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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
January-June 2019
Volume 9 | Issue 1
Page Nos. 1-52

Online since Thursday, April 11, 2019

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Elderly parturients: A rising trend p. 1
Daisy Gogoi
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Effective pain relief after caesarean section; Are we on the right path or still on the crossroad p. 3
Ashok Jadon, Rajni Bagai
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Perfect recipes for obstetric anesthesia: Need of caution in the resource constraint environment p. 7
Samina Ismail, Malika Hameed
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Comparative study of different doses of clonidine as an adjuvant with isobaric levobupivacaine for spinal anaesthesia in patients undergoing caesarean section p. 9
Neha Maheshwari, Shefali Gautam, Rajni Kapoor, Ravi Prakash, Shobhna Jafa, Rajni Gupta
Background: Various techniques of central neuraxial blockade have been tried and successfully used for caesarean section surgeries. Nowadays it is must and essential to know the possible effective dose of clonidine to overcome its known side effect like bradycardia, hypotension and sedation for better outcome of mother as well as foetus in lower segment caesarean section. We have conducted such study to compare different doses of clonidine as an adjuvant to intrathecal isobaric levobupivacaine. The plain levobupivacaine has been shown to truly isobaric with respect to CSF of pregnant women and this property got advantage over hyperbaric bupivacaine in its predictable spread. Materials and Methods: There were about 90 cases of emergency caesarean section of more than 37 weeks gestation with ASA physical status class 2 under spinal anaesthesia were randomly divided into three groups of 30 patients each. In all groups we assessed onset, two segment regression and requirement of analgesic in post-operative period, level of motor block by modified bromage scale [Table 1] and sedation by Campbell sedation score [Table 2]. Maternal and foetal hemodynamic was monitored as well. Group A (n = 30) 10 mg of 0.5% (2 ml) isobaric levobupivacaine + 15 mcg clonidine (0.5 ml). Group B (n = 30) 10 mg of 0.5% (2 ml) isobaric levobupivacaine + 30 mcg clonidine (0.5 ml). Group C (n = 30) 10 mg of 0.5% (2 ml) isobaric levobupivacaine + 45 mcg clonidine (0.5 ml). Normal saline was used to make volume of clonidine upto 0.5 ml. Result: Onset of sensory block was highest in group A with significant difference (P value <0.0001) in all three groups. Two segment regression time (in minutes) was highest in group C with significant difference (P value <0.0001) in all three groups. There was fall in systolic blood pressure (SBP) <80% of baseline was found in 0 (0.00%), 10 (33.33%) and 22 (73.33%) patients in group A, B and C respectively while fall in HR <80% of baseline was found in 0 (0.00%), 1 (3.33%) and 19 (63.33%) patients. Sedation score was 1 in 30 (100%) patients in group A, it was 1 in 10 (33.33%), 2 in 20 (66.67%) in group B while it was 1 in 5 (16.77%), 2 in 10 (33.33%) and 3 in 15 (50%) patients in group C. Conclusion: Spinal anaesthesia performed with isobaric 0.5% levobupivacaine with 30 mcg clonidine (Group B) provides better haemodynamic stability, early onset of sensory and motor blockade, decreased requirement of post-operative analgesia.
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Effect of preoperative education about spinal anesthesia on anxiety and postoperative pain in parturients undergoing elective cesarean section: A randomized controlled trial p. 14
Anila K Kalliyath, Sara V Korula, Anna Mathew, Saramma P Abraham, Mini Isac
Background: Preoperative anxiety is a common problem in all patients. The reason could be incomplete information regarding the anesthesia and surgical procedure. Cesarean section (CS) is a common surgery and treatment of postoperative pain after CS continues to be an ongoing challenge. Aim: The present study was carried out to assess if preoperative education with a handout about spinal anesthesia can reduce anxiety and postoperative pain in parturients undergoing CS under spinal anesthesia. Methods and Materials: We randomized 64 parturients into two equal groups; study (Group A) and control group (Group B). The study group was given a handout and a structured education about spinal anesthesia. The control group was given routine preoperative information. The Amsterdam preoperative anxiety and information scale (APAIS) was used to measure anxiety preoperatively and visual analogue scale (VAS) for pain at 5 h and 24 h postoperatively. Statistical Analysis: The two groups were compared using Student's t test and non-parametric Wilcoxon-Mann-Whitney U test. Result: The median difference in preoperative anxiety scores (APAIS) in the two groups was found to be 8.00 (P < 0.001), which was significant statistically. The median value of postoperative pain analyzed using VAS after giving education, at 5 h was significantly reduced in Group A (5.00) as compared to Group B (9.00). The median value of VAS score at 24 h was significantly different in both groups. It was 1.0 in Group A, whereas the same was 5.50 in Group B (P <.00). The median difference in hours in the duration of analgesia between the two groups was 0.62, which was not significant statistically (P < 0.10). Conclusion: A planned preoperative education and handout with details about spinal anesthesia can have a significant impact on reducing the preoperative anxiety and the postoperative pain in parturients undergoing elective CS under spinal anesthesia.
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I-gel for day care diagnostic laparoscopic gynecological surgery: A comparison of two regimes of IV propofol with dexmedetomidine or butorphanol p. 18
Alka Chhabra, Apoorva Gupta, Shashank Gupta, Kunal Chauhan, Sunanda Gupta
Background: Insertion of I-gel requires adequate depth of anesthesia and jaw relaxation in an unparalyzed patient. Propofol with adjuvants is commonly used to facilitate I-gel insertion. This study was conducted to compare ease of insertion by addition of either dexmedetomidine or butorphanol added to propofol for insertion of I-gel in gynecological laparoscopic surgeries. Materials and Methods: About 120 female patients, the American Society of Anesthesiologists (ASA) Grade I–II, 18–40 years, and body mass index (BMI) <30 kg/m2 were allocated randomly either to receive dexmedetomidine 0.5 mcg/kg IV (Group I) or butorphanol 0.02 mg/kg IV (Group II). Ease of insertion score was determined by jaw mobility grading, number of attempts, need of manipulation, limb movement and bucking, use of laryngoscope and muscle relaxant, and time taken for insertion. Adverse events like expiratory stridor, lacrimation, breath holding, and audible air leak after insertion were also noted. Intraoperative monitoring included heart rate (HR), mean arterial pressure (MAP), and oxygen saturation at 0–15 min of I-gel insertion. Post-operative side effects like coughing, laryngospasm, hiccups, and sedation were also noted. Results: The efficacy of successful insertion of I-gel was significantly higher in propofol-dexmedetomidine (Group I) as compared to propofol–butorphanol (Group II) (P < 0.001). Significant fall in HR from baseline to 15 min after I-gel insertion (88.65 ± 14.84 to 71.90 ± 12.15 bpm) was found in Group I as compared to Group II (87.60 ± 12.71 to 83.52 ± 10.91 bpm, P < 0.001). There was a fall in MAP from baseline values after induction upto 15 min following insertion in Group I (96.72 ± 13.54 to 86.96 ± 11.03), while in Group II fall in MAP from baseline was observed only upto 1 and 2 min of I-gel insertion (96.27 ± 9.53 to 89.42 ± 9.03) (P < 0.001). Conclusion: Addition of dexmedetomidine to propofol provided significantly better insertion characteristics for I-gel and adequate hemodynamic stability with minimal complications compared to butorphanol.
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A comparative clinical study of intrathecal bupivacaine 2.5 mg with dexmedetomidine 5 μg versus intrathecal bupivacaine 2.5 mg with fentanyl 25 μg on the duration of labor analgesia using combined spinal epidural technique p. 24
Neena Jain, Pooja R Mathur, Poorva Soni, Veena Patodi, Surendra K Sethi, Veena Mathur
Context: Adjuvants may be added to decrease motor blockade caused by intrathecal bupivacaine and prolong labor analgesia. Aim: To study the effect of intrathecal dexmedetomidine versus fentanyl when added to bupivacaine on the duration of labor analgesia, progress of labor, block characteristics, and side effects. Settings and Design: A prospective, randomized double-blind study. Materials and Methods: Sixty parturients consenting for labor analgesia were divided into two groups. Group A (n = 30) received an intrathecal 0.5% hyperbaric bupivacaine 2.5 mg and dexmedetomidine 5 μg and Group B (n = 30) received an intrathecal 0.5% hyperbaric bupivacaine 2.5 mg and fentanyl 25 μg. Partogram, visual analog score, sensory and motor blockage, progress of labor, maternal hemodynamic variations, and fetal heart rate were noted. Statistical Analysis Used: Standard qualitative and quantitative tests were used to compare data (e.g., unpaired student t-test, ANOVA, Chi-square); P value of 0.05 was considered significant. Results: Duration of labor analgesia was significantly greater in Group A as compared to Group B (254.17 ± 4.75 min vs. 123.67 ± 6.01 min, P < 0.0001). Mean onset of analgesia was earlier in Group A as compared to Group B (1.27 ± 0.37 min vs. 3.27 ± 0.37 min, P < 0.0001). Duration of the active phase of the first and second stages of labor, rate of cervical dilation, hemodynamic and side effects profile, and neonatal outcome were comparable in both groups (P > 0.05).
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Implementation and efficacy of “saving mothers score” in predicting maternal morbidity and improving maternofetal outcome p. 30
Kousalya Chakravarthy, Sunil T Pandya, Praveen K Nirmalan
Background:“Saving Mothers Score” (SMS) was developed and validated as a comprehensive obstetric score for identification of sick mothers. This study aimed to evaluate the efficacy of the SMS chart to predict maternal morbidity and improve maternal and fetal outcomes. Materials and Methods: A single-center randomized study was done on 700 subjects of two groups from February 2017 to 2018. The subjects were treated as per the existing hospital norms in Group A (n = 360) and SMS chart was used in addition to the hospital norms in Group B (n = 340). Results: Demographic data, preterm deliveries, and cesarean delivery rate were not significantly different in both groups. Postpartum hemorrhage was significantly more in Group A when compared with Group B where SMS chart was used (unadjusted odds ratio 3.22, 95% confidence interval: 1.59, 6.97, P = 0.0004). The overall morbidity was higher (P = 0.0001) in Group A. The mean hospital stay was longer in Group A (P = 0.0001). Neonatal morbidity was 14.4% in Group A and 10.3% in Group B (P = 0.169). APACHE II (mean 10.87, range 0–18) and SOFA (mean 7.75, range 0–12) scores were determined along with SMS (mean 18.87, range 5–26) in eight critically ill parturients. There was no maternal mortality in this series. Conclusion: SMS predicts maternal morbidity and can help initiation of appropriate treatment to improve maternal and hence fetal outcome. Multicentric studies are needed for further evaluation and comparison of SMS to APACHE II and SOFA scores.
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Comparison of three different fluid warming techniques used to maintain euthermia in patients who underwent cesarean section – A retrospective audit Highly accessed article p. 35
Saurabh Sud, Deepak Dwivedi, Sadhan Sawhney, Jagdeep S Bhatia, Josemine Davis, Puja Dudeja
Context: Intraoperative hypothermia is a leading cause of morbidity in the perioperative period. This retrospective audit study was planned to assess the efficacy of three different active warming devices used in maintaining euthermia in patients who underwent lower segment cesarean section (LSCS). Aims: Audit of the three different fluid warming techniques in maintaining euthermia in patients who underwent cesarean sections. Settings and Design: A retrospective audit. Materials and Methods: In total, 698 patients were included in the study who underwent LSCS and were divided on the basis of the warming technique used into Group 1 (n = 241, blood warming bath), Group 2 (n = 238, cabinet), and Group 3 (n = 219, inline warmer). The preoperative core body temperature was compared in each group with the intraoperative body temperature as well as with core body temperature measured 20 minutes after shifting the patient in the postoperative room as per the entries made in the central anesthesia registry. The incidence of the shivering was also noted from the data for each group separately. Statistical Analysis Used: One-way analysis of variance was applied for comparing the mean (SD) between the three groups and unpaired t-test was used to compare two mean (SD) values.P value <0.05 was considered significant. Results: Comparison of preoperative core body temperature (T0) with intraoperative (T1, T2) and postoperative (T3) temperatures within the groups showed significant results in Group 1 (blood warming bath), demonstrating its inefficiency in maintaining euthermia in the perioperative period. Conclusions: Cabinet and inline fluid warmer prove to be efficacious in maintaining euthermia and limiting shivering in the patients for cesarean section.
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Mallory-Weiss Syndrome complicating pregnancy – A rare near miss p. 40
Isha Chopra, Sunil T Pandya, Mangalampally Kiran Kumar, Surapaneni Tarakeswari, Hemamalini , Madapu Manokanth, Prabhakar Boddu
Mallory-Weiss syndrome (MWS) rarely occurs during pregnancy and can lead to massive bleed if occurring in the third trimester. Unrecognized MWS may lead to life threatening hemorrhage and shock affecting maternal and fetal well-being. We describe a rare case of MWS in a pregnant patient at 36 weeks of gestation with underlying pre-eclampsia, acute kidney injury, and hemodynamic instability. The possibility of mucosal tears should be kept in mind in the absence of an obvious source of bleeding.
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Management of parturient with triplet pregnancy and placenta percreta: Importance of multi-disciplinary approach p. 43
Samina Aziz Ismail, Akbar Azizullah
Obstetric conditions like placenta percreta and multiple pregnancies can be extremely challenging as they pose a high risk for both the mother and infants. In placenta percreta, placental villi penetrate through the wall of uterus into the surrounding organs including the bladder and carry a risk of massive maternal bleeding. Multiple pregnancies have greater complication rate than that in singleton pregnancy. Successful management of such challenges are best done by a multidisciplinary teamwork, where all members of a perinatal team are involved in decision making and management. We report the successful management of a triplet gestation associated with placenta percreta.
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Anesthetic management of cesarean section in parturients with severe mitral stenosis: A case series p. 46
Kirti N Saxena, Bharti Wadhwa, Devika Mishra
Mitral stenosis (MS) is the most common valvular heart disease associated with pregnancy. The increase in cardiac output during pregnancy results in deterioration of the patient's condition with progress to higher New York Heart Association class. Both general and regional anesthesias have been described for cesarean section in these patients. Anesthetic management of these patients depends upon the severity of the disease. General anesthesia has traditionally been preferred for cesarean section in patients with severe MS. Regional anesthesia has become popular as a safe choice in the recent past for cesarean section in all parturients including those with heart disease. We report three parturients with severe MS who underwent cesarean delivery under graded epidural block successfully. The parturients and the neonates were fine after the procedure.
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Thrombotic thrombocytopenic purpura during pregnancy and its overlap with the HELLP syndrome, a clinical dilemma: A case report and review of the literature p. 50
Mafdy Basta
Thrombotic thrombocytopenic purpura (TTP), when occurs during pregnancy, displays findings that could overlap with preeclampsia, especially the HELLP (Hemolysis, Elevated Liver tests, Low Platelets) syndrome. The following presentation is a case report that describes TTP in a pregnant patient whose pregnancy was also complicated by preeclampsia and illustrates some features that could help differentiate and manage this clinical dilemma.
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