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ABSTRACT
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 115-120

Selected abstracts of free papers presented during 10th national conference of association of obstetric anaesthesiologists held in Bengaluru on October 1st and 2nd 2017


Date of Web Publication7-Nov-2017

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DOI: 10.4103/2249-4472.217780

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How to cite this article:
. Selected abstracts of free papers presented during 10th national conference of association of obstetric anaesthesiologists held in Bengaluru on October 1st and 2nd 2017. J Obstet Anaesth Crit Care 2017;7:115-20

How to cite this URL:
. Selected abstracts of free papers presented during 10th national conference of association of obstetric anaesthesiologists held in Bengaluru on October 1st and 2nd 2017. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 12];7:115-20. Available from: http://www.joacc.com/text.asp?2017/7/2/115/217780

1. Comparison of Ropivacaine (0.15%) with or without Clonidine 1 μg/kg for Epidural Labour Analgesia: A Randomised Controlled Study

Megha Gupta, Indira Kumari, Vikram Bedi, Dr. Kapil Sharma

Department of Anaesthesiology, R.N.T. Medical College, Udaipur

E mail: dr_ikumari@hotmail.com

Background and Aims: To determine the effect of addition of clonidine to ropivacaine for epidural labour analgesia with regard to onset of analgesia, duration of analgesia, neonatal outcome and quality of analgesia. Materials and Methods: Sixty term parturients of ASA grade I and II with uncomplicated pregnancy, with vertex presentation, posted for on demand epidural labour analgesia after informed consent were divided in two groups. Group R (n = 30) patients received 10 ml solution consisting of 0.15% ropivacaine. Group RC (n = 30) patients received a total of 10 ml of 0.15% ropivacaine and clonidine 1 μg/kg. Characteristics of the block, onset and duration of analgesia and total analgesic requirements were noted. Pain and overall satisfaction scores were assessed with a 10-point visual scale. Mode of delivery and neonatal APGAR scores were recorded. Results: Maternal demographic characteristics were comparable between the groups. Addition of clonidine to ropivacaine shortened the onset and prolonged the duration of analgesia with decrease in ropivacaine requirement in group RC. Although, there was a significant difference between both the groups regarding VAS score and quality of analgesia, which were better in group RC. There were no significant differences between both the groups regarding motor block, hemodynamic parameters and neonatal outcomes. Conclusion: We conclude that clonidine in low doses is a useful adjuvant to local anaesthetics for epidural labour analgesia and a good alternative to opioids.

2. Comparison of Intravenous Diclofenac with Intravenous Diclofenac-Paracetamol Combination for Pain Relief after Caesarean Section

Aditi Jain, Kajal Jain, Kamlesh Kumari, Jeetinder Kaur Makkar, Shalini Gainder, Pooja Sikka

E mail: kajalteji@gmail.com

Institution: Department of Anaesthesiology, Post Graduate Institute of Medical Education & Research, Chandigarh

Introduction: Postoperative pain following cesarean section can be distressing for the mother. Diclofenac-paracetamol combination has been studied in acute pain and various operative settings, with very few studies evaluating its role in decreasing post-cesarean section pain. Objectives: To compare the analgesic efficacy of intravenous diclofenac–paracetamol combination with intravenous diclofenac in women undergoing lower segment caesarean section under spinal anesthesia. The primary outcome measure of our study was 24 hour rescue analgesic consumption. Materials and Methods: This prospective, randomized, double blind study was carried out in 120 ASA I/II primigravidae in the age group of 18–35 years. At the end of surgery, patients in the diclofenac group (group D) received i/v diclofenac 75 mg and 100 ml of i/v isotonic saline over 15–20 minutes; whereas patients in the diclofenac-paracetamol group (group DP) received i/v diclofenac 75 mg and 100 ml of i/v paracetamol 1 gram over 15–20 minutes. Postoperatively, patients received the drug combinations at 6 hourly intervals. Pain ratings were measured by 0–10 numeric rating scale at 0, 1, 2, 4, 8, 12 and 24 postoperative hours. Rescue analgesic was given if patient's NRS scores were >4. Results: 24-hour rescue analgesic consumption was significantly greater in group D as compared to the group DP (100 mg vs 50 mg, P-value = 0.000) with higher percentage of patients describing the quality of their pain relief as excellent in the DP group (19.6% vs 5.4%, P-value = 0.022). Conclusion: Intravenous diclofenac–paracetamol combination is more efficacious as compared to intravenous diclofenac in decreasing post-cesarean section pain.

3. Haemodynamic Changes following 5 IU of Oxytocin as Bolus versus 5 IU of Oxytocin as Infusion during Caesarian Section

Lavanya N Mandhal, Jeff Varghese, S. Padmanabha Bhat

Department of Anaesthesiology Yenepoya Medical College, Mangalore, Karnataka, India

Objective: To compare the haemodynamic changes following administration of equivalent doses of oxytocin as intravenous bolus versus intravenous infusion in patients undergoing caesarean section. Materials and Methods: A prospective, randomized, comparative study was conducted in one-twenty parturients (aged 25–35 years) undergoing elective caesarean delivery under spinal anaesthesia. They were randomly allocated into two groups to receive 5 IU of oxytocin after delivery of the baby. Group B (n = 60) received 5 IU of oxytocin as intravenous bolus injection. Group I (n = 60) received 5 IU of oxytocin as intravenous infusion in 100 ml of normal saline over 20 minutes. Intra-operative heart rate, systolic, diastolic and mean arterial blood pressure changes were recorded. These data were compared between the two groups. Results: There was significant increase in heart rate in the bolus group compared to infusion group. No significant changes in blood pressures were noted in both groups. Conclusion: Bolus oxytocin (at a dose of 5 IU) compared to infusion of oxytocin (at a dose of 5 IU over 20 minutes) has significantly more adverse cardiovascular events. Oxytocin as IV infusion dose is haemodynamically more stable than IV bolus dose.

4. Comparing the Effects of Diclofenac, Tramadol and Paracetamol Suppositories in Managing the Post-Operative Pain in Emergency LSCS Deliveries – A Clinical Trial

Y. R. Nikhil Chakravarthy, Gayatri Bhat. Ananda Bangera

Name of Department of Anaesthesiology K S Hegde Medical Academy

E mail: anandabangera@ gmail.com

Background: Pain has always been a major concern of mankind. Post-caesarean section pain complicates the postoperative recovery by impending the bonding between mother and newborn as well as ability to nurse. Usually strong opioids are used to combat this. NSAIDs causes reduction in opioid induced nausea, vomiting and respiratory depression are equally beneficial. Paracetamol also has beneficial effects on pain. We have compared most commonly used drugs, with easiest route of administration in the form of rectal suppositories. Aim of the study: Compare the analgesic effects of suppositories of Tramadol, paracetamol and diclofenac, regarding the duration of action, complications and side effects in emergency-LSCS patients in the post operative period. Materials and Methods: In this study 90 parturients aged between 18 to 45 years and were randomly selected under 3 groups after obtaining written informed consent and institutional ethical clearance. The 3 groups include Diclofenac suppository 100mg (Group A, n = 30), Tramadol suppository 100mg (Group B, n = 30) and Paracetamol suppository 500 mg (Group C, n = 30). Drugs were administered twice daily after surgery for 24 h. The visual analogue scale (VAS) at rest and with movements, duration of postoperative analgesia is evaluated every 2 h for over 24 h.

Results: Patient demographic characteristics are statistically significant between Group A (P = 0.000) and other two (B and C) groups but statistically insignificant between Group B (P = 0.060) and Group C (P = 0.068). Duration of analgesia is more with Group A (218.5 min) when compared with to Group B (116.5 min) and Group C (110 min). VAS score of 4 attained in to 23.3% in Group A compared to Group B 59.2% and Group A 63.3%. Incidence of the side effects like nausea, vomiting, and prurities are more with Group B. Conclusion: Diclofenac suppository through rectal route devoid of adverse side effects provides prolonged duration and quality of analgesia with fewer incidences of side effects compared to Tramadol and Paracetamol suppositories in the management of pain after emergency caesarean section.

5. A Comparative Study between 25 Gauge Quincke's and Whitacre Spinal Needle for Spinal Anaesthesia in Obstetric Patients

Shilpa G K Bhat, Co-author: Mukesh Mukundan

Department of Anaesthesiology Yenepoya Medical, College, Mangalore.

E mail: mukeshmukundan@gmail.com

Objective: To determine the success rate of lumbar puncture and ease of insertion between 25G Quincke's and Whitacre needle. Materials and Methods: Hundred obstetric patients (ASA I and II) aged between 20 to 30 years who required LSCS under spinal anaesthesia were selected, they were randomized to two groups: group “Q” using Quincke's needle and group “W” using Whitacre needle. The procedure of spinal anaesthesia was standardized including the drug and dosage. The ease of insertion, number of attempts taken to perform the lumbar puncture and the development of post-spinal headache were analysed among the two groups. Results: Preoperative characteristics of the patients were similar in both groups. In the group Q (Quincke's needle) 60% of patients achieved subarachnoid block in first attempt when compared to 50% of patients in group W (Whitacre needle). 96% of patients had a successful subarachnoid block in group Q compared to 92% of patients in group W. In group Q 6% (3 patients) developed postdural puncture headache (PDPH) when compared to group W where 2%(1 patient) developed PDPH. Conclusion: In our study, the ease of insertion was found to be better with 25G Quicke's needle when compared with 25G Whitacre needle. The success rate of lumbar puncture with Quincke's needle was better when compared to the pencil point needle while the incidence of PDPH was less in the Whitacre group

6. Effect of Saline Dilution for Postpartum Tubal Ligation

Reena R Kadni, Sujata Jesudassan

Department of Anaesthesiology, Bangalore Baptist Hospital

Postpartum tubal ligation is a common mode of birth control following vaginal or caesarean delivery. It reduces the hospital stay and cost. Aim: To study the efficacy of intrathecal fixed low dose bupivacaine and the effect of saline solution among PPTL for safe and adequate anaesthesia. Objectives: To compare the time of onset of T4 level sensory block, degree of motor block, hemodynamic stability, time of motor regression, micturition time and complications. Materials and Methods: Prospective randomized comparative trial on 90 postpartum patients at BBH under subarachnoid block. Group A: 1.5 ml of 0.5% hyperbaric bupivacaine. Group B: 1.5 ml H bupivacaine 0.5% + 1.5 ml NS. Group C: 1.5 ml H bupivacaine 0.5% + 4.5 ml. Statistical methods used were chi-square test, Fisher exact test and analysis of variance. Results: There was no significant difference in terms of patient demographic profiles, time to achieve T4 sensory block, degree of motor blockade, hemodynamics and motor regression time and time of micturition. But time to onset of motor blockade was significantly delayed in Group C. Requirement of supplementary analgesia was not significant in all groups. Conclusion: The study shows the feasibility of using low dose of 7.5 mg bupivacaine intrathecally for safe PPTL. The dose of drug is more important than volume or baricity for spread of SAB. Pregnancy induced changes persist into postpartum period for the effectiveness of low dose spinal anaesthesia.

7. Role of Intra-Abdominal Pressure in Predicting Kidney Injury in Critically Ill Obstetrical Patients

Gaurav Verma, Asha Tyagi, Shubham Lahan, A. K. Sethi

E mail: drashatyagi@gmail.com

Institution: Department of Anaesthesiology, University College of Medical Sciences & GTB hospital, Dilshad Garden Delhi

Introduction: Increase in IAP may cause renal dysfunction and Acute Kidney Injury (AKI). Besides serum creatinine and urine output, biomarkers such as urinary Neutrophil Gelatinase Associated Lipocalin (NGAL) reliably predict onset of (AKI). Obstetric patients in ICU may have presence of several risk factors for increased IAP. However, there are no studies in these patients evaluating IAP or its consequences on renal function. This prospective cohort aimed to evaluate IAP and its role in causing AKI in critically ill obstetric patients, and utility of urinary NGAL to predict AKI in these settings. Materials and Methods: We analyzed results for 48 obstetric patients admitted to our ICU for causes related directly or indirectly to pregnancy. Those with anticipated duration of stay of <24 hours, hematuria, without a Foley bladder catheter were excluded. Daily IAP was measured using previously recommended method employing indwelling Foley catheter. Hourly urine output and serum creatinine was recorded for first 2 days of ICU admission to diagnose early AKI as per KDIGO guidelines criteria. Urine was collected upon ICU admission, centrifuged and frozen at 80°C till assayed for NGAL using a commercially available ELISA kit. Results: Commonest cause of ICU admission was preeclampsia/eclampsia. Increase in IAP to ≥12 mmHg denoting intra-abdominal hypertension (IAH) was seen in 37.5% patients; and AKI in 53%. An ROC analysis was done for relationship between IAP and AKI; As well as urinary NGAL and AKI. The Area under Curve (AUC) for both was 0.504 and 0.725, respectively. The cut-off values for IAP was 8.75 having 52.9% sensitivity and 60% specificity; and for NGAL 72 ng/ml level having 71% sensitivity and 80% specificity. Conclusion: IAH and AKI are common in critically ill obstetric patients. An increase in IAP alone was not a good predictor for AKI; while urinary NGAL may be useful to predict the onset of AKI.

8. Conversion of Labour Epidural Analgesia to Anaesthesia for Emergency Cesarean Section: Problems and Solutions – A Retrospective Audit of 9070 Cases

Jyotsna M, Manokanth M, Shanti Y, Sailaja K, Aparna, Sunil T Pandya

Century Hospital, Hyderabad

E-mail: suniltp05@gmail.com

Objective: Aim of this retrospective audit is to review the anaesthesia outcomes, for emergency CS in patients who are on epidural for labour analgesia. We analysed the various problems encountered and came out with algorithmic approach to circumvent them. Materials and Methods: Retrospective audit from Hospital medical record after obtaining ethics committee clearance, of 5 yrs duration (2012–2016). 9070 parturients received epidurals for pain relief during the study period. Adequate block was defined as Modified Bromage score of “1” and Height of block assessment by deep firm pressure by using needle cap (Our standard protocol), level of D5 and above after the standard epidural top-up for CS. Failure was defined as dermatomal level below D6, having pain during surgical dissection, needing supplemental sedation, conversion of technique to either spinal or General anaesthesia. Results: Number of parturients requiring CS: 2529 of 9070 (27.7%), successful epidural for cesarean section: 2401 (94.9%), failed epidural: 128 (5.08%). Mild discomfort requiring low dose Propofol/IV Fentanyl: 54 (42.18%,), catheter falling out – SAB: 43 (33.59%), inadequate block – Spinal: 13 (10.15%), Inadequate block – GETA: 7 (5.4%), STAT cesarean section, (working epidural) – GETA: 6 (4.68%), inadequate block – CSEA: 3 (2.34%,), repeat Spinal: Nil, repeat spinal – requiring GETA: 2 (1.5%), high spinals requiring airway support: Nil. Conclusion: Clear algorithmic approach (will be presented) is of paramount importance to minimize unplanned repeat regional techniques or unplanned intubations. Good communication skills with the LW staff is essential to avoid GETA in parturients with working epidurals.

9. Comparative Study between Levobupivacaine versus Levobupivacaine with Dexmedetomidine for Transversus Abdominis Plane Block with Regard to Post-Operative Analgesic Requirement after Lower Segment Caesarean Delivery: A Randomised, Double Blind, Control Study

Aman Varshney, Manjunath Prabhu

Kasturba Medical College, Manipal

E mail: manjaparkala@ gmail.com

Objective: Difference between duration of action on post-operative analgesia with levobupivacaine versus levobupivacaine with dexmedetomidine for TAP block in comparison with control. Materials and Methods: 90 pregnant females (ASA2) undergoing lower segment caesarean delivery under spinal anesthesia, were randomly assigned into 3 groups. After surgery, one group received ultrasound guided bilateral TAP block with 20 ml 0.25% levobupivacaine, group L while second group received same volume of levobupivacaine plus 1 μg/kg body weight dexmedetomidine, group LD while third control group, group C received only spinal anesthesia. Postoperatively, patients received first rescue analgesia on demand with IV Paracetamol 1 g, recorded as time for first rescue analgesia. Visual analogue scale used for postoperative pain scores on movement and at rest. Satisfaction score, level of sedation and side effects also recorded. Results: Time for first rescue analgesia and satisfaction score was significantly more in LD and L groups as compared to C group and was more in LD group as compared to L group. Patients in LD and L groups had significant lower pain score as compared to C group and lower pain score in LD group as compared to L group. Side effects were less in LD group but comparable in both L and C groups. Conclusion: TAP block with 0.25 % levobupivacaine plus dexmedetomidine decreases postoperative analgesic requirement and pain scores in pregnant females undergoing lower segment caesarean delivery under spinal anesthesia with fewer side effects.

10. Combined Spinal-Epidural Anesthesia for LSCS In Severe Peri-Partum Cardiomyopathy – A Case Report

Subramanyam MS, Garima Sharma, Medha Huilgol, Kumar MV

Department of Anaesthesiology, Columbia Asia Referral Hospital, Bangalore, India

E-mail: docsubra@gmail.com

Peripartum cardiomyopathy (PPCM) is a rare but potentially fatal form of heart failure which affects parturient during late pregnancy or after delivery.[1],[2] 21-year-old Indian woman, G1P0 with PIH for 1 month. She presented at 36 weeks with 3-day history of worsening cough, breathlessness and orthopnea with BP - 160/90 mmHg, HR - 98/min, RR - 30/min, SpO2- 88–90% and bilateral crepitations. 2D Echo showed EF 20–25%, severe LV-systolic dysfunction with global hypokinesia. Severe PPCM was diagnosed and stabilized with infusions of dobutamine, labetalol, furosemide, MgSO4 and intermittent NIV in ICU. An urgent LSCS planned. Monitoring including IBP, CVP instituted pre-op and a Combined Spinal-Epidural Anaesthesia (CSEA) was performed with Espocan® CSE needle. Bupivacaine 6.25 mg and fentanyl 25 mcg was given in spinal. Epidural supplementation done with 3 ml of 2% lignocaine with 1-in-200000 adrenaline to augment the level up-to T6. Patient remained stable intra-operatively. Oxytocin was given as infusion to maintain hemodynamics. A 1.8 kg live baby was delivered with APGAR score (4 and 6), which needed respiratory support for 5 days. Epidural analgesia for 2 days and care in the ICU before shifting to ward after 4 days. Repeat echo 5 days later showed EF-60% with normal LV systolic function and Grade 2 LVDD. The delivery was expedited due to severe cardiomyopathy. Combined spinal-epidural anesthesia was safely administered in our patient. Neuraxial anesthesia appears ideally suited for these patients because it results in a beneficial decrease in both preload and afterload. CSE with titrated doses of LA, judicious fluids and inotropic support is a safe choice in PPCM.

References

  1. Ramachandran R, Rewari V, Trikha A. Anaesthetic management of patients with peripartum cardiomyopathy. J Obstet Anaesth Crit Care 2011;1.
  2. Pyatt JR, Dubey G. Peripartum cardiomyopathy: Current understanding, comprehensive management review and new developments. Postgrad Med J 2011;87:34-9.


11. Perioperative Management of Caesarean Section in Patient with Severe Uncorrected Coarctation of Aorta

Nitika Goel, Banashree Mandal, Indu Mohini Sen, Vardhan Prassanna

Department of Anaesthesiology, Post Graduate Institute of Medical Education & Research, Chandigarh

E-mail: nitikagoel7@gmail.com

Coarctation of the aorta occurs in 1 per 12,000 live-born babies, with a male to female ratio of 3:1.[1] Perioperative management of parturients with congenital heart disease is a challenge for the anesthesiologist. We report a 35 weeks primigravida with uncorrected severe coarctation of aorta posted for elective caesarean delivery. Her blood pressure remained persistently elevated on tablet amlodipine 2.5 mg twice a day and tablet labetalol 200 md thrice a day. Due to risk of impending eclampsia she was planned for caesarean section at 32 weeks of period of gestation. Baseline blood pressure was 250/130 mmHg in right upper limb and 150/110 mmHg in left lower limb. Nitroglycerin infusion was started at 0.5 μg/kg/min and 8 ml of 2% lignocaine infiltrate was given at incision site. Injection xylocard 60 mg and labetolol 40 mg IV were also given 90 seconds before endotracheal intubation. Modified Rapid sequence intubation done with Injection thiopentone 250 mg and succynylcholine 100 mg IV. After delivery she was administered a slow injection of dilute oxytocin 5 units, followed by an oxytocin infusion at 10 units/hour for 4 hour. At the end of surgery she was extubated and shifted to ICU. From ICU she was discharged on fifth day post surgery. Anesthetic goals are to maintain higher arterial blood pressure (ABP) proximal to coarctation, to keep ABP distal to coarctation above 60 mmHg. Presence of left ventricular hypertrophy, ischemic heart disease, and intracranial aneurysm demand for modification in the management.[2]

References

  1. Warrell D, Cox T M, Firth J, Benz D, Edward J. Oxford Textbook of Medicine. Oxford University Press; 2004.
  2. Zwiers WJ, Blodgett TM, Vallejo MC, Finegold H. Successful vaginal delivery for a parturient with complete aortic coarctation. J Clin Anesth 2006;18:300-3.


12. Idiopathic Thrombocytopenic Purpura and Pregnancy – The Purple Problem!

Shirley Joseph, Manjuladevi. M, Latha John, Shilpa Joshi

Department of Anaesthesiology, St John's Medical College & Hospital, Bengaluru

E mail: drmanjula95@yahoo.com

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder associated with the production of autoantibodies against platelet membrane glycoproteins, mainly GPIIb/IIIa and GPIb/IX, and removal of these IgG coated platelets by the reticuloendothelial system.[1] The incidence of ITP has been 1–2 cases/1000 deliveries.[2],[3] We describe a retrospective case series of 7 pregnant women with ITP who underwent caesarian section in our tertiary multispecialty center. Among them, four women (71.4%) had grade 3 thrombocytopenia (platelets <50000 cells/cu.mm.) and were managed with general anaesthesia. One patient (14.3%) who had grade 1 thrombocytopenia with platelets of 90000 cells/cu.mm. was also administered general anaesthesia owing to the declining trend of the platelet count. Two women (28.6%) who had platelets >1 lakh cells/cu.mm. were given spinal anaesthesia. Five women (71.4%) received platelet transfusion during the perioperative period due to acute bleeding. The co-existing issues of anemia and coagulopathy, steroid based complications (diabetes, obesity, osteoporosis, hypertension, immunosuppression) were managed accordingly. Those who received general anaesthesia were extubated successfully at the end of surgery. All patients had an uneventful perioperative course. Pregnancy increases risk of relapse in women with chronic ITP or worsens thrombocytopenia in women with active disease. A multi-disciplinary approach is required to anticipate and manage the complications for safe confinement.

References

  1. Sharma SK, Mhyre JM. Hematologic and Coagulation Disorders in Chestnut's obstetric anesthesia: Principles and Practice, 5th edition, David H. Chestnut et al. ed. Elsevier Saunders Philadelphia 2014. p. 1043.
  2. Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg 2009;109:648-60.
  3. Özbilgin Ş, Balkan BK, Şaşmaz B. Anaesthesia for Caesarean Section of Pregnant Women with Idiopathic Thrombocytopenic Purpura. Turk J Anaesthesiol Reanim 2013;41:175-7.


13. Perioperative Management of Acute Fatty Liver of Pregnancy with Coagulopathy and Hepatic Dysfunction

Priyadarshini Nagaraj, Subramanyam Mahankali, Garima Sharma

Department of Anaesthesiology, Columbia Asia Referral Hospital, Yeshwantpur Bangalore, India

E-mail: docsubra@gmail.com

Acute Fatty Liver of Pregnancy (AFLP) is a rare and life threatening condition of unspecific pathogenesis exclusively seen during late pregnancy and associated with poor outcome. A 29 year old primigravida, 37 weeks pregnancy was transferred from another hospital, with a 10 day history of low grade fever, anorexia and vomiting. On examination she was drowsy but oriented. Vitals were stable with good urine output Investigations revealed: Bilirubin:12.98 (Direct - 8.25) SGOT/PT - 51/32, Alkaline Phosphatase - 145, deranged coagulation (PT/INR-24.8/2.1), fibrinogen - 0.9685, Platetlets - 73000, Hyperammonemia - 70.9, creatinine - 1.68 and hypoglycaemic episodes. Diagnosis of AFLP was arrived as patient scored >6 on the Swansea Criteria. Other causes like – sepsis with DIC, HELLP, preeclampsia, viral hepatitis were excluded on clinical and laboratory investigations. An urgent LSCS was planned. Pre-op optimisation was done with injection vitamin K 10 mg, cryoprecipitate and platelet transfusion (7 + 7 units and 1 SDP) and DNS infusion. General anaesthesia was given with rapid sequence induction. Monitoring included oxygen saturation, ECG, invasive blood pressure, ETCO2 and neuromuscular monitoring with TOF. Healthy male baby was delivered. Oxytocin infusion-10 IU/hour was started post delivery. USG guided bilateral TAP block was given with 20 + 20 ml of 0.25% bupivacaine. Postoperative analgesia was provided with paracetamol 2.4 g/24 hours, tramadol 25 mg TID. Patient was extubated and shifted to SICU. By POD4 investigations returned to normal. Patients with new onset jaundice in the last trimester of pregnancy should be assessed using Swansea criteria to diagnose AFLP. Rapid optimisation and expediting the delivery helps saving both mother and baby. Anaesthetic technique should be chosen which maintains haemodynamic stability and hepatoprotecive. AFLP has a rapid onset with unpredictable progression. In our case a good maternal and fetal outcome was achieved due to early diagnosis, rapid correction of coagulation, safe anaesthesia and immediate delivery.

14. Anaesthesia Management of Patient with Transverse Myelitis for LSCS

Vinay Kukreja, Ram Mohan Gurram, P. Gayathri

Department of Anaesthesia, Yashoda Hospital Alexander Road, Secunderabad, Telangana 500003

A 23 years old Primigravida at 36 weeks of pregnancy was referred from a district hospital with a 10 day history of numbness/weakness in both her upper (2/5 power) and lower extremities (3/5 power) with retained sensations. MRI scan showed demyelination at C2-C3 levels. Caesarean section was planned under general anaesthesia. A pre-operative ultrasound was done to assess diaphragmatic function and was found to be normal. Standard monitoring was applied and a rapid sequence induction with propofol and rocuronium was used to secure the airway. A train of four neuromuscular function monitor was used to optimise muscle relation and to aid in reversal and extubation. The newborn APGAR score was 9/10 at 1 and 5 min. The patient was monitored in the surgical ICU and the post-operative course was uncomplicated with no further deterioration of neurological symptoms. Transverse myelitis is a rare neuro-inflammatory condition affecting spinal cord at various levels and is associated with autonomic dysfunction. Succinylcholine use has been reported to cause hyperkalemia. Regional anaesthesia is relatively controversial and worsening of neurological function has been reported. Regardless of the technique, general or regional anaesthesia, the risks and benefits should be discussed openly with patient and the relatives. There maybe a role for the use of ultrasound to assess diaphragmatic contractility especially when TM involves the cervical spinal cord.

15. Management of Ovarian Hyperstimulation Syndrome in Obstetric Critical Care

Keerthi S Rao, M Subramanyam, Nitin M

Department Of anaesthesia Rainbow Hospitals for Women Children, Hyderabad, Telangana

E-mail: msubrah@gmail.com

Ovulation induction is a common practice in assisted reproductive technology (ART). Ovarian hyperstimulation syndrome (OHSS) is a serious complication and in severe form can present with massive ovarian enlargement with multiple cysts, hemoconcentration induced thrombosis, prerenal AKI, 3rd space accumulation of fluid in the form of ascites, pleural, and pericardial effusion. 29 yr old with 5 weeks of gestation post IVF and embryo transfer presented with abdominal pain, distension, nausea and vomiting. She was tachycardic, tachypnoeic, hypovolemic with tense abdomen. Investigations showed haemoconcentration, hypoalbuminemia, raised blood urea and creatinine. Ultrasound showed enlarged right ovary with multiple follicles, gross ascitis, mild pleural effusion and ileus thus a diagnosis of OHSS was made and she was admitted to the obstetric ICU. Vitals, abdominal girth, input/output were strictly monitored. I.v pantoprazole, ondensetron, ranitidine, laxatives, s.c enoxaparin, iv fluids to correct fluid and electrolyte status were started. Repeated USG guided paracentesis were done over 5 days to relieve ascitis. She received continuous incentive spirometry, multiple albumin transfusions and a high protein diet. Fluid and electrolyte status gradually improved and patient was discharged when she tolerated soft oral diet, vitals were stable and abdominal distension reduced. She was continued on thromboprophylaxis for 2 weeks, followed up regularly and had an uneventful pregnancy and delivery further. OHSS is a rare but potentially life threatening complication in patients undergoing ART and poses unique challenges in the Obstetric critical care unit.

16. Role of Vasopressors in Maternal Hypotension: Case Report

Anudeep Jafra, Kajal Jain, Karan Singla

Department of Anaesthesiology, Post Graduate Institute of Medical Education & Research, (PGIMER), Chandigarh

E-mail: kajalteji@gmail.com

A number of techniques have been utilized to maintain maternal hemodynamics during cesarean section. Phenylephrine emerged as a vasopressor of choice in the last decade. But phenylephrine has been shown to cause reflex decrease in maternal heart rate and cardiac output. We present two cases of cesarean section in women with cardiac disease wherein norepinephrine was used as a vasopressor during the perioperative period along with cardiac output monitoring. We observed that there was lower incidence of bradycardia and small decrease in cardiac output. Heart rate was used as a marker for cardiac output and also as a guide to adjust the dose of vasopressors. Norepinephrine has a weak β adrenergic receptor agonist activity along with potent α adrenergic receptor activity and maintains the hemodynamics (blood pressure) without much effect on heart rate and cardiac output. Transient decrease in maternal heart rate and cardiac output in healthy women receiving phenylephrine are clearly accommodated without detrimental effects. But the impact of these hemodynamic effects in women with already compromised cardiac status is not known. Hence, future research is needed to evaluate the role of norepinephrine in maternal hemodynamics.

17. Dual CPR: The parturient and Neonate: A Challenge Won!

Arya James, Kolli S Chalam, Geetanjali T, Pankaj Punetha, Kruthika

Departments of Anaesthesia and Pediatrics, Fernandez Hospital Hyderabad, Telangana

Email: chalam.k@sssihms.org.in

Cardiopulmonary resuscitation of parturients and neonates is each considered a challenge to emergency responders, given the wide variety of physiological changes (and low physiological reserves) they present with. At our hospital, we recently faced a situation in the immediate postpartum period of a full term vaginal delivery, where both the mother and the newborn required CPR simultaneously. The mother was found suddenly unresponsive during the delivery of the foetal head, with absent carotid pulsations. The neonate had two loops of cord around his neck, and was apneic at delivery. Code Blue first responders began maternal chest compressions and neonatal bag-mask ventilation, as per ACLS guidelines. The CPR team was split into two groups. Subsequently arriving team members secured the maternal airway, responded rapidly to uterine atony and haemorrhage with uterotonic drugs and IV crystalloids, and inotropes for severe hypotension. Maternal ROSC was achieved after 15mins of high quality CPR. In view of continuing PPH, blood samples for crossmatch and DIC profile were sent. The parturient was shifted to ICU for further management. The neonate was intubated and chest compressions were performed till HR rose above 100 beats/min. Spontaneous respiration was noted after 10mins, but required assistance for a further 20mins. After securing IV access, the newborn was handed over to the neonatologist for post resuscitation care. Despite a reduced number of rescuers per patient, and an intensely stressful situation, a rapid and aggressive response resulted in both the mother and newborn being resuscitated effectively. Following equally aggressive and effective ICU management for maternal MODS, we saw both our patients go home healthy, within a week.

References

  1. 2015 AHA Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S383-96.


18. Swine Flu in Pregnancy with Fulminant ARDS with VV ECMO

Sunil T Pandya, Co-author: Praveen Nandagiri, Jayachandra, S. Tarakeswari, Harshil Joshi, M. Kiran, Satyanarayana, Raghu

Department of Anaesthesia Fernandez Hospital, Hyderabad

E mail: suniltp05@gmail.com

H1N1 in pregnancy often results in fulminant respiratory failure. Majority of them recover with supportive care along with oseltamivir therapy and conventional ventilator supportive measures. A small percentage of pregnant women may require VV-ECMO to tide over the crisis. VV-ECMO provides a good window for the lung recovery in parturients with refractory respiratory failure who do not respond to conventional lung protective and prone ventilation strategies. Mrs. S, 28 years old, 24 weeks pregnant, previous cesarean section presented to us with H1N1 ARDS, failed NIV trial. Patient was stabilized and lung protective invasive mechanical ventilation was initiated with stepping up of PEEP to maintain PFR > 200 mmHg. Despite PEEP of 16 cm H2O, had PFR of < 150 mmHg with FiO2 1, it was decided to terminate the pregnancy, do a percutaneous tracheostomy and prone ventilate. Consensus decision to deliver her vaginally was taken in view of imminent IUFD and probable ECMO support. Patient delivered by multipronged induction of labour approach. Post delivery, was put complete prone position, second session of prone ventilation, developed haemodynamic instability and cardiac arrest. Immediate ROSC achieved and VV-ECMO initiated. While on ECMO, gave several challenges – Developed heparin induced thrombocytopenia (HIT), massive secondary haemorrhage necessitating 179 units of blood and components. Also had major bleeding from tracheostomy resulting multiple sessions of rigid bronchoscopy to remove blood clots. After 27 days on VV-ECMO (This is the longest reported ECMO support in a parturient in India) and 55 days on mechanical ventilation, patient made a complete recovery without any sequelae. Consensus and safe decisions for appropriate interventions, properly orchestrated multidisciplinary team approach are the mandatory pre-requisites for improved maternal outcome in parturients requiring extra-corporeal support.

19. Role of Anesthetist in Management of Parturient with Primary Pulmonary Hypertension

Rahul Fernandez, Manjula Devi, Arpana Kedlaya, Vikram Shivappagoudar

St. John's Medical College Hospital, Bangalore

E mail: drmanjula95@yahoo.com

Pulmonary hypertension (PAH) is a progressive and fatal disease characterized by elevated pulmonary vascular resistance. Pregnancy with pulmonary arterial hypertension (PAH) in cor pulmonale is associated with very high peripartum mortality. Though the mode of delivery is decided by obstetric factors, the ideal anesthetic management is either controversial. Two cases of parturients in labor were studied based on both obstetric and anesthetic factors and outcomes. Both were managed differently with the use of regional or general anesthesia. Case 1: A 26 year old primigravida, presented with breathlessness and cough with hemoptysis at 34 weeks of gestation and was diagnosed as PAH with cor pulmonale. Due to non-progress of labor following induction, high risk emergency C-section under spinal anesthesia was performed. After extraction of baby, patient suffered cardiac arrest. She was revived with two cycles of CPR. She was intubated and peak airway pressures were high. She was shifted to the ICU where resuscitation was futile. Case 2: A 34 year old primigravida, presented with breathlessness and cough at 35 weeks of gestation and was diagnosed as PAH with cor pulmonale. High risk consent for LSCS was taken. In consultation with the obstetrician, an epidural catheter was placed to provide labor analgesia. She delivered a healthy live baby by normal vaginal delivery. The use of epidural labor analgesia has no significant risk for caesarian section. The successful conversion of labor analgesia to epidural anesthesia requires a multidisciplinary approach involving the obstetrician, anesthesiologist and cardiologist to provide best results.

20. A Caesarean Hysterectomy for Placenta Increta: Anaesthetic Safety Considerations – a Case Report

Kamya Bansal, Anju Grewal, Kamakshi Garg

Department of Anaesthesiology, Dayanand Medical College and Hospital Ludhiana, Punjab

E mail: dranjugrewal@gmail.com

Haemorrhagic emergencies are an anaesthesiologist's nightmare, especially if it occurs unexpectedly. We report successful management of an unanticipated placenta increta manifesting as massive haemorrhage while delivering the placenta during emergency lower segment caesarean section. A 25 year old parturient with previous 2 LSCS, presented at 20weeks of gestation with bleeding per vaginum. USG was suggestive of placenta previa with placenta overlying lower segment including scar. An emergency caesarean section, under general anaesthesia (since patient looked anaemic), was done. Profuse bleeding resulted on attempts to deliver the placenta, which was managed with blood and blood products and crystalloid administration. Emergency hysterectomy was performed which was immediately followed by uterine artery embolization (UAE) since the patient was actively bleeding post hysterectomy. The patient lost 10,000ml blood; was shifted to ICU and extubated the next day, followed by discharge after ten days with stable vitals. The series accreta, increta and percreta represent the abnormalities of placentation, by which trophoblasts attach, invade and even penetrate the myometrium respectively. Considering a complicated surgical course and high mortality, comprehensive planning and preparation for massive blood loss are paramount for an anaesthesiologist to reach the goal of an optimal outcome for mother and baby. For that, the mainstay are adequate amount of blood products (1:1:1 PRBCs: FFP: Platelets), maintenance of core body temperature and hemodynamic monitoring. General anaesthesia is preferred in view of profuse bleeding complicated by profound hypotension and coagulopathy and post operative ICU care. This case report underlines the importance of a well-coordinated multidisciplinary approach in a complex obstetric emergency






 

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