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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
July-December 2020
Volume 10 | Issue 2
Page Nos. 65-152

Online since Thursday, August 20, 2020

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Safe anesthesia and analgesia for obstetric patients in COVID 19 pandemic Highly accessed article p. 65
Samina Ismail, Asiyah Aman
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COVID-19: Considerations for obstetric anesthesia and analgesia Highly accessed article p. 69
Venkata Ganesh, Ridhima Bhatia, Anjan Trikha
Peripartum services are indispensable notwithstanding the COVID-19 pandemic. Providing safe and quality obstetric anesthesia is quite demanding as most signs and symptoms of COVID-19 are non-specific and overlap with the constitutional signs of pregnancy. Overloaded viral testing facilities, urgency of caesarean delivery, limited resources, capricious evidence-base, and potential exposure risk to healthcare providers further add to the challenge imposed by COVID-19. In this discourse we attempt to provide a summary of the current evidence and recommendations concerning the practice of obstetric anesthesia and analgesia.
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Ultrasound in obstetric anesthesia and critical care Highly accessed article p. 75
Ranjana Khetarpal, Puneetpal Kaur, Anuradha Borle, Anjan Trikha
Ultrasound is a safe and inexpensive imaging modality, which can be used as a diagnostic and monitoring tool in anesthesiology, along with therapeutic management of emergency and critical illness scenarios. This current review considers an array of recent applications of ultrasound in obstetric anesthesia, encouraging its use as standard practice for diagnostic and therapeutic management. The rapid advancement of clinical applications of ultrasound in obstetric anesthesia needs an appraisal for its uses and limitations. This review presents ultrasound application under various scenarios such as difficult neuraxial blockade and airway management, gastric antrum assessment, difficult intravascular access, transverse abdominal plane block for pain management, lung ultrasound, and transthoracic echocardiography and assessment of intracranial hypertension and usage in emergency and critical care in obstetrics. Each application is presented with recent advances along with limitations to its use in clinical practice. Ultrasound is becoming a versatile tool nowadays for obstetric anesthesiologists for providing the best care possible.
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P6 point acupressure versus ondansteron in prevention of carboprost-induced nausea and vomiting p. 87
G Rajaram, K Raghu, Shishir Kumar, N Nikhil
Context: Perioperative nausea and vomiting is an important clinical problem that occurs in a group of patients requiring carboprost during cesarean section. Apart from pharmacological measures, other modalities have also been introduced to decrease the incidence. Aims: Our study aimed at comparing the effectiveness of acupressure and ondansetron in the prevention of nausea and vomiting following the use of carboprost. Settings and Design: This was a prospective randomized controlled study. Methods and Materials: One hundred patients scheduled for elective caesarean section under spinal anesthesia were divided into two groups of 50 each to receive either acupressure (Group A) or injection ondansetron (Group O) 0.1 mg/kg intravenous (i.v.) immediately after spinal anesthesia. Injection carboprost 250 μg was given intramuscularly in both groups after delivery of the anterior shoulder. Incidences of nausea and vomiting were observed intraoperatively and postoperatively for 2 h. Statistical Analysis Used: Standard qualitative and quantitative tests were used to compare data. A value of P = 0.05 was considered significant. Results: A total of 11 patients had nausea, of whom 7 were in Group O and 4 patients were in Group A (P = 0.350). In total, six patients had nausea and vomiting, of whom four were in Group O and two were in Group A (P = 0.424). No statistical difference was observed between two groups in the incidences of nausea and vomiting. However, the incidence rates were low in Group A as compared to Group O. Conclusion: P6 point acupressure is as effective and comparable as ondansetron in the prevention of carboprost-induced nausea and vomiting.
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Maternal mortality in siberia and far East of Russia p. 91
Natalya Vladimirovna Artymuk, Tatyana E Belokrinitskaya, Oleg S Filippov, Maria N Surina, Natalya I Frolova, Vasiliy N Palichev
Background: Maternal mortality (MM) affects a large part of the world. Annually, 289,000 women die during pregnancy and childbirth (more than one death every 2 minutes). Moreover, an audit of maternal mortality in the world showed significant problems in assessing the maternal mortality rate. Objectives: The objective of this study was to analyze maternal deaths in the Siberian and Far Eastern Federal Districts over 5 years from 2014 to 2018. Materials and Methods: An analysis of 165 emergency notifications of cases of maternal mortality over a 5-year period from 2014 to 2018 was carried out. Additionally, 26 case histories/births of maternal deaths in the Siberian Federal District for 2018 are analyzed, and 52 emergency notifications from 2014-2018 in the Far Eastern Federal District were also included. Results: For the period between 2014 and 2018, a decrease in maternal mortality (MM) in the Siberian and Far Eastern Federal Districts was recorded, and the year 2018 was characterized by an increase in MM because of social factors. Extragenital disease was the predominant cause of MM in these subjects; however, some differences were noted in the Siberian Federal District where the leading causes were embolism and placental abruption, and in the Far Eastern Federal District where hypertensive disorders and obstetric bleeding predominated. Conclusions: The main point being made here is that patients will be better served by closing low-tier medical institutions that are potentially dangerous in terms of MM, and relocating the patients to superior medical facilities. It is necessary to further introduce clinical recommendations and develop teamwork skills in simulation training centers.
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Protocol-based management of acute pulmonary edema in pregnancy in a low-resource center p. 98
Kousalya Chakravarthy, T Swetha, Praveen K Nirmalan, Anuradha Alagandala, Nagamani Sodumu
Context: Acute pulmonary oedema (APO) in pregnant women is associated with increased maternal morbidity and mortality. Aim: The aim of this study was to evaluate the risk reduction strategy by a protocol-based approach to the management of APO in pregnancy in a low-resource center. Settings and Design: The study was conducted in a single obstetric tertiary care public sector hospital for 12 months. Materials and Methods: The pregnant women admitted with acute shortness of breath (SOB) were divided into two groups based on the implementation of pulmonary edema protocol. The data before protocol (Group A) and after (Group B) were compared. Results: A total of 38 patients were admitted with acute SOB. The incidence of APO was 0.10% (95% CI: 0.08,0.14). Majority (Group A: 92.87%; Group B: 81.25%) were admitted in the third trimester. Hypertension was the most common etiology (71.42% in Group A; 81.25% in Group B), followed by cardiovascular causes (42.85% in Group A; 6.25% in Group B) and sepsis (21.42% in Group A; 18.75% in Group B). Caesarean section was carried out in 57.14% in Group A; 62.5% in Group B. Noninvasive Ventilation (NIV) was started in 8 of 16 cases in Group B. Regional anesthesia was used in 87.5% in Group A and 100% in Group B. The maternal mortality was 9 (64.28%) in Group A as compared to 1 (6.25%) in Group B; P = 0.001. Conclusion: The protocol-based algorithm for APO in pregnancy decreases the maternal mortality. Hypertensive disorders of pregnancy are the most common cause followed by cardiac disease. NIV is useful in APO.
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Does labor epidural cause a rise in maternal temperature? An observational study at a tertiary care hospital of a developing country p. 106
Samina Ismail, Asiyah Aman, Kashif Munshi
Background and Objective: There has been a concern regarding maternal hyperthermia with labor epidural in developed countries. This study aimed to determine the frequency of rise in maternal temperature after labor epidural placement in a tertiary care hospital of a developing country. Materials and Methods: After approval from the institutional ethics review committee and informed consent, this observational cohort study was conducted on 494 nulliparous women fulfilling the inclusion criteria and requesting labor epidural. Maternal temperature was recorded by a standardized method soon before institution of labor epidural (baseline temperature) and then hourly after its placement for up to 6 h maximum or till delivery. Neonatal outcome was observed by recording Apgar score at 1 and 5 min and intensive care admissions. Results: There was a steady rise of mean temperature from baseline (36.26 ± 0.31), each hour after institution of labor epidural. The percentage of patients showing a rise in temperature increased each hour from 45% in first hour to more than 56% in the sixth hour. The temperature of ≥37.5°C was considered as hyperthermia and was observed in four patients (0.81%). The median temperature difference was not statistically significant within time point (P > 0.05). Apgar scores of newborns born to mothers with hyperthermia were 8 at 1 min and 9 at 5 min with no intensive care admissions. Conclusion: Frequency of maternal hyperthermia was found to be low compared to the incidence reported from developed countries, most probably due to difference in obstetric practice and patients demographics.
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Prophylactic co-administration of two different bolus doses of norepinephrine in spinal-induced hypotension during caesarean section: A prospective randomized double-blinded study p. 111
Savita Choudhary, Rakesh Dagar, Lalita Jeenger, Anil K Bhiwal, Swapnil Tuteja, Sunanda Gupta
Background: Vasopressors for prophylaxis and treatment of spinal hypotension have grown in popularity in recent years. Norepinephrine is now emerging as one of the feasible options for prevention as well as management of spinal-induced hypotension in caesarean section (CS). The aim of our study was to compare the efficacy of two different doses of norepinephrine as prophylaxis for spinal-induced hypotension during CS. Material and Methods: Total 110 patients were recruited in this prospective randomized double-blind study from December 2017 to June 2019. After fulfilling the inclusion and exclusion criteria, this study was conducted on 90 patients undergoing elective CS under spinal anesthesia, who were assigned into three groups of 30 patients each. Group N6received norepinephrine 6 μg as an intravenous bolus, group N4received norepinephrine 4 μg, and group C received normal saline simultaneously with subarachnoid block. Incidence of hypotension, requirement of rescue doses of norepinephrine, time of first rescue dose, hemodynamic parameters, adverse effects, and neonatal complications were assessed, compared and analyzed. Results: The incidence of post spinal hypotension was 63.33% in group N6, 80% in group N4, and 83.33% in group C (p = 0.155). Total rescue dose requirement of norepinephrine was significantly less in group N6(8.21 ± 2.97 μg) as compared to N4(9.00 ± 3.06 μg) and control group (11.00 ± 4.57 μg).(p = 0.011). The median time to first rescue dose requirement of norepinephrine was significantly delayed in group N6(6[8–4.5] min) and group N4(4[9–2.5] min) as compared to control group (4[5–2] min) (p = 0.004). Conclusion: Prophylactic intravenous bolus dose of 6 μg norepinephrine when co-administered with spinal anesthesia was found to be more effective than 4 μg norepinephrine in terms of decreasing total rescue dose requirement of vasopressor and delaying the time to first rescue dose, without significant change in the incidence of hypotension.
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Clinical comparison of prophylactic phenylephrine infusion vs. bolus regimens on maternal hemodynamics and neonatal outcomes during cesarean section p. 118
Nitesh Kumar, Mathews Jacob, Priya Taank, Shalendra Singh, Neetika Tripathi
Background and Objective: Phenylephrine bolus or infusion is used to maintain arterial blood pressure during the subarachnoid block (SAB) for cesarean section. The objective was to assess the clinical efficacy of prophylactic phenylephrine infusion or bolus doses for maternal hemodynamics maintenance and its effect on fetal outcomes. Materials and Methods: Sixty parturients were randomized to receive either a continuous prophylactic IV infusion of phenylephrine (n = 30, group A) at a dose of 0.50 μg.kg−1.min−1 or phenylephrine (n = 30, Group B) 50 μg bolus dose after the systolic blood pressure (SBP) fell by 20% from the baseline. The changes in hemodynamics, ill effects, neonatal APGAR scores, and fetal acidosis were recorded at different time intervals. Results: SBP was significantly higher over time in group A. Group A showed a significant fall in heart rate from baseline after giving SAB and remained significantly low throughout the intraoperative period (P < 0.05). In group A, 12 patients showed a fall in blood pressure of >20% from the baseline; however, hypotension was observed in 21 patients in group B (P < 0.03). The number of hypotensive episodes was higher in the group B. Incidence of hypotension in Group A was 40% (12 out of 30 patients) and 70% (21 out of 30 patients) in Group B (P < 0.037). Episodes of reactive hypertension, defined as a rise in SBP >20% of baseline value, were noted in 3 out of 30 patients in the Group A. There was also a statistically nonsignificant trend toward a less frequent incidence of nausea and vomiting in the group A (P < 0.29). There was no significant difference between the two groups in APGAR scores at 1 and 5 min after delivery (P < 0.56, 0.13). The incidence of neonatal acidosis was similar in the two groups. Conclusion: Prophylactic phenylephrine infusion is superior to therapeutic phenylephrine bolus dose for control of hemodynamics.
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Impact of labor epidural analgesia on maternal and neonatal outcomes with trial of labor in previous caesarean delivery: A prospective, controlled, longitudinal study p. 123
Bozhenkov K Aleksandrovich, Shifman E Munevich, Gustovarova T Alekseevna, Bozhenkova M Vladimirovna, Karuna Sharma, Sunanda Gupta
Background: Labor outcome with regional anesthesia following previous cesarean section has been fraught with concerns regarding uterine rupture. There is sparse literature regarding the association between the impact of epidural analgesia and labor outcome in vaginal birth after cesarean section (VBAC). This study aims to evaluate the effect of labor epidural analgesia on labor outcome following TOL (Trial of labor) in previous cesarean or normal delivery with maternal and neonatal outcomes. Material and Methods: This is a prospective controlled longitudinal study in second-gravida patients in labor. A total of 132 patients were enrolled for the study out of which 101 were divided into three groups. Group A included 38 second-gravid women with a history of previous caesarean delivery and Group B included 32 second-gravid having previous normal vaginal delivery, both the groups received epidural analgesia during labor. Group C included 31 second-gravid with a history of previous cesarean section who did not receive epidural analgesia during labor. The aim of the study was to evaluate labor outcome in terms of successful vaginal delivery with or without epidural analgesia, along with visual analogue scale (VAS) pain scores during the conduction of delivery, hemodynamic parameters, and progress of trial of labor (TOL). Other obstetric and neonatal parameters were also evaluated. Results: Vaginal delivery was conducted in all patients in Group B (32/32; 100%) and Group C (31/31; 100%), whereas in Group A, two patients underwent emergency cesarean section as a result of impending uterine rupture in one case and acute fetal hypoxia in another. According to the intensity of pain on VAS, women having previous cesarean delivery experienced more severe pain before starting epidural analgesia (VAS in Groups A and C; 7.9 ± 0.2) as compared to previous vaginal delivery (VAS; Group B 6.4 ± 0.2) (P < 0.0001). The duration of second stage of labor was significantly prolonged in parturients with previous CD (Group A 22.6 ± 1.2; Group C 25.0 ± 1.9 v/s Group B 18.4 ± 1.1) (P < 0.0001). Similarly third stage of labor was also prolonged significantly in Group A and Group C (10.1 ± 0.7, 10.2 ± 0.9) as compared to Group B (7.7 ± 0.6) (P < 0.0001). However, total duration of labor was not significantly different among the three groups. (P > 0.05) Cervical dilatation on admission to the maternity ward was 4.1 ± 1.0 (Group A and C) and 4.0 ± 1.0 (Group B). The total consumption of ropivacaine in epidural analgesia was significantly high in Group A (previous CD) (29.6 ± 1.2 mg) as compared to Group B (previous vaginal delivery) (28.1 ± 1.6 mg) (P < 0.0001). Conclusions: Epidural analgesia is an effective and safe method of analgesia for vaginal delivery after previous cesarean section, and does not involve the risk of untimely diagnosis of impending uterine rupture.
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Spinal anaesthesia for cesarean section in a case of congenital complete heart block p. 131
Manjit George, Davis Kurian, Salih V Salim
We report a case of congenital complete heart block on a temporary pacemaker who underwent an elective lower segment cesarean section under spinal anesthesia uneventfully. These patients could be completely asymptomatic but are at risk of sudden cardiovascular collapse. Spinal anesthesia is a safe option. Maintenance of hemodynamic stability including heart rate control with a temporary pacemaker is important
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Severe dilated cardiomyopathy undergoing emergency lower segment cesarean section: A case report p. 135
Sunil Thakur, Vatika Bhardwaj, Sushruti Kaushal, Aman Thakur
Dilated cardiomyopathy (DCM) is a rare condition in pregnancy and has an established grave prognosis as such. Anesthetic management of pregnant patients with dilated cardiomyopathy is quite challenging either because of preexisting DCM or the risk of precipitating sudden cardiac failure. Pregnancy in patients with preexisting DCM can further flare-up disease and can be life- threatening, especially in patients who land up in an emergency when there is less time to optimize the patient's condition. The anesthesiologist thus must have knowledge of its causes, pathophysiology, clinical features, and various anesthetic modalities available. The present case report illustrates the successful management of a parturient with preexisting DCM undergoing emergency caesarean section. It is very important that patients with DCM should have regular follow-up so that timely intervention can be done about the mode of delivery for the safety of both mother and child.
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Anaesthestic considerations in an obstetric patient with henoch schonlein purpura p. 138
Nishigandha Sawant, Hemlata Iyer, Vijay Shetty, Girish Sabnis
Henoch-Schonlein Purpura (HSP) is an IgA mediated vasculitis predominantly affecting the pediatric population. This disease may leave a lifelong residual effect on renal system with a propensity for a relapse during pregnancy leading to hypertensive and hemorrhagic complications. We present a case of a patient who had HSP in adulthood and had uncomplicated caesarean delivery under regional anesthesia.
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Fahr's syndrome presenting as seizures during pregnancy – A case report p. 140
Maddani S Sagar, Souvik Chaudhuri, Shwethapriya Rao, Sunil Ravindranath
Fahr's syndrome is a rare cause of seizures during pregnancy. It typically presents in the third decade of life, and it may be associated with gait instability, paroxysmal choreoathetosis, speech impairment, a neuropsychiatric disorder, myoclonus, and even seizures and coma. Neurological imaging revealing the symmetrical bilateral calcification along with pseudohypoparathyroidism helps in the diagnosis. Prompt treatment of the endocrine abnormalities associated with it can halt the disease process and result in neurological improvement. Thus, evaluation of seizures also requires an endocrine workup of the patient, keeping in mind rare causes like the Fahr's syndrome.
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Strengthening the delivery of sexual and reproductive health to women amidst the threat of ongoing corona virus disease 2019 pandemic p. 143
Saurabh R Shrivastava, Prateek S Shrivastava
The ongoing Corona Virus Disease-2019 (COVID-19) pandemic has emerged as one of the top most public health priorities and that all the global population is at the risk to acquire the infection. However, amidst all these developments, it should not happen that the needs of the women and girls are ignored by the public health authorities. It is very much obvious that women and girls are more exposed to the risk of acquiring the infection and also that their essential sexual and reproductive health needs will take a back seat. Moreover, we hope that the issue of maternal health continues to remain a public health priority across all nations and under no circumstances, pregnant women are deprived of routine quality assured health care, access to information & counseling for safe delivery and infection control strategies in the health care establishments. In conclusion, amidst the battle of mankind against the COVID-19 infection, the need of the hour is to simultaneously ensure uninterrupted delivery of gender-sensitive services as the consequences of the disease for women and girls goes way beyond the caseload and attributed mortality.
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Thrombocytopenia in COVID parturients: Is less more of a concern? p. 145
TN Priyanka, Anju Gupta, Sulagna Bhattacharjee
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Virtual husband during delivery! Another COVID modification p. 146
Ketan S Parikh
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Multidisciplinary approach with favorable outcome in management of placenta accreta p. 147
Saurabh Sud, Deepak Dwivedi, Shalendra Singh, Alok Raj Gautam
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Attenuation of autonomic responses to laryngoscopy and intubation with intravenous nitroglycerin in a patient with severe preeclampsia and pulmonary edema undergoing cesarean section p. 149
Patchareya Nivatpumin
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Is intramyometrial carboprost troublesome? p. 150
Shankey Garg, Sanjay Kumar, Shalvi Mahajan
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Optic nerve sheath diameter measured using ocular sonography is raised in patients with eclampsia p. 152
Mahmood Dhahir Al-Mendalawi
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