Anesthesia For Cesarean Delivery Research Articles

Association of chorioamnionitis with failed conversion of epidural labor analgesia to cesarean delivery anesthesia: A retrospective cohort study.

AimThis study aimed to examine the association between clinically diagnosed chorioamnionitis and failed conversion of epidural labor analgesia to cesarean delivery anesthesia.MethodsThis retrospective, single-center cohort study, conducted in a university hospital, enrolled term parturients undergoing emergency cesarean section after induction of epidural labor analgesia between September 2015 and May 2019. For the purpose of this study, all cases were re-examined to ensure that they fulfilled the criteria of chorioamnionitis, regardless of the actual indication for cesarean section proposed by obstetricians at the time of application. The primary outcome was failure of conversion of epidural labor analgesia to cesarean delivery anesthesia. Multivariable logistic regression analysis was performed to investigate the association between chorioamnionitis and failure of anesthesia for cesarean section.ResultsAmong the 180 parturients reviewed, 58 (43.9%) fulfilled the criteria for chorioamnionitis. Failure of epidural conversion in the chorioamnionitis (+) group was significantly higher than in the chorioamnionitis (-) group (46.6% [27/58] vs. 18.9% [14/74], crude odds ratio = 3.7, 95% confidence interval: 1.7–8.3). After adjustment for potential confounders (age, body mass index, multiparity, and duration for epidural labor analgesia), chorioamnionitis was found to be associated with failure of anesthesia for cesarean sections (adjusted odds ratio = 3.6, 95% confidence interval: 1.6–8.4).ConclusionsChorioamnionitis is associated with the failed conversion of epidural labor analgesia to cesarean delivery anesthesia.

Norepinephrine versus Ephedrine to maintain arterial blood pressure during spinal anaethesia for ceserian section

Background: Spinal anesthesia is recommended for elective cesarean sections, but maternal hypotension by may occur, resulting in severe maternal complications. To avoid spinal hypotension, many methods were attempted; fluid loading, vasopressors, or combination of both. Objectives: Our study aimed to compare administration of intermittent i.v. boluses of norepinephrine and ephedrine to guard against hypotensive effect of spinal anesthesia during delivery. Methods: This study was conducted at Qena University Hospitals, sixty cases undergoing elective ceserian section under spinal anaesthesia were enrolled. They were randomly allocated to two equal groups, group N received prophylactic i.v.bolus of norepinephrine 5 μg,group E received prophylactic bolus of i.v. ephedrine 10mg immediately after intrathecal block. Incidence of hypotension and the numbers of the boluses of vasopressors used were recorded and considered as primary outcomes, maternal complication during the surgery as secondary outcomes. Results: According to SBP, DBP, MAP there was significant lower values in groupE compared with group N. The mean number of boluses of vasopressors used during spinal anesthesia was significantly lower in Group N (2.2 vs. 5.8, P = 0.001). the mean number of hypotension episodes was also significantly lower in Group N (2.5 vs. 5.33, P = 0.001). Regarding operative maternal complications, Group N had a significantly lower nausea(16.7% vs. 66.7%, p=.001) vomiting (60% vs. 16.7%, p=0.001). shivering (23.3% vs. 0%, p=0.001). Conclusion: Norepinephrine can be used as an alternative vasopressor to maintain maternal blood pressure during spinal anesthesia for cesarean delivery, with lower incidence of maternal complication.

Change in Mallampati Score during Pregnancy, Labour and Post Labour: An Observational Study

Background Mallampati (MP) score is used to predict the ease of endotracheal intubation. Pregnancy is often associated with failed intubation during anaesthesia for caesarean delivery and contributes majorly to maternal complications that are related to anaesthesia. This study aimed to determine the change in MP grade over the course of pregnancy (first trimester, during labour and post-delivery). Methods The study was conducted on 389 pregnant women in the first trimester. Demographic data, airway characteristics and MP score of the patients were recorded at different stages of pregnancy. Change in MP grade was assessed for those patients, who have delivered vaginally. Results The mean age of the study subjects was 25.77±3.64 years. There was a significant association of MP score with weight gain (P<0.0001) and change in neck circumference (P<0.0001). There was a significant change in the number of patients with MP grade 3 and 4 was noted from first trimester (n=14; 2.26%) to 48 hours post-delivery (n=78; 24.6%) (P<0.01), showing a strong association between change in MP score and pregnancy. Conclusion There was a significant increase in the MP score over the course of pregnancy that may be attributed to gestational weight gain along with variations in the neck circumference in pregnant women. Hence, assessment of MP score is important for proper management of difficult intubation, especially in parturient.

Oxygen delivery by mask improves the PaO2 of pregnant ewes during short term anaesthesia for caesarean delivery of preterm lambs

The aim of this study was to determine if oxygen supplementation improved the PaO2 of pregnant ewes during short anaesthesia, when compared to a previous study where oxygen was not provided (Musk and Kemp, 2018). Twenty-six pregnant Merino cross ewes at 121–123 days of gestation were anaesthetised with intravenous midazolam and ketamine for subarachnoid administration of 60 mg of lignocaine and caesarean delivery of the preterm lamb. 100% oxygen was administered to the ewe by a face mask. Arterial blood samples were collected from the ewe immediately after delivery of the foetus. The ewes weighed 60.7 ± 5.5 kg and received 0.51 (0.47–0.58) mg/kg of midazolam and 10.3 (9.4–11.6) mg/kg of ketamine intravenously. The PaO2 of ewes receiving oxygen by face mask was higher than previously reported [92.6 ± 44.0 mmHg compared to 45.2 ± 11.8 mmHg (Musk and Kemp, 2018) (p = 0.0007)]. Oxygen delivery by mask improved the PaO2 of pregnant ewes during short term anaesthesia.

Management of maternal COVID-19: considerations for anesthesiologists.

To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19. Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates. Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.

A 13-Year Review of Eclampsia and Anesthetic Techniques at a Single Tertiary Care Center

Objective: To assess recent perinatal outcomes of women with eclampsia in relation with the choices of anesthesia. Materials and Methods: The electronic medical records of women with eclampsia that delivered at a single tertiary care center between January 2005 and December 2017 were retrospectively reviewed. Anesthesiologists had the discretion to decide the choice of anesthesia for cesarean delivery. Results: The authors identified 45 eclampsia cases from 113,914 deliveries during the study period. The mean ± standard deviation (SD) of maternal age and gestational age at delivery of the cases was 24.4±8.5 years and 35.4±3.0 weeks, respectively, and 32 (71.1%) were primigravids. There were 29 (64.4%), eight (17.8%), and eight (17.8%) eclampsia cases that occurred antepartum, intrapartum, and postpartum, respectively. Out of the cohort, 35 (77.8%) underwent Cesarean delivery, of which 18 (51.4%) and 17 (48.6%) received general anesthesia or combined, and regional anesthesia, respectively. There was one (2.2%) maternal and three (6.67%) neonatal deaths. The general anesthesia group had a higher incidence of platelets of less than 100,000/mL and higher admission to the intensive care unit (p<0.05). Conclusion: Eclampsia remains a cause of serious perinatal morbidity. Most eclampsia occurred without prior risks, warning signs, or a critically high blood pressure. With proper patient selection and individualization, general or regional anesthesia is safe. The higher intensive care unit admissions were likely attributable to severe sequelae of eclampsia in those that underwent a general anesthesia. Keywords: Eclampsia, General anesthesia, Spinal anesthesia, Epidural anesthesia, Perinatal outcomes

The Society for Obstetric Anesthesia and Perinatology Coronavirus Disease 2019 Registry: An Analysis of Outcomes Among Pregnant Women Delivering During the Initial Severe Acute Respiratory Syndrome Coronavirus-2 Outbreak in the United States.

Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03-2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09-2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18-2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29-3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35-0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40-9.74) due to maternal respiratory failure. In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

General anesthesia for emergency cesarean delivery: simulation-based evaluation of residents

IntroductionDecreased rates of General Anesthesia (GA) for Cesarean Section (C-section) create a learning problem for anesthesia trainees. In this context, training the management of GA for C-section using simulation techniques allows a safe environment for exposure, learning, performance improvement, and capability retention. ObjectiveAnalyze anesthesia residents’ performance regarding a simulated clinical case of GA for emergency C-section and identify specific deficits in skill acquisition. MethodsBetween 2015 and 2018, we evaluated the performance of 25 anesthesiology residents challenged by a simulated clinical case of GA for emergency C-section after the conclusion of the obstetric anesthesia rotation. Each resident performed the clinical case once followed by the assessment of their performance. Final scores were given according to the completion rate of 14-tasks, going from 0% to 100%. Two study groups were considered according to residency year for subsequent comparison of results (Group 1, second and third residency years and Group 2, fourth and fifth residency years). Results and discussionMean score was 64.29% ± 13.62. Comparatively, Group 1 obtained a higher score than Group 2 (70.63% ± 14.02 vs. 60.27% ± 11.94), although with no statistically significant difference (p = 0.063). The tasks most frequently accomplished were opioid administration (100%), rapid sequence technique (100%), pre-oxygenation (92%), gastric content aspiration prophylaxis (84%), and previous clinical history (84%). Conversely, the tasks less frequently accomplished were confirming presence of pediatrician (64%), oxytocin administration (56%), PONV prophylaxis (56%), and preoperative airway assessment (48%). ConclusionThe performance of the residents observed in this study was comparable to results previously published. The final score did not depend on the residency year.

Effect of amino acid infusion during cesarean delivery on newborn temperature: a randomized controlled trial

BackgroundThe effect of maternal amino acid (AA) infusion before and during cesarean delivery on neonatal temperature remains unknown. We hypothesized that thermogenic effects of AA metabolism would help maintain body temperature of newborn babies and their mothers.MethodsSeventy-six parturients scheduled for elective singleton term cesarean delivery were equally randomized to receive intravenous 200 ml of AA or placebo approximately 1 h before subarachnoid block (infusion rate:100 ml/h). The primary outcome was the newborn rectal temperature at 0, 5 and 10 min after birth. The secondary outcomes included the maternal rectal temperature at six time-points: T0 = before starting study solution infusion, T1 = 30 min after starting infusion, T2 = one hour after starting infusion, T3 = during spinal block, T4 = half an hour after spinal block, T5 = at the time of birth and T6 = at the end of infusion, as well as maternal thermal discomfort and shivering episodes.ResultsThere were no differences in newborn temperature between the two groups at any of the time-points (intervention-time-interaction effect, P = 0.206). The newborn temperature (mean [95%CI] °C) at birth was 37.5 [37.43–37.66] in the AA and 37.4 [37.34–37.55] in the placebo group. It showed a significant (P < 0.001) downward trend at 5 and 10 min after birth (time effect) in both groups. One neonate in the AA and five in the placebo group were hypothermic (temperature < 36.5 °C) (P = 0.20). There was a significant difference in the maternal temperature at all time points between the two groups (Intervention-time interaction effect, P < 0.001). However, after adjustment for multiplicity, the difference was significant only at T6 (P = 0.001). The mean difference [95%CI] in temperature decline from baseline (T0) till the end of infusion (T6) between the two groups was − 0.39 [− 0.55;− 0.22] °C (P < 0.0001). Six mothers receiving placebo and none receiving AA developed hypothermia (temperature < 36 °C) (P = 0.025). Maternal thermal discomfort and shivering episodes were unaffected by AA therapy.ConclusionsUnder the conditions of this study, maternal AA infusion before and during spinal anesthesia for cesarean delivery did not influence the neonatal temperature within 10 min after birth. In addition, the maternal temperature was only maintained at two hours of AA infusion.Trial registrationClinicalTrials.government, Identifier NCT02575170. Registered on 10th April, 2015 - Retrospectively registered.

Anesthesia for Cesarean Delivery

Cesarean delivery is a cornerstone of obstetric anesthesia and it is imperative for providers to have a deep understanding of the indications, preparation, techniques, and potential complications of both the procedure and the anesthesia. It is necessary to obtain a focused but thorough history and physical and to develop an appropriate individual by considering a multitude of factors including co-morbid maternal and fetal conditions, timing of delivery, technical needs of the surgeon, potential adverse events, and systems based decision making. Anesthesia providers need to determine the safest method to provide anesthesia for the mother with an aim to minimize risk to the fetus. Once the decision of which anesthetic technique will be utilized is made, the provider must have the knowledge of how to best execute the plan and remain vigilant by maintaining a back-up plan in the case of complications. Obstetric anesthesia for cesarean delivery carries a set of unique challenges and potential risks in addition to the standard risks associated with general and neuraxial anesthesia. This review contains 5 figures, 6 tables, and 86 references. Keywords: Maternal Physiology, Maternal-Fetal Considerations, Systemic Medications, Cesarean Delivery, Difficult Airway, Aspiration Prophylaxis, Supine Hypotensive Syndrome, Aspiration of Gastric Contents, Vaginal Birth After Cesarean Section (VBAC)

Effect of Preoperative Oral Carbohydrate Loading on Body Temperature During Combined Spinal-Epidural Anesthesia for Elective Cesarean Delivery.

Intraoperative hypothermia is a common complication after neuraxial block in cesarean delivery. At least 1 animal study has found that carbohydrate loading can maintain the body temperature of rats during general anesthesia, but it is unclear whether carbohydrate loading is beneficial for body temperature maintenance in parturient women during combined spinal-epidural anesthesia (CSEA) for elective cesarean delivery. Women undergoing elective cesarean delivery were randomized into a control group (group C), an oral carbohydrate group (group OC), or an oral placebo group (group OP), with 40 women in each group. Core body temperature (Tc) and body surface temperature (Ts) before and after cesarean delivery, changes in Tc (ΔTc) and Ts (ΔTs), and the incidence of side effects (eg, intraoperative shivering) were compared among the groups. The postoperative Tc (core body temperature after cesarean delivery [Tc2]) of group OC (36.48 [0.48]°C) was higher than those of group C (35.95 [0.55]°C; P < .001), and group OP (36.03 [0.49]°C; P = .001). The ΔTc (0.30 [0.39]°C) in group OC was significantly smaller than those in group C (0.73 [0.40]°C; P = .001) and group OP (0.63 [0.46]°C; P = .0048). Oral carbohydrate loading 2 hours before surgery facilitated body temperature maintenance during CSEA for elective cesarean delivery.

Epidural augmentation for urgent Cesarean Section : a nationwide Israeli survey

Background : Epidural augmentation to convert analgesia to emergency cesarean delivery anesthesia is a common practice. In this survey we examined the common augmentation practices in different hospitals in Israel. We investigated whether practices vary by hospital size and if written protocols for conversion correlate with intra-hospital homogeneity. Methods : A questionnaire containing 39 questions was sent to obstetric anesthesia unit heads and to four additional anesthesiologists (attending and residents) in 24 obstetric anesthesia units nationwide. Answers were received online anonymously using web-based survey site. Results : 99/120 participants responded to the survey. 80% of large hospitals have a detailed epidural augmentation protocol. The existence of a written protocol does not affect intrahospital management variability. Overall, 18 different drug mixtures for epidural augmentation were reported, and the most used drug combination is lidocaine, fentanyl and bicarbonate. In large hospitals, 72% add epinephrine and 96% initiate augmentation before operating room arrival. Most respondents reported a final administered total volume of 15-20 ml. In most hospitals there is no maternal or fetal monitoring during patient transfer from delivery room to the operating room, lasting 3.68 minutes on average, with a relative low risk of significant complication as a result of augmentation. Conclusion : We report variations in common practices, depending on hospital size. We recognized low rate of intra-hospital concordance between centers with or without a written protocol of augmentation. Regarding points for improvement, we would recommend adhering to the accepted institutional protocol.

The Current Role of General Anesthesia for Cesarean Delivery.

Purpose of the ReviewThe use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use.Recent FindingsUnnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery.SummaryRates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.

A Systematic Review of Phenylephrine Versus Noradrenaline for the Management of Hypotension Associated With Neuraxial Anesthesia in Women Undergoing Cesarean Section

(Anaesthesia. 2020;75:800–808) Up to 60% of women who receive spinal anesthesia during cesarean delivery experience hypotension. Phenylephrine has become the vasopressor of choice but is associated with maternal reflex bradycardia. Noradrenaline is an alternative vasopressor and is associated less with bradycardia. Noradrenaline has weak β-adrenergic activity and some studies have suggested noradrenaline is associated with fetal acidosis. This review aimed to identify randomized controlled trials comparing the use of noradrenaline and phenylephrine in women receiving spinal anesthesia for cesarean delivery.

Colloid preloading versus crystalloid preloading to prevent hypotension after spinal anesthesia for cesarean delivery: A protocol for systematic review and meta-analysis.

Background:Maternal hypotension is the most frequent complication of spinal anesthesia for cesarean delivery, and intravenous fluid preloading is a preventive measure. We aimed to assess the efficacy of colloids versus crystalloids for preloading to reduce the incidence of spinal anesthesia-induced hypotension and vasopressor requirement in healthy parturients during elective cesarean delivery.Methods:We searched the Cochrane Library, MEDLINE and EMBASE to identify all studies published to June, 2019, through OVID and PubMed. We included randomized controlled trials, comparing colloid preloading with crystalloid preloading in women having spinal anesthesia for cesarean delivery. Primary outcomes were the incidence of hypotension and vasopressor requirement. Secondary outcomes included nausea and/or vomiting, neonatal Apgar score, neonatal umbilical blood pH. We used standardized mean differences for expressing continuous outcomes and risk ratios for dichotomous outcomes. Random-effect model was performed to estimate the pooled risk ratios and standardized mean differences.Results:Thirty-three randomized controlled trials contributed data for this meta-analysis. Fewer women experienced hypotension in the colloid group compared with the crystalloid group (risk ratio: 0.72, 95% confidence interval: 0.63–0.82; 2566 women, 32 studies; P < .00001). The total ephedrine dose required was significantly lower with colloid preloading (standardized mean difference: −0.37, 95% CI: −0.64 to −0.09; 1472 women, 19 studies; P = .009). Colloid preloading was also associated with fewer phenylephrine requirement compared with crystalloid preloading (standardized mean difference: -0.54, 95% CI: -0.82 to -0.25; 169 women; P = .0002). The incidence of nausea and/or vomiting was significantly reduced with colloid preloading (risk ratio: 0.72, 95% CI: 0.55–0.95; 1601 women, 20 studies; P = .02). However, the incidence of 1-minute Apgar score < 7, umbilical artery pH < 7.2 and umbilical vein pH < 7.2 were not statistically different between groups.Conclusions:Colloid preloading is superior to crystalloid preloading in reducing the incidence of hypotension induced by spinal anesthesia and vasopressor requirement in the healthy parturients undergoing elective cesarean delivery.The PROSPERO registration number: CRD42018096402.

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia.

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Prophylactic anticoagulation for preterm premature rupture of membranes: a decision analysis

The current standard of care in the setting of preterm premature rupture of membranes involves antenatal hospitalization until delivery. The reduced physical activity during this time compounds the heightened risk for venous thromboembolism in pregnancy. Prophylactic anticoagulation can decrease this risk of venous thromboembolism; however, this benefit must be balanced against the risks of precluding neuraxial analgesia or increasing the risk of postpartum hemorrhage. The objective of this study was to determine the optimal modality for venous thromboembolism prophylaxis during hospitalization for preterm premature rupture of membranes using a decision analysis model. A decision-analytical Markov model was constructed using the TreeAge software comparing the use of unfractionated heparin, low-molecular-weight heparin or no anticoagulation in women with a singleton pregnancy who were hospitalized for preterm premature rupture of membranes after 24 weeks and remained hospitalized until delivery. Maternal outcomes examined included attainment of neuraxial analgesia (vs no analgesia for vaginal delivery or general anesthesia for cesarean delivery), venous thromboembolism, postpartum hemorrhage, and maternal death. Probabilities and utilities were derived from existing literature. Sensitivity analyses were performed to interrogate model assumptions, and a Monte Carlo probabilistic sensitivity analysis was performed to examine the robustness of the model. In this decision-analytical model, no prophylactic anticoagulation maximized maternal utilities. Clinical outcomes among a theoretical cohort of 100,000 women are shown in the Table. The 1- and 2-way sensitivity analyses supported this conclusion. Monte Carlo probabilistic sensitivity analysis indicated that no prophylaxis was the preferred choice in 56% of simulations, unfractionated heparin in 34% of simulations, and low-molecular-weight heparin in 10% of simulations. Our results do not support the routine use of prophylactic anticoagulation in women admitted to the hospital for preterm premature rupture of membranes. These findings can be used to inform clinical decisions when admitting low-risk singleton pregnancies to the hospital in the setting of preterm premature rupture of membranes.

Norepinephrine versus ephedrine for hypotension prophylaxis during cesarean section under spinal anesthesia

BackgroundSpinal anesthesia is the preferred anesthetic method for elective cesarean sections (C.S.) due to considerable risks regarding airway management associated with physiological changes of pregnancy. Hypotension is reported to occur in up to 80% of spinal anesthesia cases. Many approaches have been tried to prevent spinal hypotension, e.g., fluid loading, vasopressors, or both. The aim of this prospective, randomized, double blind study is to compare the administration of intermittent i.v. boluses of norepinephrine and ephedrine to guard against the hypotensive effect of spinal anesthesia during cesarean delivery.MethodsIn the present study, 120 pregnant female undergoing elective CS were randomly divided into “group E” for ephedrine and “group N” for norepinephrine, 60 female in each group. Standard spinal anesthetic technique using 25 spinal needle under complete aseptic technique with injection of 1.8–2.2 ml of heavy bupivacaine 0.5% plus 25 μg of fentanyl according to female height. Group E will receive 10 mg of i.v. diluted ephedrine as hypotension prophylaxis, and group N will receive 16 μg as hypotension prophylaxis at the time of intrathecal block. Measurements of intraoperative episodes of hypotension and their treatment with the same dose of the studied drug in each group, incidence of intraoperative nausea and vomiting, and APGAR score of baby at 1 and 5 min will be recorded.ResultsCompared with ephedrine, norepinephrine maintained maternal blood pressure. Further, it was associated with lower numbers of hypotension episodes, but more frequency of bradycardia during cesarean delivery.ConclusionNorepinephrine can be used as an alternative vasopressor to maintain maternal blood pressure during spinal anesthesia for cesarean delivery, with no adverse effect on neonatal outcome.

Dexmedetomidine versus fentanyl in ultrasound-guided transversus Abdominis plane block for pain relief after elective cesarean delivery

Background Transversus abdominus plane (TAP) block is one of the multimodal techniques that are used to relieve postoperative pain in cesarean delivery. Addition of adjuvants to local anesthetic agents reduces postoperative opioid consumption and helps in prolonging their analgesic effect. Aim This study compared the influences of addition of dexmedetomidine versus fentanyl to bupivacaine in ultrasound-guided TAP block for postoperative analgesia after spinal anesthesia in cesarean delivery and evaluating the time to the first dose of analgesia postoperatively as the primary outcome. Patients and methods A total of 120 female patients scheduled for elective cesarean delivery were conducted in this study. Patients were divided into four equal groups. All patients received spinal anesthesia. Group TAP received ultrasound-guided TAP block using bupivacaine, group TAP-F received TAP block with addition of fentanyl to bupivacaine, group TAP-D received TAP block with addition of dexmedetomidine to bupivacaine, whereas control group received spinal anesthesia only, and morphine was used for pain relief. Postoperative, time to first dose of rescue analgesia, number of patients who requested rescue analgesia, patient satisfaction, and visual analog pain scale were recorded. Results The time to give rescue analgesic in TAP-D group was the longest in comparison with the other studied groups. Regarding the number of patients who requested rescue analgesia, at the end of 24 h, significant differences were observed between control group and the other groups, and least number of patients who requested rescue analgesia was in TAP-D group during 24 h postoperatively, and differences between this group and the other groups were highly significant. Conclusion Dexmedetomidine as an adjuvant to bupivacaine in TAP block delayed the time to first rescue analgesia when added to bupivacaine using ultrasound-guided technique and improved patients’ satisfaction with decrease in total morphine consumption, whereas addition of fentanyl to bupivacaine has no added advantage.

Areview of 92 obstetric patients with COVID-19 in the Bronx, New York and their peripartum anaesthetic management.

The Bronx is a borough of New York City that has been profoundly affected by the COVID-19 pandemic. Limited reports exist discussing the anaesthetic management of obstetric patients infected with COVID-19. We review a cohort of obstetric patients in the Bronx with COVID-19 and report their delivery data, anaesthetic management, and maternal-fetal outcomes. We reviewed 92 pregnant patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who delivered between 1 February 2020 and 1 May 2020. Medical records were reviewed for patient characteristics, anaesthetic management, and clinical outcomes. Patients were stratified by mode of delivery and COVID-19 disease severity. Of the 92 deliveries, 49 (53%) were vaginal, 14 (15%) were scheduled caesareans, and 29 (32%) were unscheduled caesareans. 64 patients (70%) were asymptomatic for COVID-19 (mild disease: 18 patients [19%], moderate disease: 7 patients [8%], severe disease: 2 patients [2%], critical disease: 1 patient [1%]). 83 patients (90%) received neuraxial analgesia and/or anaesthesia, with combined spinal-epidural (CSE) and dural puncture epidural (DPE) as the most common techniques. 5 patients (5%) required general anaesthesia (GA) for caesarean delivery, 3 (3%) of whom were intubated for severe or critical COVID-19 disease. Given the risks associated with SARS-CoV-2 aerosol transmission, GA was avoided in all but the most critically ill patients. CSE and DPE were optimal for minimizing catheter failure rates and risk of conversion to GA. SARS-CoV-2 infection in obstetric patients may be associated with an increased risk for adverse outcomes including preeclampsia, preterm delivery, unscheduled caesarean delivery, and mechanical ventilation.