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Journal of Obstrectic Anaesthesia and Critical Care
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REVIEW ARTICLE
Headache in the parturient: Pathophysiology and management of post-dural puncture headache
Gita Nath, Maddirala Subrahmanyam
July-December 2011, 1(2):57-66
DOI:10.4103/2249-4472.93988  
Headache in the postpartum period is common and multifactorial in origin. Apart from primary causes such as tension headaches and migraine, secondary headaches such as post-dural puncture headache (PDPH) are increasingly common because of increasing use of regional anaesthesia and analgesia during childbirth. Preventive measures for PDPH include the use of smaller gauge pencil-point needles for spinal blocks; epidural needles of 18 G or less; using saline rather than air for epidural space identification and the use of ultrasound guidance, especially for difficult cases such as morbid obesity and spinal deformities. In case of accidental dural puncture (ADP), the choice is between inserting the catheter in an adjacent space or intrathecal catheterization. Current evidence seems to be in favour of inserting the epidural catheter into the subarachnoid space and using the intrathecal catheter for analgesia/anaesthesia after prominently labelling it as intrathecal, to prevent misuse. It should be removed after at least 24 hours and a 10 ml bolus of saline injected before removal of catheter may be helpful. Either way, having written protocols for the management of accidental dural puncture helps to reduce the incidence of PDPH. PDPH can be disabling in severity and can mar the whole experience of childbirth. In addition, severe untreated PDPH can cause complications such as nerve palsies, subdural hematoma and cerebral venous thrombosis. Conservative methods of treatment should be tried first such as adequate hydration, paracetamol, caffeine, sumatriptan or ACTH/hydrocortisone. Epidural blood patching is the most effective treatment for PDPH. It is more effective if done 24-48 hours after dural puncture. It is an invasive procedure with its own complications as well as a failure rate of up to 30%, so that a second or even third patch may be necessary. Both these facts should be intimated to the patient beforehand. Meticulous follow-up and evaluation of these patients is an important responsibility of the obstetric and anaesthetic team. Persistent headache, loss of the postural nature of the headache, altered sensorium, onset of focal neurological deficits and seizures are all features necessitating further investigation including neuroradiological imaging.
  17,335 2,424 1
ORIGINAL ARTICLES
The Baska Mask® -A new concept in Self-sealing membrane cuff extraglottic airway devices, using a sump and two gastric drains: A critical evaluation
Tom van Zundert, Stephen Gatt
January-June 2012, 2(1):23-30
DOI:10.4103/2249-4472.99313  
Background: In this study, we evaluated the performance of the Baska Mask® , a new extraglottic airway device (EAD) for use in anesthesia in adult patients undergoing a variety of surgical interventions. Materials and Methods: The self-recoiling membrane distally open cuff silicone mask consists of an anatomically curved airway tube with: (1) a bite block over the full length of the airway; (2) a self-sealing membranous variable-pressure cuff which adjusts to the contours of the mouth and pharynx; (3) a large sump cavity with two aspiratable gastric drain tubes; together with a number of special features such as (4) a tab for manually curving the mask to ease insertion; and (5) a suction elbow integral to one port with a second port acting as a free air flow access. The cuff of the Baska Mask® is not an inflatable balloon, but a membrane which inflates on every breath during intermittent positive pressure ventilation (IPPV) to achieve a superior seal when opposed to the larynx. An increase in IPPV pressure increases the oropharyngeal seal. With existing extraglottic airway devices, an increase in IPPV merely increases the leak. Results: Fifty patients with American Society of Anesthesiologists (ASA) physical status I-III were enrolled. We evaluated the "first attempt" and "overall insertion" success rates, insertion time, ease of insertion and removal of the device, oropharyngeal leak pressure, and anatomical position at fiberoptic view. The "first attempt" success rate was high (88%) and "overall insertion" success rates was considered "easy" to "very easy" by the operators in 92% of patients. Removal of the device was considered easy in all cases. The oropharyngeal leak pressure was above 30 cm H 2 O in all patients and the maximum of 40 cm H 2 O was achieved in 82% of the patients. In two patients, no adequate capnogram was obtained, so a smaller size mask was inserted with correction to adequate function. At fiberoptic evaluation of the anatomical position of the masks, the vocal cords could be seen, except in six patients (12%), where only the epiglottis could be visualized. Conclusion: The new EAD Baska Mask® has many novel features which should improve safety when used in both spontaneously breathing and IPPV anesthesia.
  17,256 1,701 7
REVIEW ARTICLE
Anaesthetic management of patients with peripartum cardiomyopathy
Rashmi Ramachandran, Vimi Rewari, Anjan Trikha
January-June 2011, 1(1):5-12
DOI:10.4103/2249-4472.84249  
Peripartum cardiomyopathy (PPCM) is a disease affecting the parturient during late pregnancy or immediately after delivery. This unique disorder not just endangers the life of mother and progeny but is also a financial burden to the health system due to its potential to cause prolonged and persistent cardiac function insufficiency in the mother. The hallmark of the disease is onset of decreased cardiac ejection fraction either in the late pregnancy or early puerperium. Over the last few decades, the disease has been extensively researched and investigated to formulate diagnostic guidelines and therapeutic approaches. Many theories regarding its pathophysiology have also been proposed. The clinical presentation and the basic and intensive interventional strategies of the disease are more or less similar to that of dilated cardiomyopathy due to any other cause; however, at all points of time the pregnant or lactating state of mother and the subsequent effect of the medication and therapeutic interventions on the fetus or neonate needs to be considered. Apart from intensive care management, these patients may also require anaesthetic intervention for management of painless labor and/or either vaginal or operative delivery. Favorable maternal and fetal outcome require that the basic hemodynamic goals be always kept in mind while choosing the techniques and drugs to provide anaesthesia to the patients with PPCM. Literature search of the anaesthetic management of patients with diagnosis of PPCM undergoing operative delivery reveals both general and regional anaesthesia being used with comparable outcomes.
  14,483 3,051 -
REVIEW ARTICLES
Dexmedetomidine in pregnancy: Review of literature and possible use
Abhijit S Nair, K Sriprakash
January-June 2013, 3(1):3-6
DOI:10.4103/2249-4472.114253  
Dexmedetomidine is a highly selective α-2 agonist, which when used in recommended dose in the form of an infusion, has several desirable properties like sedation, anxiolysis, sympatholysis, analgesia, decreased anesthetic requirements, maintains cardiovascular stability and provides a smooth recovery. Anesthesiologists have used this drug with great reluctance in parturients due to possible uteroplacental transfer, thereby, causing undesirable effects in the baby. However, literature shows that as dexmedetomidine has a high placental extraction, it doesn't ge transferred to the baby. We tried to review the available literature so as to find in what circumstances it has been used in parturients and in future what are the possible indications of its use in labor analgesia, cesarean section, and non-obstetric surgeries.
  12,214 1,794 10
EDITORIAL
Multimodal analgesia for cesarean section: Evolving role of transversus abdominis plane block
Samina Ismail
July-December 2012, 2(2):67-68
DOI:10.4103/2249-4472.104729  
  5,025 8,462 1
Ultrasound for obstetric neuraxial anesthetic procedures: Practical and useful?
Jason Lie, Santosh Patel
July-December 2015, 5(2):49-53
DOI:10.4103/2249-4472.165130  
  4,766 8,192 -
ORIGINAL ARTICLES
Epidural labor analgesia: A comparison of ropivacaine 0.125% versus 0.2% with fentanyl
Yogesh Kumar Chhetty, Udita Naithani, Sunanda Gupta, Vikram Bedi, Ila Agrawal, Lalatendu Swain
January-June 2013, 3(1):16-22
DOI:10.4103/2249-4472.114284  
Background: Minimum effective concentration of local anesthetics for providing optimal labor epidural analgesia and the strategies aiming to reduce their consumption are continuously being searched. Objectives: The objective of this study was to evaluate the efficacy of 0.125% and 0.2% ropivacaine both mixed with fentanyl 2 mcg/ml for epidural labor analgesia. Materials and Methods: A total of 80 parturients in active labor were randomly assigned to two groups of 40 each, to receive an epidural injection of 15 ml ropivacaine 0.125% with fentanyl (2 mcg/ml) in group R1 and 15 ml of ropivacaine 0.2% with fentanyl (2 mcg/ml) in group R2 as initial bolus dose. Same dose regimen was used as subsequent top-up dose on patients demand for pain relief. The duration and quality of analgesia, motor block, top-up doses required consumption of ropivacaine and fentanyl and feto-maternal outcome in both groups were compared. Results: Effective labor analgesia with no motor blockade was observed in both groups with no failure rate. Onset of analgesia was significantly faster in group R2 (75% parturients in 0-5 min) as compared to group R1 (25% parturients in 0-5 min), P < 0.001. Duration of analgesia after initial bolus dose was also significantly longer in group R2 (132 ± 56.81 min) than in group R1 (72.25 ± 40.26 min), P < 0.001. Mean VAS scores were significantly less in group R2 than in group R1 at 5, 60, and 90 min, P < 0.01. Requirement of top-up doses was significantly less in group R2 (0.05 ± 0.22) as compared to group R1 (0.80 ± 0.65), P < 0.001. Consumption of ropivacaine was comparable in both the groups (33.75 ± 12.16 mg in group R1 and 31.50 ± 6.62 mg in group R2 P > 0.05), but consumption of fentanyl was significantly more in group R1 (54.00 ± 19.45) as compared to group R2 (31.50 ± 6.62), P < 0.001. There were no significant changes in hemodynamics, nor adverse effects related to neonatal or maternal outcomes in both groups. Conclusion: We conclude that both the concentrations of ropivacaine (0.2% and 0.125%) with fentanyl are effective in producing epidural labor analgesia. However, 0.2% concentration was found superior in terms of faster onset, prolonged duration, lesser breakthrough pain requiring lesser top-ups, and hence a lesser consumption of opioids.
  11,741 1,197 1
REVIEW ARTICLES
Anesthesia for in vitro fertilization
Ankur Sharma, Anuradha Borle, Anjan Trikha
July-December 2015, 5(2):62-72
DOI:10.4103/2249-4472.165132  
In vitro fertilization (IVF) is one of the most recent advances in the treatment of infertility. The availability and utilization of this technology are increasing by the hour. IVF procedures are usually performed on an outpatient basis under day care surgery units. Various anesthetic modalities and analgesic regimens have been tested in different studies, but no definite conclusion so far been made regarding the preferred technique for anesthesia and pain relief for these procedures. Many anesthetic drugs have been detected in the oocyte follicular fluid and may potentially interfere with oocyte fertilization and implantation. The ideal anesthetic technique for IVF should provide good surgical anesthesia with minimal side effects, a short recovery time, high rate of successful pregnancy, and shortest required duration of exposure. The preferred method of anesthesia and analgesia should be individualized as at present there are no perfect answers.
  9,471 1,857 3
REVIEW ARTICLE
Neuraxial blocks in parturients with scoliosis and after spinal surgery
Mouveen Sharma, Ian McConachie
July-December 2016, 6(2):70-74
DOI:10.4103/2249-4472.191594  
Neuraxial blocks in parturients with scoliosis and/or previous back surgery have traditionally been avoided due to concerns such as difficulty, increased complications, and decreased efficacy. Recent studies suggest that with attention to proper anesthetic technique and improvements in surgical procedures the success rate of neuraxial blocks is improved. The use of ultrasound may also improve the success rate of neuraxial blocks and should be considered. We review the recent literature and suggest practical approaches to neuraxial blocks in these parturients.
  9,362 1,959 -
EDITORIAL
Sellick maneuver revisited
Pramod Kohli
July-December 2014, 4(2):57-58
DOI:10.4103/2249-4472.143872  
  3,277 7,796 -
REVIEW ARTICLES
Renal diseases during pregnancy: Critical and current perspectives
Sukhminder Jit Singh Bajwa, Ishwardeep Singh Kwatra, Sukhwinder Kaur Bajwa, Maninder Kaur
January-June 2013, 3(1):7-15
DOI:10.4103/2249-4472.114257  
The advancements in medicine have made early detection and management of medical diseases possible especially during the pregnancy. The physiologic alterations of pregnancy have important implications for renal structure and functions, which may possibly lead to diagnostic dilemmas and wrong interpretation of various investigations carried out during the gestational period. Renal diseases are extremely challenging to treat during pregnancy as various drugs can have adverse effect on the pregnancy outcome. In general, these patients may either progress to normal delivery or may have to undergo surgical delivery under anesthesia. Apart from these anticipated challenges, many other renal problems can develop during the pregnancy in patients with normal renal functions such as urinary tract infections, acute kidney injury or renal trauma. Planning of pregnancy in renal diseases is also associated with increased potential risks especially in patients on dialysis as well as in patients who had undergone renal transplantation.
  9,878 1,171 -
ORIGINAL ARTICLES
Comparison between phenylephrine and ephedrine in preventing hypotension during spinal anesthesia for cesarean section
Iqra Nazir, Mubasher A Bhat, Syed Qazi, Velayat N Buchh, Showkat A Gurcoo
July-December 2012, 2(2):92-97
DOI:10.4103/2249-4472.104734  
Background: Maternal hemodynamic changes are common during spinal anesthesia for cesarean delivery. Many agents are used for treating hypotension. In this study we compared the efficacy of ephedrine and phenylephrine in preventing and treating hypotension in spinal anesthesia for cesarean section and their effect on fetal outcome. Materials and Methods: A total of 100 ASA Grade I patients undergoing elective cesarean section under spinal anesthesia with a normal singleton pregnancy beyond 36 weeks gestation were randomly allocated into two groups of 50 each. Group I received prophylactic bolus dose of ephedrine 10 mg IV at the time of intrathecal block with rescue boluses of 5 mg. Group II received prophylactic bolus dose of phenylephrine 100 μg IV at the time of intrathecal block with rescue boluses of 50 μg. Hemodynamic variables like blood pressure and heart rate was recorded every 2 minutes up to delivery of baby and then after every 5 minutes. Neonatal outcome was assessed using Apgar score at 1 and 5 minutes and neonatal umbilical cord blood pH values. Results: There was no difference found in managing hypotension between two groups. Incidence of bradycardia was higher in phenylephrine group. The differences in umbilical cord pH, Apgar score, and birth weight between two groups were found statistically insignificant. Conclusion: Phenylephrine and ephedrine are equally efficient in managing hypotension during spinal anesthesia for elective cesarean delivery. There was no difference between two vasopressors in the incidence of true fetal acidosis. Neonatal outcome remains equally good in both the groups.
  9,839 1,104 5
CASE REPORTS
Anaesthetic implications of antiphospholipid antibody syndrome in pregnancy
Priyanka Garg, Prachi Gaba, Kirti N Saxena, Bharti Taneja
January-June 2011, 1(1):35-37
DOI:10.4103/2249-4472.84254  
Antiphospholipid antibody syndrome is an autoimmune disorder characterized by venous and/or arterial thromboses. When present in women of reproductive age, it is associated with recurrent loss of pregnancy. This case report summarizes the perioperative course and anaesthetic management in a patient with bad obstetrics history who had to undergo emergency caesarean section.
  9,764 1,110 -
Anesthetic management of a parturient with Guillain-Barre syndrome posted for emergency caesarian section
Abhijit Paul, Kasturi H Bandyopadhyay, Viplab Patro
January-June 2012, 2(1):40-43
DOI:10.4103/2249-4472.99321  
We report the anesthetic management of a case of Guillain-Barre syndrome in the 34 th week of gestation coming for an emergency Cesarean section. The perioperative anesthetic challenges have been discussed with emphasis on the medical and anesthetic management which includes the use of plasma-pheresis, intravenous gamma-globulin, and the safety of preservative free 0.75% isobaric ropivacaine, which was administered intrathecally in this difficult medical condition with excellent hemodynamic, maternal, and fetal outcome. The sensory and motor blocks achieved were well suited to the clinical risks and conditions.
  9,971 750 1
ORIGINAL ARTICLES
Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India
Udita Naithani, Prerna Bharwal, Sandeeep Singh Chauhan, Deepak Kumar, Sunanda Gupta, Kirti
January-June 2011, 1(1):13-20
DOI:10.4103/2249-4472.84250  
Background : The present audit was initiated to evaluate the knowledge, attitude, perception and acceptance of women toward labor analgesia and caesarean section, in a Medical College Hospital in Udaipur, India. Materials and Methods : A semi-structured interview of 200 antenatal women was conducted, to assess the knowledge, attitude and perception regarding labor analgesia and caesarean section (CS) and to estimate the correlation of awareness and acceptability with demographic variables. The data were analyzed using Epi Info 6 and the Likert type scale (0 - 10), as also the chi square test, to calculate the statistical significance. Results : Most of the patients (n = 181, 90.50%) were unaware of labor analgesia. When the option of labor analgesia was offered, only 23% (n = 46) accepted it and the most significant reason for refusal was to experience natural child birth (n = 114 / 154, 74.03%). An educational status of the graduate level had a positive impact on knowledge about labor analgesia (P = 0.0001). When the option for CS was offered, 73.50% women (n = 147; P = 0.008) refused and the most common reasons for refusal were fear of operation (53.06%, n = 78) and delay in resuming household work (46.26%, n = 68). Educational status up to the graduate level and previous surgical experience of CS had a positive correlation with preference for CS (P = 0.0092 and P = 0.0001, respectively). Conclusions : Awareness and acceptance for labor analgesia was relatively low among the prospective parturients. A higher level of education had a significant impact on their decisions regarding delivery.
  9,523 1,185 -
ABSTRACTS
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

January-June 2013, 3(1):52-59
  9,750 554 -
CASE REPORTS
Anesthetic management of cesarean section with mitral stenosis and respiratory tract infection
Madagondapalli Srinivasan Nataraj, Venkateshaiah Giri
July-December 2014, 4(2):78-80
DOI:10.4103/2249-4472.143877  
Mitral stenosis in pregnancy is poorly tolerated because of the pregnancy induced physiological changes in the cardiovascular system. Our patient had presented with cardiac failure in 5 th month of gestation due to valve area of 0.8 cm 2 . She underwent commissurotomy and was asymptomatic with valve area of 1.6 cm 2 until term when she developed lower respiratory tract infection. Anesthetic management of emergency caesarean section in this patient is discussed where neuraxial block is not well-tolerated, and general anesthesia is associated with increased morbidity in the presence of reactive airways.
  9,124 1,177 -
Anesthetic implications in systemic lupus erythematosus patients posted for cesarean section: A series of five cases
Parul Jindal, Ruchi Kapoor, Gurjeet Khurana, Jaya Chaturvedi
July-December 2013, 3(2):97-100
DOI:10.4103/2249-4472.123306  
Management of a parturient with systemic lupus erythematosus (SLE) requires a multidisciplinary approach. Although the ideal treatment strategy has not been formulated, certain management principles are recommended. We discuss the perioperative course and anesthetic management of five parturient with history of SLE who underwent cesarean section.
  9,268 896 -
REVIEW ARTICLE
Complex regional pain syndrome and pregnancy
Anjan Trikha, Dalim Kumar Baidya, PM Singh
July-December 2012, 2(2):69-73
DOI:10.4103/2249-4472.104730  
Complex regional pain syndrome (CRPS) is a chronic pain condition predominantly affecting females of the reproductive age group. Association of CRPS and pregnancy has been increasingly reported in recent literature. Anesthesiologist and chronic pain physician may be involved in the management of CRPS during pregnancy and for peripartum anesthesia management for vaginal delivery or cesarean section. Any woman suffering from CRPS should be counseled about the limited therapeutic options available during pregnancy. Medical management of CRPS is complicated by risk to breast-fed babies and teratogenicity to fetus. However, interventional management in the form of transcutaneous electrical nerve stimulation and spinal cord stimulation may be used with due precautions. Multidisciplinary involvement of obstetrician, anesthesiologist, pain physician, and neonatologist is important to ensure successful outcome.
  8,106 2,006 1
EDITORIAL
Sustaining two lives…
Yoo Kuen Chan
July-December 2013, 3(2):67-69
DOI:10.4103/2249-4472.123296  
  2,615 7,418 -
ORIGINAL ARTICLES
Clonidine versus tramadol for post spinal shivering during caesarean section: A randomized double blind clinical study
Velayudha S Reddy, Sunil Chiruvella
January-June 2011, 1(1):26-29
DOI:10.4103/2249-4472.84252  
Background : Control of post spinal shivering is essential for optimal perioperative care, which can be achieved either by oral or parental medications. The present study is designed to evaluate the efficacy and safety of intravenous low-dose clonidine and tramadol in the treatment of post spinal shivering. Materials and Methods : In this prospective, a double blind, randomized study, 90 ASA grade I or II, parturients aged 18 - 35 years, undergoing caesarean section under spinal anaesthesia, who subsequently developed shivering grade 3 or 4, were randomized into two groups, to receive either clonidine or tramadol. The efficacy and response rate of the study drugs were evaluated and recorded. Side effects like, nausea, vomiting, hypotension, bradycardia, dry mouth, sedation, skin rash and headache, if present, were recorded. All data were analyzed by using the Chi square test and the Z-test. Results : There were significant differences in the response rate between the drugs (P < 0.05). Time taken from the starting of treatment to cessation of shivering was significantly less with the tramadol group (P < 0.05), however, the frequency of nausea, vomiting, sedation and headache were also significantly more in the tramadol group Conclusion : In our study we concluded that both clonidine and tramadol control shivering. However, the response rate was higher and time taken to control shivering was lesser with tramadol, but the response rate and the side effects were lesser with clonidine.
  8,475 948 -
CASE REPORTS
Postpartum seizures with posterior reversible encephalopathy syndrome following cesarean delivery for triplets
Anita Chhabra, Sheetal Jagtap
January-June 2014, 4(1):50-52
DOI:10.4103/2249-4472.132830  
Posterior reversible encephalopathy syndrome (PRES) is a recently described clinicoradiologic entity that is associated with several medical conditions like hypertensive encephalopathy and eclampsia. It presents with rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance. It is often, but not always associated with high blood pressure. We present a case of 23-year-old patient, with unremarkable antenatal period, who developed convulsions in the immediate postpartum period following elective cesarean delivery of her triplets performed under regional anesthesia. The magnetic resonance imaging brain revealed vasogenic edema suggestive of PRES. She was managed with supportive treatment including mechanical ventilation in the intensive care unit. She recovered completely without neurological sequelae and discharged on the 8 th postoperative day. This case report highlights the importance of awareness, prompt diagnosis and treatment to improve the outcome in this potentially life-threatening, but reversible condition.
  8,908 433 -
REVIEW ARTICLE
Amniotic fluid embolism
Girendra Sadera, Bharathram Vasudevan
January-June 2015, 5(1):3-8
DOI:10.4103/2249-4472.155192  
Amniotic fluid embolism (AFE) is a rare complication of pregnancy carrying a high mortality rate. The exact pathogenesis of the condition is still not known. Diagnosing AFE needs a high suspicion as it is essentially a clinical diagnosis of exclusion. Patients with AFE are best-managed in a critical care unit by a multidisciplinary team and management is largely supportive. This review compiles the currently available information on AFE.
  7,584 1,521 3
CASE REPORTS
Gestational trophoblastic disease with hyperthyroidism: Anesthetic management
Puneet Khanna, Anil Kumar, Maya Dehran
January-June 2012, 2(1):31-33
DOI:10.4103/2249-4472.99315  
The coexistence of hyperthyroidism with gestational trophoblastic disease is a known albeit rare clinical condition. We herein report the successful anesthetic management of such a case in our institute. There are only few case reports in literature of this association. Often, the diagnosis of hyperthyroid state is retrospective one, as it can be missed in the emergency scenario of patient requiring molar evacuation. This case report highlights the perioperative management and optimization of hyperthyroid state prior to surgical evacuation of the invasive hydatidiform mole.
  7,609 931 -
Caesarean section in a patient with Myasthenia Gravis: A bigger challenge for the anesthesiologist than the obstetrician
Manoj K Sanwal, Neha Baduni, Aruna Jain
January-June 2012, 2(1):34-37
DOI:10.4103/2249-4472.99317  
Myasthenia Gravis (MG) is an acquired, autoimmune disorder affecting neuromuscular junction presenting with easy fatigability, progressive weakness, diplopia, difficulty in speaking and swallowing and even ventilatory failure in severe cases. During pregnancy the disease may go into remission or may exacerbate at any time during first, second and third trimesters or postpartum period. We are reporting the case of a 28 year old primigravida, known case of MG, who underwent caesarean section and developed muscular weakness on third postoperative day. Her neonate also had tachypnoea and hypotonia, Both, the mother and the baby were managed aggressively and responded well to therapy.
  7,670 795 1
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