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Journal of Obstrectic Anaesthesia and Critical Care
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   2017| January-June  | Volume 7 | Issue 1  
    Online since June 1, 2017

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Management of critically ill obstetric patients: A review
Manpreet Kaur, Preet Mohinder Singh, Anjan Trikha
January-June 2017, 7(1):3-12
Critically ill obstetric patients present a unique challenge as outcome of indwelling life is dependent upon the maternal well-being. Optimal patient management involves early detection and the multidisciplinary treatment by obstetricians, pediatricians, and anesthesiologists based on knowledge of physiological and pathophysiological alterations. This article aims to provide a comprehensive review of the available literature for the management of critically ill obstetric patient and recent update on commonly encountered situations.
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Efficacy of magnesium sulphate and/or fentanyl as adjuvants to intrathecal low-dose bupivacaine in parturients undergoing elective caesarean section
Shelly Rana, Dheeraj Singha, Sudarshan Kumar, Yuvraj Singh, Jai Singh, RK Verma
January-June 2017, 7(1):20-25
Background and Aim: Recent developments in the field of intrathecal adjuvants have led to accelerated functional recovery with adequate postoperative analgesia following caesarean section. Encouraging results have been obtained with the use of intrathecal magnesium with or without fentanyl in parturients. This study was conceived to evaluate the effects of adding magnesium sulphate and/or fentanyl to low-dose intrathecal bupivacaine in parturients undergoing caesarean section under subarachnoid block (SAB). Materials and Methods: Ninety, American Society of Anesthesiologists I or II, parturients for the elective caesarean section were enrolled in this prospective randomized, double-blind study. The parturients were randomly assigned to three groups. In Group M, parturients received 8.5 mg (1.7 mL) hyperbaric bupivacaine 0.5% with 50 mg (0.1 mL) magnesium sulphate and 0.4 mL normal saline. Group F received 8.5 mg hyperbaric bupivacaine 0.5% with 20 μg (0.4 mL) fentanyl and 0.1 mL of normal saline and Group MF parturients received 8.5 mg hyperbaric bupivacaine 0.5% with 20 μg fentanyl added to 50 mg magnesium sulphate. Results: Parturients in the group MF were pain free for longest period (273.70 ± 49.30 min) as compared to group M (252.67 ± 40.76 min) and group F (239.80 ± 38.45 mins) [gp MF vs F and, gp M vs F (P = 0.00)]. The total doses of rescue analgesics were least in group MF (2.43 ± 0.56) and maximum in group F (3.30 ± 0.63), with comparable neonatal outcomes in three groups. Conclusion: Our data supports synergistic action of intrathecal magnesium sulphate to fentanyl, and it is concluded that on addition of intrathecal magnesium sulphate and fentanyl to low-dose bupivacaine as adjuvant in subarachnoid block, results in prolonged duration of postoperative analgesia with lesser pain scores and lesser dose of rescue analgesia with better haemodynamic stability.
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Skin to skin: A modern approach to caesarean delivery
Aya Elsaharty, Ian McConachie
January-June 2017, 7(1):13-19
Skin to skin care (SSC) after childbirth has been practiced for many years and has become part of the standard of care in many Neonatal ICUs. SSC during Cesarean Delivery is also increasingly popular in many countries. Some of the available literature have concerns regarding methodology but, overall, SSC provides benefits to the neonate in the form of maintained temperature homeostasis, cardiovascular and metabolic stability and less irritability. For the mother there is increased satisfaction, improved breastfeeding and improved bonding with her child. SSC is safe but vigilance must be maintained during SSC as there are potential risks of sudden postnatal collapse due to airway obstruction and asphyxia. There is little information in the Anesthesia literature concerning SSC. Implications for Anesthesia care providers and for Operating Room organisation are discussed.
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Non-invasive ventilation – An effective way of delivering air for two?
Anjan Trikha, AA Kumar
January-June 2017, 7(1):1-2
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Effect of intrathecal labor analgesia using fentanyl 25 μg and bupivacaine 2.5 mg on progress of labor
Pooja Mathur, Neena Jain, Lokesh Prajapat, Kavita Jain, Deepak Garg, Vishal Khandelwal
January-June 2017, 7(1):47-51
Background: The aim of this study was to evaluate the progress of labor and hemodynamic changes in the mother and fetus with intrathecal analgesia using bupivacaine and fentanyl during normal vaginal delivery. Materials and Methods: Sixty nulliparous parturients in the active phase of labor with a cervical dilatation of >3 cm were selected for this prospective study. Group SA (n = 30) received an intrathecal injection of 0.5% hyperbaric bupivacaine 2.5 mg and fentanyl 25 μg and compared with Group C (n = 30) who refused to give consent for neuraxial analgesia. Visual analog score, progress of labor, maternal hemodynamic variations, and fetal heart rate were recorded. Statistical analysis included an unpaired and paired two-tailed t-tests. Result: Duration of the active phase of first stage of labor was shortened in group SA as compared to group C (115.50 vs. 134.0 min, P < 0.05). Duration of second stage of labor was prolonged in group SA as compared to group C (18.03 vs. 10.13 min, P < 0.05). Rate of cervical dilation was faster in group SA as compared to group C (3.021 vs. 2.486 cm/h, P < 0.05). Mean visual analog score, pulse rate, and mean arterial pressure was significantly decreased as compared to the baseline in group SA. No significant changes were noted in the fetal heart rate as compared to the baseline in both groups. Conclusions: Single-shot intrathecal analgesia using fentanyl 25 μg and bupivacaine 2.5 mg in active phase of first stage of labor associated with fast cervical dilation rate and no delay in the progress of labor.
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Maternal knowledge of the impact of obesity on complications relevant to obstetric anesthetic care
Maartje J Tulp, Laura F McDermott, Michael J Paech, Elizabeth A Nathan
January-June 2017, 7(1):37-42
Background: The number of overweight adults in Australia has more than doubled in 20 years and 50% of pregnant women in Australia are overweight. This study investigated whether pregnant women are aware of the peripartum obstetric and anesthetic risks conferred by obesity. Methods: A sample of 180 antenatal women attending an obstetric tertiary referral hospital were surveyed to identify the level of knowledge about the effect of obesity on medical, obstetric, and anesthetic outcomes, using a 23-item questionnaire. Correct responses were expressed as a percentage and comparisons, based on maternal characteristics including body mass index (BMI), performed using Mann–Whitney and Kruskal–Wallis tests for continuous outcomes and the Chi-square test for categorical outcomes. Logistic regression analysis was conducted to evaluate the maternal characteristics predictive of scores below the 50th percentile. Results: The median percentage of correct answers for all participants was 39% (interquartile range: 30–52%). More correct responses were obtained to questions about medical and obstetric complications. pre-pregnancy BMI ≥ 30 kg/m2, nulliparity, and no tertiary education were significant predictors of scores below the 50th percentile in the survey. Knowledge of the effects of obesity on anesthetic complications did not appear to be influenced by maternal age, ethnicity, or planned mode of delivery. Conclusion: The median number of correct answers was less than half, with women with a BMI < 30 kg/m2 being less knowledgeable. Knowledge about anesthetic problems and risks was less than that about medical and obstetric issues.
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Cervical dilatation in parturient receiving neuraxial analgesia: Comparison of epidural analgesia alone with combined spinal epidural analgesia
Geetha C Rajappa, Tejesh C Anandaswamy, Thejaswini J Pattadi, Asha Swarup
January-June 2017, 7(1):43-46
Background: Both epidural analgesia and combined spinal epidural analgesia (CSEA) are employed for pain relief during labor because they provide reliable analgesia compared to other modalities. Studies are equivocal with respect to their effect on the rate of cervical dilatation, duration of labor, and labor outcome. The primary outcome of the present study was to compare the effect of epidural analgesia alone with CSEA with respect to the rate of cervical dilatation. Materials and Methods: One hundred and twenty parturients with an initial cervical dilatation of <4 cm were randomized to receive CSEA or epidural analgesia alone for pain relief during labor. The rate of cervical dilatation, onset of effective analgesia, number of epidural top-ups requested, labor outcome, and the quality of analgesia was assessed in both the study groups. Statistical Analysis: Mann–Whitney and Chi-square tests were performed where applicable to compare the data between the two groups. Results: The results of the study showed that the rate of cervical dilatation was rapid with CSEA compared to epidural analgesia alone [median (interquartile range) 2 (1.2,3) v/s 1.16 (1,2)]. The onset of analgesia was earlier with combined spinal epidural (CSE v/s EA, 3.7 ± 1.3 min v/s 23.8 ± 5.8 min). Labor outcome and quality of analgesia was similar between the two groups. The incidence of pruritus was higher with CSEA than with epidural analgesia alone. Conclusion: CSEA is associated with more rapid cervical dilatation and shorter duration of first stage of labor when compared with epidural analgesia alone.
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Prophylactic crystalloids or prophylactic crystalloids with ephedrine: Comparison of hemodynamic effects during caesarean section under spinal anaesthesia using 0.5% bupivacaine
Bharath Kumar Hegde, Manjunath Timmappa Bhat
January-June 2017, 7(1):26-32
Background: Spinal anaesthesia is usually chosen for caesarean section not only because of its faster onset and reliability but also because general anaesthesia is associated with more complications. However, hypotension is one of the most common complications of spinal anaesthesia in obstetric patients. Several measures have been devised to prevent hypotension, which include left uterine displacement, infusion of crystalloids before giving spinal anaesthesia (preloading) and administration of a prophylactic vasopressor. This study compared the hemodynamic effects of preloading crystalloids or crystalloids with ephedrine for caesarean section under spinal anaesthesia using 0.5% bupivacaine. Materials and Method: In this randomized, single blind, comparative clinical study, 80 parturients (American Society of Anesthesiologists grade 1) presenting for elective caesarean section under spinal anaesthesia were allocated to one of the two groups; group I received crystalloid preload and group II received crystalloid with ephedrine before spinal block. After institution of spinal anaesthesia in the lateral position with 2.0 ml (10 mg) of bupivacaine, 0.5% (heavy) using 25 G Quincke type spinal needle, parturients were made to assume a supine position with left lateral tilt. Heart rate, systolic blood pressure and diastolic blood pressure were monitored intraoperatively every 2 minutes till delivery and every 5 minutes after delivery. The amount of ephedrine used intraoperatively was also noted and compared among different groups. Results: Incidence of hypotension was 70% in the crystalloid group and 5% in the crystalloid with ephedrine group. This difference between the two groups was statistically significant (P < 0.001). The number of patients receiving rescue bolus of ephedrine was higher in the crystalloid group (40% before delivery and 30% after delivery) compared to crystalloid with ephedrine group (5% before delivery and none after delivery); the difference was statistically significant (P < 0.001). Sixteen patients (40%) in the crystalloid group experienced nausea compared to 6 patients (15%) in the crystalloid with ephedrine group; the difference was statistically significant with a P value of 0.012. Conclusion: This study demonstrates that prophylactic ephedrine given by infusion along with crystalloids is not only a simple and effective method for prevention of hypotension during spinal anaesthesia during elective caesarean section in ASA Grade I patients but also contributes to less incidence of intraoperative nausea and vomiting.
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The clinical conundrum of atypical eclampsia
Ritu Aggarwal
January-June 2017, 7(1):63-64
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Effect of clonidine as an adjuvant for wound infiltration following caesarean section
MS Nataraj, Sathisha , RM Mohan Kumar
January-June 2017, 7(1):33-36
Context: Local anesthetics provide simple and safe means of postoperative analgesia when used for local infiltration. Role of clonidine as an adjuvant is being increasingly explored because of its peripheral action. Aims: To investigate the analgesic effect of clonidine when added to bupivacaine for wound infiltration following cesarean section. Settings and Design: A prospective, randomized double-blind study was conducted after Institutional Ethical committee approval. Materials and Methods: Sixty American Society of Anesthesiologists (ASA) physical status I or II parturients scheduled for elective cesarean delivery through pfennensteil incision were included after consent. Patients were randomly allocated to two groups; Group B (control group) received 30 ml of 0.25% bupivacaine for wound infiltration and Group C received 3 μg/kg clonidine mixed with 0.25% bupivacaine. Time to first request of analgesia, total tramadol consumption, visual analog scale (VAS) pain scores, sedation, any complications were recorded at 6th hourly interval till 24 hours. Statistical analysis used: Data and perioperative details are summarized as mean ± SD. Statistical analysis for significance was done using two sample unpaired t-test. Results: Demographic and surgical parameters were comparable. Time for first request of analgesia was prolonged in group C (254 ± 26 min vs group B 149 ± 12 min;P < 0.0001), total tramadol consumption was significantly less (P < 0.001), and pain scores were lower (P < 0.001) in clonidine group up to 12 h. Conclusions: Addition of 3 μg/kg of clonidine to 0.25% bupivacaine 30 ml for wound infiltration after cesarean section prolongs the duration of analgesia, reduces opioid consumption, and produces mild sedation without complications.
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Stuck mitral prosthesis in pregnancy – A challenge
Pankaj K Gupta, Indira Malik, AS Tomar, Vishnu Datt, Sanjula Virmani, Vithal K Betigeri
January-June 2017, 7(1):60-62
Pregnancy with prosthetic valve is a challenging situation since this is a hypercoagulable state and maintenance of anticoagulation for prosthetic valves becomes difficult due to the teratogenic effects and altered pharmacokinetics of anticoagulant drugs. This may result in prosthetic valve thrombosis which is an emergency and requires multidisciplinary approach for management. We present a case of a patient who presented with thrombosed mitral prosthesis at 34 wks of gestation; after a multispeciality consultation, she eventually underwent caesarean section followed by mitral valve replacement.
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Rigid bronchoscopy in parturient: A balancing act
Mamta Dubey, Amit K Mittal, Nitesh Goel, Jitendra Dubey
January-June 2017, 7(1):57-59
We report a case of bronchial tumour excision in a pregnant female using a combination of rigid and flexible bronchoscope under general anaesthesia. This case report highlights the anaesthetic considerations regarding airway management of the parturient during rigid bronchoscopy and measures for preservation of utero-placental perfusion. Foetal heart rate monitoring using portable ultrasonography as a point-of-care device has been emphasised.
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Does the use of a birthing pool in labour contribute to maternal hyponatraemia? Two case reports
Chris Walmsley, Tony Wong, Julian Chilvers
January-June 2017, 7(1):54-56
Maternal hyponatraemia in labour is a recognised consequence of inappropriate fluid management, both as a result of administration of hypotonic intravenous fluid and increased maternal oral fluid intake. Other less common causes of hyponatraemia in labour include inappropriate secretion of antidiuretic hormone (ADH), exogenous administration of oxytocin, reset osmostat and sodium depletion. Patients with hyponatraemia are often asymptomatic, or display non-specific symptoms such as headache, lethargy and confusion. If hyponatraemia remains undetected, symptoms can progress to seizures, coma and death. Maternal hyponatraemia in labour may also cause a corresponding hyponatraemia in the foetus/neonate. We present two recent cases of severe symptomatic maternal hyponatraemia in labour where a birthing pool was utilised, and hypothesise how birthing pool use may increase the likelihood of developing hyponatraemia.
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Delivery in a 33-year-old woman with fontan palliation
A Viappiani, P Del Sarto, A Morosan, E Pelliccia, F Forfori
January-June 2017, 7(1):52-53
Fontan procedure is a surgical treatment used for patients with various forms of congenital heart disease who cannot support biventricular circulation. It is very important in pregnant patients that the right atrium and the single ventricle can tolerate the cardiovascular adjustment. The following case report describes a parturient who underwent Fontan procedure for tricuspid atresia and pulmonic stenosis and delivered, by caesarean section at 36.5 weeks of gestation, a female infant who weighed 2400 g, without any cardiovascular complications.
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