Journal of Obstetric Anaesthesia and Critical Care

: 2013  |  Volume : 3  |  Issue : 1  |  Page : 52--59

Selected abstracts of the papers presented as poster presentation during the 5 th National conference of Association of Obstetric Anesthesiologist held in Delhi in September 2012


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. Selected abstracts of the papers presented as poster presentation during the 5 th National conference of Association of Obstetric Anesthesiologist held in Delhi in September 2012.J Obstet Anaesth Crit Care 2013;3:52-59

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. Selected abstracts of the papers presented as poster presentation during the 5 th National conference of Association of Obstetric Anesthesiologist held in Delhi in September 2012. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2019 Jun 26 ];3:52-59
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Anaesthetic management of an unconscious parturient with obstructed labour and thrombocytopenia: A case report

Ashish Khanna, Naresh Dua, Mamta Dagar, R. Sehgal, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Plasmodium vivax infection leading to thrombocytopenia is a rare entity in India. We report a case of plasmodium vivax induced thrombocytopenia in a pregnant patient who presented with deep transverse arrest.

A 24 year old, full term unconscious parturient, was referred from a peripheral hospital with deep transverse arrest and platelet count of 6,000/mm 3 with normal prothrombin and activated partial thromboplastin time. She was stabilized with platelet rich plasma, intravenous fluids and syntocinon infusion. After two hours, vaginal delivery was facilitated with vacuum extraction under monitored anaesthesia care. The neonate was intubated and ventilated because of acidosis and poor respiratory efforts.

A subsequent CT scan of the mother showed an intracerebral bleed. Emergency craniotomy was done to decompress the brain and patient was electively ventilated in the intensive care unit. Patient's trachea was extubated on the third postoperative day. On sixth day, the neonate was also successfully extubated. Both mother and neonate were discharged on 12 th postoperative day in healthy condition. This case highlights the multidisciplinary approach for successful management and outcome.

Obstetric admissions to mixed population adult intensive care unit: Burden or relief?

Satinder Gombar, Vanita Ahuja, Anudeep Jafra

Department of Anaesthesiology, Government Medical College and Hospital, Sector 32, Chandigarh, India

Introduction: Although pregnant women constitute a small number of admissions to an intensive care unit, but pose a significant challenge to the intensivist due to altered maternal physiology, fetal considerations and medical emergencies. Our aim was to assess the incidence and possible risk factors of obstetric patient admission to our mixed population adult intensive care unit (ICU).

Materials and Methods: A retrospective record analysis was done for all obstetric patients admitted to our 650 bedded tertiary care hospital over a 5-year period (June 2007 - June 2012). Obstetric patients with established or impending obstetric or medical organ failure were transferred to the mixed population adult ICU.

Results: During the 5-yr study period (June 2007 to June 2012) there were 21943 deliveries and out of these 164 women were admitted to the ICU contributing to 7.43 patients per 1000 deliveries for all obstetric hospital admissions. The mean ages of women were 25.32±4.11 with length of ICU stay 7.09 days (interquartile range of 3-8 days). The ICU admissions included 154 patients (93.90%) with obstetric disorders and 10 patients (6.09%) with medical disorders. The common disorders were preeclampsia 39(23.78%), puerperal sepsis 38(23.17%) and admissions following postoperative lower segment cesarean section 33(20.13%). Maternal mortality rate was of 48 (29.26%) for patients admitted in ICU. Factors that were significantly associated with higher mortality rate were absence of prenatal care, transfer to ICU >24 hrs after onset of the acute problem, and severity of illness at the time of admission as assessed by the SAPS II score.

Conclusion: Obstetric admission to mixed population adult ICU is small and early detection of problems and prompt referral could possibly reduce maternal mortality rate.

Comparative evaluation of efficacy of transcutaneous electrical nerve stimulation administered by dermatomal stimulation versus acupuncture points stimulation for labour analgesia

Kirti N. Saxena, Bharti Taneja, Sunil Shokeen

Department of Anaesthesiology, MAMC and LNJP Hospital, New Delhi, India

Introduction: Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological method based on gate theory of pain and provides analgesia noninvasively. Application of TENS requires simple training and can be self administered by patients with low potential for side effects. TENS can be administered by either dermatomal stimulation or by stimulation of acupuncture points for labour analgesia.

Materials and Methods: A prospective randomized study was conducted on 40 ASA grade 1 parturients with 37 to 42 weeks gestation in active stage of labour without any fetal or maternal complication, after obtaining hospital ethics committee approval and informed patient consent. The parturients were randomly allocated into two groups comprising of 20 parturients each. Group D parturients received TENS by dermatomal stimulation and Group A parturients received TENS by acupuncture points stimulation. VAS score was used to assess pain, ambulation was studied by ambulation grading, and maternal satisfaction was assessed by satisfaction score. Obstetrical outcome was studied by the obstetrician and fetal outcome was assessed by Apgar score.

Results: Parturients in group D reported significant decrease in VAS score, rescue analgesic requirement, decreased incidence of back pain, better satisfaction score and better ambulation as compared to group A. Obstetrical and fetal outcome were similar in both groups. No side effects were seen in either group.

Conclusion: Administration of TENS by dermatomal stimulation is more effective as compared to acupuncture point stimulation for pain relief during labour.

Use of proseal Lma in patients undergoing elective LSCS

Shalini Saini

Department of Anaesthesiology, UCMS and GTB Hospital, Delhi, India

Introduction: Anaesthesia for caesarean section poses many challenges unique to the obstetric patient due to various anatomical and physiological changes in the airway and respiratory system associated with pregnancy. These changes make these patients vulnerable to desaturation and a possible difficult airway. The choice of anaesthesia for caesarean section depends on the indication of the surgery, maternal status and the degree of urgency. However general anaesthesia (GA) is necessary in several situations. Supraglottic airway devices are an emerging method to secure airway especially in difficult situations. The use of PLMA has been reported successfully as a rescue device in difficult intubation situations and also in patients undergoing caesarean section without any complications. We planned to use PLMA in patients undergoing LSCS and compare it with tracheal tube (TT) for any changes in airway, hemodynamic stability and complications.

Materials and Methods: The study design was prospective, randomised controlled study. With Ethics committee approval and after obtaining informed consent, patients undergoing LSCS under GA belonging to ASA grade 1 and 2 were included. Patients with history of less than 6 hrs of fasting, known/predicted difficult airway, obesity, GERD, hypertensive disorder were excluded. A standard anaesthesia protocol was followed. Patients received aspiration prophylaxis, were preoxgenated, underwent RSI technique and airway was secured with either PLMA or TT. At the insertion of device- ease of insertion, adequacy of ventilation was observed. Hemodynamic changes were noted at insertion and removal. Intra-operatively, incidence of regurgitation and aspiration was noted. Data was analysed by unpaired t- test, Chi-square /Fisher's test.

Results: The findings of our study indicated that PLMA was easy to insert with comparable insertion time to TT and adequate ventilation was achieved immediately. Minimal hemodynamic changes were seen with PLMA as compared to TT at insertion and removal and this difference was significant. There was no incidence of regurgitation with the use of PLMA. Incidence of postoperative sore throat was minimum with PLMA (p<0.05).

Conclusion: PLMA appears to be a safe alternative to TT for selected obstetric patients undergoing elective LSCS.

A prospective randomized double blind study to evaluate and compare labour analgesia using Ropivacaine 0.2% in combination with Fentanyl 2μg/ml and Bupivacaine 0.1% in combination with Fentanyl 2μg/ml using Patient Controlled Epidural Analgesia (PCEA) technique

Saba Ahad, Prabhaker AK, B. N. Seth

Department of Anaesthesiology, Sant Parmanand Hospital, New Delhi, India

Background: Ropivacaine produces less motor block compared to Bupivacaine and may prevent prolongation of labour after epidural analgesia.

Materials and Methods: This prospective, double blind study was designed to evaluate and compare the effects of 0.2% Ropivacaine with Fentanyl 2μg/ml and 0.1% Bupivacaine with Fentanyl 2μg/ml using patient controlled epidural analgesia in labouring women with respect to duration of labour, maternal satisfaction and side effects of the drugs. After obtaining hospital ethics committee approval and informed patient consent, we randomized 100 (50 in each group) ASA physical status I and II parturients in the age group 18-30 years with term singleton pregnancy to receive epidural labour analgesia using either of the two drug combinations. Analgesia was started with 12ml of study solution as a bolus dose followed by basal infusion of 8ml/hr through patient controlled epidural analgesia with patient demand dose of 5ml with a lockout interval of 15 minutes (20ml/hr limit). Parturient who experienced inadequate analgesia were given an additional 8 ml bolus of study solution in increments of 4 ml.

Results: Both Bupivacaine and Ropivacaine provided effective labour analgesia with little or no difference in maternal satisfaction, mode of delivery, or other labour characteristics. In our study Ropivacaine caused less motor block particularly in prolonged duration of labour. This finding may be attributable to differences in drug potency between the two drugs. Although the use of Ropivacaine resulted in an increase in the duration of first stage of labour in the parturient who delivered vaginally, there were no differences in other outcomes. It is possible that Ropivacaine is less cardiotoxic than Bupivacaine when high doses are used but this is clinically unimportant in the usual dose range used for labour analgesia. Conclusion: Therefore, from a clinical and safety perspective, either drug is a reasonable choice for labour analgesia.

Anaesthetic management of a parturient with Takayasu Arterits associated with severe aortic regurgitation

Ravindran Chandran

Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India

Introduction: Takayasu arteritis is a chronic progressive inflammatory occlusive arteritis involving major blood vessels including subclavian, carotid and renal arteries. Anaesthetic concerns includes maintenance of haemodynamic stability in these patients as increase in systemic vascular resistance may lead to cerebral hemorrhage, cardiac failure and hypotension may lead to cerebral, renal, intestinal ischemia. We describe the anaesthetic management of cesarean section in a patient with Takayasu arteritis with severe aortic regurgitation by using combined spinal epidural technique.

Case Report: A 21-year-old primigravida (height 160 cm; weight 45 kg; 38 wks pregnancy) presented to the labour and delivery unit for caesarean section. She is a known case of Takayasu arteritis with 95% bilateral subclavian stenosis and 75% bilateral carotid stenosis. She had severe respiratory distress with palpitation during her fifth month of pregnancy and was diagnosed to have severe aortic regurgitation. Anaesthesia plan was to achieve a subarachnoid block with minimal dose of bupivacaine with the help of CSE technique. Monitoring included pulse oximetry, ECG, invasive blood pressure and CVP. The block was achieved with 7 mg bupivacaine and 25 mcg fentanyl. Intra-operative events were uneventful with minimal haemodynamic changes.

Conclusion: Anaesthetic challenges includes, achievement of good block levels with minimal haemodynamic changes and adequate organ perfusion. Combined spinal epidural technique is a useful technique in these patients as low dose subarachnoid block helps in maintaining good hemodynamic stability and supplementary local anaesthetics can be given through epidural route.

Post dural puncture headache in patients undergoing LSCS under sub arachnoid block: A morbidity analysis

Rishi Anand, Rachna Bhutani, P. Jain, B. Sharma, R. Sehgal, Arti Sharma, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Background: Post dural puncture headache (PDPH) is one of the most agonising complications of subarachnoid block (SAB). Previous studies have reported higher incidence in young women population. In this study factors affecting incidence of PDPH in pregnant women undergoing lower segment caesarean section (LSCS) were analysed.

Materials and Methods: This retrospective observational study was undertaken in patients who underwent caesarean section under subarachnoid block during period extending from 1 st January 2012 to 30 th June 2012 at a tertiary care referral Hospital. All records regarding intra operative management and postoperative follow up of above mentioned patients were collected and incidence of PDPH in relation with possible influencing factors like position of patients while performing SAB, type and size of needle, number of attempts and position of the patients during the block were noted.

Results: Total number of patients studied was 314. The incidence of PDPH was 4.46% (14/314). All cases of PDPH were reported in patients who received SAB with 25G Quincke needle. None was reported with 27G Whitacre needle. Incidence of PDPH was higher in patients if SAB was performed in sitting position (64.28%) in comparison to lateral position.

Conclusion: From the result of this retrospective study 27G Whitacre needle should be preferred to 25G Quincke needle for performing SAB. Lateral positioning of patient appears to be a better choice over sitting position to reduce the incidence of PDPH in our study.

Anaesthetic management of a case of large ASD with mild pulmonary hypertension in labour

Preety Sahu, W. S. Thatte, V. R. R. Chari

Department of Anaesthesiology, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Introduction: Atrial Septal Defect, a congenital disorder allows blood flow between the left and right thatria through th inter-atrial septum. Pulmonary hypertension is defined as a mean pulmonary arterial pressure greater than 25mmHg at rest or greater than 30mmHg during exercise.

Case Report: A 26 years old primigravida, 37 weeks gestation in labour was transferred from private hospital and caesarean section was planned. Patient was a known case of ASD since childhood with following findings in her case paper. She had a history of repeated URTI, moderate breathlessness.

On examination, the patient was pale, and had bilateral pitting pedal edema. Rest of the general examination was normal. No abnormality was detected in examination of the respiratory system. A pansystolic murmur was audible in the pulmonary and mitral areas, and S2 was wide split and fixed. The ECG showed right axis deviation, and incomplete RBBB. 2D ECHO showed grossly dilated left and right atrium and right ventricle, mild pulmonary hypertension, large ostium secondum ASD with left to right shunt. The ejection fraction was 60%.

The patient was premedicated with 0.2mg iv Glycopyrrolate. The patient was preoxygenated with 100% Oxygen for 3 min., and induction was done with injection Propofol 50mg, injection Ketamine 25mg and injection Rocuronium 40mg. Ketamine was used to maintain SVR. The patient was intubated with 7.0 mm cuffed endotracheal tube. The maintenance of anesthesia was done with oxygen, and N2O.

After delivery of child, inj. oxytocin 15units, Fentanyl 50mcg was given iv. Reversal of neuromuscular blockade was done with Neostigmine 2.5mg and Glycopyrrolate 0.5mg. Neostigmine 0.5mg and Naloxone 400mcg were given to avoid residual neuromuscular block and possible respiratory depression by opioid analgesic as patient was extubated in reasonable deeper plane of anaesthesia.

Post-extubation vitals were stable.

Conclusion: Here we present a case of ASD who had come for cesarean section in an emergency and underwent uneventful anaesthetic management. Anaesthetic management in such patients should focus on avoiding increase in pulmonary vascular resistance, decrease in systemic vascular resistance and avoiding hypoxia and hypercarbia.

Comparative evaluation of phenylephrine and ephedrine for treatment of spinal-induced hypotension in caesarean section

Mandeep, Dua C. K., Rashmi Sharma, Ragi Jain

Department of Anaesthesiology, Santosh Medical College and Associated Hospital, Ghaziabad, Uttar Pradesh, India

Introduction: Ephedrine is a commonly used vasopressor for spinal-induced hypotension, since it preserves the uteroplacental blood flow. Now, phenylephrine is also being used safely because it selectively spares uteroplacental blood flow.

Aim: To compare the effectiveness of phenylephrine and ephedrine in treatment of post-spinal hypotension and to observe and compare any maternal and fetal side effects.

Design and Setting: Prospective randomized double blind comparative study on 40 female pregnant patients undergoing caesarean section under spinal anesthesia using 2.5 ml of 0.5% hyperbaric bupivacaine.

Material and Methods: Forty pregnant female patients with ASA I and II aged between 20-35 years were included in the study, after obtaining hospital ethics committee approval and informed patient consent.. All the patients were given standard premedication and anti-aspiration prophylaxis. Preloading with ringer lactate (10ml/kg body weight) was given. Patients were divided randomly into two groups. Group E received 6mg ephedrine and Group P received 100mcg phenylephrine (I.V) for post-spinal hypotension Various parameters like heart rate, blood pressure, sensory and motor block, rescue analgesic, antiemetic and APGAR score were observed.

Result and Conclusions: Both ephedrine and phenylephrine effectively treated post-spinal hypotension without any adverse effects on Apgar score. Requirement of vasopressor boluses was more with phenylephrine as compared to ephedrine. Phenylephrine produced significant bradycardia.

Parturient with protein S deficiency for elective LSCS - Anesthetic implications

Heer Pansuria

Department of Anaesthesiology, Dr. D. Y. Patil Hospital and Research Centre, Pimpri, Pune. India

Introduction: Protein-S deficiency is autosomal dominant disorder manifested with thromboembolic events. Protein S is vitamin K dependant antithrombotic plasma protein that serves as cofactor for activated protein C. Normal pregnancy is associated with hypercoagulable state. With protein S deficiency, intravascular coagulation cascade is accentuated. Here we discuss anesthetic management of a parturient with protein S deficiency presented for cesarean section.

Case Report: 38 year old primigravida, conceived by IVF (Twin pregnancy) had one episode of right facial paresis at 16th wk, relieved within a week by IV steroids. MRI detected multiple infarcts in area of left middle cerebral artery. Diagnosed as protein S deficient- started on LMWH (aPTT adjusted twice normal). The patient also had PIH and GDM and was started on medication.

After 34 weeks, elective LSCS was planned. LMWH was stopped 24 hours prior to surgery. NBM checked, aspiration prophylaxis given, Preloading done, Stockings applied to avoid DVT. As INR: 1.08 and aPTT: 30 sec, spinal anesthesia given with 0.5%/2ml bupivacaine heavy and 20mcg Fentanyl. Intra-operative course was uneventful. Post-operative advice to start warfarin 48 hours after surgery, to stop LMWH when INR is between 2-3 and to get all blood relatives tested for protein S deficiency.

Conclusion: In pregnant patients, due to increased risk of aspiration and difficult intubation, regional anesthesia should be preferred whenever possible. Neuraxial anesthesia is safe in patients with protein S deficiency if appropriate work up is done and patient is off anticoagulants for sufficient time.

Intrauterine fetal transfusion- Anesthetic considerations

Mithilesh Kumar, Anjali Gera, Savitar Malhotra, Nandita, C. Sahai, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi India

Infusion of RBCs into the fetus is one of the most successful treatments for severe fetal anemia due to any cause. The most common cause of fetal anemia is Rh incompatibility between mother's blood type and that of the fetus (Rh isoimmunization). Ultrasound guided intravascular intrauterine transfusion of blood into umbilical circulation represents a significant step towards the management of severely Rh alloimmunized fetus.

We present the experience of intrauterine transfusion at our centre. In 6 pregnancies complicated by red cell isoimmunization, a total of 10 cordocenteses (9 transplacental and 1 intrahepatic) and blood transfusion were performed. A pre-procedure ultrasound was done for fetal weight, liquor quantity, and confirmation of position of the placenta and the cord. Transfusions were commenced at 24-34 weeks gestation and repeated up to 4 times, at an interval of 1-4 weeks.

The procedures were done under all aseptic conditions in an operating room with proper preparation of the mother. Under light sedation, local anesthesia was infiltrated at the site of needle insertion. A muscle relaxant (pancuronium 0.1 mg/kg) was given to the fetus to avoid movement during needle insertion.

The volumes of transfused blood were 5-150 ml, the hematocrit 62-88% and the rate of transfusions 1-15 ml/min. The pre-transfusion fetal hematocrits were 5-34% and the post-transfusion ones 28-60%. Of the 6 pregnancies, 4 delivered at 31-39 weeks and one underwent emergency LSCS due to fetal bradycardia and one baby was stillborn.

The intravascular intrauterine transfusion of red cells to a hydropic fetus notably improved the survival.

Epidural anaesthesia in patients with mitral stenosis for caesarean section - 3 Case Reports

Govindraj Bhat M., Gayathri Bhat, Sumalatha R. Shetty, Soumya Rao

Department of Anaesthesiology, K. S. Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India

Introduction: Mitral Stenosis is the predominant valvular lesion in most of the parturient. The incidence of maternal cardiac complications correlates with the severity of the mitral stenosis (67% for severe, 38% for moderate and 26% for mild disease). The pregnant patient with the heart disease challenges the skills in an anaesthesiologist. There is a trend towards Epidural anaesthesia in obstetrics and is the choice in the patient with mitral stenosis. Here we describe the successful management 3 cases.

Materials and Methods: We describe our management of 3 cases for LSCS with mitral stenosis. Case 1 was a primigravida at 39 wks of gestation with severe MS. Case 2 and Case 3 were primi and multigravida at 39 wks and 36wks of gestation respectively with moderate MS. Choosing an epidural anaesthesia in such type of patients demands expertise of the technique of introducing epidural catheter in pregnant patients, careful titration of local anaesthetic drugs with maintenance of arterial blood pressure. Hypotension is treated with fluid infusion and appropriate vasopressors to prevent the drop in systemic vascular resistance. Preoperative evaluations and medications, intraoperative meticulous monitoring of BP with invasive arterial line and the post operative pain relief was achieved in all the three cases.

Results: Keeping in mind the life-threatening complications in women with mitral stenosis, proper and adequate perioperative as well as postoperative care resulted in successful discharge of mothers with the newborns.

Conclusions: Thus we confirm epidural as a regional anaesthesia is effective in managing LSCS in patients with mitral stenosis.

Simultaneous caesarean section and craniotomy: Anaesthetic management

Rohit Jain, Dhiraj Mehra, Ashwin Marwaha, R. Sehgal, A. Jain, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

A 25-yr-old female patient presented with 8 months gestation with complaints of fever, decreased food intake and speech since 3-4 days and altered sensorium and irrelevant talk since 15 days. On detailed investigation she was found to be suffering from cortical vein thrombosis with right temporo-parietal haemorrhagic. Infant on treatment and had acute bilateral paraventricular and left temporal pole medial infarct. Her sensorium deteriorated rapidly and had seizures. She was intubated and put on mechanical ventilation. In view of her deteriorating condition, she was taken up for emergency LSCS to save the live fetus and decompressive craniotomy to save the mothers life. Emergency LSCS was done under GA and live fetus sent to nursery. Emergency LSCS was followed by bitemporal decompressive craniotomy. Further management and implications will be discussed.

An observational study on the effects of vasopressin on hemodynamic parameters during myomectomy

Anand Jain, Abhjit Singh, Anjeleena Kumar Gupta, R. Sehgal, VP. Kumra, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Intramyometrial injection of vasopressin has been known to reduce bleeding during uterine myomectomy. However the 'relatively long' clinical effect and the hemodynamic perturbations associated with the use of vasopressin pose a challenge for the anaesthesiologists. We studied the hemodynamic alterations during and after the injection of vasopressin as a hormonal tourniquet in 30 ASA 1/2 category patients, undergoing laparoscopic myomectomy in our tertiary level hospital. There were no significant hemodynamic changes observed with the use of vasopressin in lower doses and concentration. Also, the use of vasopressin significantly reduced the intraoperative blood loss and need for blood transfusion. However, one patient had significant drop in O 2 saturation associated with loss of bilateral radial pulse, which was conservatively managed and it resolved with in few minutes. In conclusion, vasopressin can be effectively used to reduce intraoperative blood loss during laparoscopic myomectomy with insignificant hemodynamic changes

Posterior reversible encephalopathy syndrome: Report of two obstetric cases

Megha Pruthi, Poonam Gupta, Prateek Verma

Department of Anaesthesiology, Safdarjung Hospital, New Delhi, India

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinico radiologic syndrome of vasogenic edema in the central nervous system leading to headache, seizure, confusion and frequent visual loss. Acute hypertension, eclampsia, immunosuppressive medication, infection or autoimmune diseases can all result in this condition. The biologic basis is likely an insult to cerebral vascular autoregulation. MRI is diagnostic, typical lesions predominate in the posterior white matter, with some involvement of the overlying cortex; and are hyperintense on T2-weighted images. Early recognition of this condition is of paramount importance because prompt control of blood pressure or withdrawal of immunosuppressive agents will cause reversal of the syndrome. Delay in the diagnosis and treatment can result in permanent damage to affected brain tissues.

Materials and Methods: Two obstetric patients presenting in intensive care unit with clinical and radiological correlation of PRES were studied and found to have two different causes for similar presentation.

Results: Posterior reversible encephalopathy syndrome (PRES), also known as posterior reversible leukoencephalopathy, reversible posterior cerebral edema syndrome, can occur in perpuerium as a result of eclampsia as well as sepsis in obstetric patients.

Conclusion: PRES should always be considered as an important differential diagnosis in a postpartum female with seizires, eclamptic or non eclamptic, as diagnosis has important therapeutic and prognostic implications because the reversibility of the clinical and radiologic abnormalities is contingent on the prompt recognition, prompt control of blood pressure, control of sepsis and/or discontinuing the offending drug. On the contrary, when unrecognized, conversion to fatal irreversible cytotoxic edema may occur.

Influence of epidural ropivacaine with fentanyl infusion on labour outcome: A case series of 30 parturients

Seema Shreepad Karhade, Dr. Shalini Sardesai, Dr. Shalini Thombre

Department of Anaesthesiology, Smt. Kashibai Navale Medical College and Hospital, Pune, Maharashtra, India

Introduction: Ropivacaine has been introduced into obstetric anaesthesia practice with proposed advantage causing less motor blockade compared to previously used L. A like Bupivacaine. But it is still unclear whether Ropivacaine is associated with any clinical benefits with regard to obstetric outcome. Hence we tried to find out obstetric and neonatal outcome with 0.2% Ropivacaine with 25 mcg of Fentanyl.

Aims and Objectives: To study analgesic efficacy, degree of motor blockade, incidence of operative (LSCS), normal vaginal, assisted vaginal deliveries and duration of second stage and immediate neonatal outcome.

Materials and Methods: Thirty, ASA 1 & 2 labouring primies with term cephalic, singleton pregnancies in active labour, having contractions at least 1 in 5 min. with cervical dilatation 3-4 cm were enrolled in this prospective study. Parturients having PIH, IDDM, fetal distress, fetal anomalies, APH, medical contraindications for epidural analgesia were excluded.

Ropivacaine 0.2% with 25 mcg of Fentanyl was given as an epidural bolus. Half an hour after the bolus a continuous infusion of 0.2% Ropivacaine at a rate of 10 ml/hr was started in all parturients. Pulse rate, NIBP, FHS, BMS, VAS, SpO2, extent of sensory block, duration of 1st, 2nd, 3rd stage of labour, mode of delivery, APGAR score of baby and any adverse effects were monitored.

Conclusion: The study drug does not have any adverse effect on maternal and fetal haemodynamics with satisfactory pain relief, no motor blockade, shortening of 2nd stage of labour and good neonatal outcome.

Comparative study of clonidine and fentanyl as adjuvant to intrathecal 0.5% hyperbaric bupivacaine in lower abdominal gynaecological surgeries

Neeraj Aggarwal

Department of Anaesthesiology, Pune, Maharashtra, India

Introduction: Clonidine is a partial α-adrenoceptor agonist used intrathecally with a well established record of efficacy, and safety. Its addition to local anaesthetic prolong the duration of both motor and sensory spinal blockade. Fentanyl, a lipophilic opioid, has rapid onset of action following intrathecal administration. Purpose of this study to compare onset and duration of sensory and motor block, haemodynamic changes and level of sedation on the table compared. Efficacy of post op analgesia following intrathecal bupivacaine with clonidine vs. intrathecal bupivacaine with fentanyl also compared.

Methods: Sixty female patients of ASA 1 and 2 of 20-60 yr scheduled for elective lower abdominal gynecological surgery were included, after obtaining hospital ethics committee approval and informed patient consent.. They were randomized by double blind method to receive either clonidine 50 microgram along with bupivacaine 3ml or fentanyl 30 microgram along with bupivacaine 3ml. Baseline parameter ECG, HR, NIBP, SPO2 were recorded before administering Subarachnoid block. After block, haemodynamic parameter, sensory level, motor blockade and sedation score were assessed at regular interval. Post-operative analgesia was assessed by VAS method.

Result: Time of onset sensory and motor blockade was comparable in both groups fentanyl being faster than clonidine. Time taken for segment regression and recovery of motor blockade was significant prolong in clonidine group. Hemodynamically bradycardia and hypotension more in clonidine but can be controlled by drugs. Post op analgesia better in clonidine.

Conclusion: Clonidine provides better and prolonged post-op analgesia though there is mild bradycardia and hypotension which can be easily controlled by drugs.

Comparision of ondansetron and ondensetron with dexamethasone to prevent postoperative nausea vomiting in short gynaecological procedures under general anaesthesia

Preety Sahu, WS Thatte, VRR Chari

Department of Anaesthesiology, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Introduction: The purpose of this study was to compare the efficacy of ondansetron-dexamethasone combination with ondansetron alone for prevention of postoperative nausea and vomiting. Ondansetron is a 5HT3 receptor antagonist. It exerts its effects by binding to the serotonin 5HT3 receptor in the chemoreceptor trigger zone (CTZ) and at vagal afferents in the gastrointestinal tracts. Dexamethasone is a glucocorticoid that produces strong antiemetic effect, by an undetermined mechanism.

It may act through prostaglandin antagonism, serotonin inhibition in the gut and by releasing endorphins.

Materials and Methods: Ater obtaining hospital ethics committee approval and informed patient consent, Patients were randomised into Group I and Group II, 30 in each group by double blind method. Group I received 4 mg of ondansetron intravenously, whereas Group II received ondansetron 4 mg and dexamethasone 8 mg i.v. 2 minutes before the induction of anaesthesia. Following pre-oxygenation, premedication with inj. glycopyrrolate 0.2mg, inj butorphenol 0.02mg/kg, the induction was done with inj. Propofol i.v. 2mg/kg & maintained with 33% O2, 66%N 2 O & 0.6-0.8% of isoflurane with patient breathing spontaneously. Patients were observed postoperatively for nausea, vomiting at 1, 6, 12, 24 hour.

Results: A complete response (no nausea, no vomiting) for 24 hrs postoperative period occurred in 80% of patients with ondansetron with dexamethasone group. In the ondansetron group it occurred in 50% of the patients. Only 2 patients (10%) in O + D group required antiemetic rescue, compaired to 9 patients (30%) in O group. The percentage of side effect was same in both the groups, most common being headache.

Conclusion: In the 24 hours post operative period ondansetron with dexamethasone was more effective then ondansetron alone for postoperative nausea and vomiting.

Doppler velocimetric changes following labour epidural analgesia in growth restricted fetuses with impaired umbilical blood flow: A randomised control trial

Suhken Samanta, Kajal Jain, Neerja Bhardwaj, Vanita Jain, Veenu Singla

Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Introduction: Epidural local anesthetics have been shown to improve uteroplacental blood flow in preeclamptic women during antenatal period and labor. We hypothesized that continous epidural labour analgesia (LA) with ropivacaine may improve uteroplacental blood flow in parturients with impaired umbilical blood flow and fetal growth restriction (FGR).

Methods: Thirty six pregnant women at term gestation with sonographic evidence of umbilical artery Systolic-Diastolic ratio ≥ 3(FGR) were assessed for eligibility to this randomized trial, after obtaining hospital ethics committee approval and informed patient consent.. In group E (Epidural) parturients received an incremental bolus of 10 ml ropivacaine 0.1% with 2μ/ml fentanyl followed by 5-15ml/hr continous infusion of the same drug. In group T (Tramadol), parturients received intramuscular tramadol 1mg/kg repeated every 4 hourly. Various Doppler indices like umbilical artery, bilateral uterine arteries pulsatility index, resistance index, systolic-diastolic ratio were measured at 0 hour, 1hour and 6 hour of LA in both the groups by a blinded radiology consultant. The primary outcome measure of the study was to assess changes in doppler pulsatility index, a measure of vascular resistance that is inversely related to blood flow Neonatal outcome was assessed by noting cord blood pH, base deficit and apgar score.

Results: Data from 30 laboring women, who completed the study, was analyzed. The pulsatility index (p=0.001), resistance index (p=0.001) and systolic-diastolic ratio (p=0.001) in umbilical arteries reduced at 1 st hour and 6 th hour from baseline in group E as compared to group T where indices increased at 1 st hour from baseline. However in this group, there was a decrease in doppler indices at 6 th hour as compared to 1 st hour value which was statistically not significant. A higher neonatal pH (p=0.039) and lower base deficit (p=0.013) was observed with epidural analgesia.

Conclusion: Our data suggest that Doppler blood flow improved as seen by decreased value of various Doppler indices with epidural LA. The analgesic efficacy, neonatal outcome and maternal satisfaction was also reported to be better with epidural analgesia. Although numerous Doppler flow studies on the effect of neuraxial blockade during labor on umbilical and uterine arteries have been published all were in normal labor. Our investigation is perhaps the only one in growth restricted fetuses with impaired Doppler indices.

Umbilical artery vascular resistance decreased and blood flow improved in epidural labour analgesia in parturients with growth restricted fetuses with mixed etiology in compared to intramuscular tramadol. And this result reflected in neonatal cord blood gas analysis and blood sugar level. The analgesic efficacy and maternal satisfaction is better with epidural analgesia.

Obstetric ICU - Need of the hour?

Sakshi Arora, Ranju Singh, Nishant Kumar, Aruna Jain

Department of Anaesthesiology, Lady Hardinge Medical College, New Delhi, India

Objective: This audit was carried out to ascertain whether a separate obstetric Intensive Care Unit (ICU) is justified in a tertiary level center of a developing country where the predominant hospital load of female patients is in the child bearing age.

Methods: The pattern of obstetric admissions and mortality in the general ICU of a tertiary care Hospital, over a 6 year (January 2006 to December 2011) period was retrospectively reviewed. Relevant data was extracted from the patients' case files, ICU records and hospital medical records department.

Results: Out of total 1005 admissions in the ICU, 396 (39.40%) were obstetric cases. Obstetric mortality in the ICU was 19.19% (76/396) compared to total mortality of 29.95% (301/1005). Obstetric mortality of the hospital was 220 implying that 144 patients couldn't receive intensive care. Maternal mortality in ICU was mainly due to pre eclampsia and eclampsia 34.21%, hemorrhage 22.36%, anemia 13.15%, heart disease 6.57%, other medical illness (ARDS, jaundice and hepatic encephalopathy) 23.67%.

Conclusion: Late presentation of patients coupled with inadequacy of a specialized obstetric ICU may have contributed to high maternal mortality in this audit. In a hospital which caters to such a large number of obstetric patients, an obstetric ICU seems to be justified.

Comparision of intravenous phenylephrine with intravenous mephentermine for management of post spinal hypotension in caeserian section and effects on neonate

Rajan Kumar

Department of Anaesthesiology, Dr. DY. Patil Medical College, Pune, Maharashtra, India

Introduction: This study is aimed at comparing the efficacy of intravenous bolus Phenylephrine or Mephentermine for management of fall in arterial blood pressure during spinal anesthesia in caesarian section.

Material and Methods: Sixty parturients under ASA 1 and ASA 2 scheduled for caesarian section at term were divided randomly into two groups of 30 each by double blind method, after obtaining hospital ethics committee approval and informed patient consent. Group (P) received Phenylephrine 100 mcg in 1 ml intravenously as bolus. Group (M) received Mephentermine 6 mg in 1 ml intravenously as bolus, whenever Blood Pressure falls by more than 20% of baseline.

Results: Fall in blood pressure in all patients was 20 to 25 % of baseline. Correction of fall in blood pressure was within 1 minute in the Phenylephrine group and 2 to 3 minute in Mephentermine group. Fall in pulse rate was 15 to 17 % of baseline in Phenylephrine group but not seen in Mephentermine group. Six cases had to be given Atropine 0.3 mg to manage bradycardia. There was no significant effect of vasopressors on fetus in terms of Apgar score.

Conclusion: At the doses of Phenylephrine and Mephentermine administered in this trial the ability of these drugs to manage hypotension during caesarian section proved to be similar, though Phenylephrine has quicker control of hypotension and less number of bolus dose are required to manage hypotension than Mephentermine. Phenylephrine causes reduction in heart rate which may be advantageous in cardiac patients and in whom tachycardia is undesirable.

Evaluation of analgesic efficacy of the combination of fentanyl with low dose bupivacaine vs. ropivacaine using patient controlled epidural analgesia for control of labour pain

Nitin Ahuja, Sukanya Mitra, Lakesh Anand, Reeti Mehra

Department of Anaesthesiology, Government Medical College and Hospital (GMCH), Sector 32, Chandigarh, India

Introduction: One of the most popular and efficient method of pain relief is the epidural analgesia technique. Low concentrations of bupivacaine or ropivacaine provide excellent analgesia without significant motor block.

Materials and Methods: A total of 60 parturients with the following major inclusion criteria of: ASA grade I and II; cephalic presentation at ≥ 36 wk of gestation; In early spontaneous labour (cervical dilation ≤ 5 cm); baseline pain score >30 (on a 0-100 VAS); able to use PCEA pump and requesting epidural analgesia for labour, were included in the study. This was a prospective, randomized and double blind study, conducted after approval by hospital ethics committee and informed patient consent. Sixty parturients were randomly assigned to two groups of 30 each to receive one of the following regimens of 0.1% ropivacaine with 2 μg/ml of fentanyl (Group I) or 0.1% bupivacaine with 2 μg/ml of fentanyl (Group II) solution to maintain epidural analgesia. The primary outcome was to evaluate and compare the analgesic efficacy of combination of low dose bupivacaine and ropivacaine with fentanyl for control of labour pain and note the side effects if any.

Results: Among the two comparator groups, group I, with 0.1% bupivacaine, observed significantly lower VAS scores at hours 1 and 2 (p < 0.001 and 0.05 respectively), lower total drug consumption (Mean: 48.47 ± 16.735 mg, p = 0.019) and lower bolus requirement (Mean: 1.40 ± 0.894, p = 0.010), compared to group II, with 0.1% ropivacaine. But, the motor blockade was significantly lesser in the 2 nd group (0.1% ropivacaine plus 2 μg /ml of fentanyl) during the 4 th and the 5 th hour (p = 0.009 and 0.001 respectively). The rest of the recorded parameters, neonatal outcome, maternal satisfaction, mode of delivery and onset time were similar for both the groups.

Conclusion: Both the combinations, 0.1% ropivacaine and 0.1% bupivacaine in combination with 2 μg/ml of fentanyl, are overall observed to be equally effective for labor analgesia. There was no difference in other outcome parameters in both groups.

Relationship between the mode of delivery and initiation of breast feeding: an observational study

Ashish Gandhi, Anjeleena Kumar Gupta, Ichha Kaur, B. Sharma, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Background: Breast feeding is an extremely time sensitive relationship which is associated with benefits for lifelong health of both mother and child. All mothers irrespective of their mode of delivery should initiate breast feeding within half an hour of delivery in accordance with baby friendly hospital initiative of WHO/UNICEF.

Objective: To study the relationship between the mode of delivery and the time of initiating breast feeding and to evaluate whether the WHO guidelines in this regard are being followed.

Methods: It is an observational study carried out in a tertiary care centre in an urban educated population, after approval by hospital ethics committee and informed patient consent. One hundred fifty females who had their delivery conducted in our hospital were enrolled. The data was collected using a questionnaire regarding parity, mode of delivery, knowledge about breast feeding, time of first breast feed and bonding were statistically analyzed.

Results: Majority of mothers lacked knowledge about the appropriate time of initiation of breast feeding. Significant delay in the time of initiation of breast feeding was noticed among women who delivered via caesarean section as compared to those who delivered vaginally. Rates of early breast feeding were even lower in patients who underwent emergency caesarean sections.

Conclusion: There was a delay in initiating the breast feeding irrespective of the mode of delivery. There is a need to identify the hospital practices which hinder breast feeding. Every effort should be made the first breast feeding on the operation table itself.

Anaesthetic management of a pregnant patient with primary pulmonary hypertension

Mamta Sethi, Raj Tobin, Ripul Oberoi, Deep Arora

Department of Anaesthesiology, Max Superspeciality Hospital, Saket, New Delhi, India

Introduction: Primary pulmonary hypertension is defined as sustained elevation of mean pulmonary artery pressure greater than 25mmHg without any identifiable cause. It usually affects women of child bearing age resulting in a maternal mortality of greater than 50%.

Case Report: A 24 year old primigravida with 32 weeks gestation presented with complaints of abdominal pain, progressive increase in dyspnea and pedal oedema. She was diagnosed with primary pulmonary hypertension (mean PAP 46 mmHg & RVSP 90mmHg) with right ventricular failure. Medical management with injection frusemide, enoxaparin and tablet sildenafil was initiated. She underwent elective caesarean section under combined spinal epidural block. The intraoperative period was uneventful. Postoperatively she was tachypneic and was intubated on 2 nd postoperative day. She developed right heart failure with left lung collapse. Tablet sildenafil, bosentan, digoxin and enoxaparin were restarted. On 3 rd postoperative day she developed atrial flutter with hypotension and stabilized hemodynamically with noradrenaline and amiodarone infusion. She was weaned off the ventilator on 8 th postoperative day. Post-extubation she had signs of right heart failure and required BiPAP support for 2 days. She was discharged after 24 th postoperative day.

Conclusion: Primary pulmonary hypertension during pregnancy is a fatal condition. Maintaining a low pulmonary vascular resistance and avoiding a decrease in right ventricular preload can lead to a favourable outcome in these patients

A randomized control trial to evaluate the effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain after lower segment caesarean section

Deepti Gupta, Ranju, Aruna Jain

Department of Anaesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Introduction: Intrathecal clonidine prolongs spinal anaesthesia but the optimum dose in caesarean section is not yet known. We evaluated the effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain after lower segment caesarean section (LSCS).

Materials and Methods: After approval by hospital ethics committee and informed patient consent, 105 parturients carrying a singleton fetus at term, scheduled to undergo elective LSCS under spinal anaesthesia were randomized in a double blind fashion to one of the three groups. Group BF (n= 35) received 2ml of 0.5% hyperbaric bupivacaine + 25μg fentanyl, Group BC 50 (n= 35) received 2ml of 0.5% hyperbaric bupivacaine + 50μg clonidine, Group BC 75 (n= 35) received 2ml of 0.5% hyperbaric Bupivacaine with 75μg clonidine.

Results: The duration of postoperative analgesia was 184.73 ± 68.64 minutes in group BF, 360.71 ± 86.51 minutes in group BC 50 and 760.50 ± 284.03 minutes in group BC 75 , p<0.001. The incidence of hypotension was comparable, p=0.932 whereas the incidence of nausea and pruritis was significantly lower in groups BC 50 & BC 75 as compared to group BF, p<0.001. No other side effects of intrathecal clonidine were detected. Neonatal outcome was similar in all the three groups.

Conclusions: Addition of 75μg clonidine to hyperbaric bupivacaine in spinal anaesthesia for LSCS significantly prolongs the duration of postoperative analgesia without any increase in maternal side effects. There was no difference in neonatal outcome.

Frequency of anxiety in patients having caesarean section in general or regional anaesthesia

Darshana Maheshwari, Samina Ismail

Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan

Introduction: Patients undergoing surgery experience anxiety, which may be even higher in obstetric patients because of additional concerns of fetus being exposed to anaesthesia. The objective of our study was to determine the frequency of anxiety and its impact on the parturient's decision regarding the choice of anaesthesia for their caesarean section (CS).

Materials and Methods: This was a prospective cross sectional study. A total of one hundred fifty four patients were enrolled in the study for a period of three months after approval by hospital ethics committee and informed patient consent. Patient's demographic data, level of education, occupation, previous anaesthesia experience, source of information and patient's choice of anaesthesia was recorded by primary investigator. Anxiety was measured by using visual analogue scale (VAS). Patient labeled as anxious if VAS ≥ 50.

Results: Overall 56.49% patients were anxious coming for elective CS. Frequency of anxiety was 91.50% in general anaesthesia (GA) group, while 26.50% in regional anaesthesia (RA) group. The difference in anxiety between both groups was statistically significant (p value of 0.0005). Age of the parturient had no influence on anxiety. Education level of the parturients i.e., Intermediate and graduates were more anxious in GA (95% and 90%) as compare to RA (37% and 23.5%). Primigravida were more anxious both in GA and RA with 100% and 82% respectively.

Conclusion: Frequency of anxiety was statistically higher in GA group as compare to RA group. Hence we need to employ measures to reduce anxiety and enhace the rate of RA in our tertiary care unit.

Primary pulmonary hypertension for caesarean section - A case report

Ishtiyaque Hussain, Manish Gupta, R. Sehgal, VP. Kumra, J. Sood

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Background: Primary pulmonary hypertension (PPH) is a progressive and fatal disease characterized by elevated pulmonary artery pressures (>25mm Hg) in the absence of any known aetiology. The patients are usually advised not to become pregnant as the chances of decompensation are high and the disease is associated with a high mortality rate (30-50%) even in the most advanced tertiary care centres. We describe a case of a pregnant woman with severe PPH who underwent elective caesarean section under regional anaesthesia with good maternal and neonatal outcome.

Anaesthetic Technique: A 29 yr female, known case of PPH presented at 14 wks of pregnancy was managed in consultation with the cardiologist. At 29 weeks elective LSCS was planned due to worsening cardiac status as she developed breathlessness & chest pain along with rapid increase in pulmonary artery pressures despite sildenafil therapy. CVP & intra-arterial lines were put under local anaesthesia. Combined spinal epidural anaesthesia was administered with slow and gradual supplementation of central neuraxial block. Subarachnoid block (0.5 ml 0.5% bupivacaine + fentanyl 25μg) was supplemented with slow increments of epidural bupivacaine to a total dose of 15 ml. Inj. fentanyl 60μg + midazolam 1mg I.V. were given after delivery. Postoperative pain relief was provided with epidural PCA in CCU. O 2 inhalation and Inj. frusemide were also given. Patient had an uneventful recovery and was later discharged.

Conclusion: We recommend that parturients with PPH should be managed using a multidisciplinary approach and needs follow up care in a tertiary care center.