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Journal of Obstrectic Anaesthesia and Critical Care
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Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 41-48

Selected abstracts of the papers presented as poster presentations during the 7 th National Conference of Association of Obstetric Anaesthesiologists held in Varanasi 2013

Date of Web Publication15-Apr-2015

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How to cite this article:
. Selected abstracts of the papers presented as poster presentations during the 7 th National Conference of Association of Obstetric Anaesthesiologists held in Varanasi 2013. J Obstet Anaesth Crit Care 2015;5:41-8

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. Selected abstracts of the papers presented as poster presentations during the 7 th National Conference of Association of Obstetric Anaesthesiologists held in Varanasi 2013. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2022 Dec 10];5:41-8. Available from: https://www.joacc.com/text.asp?2015/5/1/41/155202

Efficacy of intravenous fluid warming for maintenance of core temperature during lower segment caesarean section under spinal anaesthesia

Gayatri Tanwar, Parveen Goyal, Sandeep Kundra, Shruti Sharma, Anju Grewal, Tej K Kaul, M Rupinder Singh

Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Introduction: Maintenance of body temperature of obstetrical patients undergoing caesarean section is complicated by a variety of factors including heat loss to atmosphere, infusion of fluids at room temperature, disruption of thermoregulatory mechanisms by epidural or spinal anaesthesia and redistribution hypothermia. Infusion of warm fluids is an important method of heat conservation. Hence, we evaluated the efficacy of intravenous fluid warming in preventing hypothermia by observing the change in core temperature with intravenous fluids at room temperature (22 ° C and 39 ° C) in patients undergoing lower segment caesarean section under spinal anaesthesia.

Materials and Methods: Sixty-four patients belonging to ASA grade I and II were randomly allocated to either of the two groups. Group I received intravenous fluids at room temperature (22 ° C) and group II received intravenous fluids via fluid warmer (39 ° C). Core temperature was recorded at every 1 min for the first 5 min, followed by 10 min till the end of surgery using a tympanic thermometer.

Results: The mean decrease in core temperature in group I was 2.184 ± 0.413 and 1.934 ± 0.439 in group II. The comparison of group I and II showed a statistically significant difference in mean core temperatures at times 5, 50, 60, 70, 80 and 90 min and immediately on arrival in the recovery room. A lower incidence of shivering was seen in group II patients, but the difference in the two groups was not statistically significant.

Conclusion: Infusion of warm intravenous fluids resulted in a lesser degree of fall in core temperature, thereby providing a significant temperature advantage. However, this did not translate to prevention of postoperative shivering.

Comparative evaluation of post dural puncture headache in hilly and plain region parturients after lower segment caesarean section under subarachnoid blockade

Aradhana Arya, Urmila Palaria, Bikramjit Das, AK Sinha

Department of Anesthesiology and Critical Care, Government Medical College, Haldwani, Uttarakhand, India

Introduction: Subarachnoid block is the most popular technique for lower segment caesarean section (LSCS) but, has been reported to result in unacceptably high incidence of PDPH further aggravated by high altitude. Possible causes include chronically increased CSF pressure, dehydration and altered sensitivity to intracranial pressure. The most important factor contributing to high incidence of PDPH is supposed to be the gauge, needle types and entrance angle of the needle bevel to the longitudinal axis of the spinal cord. With the Quincke needle the incidence and severity of PDPH are directly related to the size of needle.

Aims: To compare the incidence of PDPH between plain area and hilly area parturients undergoing lower segment caesarean section under subarachnoid blockade (SAB).

Materials and Methods: It was a prospective, double-blind clinical trial. ASA I/II grade parturients aged between 20-30 yrs undergoing LSCS under spinal anaesthesia were enrolled in the study. Parturients were divided into two groups of 30 each {Pn (upto 1000m ht) = 30 and Hn (beyond 2000 m ht) = 30}. SAB was given with 2.2 ml of 0.5% Bupivicaine heavy through 26 guage spinal needle (BD Quincke) between L3-4, L4-5 using standard protocol. Following surgery, parturients were instructed to lie supine as long as possible and increase the water intake. In post-operative phase, all parturients were assessed for PDPH (time of occurrence, frequency, severity, association with other signs and symptoms and relieved by) for 48 hrs on the basis of a preformed questionnaire format. Data were analyzed using SPSS 16.

Results: The demographic characteristics of the parturients in both groups were similar. Of the 60 parturients, three parturients were excluded from the study as they required more than 2 pricks (one from each group) and one highlander parturient required change to GA. When we compared the characteristics of PDPH between two groups, it was found to be statistically insignificant (P > 0.05).

Conclusion: Considering occurrence of physiological changes in high altitude parturients and adopting desirable modification in anaesthesia technique and equipment (namely needle size), spinal anaesthesia can be safely administered. The main objective of the study is to encourage anaesthesiologists to make every effort to minimize the risk of PDPH by optimizing factors those can be controlled in high altitude parturient.

Comparative study of efficacy of intrathecal fentanyl and magnesium as adjuvants to hyperbaric bupivacaine in mild pre-eclamptic patients undergoing caesarean section

Bharat Arora

Department of Anaesthesiology and Critical Care, Silchar Medical College, Cochar, Assam, India

E-mail: [email protected]

Aims: Adequate analgesia following caesarean section decreases morbidity, hastens ambulation, improves patient outcome and facilitates care of the newborn. Intrathecal magnesium, an NMDA antagonist, has been shown to prolong analgesia without significant side effects in healthy parturients. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of fentanyl or magnesium given intrathecally with hyperbaric 0.5% bupivacaine in patients with mild preeclampsia undergoing caesarean section.

Materials and Methods: Sixty women with mild preeclampsia undergoing caesarean section were included in a prospective, double blind, controlled trial. Patients were randomly assigned to receive spinal anaesthesia with 2 mL 0.5% hyperbaric bupivacaine with 12.5 μg fentanyl (group F) or 0.1 mL of 50% magnesium sulphate (50 mg) (group M) with 0.15 ml preservative free distilled water. Onset, duration and recovery of sensory and motor block, time to maximum sensory block, duration of spinal anaesthesia and postoperative analgesia requirements were studied. Statistical comparison was carried out using the Chi-square or Fisher's exact tests and Independent Student's t-test where appropriate.

Results: The onset of both sensory and motor block was slower in the magnesium group. The duration of sensory block (246 vs. 284 min) and motor block (186.3 vs. 210 min) were significantly longer in the magnesium group. Total analgesic top up requirement was less in group M. Haemodynamic parameters were similar in the two groups. Intrathecal magnesium caused minimal side effects.

Conclusions: Since fentanyl and other opioid congeners are not available throughout the country easily, magnesium with its easy availability and less side effects, can be a cost effective alternative to fentanyl in managing PIH patients given along with bupivacaine intrathecally in caesarean sections.

Effect of 0.1% levobupivacaine, bupivacaine and ropivacaine with fentanyl on ambulation in labor analgesia: A randomised comparative study

Meenoti Potdar, Laxmi Kamat, Tanya Jha

Department of Anaesthesiology, Dr. LH Hiranandani Hospital, Mumbai, Maharashtra, India

Introduction: Combined spinal epidural (CSE) is the commonly used method for labor analgesia. The effect of ambulation of the duration and outcome of labor is well established. In our study we decided to compare bupivacaine, with newly emerged drugs ropivacaine and levobupivacaine and study their effect on ambulation in labor analgesia. Fentanyl was used intrathecally in our study for faster onset and good quality analgesia.

Aim: To assess and compare the effect of 0.1% levobupivacaine-fentanyl with 0.1% bupivacaine- fentanyl and 0.1% ropivacaine-fentanyl on ambulation in labor analgesia.

Materials and Methods: This is a prospective randomised double blind comparative study. After written informed consent 150 patients were includedin our study and randomly divided into three groups. Group L-received 0.1% levobupivacaine with 1 mcg/cc fentanyl epidurally, Group B- received 0.1% bupivacaine with 1 mcg/cc fentanyl epidurally and Group R- received 0.1% ropivacaine with 1 mcg/cc fentanyl epidurally. Baseline parameters like demographics, VAS score, cervical dilatation, effacement and station were noted and the patients were monitored for the onset of analgesia, level of sensory and motor blocks, motor blockade as per modified Bromage scale, ambulation, duration and final outcome of labor.

Results: The demographics in all the three groups were comparable. Bupivacaine 0.1%, ropivacaine 0.1% and levobupivacaine 0.1% co-administered with fentanyl provide rapid and complete analgesia. The incidence of motor blockade, onset and duration of analgesia and effect on ambulation are same in all three groups.

Conclusion: Bupivacaine, levobupivacaine and ropivacaine provide reliable analgesia and are comparable in terms of motor blockade and effect on ambulation in labor analgesia.

Evaluation of hypotension in pre eclamptic and healthy parturients undergoing lower segment caesarean section during spinal anaesthesia

Vijita Pandey, Urmila Palaria, AK Sinha, Bikramjit Das

Department of Anesthesiology and Critical Care, Government Medical College, Haldwani, Uttarakhand, India

Introduction: The safety of regional anaesthesia in preeclamptic patients is well established. It has long been argued that titrated epidural blocks are safe, single shot spinal or CSE techniques may produce profound hypotension. Spinal anaesthesia should be avoided because of the risk of severe hypotension. Several studies have shown that the hemodynamic effects of spinal and epidural anaesthesia are similar with no adverse effects on mother and fetus. This is especially true when a small-dose spinal anaesthesia is used as part of a combined spinal-epidural technique.

Aims: To compare the incidence and severity of hypotension in mild preeclamptic and healthy parturients going for lower segment caesarean section under spinal anaesthesia.

Materials and Methods: Fifty parturients were randomized into two groups A and B (n = 25 each). Group A included healthy parturients while group B included mild preeclamptic parturients. Standard non-invasive hemodynamic monitoring (NIBP, PR, SPO2, ECG) was done at 3 mins interval. Parturients were preloaded with 15 ml/kg of ringer's lactate over 20 mins prior to subarachnoid block (SAB). SAB was given with 2 ml of 0.5% bupivacaine (H) in L 3-4 or L 4-5 inter space. Parturients were put in supine position maintaining left uterine displacement. Hypotension was regarded as >30% fall in MAP from base line and was treated with IV fluids and vasopressor. Apgar scoring also done at 1 and 5 mins interval. Statistical analysis was done with SPSS 16. Data were compared in each study group by using the paired Student's t-test. A P-value of <0.05 was used to indicate statistical significance.

Results: Healthy parturients showed fall in BP from baseline more than that of preeclamptic parturients following spinal anaesthesia but the incidence was statistically insignificant. IV fluid and vasopressor requirements were greater in healthy parturients. Apgar scores at 1 and 5 min were comparable in both the groups.

Conclusion: Our study shows that mild preeclamptic parturients may safely go for caesarean section under spinal anaesthesia without significant adverse effect on mother and baby.

A randomised trial comparing prophylactic phenylephrine or ephedrine following spinal anaesthesia for emergency caesarean delivery in acute foetal compromise

P Vivekananthan, Kajal Jain, Jeetinder Kaur Makkar, Siva Subramani

Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India

Introduction: Maintenance of maternal blood pressure using phenylephrine is associated with higher umbilical artery pH (UA pH) than ephedrine following elective low risk caesarean delivery (CD). The effect of these vasopressors on cord blood gases in cases of acute foetal compromise is not clear.

Aim: To study the effects of ephedrine or phenylephrine infusion following spinal anaesthesia (SA) on foetal acid base status in cases of emergency CD indicated for actual or potential foetal compromise.

Materials and Methods: Randomized prospective trial in a tertiary care hospital involving 94 healthy term parturients undergoing spinal anaesthesia for emergency CD (Category II). Enrolled participants were randomized to receive a prophylactic infusion of ephedrine at 2.5 mg/minute or phenylephrine at 30 μg/minute for maintenance of blood pressure following SA. Systolic blood pressure was targeted between 90-110% of baseline. Cord gases were analyzed immediately following birth of baby. Incidence of fetal acidosis defined as UA pH <7.2 and/or base deficit >12 mmol/l was taken as main outcome measure.

Results: Acidosis was observed in 14 newborns with ephedrine use and in 9 with phenylephrine (P = 0.22). 15/23 newborns with base deficit >12 mmol had low 1-min Apgar scores. Ephedrine group had higher oxygen content in UA (P = 0.03). Incidence of maternal nausea and vomiting was more with ephedrine than with phenylephrine (22.2% vs 4.4%; P = 0.02) despite similar minimum recorded SBP. Maternal bradycardia was higher with phenylephrine [P = 0.02]. There was no adverse neonatal outcome.

Conclusions: Use of either of the vasopressors following SA in cases of acute foetal compromise showed similar foetal acid base status. With use of ephedrine more mothers complained of nausea/vomiting. Phenylephrine infusion caused dose dependent bradycardia which warrants further work on it's dose and mode of administration.

Caesarean section in patient with achondroplasia

Karampal Singh, Punam Raghove, Geeta Ahlawat, Sarla Hooda

Department of Anaesthesiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

E-mail: [email protected]

There are more than 100 different types of dwarfism. Achondroplasia is the most common form of this rare condition. Although inherited as an autosomal dominant condition, 80% of cases result from spontaneous mutation. Underdevelopment and premature ossification of bones result in characteristic craniofacial and spinal abnormalities. Achondroplasia presents many challenges to the anaesthesiologist. Factors that can cause difficult intubation include limited mouth opening, large tongue, atlanto-axial instability, limited neck extension, sleep apnea and midface hypoplasia. Severe kyphosis, scoliosis, spinal stenosis and unpredictable spread of local anaesthetics in the epidural space and subarachnoid space make regional anaesthesia difficult and unpredictable. Fertility rate is low in achondroplasia and pregnancy is complicated by decreased functional residual capacity and severe supine hypotension syndrome. We present a case of 104 cm, term achondroplastic dwarf who had fetal distress and successfully underwent caesarean delivery under general anaesthesia.

Sudden onset severe preeclampsia during caesarean section unmasked by bolus dose ephedrine

Sameer Desai

Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

E-mail: [email protected]

Introduction: We present a case of sudden onset of severe preeclampsia, which manifested during caesarean section following a bolus dose of ephedrine.

Case Report: A 27 year parturient, who had regular antenatal follow-up with normal blood pressure (BP) measurements and investigations, presented for elective caesarean section. The day prior to the surgery, BP measured at 4 hours interval were normal and urine albumin was negative. Spinal anaesthesia was given with 2.2 ml of hyperbaric bupivacaine 0.5%. After achieving block level of T4, caesarean section was started. About 5 minutes after the subarchnoid block, the patient developed hypotension with BP of 90/56 mm Hg and HR of 60/min. A bolus dose of ephedrine 15 mg was given intravenously for treatment of hypotension. Immediately, the BP increased to 180/110 mm Hg and the HR to 120/min. The hypertension and tachycardia were presumed to be due to increased response to the ephedrine. A live, active baby was delivered at 9 th minute after the spinal block. The patient complained of severe headache, vomiting and visual blurring during the caesarean section which lasted for about 45 minutes. Throughout caesarean, her BP persisted to be high in the range of 150/90 to 170/106 mm of Hg and HR around 110/min. The persistence of high BP and HR beyond the usual duration of ephedrine raised suspicion of intracranial haemorrhage, other neurological diseases or preeclampsia. She was transferred to ICU and intravenous metoprolol 1 mg was given for control of HR and BP. In the ICU, patient developed tonic-clonic convulsions, which were immediately aborted by intravenous diazepam 5 mg and phenytoin. MRI of brain performed next day showed minimal cerebral edema with no evidence of any intracranial haemorrhage. The urine albumin was 1 gm/L confirming the diagnosis of preeclampsia. She was put on antihypertensive nifedipine. The mother and baby were discharged from hospital uneventfully.

Conclusion: In parturients prone for preeclampsia, large bolus dose of ephedrine can precipitate the same. If parturients develop severe hypertension, headache, visual disturbances, preeclampsia should be thought as a possibility, even in the absence of prior history of preeclampsia.

A prospective randomized study to compare and evaluate flexible fiberoptic bronchoscope and video stylet as intubating devices

Sonali Bansal, Syed Hussain Amir, Qazi Ehsan Ali, Shahla Haleem

Department of Anaesthesiology, Jawahar Lal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Introduction: A recent British Survey has concluded that the leading cause of anaesthesia related injury is the inability to intubate the trachea and secure the airway. Conventional rigid direct laryngoscope aids tracheal intubation successfully in 98.1% of cases while remaining 1.9% cases require equipments for management of difficult airway. Fiberoptic intubation has emerged as the "gold standard" method in cases of anticipated difficult tracheal intubation, but the instrument is costly, bulky and needs preparation time which makes it unavailable for anaesthesiologists to be used in emergency cases. This has raised the need of other devices and video stylet is one of them. It is portable, cheap, no special training is required and does not need preparation time. These features made us curious to compare the two devices.

Materials and Methods: 30 patients for obstetric surgeries were included for this study. Patients were randomly divided into two groups of 15 each using computer based random number tables. Two devices were compared for laryngoscopy and intubation time, number of attempts for successful intubation, ease of intubation, hemodynamics and complications.

Results: Two devices were comparable in all aspects. Intubation time was less with video stylet. However, success rate was higher in cases of fiberoptic intubation with lesser complications and less hemodynamic changes.

Anesthesia for parturients with spondyloepiphyseal dysplasia: A great challenge

Swati Jindal, Sukanya Mitra, Richa Saroa, Sanjeev Palta

Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, Haryana and Punjab, India

Spondyloepiphyseal dysplasia tarda (SEDT) is an extremely rare genetic disorder characterised by bone dysplasia leading to multiple epiphyseal and vertebral changes of varying severity. Due to several structural and functional abnormalities these patients pose a challenge for an anesthesiologist in the perioperative period. A 28-year old primi gravida was scheduled for elective cesarean section at 37 weeks of gestation. She was a diagnosed case of SEDT (height 135 cm), wheelchair bound for daily routine chores at the time of presentation. The flexion deformity of the knee joint and hip joint made it difficult for her to lie down straight and even prevented lateral positioning. She could sit with two pillows behind her back and a pillow below her knee. Presence of kyphoscoliosis and contracted pelvis made uterus an intra-abdominal organ at early gestation, causing exaggerated respiratory compromise and aortocaval compression. Although regional anaesthesia was considered a safer option in her case, she did not consent for the same, further adding to the anaesthetic dilemma. Hence, it was decided to conduct cesarean section under general anesthesia. General anesthesia was not without risks too. She had limited neck movements but her mouth opening was adequate. These patients may have atlantoaxial instability due to odontoid hypoplasia which may cause significant spinal cord compression. There may also be associated laryngotracheal stenosis. Foreseeing these issues, awake nasal fibreoptic intubation was done and trachea was intubated with cuffed PVC 6.5 mm ID ETT uneventfully. The entire surgical procedure was uneventful. After reversing the residual neuromuscular blockade trachea was extubated over tube exchanger once the patient regained consciousness and was responding to verbal commands. Proper assessment especially from early period of pregnancy, meticulous planning of airway management with special care to prevent any untoward neurological injury may be required in the successful management of patients with SEDT.

Intravenous paracetamol as an adjunct to patient-controlled epidural analgesia with levobupivacaine and fentanyl in labour: A randomized controlled study

Kanika Gupta, Sukanya Mitra, Vanita Ahuja, Richa Saroa, Poonam Goel

Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, Haryana and Punjab, India

Introduction: Patient-controlled epidural analgesia (PCEA) using a combination of levobupivacaine and fentanyl is an effective treatment available for pain control during labour and delivery. However, there is still scope of further improving the scenario by studying whether addition of a long-established safe and well-tolerated analgesic like paracetamol by the intravenous (i.v.) route to the intrapartum labour analgesia regime as above can reduce the total hourly consumption of the anaesthetic-opioid combination. If demonstrated to have drug-sparing effect, then this new regime could enhance analgesic efficacy without compromising the safety for both mother and child.

Aims: To evaluate the effect of i.v. infusion of 1000 mg of paracetamol on the average hourly consumption of levobupivacaine and fentanyl combination given as PCEA in labouring parturients.

Materials and Methods: In this randomized placebo-controlled trial, 80 parturients were randomly assigned to two groups of 40 each to receive either 1000 mg (100 ml) i.v. paracetamol or 100 ml normal saline as placebo 30 min before the procedure. After insertion of the epidural catheter all patients received 10 ml of levobupivacaine 0.1% with 2 μg/ml fentanyl. A continuous background infusion of 6ml/h of 0.1% of levobupivacaine with 2 μg/ml of fentanyl was immediately started with a provision of patient-controlled bolus of 5 ml of 0.1% of levobupivacaine with 2 μg/ml of fentanyl with a lock-out interval of 12 min.

Results: The average hourly drug consumption in the Paracetamol group was significantly lower as compared to Placebo group (7.035 ± 0.83 ml/h vs. 8.124 ± 1.34 ml/h; P < 0.05). The number of boluses taken were also significantly less in paracetamol group (1.00 ± 0.93 vs. 1.43 ± 0.90; P < 0.05).

Conclusion: The use of 1000 mg i.v. paracetamol decreases the average hourly drug consumption as well as number of boluses taken through epidural route. Thus i.v. paracetamol is a safe and effective adjunct to PCEA in labour analgesia.

Feto-maternal outcome of epidural analgesia by using dexmedetomidine and fentanyl as adjuvants with levobupivacaine: A prospective, randomized, double blind comparative study

Saurabh Suman, G Yadav

Department of Anaesthesiology, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Background: The delivery of the infant into the arms of a conscious and pain-free mother is one of the most exciting and rewarding moments in medicine. For painless labour, epidural has been the prevalent technique provided to a large number of parturients. We used levobupivacaine because it is a newer local anaesthetic which has known to have less cardiotoxicity than racemic bupivacaine. Adjuvant was added to ensure minimum motor blockade (which was obtained by reducing concentration of LA) and to increase the duration of analgesia.

Aims: To compare dexmedetomidine and fentanyl as adjuvants to epidural levobupivacaine in terms of duration of analgesia, motor power, progress of labour and APGAR score in neonate.

Materials and Methods: After taking ethical clearance, forty parturients with uncomplicated full-term pregnancies in spontaneous labour having cervical dilation of 3 to 4 cm, were given epidural analgesia using PCEA solutions of 0.0625% levobupivacaine with either dexmedetomidine 2 mcg/ml or fentanyl 2 mcg/ml.

Results: Onset of analgesia was 14.6 ± 1.9 minutes. Median VAS score after 5, 15, 30, 60, 90, 120 and 150 minutes were 2. Mean delivery time was 140 minutes. Two parturients had vomiting. Ceasarean section was performed in two cases. Oxytocin augmentation was needed in 23% of the parturients. No neonate had Apgar score <8. There was transient decrease in respiratory rate in fentanyl group which was statistically insignificant (P > 0.05).

Conclusion: Both the groups were equally effective in terms of duration of analgesia, motor power, progress of labour and Apgar score in neonate.

Comparative study of feto-maternal outcome in painless labour by using fentanyl, clonidine and dexmedetomidine as adjuvants with ropivacaine

BP Das, RB Singh

Department of Anaesthesiology, Institute of Medical Sciences, Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Aim: To compare fetomaternal outcome in painless labour with fentanyl, clonidine and dexmedetomidine as adjuvants with ropivacaine in terms of analgesic effect, success rate of vaginal delivery, complications, neonatal outcome and maternal satisfaction.

Materials and Methods: A prospective, double-blind, comparative study was done on 90 multiparous ASA-grade I and II parturients at term with spontaneous onset of labour and willing to receive labour analgesia. Parturients were randomly allocated into 3 equal groups (GROUP F, C, D) of 30 parturients each, based on adjuvant fentanyl, clonidine or dexmedetomidine with 0.1% ropivacaine, respectively. The epidural catheter was placed at L3-L4 space either before the active phase of labour or in active labour when cervical dilatation was ≥3 cm. When labour was well established and was progressing well (regular contractions 3-4 min apart and lasting for about 1 min, cervical dilatation of 3-4 cm for multiparous patients and fetal head was well engaged), 10 ml of 0.2% ropivacaine bolus alone was given in incremental fashion and then connected with their respective PCEA solutions. Group-F received ropivacaine 0.1% with fentanyl 2 mcg/ml. Group-C received ropivacaine 0.1% with clonidine 2 mcg/ml. Group-D received ropivacaine 0.1% with dexmedetomidine 2 mcg/ml. PCEA pump was set at 6 ml/hr continuous basal infusion and 1.5 ml of demand bolus with a 15 min lock-out interval (total 6 ml/hr). In 2 nd stage (at full cervical dilatation) 10 ml bolus of the respective solution was given in sitting position (perineal dose) which helped in episiotomies/other operative delivery and PCEA was continued up to the completion of delivery. Patients were monitored at 0, 10, 20, 30 min after giving 1 st epidural bolus dose and then at 30 min interval for ongoing labour for pain relief (VAS, subjective and objective assessment), sedation (RSS), motor blockade (Bromage score), progress of labour (duration of 1 st stage and 2 nd stage), mode of delivery, fetal APGAR score (at 1 min and 5 min), vitals (HR, NIBP, RR, SpO2), overall patient satisfaction and complications. The statistical analysis was done both qualitatively (Fisher-exact test/chi-square test) and quantitatively (one way analysis of variance test with post-hoc intergroup comparisons using Bonferonni's correction).

Results: The pain relief was almost equal in all 3 groups with onset of pain relief quickest in group-D and had no complaints of any marked weakness of lower limbs (though group-D had a higher incidence of sedation and motor block). Rate of instrumentation/caesarean delivery had insignificant difference among the groups. There was not a single case of fetal distress and most of the parturients showed satisfactory response to PCEA. Though there were complications like bradycardia and hypotension in group-C and a transient respiratory depression in group F, but they could be easily managed without the need of any vigorous resuscitation.

Conclusion: It was concluded that parturients showed satisfactory response to PCEA with each of the 3 adjuvants and also wanted to receive the same in future pregnancies and recommended it to other parturients. There was absolute pain relief without significant motor blockade, more so with dexmedetomidine as adjuvant, without any increase in instrumentation/caesarean deliveries or any adverse fetal outcomes.

Efficacy of parenteral tramadol as labour analgesic: A comparison with epidural

Uma Pandey, Shreya Thapa

Department of Obstetrics and Gynaecology, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Objective: To compare analgesic efficacy of intramuscular Tramadol (synthetic opioid) to that of epidural analgesia during labour.

Materials and Methods: 20 patients were included in this pilot study. They were all nulliparous women with singleton pregnancies. The presentation of fetus was cephalic in all mothers. 10 women were given Tramadol and 10 women were given epidural for labour analgesia. Pain score chart was used to assess the severity of pain. The parameters analysed were pain relief with epidural analgesia or Tramadol, effect on the progress of first stage of labour and incidence of instrumental delivery.

Results: Epidural did provide better pain relief than Tramodol but it prolonged the second stage of labour and increased the incidence of instrumental vaginal delivery. There was increased incidence of bladder catheterisation due to urinary retention in epidural analgesia group. There was no increased incidence of respiratory depression in neonates of mothers who received Tramadol as analgesic.

Conclusion: The analgesic efficacy and maternal satisfaction was good in mothers who received epidural analgesia than with Tramadol. This pilot study concludes that epidural is a better labour analgesic but Tramadol can be an option if facilities for epidural aren't available in low resource setting. Epidural didn't affect the fetal conditions but increased the incidence of instrument vaginal delivery.

Maternal satisfaction and causes of dissatisfaction after spinal anaesthesia in caesarean cases: A survey

Anjali Rani, Shreya Thapa, Kalpana Singh

Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Introduction: Spinal anaesthesia is most commonly used anaesthesia for caesarean section by anaesthetists. The reasons for this are that it is safe, does not cause fetal depression and avoids the risks of general anaesthesia. In this study we wanted to see the patient satisfaction rate with spinal anaesthesia and the causes of dissatisfaction. However some patients prefer general anaesthesia because of discomfort.

Materials and Methods: Cross sectional study was done in the Department of Obstetrics and Gynaecology, IMS, BHU, Varanasi. Total of 116 patients were observed. The patients who underwent caesarean section under spinal anaesthesia were included. A pre structured questionnaire was filled on first postoperative day and following points were observed - Pre-anaesthetic counselling, number of attempts, Patient satisfaction, side effects, causes of dissatisfaction.

Results: In our study 84.48% patients were satisfied with spinal anaesthesia. In 67.24% patients spinal anaesthesia was given with single prick. In 22.41% it was done in 2 to 3 pricks and in 10.34% it was done in more than 3 pricks. In 3.44% of patients, spinal anaesthesia failed and general anaesthesia was given. Pre-anaesthetic counselling was done in 81.04% cases. Post dural puncture headache was observed in 12.06% and nausea and vomiting were present in 22.41%. Spinal hypotension was reported in 0.86%. Numbness in lower limb was present in 3.44% cases. The causes of dissatisfactions were multiple pricks (10/34%), inadequate analgesia (2.58%), failed spinal anaesthesia (3.44%) and backache (22.41%).

Discussion: Our study shows satisfaction rate with spinal anaesthesia was 84.48%. The causes of dissatisfaction were multiple pricks (10.34%) and failed spinal anaesthesia (3.44%) cases. There are certain limitations of this study. Some patients, to please the doctors, may respond satisfaction. Backache and vomiting can be because of other causes also. It also depends on the skill of the anaesthetist.

Conclusion: The study shows that there is high level of maternal satisfaction with spinal anaesthesia but it can be further improved by proper counselling and by improving the skill of anaesthetist. The side effects can be decreased by taking proper precautions.

Comparison of early destarvation versus late destarvation in post LSCS: An observational study

Nitika Madavi, Meenoti Potdar, Laxmi Kamat

Department of Anaesthesiology, Dr. LH Hiranandani Hospital, Mumbai, Maharashtra, India

Introduction: LSCS is one of the most commonly performed surgeries. The starvation period for these patients preoperatively is atleast 6 hours for solids and liquids. These patients are destarved post operatively after the return of bowel sound or passage of flatus, which leads to starvation period approximately 6-8 hours. This leads to overall starvation status of more than 12 hours.

Aim: To assess and compare the effects of early destarvation and late destarvation in LSCS patients with respect to hemodynamic parameters, gastro intestinal functions, incidence of nausea, vomiting, thirst and hunger post operatively. The secondary outcome such as time for ambulation, length of hospital stay and maternal satisfaction were also observed.

Materials and Methods: This is prospective randomised single blinded study conducted on 200 patients undergoing uncomplicated elective LSCS for a period of one year from Aug 13 to July 14. They were randomly divided into 2 groups of 100 each.

Early Destarvation: Patients were destarved within one hour post operatively in recovery room with sips of 100 ml water followed by jelly. Patients were started with liquid diet within 3-4 hours and if well tolerated, were given soft diet by 6 hours.

Late Destarvation: Patients were destarved after 4 hours with sips of water followed by liquid diet by 6 hours and soft diet after 12 hours.

Results: Demographic data were comparable within groups. The incidence of nausea, vomiting, pain in abdomen and post-operative ileitis in both the groups was comparable. Early feeding was well tolerated, early ambulation was possible, maternal satisfaction was higher and length of hospital stay was reduced in early destarvation. The intensity of hunger and thirst was higher in late destarvation group.

Conclusion: There was no detrimental effect of early destarvation on post-operative outcome in 100 LSCS patients.

Perception of anaesthesiologists and gynaecologists about establishment of epidural analgesia in labour

Jagdeep Sharma, Ruchi Gupta

Department of Anaesthesiology, Sri Guru Ram Dass Institute of Medical Sciences and Research, Amritsar, Punjab, India

Epidural provides excellent analgesia in labour and also helps in allaying the maternal anxiety and discomfort. American College of Obstetricians and Gynecologists summarizes the background to use of epidurals as "Labour results in severe pain in many women". But due to varying perceptions by anesthesiologists and gynecologists the use of epidural has not reached the desired goals. Various factors affecting perceptions by the anesthesiologists, gynecologists and patients were studied through a survey. The hindering factors were identified and solutions to these problems were formulated. The common factors among anesthesiologists came out to be lack of experience, training and lack of trained anesthesiologist for round the clock monitoring of patients. Factors regarding gynecologists were cost of care for the patient and worry about effects of epidural on labour progress. Due to the Janani Suraksha Yojna being implemented in government institutes the patients in labour are being given financial benefits and so they prefer going to these institutes. Thus, better use of epidural can be made by mending out these factors. Imparting better training and knowledge to the budding anaesthesiologists, allaying worry among gynecologists about effects of epidural on the progress of labour and health insurance for all the people can lead to a better and effective use of the techniques of labour analgesia.

Chronic kidney disease in pregnancy: An anaesthetic challenge

Swetha Rudravaram, Anjeleena Gupta, Bimla Sharma, Jayashree Sood, Rohitash Sharma

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

Introduction: Chronic kidney disease (CKD) during pregnancy is uncommon. The pregnant woman with CKD when compared to normal parturient is more prone to haemodynamic instability and acid-base imbalance. Anaesthetic and obstetric management of these parturients is extremely important as both maternal and foetal mortality is high.

Case-Discussion: A 39 year old G 3 P 2 L 1 , known case of IgA nephropathy with CKD stage V, was admitted at 34 weeks of gestation for safe delivery. She was thoroughly investigated and was found to have anaemia (Hb 8.1 gm/dl), hypoalbuminaemia, deranged renal function and poor cardiac function with ejection fraction of 42%. She was on antihypertensive medications, maintenance hemodialysis biweekly and on dietary restriction of proteins. She went into premature labour with pulse 132 beats/min, blood pressure 186/130 mm Hg and developed respiratory distress (RR 32/min) with SpO 2 70%. She was kept in head up position with oxygen supplementation (FiO 2 0.6) with the mask and was administered furosemide (80 mg) and morphine in incremental doses (total 9 mg) intravenously. However, she developed bilateral crepitations and frank pulmonary oedema. She was intubated and positive pressure ventilation was started. A decision for immediate caesarean section was made as a life saving procedure for both mother and fetus. Postoperatively, she was shifted to intensive care unit for elective ventilation and subsequently discharged from the hospital in stable condition.

Conclusion: Timely intervention and decision are of utmost importance in the prevention of any catastrophic event in a parturient. Anaesthesiologist involvement should start in the early antenatal period in high risk pregnancies. A good team work with multidisciplinary approach among the obstetrician, anaesthesiologist and pediatrician is vital for successful maternal and foetal outcome.

Emergency caesarean section in a severe kyphosis patient: A case report

Sarvesh, Saru Singh, JC Dureja

Department of Anaesthesiology, BPS Government Medical College for Women, Sonepat Haryana, India

Introduction: Kyphosis and kyphoscoliosis arefrequently encountered in anaesthesia practice, posing anaesthetic challenges due to cardiac and pulmonary dysfunctions. Pregnancy in a kyphoscoliotic patient aggravates or complicates the things further, since the physiological changes of both superimpose on each other, making anaesthetic management much more difficult. We present a case of a full term pregnant patient with severe kyphosis; presenting for emergency caesarean section which highlights the above issues.

Case Discussion: A 22-year-old full term primigravida, 51 kg in weight, 127 cm of height, with severe kyphosis presented to us in labour. She was diagnosed to have obstructed labour due to cephalopelvic disproportion with fetal distress. Hence, she was posted for emergency caesarean section. On assessment she was found to have severe kyphosis deformity of the spine. On examination she had tachypnoea with respiratory rate 30 breaths per minute. Her pulse rate was 98 beats/min and blood pressure was 106/70 mmHg with SpO 2 94% on room air. On auscultation of the chest she had bilateral vesicular breathing with no added sounds. Other systemic examinations revealed no significant findings. Her hematological and urine examinations were within normal limits. Because of the emergent situation, no further investigations to assess pulmonary functions could be done. In view of the compromised pulmonary reserve as judged clinically, it was decided to administer regional anaesthesia, with alternative plans kept ready in case of failed spinal. Spinal anaesthesia was administered successfully in the third attempt, in the space just below the hump in midline sitting position, using 1.4 ml of 0.5% bupivacaine. The sensory block was achieved up to T6 level after four minutes and initial hypotension (B.P. 80 mmHg) was managed easily with mephentermine 3 mg i.v once. The intra and postoperative course of the patient was uneventful.

Conclusion: Considering the cumulative physiological derangements in cardiac and pulmonary functions in a pregnant patient with severe kyphosis, spinal anaesthesia was opted with successful outcome.

Successful outcome in a patient with twin pregnancy with glioma of brain

Anjali Rani

Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Gliomas during pregnancy are rare. Primary CNS tumors occur in 6 in 100000 females but are rare in pregnancy. It is one of the non obstetrical causes of maternal mortality and morbidity. Normally these patients are advised not to become pregnant. The benefit-to-risk ratio should be carefully evaluated and discussed prior to getting pregnant. Our patient is primigravida with twin pregnancy with glioma in temporal lobe of brain diagnosed by MRI. The patient had non specific symptom like seizure and no focal neurological deficit. Caesarean section (CS) was done under general anaesthesia at term with multidisciplinary group, including a neurosurgeon, obstetrician, anaesthesiologist and neonatologist. She has being followed up and is in good health. In gliomas, maternal mortality and morbidity increases because of increase in intracranial pressure. In this patient it was low grade glioma and was asymptomatic and so "watch and wait" policy was observed. Studies have shown that general anaesthesia is safe and well tolerated during pregnancy. Airway management must address the avoidance of increases in intracranial pressure, the presence of a potentially full stomach, pregnancy-induced changes to the airway and enlarged breasts, which increase the incidence of a difficult intubation. It is important to preserve cerebral and utero-placental perfusion by maintaining hemodynamic stability. Extubation should be delayed until the patient is sufficiently awake for the patient's airway to be protected from regurgitation and pulmonary aspiration. The postoperative management of pregnant patients following neurosurgical intervention is similar to that of non-pregnant patients.

Intensive care for obstetric patients in a tertiary care teaching hospital

Shuchi Jain, Madhu Jain

Department of Obstetrics and Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Introduction: With increasing awareness and recent advances in critical care, it is mandatory to have an Intensive Care Unit in each hospital to render utmost care to those who need it. Besides the patients suffering from trauma and poisoning, some obstetric patients also need intensive care to save their lives.

Aim: The objective of this study was to find out the indications for admission of obstetric patients in Intensive care, clinical features at the time of admission, duration of stay and their final outcome.

Patients and Methods: All obstetric patients, in antenatal period and up to 4 weeks post partum, who required Intensive care management over the last eighteen months were part of this study.

Result: Most of the patients were in antenatal period. The commonest indication was obstetric hemorrhage, followed by medical disorders in pregnancy but only few patients required ventilatory support. The common causes of mortality were disseminated intravascular coagulation and multi-organ failure.

Conclusion: A state of the art and committed Obstetric Intensive Care Unit is mandatory in a tertiary care hospital to decrease the maternal morbidity and mortality. Intensive observation and care allowed for early recognition, prevention and treatment of complications. Critical care is a bona fide part of obstetric practice and should be incorporated into training program for post-graduates.

Pregnancy with acute intermittent porphyria: A case report

Shreya Thapa, Sulekha Pandey, LK Pandey

Department of Obstetric and Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Acute intermittent porphyria (AIP) is a rare autosomal dominant metabolic disorder affecting the production of heme, the oxygen-binding prosthetic group of hemoglobin. It is characterized by a deficiency of the enzyme hydroxyl methyl bilane synthase. Without this cytoplasmic enzyme, heme synthesis cannot finish, and the metabolite porphobilinogen accumulates in the cytoplasm. Some additional factors must also be present such as drugs, hormones, dietary changes, infectious diseases and surgery that trigger the appearance of symptoms, which include neurological disorders, abdominal pain, constipation and muscle weakness. We hereby present a case of AIP with Pregnancy Induced Hypertension with bad obstetric history, who was delivered by LSCS under epidural anaesthesia. Her antenatal and perioperative period was uneventful with a good neonatal outcome.

Eisenmenger's syndrome in pregnancy: A case report

Abhishek S, SK Mathur

Department of Anaesthesiology, Institute of Medical Sciences, Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Introduction: Eisenmenger's syndrome consists of pulmonary hypertension with a reversed or bidirectional shunt at the atrioventricular or aortopulmonary level. It is a form of cyanotic congenital heart disease not usually amenable to corrective surgery. Initially, left-to-right intracardiac shunting is associated with increased flow (and sometimes transmitted pressure) through the pulmonary vasculature. This results in pulmonary arterial hypertension and associated elevation in right heart pressures leading to reversal of the shunt with either right-to-left or bidirectional flow, which is called Eisenmenger syndrome. As a result of the right-to-left shunt, patients are chronically hypoxemic, hence cyanotic. Congenital heart defects that can lead to Eisenmenger syndrome include: Atrial septal defects, ventricular septal defects, persistent arterial ducts, as well as more complex defects such as atrioventricular septal defects, truncus arteriosus, aortopulmonary window, complex pulmonary atresia, and the univentricular heart. It is, however, compatible with leading an active life in early adulthood and due to advances in medical therapy it is not uncommon for patients with this syndrome to live to 30 years or more. Occasionally, therefore, anaesthesiologists and surgeons will be required to care for these patients when they present for incidental surgery. Eisenmerger's syndrome in pregnancy is usually associated with high mortality rates (nearly 30-50%). Unfortunately, pulmonary hypertension is aggravated during pregnancy and often leads to an unfavorable outcome. Here, we report a successful pregnancy in a woman with Eisenmenger syndrome but later died on post operative day 6.

Case Report: A 25 year-old woman, primi gravida and an unbooked case of pregnancy with term gestation was referred to us with history of chronic bronchitis since 3 years, pre eclampsia since 1 month and leaking per vagina since 24 hours. There was peripheral cyanosis, polycythemia (hematocrit of 63.5 %), digital clubbing. On auscultation of the chest there was course crepititions in right mammary, infra mammary, axillary and infra axillary areas and ronchi in the left mammary, axillary and infra axillary areas. Auscultation of the heart revealed normal heart sounds and a systolic murmur. A loading dose of inj magnesium sulfate was given and the patient was shifted for emergency ceaserean section due to fetal bradycardia. Spinal anaesthesia was administered and a live female baby was delivered, which weighed 2.25 kg and cried immediately after birth with Apgar score of 7/9/10. No intra operative complications occured. Post operatively the patient was shifted to high dependency unit and was put on oxygen therapy. As the dyspnea worsened and saturation was consistently below 80% she was shifted to intensive care unit and 2D echo and doppler report showed two muscular VSD, 10 mm and 17 mm in dimensions with bidirectional flow, severe pulmonary hypertension (pulmonary artery pressure of 85 mmHg) and moderate to severe tricuspid regurgitation and good left ventricular systolic function with ejection fraction of 60%. Four days after delivery, the patient had generalized seizures which were controlled with Inj. thiopentone and phenytoin. Two days later the patient developed severe ventricular tachycardia and cardiac arrest. CPR was initiated and DC shock was given with no success. The patient died six days after the ceaserean section.


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