Trauma in pregnancy presents a unique challenge, because of the anatomical and physiological changes of pregnancy, and the assessment and treatment of pregnant patients differ accordingly. In this review article, the focus is on familiarizing the anesthesiologists with physiological changes of pregnancy, their effect on response to trauma, resuscitation, and anesthetic management of trauma patient during pregnancy.

Context: There is a paucity of studies comparing crystalloid preload and coload in parturients undergoing cesarean section under spinal anesthesia from India. Aims: To compare crystalloid preload and coload for the prevention of maternal hypotension in parturients undergoing cesarean section under spinal anesthesia. Secondary outcomes studied included requirement of ephedrine for treatment of hypotension, maternal nausea and vomiting, neonatal APGAR scores and acid base status. Settings and Design: Tertiary level, teaching hospital. Prospective, randomized study. Materials and Methods: Hundred parturients, aged 20 to 40 years, American Society of Anesthesiologist (ASA) physical status 1 or 2, with singleton, uncomplicated pregnancies scheduled for cesarean section under spinal anesthesia were randomized into two groups. Subjects in group P received 15 ml/kg of lactated Ringer's (RL) solution as preload over 20 min before the placement of spinal block, while those in group C received 15 ml/kg of RL over 20 min, starting as soon as CSF was tapped. Statistical Analysis Used: Student's t-test, Chi-square test, Fisher's test. Results: The number of parturients developing hypotension in group P and C was 30 and 23 respectively and was comparable statistically. More number of patients developed nausea (19 versus 10, P = 0.0473) and vomiting (14 versus 6, P = 0.0455) in group P as compared to group C and these values were statistically significant. The mean number of doses of ephedrine required (2.6 in group P and 1.8 in group C) and the total dose of ephedrine used (14.2 mg and 12.6 mg in groups P and C respectively) in the groups were comparable statistically. Conclusions: Both preloading and coloading with 15 ml/ kg of RL solution are ineffective in the prevention of spinal-induced maternal hypotension. We recommend frequent monitoring of maternal blood pressure (at 1-min intervals) and prompt treatment of maternal hypotension with vasopressors for better neonatal outcomes.

Background: Epidural volume extension (EVE) with saline in the epidural space during a CSE technique can result in cephalad extension of the block and may be accompanied by episodes of hypotension. It also allows CSE to be performed with small initial intrathecal doses of local anesthetic. Objectives: We investigated the difference in block characteristics and hemodynamic profile with CSE-EVE using either saline or colloid in the epidural space. Materials and Methods: This prospective, randomized, controlled study was conducted in 99 parturients, ASA grade I or II, with gestational age 37 weeks or more, undergoing elective cesarean section under CSEA. Women were randomly distributed into three groups: Group NEVE (CSE with no EVE), Group EVE-S (CSE followed by EVE using 5 ml of 0.9% saline), and Group EVE-H (CSE followed by EVE using 5 ml of 6% hydroxyethyl starch (HES) 200/0.5). All the groups received 6 mg of 0.5% hyperbaric bupivacaine with 25 mcg fentanyl intrathecally, while Groups EVE-S and EVE-H also received 5 ml of saline or HES in the epidural space. All blocks were performed using needle through needle CSE technique via midline approach at the L _4-5 interspace with the women in the left lateral position. Block characteristics and hemodynamic parameters were recorded by an independent anesthesiologist. Data were compared with Chi-square, t test, and ANOVA using Epi info 6 with P < 0.05 as significant. Results: The peak sensory level and the time taken to achieve it was significant in Group EVE-S (P = 0.003 temperature, P = 0.007 pinprick, P = 0.000 time) as compared to Group NEVE while Group EVE-H was intermediate as compared to the other two groups. In Group EVE-S, there was a difference in the mean peak sensory levels as assessed by temperature (thoracic T _4.88±1.01 ) and pinprick (T _5.04±1.02 ), whereas it was the same in the other two groups (T _6.10±1.41 in Group NEVE and T _5.44±1.35 in Group EVE-H). The requirement for ketamine supplementation was significantly more in Group NEVE (54.5%) as compared to Group EVE-S (24.2%) and Group EVE-H (27.3%), P = 0.018. The motor block characteristics were comparable in all the three groups (P > 0.05).The lowest attained values of heart rate, systolic, and diastolic blood pressure were significantly less in Group EVE-S versus Group NEVE (P = 0.019, 0.008, and 0.001, respectively), while hemodynamic parameters in Group EVE-H were intermediate. Incidence of hypotension was significantly more in Group EVE-S (n = 20, 60.6%), as compared to Group NEVE (n = 9, 27.3%, P = 0.02) and Group EVE-H (n = 13, 39.4%). Conclusion: We conclude that an intrathecal dose of 6 mg hyperbaric bupivacaine with 25 mcg fentanyl is adequate for cesarean section when used in CSE with the EVE technique, using 0.9% saline or 6% HES. However, EVE with HES provides optimal hemodynamic profile as compared to EVE with saline.

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.

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.

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.

We report a rare case of successful thrombolysis of right heart emboli-in-transit causing cardiac arrest, during caesarean section in a 42-year-old primigravida. This was diagnosed by intra-operative echocardiography. Return to spontaneous circulation was achieved. This was followed by massive post-partum haemorrhage managed conservatively. The lady was discharged home with a Greenfield Inferior Vena Caval filter and Warfarin. Systemic thrombolytic therapy is a challenging decision to make but is usually recommended if it is not contraindicated and the thrombi are demonstrated in more than one cardiac chamber, entailing a higher risk of surgical intervention. However, the potential for massive obstetric bleeding and further side effects must be considered and adequate strategies and resources should be available.

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.

Fetal bradycardia is common following spinal opioids administered for pain relief during labor. This slowing is usually benign and short lived. Although it leads to some anxiety among obstetricians and anesthesiologists, it rarely results in urgent operative delivery. Here, we are reporting a case where urgent caesarean delivery was needed due to severe and persistent fetal bradycardia following low-dose intrathecal fentanyl. Fetal bradycardia possibly was due to hypertonic uterine contractions complicated by tightly wrapped cord round the neck.

Tetralogy of fallot (TOF) is the most commonly encountered congenital cyanotic heart disease in pregnant females and maternal mortality approaches 10% in unrepaired TOF. General anesthesia is classically considered the technique of choice for incidental surgery in TOF and neuraxial anesthesia is considered relatively contraindicated. However, general anesthesia for caesarean section can increase maternal morbidity. We report two cases of caesarean section performed under combined spinal epidural (CSE) anesthesia and epidural anesthesia respectively in patients with uncorrected TOF. Adequate preloading to maintain hydration, continuous invasive monitoring, gradual extension of neuraxial blockade by epidural/CSE technique, and judicious use of phenylephrine infusion enabled us to successfully manage both the cases without any complication.

Double outlet right ventricle (DORV) is a rare congenital heart defect involving the great arteries. In DORV, both aorta and pulmonary artery arise from the right ventricle resulting in admixture of blood. We report a 22-year-old parturient with DORV and severe pulmonary stenosis who underwent caesarean delivery at 36 weeks gestation with low dose combined spinal-epidural anesthesia. This lady was assessed by echocardiogram to have situs inversus, dextrocardia, severe pulmonary artery stenosis (gradient = 146 mm Hg), DORV with subarterial VSD (1 cm). She had 95% room air saturation and her blood investigations were within normal limits. We established a peripheral venous access and radial arterial line for continuous blood pressure monitoring. Combined spinal epidural anesthesia was considered a better option. Epidural catheter was secured at L ₂ -L ₃ space and fixed after giving test dose 3 mL 2% lignocaine. Subarachnoid block administered at L ₃ -L ₄ level using 1.2 mL of 0.5% heavy bupivacaine. A sensory block of T ₁₀ was obtained which was supplemented with 4 mL 0.75% ropivacaine to obtain a level of T ₆ . Patient tolerated the procedure well. She was shifted to post-operative ICU. Post-operative pain was managed with epidural 0.2% ropivacaine at 4 mL/h. Patient remained hemodynamically stable throughout the procedure and in the postoperative period while she was being followed up for subsequent 48 h.