuabted at a MAC of 0.3 to prevent emergence response.
Result: The hemodynamics were stable throughout the procedure and the post-surgical extubation was uneventful. Postoperative pain relief provided by an epidural infusion prevented further postpartum hemodynamic alterations.
Conclusion: Concomitant epidural placement with general anaesthesia proved beneficial in this young primigravida with severe mitral and aortic valve stenosis, by providing optimal conditions for surgical intervention, without major hemodynamic modifications as is usual with the conventional exclusive employment of spinal or general anaesthesia.
Comparison of effects of nalbuphine hydrochloride and clonidine hydrochloride as an adjuvant to intrathecal 0.5% bupivacaine in patients undergoing abdominal hysterectomy
Dikshitha Chetty, Fareed Ahmed
Department of Anaesthesiology and Critical Care, Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India
Background: Various adjuvants for prolongation of intraoperative and postoperative analgesia have been clinically studied in the literature.
Aim: This study was done to evaluate and compare the effects of nalbuphine and clonidine as an adjuvant to bupivacaine in spinal anaesthesia.
Materials and Methods: In this prospective, randomized, placebo control, double blind and comparative study total 90 patients of ASA grade I and II undergoing abdominal hysterectomy under sub-arachnoid block were randomly divided into three groups. In addition to 15 mg of 0.5% hyperbaric bupivacaine administered, patients of groups BS, BN and BC received 0.9% normal saline,1.6 mg Nalbuphine and 30 μg Clonidine and respectively. Total volume of drugs administered intrathecally was made up to 3.5 ml by addition of sterile isotonic normal saline in all groups. The onset time and duration of sensory and motor block, duration of analgesia, and total dose of postoperative analgesic requirement in first 24 hours were compared among three groups. The hemodynamic changes and side effects were also recorded.
Results: Patients in Group BN and BC had significantly faster onset of sensory and motor block than patients in Groups BS with Groups BN and BC having comparable onset of sensory and motor block. The mean time of two segment sensory block regression were 94.0 ± 24.4, 121.0 ± 21.4 and 166.5 ± 23.3 minutes in Group BS, BN and BC respectively (P < 0.05). The regression time of motor block to reach Bromage grade II was comparable among group BS (116.3 ± 16.4) and group BN (130.6 ± 20.9) and significantly longer in Group BC (218.5 ± 52.7). The mean duration of analgesia was 131.0 ± 20.5, 218.3 ± 35.1, and 330.7 ± 47.7 minutes in groups BS, BN and BC respectively (P < 0.05). Clonidine group showed significantly less and delayed requirement of rescue analgesic postoperatively.
Conclusion: Intrathecal clonidine is associated with prolonged motor and sensory block, better hemodynamic stability and less postoperative analgesic requirement as compared to nalbuphine.
A study on the outcome of antepartum ecclampsia: Should we be optimistic?
Divya Reddy A, Naima Fathima
Department of Anaesthesiology and Department of Obstetric and Gynecology, SVS Medical College Hospital, Mahabubnagar, Telengana, India
Introduction: Eclampsia is a serious and preventable complication of Preeclampsia contributing significantly to serious maternal morbidity and mortality. It is categorized as high risk pregnancy due to associated complications such as Renal Failure, Disseminated Intravascular Coagulation, HELLP syndrome and coma. When Preeclampsia is detected early by regular antenatal check ups, judicious and timely intervention can prevent Eclampsia. Multidisciplinary management involving Obstetrician, Neonatologist, Anaesthetist and Intensivist is highly recommended for good outcome.
Background: Our study is carried out at a District level, teaching hospital where 80% of patients are unbooked and from low socio economic strata.
Aims: 1) To study the outcome of pregnancy, 2) to study maternal, neonatal mortality and serious maternal morbidity.
Materials and Methods: This is a retrospective study done by analysing all the women who were admitted with Antepartem Eclampsia between July 2014 to June 2015 (1 year).
Results: In one year there were 32 cases of Antepartum Eclampsia. Majority, 75% of the women were young, in the age group of 18-23yrs, 22% were between 24-27 yrs. All the women were from rural areas. 31% were referred from other hospitals and 69% were direct arrivals. 82% were primis and multipara >1 was 18%. 75% of women were 36weeks or more into their pregnancy and 25% were between 32-36weeks. Only 12.5% were booked cases and 87.5% were unbooked cases. History of Preeclampsia was present in 22%. 78% did not have documentation of HTN. One patient underwent bilateral cardiac valve replacement 6years ago. All the women received MgSo4 according to Pritchard's regime. Mode of delivery - 25% had vaginal delivery. 75 % (24) had Emergency Caesarean Section under spinal anaesthesia. Birth weight of the babies - 15% (5) birth weight was 1-1.5 kg, 25% (8) were 1.5-2 kg, 44% (14) were 2-2.5 kg, 16% (5) 2.5-3 kg and 3% (1) was >3 kg. There were 5 neonatal deaths. 8 babies were admitted in NICU. There were no intraoperative or post operative complications. 3 women were admitted in ICU. There were no maternal deaths.
Conclusion: Our study shows that with timely and appropriate management of Eclampsia, maternal morbidity and mortality can be reduced significantly.
Poster presentation Perioperative management of a 30 years female with gestational hypertension and anaemia for emergency LSCS with development of pulmonary oedema and eclampsia in postoperative period
Divya Tewari, Sarika Lonkar, Sonal Khatavkar
Department of Anaesthesiology, DR. D.Y. Patil Medical College, Navi-Mumbai, Maharashtra, India
Background: Uncontrolled gestational hypertension poses multiple challenges to the anaesthetist during the perioperative period. A multigravida with history of gestational hypertension in previous pregnancies is more prone to progress to pre eclampsia or eclampsia and develop multiple complications. It requires vigilance and prompt management of complications that arise not only in the intra operative but also during the post operative period in order to minimize maternal morbidity and mortality.
Case Report: A 30 yrs female G5P2L2, 36. 4 wks of gestation with gestational hypertension and anemia came for emergency LSCS in view of fetal distress. She had a history of gestational hypertension in the previous two pregnancies for which she had taken irregular treatment. On examination, BP - 150/100 mm Hg, pulse-117/min, RS and CVS-NAD. Hb-8 gm%, INR 1.92, platelets 1.8 lakhs, LFTs and RFTs - normal, urine proteins 1+. LSCS was done under general anaesthesia. Patient was shifted to the ICU. 2 hrs later, the patient had drop in saturation from 100% to 96% on O2 via face mask with bilateral basal crepts on auscultation. CXR was done which showed features suggestive of pulmonary edema. Next morning, she had an episode of generalized tonic clonic convulsion. Patient was intubated immediately. Magnesium sulphate, Diuretics, antibiotics, steroids, Labetalol, PCV, FFPs and platelet transfusions were used to manage the patient. 2 days later she was shifted from the ICU to the ward from where she was eventually discharged in good health.
Conclusion: Pulmonary edema and eclampsia can be life threatening complications seen in multigravida patients having history of PIH in previous pregnancies. Prior anticipation and immediate management of the complications helped to reduce the patient morbidity and prevent mortality in our case.
Successful anaesthetic management of elective caesarean in a previous caesarean section patient diagnosed of peripartum cardiomyopathy: A case report
Gokula Krishnan, Udita Naithani, Devendra Verma
Department of Anaesthesiology, RNT Medical College and Associated Hospitals, Udaipur, Rajasthan, India
Introduction: Peripartum cardiomyopathy is a rare, dilated form of cardiomyopathy of unknown cause that arises during peripartum period, i.e., from 3 rd trimester of pregnancy until 5 months after delivery. It occurs in women with no history of heart disease. The estimated incidence is 1 in 3000 to 1 in 4000 live births. Risk factors are obesity, multiparity, advanced maternal age (>30 yrs), multifetal pregnancy and preeclampsia. Possible etiology may be viral myocarditis or maladaptive responses to the hemodynamic stresses of pregnancy. An echocardiography prior to delivery gives idea about severity status parturient and mode of delivery and anesthetic technique feasible.
Aim: To assess the anesthetic concerns in elective LSCS in a patient with asymptomatic peripartumcardiomyopathy.
Case Report: A 35 year old previous cesarean having peripartum cardiomyopathy with 36 weeks gestation posted for elective cesarean section. Preanesthetic evaluation showed no symptoms of heart failure except for raised blood pressure but echocardiography suggested LV size in upper limit with global hypokinesia of LV and LVEF-40%, mild pulmonary hypertension (PAH). Weighing risks and benefits we planned for elective cesarean section under low dose spinal anesthesia with supplement and being prepared for anticipated complications.
Results: Cesarean section conducted successfully with baby delivered being healthy without any intraoperative complications. Patient was monitored in ICU over next 3 days and shifted to post cesarean ward. Later patient discharged without any complications.
Conclusion: With patient being clinically stable and the knowledge of hemodynamic derangements, low dose 0.5% bupivacaine heavy spinal anesthesia with fentanylseems to be better choice in such cases.
Anaesthetic management of a case of large atrial septal defect with rheumatic heart disease with gestational hypertension with hypothyroidism for elective caesarean section
Hemalataha S, Kartheek H, Nalini Kotekar
Department of Anaesthesiology, JSS Medical College and Hospital, Mysore, Karnataka, India
Introduction: Atrial septal defect (ASD) is the most common congenital acyanotic heart disease in adults, most commonly seen congenital cardiac lesion in women of child bearing age.
Case Report: A 30 year old, G2P1L1 37 weeks gestation posted for elective caesarean section diagnosed congenital ASD, rheumatic heart disease (RHD) since age of 14 years. on Inj Penicillin prophylaxis for 6 years hypothyroidism since 2 years on Tab Thyronorm 100 ug, diagnosed gestational hypertension since 1 week on Tab Nifedipine 10 mg, previous Lower segment caesarean section (LSCS) under subarachnoid block (SAB), uneventful. O/E Height 172 cm, weight 88 kg no pallor/oedema. CVS- S1S2+, S2 widely split and fixed, ejection systolic murmur heard in the second intercostal space Lungs clear. Other systems normal.
Investigations: Hb 11.7 gms%, other blood, biochemical investigations, ECG-WNL, 2D Echo- congenital heart disease, large ostium secundum 32 mm, mild tricuspid regurgitation with moderate pulmonary artery hypertension (PAH) 54 mm Hg, RA, RV and MPA dilated. Case accepted as ASA GIII with high risk consent. Under strict asepsis, SAB given with 2 ml 0.5% Inj Bupivacaine + 30 microgram Inj Clonidine at L3-L4 interspaces. Perioperative hemodynamics stable and uneventful. For postoperative pain Inj Tramadol 50 mg im BD and Inj Paracetamol 1 gm IV TID. Patient had an uneventful postoperative period, discharged after 1 week. Advised follow up with cardiologist 2 months later for surgical closure of ASD.
Discussion: Unrepaired left to right shunt poses complications like severe PAH, right sided heart failure, atrial fibrillation/flutter, stroke and reversal of shunt flow.
Anaesthetic Goals: Avoid- reversal of shunt and increase in shunt flow, increase in pulmonary and decrease in systemic vascular resistance (PVR and SVR), hypotension, hypoxia, hypercarbia, accidental injection of air. Maintain adequate preload and afterload, supplementation of inspired O2. Though literature suggests general anaesthesia for ASD patients for surgeries, we have chosen SAB as the patient is hypothyroid to avoid delayed recovery, postoperative elective ventilation also polypharmacy of GA, Patient had an uneventful previous LSCS - under SAB, time constraints as this was the first case on the table.
Conclusion: we had successful outcome with SAB in this case, but no definite conclusions can be drawn from single case, one should tailor the anaesthetic technique to avoid complications with meticulous perioperative planning and monitoring.
Intensive care admissions, management and outcome of critically ill post-partum patients in a tertiary care hospital in south India: A retrospective study
Jakkam Chaitanya, M Hanumantha Rao, P Janaki Subhadra, M Madhusudhan
Department of Anaesthesia and Critical Care, Sri Venkateshwara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
Introduction: Management of the critically ill post-partum women in an ICU is a unique challenge to ICU Physicians. Infrequent admission of the obstetric patients results in high morbidity and mortality because of lack of awareness about the complications in patient population.
Mode of Study: Retrospective study.
Materials and Methods: After obtaining approval from Institutional Ethical Committee a data of 21 patients was collected from the hospital records admitted to various intensive care units viz RICU, MICU and ANCU, at Sri Venkateswara Institute of Medical Sciences (SVIMS) Hospital, Tirupati which is a tertiary care hospital, due to post-partum medical problems in the previous year i: e from June 30 th 2015 to July 1 st 2014.
Results: In our study most common admissions to ICU were because of infection related (33.3%) -Sepsis etiology followed by hypertensive disease of pregnancy (19%). Out of various interventions done in the study group, mechanical ventilatory support (12/21, 57.1%) topped the list of interventions, followed by artificial renal support (9/21, 42.9%). This could probably be due to the availability of the facilities required to manage these patients (MVS, Haemodialysis, invasive interventions and monitoring etc.,) only in our hospital in our region. In our study we found that those patients who stayed longer in ICU (discharged vs death-19.79 + 21.24 vs 5.00 + 1.41), P-value of 0.008, longer the hospital stay the better was the outcome (discharged vs death -27.74 + 20.97 vs 7.50 + 2.12), P-value of 0.001. In addition those patients with low APACHE II score had a better outcome (discharged vs death -14.68 + 8.57 vs 33.50 + 6.36), P-value of 0.008.
Conclusion: In our study we have concluded that patients who stayed longer in ICU/hospital with low APACHE II score survived better. Early admission in the course of illness and aggressive intervention through a team approach involving obstetricians, intensivists and anaesthetists in managing these patients could result in better outcome.
Atypical postdural puncture headache
Jennie Evelyn K, Sunidhara P, Subrahmanyam M
Department of Anesthesiology, Rainbow Hospitals, Hyderabad, Telangana, India
Background: In Obstetrics, postdural puncture headache is a well-recognized complication, presenting as fronto-temporal or occipital headache, worsening with ambulation and improving in decubitus position. Occasionally, patients present with non-postural headache. Here are two case reports, which have atypical manifestations.
Case 1: Mrs. S, 33 years, G2P1L1 with 38 weeks of gestation (ASA I) came for vaginal birth after caesarian. There was an accidental dural puncture during epidural placement, managed by infusing local anesthetic through intra-thecal catheter, as per our unit protocol. She underwent emergency LSCS for non-progression. Intra-thecal catheter was removed after 24 hours. She complained of headache and was treated conservatively. She had considerable relief and was discharged on 3 rd day. On 6 th post-operative day, she presented with inappropriate talk, disorientation and tonic posturing, en route to hospital. Suspecting post-partum psychosis, she was treated accordingly. She had high blood pressure recordings, blurring of vision, followed by 2 nd episode of seizure and was treated medically. Suspecting Posterior reversible encephalopathy syndrome neurologist was consulted, advised MRI which confirmed Posterior reversible encephalopathy syndrome. She was discharged after 5 days, with full recovery of symptoms.
Case 2: Mrs. T, 27 years, G4P2L2A1 with 37 weeks of gestation with MCDA twins, (ASA I) came in labour. She had normal delivery under Epidural Analgesia (second attempt). She delivered uneventfully. Following day, she complained of headache, backache and tenderness near left scapular region and treated conservatively, suspecting a muscle spasm. Headache was very severe and had no postural variation. Neurologist was consulted, advised MRI which was normal. Diagnosed as Atypical postdural puncture headache, she was managed conservatively. She was discharged on 4 th day. Came back 3 days later with severe headache, which was now postural. An Epidural Blood patch was done which resolved her complaints completely.
Conclusion: Atypical presentation of postdural puncture headache is uncommon (about 5%). It is critical to correctly identify those patients, because intra-cranial hypertension can lead to significant morbidity and differential diagnosis must be excluded. Therefore in such cases, we recommend prompt neurological examination, MRI, regular clinical monitoring, follow up and systematic examination.
Non invasive ventilation (NIV): A safe option for respiratory failure in pregnancy? A retrospective review of 107 cases
Jyothima Pippalapalli, Kousalya Chakravarthy, Shanthi Y, Sailaja K, Sunil T Pandya
Department of Anaesthesia, Pain and Critical Care, Prerna Anaesthesia and Critical Care Services, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: Maternal hypoxia is one of the common reasons for obstetric admissions to the intensive care unit (ICU) and carries a high foeto maternal morbidity and mortality. The intrinsic difficulty in airway management of obstetric population makes NIV a better option. We report a retrospective analysis of 107 cases of maternal hypoxia successfully managed with NIV.
Aim: To analyze the efficacy and safety of NIV with a protocolised approach, in pregnant patients admitted in OCCU with respiratory failure.
Materials and Methods: This is a retrospective analysis of pregnant patients with respiratory distress, admitted in Fernandez hospital, over a period of 10 yrs from Jan 2005-December 2014. The data is obtained from hospital records and ICU records database.
Result: The mean age 28 ± 2, 21.3% had BMI >33, 73% of them were G2 or more. 12% were in 1 st , 58% in 2 nd and 30% in 3 rd trimester.
Observation: 85% had initial PaO 2 /FiO 2 ≤ 200. Mean APACHE II Score was 19. Average duration of NIV: Continuous - 11 hrs / intermittent 48 ± 6 hrs. Mean ICU stay was 5.5 days and mean Total Hospital Stay was 11.8 days.
Results: Increase in PaO 2 /FiO 2 ratio is taken as the end point. Fall in PaO 2 /FiO 2 <200 or a clinical deterioration are taken as failed NIV. Failed NIV-4 patients. Of 107, 88 were >28 wks of gestation, and 83 neonates (94.93%) survived. No documented aspiration or ulcerations noted. Maternal mortality was nil in our series.
Conclusion: NIV can be used successfully both as a primary ventilator mode in acute respiratory failure in pregnancy and also as a supportive mode to enhance the respiratory mechanics with protocolised approach. However large prospective multicentric study is proposed to document its universal safety without compromising the materno foetal safety.
Super Obesity - BMI 50 and more; super risks at delivery
Kallur Sailaja Devi, Adapa Geeta, Sachan Jyoti
Department of Anaesthesiology, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: Morbid Obesity is a growing public health problem in India. Super obesity is defined as any individual with body mass index (BMI) of >50 kg/m 2 and the incidence is increasing. Apart from associated increased prevalence of diabetes and hypertension, these mothers are more likely to have complications like difficult anesthesia and delivery, increased interventions and surgical site infections. Several studies have compared obese women to normal weight pregnant women, but there are limited studies on women with BMI more than 50 kg/m 2 .
Aim: To evaluate maternal characteristics and risks associated with super obese pregnant women.
Materials and Methods: We did a retrospective study at Fernandez Hospital, a tertiary perinatal care centre with 8,000 deliveries per annum. We included pregnant women with BMI >50 at booing. The data was collected from electronic records. Demographic variables were studied. The outcomes studied were caesarean section rates, complications with anaesthesia, surgical site infection rate and neonatal outcomes.
Results: We had 15 mothers with BMI more than 50 in the study period out of 22821 deliveries (incidence of 1 in 1521 deliveries). Vaginal delivery was attempted in 11 cases, 4 had prelabour caesarean section. Caesarean section rate was 54.5 % in women who were allowed for vaginal delivery. There was no perinatal mortality, with one baby having perinatal asphyxia due to difficult delivery. Epidural was taken by 7 (63.3%) mothers in planned vaginal delivery group. The epidural catheter had to be re-inserted in 6.6% cases compared to 2.1% as per hospital rates. General anesthesia was required in 6.6% women for caesarean section after labour analgesia compared with 0.34% in the control group for women with BMI <50. Multiple attempts were made for 4 out of 11 (36.3%). Surgical site infection was seen in 33.3% (5) cases, of which two needed resuturing.
Conclusion: Super obese pregnant women have more of caesarean section rates, difficulties and complications with epidural anesthesia and increased wound infection rates. These women need delivery at tertiary care centre with experienced anesthetist and surgeon.
Comparison of median and paramedian approach for administering spinal anesthesia in patients undergoing cesarean section
Keerthi S Rao, Dhrithiman Chakrabarti, Deepthi BS
Department of Anaesthesiology, JJMMC Davangere, NIMHANS, Karnataka, India
Background: The purpose of this study is to compare the characteristics of median (M) vs. paramedian (P) approach for administration of spinal anesthesia in patients posted for caesarean section, with regard to number of pricks per procedure, number of redirections per prick, duration of procedure, incidence of venous puncture and patient discomfort score.
Materials and Methods: The study was conducted in a randomised, single blind, comparative on 100 patients presented for caesarean section. After informed consent the selected patients were administered spinal anesthesia in L3-4 interspinous space using approach as dictated by the randomisation. If the lumbar puncture failed by the given approach after 2 pricks, the other approach was used for further two pricks, failing which the patient was excluded from the study and general anesthesia was administered to conduct the case. The crossover cases were analysed by intention-to-treat analysis.
Results: The mean pricks per procedure (M vs. P) (1.36 vs. 1.10), duration of procedure (sec) (59.83 vs. 37.62) were significantly less in paramedian group compared to the median group. The mean redirections per prick (1.56 vs. 2.84) were more in paramedian group but the difference was not significant. The mean patient discomfort score (0.4 vs. 0.1) was significantly more in median group. The paramedian group recorded less venous puncture than the median group (0.14 vs. 0.08) but the difference was not significant.
Conclusion: Paramedian approach may be a better approach as compared to the median for administering spinal anesthesia in caesarean section patients, mostly due to the difficulty encountered in achieving adequate flexion in pregnant patients without causing discomfort and due to the ease of lumbar puncture using paramedian approach in an unflexed spine.
Successful anesthetic management of elective cesarean section in a patient with severe mitral stenosis with kyphoscoliosis
Madhanmohan C, Udita Naithani, Devendra Verma
Department of Anaesthesiology, RNT Medical College and Associated Hospitals, Udaipur, Rajasthan, India
Introduction: Rheumatic heart disease (RHD) is the leading cause of valvular heart diseases in India. Mitral stenosis (MS) being the most common presentation (40%) of RHD, can lead to severe cardiac compromise especially in parturient. Such patients with associated skeletal deformity like kyphoscoliosis and contracted pelvis can deliver by cesarean section only. Severe kyphoscoliosis in parturients varies from 1 in 1500 to 1 in 12000 pregnancies. Physiological cardiovascular and pulmonary changes during pregnancy like increased blood volume, cardiac output and reduced lung compliance should be considered during the term, peripartum and in immediate postpartum period. Proper cardio pulmonary examinations like echocardiography and pulmonary function test prior to delivery give idea about the severity status of the parturient and also guide us about the mode of delivery and anesthetic techniques feasible.
Aim: To assess the anesthetic concerns in elective LSCS in a patient with severe Rheumatic origin Mitral stenosis with associated kyphoscoliosis and contracted pelvis.
Case Report: A 20 year old primigravida having RHD with severe MS and pulmonary hypertension with kyphoscoliosis with 37 weeks gestation with cervical dystocia posted for elective cesarean section. Preanesthetic evaluation showed severe MS (valve area -0.9 cm 2 ), pulmonary hypertension with LVEF - 40% with mild dyspnea on rest with normal airway. Weighing risks and benefits we planned LSCS under general anesthesia (GA) with tracheal intubation being prepared for its anticipated complications. LSCS underwent in GA with opioid based induction, rapid sequence intubation, fluid restriction that resulted in negligible hemodynamic derangements and a healthy baby delivered. Post extubation she had mild crepitations which was successfully treated with diuretics and mask oxygenation rest uneventful.
Conclusion: With the knowledge of cardiac, hemodynamic derangements and necessary measures to handle them in a case of severe mitral stenosis with pulmonary hypertension, general anesthesia seems to be the better choice.
Skeletal fluorosis in term pregnancy: Another cause of unanticipated difficult airway
Mohd Qurram Parveez, Komal Gandhi, Kajal Sharma
Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
Skeletal fluorosis is a major public health problem in India. It is characterized by an overall increase in bone mass and ossification of ligaments and interosseous fasciae, including interspinous ligament. Lumbar spine is most commonly affected followed by cervical spine. We present a case of term pregnancy who posed a challenge for the attending anesthesia team because of skeletal fluorosis.
Case: A young primigravida was posted for emergency Caesarean delivery in view of non reassuring fetal heart rate trace. Her general physical examination was normal except apparent discolouration of teeth on oral examination with Malampati class 2. After failed attempts for subarachnoid block, general anaesthesia with endotracheal intubation and controlled ventilation was planned. During modified rapid sequence induction, laryngoscopy revealed a Cormack Lehane score 4 view which could not be improved due to unnoticed 'fixed' neck in successive attempts. This situation turned into 'can ventilate, cannot intubate' scenario which was managed with the 'only' available airway rescue- classic LMA for uneventful Caesarean delivery. Postpartum radiographs and dentistry consultation revealed diagnosis of 'fluorosis.'
Discussion: This case emphasizes preoperative basic airway examination, preparedness of difficult airway cart and due consideration to associated pathological changes (skeletal fluorosis) if known, in the setting of obstetric emergencies requiring general anesthesia.
Magnesium sulphate versus dexamethasone as adjuvants to bupivacaine during open transversus abdominis plane block for lscs patients
Mopuru Pradeep, Madhu Velayuden
Department of Anaesthesiology, Sree Gokulam Medical College, Trivandrum, Kerala, India
Introduction: Pain in abdominal surgeries is related to somatic pain signals derived from the abdominal wall. Inadequate post operative pain control leads to patient discomfort, immobilisation, thromboembolic phenomenon and pulmonary complications.
Tap Block: Rafi in 2001, Inject local anaesthetic into the plane between internal oblique and transversus abdominis muscles. Anaesthetise Intercostal nerves (T6-T11), Subcostal nerve (T12), Ilio-inguinal and Ilio-hypogastric nerves (L1).
Objectives: To compare magnesium sulphate and dexamethasone as adjuvants to bupivacaine during open TAP block for LSCS patients. Time to first analgesia, pain scores at 2, 6, 12, 24 hours, haemodynamic data and side effects are considered.
Materials and Methods: 50 adult patients undergoing elective LSCS under LSAB through a pfannenstiel incision. At the time of wound closure, following peritoneal closure, drugs were given into bilateral TAP under direct vision. Group M - 20 ml 0.25% Bupivacaine + 1 gm Magnesium sulphate. Group D - 20 ml 0.25% Bupivacaine + 8 mg Dexamethasone. Time to first analgesia is the time after which first dose of rescue analgesia is given. Pain scores at 2/6/12/24 hours noted on the basis of visual analog scale (VAS).PONV was assessed during PONV assessment scale. Statistical analysis was done using SPSS 20.0.
Results: No statistically significant differences were observed in age (P = 0.341), body weight (P = 0.271), or pregnancy frequency (P = 0.912) between the groups. Statistically significant pain scores were observed at 6 hours (P = 0.01) and 12 hours (P = 0.02).Pain scores were statistically insignificant at 2 hours and 24 hours. All the 50 members in the study had a PONV score of 0 and OAA/S score of 5 throughout the first 24 hours of the study.
Discussion: Time to first analgesia was longer in Group D compared to Group M. Haemodynamics were more stable in Group M compared to Group D. Pain scores were similar at 2 hours, but were better in Group D at 6 hours and 12 hours. No sedation or PONV were noted in both groups.
Conclusion: Dexamethasone produces a longer duration of post op analgesia with no deleterious effects on haemodynamic status and no side effects compared to magnesium sulphate, when added to bupivacaine for TAP block.
Emergency mitral valve replacement and caesarean section in parturients: Two case reports
Nagaraja PS, Naveen G Singh
Department of Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysore, Karnataka, India
Background: Cardiac surgery during pregnancy using cardiopulmonary bypass (CPB) has resulted in MMR of about 3-15%. CPB also alters placental perfusion which can increase IMR. The aim of the article was to alter the routine CPB and anaesthesia protocol to reduce both maternal and infant mortality rate.
Case Report: Here we report two cases of parturients with severe MS; post PTMC developed acute MR due to anterior mitral leaflet tear. They were taken up for emergency mitral valve replacement followed by LSCS. Both the neonates delivered had low APGAR scores, hence were intubated and mechanically ventilated. Inj Nalaxone was given to reverse respiratory depression caused by opioids and were extubated after satisfying extubation criteria.
Discussion: Review of the literature showed case reports who underwent caesarean section followed by CPB initiation for valve surgery. But in our case MVR was done prior to LSCS as the mother had unstable haemodynamics and caesarean section could lead to PPH, increasing maternal morbidity and mortality. Hence our primary goal was to save the mother so with informed consent of patient relatives MVR was performed prior to LSCS. However, all the measures were taken to monitor foetal wellbeing throughout CPB. The routine CPB management (i.e hemodiluted, nonpulsatile, and low flow) in paturient with heart disease might be detrimental to both mother and the fetus. General anaesthesia, Bispectral index maintained between 40-60, left uterine displacement avoiding IVC compression, normocarbia to maintain uterine blood flow, hematocrit about 28%, scavenging of the cardioplegia solution from the right atrium, normothermia, high pump flow rate to maintain a mean perfusion pressure of 70mmHg, shorter CPB time and foetal heart rate monitoring were the primary goals which resulted in favourable fetal and maternal outcome.
Conclusion: A multidisciplinary team comprising of cardiac anaesthesiologist, Cardio thoracic surgeon, Obstetrician, paediatrician, perfusionist and intensivist are desirable for successful management of such patients.
Anaesthetic management in postmitral valve replacement patient with atrial fibrillation undergoing caesarean section
Nagaraju TR, Chirag Patel
Department of Anaesthesiology, Institutional Affiliation: BJ Medical College, Ahmedabad Gujarat University, Ahmedabad, Gujarat, India
Background: Rheumatic heart disease is still a major heart problem associated with pregnancy in India, despite its declining trend. Rheumatic mitral stenosis forms 88% of the heart diseases complicating pregnancy in the tertiary referal centre in India. With the advent of intensive obstetric and anaesthetic multidisciplinary approach, the morbidity and mortality in pregnant women with heart disease is lower in the recent years.
Aim: Management of patients with prosthetic heart valves for non-cardiac surgery involves cardiac assessment for valvular function, residual pathology, infective endocarditis and functional status; assessment of the status of anticoagulation; neurological evaluation for detecting any impairment due to thromboembolism.
Materials and Methods: With routine investigation except APTT preoperatively Informed written consen was taken. In the OT after securing IV line, base line vital parameters noted. Following stabilizing the patient haemodynamic status Patient premedicted, preoxygenated, induced and anesthesia maintained throughout the procedure without any intraoperative complication patient was extubated successfully. Post extubation atrial fibrillation was managed appropriately and shifted to post operative ward for observation. Anticoagulants, Analgesia, DIGOXIN, Prophylaxis against infective endocarditis started accordingly. Coagulation profile and serum electrolytes measured regularly.
Result: With the appropriate anticoagulation bridging therapy, antiarrythemic therpy, we managed a 28 yr lady with Post MVR status with Atrial fibrillation undergoing cesarian section with out any intraoperative and post operative complication.
Conclusion: With the advent of intensive obstetric and anaesthetic multidisciplinary approach, the morbidity and mortality in pregnant women with heart disease is lower in the recent years.
Maternal obesity: Anesthetic implications and perioperative outcome: A prospective study of 1032 pregnancies over a year
Neelima† , Kousalya C * , Y Shanthi * , K Sailaja * , Sunil T Pandya **
† Fellow Obstetric Anesthesia Fernandez Hospital Hyderabad, * Consultant Anesthetists Fernandez Hospital ** HOD Anaesthesia, Obstetric Critical care and Pain medicine, Fernandez Hospital, Hyderabad, Telangana, India
Introduction: The change in the life style has caused increase in the prevalence of maternal obesity increasing the maternal and neonatal morbidity.
To evaluate the anesthetic implications and perioperative outcome of parturients with BMI >30 kg/m 2 who underwent caesarean section and those requesting Labour Epidurals.
Materials and Methods: This prospective study is done in Fernandez Hospital for Women and Newborn, Hyderabad between Jan. 2014 and Jan. 2015 over a period of 1 year. The pregnant patients were analyzed as 2 groups. Group A: Obese Class I BMI 30 -34.9. Group B: Obese Class II and III BMI - >35.
Results: A total of 1032 patients with BMI >0 were analyzed. The incidence of obesity is 22.5% in our hospital. The statistical significance between Group A and Group B was analyzed by chi square test and a P value of <0.05 was taken as statistically significant.
Conclusion: Maternal obesity is associated with increased materno fetal morbidity, anaesthetic and peri operative risks. The magnitude of risk increases with the degree of obesity.
Effect of maternal hyperuricemia on post-spinal hypotension and uterine tone in normotensive parturients undergoing non-elective caesarean delivery: A prospective observational study
Nidhi Bhatia, Shanmugam R, Kajal Jain, Pooja Sikka, Indu Varma
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab and Haryana, India
Background: Uric acid (UA) is considered a marker of oxidative stress that has also been implicated in labor. Further, during pregnancy, oxidative stress and ROS have been shown to cause impaired relaxation of vascular smooth muscles and significantly impaired contractility of the myometrium. Given these associations, we hypothesize that serum uric acid levels may increase during labor with a decrease in incidence of post-spinal hypotension and impairment of uterine contractility in laboring women undergoing non elective cesarean deliveries.
Aims: To observe the effects of hyperuricaemia on incidence of post spinal hypotension, use of supplemental uterotonics, intraoperative blood loss and short term neonatal outcome.
Materials and Methods: Following ethics committee approval and written informed consent, this prospective observational study was conducted in laboring women with singleton pregnancy and normal blood pressure undergoing non elective cesarean delivery. Samples for uric acid estimation at admission to labor room and prior to shifting for cesarean delivery were obtained. LSCS was carried out under SAB using 10 mg of 0.5% hyperbaric bupivacaine with 15 μg fentanyl. Before delivery of the baby our target was to keep SBP >100 mmHg or to prevent a fall of more than 20% in the MAP using IV Phenylephrine 50 μg boluses. Episodes of hypotension and total dose of vasopressor given upto the time of uterine incision was recorded. Following expulsion of placenta, uterine tone and contractility was recorded every 2 minutes for 10 minutes and graded as satisfactory (score >7) or unsatisfactory(score ≤7). In cases of unsatisfactory uterine tone use of other uterotonics as well as any other measures taken to manage uterine atony (like uterine massage) was recorded. Intraoperative blood loss was estimated using modified Gross formula. Neonatal outcome was evaluated by noting the Apgar scores and analyzing cord blood for presence of acidosis.
Results: There was a significant decrease in the incidence of post-spinal hypotension in parturients with increased uric acid levels. Vasopressor use was also significantly decreased in these patients.
Conclusion: Elevated serum uric acid levels in parturients undergoing cesarean delivery with neuraxial anaesthesia correlated with decreased incidence of post-spinal hypotension.
Anesthetic management of a patient with pituitary microadenoma for caesarean section
Nikunj Vachhani, Aarti Prabhune, Jitendra K Shirsagar
Department of Anaesthesiology, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
Background: Pituitary tumors during pregnancy can be really challenging to an anesthesiologist in view of raised intracranial tension. We want to report successful anesthesia management for a patient undergoing elective caesarean section in a known case of pituitary micro adenoma.
Aim: To assess the feasibility of spinal anesthesia in pregnant patient with pituitary micro adenoma to avoid general anesthesia and its complications. 27 years old, 37 weeks primigravida with breech presentation was posted for elective caesarean section. She had history of infertility with irregular menses, weight gain and irritability. After investigations, was diagnosed to have pituitary micro adenoma (<10 mm size). Hence, was started on Tab. Caberlin 0.5 mg, Tab. Ecosprin 75 mg and Tab. Glycomet 500 mg since duration of six months. There were no clinical signs of raised intracranial tension. Systemic, airway and fundal examination was normal. All hematological, biochemical and hormonal investigations were within normal limits. General anesthesia can cause rise in intracranial pressure associated with laryngoscopy, intubation and extubation whereas spinal anesthesia can lead to decrease in intracranial pressure due to CSF leak if multiple attempts were made.
Materials and Methods: Before shifting to operation theatre, aspiration prophylaxis was given. She was preloaded with IV Ringers Lactate and was monitored using ECG, NIBP, Pulse rate, Spo2. Spinal anesthesia was administered after discussing benefits and perioperative risk of regional and general anesthesia with the patient and relatives. Patient preferred to take spinal anesthesia. Spinal anesthesia was given with 27G Whitacre spinal needle under all aseptic precautions at the level L3- L4 in first attempt.
Result and Conclusion: Patient remained hemodynamically stable intraoperatively and was discharged on postoperative day 3. There was no evidence of PDPH or any other side effects of spinal anesthesia. Hence, we conclude that spinal anaesthesia, in experienced hands can be safely administered in patients with pituitary micro adenoma without raised ICT, with an added advantage of an awake patient to alert early in event of an intracranial complication.
Epidural labour analgesia: Comparison of patient controlled analgesia versus continuous infusion with levobupivacaine and fentanyl
Nishanth Baliga, Akkamahadevi P
Department of Anaesthesiology, Kasturba Medical College, Mangalore, Jagadguru Sri Shivarathreeswara University, Mysore, Karnataka, India
Background: The pain of childbirth is arguably the most severe pain most women will endure in their lifetime. Epidural analgesia is the gold standard for labour analgesia. Epidural analgesia may be maintained with intermittent bolus injection, continuous epidural infusion or patient controlled epidural analgesia, with or without background infusion.
Aim of the Study: To compare the efficacy and safety of patient controlled epidural analgesia with basal continuous infusion versus continuous epidural infusion using levobupivacaine and fentanyl. To compare quality of analgesia, side effects, local anesthetic consumption, maternal and fetal outcome between the two groups.
Materials and Methods: Sixty parturients above the age of 18 who requested pain relief in labour were selected. The study population consisted of 60 parturients. They were divided into 2 groups of 30 each. Group I - Patient Controlled Epidural Analgesia with background infusion of 6 ml/hr, bolus dose of 5 ml, lockout interval of 10 minutes with maximum dose of 20 ml/hr. Group II- Continuous epidural infusion at a rate of 8 ml/hr with bolus dose of 12 ml. Both the groups received a mixture of levobupivacaine 0.125% with fentanyl 2 microgram/ml.
Results: The quality of analgesia was comparable between the two groups however the incidence of breakthrough pain and rescue boluses needed were more in CEI group. The incidence of motor blockade was more in CEI group. Maternal satisfaction was better with PCEA. There was no increased incidence of caesarean section, instrumental delivery in both the groups. There was no prolongation of labour, delay in breast feeding, significant complications in both the groups.
Conclusion: In our study, the analgesia provided during labour by both the techniques were satisfactory and comparable. Patient controlled epidural analgesia provides better maternal satisfaction scores, lesser incidence of breakthrough pain, motor blockade and rescue boluses when compared to continuous infusion.
Anaesthetic management of a morbidly obese parturient undergoing cesarean section
Nithin Pinninti, Shailesh Bhadla, Shailesh K Shah
Department of Anaesthesiology, BJ Medical College, Gujarat University, Ahmedabad, Gujarat, India
Background: Obesity is a broad term and defined as a condition in which body fat is in excess beyond a point incompatible with physical and mental health and normal life expectancy. Morbid obesity is defined as BMI of greater than 40.
Aim: To manage a case of morbidly obese 28yr old parturient female with weight of 178 kgs and height of 164 cm with BMI of 66 kg/m 2 require proper prep evaluation, look for associated co-morbidities, check for vascular access, airway assessment, vitals and anatomical landmarks for regional anaesthesia.
Materials and Methods: Morbidly obese patient require great care while positioning for spinal anaesthesia. Procedure should be started with patient in sitting position with retraction of fat pads on back by assistant to facilitate for proper induction. Extra care should be taken while positioning patient in reverse trendelenberg following spinal anaesthesia with proper head, neck and shoulder support and observing oxygen saturation.
Result: Patient was managed successfully and induction delivery time was 35 min. Patient's oxygen saturation was maintained between 98-99% throughout the procedure.
Conclusion: Managing a case of morbidly obese parturient patient for cesarean section includes detailed pre anaesthetic check up, to look for associated medical comorbidities, expertise in regional anaesthesia and airway management, proper positioning during spinal anaesthesia as well as intraoperatively, maintain vascular access and vitals especially oxygen saturation throughout procedure.
To study the effect of intratheal fentanyl plus bupivacaine by using two separate techniques of administration in caessarean section
Noopur Bansal, SD Ladi
Department of Anaesthesiology, Bharati Vidyapeeth Deemed University, Pune, Maharashtra, India
Background: Potentiating the effect of local anaesthetics by addition of intrathecal opioids like fentanyl minimizes the dose of bupivacaine, thereby reducing the side effects of higher doses of bupivacaine in caesarean sections. Addition of fentanyl to bupivacaine may affect the density of hyperbaric solution, hence its spread. To improve the efficacy and minimize the side effects, we have given the drugs sequentially in our study.
Aims: To compare the onset of sensory and motor block, intraoperative side effects, haemodynamic stability, sensory and motor block regression and duration of post operative pain relief in recovery room in these two techniques of drug administration.
Materials and Methods: Prospective randomized study was conducted in 60 parturients divided into two groups of 30 patients each. In study group, 1.5 ml bupivacaine and 0.5 ml fentanyl were given in separate syringes sequentially and in control group, the same amount of drugs was given in the same syringe for spinal anesthesia. Pain was assessed using VAS sore, motor block using Extended Modified Bromage Scale.
Result: The mean time required for the onset of maximal sensory block (T6) in the study and control group was 2.7 minutes and 5.03 minutes and motor block (Bromage Scale 3) in the study and control groups was 3.1 minute and 7.23 minutes respectively. The mean time required for regression of sensory block (L1) in the study and control group was 173 minutes and 116 minutes and motor block (Bromage Scale 0) in the study and control group was 168 minutes and 124 minutes respectively. Mean time required for rescue analgesia in study and control group was 189 minutes and 142 minutes respectively. Hemodynamic stability was more in study group. Pruritis was more in study group (13.66%) than control group (6.9%).
Conclusion: Due to faster onset, prolonged duration of sensory and motor block, better hemodynamic stability and prolonged duration of rescue analgesia in study group, it can be concluded that fentanyl and bupivacaine should be given sequentially in spinal anesthesia for caesarean section.
Evaluation of thrombocytopenia as a near miss criteria; does HTN matter?
Pallavi Chandra, Nuzhat Aziz
Department of Anaesthesiology, Fernandez Hospital, Hyderabad, Telangana, India
Thrombocytopenia in pregnancy is seen in 6% of all pregnancies, with a majority belonging to mild category of gestational thrombocytopenia. Severe thrombocytopenia of less than 50,000/ cumm is rare and has been included as a criteria for the definition of maternal near miss morbidity (MNM). We wanted to determine if hypertension (HTN) was a predictor of poor outcome in this category of MNM.
Aims and Objectives: We aimed to determine the incidence of severe thrombocytopenia in our MNM cases and study the characteristics and outcomes of these mothers, with and without hypertension.
Materials and Methods: An audit of NMN cases from January 2011 to December 2014 was undertaken at Fernandez Hospital, Hyderabad, which is a private tertiary referral perinatal centre with 8000 deliveries annually. WHO 2009 criteria was used for defining maternal near miss morbidity. Severe thrombocytopenia less than 50,000 was used as a inclusion criterion and divided into two groups based on the presence or absence of hypertension. Etiology of thrombocytopenia and outcomes (MNM morbidity indicators) and maternal death were studied.
Results: During the study period we had 263 MNM cases in 28,836deliveries giving an incidence of 9/1000 live births. Severe thrombocytopenia was present in 99 mothers (37.6%). 38 (38.3%) were associated with hypertension and 61 were normotensive. The study group of thrombocytopenia with HTN had less incidence of PPH (15 Vs 24%), but with higher need for ventilation (34% vs 26%) and similar transfusion needs. Perinatal deaths and maternal deaths were higher in HTN group.
Discussion and Conclusion: Hypertension is a predictor of adverse outcome in severe thrombocytopenia related maternal near-miss.
Comparative study of fractionated dose vs bolus dose injection in spinal anaesthesia undergoing LSCS
Poonam Nehra, Deepika Baria, Jigisha Badheka, Khatija Dalwani, Vandana Parmar
Department of Anaesthesiology, PDU Medical College, Rajkot, Gujarat, India
Background and Aim: Central neuraxial blockage holds good place for anaesthesia for surgical procedures on abdomen and lower limb. Spinal anaesthesia has rapid onset of anaesthesia but simultaneously causes precipitous hypotension. In spinal anaesthesia with fractionated dose, local anaesthetic is injected in subarachanoid space in fractions with time gap, which provides dense block with haemodynamic stability and prolongs the duration of analgesia. Literature search doesn't revealed studies comparing these two techniques, so we decided to do this prospective, randomized, double blind study with the aim to compare fractionated dose vs bolus dose in spinal anaesthesia for haemodynamic stability and duration of analgesia in patients undergoing LSCS.
Materials and Methods: After getting clearance from ethical committee present study was carried out on 60 patients undergoing LSCS. Patients were divided into two groups in Group B patients received single bolus spinal anaesthesia with inj. bupivacaine heavy (0.5%) and in Group F patients received fractionated dose with 2/3 rd of the total dose given initially followed by 1/3 rd dose after 60-90 seconds. Time of onset and regression of sensory and motor blockage, intraoperative haemodynamics and duration of analgesia were recorded and analysed with students unpaired t test.
Results: Our study shows patients characteristics, onset of sensory and motor blockage and maximum sensory level achieved were comparable between two groups. All the patients were haemodynamically stable in group F as compared to group B. 5/30 in group F and 14/30 patients in group B required vasopressor. Duration of sensory and motor block and duration of analgesia was longer in group F (273.83 + 20.62) compared to group B (231.5 + 31.87) P < 0.05.
Conclusion: Fractionated dose of spinal anaesthesia provides greater haemodynamic stability and longer duration of analgesia compared to bolus dose.
Airway changes following labor and delivery in preeclamptic parturients: A prospective observational study
Pragya Ahuja, Kajal Jain, Neerja Bhardwaj
Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab and Haryana, India
Background: Upper airway changes have been reported during labor of normal parturients using Mallampati scoring. Upper airway volumes have been measured through acoustic reflectometry which have confirmed this change. There is lack of data evaluating airway changes in laboring pre-eclamptic patients through either mallampati grading or sonography.
Aim: To assess airway changes during labor and delivery in severe pre-eclamptic parturients as compared to normotensive parturients.
Materials and Methods: After ethical clearance, 40 laboring parturients who fulfilled eligibility criteria and were willing to partcipate were enrolled in this study. Of these, n = 20; severely pre-eclamptic and n = 20; normotensive parturients. We used Samsoon modification of Mallampati grading to assess parturients' airway. Upper airway was photographed prior to active stage of labor (T1), within one hour (T2), and within 24-48 hours of delivery (T3). In the second part of study, using submandibular sonography, the anteroposterior thickness of the geniohyoid muscle and anterior neck soft tissue thickness from skin at the level of hyoid bone and at the level of vocal cords, were measured, at the same times to assess pharyngeal changes. Primary outcome was to observe class of Mallampati grading and change in class, if any. Factors such as duration of labor, intravenous fluids administered and total dose of oxytocin administered were evaluated for their predictive value.
Results: There was a statistically significant increase in airway class within both the groups from prelabour to postlabour [normotensive (P < 0.007); preeclamptics (P < 0.002)]. However the percentage of parturients showing airway changes was more in pre-eclamptics (50%) These changes did not revert to normal in the postpartum period in both the groups [P values <0.014; <0.007, respectively]. A statistically significant increase in anterior soft tissue thickness at the level of hyoid bone was noted in pre-eclamptics at T1 when compared with normotensives (P < 0.032). A positive correlation was found between airway changes during labor and duration of labor (P < 0.001).
Conclusion: Pre-ecalmptics parturients show a higher incidence of airway worsening during labor as compared to normotensive parturients. Further research comparing sonographic measurements and laryngoscopic view may aid in recognition of a difficult airway in parturients.
Intravenous dexamethasone as an adjunct to patient-controlled epidural analgesia with levobupivacaine and fentanyl in labouring patients; a prospective, double-blind, randomized placebo controlled trial
Pratibha Dube, Sukanya Mitra, Richa Saroa
Department of Anaesthesiology, Panjab University, Government Medical College and Hospital, Chandigarh, Punjab and Haryana, India
Background: Neuraxial analgesic techniques are gold standards for pain relief during labour and delivery. The addition of adjuvants have shown to improve the quality of analgesia and decrease the effective dose of of local anaesthetic. Institute: Government Medical College and Hospital, Chandigarh, India.
Aim: To assess the effect of intravenous dexamethasone vs saline (placebo) in reducing the hourly average consumption of epidural levobupivacaine and fentanyl in labouring parturients.
Materials and Methods: Eighty healthy parturients belonging to ASA physical status I and II, age >18 years, nulliparous, single gestation, cephalic presentation at ≥36 wk of gestation, in early labour (cervical dilation ≤5 cm) expected to have a vaginal delivery with baseline pain score >3 (on 0-10 VAS) requesting epidural analgesia were chosen for the study. After approval by Institutional Ethics Committee and obtaining written informed consent, the parturients were randomly assigned to two groups of 40 each using computer generated random numbers. The dexamethasone Group (Group I, n = 40) received 8 mg of dexamethasone intravenously in 50 ml normal saline 45 min before the epidural. The patients in the Placebo Group (Group II, n = 40) received 50 ml normal saline. Epidural catheter was inserted in patients of both the groups and 10 ml of levobupivacaine 1 mg/ml (0.1%) with 2 μg/ml fentanyl was injected as a bolus. All patients then received continuous background infusion of 5 ml of 0.1% of levobupivacaine with 2 μg/ml of fentanyl with the provision of patient-controlled bolus of 5 ml of 0.1% of levobupivacaine with 2 μg/ml of fentanyl. Visual analogue pain scores, motor blockade, level of sensory block, supplementary boluses, mode of delivery, and neonatal APGAR score were recorded. The primary outcome was hourly epidural drug consumption (ml/h).
Results: Hourly drug consumption was significantly lower in the Dexamethasone Group than Placebo Group (10.34 ml ± 1.79 vs. 11.34 ± 1.83, P < 0.05). Dexamethasone Group also required significantly less number of bolus doses than the Placebo Group. There were no other significant differences between different outcome measures within the two groups.
Conclusion: Intravenous administration of 8mg of dexamethasone significantly decreased hourly average drug consumption and the number of boluses through the epidural route, thus providing the epidural drug dose sparing effect.
Anaesthetic management for bilateral tubal ligation in patient with Opalski syndrome
Preeti Labani, Veena Asthana, Rupali Sharma
Department of Anaesthesiology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
Background: Lateral medullary syndrome (Wallenberg's syndrome) is a relatively common vertebrobasilar vascular syndrome. However, ipsilateral hemiparesis as part of lateral medullary infarction is rare, and is known as Opalski's syndrome.
Aim: We present the Pre anaesthetic evaluation and anaesthetic management of the patient with Opalski syndrome posted for tubal ligation in our setting.
Materials and Methods: Case characteristics: A 26 yr old female with second gravid and parity was scheduled for bilateral tubal ligation in view of contraception with previous two normal deliveries. She had history of hypertension during 2 nd pregnancy and history of headache, dysarthria, dysphagia, ataxia, and hoarsness of voice and had right side facial weakness with sensory loss on the same side in the postpartum period around 8months back. With further investigations patient was diagnosed as atypical postpartum stroke presenting as opalski syndrome.
Results and Outcome: This case highlights the rarity of the particular syndrome and careful preoperative history taking is the key for successful perioperative management and good postoperative outcome. Emphasis is to be given on the fact that not all the hypertensives during pregnancy should be managed as gestational hypertension but also to be evaluated for other clinical entities. Spinal anaesthesia should not be given in such cases and the case was managed by giving general anaesthesia.
Conclusion: A good preanesthetic assessment and history taking gave a good perioperative management is needed for a safe and a satisfactory outcome avoiding complications.
Comparison of hemodynamic effects of colloid preloading and coloading in spinal anesthesia for lower segment caesarean section
Priyanka Chuttani, Poonam Arora, PL Gautam, M Rupinder Singh
Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Background: Crystalloid preloading is routinely done to prevent maternal hypotension secondary to subarachnoid block. While preloading with crystalloid can be ineffective due to its short stay in intravascular space, colloid preloading can result in volume overload and pulmonary edema. Volume coloading has been proposed to be more physiological. Studies however have reported conflicting results in this regard.
Aims: To compare hemodynamic effects of colloid versus crystalloid preloading versus colloid coloading in spinal anesthesia for lower segment caesarean section.
Materials and Methods: After obtaining IRB approval and informed consent, ninety ASA grade I/II parturients with full term uncomplicated singleton pregnancy undergoing LSCS under spinal anesthesia were randomly assigned into three groups of 30 each. Group A received preloading with 10 ml/kg of colloid (6% HES), Group B coloading with 10 ml/kg of colloid (6% HES), Group C preloading with 10 ml/kg of crystalloid (RL/NS). Hemodynamic parameters HR, DBP, SBP, MAP, ECG, SpO 2 , RR were recorded every 5 minutes till the end of caesarean section, and then every 15 minutes for 1 hour, half hourly for next 6 hours and then hourly for next 5 hours post-operatively.
Results: The incidence of hypotension was 36.6%, 40% and 60.6% in groups A,B and C respectively. Colloid preloading was found to be better in reducing the incidence of maternal hypotension than crystalloid preloading (P value-0.042). Colloid coloading decreased the incidence of hypotension more than crystalloid preloading (P value-0.047).
Conclusions: Colloid preloading and coloading both are equally efficacious and superior in preventing hypotension in comparison to crystalloid preloading.
Intrathecal buprenorphine and fentanyl for postoperative analgesia in caesarean sections: A randomized double blind controlled study
Priyanka SH, Gayathri Bhat, Ananda Bangera
Department of Anaesthesiology, Nitte University, KS Hedge Medical Academy, Mangalore, Karnataka, India
Background: Pain relief in postoperative period is a matter of concern in parturients. Spinal anaesthesia is the preferred means for caesarean section, being simple to perform, economical and produces rapid onset of anaesthesia and complete muscle relaxation. Intrathecal opioids are combined with local anaesthetics to improve the onset time of block, duration and quality of analgesia, intraoperatively and postoperatively.
Aim: This study was designed to compare the efficacy of intrathecal buprenorphine and fentanyl as an adjuvant to prolong the post operative analgesia.
Materials and Methods: 90 parturients of ASA PS grade I and II scheduled for elective LSCS under subarachnoid block were randomly allocated into 3 groups. Group A were administered 2 ml of 0.5% hyperbaric bupivacaine with 0.3 ml of 0.9% saline. Group B were administered 2 ml of 0.5% hyperbaric bupivacaine with 90 μg of buprenorphine (0.3 ml). Group C were administered 2 ml of 0.5% hyperbaric bupivacaine with 15 μg of fentanyl (0.3 ml). Efficacy of buprenorphine and fentanyl as adjuvants in terms of haemodynamic variables, onset and duration of sensory and motor block along with side effects were recorded.
Results: There were no significant hemodynamic changes between the three groups. There was significant decrease in the time required to reach peak sensory blockade in fentanyl and buprenorphine groups compared to control group (P value = 0.007). Onset of motor blockade was significantly faster in fentanyl and buprenorphine groups (P value < 0.001) compared to control group. Mean duration of analgesia was significantly prolonged in group B (253 ± 15.12 min) and Group C (254 ± 15.22 min) than the control group (112.5 ± 7.628 min). There was no significant effect on Apgar score of the neonate.
Conclusion: Intrathecal opioids as adjuvants to hyperbaric bupivacaine are well tolerated by the parturient and neonate during caesarean section. The benefits are significant and far out weigh the side effects with prolonged post operative analgesia.
Pregnancy, myocardial infarction and split-site hospitals: A management challenge
Department of Anaesthesiology, Hull Royal Infirmary, UK
A 29 weeks pregnant lady (G2, P1) presented, with chest pain, breathlessness and ST segment depression. Echocardiogram showed good LV function with no RWMA. She was admitted to CMU and treated for NSTEMI. Angiogram revealed dissection of left circumflex artery (LCX) and >90% obstruction in left anterior descending artery (LAD). Provisional diagnosis of viral myo-pericarditis or NSTEMI. An MDT agreed on following i) an elective LSCS at 33 weeks under GA or spinal ii) labour analgesia with Entonox/ PCA /epidural, iii) Elective percutaneous coronary intervention at 3 months postpartum or an emergency PCI if she becomes unstable. Considering that obstetric and cardiac services are on two different sites (6 miles apart), it was decided that her elective /emergency LSCS should be done in a cardiac theatre. At 31 weeks, patient developed a large haematoma in anterior abdominal wall and dropped Hb to 7.7 (gm/dl). Her antiplatelet and LMWH therapy was stopped, RBC (2 units) transfused and transferred to obstetric unit. At 32 weeks, patient went into labour and delivered a healthy baby; labour analgesia was achieved with Entonox. On the 4 th postoperative day, patient developed chest pain and transferred to cardiac unit. Angiogram showed new dissection in left LAD with distal thrombus. Considering she was high risk for stent thrombosis, cardiologists decided to treat her medically. She remained haemodynamically stable and was discharged from hospital.
Discussion: Spontaneous coronary artery dissection (SCAD) accounts for >27% of myocardial infarction cases in pregnancy.  Because of its rarity, evidence-base to manage this condition is non-existent. For us, the key challenge was how to balance her cardiac needs with obstetric needs, in two different hospitals, this was unique, and warranted a lot of thinking, planning and resource allocations. Thrombolysis is best avoided in patients with dissection and PCI is considered the preferred management.
- Roth A, Elkayam U. Acute MI associated with pregnancy. J Am Coll Cardiol 2008;52:171-80.
Effectiveness of addition of intrathecal tramadol with hyperbaric bupivacaine in prevention of shivering in parturients undergoing caesarean section under spinal anaesthesia: A randomized placebo-controlled study
Rakshith Prasad B, Chakravarthy Joel J, Varghese Zachariah K
Department of Anaesthesiology, Bangalore Baptist Hospital, Bangalore, Karnataka, India
Background: Intravenous tramadol has been in use for the treatment of post-anaesthetic shivering, although associated with nausea and vomiting.
Aims: To assess the efficacy of addition of tramadol to bupivacaine in subarachnoid block to reduce the incidence of shivering and to evaluate it's effects on the motor and sensory aspects of the block while studying its adverse effects.
Materials and Methods: One hundred parturients undergoing Casarean Section in a teaching hospital were randomly divided into 2 groups of 50 each. Group T received 0.2 ml (10 mg) of tramadol with 2 ml of 0.5% bupivacaine. Presence of shivering was recorded intra- and post-operatively. The sensory and motor aspects of the block, as well as adverse effect profiles in both the groups were recorded and compared. Statistical analysis on the data collected was done using Student t test (two tailed, independent) for continuous variables and Chi-square/ Fisher Exact test for categorical variables between two groups.
Results: Shivering was noted in 66% of the patients in Group NS as against the 16 % noted in Group T with majority of the cases (88%) noted in the intraop period. The mean duration to 2-segment regression was 135 ± 26 min in group T vs 104 ± 22 min in group NS and duration to 1-grade motor block regression was 128 ± 21 min in Group T vs 103 ± 18 min in Group NS. The analgesic effect of the block lasted for a mean duration of 232 mins in Group T and 176 mins in Group NS while the nausea and vomiting were increased in group T vs NS with no clinically significant changes in the hemodynamic parameters.
Conclusions: Tramadol (10 mg) along with bupivacaine given intrathecally plays a significant role in reducing the incidence of anaesthesia induced shivering in parturients while prolonging both the sensory and motor components of the subarachnoid block.
Intravenous butorphanol administration reduces intrathecal morphine-induced pruritus after cesarean delivery: A randomized, placebo-controlled study
Ranjita Baksi, Daisy Karan, Ankita Mohta
Department of Anaesthesiology, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha, India
Aim: Pruritus associated with intrathecal opioid administration is a common side effect. There is evidence that κ-opioid receptor agonists have antipruritic activity. Butorphanol has agonist actions at both κ-opioid and μ-opioid receptors. This study was designed to evaluate the antipruritic efficacy of butorphanol after intrathecal morphine administration in the setting of a randomized study of parturients undergoing cesarean section.
Materials and Methods: Fifty women of ASA Grade 1 and 2 posted for elective cesarean section who received spinal anesthesia with 2.2 ml 0.5% hyperbaric bupivacaine and 0.125 mg preservative-free morphine were included in this study. After delivery of the baby, the parturients were randomly allocated to two groups: Butorphanol group (n = 25) and physiological saline group (n = 45). In the butorphanol group, parturients received an intravenous loading dose of 1 mg butorphanol followed by infusion of 0.2 mg/h butorphanol. The physiological saline group received an infusion of the same volume of physiological saline. The presence of pruritus, visual analog scores for pain, sedation scores, and adverse effects were recorded 1, 2, 4, 6, 8, 10, 12, and 24 h after intrathecal morphine administration.
Results: The incidence of pruritus at 24 h was significantly more frequent in the physiological saline group than in the butorphanol group. The severity of pruritus was significantly greater in the saline group than in the butorphanol group 2, 4, 6, 8 and 10 h after intrathecal morphine injection. The visual analog scale scores at 24 h were significantly lower in the butorphanol group than in physiological saline group. The Ramsay sedation score in the butorphanol group was significantly higher than that in the physiological saline group after 1, 2, 4, 6, 8, 10, 12, and 24 h. There were no significant differences between the two groups in nausea/vomiting and other adverse effects.
Conclusion: Administration of intravenous butorphanol after delivery of the baby can reduce pruritus that has been induced by intrathecal morphine administration in cesarean delivery with spinal anesthesia.
Anaesthestic challenges and peri operative management in a case of undiagnosed peripartum cardiomyopathy, eclampsia with acute pulmonary edema undergoing emergency cesarean section
Ranjita Baksi, Ranjita Acharya, Shaswat Pattnaik
Department of Anaesthesiology, IMS and SUM Hospital, Bhubaneshwar, Odisha, India
Introduction: Eclampsia with unremitting seizure and severe hypertension can be life threatening for both mother and fetus. Associated cardiac disease in pregnancy also pose multitude of challenges for both obstetrician and anesthetist. This situation can get worse if preexisting cardiac status is not known beforehand.
Case Summary: We report a case of 21 yr G₂A₁ term pregnancy presenting with unremitting seizure, severe hypertension and acute pulmonary edema to casualty. She was unconscious and was with severe respiratory distress, so intubated in casualty. As there was foetal distress emergency cesarean section was planned. She received Inj. Labetolol and Inj. Magnesium Sulphate in casualty. In OT she was induced with Thiopentone Sodium and Vecuronium Bromide. Inj Furosemide, Inj Lignocaine 2% preservative free was given and was put on positive pressure ventilation in pressure control mode with PEEP. With this, she was resuscitated successfully and emergency cesarean section was performed. Then the newborn was shifted to NICU and mother to Intensive care unit for further management. Diagnosis of peripartum cardiomyopathy was made after echocardiography done in post op period. The mother and baby were discharged uneventfully after 7 days to home.
Conclusion: High index of suspicion with multidisciplinary approach and close peripartum monitoring is essential in such cases presenting for emergency first time to casualty.
Post-spinal chemical meningitis: A "red herring" in a case of cerebral venous thrombosis. An anaesthetist's dilemma
Roneeta Nandi, KN Saxena, Roneeta Nandi
Department of Anaesthesiology, Lok Nayak Jai Prakash Hospital, Maulana Azad Medical College, New Delhi, India
Introduction: Cerebral venous thrombosis (CVT) is a rare complication of puerperium presenting with headache, vomiting and focal deficit. It is often misdiagnosed as a complication of neuraxial anaesthesia, postdural puncture headache (PDPH). This case is being reported to highlight the differential diagnosis in patients with symptoms resembling PDPH after delivery. We shall discuss the diagnostic dilemma of this cinical entity.
Case Report: A 23 years old third gravida woman at 38 weeks' gestation in labour was admitted to our hospital for cesarean section in view of previous two cesarean section. A 25-gauge spinal needle was used to give spinal anesthesia in left lateral position with 2.0 ml bupivacaine 0.5% (heavy). The Cesarean section was uneventful and post operatively the patient was conscious, oriented, pain free and vitals were within normal limits. After 4 hours, the patient experienced headache involving the occipital region followed by 2 episodes of vomiting. She was treated conservatively with fluids and analgesics by the obstetricians. A few hours later, patient developed altered sensorium and was not responding to commands or moving her limbs. Anesthesiologists were called to assess the patient for post dural puncture headache (PDPH) or chemical meningitis. Laboratory investigations and CT head were grossly normal, and conservative management followed with not much improvement in the status of patient. An MRI scan on fourth postoperative day was done which suggested left transverse and sigmoid sinus thrombosis (CVT). The patient was admitted to the neurology intensive care unit and anti-coagulation with subcutaneous heparin was started. All pain and neurological symptoms subsided in a week and patient was shifted to ward, and discharged 2 weeks later on oral clopidogril and methylcobalamine. Patient is being followed up in neurology OPD and a check MRI is planned.
Conclusion: High index of suspicion must be maintained for CVT in puerperium, as early detection and management are life-saving.
Presumed venous air embolism during cesarean section: A case report
Rupak Kundu, Mridu Paban Nath
Department of Anaesthesiology, Guwahati Medical College, Assam, India
Case Discussion: 27 yrs old G2P0 women at 41 weeks of gestation was planned to under go elective CS under GA. Following delivery of baby and manual removal of placenta, ETCO2 and SpO2 started dropping abruptly. BP also dropped to 60/42 mmHg. Surgeon was informed about possibility of VAE and resuscitation measures started with 100% oxygen. N20 stopped. Pt responed to resuscitation. After completion of surgery, she was shifted to ICU and monitored. She was stable in postop period.
Discussion: Despite accounting for roughly 1% of maternal death, VAE has remained a relatively under recognised complication of CS. In fact studies have shown that VAE occurs in 93-100% of CS. Though small VAE typically go unnoticed, entrapment of >3 ml/kg of air in vein causes cardiovscular collapse.
Conclusion: Anaesthestiologist should remain vigilant during exteriorizing the uterus VAE should remain high on the diffential diagnosis
- Kaunitz AM, Hughes JM, Grimes DA, Smith JC, Rochat RW, Kafrissen ME. Causes of maternal mortality in United States. Obstet Gynecol 1985;65:605-12.
- Lew TW, Tay DH, Thomas E. Venous Air embolism during cesarean section: More common than previously thought. Anaesth Analg 1993;77:448-52.
Outcome of labor in labouring parturients receiving epidural analgesia with ropivacaine
Sandhya Khatnawlia, Anju Grewal, Amandeep Kaur, Aashima Taneja
Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Background: Epidural analgesia provides satisfactory pain relief from labor pains. However few parturients in whom epidural is contraindicated need to be give another form of labor analgesia. Parenteral tramadol provides effective analgesia with low risk of respiratory depression. Scientific literature is insufficient to recommend its safe use for labor in comparison with epidural analgesia.
Aims: Comparative evaluation of analgesic efficacy, hemodynamic profile, labor and fetal outcome.
Materials and Methods: After obtaining IEC approval and written informed consent, a total of 100 parturients in active labor requesting labor analgesia were randomly allocated into two groups A and B. Group A parturients were given IV Tramadol 1 mg/kg/body weight as loading dose followed by 100 mg in 500 ml NS @ 16-24 drops/minute. Group B parturients received epidural analgesia with ropivacaine 0.2% using PCEA infusion@6-10 ml/hour after a standard 2 ml bolus. Noninvasive blood pressure, pulse rate, fetal heart rate, SpO2, VAS, Ramsay sedation score for somnolence, duration of each stage of labor, mode of delivery, fetal heart rate, APGAR score and maternal satisfaction score were recorded.
Results: Pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and SpO2 were statistically significantly lower after 15 mins in Group B in comparison with Group A; however there was no clinically significant hypotension. Mean VAS score and patient satisfaction were superior in Group B. Both groups were comparable for degree of somnolence, motor blockade, duration of labor and neonatal outcome. An increased incidence of instrumental vaginal deliveries was observed in Group B(36%). There was no significant difference for cesarean rates among two groups.
Conclusions: Epidural analgesia provided superior quality of pain relief, higher maternal satisfaction, stable hemodynamics, minimal motor blockade and negligible side effects. Tramadol was less effective for labor analgesia however exhibited stable hemodynamics and minimal adverse effect profile.
An anesthesia challenge for removal of intracranial tumour compressing optic chiasma to prevent blindness in a 32 week pregnant patient: A case report
Santosh Kumar Raulo
Department of Anaesthesia, Care Hospital, JCI, NABH, Hyderabad, Telengana, India
Planning of anaesthesia for a pregnant lady coming for neurosurgery has always been a challenging task for the anaesthesiologist. The incidence of intracranial neoplasm in 25-34 years aged parturient is reported as 6.9/100,000. Surgery for an intracranial tumor in parturients is even rarer. Firstly the surgery is a semi-emergency condition otherwise would wait till full term, secondly foetus is involved in the process and the primary goal will be to continue pregnancy till full term. Most of the anaesthesia drugs used will cross placental barrier to affect the foetus. Planning should be meticulously done to prevent adverse events in the OT, should be able to deliver the baby in emergency if necessary and the required teams should be present in OT to handle such situations if arise. This case report makes successful removal of brain tumour by prevention of blindness with continuing pregnancy till full term followed by normal delivery with live baby without any complication. A 27 years parturient with 32 weeks gestational age (Gravida 2 Para 1 Live 1), wt 60 kg presented with h/o headache on and off since last 3 month, decreased vision in right eye since last 1 month, rapidly worsening since last 1 week. Neurological examination revealed right side temporal visual field defect and MRI of brain show 2 cm space occupying lesion between mammilary body and chiasma mostly meningioma. The bifrontal craniotomy to decompress chiasma so to halt blindness was planned. The anesthesia technique modified with particular attention was given to maintain stable maternal hemodynamics to avoid uterine hypoperfusion and foetal hypoxia intraoperatively. Therefore the major challenge of neuroanesthesia during pregnancy is to provide an appropriate balance between competing, and even contradictory, clinical goals of neuroanestheiology and obstetric practice.
A comparative study of patient controlled epidural analgesia vs continuous epidural infusion in labour analgesia using ropivacaine with fentanyl
Sarvesh Srivastava, Purnendu SM
Department of Anaesthesiology, AFMC, Pune, Maharashtra, India
Background: Out of various techniques of labour analgesia neuraxial techniques are the gold standard and most widely practised in today's world. With advent of infusion pumps and patient controlled analgesia pumps EA has become norm of labour analgesia in present times.
Aim: The aim of the study is to compare Continuous Epidural Infusion (CEI) and Patient Controlled Epidural Analgesia (PCEA) as a tool in labour analgesia.
Materials and Methods: All primigravida parturients in ASA I and II, who requested for labour analgesia were invited to participate in the study. After obtaining parturients consent, epidural catheter was inserted using standard technique being followed at our instution. All parturients recieved 10 ml of study drug solution (Ropivacaine 0.1% + Fentanyl 2 mcg/ml). After initial pain relief was achieved, parturients were randomized into two groups (PCEA and CEI) using closed envelope technique. In PCEA group, parturients recieved a background continuous infusion of 6 ml/hr of same solution. Whenever parturient felt requirement of additional analgesia they recieved a bolus of 6 ml of study solution on pressing the remote. PCEA pump was set with lockout period of 20 min. In CEI group, parturients recieved continuous background infusion at 10 ml/hr and rescue bolus of 7 ml on demand was provided once in every 30 minutes. Parturients were assessed for 1. Total drug requirement as calculated by Mean Hourly Requirement, 2. Pain relief using VAS score and 3. Motor blockade using Bromage's scale. Secondary outcomes like hemodynamic variation, duration of stages of labour etc were also recorded.
Results: There was significant difference in both groups in terms of Mean Hourly Requirement. Parturients in PCEA group required significantly less drugs as compared to CEI group. Other outcomes were comparable in both groups.
Conclusion: Our study confirmed that PCEA is a better alternative to CEI as many studies conducted in developed countries have established. PCEA group parturients require less local anaesthetics and opioids which contributes towards lesser incidence of complications. Quality o pain relief is comparable to any other technique.
Tryptase negative Anaphylaxis, an interesting case in the context of major obstetric haemorrhage
K Sasi Kumar, R Rathod, CG Kaleekan, N Hester
Department of Anaesthesiology, Barking, Havering and Redbridge University Hospitals, Romford UK
Anaphylaxis during pregnancy, labour and delivery can be catastrophic for the mother and baby. During the first three trimesters, aetiologies are similar to those in non-pregnant women. During labour and delivery, common aetiologies are beta-lactam antibiotics, latex, and other agents used in medical and peri-operative settings, including less commonly blood products. Anaphylactic transfusion reactions are more frequent with components containing a high volume of plasma. In most cases, the exact cause is unknown. We report a case of a 35 year old lady who had her 4 th caesarean section for a twin pregnancy. She had a combined spinal and epidural (CSE) and after a 1.7L blood loss intra-operatively was taken to recovery for monitoring. The patient continued to bleed in recovery where she was resuscitated. During resuscitation, she developed an anaphylactic reaction. The anaphylaxis was dealt with, but ongoing bleeding meant the patient had to return to theatre. She had a hysterectomy and later required uterine artery embolisation. The patient returned to theatre on two further occasions due to persistent bleeding. In this case report, we discuss anaphylaxis in the context of major obstetric haemorrhage. The cause of anaphylaxis remained undetected and the tryptase levels were within normal limits.
Anesthetic management of a parturient with Takayasu's arteritis for Caesarean section under spinal anesthesia: A case report
Devendra Verma, Udita Naithani, Lalit Raiger, Shekhar Suman Saxena, Yogendra Singhal
Department of Anaesthesiology, RNT Medical College, Udaipur, Rajasthan, India
Background: Takayasu's arteritis (TA) is a rare, chronic progressive idiopathic connective tissue disorder resulting in panendarteritis, which is complicated by uncontrolled hypertension, end organ dysfunction, stenosis of major blood vessels and difficulties in monitoring arterial blood pressure. Aims: To discuss anesthetic implications and management in a patient with TA for cesarean section under spinalanesthesia.
Case Report: We present a case of 25 year old parturient, a known case of TA with schizophrenia, bad obstetric history and was planned for elective caesarean section. She had a past history of severe anemia, renal failure, retinopathy, dyslipidemia, occluded right carotid artery. She was on low molecular weight heparin and olanzapine. On examination only bilateral femoral, left carotid with feeble right carotid arterial pulsations were palpable. Intraoperatively we were able to monitor her HR with ECG, NIBP with oscillometry, PR and SpO 2 withpulse oximeter. Our keystones for intraoperative management were to maintain normal cerebral perfusion and to prevent end organ damage by keeping MAP within 90-110 mmHg. We chose to give her spinal anesthesia as it allows to monitor cerebral perfusion through patient's level of consciousness and also avoids responses to GA. After preloading, subarachnoid block was given using 2 ml of Inj. 0.5% hyperbaric bupivacaine. A healthy male child was delivered. Intraoperatively two episodes of fall in MAP of <90 mmHg which were managed with Inj. Mephentermine 6 mg i/v. After 6 days of admission in ICU, healthy baby and mother were uneventfully discharged, while patient was put on Tab. Aspirin and asked for regular follow-ups.
Conclusion: We conclude that spinal anesthesia with maintenance of mean arterial pressure is a safe, reliable and inexpensive technique to accomplish cesarean section in a parturient having TA.As the patient remains awake assessment of cerebral function is easy without need of sophisticated neurological monitors as required in general anesthesia. This report also highlights the importance of detailed Preanesthetic evaluation, active participation of multiple specialties in overall peripartum management of patient with Takayasu's arteritis.
Comparision of clinical efficacy of isobaric levobupivacaine and hyperbaric bupivacaine in spinal anesthesia for caesarean section: A prospective, randomized clinical study
Shuchi Mathur, DevendraVerma, Udita Naithani, Madhanmohan C
Department of Anaesthesiology, RNT Medical College, Udaipur, Rajasthan, India
Background: Levobupivacaine, the isolated S-enantiomer of racemic bupivacaine has been recently introduced in spinal anesthesia as it has less potential for cardiovascular and central nervous system toxicity than bupivacaine. There is however lack of comparative studies and adequate information on the analgesic and anaesthetic potency of intrathecal isobaric levobupivacaine in comparision to commonly used local anesthetic hyperbaric bupivacaine, especially in obstetric practice.
Aims: To compare ED 95 dose of isobaric levobupivacane (13 mg) with commonly used regime hyperbaric bupivacaine (10 mg) in spinal anesthesia for elective caesarean delivery regarding sensory-motor block characteristics, clinical efficacy (success rate), hemodynamic profile and complications.
Materials and Methods: 60 ASA I, II parturients having uncomplicated pregnancy scheduled for elective caesarean section were enrolled. Patients were randomly assigned into 2 equal groups as: Isobaric levobupivacaine (0.5%, 2.6 ml = 13 mg) in group L and hyperbaric bupivacaine (0.5%, 2 ml = 10 mg) in group B. Different doses of 2 agents were used to make their equipotent dose regime because relative potency ratio of levobupivacaine/bupivacaine is reported as 0.71(95% C.I 0.51-0.98) in spinal anesthesia. Sensory and motor block assessments were done using pin prick method and Bromagescore (0-3) respectively. Sensory-motor block characteristics, hemodynamicprofile, anaesthetic supplementation and complications were recorded. Intrathecal drug regime was considered effective if peak sensory level to pinprick of T 6 or above and Bromage score of 2 or 3 was achieved in 10 mins after SAB and if intraoperative anesthetic supplementation was not required and clinical efficacy of the 2 drug regime was compared using these success rates. Categorical variables were presented as number (proportion) and compared using chisquare test. Continuous variables were presented as mean ± SD and compared using t-test. P value <0.05 was considered as statistically significant to analyse data
Results and conclusion: Will be presented in conference as study and analysis is going on.
A comparative study of intrathecal isobaric Ropivacaine with hyperbaric bupivacaine for Elective caesarean section
TV Sree Krishna, A Sahoo, SG Murthy, AS Kameshwara Rao
Department of Anaesthesiology, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
Aims and Objectives: To compare the clinical effects of 2 ml of 0.75% Intrathecal Isobaric Ropivacaine with 2 ml of 0.5% Hyperbaric Bupivacaine for Elective Cesarean Section.
Materials and Methods: 100 parturients belonging to ASA physical status I and II scheduled for elective cesarean section were randomly selected for the study and are divided into two groups of 50 each Group B patients received 2 ml of 0.5% hyperbaric Bupivacaine Intrathecally. Group R patients received 2 ml of 0.75% isobaric Ropivacaine Intrathecally. Onset and duration of sensory block, onset and duration of motor block, maximum height of sensory block, quality of anesthesia, and time of request for analgesia, hemodynamic parameters and adverse effects if any were studied.
Conclusion: Ropivacaine 15 mg (2 ml of 0.75% isobaric Ropivacaine) provides comparable quality of sensory block but has slower onset and significantly shorter duration of motor block compared to bupivacaine.
Comparison of the effects of lateral and sitting position during induction of spinal anaesthesia with plain levobupivacaine in cesarean section
Sreekanth Ramakrishnan, Ramesh Pathak, SD Yennawar, N Nandanwankar
Department of Anaesthesiology, Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
Aims and Objectives: To study characteristic effects and haemodynamic changes and the side effects at induction, during and post operative period.
Materials and Methods: 50 patients with ASA grade1 and 2 into: Spinal anaesthesia given in L3-4 space with quinckes 25G needle. GROUP (L): 25 Patients in lateral position given 2 ml (10 mg) levobupivacaine, GROUP(S): 25 Patients in sitting position kept for 2 minutes after spinal and then to supine with 2 ml (10 mg) levobupivacaine.
Mephenteramine dose with P value of 0.11 and number of patients requiring P value of 0.72 Apgar score at 1 and 10 with P value 0.2. No patient's headache, paresthesia, shivering, vomiting even 48 hrs after surgery.
Discussion: Studied comparison on basis of age, sex, weight, height, gestational weeks and duration of surgery.
Conclusion: Isobaric levobupivacaine in women at term produces subarachnaoid block at dermatomal level and the effects of haemodynamic status is not influenzed by gravity and can be used safely as alternative in cesarean section.
Effect of postural changes on inferior vena cava dimensions and its influence on hemodynamics during caesarean section under spinal anaesthesia
Stalin Vinayagam, Pankaj Kundra, Arunsekar Gnanasekaran
Department of Anaesthesiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
Background: Caesarean section under spinal anaesthesia is commonly associated with hypotension which can lead to maternal and foetal complications. Compression of inferior vena cava (IVC) by gravid uterus is the key factor responsible for this hypotension. Abdominal ultrasound by a subcostal approach is a rapid, non-invasive, bedside test to assess IVC compression in term parturients, which in turn can predict intraoperative hypotension.
Aims: The primary aim of this study was to determine IVC dimensions in supine, recumbent with wedge and left lateral position in term parturients and also to study their influence on intraoperative haemodynamics under spinal anaesthesia.
Materials and Methods: Thirty two ASA physical status 1 and 2 full-term parturients in the age group 20 to 30 with singleton pregnancy scheduled to undergo elective caesarean section under subarachnoid block were included in this study. All parturients were subjected to abdominal ultrasound preoperatively for measuring the IVC diameter in 3 different body positions- supine, recumbent with wedge and left lateral position. Inferior vena cava diameter was recorded both during end expiration and end inspiration in all three positions and collapsibility index (%) of IVC was calculated in all three positions. After taking all aseptic precautions, spinal anaesthesia was given with 1.8 ml of bupivacaine 0.5% and intra-operative hemodynamics were recorded. Postoperatively at the time of discharge, ultrasound was repeated to record all the parameters.
Results: IVC dimensions measured during end inspiration and end expiration demonstrated significantly higher values in recumbent with wedge and left lateral when compared to the supine (P < 0.0001). Collapsibility index showed significantly lower values in recumbent and left lateral position compared to supine position (P < 0.0001). Among the parturients who developed hypotension, a greater fall in systolic blood pressure (>20%) was noted in patients with collapsibility index of 13.6 [95% CI: 11.5-17.1] in recumbent with wedge position.
Conclusion: Thus, we conclude that in term parturients, there is a significant change in IVC dimensions with change in position and collapsibility index of IVC can predict intraoperative hypotension during caesarean section under spinal anaesthesia.
Idiopathic pulmonary arterial hypertension and pregnancy How prepared are we?
Y Subhashini, S Tarakeswari, Jyothima P
Department of Anaesthesiology, Fernandez Hospital, Hyderabad, Telangana, India
Background: Pregnancy in women with pulmonary arterial hypertension (PAH) is known to have high maternal mortality (25-30%). Often, a patient with PAH decides to continue pregnancy despite medical recommendations. The estimated incidence is 1.1/100000 pregnancies.
Aim: We present our experience with idiopathic pulmonary arterial hypertension complicating pregnancy.
Materials and Methods: Retrospective observational study from 2000-2015 (March) at Fernandez Hospital, Hyderabad, India, a tertiary referral hospital with 8000 deliveries per year.
Results: We had 8 parturients with PAH. Median age was 23 years. Five women were diagnosed denovo to have PAH during antenatal period. Two patients had prepregnancy counseling. 50% of parturients were classified as NYHA functional class III-IV during pregnancy. 6 out of 8 patients (75%) had severe pulmonary hypertension. Six mothers received Graded epidural analgesia. An arterial line and a central venous catheter for the monitoring of right atrial pressure along with careful monitoring of arterial oxygen saturation and cardiac rhythm, in the peripartum period was followed in the maternal intensive care unit. Seven of the patients were on Sildenafil and 1 was on Tadalafil. Mean Gestational age at delivery was 34 weeks. Caesearean section rate was 100%. Six patients received antenatal thromboprophylaxis and all patients were put on postpartum thromboprophylaxsis. 50% of neonates were small for gestational age and the average birthweight was around 1.8 Kg. One patient required blood transfusion postoperatively. There was one maternal death in 2000 with severe therapy resistant circulatory collapse following postpartum hemorrhage within 5 hours of delivery.
Conclusion: Women must balance the best estimate of risk with the value they put on pregnancy. The decision to continue pregnancy should be supported by an empathetic group of health care professionals who would optimize the treatment, pregnancy outcomes and maternal survival.
Non-pharmacological ways to maintain hemodynamics under spinal anesthesia for cesarean section: Our experience
Subramanyam Kalavala Lakshminarayana
Department of Anaesthesiology, Government Medical College and Government General Hospital, Anantapur, Andhra Pradesh, India
Introduction/Background: Hypotension is the most common complication encountered under spinal anesthesia more so in cesarean deliveries. This is usually due to venous pooling in the lower half of the body and the additional factor-supine hypotension syndrome commonly seen in Obstetrics.
Aim: This study was aimed to assess the usage of non pharmacological maneuvers to restore blood pressure in cesarean sections.
Materials and Methods: This study included 505 patients of ASA grade I, undergoing elective cesarean section over a period of 8 months. Patients with anemia, PIH, multiple pregnancies were not included in the study. Non pharmocological ways-pushing the gravid uterus to left until delivery of baby and cohydration with 0.5 litre of ringer's lactate were employed. Vasopressor drug used in our study is inj. Mephenteramine in 3 mg bolus doses.
Results: In our study, 484 (96 %) patients responded to non pharmacological ways of treatment. About 21 (4%) patients required use of mephenteramine iv bolus of 3 mg aliquots. In majority of the patients our study, hypotension got corrected naturally when the pressure on the great vein is relieved by pushing the gravid uterus to left and coloading with crystalloids. Only 4 % of the patients required use of vasopressors. This once again exemplifies the notion - TREAT THE CAUSE - rather than unnecessary usage of vasopressor with its adverse effects on mother and fetus.
Discussion: Various non pharmacological ways to maintain hemodynamics under spinal anesthesia for cesarean section were discussed.
Management of post dural puncture headache in parturients: A comparative study of bilateral greater occipital nerve block and conventional treatment with paracetamol and caffeine
Sujata Ghosh, Dhurjoti Prosad Bhattacharjee
Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India
Background: The traditional management of post dural puncture headache (pdph) in parturients is not always successful especially in severe and resistant forms. Conventional medications and epidural blood patch are not without complications in parturients especially lactating mothers. Newer drugs like gabapentin and pregabalin are avoided in lactating mothers. Bilateral Greater Occipital nerve block can be performed in pdph following LSCS under spinal anaesthesia with encouraging results.
Aims: To compare the effectiveness of paracetamol with caffiene tablets and bilateral greater occipital nerve block in the management of post dural puncture headache in parturients undergoing LSCS under spinal anaesthesia.
Materials and Methods: 60 parturients aged 20-35, who developed pdph (grade III or above) following LSCS under spinal anaesthesia, were randomly divided into two groups of 30 each. Group GN (n = 30) received bilateral Greater Occipital Nerve Block and group CP received conventional treatment with tablets containing caffeine and paracetamol. Epidural Blood patch was offered if the headache did not subside 48 hours after treatment. Parameters studied were time of onset and relief of headache, analgesic consumption, time to discharge and side effects.
Results: The two groups GN and CP had comparable demographic data. The time of onset of pdph was also comparable. Patients in Group GN showed significantly lower numerical rating scores than Group CP (P < 0.05). A statistically significant number of parturients showed complete pain relief in group GN when compared to Group CP (P < 0.001). Analgesic consumption and side effects were lower in Group GN.
Conclusion : Bilateral Greater occipital nerve block is a promising alternative technique of management of pdph in parturients undergoing LSCS under spinal anaesthesia.
Anaesthetic management of complete heart block in pregnancy for caesarean section
Sunidhara P, Subrahmanyam M
Department of Anaesthesiology, Rainbow Hospitals, Hyderabad, Telangana, India
Background: Complete heart block is rare during pregnancy. Majority of cases remain asymptomatic and do not need any active intervention during peri-partum period. Rarely, it can have serious implications during delivery, more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra-operative period. We report successful anaesthetic management using sub-arachnoid blockade for LSCS in two parturients with complete heart block.
Case Reports: 2 cases are reported. Both parturients were primigravidas at 38 weeks of gestation with asymptomatic complete heart block. First one was diagnosed at 4 years of age as congenital complete heart block and second case was diagnosed in antenatal checkup. Both were asymptomatic, were evaluated by cardiologist with 12 lead ECG and 2D-echocardiography. ECG showed complete heart block with narrow QRS complex (heart rate 60/minute in case 1 and 46/minute in case 2) and echocardiography showed structurally normal heart in both cases. Chronotropic stress test with atropine showed no response but with isoprenaline at 2 micrograms/minute IV, increased heart rate to >80/minute in both cases. They were taken up for emergency LSCS for non-reassuring fetal status. Right IJV was cannulated for a potential emergency pacemaker insertion. Emergency LSCS done under spinal anaesthesia at L3-L4 level with 1.8 ml hyperbaric 0.5% bupivacaine and 0.5 ml fentanyl (25 micrograms).Table positioning was adjusted to achieve a T6 level block. Complete haemodynamic (including arterial line) monitoring was done in intra-operative and post-operative period. Heart rate was maintained with Isoprenaline infusion in case 2 and there was no hypotensive episode in either case.
Conclusion: Spinal anaesthesia can be safely administered without prophylactic trans-venous pacing in an uncomplicated case of complete heart block provided they are under continuous ECG monitoring with temporary pacing at standby. Joint consultation between obstetrician, anaesthesiologist, cardiologist and paediatrician resulted in optimal outcome.
Caesarean Section in patient with Hypertrophy cardiomyopathy done under epidural anaesthesia: Case report
Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
Introduction: Hypertrophy cardiomyopathy (HCM) is one of the most common genetic cardiovascular diseases. It can affect people of any age with equal incidence in men and women.  there is tremendous variation in how HCM presents and progresses. Some patients may develop abnormal heart rhythms (arrythmias) that may put them at increased risk for sudden cardiac death. Young patients coming for some other surgery may have incidental diagnosis of this condition and may pose considerable challenge for the Anaesthetists. We report here a case of young female for elective LSCS who had diagnosis of HCM during antenatal check up.
Case Report: A 28 years old women, primigravida presented at 37 weeks of gestation with a diagnosis of HCM, which was diagnosed in 1 st trimester during being investigated for murmur on auscultation. Throughout the gestation period patient was asymptomatic. Echocardiographic (ECHO) examination demonstrated HCM features with a peak outflow gradient of 36 mm of Hg, left atrial enlargement and mild mitral insufficiency. Normal vaginal delivery was planned but on 37 weeks liquor became inadequate at 36 weeks thus patient had to be taken for elective LSCS. Epidural anaesthesia was given and case was done successfully.
Discussion: Regional anesthesia is considered to be dangerous in these patients, especially in those with obstructive HCM, vasodilation associated with sympathetic blockade of the lower extremities may lead to a critical reduction of preload and afterload.  Nonetheless, epidural anesthesia alone or combined with spinal anesthesia has been used safely for vaginal delivery in patients with HCM. Our report indicates that cesarean section also may be managed safely with epidural anesthesia in patients with HCM, by using CVP monitoring and maintaining euvolemia or slight hypervolemia.
- Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation 1995;92:785-9.
- Oakley GD, McGarry K, Limb DG, Oakley CM. Management of pregnancy in patients with hypertrophic cardiomyopathy. Br Med J 1979;1:1749-50.
Simulation skills translated to high quality clinical anaesthesia "An Experience"
Varsha Vyas, Surekha Patil, Amit Nagpal, Ravitej
Department of Anaesthesiology, Dr. DY Patil Medical College, Navi Mumbai, Maharashtra, India
Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful management of a patient undergoing cesarean section under general anaesthesia. We conducted an obstetric anaesthesia workshop where in we created a similar scenario. Learning objectives were proper assessment of the patient, planning the anaesthesia, aspiration prophylaxis, proper pre-oxygenation, airway assessment and management strategy, cricoid pressure, adequate analgesia following baby delivery and administration of uterotonics and vasopressors along with fluid resuscitation. Neonatal resuscitation was also enacted during the workshop. In a clinical setting we needed to deliver general anaesthesia for a case of cesarean section with a history of chicken pox 1 week before the surgery. The rashes on patients back and recent history of disease were contra-indications for regional anaesthesia techniques. The resident was able to implement all the protocols, resuscitation measures and proper management. Upon debriefing, it was determined that the previous training influenced proper planning and management of the present case. Successful implementation of high quality patient safety methods and delivering high quality anaesthesia was achieved by simulation training.
A comparative study of effects of sitting and lateral positions on quality of block during induction of spinal anaesthesia in patients undergoing caesarean section
Varun Chander Gutti
Department of Anaesthesiology, Deccan College of Medical Sciences, Hyderabad, Telangana, India
Background: It has been a long known debate as to which position is better for a spinal anesthesia. Off late many anesthetists have preferred using sitting posture of giving a spinal anesthesia. This study aims at establishing the facts and a review the basics related to giving a spinal anesthesia.
Aim of the Study: To assess effect of posture on quality of spinal block in patients undergoing caesarean section - To compare sitting and lateral positions during spinal anesthesia.
Material and Methods: A total of 40 parturient were enrolled for the study. They were divided into 2 groups of 20 parturient each (cases and controls). Group 1 received 2.2cc of hyperbaric bupivacaine in sitting posture and Group 2 received 2.2cc of hyperbaric bupivacaine in lateral posture.
Characteristics assessed: Height of block assessed by loss of pin prick at 1min, 5 min and 45 min Pulse and systolic blood pressure recorded at 0, 1, 3, 5, 10,15, 20, 25, 30,35 min Quality of sensory block and motor block assessed by grading as excellent, good, acceptable, poor.
- Hemodynamic stability is the same in both groups.
- Quality of analgesia and muscle relaxation are same in both groups.
- It is technically easier to insert spinal needle in sitting position.
- Other than this, sitting position does not offer any other advantage.
A randomized trial to compare the effects of spinal versus general anaesthesia on fetal acid base status during emergency cesarean delivery in acute fetal compromise
Vivekanathan P, Kajal Jain, Jeetinder Kaur, Makkar, Shalini Gainder, Venkaeshan S
Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
Background: Spinal anaesthesia is the most preferred technique for the conduct of cesarean delivery because of its ease of administration safety and efficacy, its superiority was questioned with respect to fetal acid base status. The data comparing different modes of anaesthesia and neonatal outcome in cases of emergent cesarean deliveries is deficient.
Aim: To compare the effects of spinal and general anaesthesia on fetal acid base status in women requiring emergency cesarean delivery indicated for acute fetal compromise.
Materials and Methods: Randomized Prospective Trial in a Tertiary Care Hospital involving 94 healthy term parturients for emergency CD (Category II). Enrolled participants received either spinal or general anaesthesia. Systolic blood pressure was targeted between 90-110% of baseline and phenylephrine boluses were used to treat hypotension in both groups. Cord gases were analyzed immediately following birth of baby. Incidence of fetal acidosis defined as UA ph <7.2 and/ or base deficit >12 mmol/l is taken as main outcome measure.
Results: Acidosis was observed in 9 newborns in general anaesthesia group and in 11 newborns in spinal anaesthesia group. Cord base deficit ≥12 mmol was comparable in both the groups. Seven babies of these 19, had associated low 1-minute Apgar score. Immediate neonatal resuscitation was required in n = 5 /7 babies using bag mask ventilation with oxygen supplementation. Maternal hemodynamics were acceptable in the two groups. There was no maternal/neonatal morbidity or mortality in the 24 hour follow up period.
Conclusions: In conclusion, the current study showed that there was no difference in the incidence of fetal acidosis despite small differences between groups in umbilical artery PaO2. The neonatal outcome was favorable in both the groups. Nevertheless, spinal anaesthesia using prophylactic phenylephrine may be the technique of choice considering its simplicity, efficacy and safety
Peri-mortem cesarean section following maternal cardiac arrest leading to favorable outcome: A case report
SI Zubair * , Manokanth Madapu ± , Sunil T Pandya #
* Fellow in obstetric anaesthesia, ± Consultant in anaesthesia, # Head dept of pain and critical care,
#*± Prerna anaesthesia and critical care services, *± Fernandez Hospital, Hyderabad, Telangana, India
Background: Cardiac arrest in pregnancy is a rare event in which the speed of the response and attention to a number of pregnancy-specific interventions is crucial to the outcome. The commencement of a perimortem Caesarean delivery (PMCS) within 4 min of the onset of the arrest has been recommended as a technique to potentially improve survival in both the mother and the fetus. We report a case where the patient presented in hypoxia and PEA (pulseless electrical activity) arrest to the emergengy room. Prompt initiation of ACLS (advances cardiac life support) with PMCS in emergency room saved both mother and the fetus.
Case Report: We report and discuss the case of a 22 yr old pregnant patient with 35 + 6 wks of gestation presenting with un-recordable pulse and blood pressure, tachypnea with saturation of 77% in the emergency room. Patient was deemed to be in PEA arrest with severe hypoxemia and florid pulmonary oedema. Immediate chest compressions were initiated and additional help including neonatologists and obstetricians were called in. Patient underwent a perimortem cesarean delivery and simultaneous fetal and maternal resuscitation in the emergency room. She had a prompt return of spontaneous circulation (RoSC) after delivery of the fetus. She was shifted to the operation theater for closure and later to the ICU for further management. She was extubated on second post- op day. A thorough history for her family members revealed a child hood cardiac condition. Cardiac assessment and 2 D ECHO were in pointing towards a non-compaction cardiomyopathy as the cause of arrest in our patient. She was discharged with a healthy neonate on ninth post op day.
Discussion: When a pregnant patient who suffers a cardiac arrest, it is important to act quickly and decisively while also keeping in mind the unique priorities of this rare situation. In this case report we discuss about various aspects that need attention, like modifications in ACLS, timing of initiation of PMCS, causes of cardiac arrest in pregnant patient and need for multidisciplinary training with regular practice drills for positive outcomes. We will also present experience and outcomes at our institution in managing cardiac arrest in pregnancy.