Anesthesia In Women Research Articles

Parturients with hypertrophic cardiomyopathy: case series and review of pregnancy outcomes and anesthetic management of labor and delivery

BackgroundAdvances in understanding the pathogenesis, diagnosis and management of hypertrophic cardiomyopathy have resulted in increased longevity and a better quality of life of affected patients considering pregnancy. Several case series which focused predominantly on obstetric details have reported generally good outcomes. However, there remains a paucity of data on the specifics of obstetric anesthesia in women with hypertrophic cardiomyopathy. MethodsAfter Institutional Review Board approval, we reviewed antepartum transthoracic echocardiograms, cardiology, obstetric, anesthetic, and nursing labor records with a focus on anesthesia for labor and delivery and early postpartum complications in patients with hypertrophic cardiomyopathy who delivered between January 1993 and December 2013. ResultsThere were 23 completed pregnancies in 14 patients: 12 parturients (52%) delivered vaginally, of whom seven (30%) required assistance (forceps, vacuum), and 11 (48%) had a cesarean delivery. In 17 cases (74%) delivery was uneventful, but six patients (26%) had complications including congestive heart failure (n=3) and postpartum hemorrhage (n=3). All patients had neuraxial labor anesthesia/analgesia, and none received general anesthesia. No hemodynamic instability or fetal distress directly related to anesthesia was documented. ConclusionThe database search of approximately 160000 deliveries over 20years revealed only a small number of hypertrophic cardiomyopathy patients with completed pregnancies. No maternal or neonatal deaths were documented. Overall morbidity rate was 26% with a 13% incidence of peripartum congestive heart failure. In patients with mild to moderate disease, neuraxial anesthesia was safe, effective and well tolerated with no hemodynamic instability related to administration of local anesthetics.

Effect of intracervical anesthesia on pain associated with the insertion of the levonorgestrel-releasing intrauterine system in women without previous vaginal delivery: a RCT

Is the pain associated with levonorgestrel-releasing intrauterine system (LNG-IUS) insertion reduced by intracervical anesthesia in women without previous vaginal birth? Intracervical anesthesia was not associated with reduced pain in women without previous vaginal birth. The pain associated with the insertion of intrauterine contraceptives (IUCs) is a limiting factor for the use of these contraceptives by some women. No prophylactic pharmacological intervention has proven efficacy in relieving pain during or after the insertion of IUCs. However, previous studies included women with previous vaginal delivery, and injectable intracervical anesthesia was not evaluated in any of these studies. This was a randomized, open, parallel-group clinical trial that evaluated 100 women without previous vaginal delivery who wished to use the LNG-IUS for the first time. These women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h later. The 100 women were randomized into two groups: (i) use of a non-steroidal anti-inflammatory drug (NSAID) (ibuprofen, 400 mg) 1 h prior to LNG-IUS insertion; or (ii) 2% lidocaine intracervical injection 5 min prior to LNG-IUS insertion. The women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h after insertion. Two pain scales were used (the visual analogue scale and the facial pain scale) in addition to assessing the ease of insertion (as rated by the provider) and the level of discomfort during the procedure (as rated by the patient). Multivariate logistic regression was performed to analyze the predictors associated with moderate/severe pain. The pain and discomfort associated with LNG-IUS insertion, and the ease of insertion of the LNG-IUS did not differ between the groups. Nulliparity was more associated with moderate/severe pain [adjusted odds ratio (OR): 3.1 (95% confidence interval (CI): 1.3-7.80]. Injectable intracervical anesthesia use reduced the risk of moderate/severe pain by 40% [adjusted OR: 0.6 (95% CI: 0.2-1.4)]. The difference between the mean pain score in the intracervical anesthesia group and the NSAID group was <10%; thus, the effect size of the intervention was not significant. Intracervical anesthesia was compared with an oral medication in this study. Intracervical injection of a saline solution or even a dry needling as the placebo for a double-blind study could be a more adequate control; however, this approach was not a protocol approved by the institutional review board. Considering that the majority of the insertions were easy (>80% in both groups), the results may not be extrapolated to difficult insertions with moderate/severe pain where local anesthesia may have a role. The findings can be generalized to most insertions in nulliparous women or in those without a previous vaginal delivery. There is currently no evidence to recommend the routine use of prophylactic intracervical anesthesia prior to LNG-IUS insertion; there is no evidence that this treatment reduces insertion-related pain. RAF and CSV give occasional lectures for Bayer Healthcare. This study received funding from the National Institute of Hormones and Women's Health, National Council for Scientific and Technological Development (CNPq). NCT02155166.

Spinal anesthesia for cesarean delivery in a woman with neuromyelitis optica.

Neuromyelitis optica (NMO), or Devic's disease, is an idiopathic severe demyelinating disease that preferentially affects the optic nerve and spinal cord. Neuraxial anesthesia in women with multiple sclerosis is widely accepted, but reports of the use of neuraxial anesthesia in patients with NMO are scarce. We report the case of a morbidly obese primigravida undergoing a planned cesarean delivery at 32 weeks' gestation due to an acute exacerbation of NMO, managed with spinal anesthesia. Other than increased intraoperative hyperalgesia requiring inhaled nitrous oxide/oxygen, the mother experienced no apparent anesthetic-related complications.

Pregnancy and delivery in women with esophageal varices due to hepatic vein thrombosis

Aim: Retrospective analysis of the course of pregnancy, labor and mode of anesthesia in women with portal hypertension and esophageal varices induced by portal vein thrombosis.Material: From 2000 to 2012 seven pregnant were admitted. None had liver transplantation (Ltx), the varicose have been in the 1st stage. Each of them has been consulted by the obstetrician, transplant surgeon and anesthetist. The patient condition during pregnancy, labor and postpartum period was analyzed.Results: Pregnancy in five cases proceeded physiologically. In one threatening miscarriage was diagnosed and treated with gestagens, two patients had tocolytic. One required variceal banding twice. In three thrombocytopenia worsened, with platelet count < 70 g/L (up to 59 g/L). They received platelet transfusion before delivery. In one case, significant hipoproteinemia (4.7 g/L) occurred. In a case, GDM G1 and oligohydramnios were found. All women delivered at term (37–40 Hbd). In all general anesthesia with the use of remifentanil was done. There were no fluctuations in MAP and HR. Incision to delivery time was 2.5 min. Time from opioid administration to birth was <4 min. All children were born in good condition, weight 10–90 percentile. Regional anesthesia is contraindicated in patients with thrombocytopenia. In patients with esophageal varices sudden increase in heart rate and blood pressure can cause hemorrhage.Conclusion: Patients with portal hypertension can deliver at term. It is a high-risk pregnancy. In this group it is desirable to shorten the second stage of labor or complete it by c-section under general anesthesia with remifentanyl which allows getting desired analgesia without complications in the newborn. Surveillance of pregnant with portal hypertension must include monitoring of liver function and coagulation disorders.

Influence of Preoperative Anxiety on Hypotension After Spinal Anesthesia in Women Undergoing Cesarean Delivery

Influence of Preoperative Anxiety on Hypotension After Spinal Anesthesia in Women Undergoing Cesarean Delivery

Combined intracervical and paracervical anesthesia in comparison with intracervical anesthesia in office hysteroscopy

Objective The aim of the study was to compare the efficacy of intracervical anesthesia with that of combined intracervical and paracervical anesthesia in women undergoing office hysteroscopy. Study design The current study was a randomized controlled trial. The study included women referred for office hysteroscopy. The included women were randomized into one of the three groups: group 1 included women who received no local anesthesia; group 2 included women who received intracervical local anesthesia; and group 3 included women who received both intracervical and paracervical local anesthesia. Pain was assessed [using a 10-cm visual analog scale (VAS)] during the procedure and 10, 30, and 60 min after the procedure. Results A total of 84 women were recruited into the trial. The median VAS for pain was significantly lower in women who received cervical analgesia (groups 2 and 3) when compared with women who received no analgesia (group 1), during the procedure as well as 10, 30, and 60 min after the procedure. The median VAS for pain was significantly lower in women who received combined intracervical and paracervical analgesia (group 3) when compared with women who received only intracervical analgesia (group 2) during the procedure and 10 min after the procedure. However, the difference between the latter two groups with respect to the VAS for pain 30 and 60 min after the procedure was not significant. Conclusion When compared with intracervical anesthesia, combined intracervical and paracervical anesthesia was associated with less pain perception during the procedure and 10 min after the procedure in women undergoing office hysteroscopy.

Prophylactic Ondansetron Does Not Prevent Shivering or Decrease Shivering Severity During Cesarean Delivery Under Combined Spinal Epidural Anesthesia

Cesarean delivery is commonly performed under regional anesthesia, which is often associated with maternal shivering. This can cause distress and interfere with monitoring. The study objective was to evaluate the antishivering efficacy of ondansetron, which reduces the incidence and severity of shivering in nonobstetric patients. We hypothesized that there would be a significant decrease in the incidence and/or severity of shivering in women who are given intravenous ondansetron 8 mg before combined spinal epidural (CSE) anesthesia, when compared with placebo. This was a randomized, double-blinded, parallel-group, placebo-controlled trial of 118 women scheduled for elective cesarean surgery. Women received either intravenous ondansetron 8 mg (n = 58) or saline (n = 60) before CSE anesthesia (intrathecal hyperbaric bupivacaine 0.5% 2.2-2.5 mL plus fentanyl 15 μg). The incidence and severity of shivering, measured on a validated 5-point scale, and other outcomes, such as nausea, pruritus, headache, or satisfaction, were assessed at 3 time points during the surgery and postoperative period. The incidence of shivering at any time point did not differ significantly between groups: ondansetron 41% versus placebo 47% (P = 0.54). The incidence of severe shivering at any time was not significantly different: ondansetron 32% versus placebo 33% (P = 0.79). There were no significant differences between the groups for any secondary outcomes. Intravenous ondansetron 8 mg before performing CSE anesthesia in women undergoing elective cesarean delivery does not decrease the incidence or severity of shivering.

Influence of preoperative anxiety on hypotension after spinal anaesthesia in women undergoing Caesarean delivery

We designed a prospective observational study to assess the effect of preoperative anxiety on hypotension after spinal anaesthesia. After IRB approval and signed informed consent, 100 healthy term parturients undergoing elective Caesarean delivery under spinal anaesthesia were enrolled. Direct psychological assessments of preoperative anxiety were verbal analogue scale (VAS) (0-10) anxiety score and State-Trait Anxiety Inventory questionnaire (STAI-s); salivary amylase was measured as an indirect physical assessment of anxiety. Direct and indirect anxiety data were transformed into ordinal groups for low, medium, and high anxiety (VAS: low 0-3, medium 4-6, high 7-10; STAI-s: low <40, medium 40-55, high >55; log(10) salivary amylase: low <3, medium 3-4, high >4). Spinal anaesthesia was performed using hyperbaric bupivacaine 10 mg and fentanyl 20 μg. All patients received i.v. crystalloid 500 ml prehydration and 500 ml cohydration. Hypotension was treated by standardized protocol (fluid bolus and ephedrine or phenylephrine depending on maternal heart rate). Systolic arterial pressure (SAP) was measured at baseline and every minute after spinal anaesthesia. The effect of low, medium, and high anxiety groups on the maximum percentage change in SAP (%ΔSAP) was assessed (one-way analysis of variance, Tukey's honestly significant difference). Ninety-three patients were included in analysis. There was a significant effect of direct psychological measures of anxiety on %ΔSAP (VAS P=0.004; STAI-s P=0.048). There was a significant difference between low and high anxiety groups (VAS P=0.003; STAI-s P=0.038), but not between other anxiety groups. Salivary amylase did not correlate with %ΔSAP. Preoperative anxiety assessed by VAS had a significant effect on hypotension after spinal anaesthesia.

Management of spinal anaesthesia-induced hypotension for caesarean delivery

Management of spinal anaesthesia-induced hypotension for caesarean delivery

Neurological Disorders in Pregnancy

This paper reviews the current concepts and outlines appropriate management of conditions such as epilepsy, headache, benign intracranial hypertension, myasthenia gravis, multiple sclerosis, Bell's palsy and cerebrovascular disorders. It also discusses briefly, labor analgesia and anaesthesia in women with neurological disorders. Keywords: Neurological, pregnancy, epilepsy, myasthenia gravis, multiple sclerosis, benign intracranial hypertension, Bell's palsy, cerebrovascular, headache, AEDs, pulsation (IABP), Pre-eclampsia

Pain during Root Canal Treatment: An Investigation of Patient Modifying Factors

The study highlighted the effect of patient-related factors on levels of pain felt by subjects during root canal treatment, as well as the association between treatment duration and pain severity. Maxillary central incisors with either necrotic pulp or irreversibly inflamed pulp, with or without preoperative pain were studied in 160 subjects aged 18 years and above. Subject's age and gender as well as pulp status and preoperative pain status were recorded. The procedure was done using a standard protocol. Visual analog scale was used to record the level of pain felt. Those cases with irreversible pulpitis felt higher pain. None with necrotic pulp experienced intense pain, while those in the 51 to 60 year age bands had severe, unbearable or intense pain. Mild pain was a common denominator in all age bands. Pain level increased with treatment duration. Except for age, the level of pain felt by subjects during RCT is significantly correlated with gender and pulp status. Furthermore, the experienced pain levels increased with treatment duration. Clinicians should be prepared to make use of supplemental local anesthesia in women and in teeth with IP.

Ropivacaine: A review of its pharmacology and clinical use

Ropivacaine is a long-acting amide local anaesthetic agent and first produced as a pure enantiomer. It produces effects similar to other local anaesthetics via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is less lipophilic than bupivacaine and is less likely to penetrate large myelinated motor fibres, resulting in a relatively reduced motor blockade. Thus, ropivacaine has a greater degree of motor sensory differentiation, which could be useful when motor blockade is undesirable. The reduced lipophilicity is also associated with decreased potential for central nervous system toxicity and cardiotoxicity. The drug displays linear and dose proportional pharmacokinetics (up to 80 mg administered intravenously). It is metabolised extensively in the liver and excreted in urine. The present article details the clinical applications of ropivacaine and its current place as a local anaesthetic in the group.

An observational study of skin conductance monitoring as a means of predicting hypotension from spinal anaesthesia for caesarean delivery

Background Hypotension after spinal anaesthesia is a common and important complication at caesarean delivery. Skin conductance monitoring has been shown to predict post-spinal hypotension in elderly patients and may be a rapid, non-invasive means of predicting risk in the obstetric population. Methods Women having elective caesarean delivery were included in this observational pilot trial. Baseline data were obtained for blood pressure, heart rate and skin conductance variables before administration of spinal anaesthesia and at 1-min intervals for 20 min thereafter. Correlations between baseline data and minimum post-spinal blood pressure were calculated, and the predictive value of baseline variables was estimated by use of receiver operator characteristics. Results Forty women completed the study. Spinal anaesthesia was followed in most cases by a significant reduction from baseline in systolic blood pressure [0–9% n = 2 (5%), 10–20% n = 21 (52.5%), 20–30% n = 12 (30%), >30% n = 5 (12.5%)]. Minimum systolic blood pressure was >100 mmHg in 25 (62%), 80–100 mmHg in 12 (30%) and <80 mmHg in 3 (7.5%) patients. Fasting times, spinal block distribution, baseline heart rate, blood pressure or baseline skin conductance did not predict post-spinal hypotension or neonatal outcome. Conclusion In contrast to a previous report in elderly patients, we were unable to demonstrate a significant relationship between baseline sympathetic tone, measured by skin conductance, and hypotension following spinal anaesthesia in women undergoing elective caesarean delivery.

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery: A Comparison Between Women With and Without Prior Labor

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery: A Comparison Between Women With and Without Prior Labor

Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study

We conducted a prospective observational survey of pregnant women with cardiac disease. The aim was to analyse and present the mode of delivery, outcome, and haemodynamic changes during a caesarean section under regional anaesthesia in women with cardiac disease. All pregnant women with a cardiovascular diagnosis, except hypertension, were included in the registry. Based on the cardiac diagnoses, and on the New York Heart Association classification, a multidisciplinary group made recommendations for each patient and decided on the mode of delivery. The data from continuous, invasive haemodynamic monitoring in intermediate- and high-risk patients under regional anaesthesia for a caesarean section were analysed and presented. The hospital had approximately 9000 deliveries in the period from November 2003 to April 2008. A total of 113 pregnancies in 107 women were included. Thirty-two (28.3%) pregnancies were classified into the high-risk category. Of 103 deliveries, caesarean sections were performed in 59 (52.2%) cases, with regional anaesthesia in 51 patients (18 emergencies), general anaesthesia in eight patients (five emergencies), and a planned vaginal delivery in 44 patients. There was no mortality among the mothers or the babies during the hospital stay or 6 months postpartum. Pre-operative cardiovascular stability during the caesarean section was maintained by volume and phenylephrine infusion guided by invasive monitoring of haemodynamic variables. Our study suggests that pregnant women with cardiac disease may safely deliver the baby by a caesarean section under regional anaesthesia. According to our findings, haemodynamic stability can be obtained by titrated regional anaesthesia, intravenous (i.v.) volume, phenylephrine infusion, and small repeated doses of i.v. oxytocin guided by invasive monitoring.

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery: A Comparison Between Women With and Without Prior Labor

BACKGROUND:An end-tidal concentration of 1% sevoflurane (1% ETSEVO) in 50% nitrous oxide (N2O) during elective cesarean delivery has been associated with bispectral index (BIS) values >60, which are associated with an increased risk of awareness. We hypothesized that BIS values during sevoflurane-N2

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery

Obstetric analgesia and anaesthesia in women with inherited bleeding disorders

A retrospective review was carried out on the methods of obstetric analgesia/anesthesia used in 80 pregnancies amongst 63 women with inherited bleeding disorders (19 factor XI deficiency, 16 carriers of haemophilia, 15 von Willebrand disease, seven platelet function disorders, four factor VII deficiency, one factor VII and XI deficiency and one factor X deficiency). In 72 pregnancies, the woman was seen antenatally in a multidisciplinary clinic to discuss and plan pain relief options. Regional block was performed for 41 pregnancies. The mothers were known to have a bleeding disorder in 35 of these pregnancies. Prophylactic cover was given in 10 pregnancies prior to the insertion of regional block but not required in the remaining 25 pregnancies because the coagulation defects had spontaneously normalised at term. There were six reported adverse effects from regional block similar to that found in the general population: inadequate anesthesia/analgesia (2), bloody tap (2), hypotension and a possible dural puncture which was treated conservatively. There were no reports of long-term complications. The findings show that it is possible to offer women with inherited bleeding disorders the option of regional block provided their coagulation defects have normalised, either spontaneously during pregnancy or following adequate haemostatic cover.

Bispectral Index Values During Sevoflurane-Nitrous Oxide General Anesthesia in Women Undergoing Cesarean Delivery: A Comparison Between Women With and Without Prior Labor

An end-tidal concentration of 1% sevoflurane (1% ET(SEVO)) in 50% nitrous oxide (N(2)O) during elective cesarean delivery has been associated with bispectral index (BIS) values >60, which are associated with an increased risk of awareness. We hypothesized that BIS values during sevoflurane-N(2)O general anesthesia for cesarean delivery would be lower in women with prior labor compared with women without prior labor. Forty patients undergoing cesarean delivery were enrolled in this observational study. One group had urgent surgery after labor (labor group, n = 20) and the other had elective surgery without labor (control group, n = 20). General anesthesia was induced with thiopental 4 mg/kg, followed by succinylcholine 1.5 mg/kg, and maintained with 1% ET(SEVO) and 50% N(2)O in oxygen. BIS values, systolic arterial blood pressure, heart rate, plasma stress hormone concentrations, Apgar scores, and postoperative analgesia variables were assessed and compared between groups. BIS values during the period between intubation and delivery were lower in the labor group than in the control group (P < 0.001). Plasma norepinephrine concentrations increased at delivery compared with baseline in both groups. They were higher in the labor group than in the control group both at baseline and at delivery. Systolic arterial blood pressure, heart rate, Apgar scores, surgical characteristics, and plasma concentrations of vasopressin and cortisol were not different between groups. Postoperative visual analog scale pain scores were similar between groups, while the labor group consumed less analgesics (P < 0.01) during the first 24 h after the operation. Prior labor was associated with lower intraoperative BIS values during sevoflurane/N(2)O general anesthesia and reduced postoperative analgesic consumption in women undergoing cesarean delivery compared with women without prior labor.

This Month in Anesthesiology

This Month in Anesthesiology