Anesthesia In Obstetric Patients Research Articles

Neuraxial Anesthesia in Obstetric Patients with Thrombocytopenia: Practice Patterns and Clinical Correlates

Introduction: Thrombocytopenia, (platelets under 150x10 9/L) is observed in 10% of pregnancies with counts below 100x10 9/L seen in 1-2% (Reese et. al, 2018, Gernsheimer, 2012). Neuraxial anesthesia is an effective pain management strategy for vaginal delivery and a safe alternative to general anesthesia for c-section. Although the precise risk of spinal hematoma has not been established in this patient population, it remains a common barrier to neuraxial procedures (Bernstein et. al, 2016). The hematology/maternal fetal medicine clinic (MFM) was created in our academic institution in February 2018 in response to the need to provide multidisciplinary care to patients with hematologic disorders in the context of pregnancy, including those with thrombocytopenia. Objectives: To establish the rate of neuraxial anesthesia in patients with thrombocytopenia seen in the multidisciplinary hematology/MFM clinic in our academic institution between 2018 and 2023 and identify clinical characteristics and practice patterns that affect the ability of this patient cohort to receive neuraxial procedures. Methods: Medical charts from all patients with thrombocytopenia affecting pregnancy evaluated in the hematology/MFM clinic (n=40 patients) were retrospectively reviewed. Baseline demographics, laboratory values, medical interventions (platelets directed treatment, neuraxial anesthesia, delivery route) and delivery outcomes were captured and analyzed using descriptive statistics (Table 1). Results: 40 patients underwent 44 deliveries. 33 (75%) were able to receive neuraxial anesthesia for delivery (15 vaginal and 18 c-section) ( Table 1) The median platelet count at the time of delivery was 105x10 9/L with 30 of 33 of the neuraxial deliveries occurring with platelet counts greater than 70x10 9/L (threshold recommended by the SOAP consensus (Bauer et. al, 2021)). The median platelet count at time of delivery for those who received neuraxial anesthesia was higher than for those who did not receive neuraxial (110x10 9/L vs 77x10 9/L). Rates of platelet directed treatment were similar in all patients independent of whether they received neuraxial anesthesia. Overall patients that did not receive neuraxial anesthesia delivered earlier and many delivered prior to their scheduled date. Despite the hematology/MFM clinic facilitating OB anesthesia consultations, a large proportion of patients were not evaluated prior to admission for delivery. Of the 11 patients that did not receive neuraxial anesthesia, 4 did not desire it, but would have been eligible based on their platelet counts at delivery ( Figure 1). Conclusions: These preliminary results indicate that a multidisciplinary approach can effectively treat thrombocytopenia in pregnant people and enable them to receive desired neuraxial anesthesia. Pre-term labor, precipitous delivery, and medical complications of pregnancy remain challenges to pregnant patients receiving neuraxial anesthesia. Future directions include examining which clinical interventions facilitate neuraxial anesthesia for pregnant patients in a larger population.

Managing Failed Spinal Anaesthesia in Obstetric Patients: a Comprehensive Overview

Failure of spinal anaesthesia can lead to significant concerns for patients and anaesthetists. This article provides a comprehensive guide to understanding and effectively managing spinal anaesthesia failure. It covers strategies for prevention, appropriate responses to different types of block failure, the possibility of repeating the block, and the circumstances in which recourse to general anaesthesia is required. Follow-up initiatives are also discussed, emphasizing the importance of clinical documentation and investigating local anaesthetic effectiveness. This guide aims to enhance patient safety and improve the quality of care in spinal anaesthesia.

Accidental subdural block after epidural anesthesia in obstetric patient: Case report

Background: Although often overlooked, subdural anesthesia is a relatively common complication. It can present with a wide range of symptoms, from unexpectedly high sensory and limited motor blocks to significant hemodynamic and respiratory effects.
 Case Presentation: This case report documents the labor and delivery of a 26-year-old primigravida at 40 weeks gestation who requested an epidural at 4 cm. A 500 ml lactated Ringer's solution bolus was initiated prior to the procedure and a Tuohy needle, size 18-gauge, was utilized to locate the epidural space. Following a negative aspiration and falling meniscus test, a bolus of 8 ml containing a combination of 0.2% ropivacaine with 2 mcg/ml fentanyl was administered, resulting in a brief drop in blood pressure, which responded to ephedrine. An epidural infusion of 0.2% ropivacaine with 2 mcg/ml fentanyl was then started and continued until the decision was made to perform a caesarean section due to lack of progress. Prior to surgery, the epidural was supplemented with 15 ml of 0.75% ropivacaine and 50 mcg of fentanyl. Following the successful delivery of a healthy baby, the patient reported difficulty breathing, and her oxygen saturation dropped to 90%. She was intubated without medication and later extubated after the completion of surgery. The epidural provided pain relief for six hours postoperatively and the patient recovered fully without any neurological deficits.
 Conclusion: The case report describes an epidural anesthesia that resulted in respiratory depression and unconsciousness without sympatholysis. The local anesthetic diffused into the dura- arachnoid interface, or the subdural space, which facilitated the movement of the anesthetic cephalad. However, the patient experienced complete neurological recovery. This case demonstrates the importance of careful monitoring and prompt intervention in the event of complications during epidural anesthesia.
 Keywords: subdural anesthesia, primigravida, ropivacaine, unconsciousness.

A Case Report of Spinal Anesthesia for Cerclage Placement in the Setting of Severe Hypertrophic Obstructive Cardiomyopathy.

Neuraxial anesthesia is preferred over general anesthesia in obstetric patients to avoid airway manipulation, aspiration, and maternal-fetal transfer of medications; however, a sudden sympathetic block is generally avoided in patients with hypertrophic obstructive cardiomyopathy (HOCM). The case of a 31-year-old G2P0010 with HOCM with severe resting left ventricular outflow tract (LVOT) obstruction and systolic anterior motion of the mitral valve undergoing a cerclage under choroprocaine spinal anesthesia is presented. Risks and benefits of general versus neuraxial anesthesia, and epidural versus spinal anesthesia, in this specific setting are reviewed.

Anesthetic Management of von Willebrand Disease in Pregnancy: A Retrospective Analysis of a Large Case Series

(Anesth Analg. 2021;133:1244–1250) Von Willebrand disease (vWD) affects 1% to 2% of the population and can complicate neuraxial anesthesia in obstetric patients. Currently, there are no clear guidelines for the pretreatment and timing of neuraxial anesthesia in pregnant patients with vWD. Previous reports suggest safe neuraxial anesthesia is attainable in these patients when appropriate precautions are taken. This study described the management of neuraxial techniques in pregnant patients with vWD over 20 years at a single tertiary center.

P.42 Unsuccessful conversion of epidural analgesia to epidural anaesthesia in obstetric patients

P.42 Unsuccessful conversion of epidural analgesia to epidural anaesthesia in obstetric patients

P.8 High-flow nasal oxygenation during induction of general anaesthesia in obstetric patients: a systematic review

P.8 High-flow nasal oxygenation during induction of general anaesthesia in obstetric patients: a systematic review

Neuraxial Techniques for Parturients with Thromboprophylaxis or Thrombocytopenia.

Pharmacologic thromboprophylaxis from venous thromboembolism (VTE) and thrombocytopenia in pregnancy results in conditions that may preclude the use of neuraxial anesthesia due to a perceived risk of spinal/epidural hematoma. Spinal epidural hematoma is a recognized complication in patients who are hypocoagulable and may lead patients to undergo general anesthesia for delivery or other procedures, which carries numerous complications in obstetric care. A robust understanding of maternal physiologic changes in coagulation status, review of consensus statements, and safety bundles may help to maximize the use of neuraxial anesthesia in obstetric patients who might otherwise be denied these anesthetic techniques.

Pragmatic Approach to Neuraxial Anesthesia in Obstetric Patients With Disorders of the Vertebral Column, Spinal Cord, and Neuromuscular System

(Reg Anesth Pain Med. 2021;46:258–267) Approximately 40% of women of childbearing age are affected by vertebral column, spinal cord, and neuromuscular system disorders and conditions, raising questions about neuraxial anesthesia safety and efficacy for labor analgesia and obstetric surgical anesthesia. As research regarding how to approach neuraxial anesthesia during care is limited, the aim of this review is to familiarize anesthesiologists with anatomy, present available data, and empower physicians to use a pragmatic approach to neuraxial anesthesia.

What's New in Neuraxial Labor Analgesia.

Purpose of ReviewThis article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed.Recent FindingsThere has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia.SummaryNeuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30kg.m-2 ); low BMI (<18.5kg.m-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p=0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential...

The crossed-leg position increases the dimensions within the acoustic target window for neuraxial needle placement in term pregnancy: a prospective observational study

IntroductionNeuraxial anesthesia in obstetric patients may be difficult to achieve due to anatomical changes in pregnancy. The crossed-leg position may help in optimizing patient position. We prospectively evaluated the utility of the crossed-leg position compared with a standard position using ultrasound measurements. MethodsThirty women with term singleton pregnancy admitted for vaginal delivery were recruited. Women with a history of spinal trauma or surgery, congenital spinal abnormality, advanced first stage of labor or a language barrier were excluded. Two anesthesiologists, blinded to each other’s measurements, scanned each subject in the crossed-leg position and standard position. Measurements of the lengths of the posterior longitudinal ligament, ligamentum flavum and interlaminar distance were recorded at the L3-L4 interspace. Comfort level in each position was scored on a Likert Scale. ResultsTwenty-nine women completed the study (complete data n=28). Significant increases were observed in the lengths of the posterior longitudinal ligament (mean difference 2.2 mm, 95% CI 1.3 to 3.2; P <0.001), ligamentum flavum (mean difference 1.4 mm, 95% CI 0.7 to 2.1; P <0.001) and interlaminar distance (mean difference 1.4 mm, 95% CI 0.4 to 2.5; P=0.006) in the crossed-leg position. No significant differences in comfort were observed. ConclusionWe demonstrated a significant increase in the sonographically measured lengths of the posterior longitudinal ligament, ligamentum flavum and interlaminar distance in the crossed-leg position when compared with the standard position. Both positions were comfortable. Further studies should explore whether these findings translate clinically into easier needle placement in the crossed-leg position.

Effectiveness of Prophylactic Intranasal Phenylephrine in Prevention of Nasal Congestion and Hypotension after Spinal Anaesthesia in Obstetric Patients: A Randomised Double Blinded Study

Effectiveness of Prophylactic Intranasal Phenylephrine in Prevention of Nasal Congestion and Hypotension after Spinal Anaesthesia in Obstetric Patients: A Randomised Double Blinded Study

Role of prednisolone in management of post-dural puncture headache after spinal anesthesia in obstetric patients

Background and Aims: Post-dural puncture headache (PDPH) is a common cause of morbidity in patients subjected to dural puncture for spinal anesthesia. PDPH is mostly a benign condition but can lead to delayed hospital discharge and considerable morbidity for the parturient. We aimed to study whether there is a positive role of prednisolone in post dural puncture headache management (after spinal anesthesia) in patients undergoing lower segment cesarean section (LSCS). Methodology: A randomized controlled trial was conducted at department of gynecology and obstetrics, in Combined Military Hospital (CMH), Nowshera, from April 2018-September 2018. A sample size of 60 patients was determined through WHO calculator. Patients were selected through non probability consecutive sampling after ethical committee approval and consent forms were taken. Patients were randomly categorized into two groups. Group A was given tablet prednisolone while Group B was given a placebo tablet. Patients were followed for pain measurement using visual analogue scale (VAS). Data were analyzed using SPSS version 24. T-test and Chi-square test were applied. A p ≤ 0.05 was considered significant.Results: A total of 60 women undergone c sections were included in study. Mean age of women was 28.5 years ± 4.3. Mean pain scores were significantly reduced in prednisolone group as compared to placebo at 24, 48, 72 and 96 h (p = 0.00). Majority of patients in placebo group had severe headache as compare to oral prednisolone group after 96 h (p = 0.00).Conclusion: Post-Dural Puncture Headache is a major complications following LSCS in spinal anesthesia. Oral prednisolone usage is very effective in lowering severity of headache and duration of PDPH. Oral prednisolone also limits adverse events associated with PDPH after LSCS performed in spinal anesthesia.Citation: Afridi N, Fareed A, Fatima A, Role of prednisolone in management of postdural puncture headache after spinal anesthesia in obstetric patients . Anaesth. pain &amp; intensive care 2019;23(2):168-171

The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-Analysis

(Anesth Analg. 2018;126:552–558) Spinal-induced hypotension, if not treated, can result in adverse maternal and neonatal outcomes (maternal cardiovascular collapse and fetal acidosis). Glycopyrrolate, an anticholinergic with quaternary amine structure, has limited ability to cross-membranes and may thereby have potential to reduce hemodynamic changes after spinal anesthesia in obstetric patients. The authors of this meta-analysis evaluated the literature to determine if prophylactic glycopyrrolate reduces the incidence of hypotension and total vasopressor dose required during elective cesarean delivery under spinal anesthesia.

Current status and future development directions regarding general anesthesia of cesarean section

Background With the increasing use of neuraxial block techniques, usage of general anesthesia on obstetric patients is decreasing. This tendency means that anesthetists have fewer chances to perform obstetric general anesthesia in their training. Objective This review aims to describe the current status and future research directions regarding general anesthesia usage on cesarean section. Content For obstetric patients, rapid-sequence induction using thiopental and suxamethonium has traditionally been recommended as standard method. In recent years, propofol, rocuronium and remifentanil have been widely used for anesthesia induction in obstetric patients. Airway management during general anesthesia in obstetric patients is very important, because inability to secure airway safety can result in severe adverse outcomes to mother and baby. For parturients undergoing cesarean section under general anesthesia, it is essential to maintain sufficient uterine contraction, prevent intraoperative awareness and provide adequate postoperative analgesic management. Trend Continuous efforts are still required to improve the safety of general anesthesia in obstetric patients. Key words: Cesarean section; Anesthesia, general; Airway management; Intraoperative awareness; Postoperative analgesia

Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low–Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma

(Anesth Analg. 2017;125(1):223–231) National guidelines stipulate that pregnant women at risk for venous thromboembolism, such as women undergoing cesarean delivery (4-fold increased risk compared with vaginal delivery), receive thromboprophylaxis via mechanical means, low–molecular-weight heparin (LMWH) and or unfractionated heparins (UFHs). Because of a limited number of studies addressing the boundaries for safe use of neuraxial anesthesia in obstetric patients receiving thromboprophylaxis, or anticoagulated patients, the authors of the present review report on all cases of spinal epidural hematoma (SEH) after neuraxial blockade in this population of obstetric patients.

Preprocedural Ultrasound Assessment Does Not Improve Trainee Performance of Spinal Anesthesia for Obstetrical Patients: A Randomized Controlled Trial

(J Clin Anesth. 2017;37:21–24) Although spinal ultrasound can assist with identification of axial anatomical structures and intervertebral spaces, there are ergonomic challenges with needle angulation and depth. In fact, some studies with residents have suggested that there is no benefit to using ultrasound assistance for epidural placement. However, these studies were limited by small size or specificity to center. In the present study, the authors evaluated the impact of additional information provided by preprocedural ultrasound examination among trainee anesthesiologists performing spinal anesthesia in obstetric patients undergoing elective cesarean delivery in a blinded, randomized controlled trial.

Effect of Anaesthesia Method on Preoperative Anxiety Level in Elective Caesarean Section Surgeries.

In this study, the effect of the anaesthesia method on preoperative anxiety in parturients scheduled to undergo elective caesarean surgery was investigated. After Dicle University Ethics Committee approval, 100 American Society of Anesthesiologists (ASA) II parturients, aged between 18 and 45 years, were included in this study from 2011 to 2012 at the Dicle University Faculty of Medicine, Department of Anaesthesiology. The parturients were divided into two groups, with 50 patients in each group: general anaesthesia (GA) and spinal anaesthesia (SA). Patients were evaluated during the preoperative visit. Demographic data and STAI TX-1 form to measure preoperative anxiety were recorded. There were no significant differences between the two groups in maternal age, gestational age, level of education and number of children (p>0.05). The average anxiety score was significantly higher in the SA group than in the GA group (p<0.05). In conclusion, spinal anaesthesia is associated with a higher preoperative anxiety level than general anaesthesia in obstetric patients. Therefore, it is necessary to take prevention against preoperative anxiety for the patients undergoing caesarean section surgeries under spinal anaesthesia.