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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 8 | Issue 2
Page Nos. 63-117

Online since Wednesday, October 3, 2018

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EDITORIAL  

Training initiatives for safe obstetric anesthesia care p. 63
Anju Grewal, Nidhi Bhatia
DOI:10.4103/joacc.JOACC_54_18  
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REVIEW ARTICLE Top

Initial management of a pregnant woman with trauma Highly accessed article p. 66
Richa Aggarwal, Kapil Dev Soni, Anjan Trikha
DOI:10.4103/joacc.JOACC_4_18  
Trauma is a leading nonobstetric cause of mortality among pregnant women. Managing a pregnant trauma victim is a unique challenge as one is dealing with two lives at the same time. Initial optimal management of a parturient plays an important role in survival. Various physiological and anatomical changes occur in pregnancy that has important implications in the management. Some complications like abruption placenta, rupture uterus, amniotic fluid embolism and isoimmunization are peculiar to pregnant trauma patients. In this review, we discuss the initial management of parturient with trauma along with various physiological and anatomical changes and their implications.
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ORIGINAL ARTICLES Top

Predictors of mortality in critically ill obstetric patients in a tertiary care intensive care unit: A prospective 18 months study p. 73
Kanwalpreet Sodhi, Venus Bansal, Anupam Shrivastava, Manender Kumar, Namita Bansal
DOI:10.4103/joacc.JOACC_57_17  
Introduction: Intensive care units (ICUs) receive obstetric patients with medical and surgical complications as well as obstetrical emergencies. These patients needing intensive care present an exclusive challenge both for the obstetrician as well as the intensivist. In developing countries such as India, due to scarcity of ICU resources, maternal morbidity and mortality of such patients is high. Objectives: The aim of our study was to examine the pattern of admission, prevalence, causes, and the outcomes of critically ill obstetric patients admitted to an Indian ICU and the factors affecting mortality. Materials and Methods: A prospective study of all obstetric patients (pregnant and within 6 weeks postpartum) admitted in a 48-bedded ICU of a tertiary care hospital over a period of 18 months from January 2015 to June 2016 was done. The data collected included demographics, obstetric and medical history, illness severity scores, organ failures, treatment given, the ICU stay, hospital stay, and outcomes. Results: A total of 48 obstetric patients were admitted in the ICU during the study period. Mean age was 29.27 ± 5.910 years, mean APACHE-II was 12.77 ± 7.553, and SOFA score was 6.36 ± 4.235. Postpartum hemorrhage was the commonest cause for ICU admission (23%). Of the study patients, 40% had sepsis, 33% had multiorgan failure, 48% required ventilator support, and 25% had need for vasopressors. Mortality of study patients was 8.3%. Average ICU stay was 6.6 days. APACHE-II, SOFA scores, ICU stay and hospital stay, and multiorgan failure are significant predictors of mortality in obstetric critically ill patients. Conclusion: APACHE-II, SOFA scores, and ICU stay are strong predictors of maternal mortality in ICU. APACHE-II and SOFA scores overpredict mortality in obstetric patients. Early assessment and intervention of critically ill obstetrical patients with a team approach involving obstetricians and intensivists is ideal. All obstetric residents should have a mandatory short ICU training.
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Effect of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided transversus abdominis plane block for post-operative pain relief in cesarean section p. 79
Prannal Bansal, Dinesh Sood
DOI:10.4103/joacc.JOACC_53_17  
Introduction: Peripheral nerve blocks after cesarean section (C-section) reduce post-operative use of analgesic agents. Transversus abdominis plane (TAP) block is an effective way to provide postoperative analgesia. TAP block with ropivacaine alone has not consistently been proven to be useful after C-section, and dexmedetomidine has not been studied as an adjuvant to ropivacaine for TAP blocks after C-section. Objective: To compare the combination of dexmedetomidine and ropivacaine to ropivacaine alone for TAP block after C-section for time to onset of pain and time to rescue analgesia. Materials and Methods: Forty American Society of Anesthesiology grade I or II patients undergoing C-section were enrolled in this randomized, controlled, double-blind study. Twenty patients each were allocated to two groups receiving bilateral TAP block. Test group received TAP block with 3 mg/kg of ropivacaine with 50 μg of dexmedetomidine. Control group received TAP block with 3 mg/kg of ropivacaine. Patient demographics, time to initial reporting of pain, time to first rescue analgesia, quality of block, and side effects were recorded. Results: Time to initial onset of pain (6.6 vs. 5.03 h; P = 0.01) and time to first rescue analgesia (7.8 vs. 6.47 h; P = 0.03) were significantly longer in the test group compared with control group. The two groups were similar in demographics and quality of block. No significant difference in side effects was noted between the two groups. Conclusion: Addition of dexmedetomidine to ropivacaine for TAP block in patients undergoing C-section prolonged the time to initial onset of pain and time to first rescue analgesia.
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Development and validation of saving mothers score: A comprehensive scoring system for early identification of sick mothers p. 83
Kousalya Chakravarthy, Sunil T Pandya, Praveen K Nirmalan
DOI:10.4103/joacc.JOACC_51_18  
Context: Early identification of high-risk parturient and maternal physiological deterioration may reduce maternal morbidity and mortality. Aims: This study aimed to develop a comprehensive scoring system 'Saving Mothers Score' (SMS) to identify the sick mothers and validate SMS against the existing Modified Early Obstetric Warning System (MEOWS). Settings and Design: The SMS was developed through a formative research, item pool generation, content and construct validity. Methodology: Thirty-three (33) items were identified and pooled into three parameters pregnancy-related risk factors, physiological variables and biochemical tests. Each item was given a colour coding and a score. The trigger and score of SMS was prospectively analysed in 120 obstetric in-patients. Statistical Analysis Used: Tests of diagnostic effectiveness and 95% confidence intervals (95% CI) around point estimates. Results: Forty six women triggered (38.33%; 95% CI: 29.96, 47.26) and 41 (81.93%, 95% CI: 77.54, 95.91) of these 46 women developed morbidity. The overall accuracy of SMS chart was similar for trigger [sensitivity 60.9%; specificity 98.6%, area under receiver operator characteristic curve (AUROC) 0.80] and scoring (sensitivity 56.1%; specificity 92.4%, AUROC 0.74) with positive predictive value (PPV) and negative predictive value (NPV) of 96.6% and 80.2%, respectively. The accuracy of SMS was comparable to MEOWS (sensitivity 54.6%, specificity 97.8%, PPV 92.5% and NPV 79.9%). Conclusions: The diagnostic effectiveness of SMS was comparable to MEOWS. SMS may be used as a screening test to identify a sick mother. SMS can predict morbidity, help in triage and early intervention or timely referral to a higher centre.
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Evaluating the efficacy of low-dose hyperbaric levobupivacaine (0.5%) versus hyperbaric bupivacaine (0.5%) along with fentanyl for subarachnoid block in patients undergoing medical termination of pregnancy and sterilization: A prospective, randomized study p. 90
Sakshi Thakore, Nirdesh Thakore, Rama Chatterji, Chandra Shekhar Chatterjee, Samridhi Nanda
DOI:10.4103/joacc.JOACC_51_17  
Background: Spinal anesthesia using low doses of local anesthetics with opioids is emerging as a useful technique for day care surgeries. Levobupivacaine, a lesser toxic enantiomer of bupivacaine, has now been increasingly used in various gynecological surgeries. However, its use has not been demonstrated in medical termination of pregnancy (MTP) with sterilization (a kind of day care surgery). This study was performed to compare analgesic and anesthetic effectiveness of low-dose hyperbaric 0.5% levobupivacaine and hyperbaric 0.5% bupivacaine in combination with fentanyl in spinal anesthesia in patients undergoing MTP with sterilization. Methods: A comparative, randomized, double-blind study was conducted in 90 patients scheduled to undergo elective MTP with sterilization. Group levobupivacaine (L) (n = 45) received 7.5 mg (1.5 mL) of 0.5% isobaric levobupivacaine + 1 mL of 5% dextrose and fentanyl 25 mcg (0.5 mL), while group bupivacaine (B) (n = 45) received 7.5 mg (1.5 mL) of 0.5% hyperbaric bupivacaine + 1 mL of normal saline and fentanyl 25 mcg (0.5 mL). They were compared with respect to onset and duration of sensory and motor block, time to reach highest sensory level, time to two segments' regression, and total duration of analgesia. Results: Sensory and motor block onset and time to achieve highest level of sensory block were significantly delayed in group L (P < 0.05). Duration of sensory block and duration of analgesia was longer in group L than group B. Motor block duration was significantly shorter in L group (88.4 ± 12.4 min in group L and 133.9 ± 28.1 min in group B). Both groups were comparable in terms of hemodynamic parameters and adverse effects. Conclusion: This study suggests that 7.5 mg of 0.5% levobupivacaine usage in spinal anesthesia provides longer duration of analgesia and better sensory blockade with minimal motor block when compared with 0.5% bupivacaine along with fentanyl and may be a better alternative to bupivacaine in day care surgeries.
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CASE REPORTS Top

Labor analgesia with intradermal sterile water block in a patient with dilated cardiomyopathy p. 96
Nitin Choudhary, Kirti Nath Saxena, Bharti Wadhwa
DOI:10.4103/joacc.JOACC_10_18  
Epidural analgesia is the gold standard for providing labor analgesia, but an obstetric anesthesiologist should be well versed with many other non-pharmacological modalities of pain management. The present case highlights the importance of non-pharmacological methods of labor analgesia that might be the only options available in certain subset of patients to provide adequate labor analgesia.
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Perioperative anesthetic management of a pregnant mother with placenta percreta p. 99
Roshana Prasad Mallawaarachchi, Ramani Pallemulla
DOI:10.4103/joacc.JOACC_8_18  
Placenta percreta is a rare condition during pregnancy in which the abnormal presentation of placenta penetrates the uterine wall and invades into the surrounding organs including bowel and bladder. With the increasing rate of cesarean sections, the incidence of placenta percreta has also increased. This is a condition which gives rise to a major obstetric hemorrhage, peripartum hysterectomy, and maternal and fetal morbidity and mortality. This case report presents a successful obstetric and anesthetic management of a patient with preoperatively diagnosed placenta percreta.
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Neurovascular lesions in parturients: Anesthetic management for cesarean section p. 102
Fung Chen Tsai, May Un Sam Mok, Nicole C Keong
DOI:10.4103/joacc.JOACC_18_18  
Cerebral arteriovenous malformation (AVM) or aneurysm in pregnancy is a complex situation and there is no definite recommendation regarding mode of anesthesia for patient with this type of intracranial pathology. We present a case series on the anesthetic management in two pregnant patients with either cerebral AVM or aneurysm presenting for elective cesarean section. Our case series highlights the following: (1) team working and collaboration with neurosurgeon and obstetrician to improve patient outcome; (2) crucial role of anesthetic management in reducing perioperative complications; (3) anesthetic management goals so as to minimize the risk of hemorrhage from an AVM or aneurysm.
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Anaesthesia for surgical decompression of pott's spine in second trimester of pregnancy with lung isolation technique: An interesting case report p. 105
Veena Ganeriwal, Paulomi Dey, Sukanya Khan
DOI:10.4103/joacc.JOACC_24_18  
Spinal tuberculosis (Pott's disease) during pregnancy is reported to be rare and can be associated with destruction of the intervertebral disc and adjacent vertebrae that can lead to cord compression and thereby paraplegia or quadriplegia. Awareness of signs and suitable investigations may be delayed due to pregnancy, as patient and clinician may attribute these to the gravid state. The existing literature is limited and inconclusive regarding general anaesthesia using double-lumen endotracheal tube with lung isolation technique in the surgical decompression of spinal tuberculosis during pregnancy. We describe the successful anaesthesia management of a 26-week primigravida with 3rd to 5th thoracic spine (T3–T5) tuberculosis with paraparesis who underwent T4 corpectomy with T3–T5 fusion through transaxillary transthoracic approach.
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Anesthetic management of parturient with hyperhomocysteinemia for cesarean section p. 108
Radha Gupta, Swaran Bhalla, Sukirti Prakash, Nitish Upadhyay
DOI:10.4103/joacc.JOACC_44_17  
Hyperhomocysteinemia is due to genetic and acquired changes in the metabolism of homocysteine. It is associated with an increased risk for vascular occlusive disease and thrombosis. Because methylene tetrahydrofolate reductase abnormality is a genetic disorder and hyperhomocysteinemia along with pregnancy in women further aggravates the risk of thrombosis; therefore, these patients undergo antepartum anticoagulant treatment with low molecular weight heparin. These patients pose a unique challenge to anesthetist, when it comes to choosing a type of anesthesia. Neuraxial anesthesia techniques may be relatively contraindicated in anticoagulated patients and nitrous oxide may exacerbate the condition, by inhibiting the conversion of homocysteine to methionine. In this study, we intend to discuss the anesthetic implications and management of a pregnant patient with hyperhomocysteinemia undergoing cesarean section.
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Operative hysteroscopy intravascular absorption syndrome: The gynecological transurethral resection syndrome p. 112
Rajeev Chauhan, Venkat Ganesan, Ankur Luthra
DOI:10.4103/joacc.JOACC_22_18  
Hysteroscopy is becoming fairly common in most centers these days, both as a diagnostic and therapeutic tool especially for short day-care procedures, reducing unnecessary hospital admissions and overuse of resources. However, these procedures are not without complications, and some could be delayed and potentially fatal if a high index of suspicion is not maintained. One such rare yet one with a high mortality among urological patients is the transurethral resection syndrome on which there is a cornucopia of literature in the form of articles and chapters. There are very few highlighting a similar syndrome of sorts called the operative hysteroscopy intravascular absorption syndrome. Here, we describe one such case, and in brief, the anesthetic management options for hysteroscopic procedures to prevent such a complication.
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Amniotic fluid embolus in the absence of disseminated intravascular coagulation and respiratory failure: A diagnostic challenge p. 115
Fiona C Oglesby, Sara-Catrin Cook, Fiona E Kelly, Chris Marsh
DOI:10.4103/joacc.JOACC_33_18  
Amniotic fluid embolism (AFE) is a potentially catastrophic complication unique to pregnancy, characterised by its poorly understood pathophysiology and diverse clinical manifestations. We present the case of a 37-year-old G1P1 mother, who developed sudden cardiovascular collapse in the immediate post-partum period. We detail the diagnostic uncertainty surrounding the condition and use this case to illustrate the clinical spectrum of AFE presentation.
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