The Complex Triad of Pregnancy, Neurosurgery, and Anesthesia: Insights from a Single-Center Case Series and Literature Review

<h3>Introduction</h3> Intrapartum caesarean delivery (CD) is a common obstetric intervention. Published cohorts report up to 31,2% of intrapartum CD among parturients admitted to delivery room.¹ It also represents 60 to...

Background/Objectives: The optimal anesthetic technique for category 2 and 3 cesarean deliveries remains debated, with concerns about impacts on decision-to-delivery interval (DDI) and perinatal outcomes. This study examined the influence of epidural, spinal, and general anesthesia on DDI, surgical and postoperative complications, and neonatal outcomes. Methods: This prospective cohort study at a tertiary perinatology center enrolled parturient women undergoing category 2 and 3 cesarean deliveries. Three DDI phases were assessed for each anesthetic modality: transfer time (decision for cesarean section to admission in the operation room), anesthetic time (admission to incision), and delivery time (incision to delivery of the neonate). The surgical procedure time (incision to closure), neonatal (5 min Apgar score, umbilical artery pH/base excess, neonatal intensive care unit (NICU) admission) and maternal (blood loss, surgical and postoperative complications) outcomes were also analyzed for each group. Results: There were 215 women (122 category 2 and 93 category 3) included. The use of epidural and general anesthesia was associated with significantly shortened DDI compared to spinal anesthesia (p &lt; 0.001). This difference was due prolonged transfer (p &lt; 0.05) and anesthetic times (p &lt; 0.001), respectively. No cases of umbilical artery pH below 7 were observed in any group. No significant differences were observed in the incidence of umbilical artery pH between 7 and 7.10 or in base excess below −12 nmol/L (p = 0.416 and p = 0.865, respectively). NICU admission was higher with both general and spinal anesthesia (p = 0.021), but mainly due to a higher proportion of preterm births, both before the 32nd week (p = 0.033) and between the 32nd and 37th week of pregnancy (p &lt; 0.001). General anesthesia was associated with higher maternal blood loss (p = 0.026) and a higher rate of postoperative complications (p = 0.006). Conclusions: In category 2 and 3 cesarean deliveries, general and epidural anesthesia were associated with shorter DDI compared to spinal anesthesia with no differences in neonatal outcomes. General anesthesia was associated with a higher risk of maternal complications compared to neuraxial anesthetic techniques.

Moyamoya disease, a rare chronic cerebrovascular disease with a fragile vascular network at the base of the brain, can cause ischemic or hemorrhagic strokes or seizures. Precise blood pressure control and adequate analgesia are important for patients with moyamoya disease to prevent neurological events such as ischemia and hemorrhage. This study aimed to compare the intraoperative mean arterial pressure of pregnant women with moyamoya disease according to the mode of anesthesia (general anesthesia versus spinal anesthesia) used during cesarean delivery. We retrospectively reviewed the medical records of 87 cesarean deliveries in 74 patients who had been diagnosed with moyamoya disease before cesarean delivery. The primary outcome, intraoperative maximum mean arterial pressure during anesthesia, was compared according to the type of anesthesia administered (general versus spinal anesthesia). Other perioperative hemodynamic data (lowest mean arterial pressure, incidence of hypotension, vasopressor use, and antihypertensive agent use), maternal neurologic symptoms, neonatal outcomes (Apgar scores <7, ventilatory support, and intensive care unit admission), maternal and neonatal length of stay, postoperative pain scores, and rescue analgesic use were assessed as secondary outcomes. While the lowest blood pressure during anesthesia and incidence of hypotension did not differ between the 2 groups, the maximum mean arterial pressure during anesthesia was lower in the spinal anesthesia group than that in the general anesthesia group (104.8 ± 2.5 vs 122.0 ± 4.6; P = .002). Study data did not support the claim that maternal neurologic symptoms differ according to the type of anesthesia used (5.6% vs 9.3%; P = .628); all patients recovered without any sequelae. The postoperative pain scores were lower, and fewer rescue analgesics were used in the spinal anesthesia group than in the general anesthesia group. Other maternal and neonatal outcomes were not different between the 2 groups. Compared with general anesthesia, spinal anesthesia mitigated the maximum arterial blood pressure during cesarean delivery and improved postoperative pain in patients with moyamoya disease.

OPINION article Front. Pharmacol., 14 April 2014Sec. Cardiovascular and Smooth Muscle Pharmacology Volume 5 - 2014 | https://doi.org/10.3389/fphar.2014.00074

Objective To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method. Methods A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012–2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events. Results Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p = .013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69–46.40% in others, p < .001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12–15% in others, p < .001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44–6.56, p = .0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081–7.448, p = .0342). Conclusion Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods. Abbreviations NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.

Objective: Spinal anesthesia (SA) is the preferred option for cesarean delivery because of its lower risk to both the mother and fetus.However, general anesthesia (GA) is used in emergencies to minimize the time between the decision to proceed with surgery and delivery.We compared neonatal out comes associated with different anesthesia types in cesarean delivery, specifically SA and GA.Further more, we examined the factors influencing the use of GA in cesarean deliveries.Methods: A total of 154 and 208 patients with a gestational age of 37 weeks who received GA (GA group) and SA (SA group), admitted between January 2011 and December 2020, were analyzed.Results: Of all the patients, 41.3% underwent GA.The reasons for GA were as follows: unknown causes (including failed SA, 28.2%), placenta previa (25.0%), maternal request (21.3%), maternal health condition (13.8%), and fetal health condition (11.7%).Apgar scores at 1 and 5 minutes in the GA group were significantly lower than in the SA group.The incidences of resuscitation at birth, admission to the neonatal intensive care unit, and respiratory support were higher in the GA group than in the SA group.Conclusion: SA during cesarean delivery was associated with better neonatal outcomes.It is crucial to minimize the use of GA during cesarean delivery when it is not medically necessary to improve maternal and neonatal outcomes.

Maternal complications in repeat cesarean section are increasing with the rising rate of cesarean section in the world. The aim of this study to evaluate intra-operative maternal complications of previous one and two cesarean section. It needs to the highlight for proper antenatal care and complication can be anticipated during surgery.Objective:To determine the frequency of intra-operative maternal complications among women undergoing repeated Caesarean section at Isra University hospital, Hyderabad.Material and methods:STUDY DESIGN: Cross-sectionalSETTING: The study was conducted obstetric and gynecology department of Isra University Hospital Hyderabad.DURATION OF STUDY: The study was of six months and the study process was carried out from 15th Agust 2011 to 15th February 2012.SAMPLE SIZE: 280 casesSAMPLE TECHNIQUE: Non probability, purposive samplingSAMPLE SELECTION:Inclusion criteria: All the pregnant women with history of previous one and previous to caesarean section availing obstetric and gynecology facilities at Isra University Hospital, Hyderabad Women regardless of any age group.  Exclusion criteria:•         Pregnant women with no history of caesarean section•         Pregnant women who refused to participate in the studyRESULTS:     The mean + SD age was found to be 29.94 + 5.03 years; The maximum age of participants in this study was 45 years while the minimum age was 17 years. The age distribution of study participants was normally distributed. Regarding intra-operative complications, the prevalence of Adhesion is very high and alarming i.e. 97.5% among pregnant women undergoing repeated Caesarean section delivery. The prevalence of uterine scar dehiscence was not very high and it was confined to 17.9% in our study. The prevalence of difficult delivery of fetus a maternal complication was around 12% in our sample. The prevalence of excessive blood loss as an Intra-operative maternal complication was found to be 19% in our study. The prevalence of Caesarean Hysterectomy as an Intra-operative maternal complication was very minimum i.e. <2% in our sample. With regard to the association of age with intra-operative complication Adhesion among study participants, there was no difference in the mean age of two groups as evidenced by p-value of 0.103. Moreover, there was no association between age with intra-operative complication uterine scar dehiscence as evidenced by p-value of 0.837. Interestingly no association was observed between previous history of Caesarean section with intra-operative complication Adhesion among study participants. There was a significant association between previous history of Caesarean section and uterine scar dehiscence in our study.Conclusion: The present research makes a strong case that the prevalence of intra-operative complications among pregnant women undergoing repeated Caesarean section is not uncommon at Isra University hospital Hyderabad, Pakistan. This issue can have serious implications for maternal mortality and morbidity. Multiple cesarean deliveries are associated with one of the intra-operative complications “Uterine scar dehiscence”. The risk of major complications increases with cesarean delivery number.

291 Neonatal and maternal outcomes in laboring nulliparas by cesarean and operative vaginal delivery rates

To estimate the incidence of gestational diabetes mellitus (GDM) according to The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and the pregnancy complications in women fulfilling these criteria but who are not considered diabetic according to the Canadian Diabetes Association criteria. We estimated the rate of GDM according to the IADPSG criteria from November 2008 to October 2010. Then, we conducted a chart review to compare maternal and neonatal outcomes between women classified as GDM according to the IADPSG criteria but not by the Canadian Diabetes Association criteria (group 1; n=186) and nondiabetic women according to both criteria (group 2; n=372). Results were expressed as crude (odds ratio [OR]) or adjusted OR and 95% confidence interval (CI). The study has a statistical power of 80% to detect a difference between 16% and 8% in large for gestational age newborns (α level of 0.05; two-tailed). The rate of GDM using the IADPSG criteria was 27.51% (95% CI 25.92-29.11). Group 1 presented similar rates of large-for-gestational-age newborns (9.1% compared with 5.9%, adjusted OR 1.58, 95% CI 0.79-3.13; P=.19), delivery complications (37.1% compared with 30.1%, OR 1.37, 95% CI 0.95-1.98; P=.10), preeclampsia (6.5% compared with 2.7%, adjusted OR 2.40, 95% CI 0.92-6.27; P=.07), prematurity (6.5% compared with 2.7%, OR 1.10, 95% CI 0.53-2.27; P=.85), neonatal complications at delivery (13.4% compared with 9.7%, OR 1.45, 95% CI 0.84-2.49; P=.20), and metabolic complications (10.8% compared with 14.2%, OR 0.73, 95% CI 0.42-1.26; P=.29) compared with group 2. Women classified as nondiabetic by the Canadian Diabetes Association Criteria but considered GDM according to the IADPSG criteria have similar pregnancy outcomes as women without GDM. More randomized studies with cost-effectiveness analyses are needed before implementation of these criteria. II.

Background: General anesthesia for cesarean section is being less popular for cesarean section in present days but sometime general anesthesia is inevitable. The aim of the study is to assess the trends of general anesthesia, indications, clinical outcome in mother and fetus in high altitude setting of tertiary care center of Nepal. Methods: We conducted descriptive cross-sectional study all cases of cesarean section in Karnali Academy of health Sciences (KAHS) located at high altitude over three years period in our institute. Data were retrieved from the hospital records during three fiscal year (Jan 1st 2017 to Jan Dec 31st 2019). The record of all the patients who underwent cesarean section under general anesthesia was reviewed for demographic details, indication of general anesthesia, trends for general and spinal anesthesia and maternal and neonatal outcome. Results: Out of total deliveries 2175, 309 (14.2%) cases account for cesarean section. Among them, 52 (17%) required general anesthesia . Eclampsia 19(36%) remain the major indication for General Anesthesia in cesarean section followed by failure of spinal anesthesia number 14 (26%) , cord prolapse six (12%), antepartam haemorrhage five (10%), spinal site infection four (8%), Khiphoscoliosis two(4%), Patients request two (4%). Use for general anesthesia technique was consistent for three years with slow rise in use of spinal anesthesia . There was no any anesthesia related maternal mortality and nine intraoperative neonatal Conclusions: General anesthesia practices are consistently required in rural high-altitude setup. Eclampsia is the commonest indication followed by failure of spinal anesthesia and cord prolapse. Neonatal outcome is still not good.

BackgroundHemorrhagic stroke during pregnancy is a rare but life-threatening condition, commonly resulting from ruptured cerebrovascular malformations or aneurysms that lead to intracerebral or subarachnoid hemorrhage (SAH). This case demonstrates favorable maternal and neonatal outcomes following rapid multidisciplinary coordination and timely delivery, adding valuable insight into decision-making in late-pregnancy intracerebral hemorrhage (ICH).Case DescriptionWe report a case of a 39-year-old woman at 35 weeks of gestation who presented with sudden-onset neurological symptoms and was diagnosed with spontaneous ICH. On admission, a multidisciplinary team including obstetricians, anesthesiologists, and neurologists was involved. Due to the lesion’s anatomical distribution, endovascular intervention was deemed unsuitable. An emergency cesarean section under general anesthesia was performed to optimize both maternal and fetal outcomes. Postoperatively, the patient was closely monitored, and both maternal and neonatal outcomes were favorable.ConclusionsEarly recognition and an individualized, multidisciplinary approach are essential to improving outcomes for both mother and fetus. This case highlights that, in selected scenarios, prompt delivery combined with conservative neurocritical management can lead to successful results and contribute to the limited body of literature guiding care in such complex situations.

671: Prevalence of obstructive sleep apnea (OSA) in pregnancy

Safe obstetric anaesthesia in low- and middle-income countries—a perspective from Africa

External cephalic version in twin pregnancies with non-vertex-presenting twin.

Introduction: Kyphoscoliosis with pregnancy is a rare but serious disorder which often requires caesarean delivery. Both general and regional anaesthesia have been used in these cases but data regarding outcomes with spinal anaesthesia (SA) are limited. Methods: We conducted a retrospective study to identify patients with kyphoscoliosis undergoing caesarean delivery at a tertiary care hospital in India. Those parturients who received SA were compared with those receiving general anaesthesia (GA group) with respect to cardiorespiratory parameters, maternal outcomes and neonatal outcomes. Results: The GA group had significantly worse cardiorespiratory parameters including pulmonary function tests, right atrial pressures and cardiac ejection fraction as compared to SA group. All the GA group patients required mechanical ventilation while no patients in the SA group needed mechanical ventilation. Intraoperative hypotension was more common in the SA group. Neonatal outcomes were worse in the GA group with lower Apgar scores at 1 and 5 min and more nursery admissions than the SA group. No maternal or neonatal deaths occurred in either group. Conclusion: Kyphoscoliotic parturients scheduled for CD can be successfully managed with SA with good maternal and neonatal outcomes. GA may be reserved for severe kyphoscoliotic parturients with cardiorespiratory complications. The safety of SA in severe kyphoscoliosis requires further studies.