Misconceptions Related to Neuraxial Anesthesia and Effect of Obstetrics Education on Patient Satisfaction after Cesarean Section in King Abdulaziz Medical City

Recommendations regarding the use of spinal and epidural anesthesia for patients with von Hippel-Lindau (VHL) disease are unclear [1-3] and even contradictory [4,5] due to the possible presence of vascular malformations (hemangioblastomas) in the spinal cord. We report a case of a patient with VHL disease and coexisting multiple sclerosis whose cesarean section was successfully managed with epidural anesthesia. Case Report A 45-yr-old patient, gravida 2, para 1, presented for repeat cesarean section at 38 wk gestation. She had a history of VHL disease that was manifested by hemangioblastomas in her retinae and cerebellum, pheochromocytomas, and pancreatic carcinoma. Twenty years previously, pheochromocytomas had been discovered when she developed a hypertensive crisis during her first pregnancy, requiring delivery of her child by cesarean section under general anesthesia. She subsequently underwent bilateral adrenalectomies and has been receiving chronic steroid replacement therapy. Her pancreatic carcinoma was excised via a pylorus-sparing Whipple procedure 2 yr earlier, which resulted in severe gastroesophageal reflux. The patient's multiple sclerosis symptoms had been mild and intermittent, consisting mainly of heat-induced fatigue and lower extremity weakness. Her medications included prednisone 7.5 mg and fludrocortisone acetate 0.05 mg/d. The patient's vital signs were within normal limits, as were her cardiovascular, respiratory, and airway examinations. A recent total spine magnetic resonance image revealed gadolinium-enhanced lesions in the dorsal spinal cord at T8-9 and at L2 that were "suggestive of very small hemangioblastomas" (Figure 1). There was no cord compression, and the vertebral bodies and intervertebral spaces appeared normal.Figure 1: Sagittal magnetic resonance image of the patient's lumbar spine. Spinal hemangiomas appear as white opacities between the arrows at T8 and L2. The site of epidural needle insertion is delineated by the asterisk at L3-4.To avoid the stress of labor and to minimize the risk of disrupting central nervous system (CNS) hemangioblastomas during contractions, delivery by cesarean section was planned. The patient expressed a very strong desire to be awake for the delivery. Radiologic consultations suggested that the risk of lacerating a spinal cord lesion during neuraxial anesthesia was minimal because these hemangioblastomas were small and well documented as being distant from the site of needle insertion. Despite a clear understanding that regional anesthesia might cause disruption of an hemangioblastoma, which might result in paralysis, the patient wished to proceed with regional anesthesia and gave informed consent. Hydrocortisone (100 mg IV) was administered preoperatively. After IV hydration, a 20-gauge catheter was inserted 3 cm into the epidural space via a 17-gauge Tuohy-Weiss needle placed at the L3-4 interspace. After a 3-mL test dose of 2% lidocaine with epinephrine 1:200,000 was given via the catheter, incremental injections of alkalinized 2% lidocaine with epinephrine were administered to achieve a T4 level. A cesarean section was then performed yielding a healthy infant with Apgar scores of 9 and 9 at 1 and 5 min, respectively. Surgery and recovery were uneventful. The patient was ambulating 8 h later, and her neurologic examination remained normal. She denied having any neurologic sequelae 2 mo after her surgery. Discussion VHL disease is an autosomal dominant disorder with variable penetrance characterized by hemangioblastomas of the retina, cerebellum, and spinal cord. It is also associated with renal cell carcinomas, pancreatic cysts and tumors, and pheochromocytomas [6,7]. The VHL gene seems to be a tumor-suppressive gene with "loss of function leading to unchecked cell growth and tumorigenesis" [7]. Complications include blindness, progressive neurological impairment, and death. The prevalence of this disease is estimated as 1:35,000 to 1:40,000 [7]. The main anesthetic concerns for a patient with VHL disease involve complications arising from pheochromocytomas and CNS hemangioblastomas [8]. Pheochromocytomas are present in approximately 7%-19% of patients diagnosed with VHL disease [6], and perioperative mortality can be 25%-50% if they remain undiscovered until the time of surgery [9]. Because CNS hemangioblastomas may be present, using neuraxial anesthesia in patients with VHL disease is controversial. The first report of a patient with VHL disease receiving an epidural anesthetic appeared in 1986 [4]. The authors stated that an epidural needle and catheter were unlikely to disrupt intramedullary lesions in the posterior columns of the spinal cord [4]. However, the authors of a subsequent article asserted that both spinal and epidural techniques are contraindicated in all patients with VHL disease because of the inherent risk of rupturing a hemangioblastoma [5]. We believe that the choice of anesthetic technique must be evaluated on an individual basis. In our pregnant patient with vascular malformations of the spinal cord and active gastroesophageal reflux, the epidural technique avoided the need for general anesthesia and the risks of laryngoscopy. Although there is a chance of injuring a spinal cord hemangioma by perforating the dura with an epidural needle or by passing a catheter intrathecally into a lesion, this probability was low based on the radiographic documentation of their size and locations. Spinal anesthesia was not chosen because we believed that a needle directed intrathecally has a greater potential of contacting a spinal cord lesion than a needle or catheter intended for the epidural space. In conclusion, epidural anesthesia was successfully performed in a patient with VHL disease and multiple sclerosis without neurologic sequelae. Epidural anesthesia should not be ruled out in patients with VHL disease based solely on this diagnosis. Rather, the choice of anesthesia technique should be determined after careful evaluation of the extent of the patient's disease, including a review of radiologic studies of the CNS. Consideration should also be given to the nature of the surgical procedure, to the circumstances surrounding the surgery, and to the patient's desires.

Recommendations regarding the use of spinal and epidural anesthesia for patients with von Hippel-Lindau (VHL) disease are unclear [1-3] and even contradictory [4,5] due to the possible presence of vascular malformations (hemangioblastomas) in the spinal cord. We report a case of a patient with VHL disease and coexisting multiple sclerosis whose cesarean section was successfully managed with epidural anesthesia. Case Report A 45-yr-old patient, gravida 2, para 1, presented for repeat cesarean section at 38 wk gestation. She had a history of VHL disease that was manifested by hemangioblastomas in her retinae and cerebellum, pheochromocytomas, and pancreatic carcinoma. Twenty years previously, pheochromocytomas had been discovered when she developed a hypertensive crisis during her first pregnancy, requiring delivery of her child by cesarean section under general anesthesia. She subsequently underwent bilateral adrenalectomies and has been receiving chronic steroid replacement therapy. Her pancreatic carcinoma was excised via a pylorus-sparing Whipple procedure 2 yr earlier, which resulted in severe gastroesophageal reflux. The patient's multiple sclerosis symptoms had been mild and intermittent, consisting mainly of heat-induced fatigue and lower extremity weakness. Her medications included prednisone 7.5 mg and fludrocortisone acetate 0.05 mg/d. The patient's vital signs were within normal limits, as were her cardiovascular, respiratory, and airway examinations. A recent total spine magnetic resonance image revealed gadolinium-enhanced lesions in the dorsal spinal cord at T8-9 and at L2 that were "suggestive of very small hemangioblastomas" (Figure 1). There was no cord compression, and the vertebral bodies and intervertebral spaces appeared normal.Figure 1: Sagittal magnetic resonance image of the patient's lumbar spine. Spinal hemangiomas appear as white opacities between the arrows at T8 and L2. The site of epidural needle insertion is delineated by the asterisk at L3-4.To avoid the stress of labor and to minimize the risk of disrupting central nervous system (CNS) hemangioblastomas during contractions, delivery by cesarean section was planned. The patient expressed a very strong desire to be awake for the delivery. Radiologic consultations suggested that the risk of lacerating a spinal cord lesion during neuraxial anesthesia was minimal because these hemangioblastomas were small and well documented as being distant from the site of needle insertion. Despite a clear understanding that regional anesthesia might cause disruption of an hemangioblastoma, which might result in paralysis, the patient wished to proceed with regional anesthesia and gave informed consent. Hydrocortisone (100 mg IV) was administered preoperatively. After IV hydration, a 20-gauge catheter was inserted 3 cm into the epidural space via a 17-gauge Tuohy-Weiss needle placed at the L3-4 interspace. After a 3-mL test dose of 2% lidocaine with epinephrine 1:200,000 was given via the catheter, incremental injections of alkalinized 2% lidocaine with epinephrine were administered to achieve a T4 level. A cesarean section was then performed yielding a healthy infant with Apgar scores of 9 and 9 at 1 and 5 min, respectively. Surgery and recovery were uneventful. The patient was ambulating 8 h later, and her neurologic examination remained normal. She denied having any neurologic sequelae 2 mo after her surgery. Discussion VHL disease is an autosomal dominant disorder with variable penetrance characterized by hemangioblastomas of the retina, cerebellum, and spinal cord. It is also associated with renal cell carcinomas, pancreatic cysts and tumors, and pheochromocytomas [6,7]. The VHL gene seems to be a tumor-suppressive gene with "loss of function leading to unchecked cell growth and tumorigenesis" [7]. Complications include blindness, progressive neurological impairment, and death. The prevalence of this disease is estimated as 1:35,000 to 1:40,000 [7]. The main anesthetic concerns for a patient with VHL disease involve complications arising from pheochromocytomas and CNS hemangioblastomas [8]. Pheochromocytomas are present in approximately 7%-19% of patients diagnosed with VHL disease [6], and perioperative mortality can be 25%-50% if they remain undiscovered until the time of surgery [9]. Because CNS hemangioblastomas may be present, using neuraxial anesthesia in patients with VHL disease is controversial. The first report of a patient with VHL disease receiving an epidural anesthetic appeared in 1986 [4]. The authors stated that an epidural needle and catheter were unlikely to disrupt intramedullary lesions in the posterior columns of the spinal cord [4]. However, the authors of a subsequent article asserted that both spinal and epidural techniques are contraindicated in all patients with VHL disease because of the inherent risk of rupturing a hemangioblastoma [5]. We believe that the choice of anesthetic technique must be evaluated on an individual basis. In our pregnant patient with vascular malformations of the spinal cord and active gastroesophageal reflux, the epidural technique avoided the need for general anesthesia and the risks of laryngoscopy. Although there is a chance of injuring a spinal cord hemangioma by perforating the dura with an epidural needle or by passing a catheter intrathecally into a lesion, this probability was low based on the radiographic documentation of their size and locations. Spinal anesthesia was not chosen because we believed that a needle directed intrathecally has a greater potential of contacting a spinal cord lesion than a needle or catheter intended for the epidural space. In conclusion, epidural anesthesia was successfully performed in a patient with VHL disease and multiple sclerosis without neurologic sequelae. Epidural anesthesia should not be ruled out in patients with VHL disease based solely on this diagnosis. Rather, the choice of anesthesia technique should be determined after careful evaluation of the extent of the patient's disease, including a review of radiologic studies of the CNS. Consideration should also be given to the nature of the surgical procedure, to the circumstances surrounding the surgery, and to the patient's desires.

BACKGROUND AND OBJECTIVES:Pregnancy and delivery can involve complications that necessitate admission to critical care facilities. The objective of our study was to assess the incidence, indications, and outcomes of obstetric patients requiring admission to an intensive care unit (ICU) in a tertiary care hospital, in Saudi Arabia.DESIGN AND SETTING:Retrospective cohort study of consecutive obstetric admissions to the ICU at the King Abdulaziz Medical City over a 10-year period.PATIENTS AND METHODS:We collected baseline demographic data and acute physiology and chronic health evaluation II (APACHE II) scores. ICU mortality was the primary outcome.RESULTS:Over 10 years, 75 obstetric patients were admitted to the ICU, and 59 of these patients (78.6%) were admitted during the antepartum period. The main obstetric indication for ICU admission was pregnancy-induced hypertension (21 patients, 28%) and the leading non-obstetric indication was sepsis (12 patients, 16%). The APACHE II score was 19.59 (15.05). The predicted mortality rate based on the APACHE II score was 21.97%; however, there were only six maternal deaths (8%) among the obstetric patients admitted to the ICU.CONCLUSION:The overall mortality was low. A team approach facilitated the application of optimal care to these patients. Obstetric patients had better outcomes than those predicted by the APACHE II scores. Appropriate antenatal care is important for preventing obstetric complications.

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Preoperative anxiety is a major concern for patients undergoing neuraxial anesthesia, often leading to increased physiological stress and reduced satisfaction. Recently, multimedia-based education has been encouraged as a new approach to enhancing patient understanding and reducing anxiety. This paper investigates whether multimedia-based patient education improves preoperative anxiety, patient satisfaction, and hemodynamic stability in patients undergoing neuraxial anesthesia. According to PRISMA 2020 guidelines, a comprehensive search was conducted across multiple databases, including Scopus, Web of Science, PubMed, and Google Scholar. The selection criteria included interventional studies assessing multimedia-based preoperative education compared to conventional methods. Anxiety levels, patient satisfaction, and hemodynamic parameters were analyzed. A total of 10 studies involving 1016 patients were included. Nine studies demonstrated a significant reduction in preoperative anxiety among patients receiving multimedia education, while one study found no significant difference. Patient satisfaction was significantly higher in multimedia-educated groups, suggesting an improved patient experience. Additionally, three studies reported better hemodynamic stability, including lower heart rates and blood pressure fluctuations, in patients exposed to multimedia education. Multimedia-based education effectively reduces preoperative anxiety, improves patient satisfaction, and enhances hemodynamic stability in neuraxial anesthesia. However, variations in content, duration, and study design highlight the need for further high-quality research to standardize multimedia interventions and assess long-term outcomes.

Background & Objective: Preoperative anxiety is commonly reported among obstetric patients. This anxiety can lead to increased postoperative pain, prolonged hospital stays and hemodynamic fluctuations. The present study was conducted to determine the effect of pre-operative anxiety on hemodynamic changes and post-operative pain in obstetric patients undergoing elective Cesarean Section (CS).Materials & Methods: This descriptive, analytical study was conducted on 240 pregnant women who referred to Alzahra Hospital for cesarean section during 2023. The State-Trait Anxiety Inventory (STAI) and Visual Analogue Scale (VAS) were used, respectively, to assess patients' preoperative anxiety and postoperative pain.Results: The data of 240 eligible women were analyzed. 38 patients (15.8%) had severe preoperative anxiety, 124 women (51.7%) had moderate preoperative anxiety, and 13 women (32.5%) had Mild preoperative anxiety. 148(61.7%) of mothers undergoing cesarean section had mild post-operative pain, 79(32.9%) of mothers had moderate post-operative pain and Only 13 women (5.4%) reported severe post-operative pain. There was a significant association between preoperative anxiety severity and postoperative pain (P<0.0001). The higher level of education (P=0.014), older ages (P<0.0001), a history of previous surgery (P<0.0001) and a greater number of pregnancies (P<0.0001) were significantly associated with lower severity of anxiety.Conclusion: There was a significant association between preoperative anxiety and postoperative pain in cesarean section as well as hemodynamic parameters. A very small percentage of mothers suffered from severe anxiety peri-operation, and a small percentage reported severe and acute post-operation pain.

Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013. To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels. The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013. We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery. Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest. Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.

BACKGROUND:External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery.METHODS:We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction.RESULTS:Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88–3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36–3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33–4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95% CI, 3.14–27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16–0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = −1.61; 95% CI, −1.92 to −1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = −1.61; 95% CI, −1.92 to −1.31) and inhalational (SMD = −1.19; 95% CI, −1.58 to −0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64–2.43).CONCLUSIONS:Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.

We investigated parturients' preference for neuraxial vs general anaesthesia, while they have experienced both techniques in the past. A total of 102 parturients who underwent elective caesarean section under general or neuraxial anaesthesia at different times completed a questionnaire comparing the two techniques. According to our results, 98% vs 51% (p < 0.001) of the women saw the baby and 51% vs 29% (p = 0.003) ambulated in the neuraxial and general anaesthesia groups, respectively, within the first 24 h postoperatively. Neuraxial anaesthesia was associated with less pain assessed by the Verbal Analogue Scale (VAS) (54 ± 21 vs 72 ± 20 p < 0.001), fewer days of hospital stay (4 ± 0.5 vs 5 ± 1.5, p = 0.001) and higher satisfaction scores (77 ± 18 vs 52 ± 24, p = 0.001) vs general anaesthesia. Finally, 80% of the women would choose neuraxial anaesthesia for a future caesarean section.

To study if patient preoperative anxiety is related to age and gender and to compare preoperative anxiety with postoperative patient and surgeon satisfaction in dental implant surgery under intravenous conscious sedation. Dental implants were placed in 102 patients under local anesthesia and intravenous conscious sedation. The procedures were performed with or without dental extractions, and with or without bone regeneration. Anxiety was evaluated using Corah's Dental Anxiety Scale and levels of surgeon and patient satisfaction were evaluated on an adapted scale. Low preoperative anxiety was observed in 27.8% of patients, moderate in 50%, and high in 22.2%. Mean value of anxiety was 9.8+/-3.7. The level of surgeon satisfaction was adequate in 87.8% of the surgeries; patients were awake and nervous in 4.4% of surgeries, and excessively sleepy, with little cooperation in 7.8% of surgeries. Regarding patient satisfaction, the procedure was comfortable for 23.3% of patients, neither comfortable nor uncomfortable for 28.9%, a slightly uncomfortable experience for 36.7%, and very uncomfortable for 10% of patients. Younger patients and women were observed to have more anxiety, the difference being statistically significant. Patients with higher preoperative anxiety expressed a lower level of satisfaction, with statistically significant differences. There was no significant relationship between preoperative patient anxiety and postoperative surgeon satisfaction. Anxiety was higher in younger patients and women. In this study, a higher preoperative patient anxiety was associated with lower patient satisfaction, but had no influence on postoperative surgeon satisfaction.

Context: Anxiety is felt in women undergoing elective cesarean section. In obstetric patients, literature has reported a higher level of preoperative anxiety than the general surgical population. One of the commonest surgical procedures in obstetrics is Caesarean section (CS). Preoperative anxiety has been described as being associated with several adverse physiological and psychological effects. Aim: This review aimed to determine the relationship between preoperative educational sessions and anxiety levels among women undergoing cesarean section. Methods: The search strategy of this study relies on some of the electronic bibliographic databases under the Medicine, Nursing, and Health Sciences departments. Various databases have been used to include different perspectives in the findings, CINAHL, Ovid MEDLINE, Pub Med, and Embase databases used to collect primary articles for this study. Results: The current review of the literature included seven quantitative studies that fulfill the inclusion criteria. The included studies revealed the intervention used as mental health training (one study), video is used in three studies, and health instruction in five studies. Two studies used both video and health instruction. In terms of the effect of preoperative sessions on anxiety level, four out of seven studies reported a decrease in the anxiety level. In comparison, the remaining three studies reported a non-significant educational intervention effect in decreasing the women’s anxiety. Conclusion: Most of the reviewed studies indicated that preoperative education intervention could positively impact anxiety levels among women undergoing CS. This makes the reviewed theme open for further randomized control intervention studying.

The reported incidence of post--dural puncture headache (PDPH) after neuraxial anaesthesia varies widely, depending on patient and procedural risk factors. Most previous studies have had small sample sizes and focused on obstetric patients. This study aimed to investigate the incidence of PDPH and factors associated with PDPH in non-obstetric and obstetric patients after neuraxial anaesthesia. We identified patients who underwent surgery with neuraxial anaesthesia between July 2010 and December 2017 from a Japanese nationwide inpatient administrative claims and discharge database. Factors associated with PDPH (body mass index (BMI), depression, spinal abnormalities, academic hospital and location of epidural anaesthesia) were examined using multivariable logistic analyses. The incidence of PDPH in non-obstetric patients after spinal anaesthesia, epidural anaesthesia and combined spinal epidural anaesthesia was 0.16%, 0.13% and 0.23% and in obstetric patients was 1.16%, 0.99% and 1.05%, respectively. Higher BMI was associated with decreased incidence of PDPH in non-obstetric patients receiving spinal anaesthesia and obstetric patients receiving epidural anaesthesia. In female patients receiving spinal anaesthesia, a history of depression was associated with increased incidence of PDPH. Being in an academic hospital was associated with decreased incidence of PDPH in male patients receiving spinal anaesthesia and female patients receiving spinal or epidural anaesthesia, but increased incidence of PDPH in male patients receiving epidural anaesthesia. Lumbar epidural anaesthesia was associated with increased incidence of PDPH in male patients, but decreased incidence of PDPH in obstetric patients compared with thoracic epidural anaesthesia. The present study identified several potential new risk factors for PDPH, and revealed that the incidence of PDPH in non-obstetric patients after neuraxial anaesthesia was lower than in obstetric patients.

“Prevalence and associated factors of preoperative anxiety among obstetric patients who underwent cesarean section”: A cross-sectional study

The COVID-19 pandemic, is an ongoing pandemic caused by corona virus.It can lead to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).As of 9 March 2021, more than 117 million cases have been confirmed, with more than 2.6 million deaths attributed to COVID-19, making it one of the deadliest pandemics in history. As the pandemic evolves rapidly, there are data emerging to suggest that pregnant women diagnosed as having coronavirus disease 2019 can have severe morbidities (up to 9%). The aim of this article is to bring attention to all steps that should be followed in obstetric patients with positive COVID-19. This is a litterature review, refering to international guidelines and international collegues experiences , especially from Wuhan and USA. In contrast to earlier data that showed good maternal and neonatal outcomes, the latest data suggest that pregnant woman can have severe morbidities. Exposure to virus predisposes both mother and fetus to an increased risk of infection and severe adverse maternal and perinatal outcomes. The anesthesia management of the patient with a suspected or confirmed COVID-19 infection presents a major challenge for anesthesia professionals because of the pathophysiologic and confirmed rapid human-to- human transmission of the virus through symptomatic and asymptomatic carriers. As with SARS and MERS, the most critical goal in the OR is to prevent cross-contamination by implementing stringent anesthesia guidelines and infection control strategies in the perioperative setting. Pregnant women with suspected or confirmed COVID-19 should be triaged and their condition categorized as mild, severe, or critical. Asymptomatic and mild cases should be isolated at home, and be taken care throw all the process until the day of the delivery. Severe and MOF patients should be taken care in the hospital by a multidisciplinary group. Vaginal delivery is recommended in stable patients because viral shedding and vertical transmission have not been reported. There are international recommendations starting to continuous CTG monitoring due to possible increased risk of fetal distress, monitor temperature, respiratory rate. Under normal labor progression, vaginal examinations should be minimized. Neuraxial analgesia is not contraindicated, and by providing good analgesia, it may reduce cardiopulmonary stress from pain and anxiety. Although evidence of mother-to-child transmission is lacking, early cord clamping may be discussed with the patient. The patient could informedly decide skin-to-skin contact with the newborn , ensuring precautions for respiratory droplets with the use of a mask as well as hand and skin hygiene. Caesarean section should follow usual obstetric indications. The potential risk of vertical transmission is not an indication for caesarean section. Because of pulmonary complication known in COVID-19, the regional anesthesia is recommended unless there are no contraindication. Before neuraxial anesthesia must be done blood count test, especially to asses the platelet count. If general anesthesia is required , the anesthesia machine must be prepared with an HMEF between the circuit and the patient’s airway. The most experienced anesthesia provider should be dedicated to the intubation. The anesthetist should manage the pain, preferably with NSAIDS, the PONV using antiemetics and VTE prophylaxis. COVID-19 is highly contagious, and this must be taken into consideration when planning intrapartum care. Rational use of personal protective equipment is key in preventing infection in attending professionals. The first of all is ’’ Primum non nocere’’, it should be done the best for the pregnant patient and for the newborn protecting the personnel. There are still limited data on the care and management of the parturient with COVID-19. It is paramount that our profession shares our experiences and practices to help guide our multidisciplinary approach in delivering the best care possible to these women.

Preprocedural ultrasound for neuraxial blockade in nonobstetric patients. Should it be considered as a standard of care?