Prophylaxis of norepinephrine (NE) at a constant rate has been demonstrated to be as efficacious as prophylaxis of phenylephrine (PE) at equivalent doses for the prevention of maternal hypotension during cesarean section. Nevertheless, the impact of prophylactic infusion of NE or PE at a constant rate on pregnant women on fetal outcomes remains to be elucidated. 90 women scheduled for caesarean section under spinal or combined spinal-epidural anesthesia were randomly assigned to either the NE or PE group. The "study drug" (NE or PE) was administered intravenously at a rate of 15mL/h from the time of injection of subarachnoid solution until the time of delivery of the fetus. Fetal umbilical artery (UA) blood was collected for blood gas analysis. The primary outcome of the study was base excess, and the incidence of fetal acidosis (Defined as base excess < 6mmol/l) and blood glucose levels were also assessed. The UA base excess mean (standard deviation) was not different from the NE group, - 1.6 (2.6) versus - 2.4 (2.9) in the PE group (P = 0.223). The incidence of fetal acidosis was 4.7% (NE) versus 14.3% (PE), with no statistically significant difference (P = 0.308). However, fetal blood glucose levels were significantly lower in the NE group, 3.16 (0.43) versus 3.43 (0.60) in the PE group (P = 0.019). Prophylactic infusion of equivalent doses of NE at a constant rate resulted in fetal base excess values and an incidence of acidosis comparable to that of PE. However, a lower fetal UA blood glucose value was observed in the NE group, a finding that warrants further investigation.

Contribution of the CAESARE tool in the management of non-reassuring fetal status at risk of acidosis.

Introduction: Spinal anesthesia for cesarean delivery may be associated with hypotension and fetal acidosis. Phenylephrine, an α1 adrenergic receptor agonist, is effective in treating hypotension with the benefit of less placental transfer.Objective: The objective of this study was to determine the optimum dose of prophylactic phenylephrine infusion for preventing spinal anesthesia-induced hypotension in women undergoing elective cesarean delivery and to assess its effect on fetal outcomes, as measured by APGAR scores at 1, 5, and 10 minutes.Methodology: Two hundred and forty patients were included in this double-blinded study. Women undergoing elective cesarean section were preloaded with crystalloids and then randomly allocated to receive prophylactic Phenylephrine infusion at either 25, 50, 75, or 100 µg/minute immediately after spinal anesthesia (Groups A, B, C, and D, respectively). Maternal hemodynamic parameters, total dose of phenylephrine used, APGAR score, and incidence of maternal complications like reactive hypertension, bradycardia, nausea, and vomiting, as well as fetal complications like fetal acidosis, were noted. The study was registered with the Clinical Trials Registry of India (CTRI/2019/07/020231, dated July 17, 2019)Results: Demographic parameters were comparable across all four groups (P > 0.05). The incidence of maternal hypotension was lowest in Group B (50 µg/minute) at 15.0%, compared to 41.7% in Group A, 30.0% in Group C, and 23.3% in Group D (P = 0.001). Maternal adverse events such as nausea/vomiting occurred in 5% of Group B, 28.3% of Group A, 31.7% of Group C, and 20% of Group D (P = 0.016). Mean phenylephrine requirements were 692 ± 67 µg (Group A), 1,269 ± 120 µg (Group B), 592 ± 115 µg (Group C), and 439 ± 83 µg (Group D) (P < 0.001). Mean APGAR scores at 1 minute were above 8.4 for all groups; all neonates had mean APGAR scores above 9.8 by 5 minutes (P > 0.05). Maternal complications such as bradycardia ranged from 25% to 63% across groups. The frequency of bradycardia was significantly higher in Groups C (63.3%) and D (60%) than in Groups A (26.7%) and B (25%) (P < 0.001). The 95% confidence intervals for major outcomes indicated statistical significance for these comparisons.Conclusions: We concluded that starting prophylactic Phenylephrine infusion at 50 µg/minute immediately after spinal anesthesia was an effective and simple method of reducing the incidence, frequency, and magnitude of hypotension in elective cesarean section with no adverse effect on neonatal outcome.

Introduction: Timely recognition of fetal oxygenation disorders is essential to prevent irreversible injury. Cardiotocography (CTG) and biophysical profile (BPP) are widely used for fetal surveillance, yet their diagnostic and predictive performance relative to umbilical artery (UA) pH and neonatal outcomes warrants further evaluation. This study assessed the efficacy of CTG and BPP in predicting fetal acidosis and a low one-minute Apgar score (AS) and examined their value for identifying fetal hypoxia and asphyxia.Material and methods: We conducted a retrospective study of 119 hospitalized pregnant women at the Department of Perinatology, University Clinical Center of the Republic of Srpska in Banja Luka, with gestational age ≥ 27 weeks, singleton pregnancies, and no fetal malformations. CTG tracings were classified as normal, equivocal, or pathological. The BPP was scored (0-10) and categorized as normal, equivocal, or pathological. We correlated test results with UA pH (acidosis < 7.20; pre-acidosis 7.20-7.24; normal ≥ 7.25) and the one-minute AS. We calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, and used appropriate significance tests.Results: CTG and BPP showed similar predictive performance for detecting acidosis and a low one-minute AS. Both methods demonstrated statistically significant associations with UA pH and AS (p < 0.001). Perinatal mortality was 1.68% and morbidity was 24.37%; fatal outcomes were associated with pathological findings on both tests, acidosis, and a low AS.Conclusion: CTG and BPP are useful predictors of fetal hypoxia and asphyxia. Integrated use and careful interpretation of both tests can aid in identifying compromised fetuses and guiding timely decisions about the mode and timing of delivery, with the potential to reduce adverse perinatal outcomes.

ABSTRACTObjectiveTo investigate the morbidity associated with assisted vaginal birth (AVB) and an occipito‐posterior (OP) fetal head position.DesignObservational study based on secondary analyses of a randomised controlled trial and cohort study.SettingTwo university affiliated maternity hospitals in Ireland.PopulationA combined cohort of 1081 nulliparous women at term who were assessed for AVB in the second stage of labour.MethodsUnivariable and multivariable logistic regression analyses were performed.Main Outcome MeasuresPostpartum haemorrhage (PPH), obstetric anal sphincter injury (OASI), fetal acidosis, neonatal trauma, failed or abandoned AVB leading to caesarean section (CS).ResultsOf the 1081 AVBs, a total of 192 (17.8%) had an OP position at the outset, with 103 of these (53.6%) rotated to occipito‐anterior (OA) prior to AVB and 89 (46.4%) remaining OP. AVB completed in a non‐rotated OP position compared with OP rotated to OA was associated with an increased risk of PPH (34% [30/89] vs. 15% [15/103], adjusted Odds Ratio (adj OR) 3.57; 95% Confidence Interval (CI) 1.68 to 7.58), OASI (22% [14/65] vs. 2% [2/98], adj OR: 12.62; 95% CI: 2.65 to 60.12) and CS (27% [24/89] vs. 5% [5/103], adj OR: 8.99; 95% CI: 3.14 to 25.74). There were no significant differences in neonatal outcomes. The diagnosis of OP was incorrectly assigned as either OA or occipito‐transverse (OT) in 35 of the 192 cases (18.2%).ConclusionsThis study highlights the associated morbidity when attempting an AVB with a non‐rotated OP position rather than rotating to OA.

Brain death, or death by neurologic criteria (BD/DNC), is the permanent loss of brain function, defined by coma with loss of capacity for consciousness and complete brainstem areflexia, including the inability to breathe spontaneously. The 2023 American Academy of Neurology/American Academy of Pediatrics/Child Neurology Society (CNS)/Society for Critical Care Medicine guidelines state that pregnancy is not a contraindication for BD/DNC evaluation. Clinical evaluation of BD/DNC includes an apnea test to demonstrate the absence of spontaneous respiratory effort in response to hypercapnia and acidosis. The safety of apnea testing to the fetus in pregnant patients remains uncertain.We convened a panel of experts in BD/DNC, neurocritical care, maternal-fetal medicine, neonatology, fetal/neonatal/child neurology, and pediatric/fetal anesthesiology to perform a scoping review of apnea testing in pregnant persons. We found no studies directly assessing safety of apnea testing on the fetus. Apnea testing consists of fetal exposure to parental hyperoxia and hypercapnia; therefore, we searched for evidence related to these conditions in pregnancy. Case reports, series, and literature on physiologic changes induced during apnea testing and their potential effects on placental, fetal systemic, and fetal cerebral circulations were identified. In reported cases of BD/DNC in pregnant persons, some authors described explicitly avoiding apnea testing because of safety concerns, but whether apnea testing was performed at all was inconsistently reported. Evidence from studies evaluating hyperoxia and hypercapnia in healthy pregnant persons and in other animal models suggested possible adverse effects caused by reduced uteroplacental blood flow, fetal metabolic acidosis, and hypercapnia-induced cerebral hyperperfusion. Further possible complications of apnea testing, such as hypotension or hypoxemia in pregnant persons, could also contribute to fetal injury. These potential detrimental risks to the fetus raise the question as to whether apnea testing should be deferred if a fetus may be viable. Ancillary tests, such as radionuclide cerebral blood flow imaging or transcranial Doppler ultrasonography, can be used if the remainder of the BD/DNC evaluation and neurologic examination is otherwise consistent with BD/DNC. Further research is essential to assess the physiologic consequences of apnea testing in pregnant persons and potential risks to the fetus.

Ex-vivo evidence of the human umbilical cord as a physiological buffer against fetal acidosis.

Spinal anesthesia is a form of regional anesthesia administered by injecting a local anesthetic into the subarachnoid space and is commonly employed in cesarean section (C-section) procedures. One of its major side effects is hypotension, which, if not properly managed, can compromise uteroplacental perfusion and potentially result in fetal hypoxia, acidosis, and neonatal complications. Preoperative intravenous fluid administration is a preventive strategy aimed at stabilizing blood pressure by increasing central blood volume. This study aimed to examine the effect of preoperative fluid administration on blood pressure stability in C-section patients undergoing spinal anesthesia at the Regional General Hospital at Sekarwangi. A quantitative analytic approach with a pre-test and post-test design was employed. The study population consisted of 62 C-section patients who received spinal anesthesia within the last three months. Data were analyzed using the Paired Samples t-test. The results showed a statistically significant difference in blood pressure before and after fluid administration (p = 0.000 &lt; 0.05), indicating that preoperative fluid administration had a significant effect on blood pressure stability. Future studies are recommended to employ research designs that better control for external variables and address the limitations of the present study.

Introduction: Birth by cesarean section (C-section) has increased significantly, with a high risk of maternal hypotension due to spinal anesthesia. Objective: This study aims to compare the prophylactic effectiveness of phenylephrine 100 mcg and ephedrine 10 mg in preventing spinal anaesthesia induced hypotension in C-section patients. With a focus on safety and reducing the incidence of fetal acidosis, the results of the study are expected to provide clinical insights that can improve the safety and quality of care for pregnant women undergoing this procedure. Methods: This study compared the effectiveness of phenylephrine 100 mcg and ephedrine 10 mg in preventing hypotension due to spinal anesthesia in cesarean section patients in four hospitals in Medan, Indonesia. Using a double-blind design, 40 patients aged 18-40 years were randomly selected, and blood pressure and heart rate were measured before and after anesthesia. Data were analyzed using SPSS, and ethical aspects were taken care of through informed consent. Results: This study found that phenylephrine 100 mcg was more effective than ephedrine 10 mg in preventing spinal anaesthesia induced hypotension in cesarean section, with more stable blood pressure and mean arterial pressure (MAP) at the 5th, 10th, and 15th minutes (p-value &lt; 0.05). Although ephedrine remained above 100 mmHg for systolic blood pressure (SBP), the incidence of nausea and vomiting was slightly higher in the ephedrine group. Results support phenylephrine as the primary choice for hypotensive management. Conclusion: Phenylephrine 100 mcg is more effective than ephedrine 10 mg in preventing hypotension due to spinal anesthesia, without increasing heart rate. Despite causing nausea, ephedrine has a higher incidence of vomiting. Ephedrine is recommended if phenylephrine is not available, with further studies needed for lower doses of phenylephrine.

Fetal monitoring remains a significant challenge within the medical field due to the lack of clinical tools for assessing fetal health. Blood pH is a critical indicator of the acid-base balance and may provide crucial insight into the fetal well-being. Current monitoring techniques for the fetal environment are limited to measuring heart rate or spatial information without supplying information into blood and tissue health. This study proposes a strategy for continuous fetal blood pH monitoring by using near-infrared (NIR) spectroscopy and extracting features in the spectral fluctuations. These methods are applied to data collected from a hypoxic lamb model and viability assessed with a convolutional neural network (CNN). Results showed that the machine learning (ML) model was capable of extracting features relating to changes in the fetal blood pH with a mean estimation error below 0.05 pH units.Clinical relevance-Application of the proposed methods would enable clinicians to further evaluate fetal health by measuring the blood acidity. Currently, there are no methods for measuring fetal blood pH, and the acid-base balance may be affected by present or previous health risks that are not observable with current medical tools. Not only does this study address diagnosing fetal acidosis, but also allows for continuous fetal blood pH measurements.

Iron is a fundamental component during pregnancy; however, there is a lack of understanding of how iron deficiency (ID) during the second trimester affects maternal and infant outcomes. We aimed to investigate the prevalence of ID among pregnant women during the second trimester of pregnancy and to evaluate the associations with adverse maternal and infant outcomes. This was an exploratory analysis of data from a longitudinal cohort study including singleton pregnant women at a single center, where P-ferritin was analyzed in blood samples drawn between 24 and 28weeks gestation. Multivariable regression analyses with Bonferroni corrections were used to evaluate the association between ID (P-ferritin <15µg/L) in the second trimester and maternal and infant outcomes. Second trimester ID was found in 182 of the 449 included women (40.5%), among whom anemia was present in 4.4%. Women with ID were more often multiparous (73.1% vs. 52.4%) and subsequently treated with intravenous iron infusion (5.5% vs. 1.1%). Infants born to women with ID had a significantly higher placental weight (700g vs. 630g), higher birth weight (3713g vs. 3522g), birth weight z-score (0.3 vs. -0.1), and significantly lower prevalence of small for gestational age (2.7% vs. 9.8%) compared to women with normal iron levels. ID in the second trimester of pregnancy was not associated with adverse maternal or infant outcomes such as emergency cesarean section, induction of labor, preterm birth, or fetal acidosis. Despite recommended iron supplements from 10weeks gestation, ID was frequent among pregnant Danish women in the second trimester and associated with accelerated placental and infant growth, but not adverse pregnancy outcomes. This study indicates that the clinical relevance of the current cut-off level for ID in the second trimester of pregnancy among pregnant Danish women needs further investigation.

Postspinal hypotension (PSH) during cesarean section (CS) often causes maternal intraoperative nausea and vomiting (IONV) and fetal acidosis. Phenylephrine (PE) and norepinephrine (NE) are commonly used for management; however, the optimal agent and method (bolus vs. infusion) remains uncertain. This review assessed bolus and infusion of PE and NE for IONV and PSH during CS. Systematic searches of MEDLINE, Embase, CENTRAL, and unpublished studies identified randomized controlled trials (RCTs) on PE and NE administration during CS under spinal anesthesia. Primary outcomes included IONV and PSH, whereas secondary outcomes encompassed Apgar scores, umbilical artery pH, rescue vasopressor bolus requirements, and adverse events. A random-effects meta-analysis and the Confidence in Network Meta-Analysis tool were utilized. Among 74 RCTs (7798 patients), NE and PE infusion reduced IONV compared with PE bolus (risk ratio [RR]: 0.47; 95% confidence interval [CI] 0.34-0.66; RR: 0.54; 95% CI 0.42-0.69, high confidence). Similarly, these approaches reduced PSH (NE infusion: RR: 0.25; 95% CI 0.21-0.31, high confidence; PE infusion: RR: 0.29; 95% CI 0.24-0.34, moderate confidence). Rescue vasopressor bolus requirements showed a similar trend. Apgar scores and umbilical artery pH were comparable across all groups. Adverse event varied, with bradycardia more common with PE, tachycardia with boluses, and dizziness with PE bolus. Hypertension was more frequent with infusions. In prophylactic studies, hypotension trends persisted, but no differences were observed in IONV. Prophylactic continuous infusion appears to be a favorable strategy for managing PSH and IONV during CS. No significant difference was observed between PE and NE infusions in preventing PSH and IONV.

(Anesth Analg. 2025;140(1):175–184. doi: 10.1213/ANE.0000000000006872) General anesthesia is required in pregnant women for various types of surgery, including both obstetric and nonobstetric procedures. During pregnancy, progesterone increases maternal minute ventilation, leading to mild respiratory alkalosis. This change reduces maternal carbon dioxide (partial pressure of carbon dioxide in arterial blood or paCO2 levels and alters blood gas values when compared with nonpregnant individuals. Clinical guidelines recommend maintaining maternal paCO2 around 30 mm Hg during general anesthesia in pregnancy. However, the impact of this target on fetal outcomes is not well understood. It is known that both high and low paCO2 levels can affect fetal health in different ways. High maternal paCO2 can increase uterine blood flow and facilitate oxygen release to tissues, however, it may also lead to fetal acidosis. Conversely, low maternal paCO2 can enhance fetal CO2 elimination, however, might reduce uterine blood flow and oxygen delivery to the fetus. Thus, determining the optimal maternal paCO2 level during general anesthesia is critical for balancing fetal oxygenation and avoiding adverse effects.

Abstract IntroductionAccurate detection of fetal acidosis in labor is an unmet clinical need. Objectives of this study are: To run a pilot validation of a subcutaneous biosensor for continuous lactate monitoring (CLM) to detect acidosis in a fetal lamb model of asphyxia. Assess the feasibility of the CLM biosensor for intrapartum fetal monitoring by correlating sensor‐detected lactate levels with contemporaneously collected blood lactate values. MethodEwes (n = 3) with singleton pregnancy were anesthetized and the lamb's head was exteriorized. Multiple biosensors were placed onto the lamb scalp, with electrical current outputs captured. Jugular venous blood samples were collected at regular intervals across the protocol, and lactate and other physiological parameters were recorded. After baseline, the umbilical cord was occluded for 10 min, with recordings continuing over at least 3 h during recovery.ResultsNine biosensors were tested across three animals. Six of the nine had a clear response to lactate rise from an acute hypoxic event, with five of these having strong correlation (R2 &gt; 0.93). These five sensors responded to change in venous lactate from as low as 1.6 mmol/L up to 8.4 mmol/L over a range of pH (7.04‐7.38) and pvO2 (1.6‐23.5 mmHg) over 5.5 h, demonstrating the utility of the biosensor in monitoring in‐vivo lactate levels.ConclusionThis study demonstrates the capability of an innovative subcutaneous biosensor for CLM in detecting early signs of fetal lactic acidosis, highlighted by the strong correlation between sensor current and venous blood lactate levels. This technology has the potential to enable continuous fetal lactate measurement, with the ability to revolutionize intrapartum care and improve neonatal outcomes by enabling crucial early detection and management of fetal asphyxia during labor and delivery.

Adding μ-opioid receptor agonists to local anesthetics are usually used for labor analgesia, while they are associated with pruritus. Kappa opioid agonists (dezocine) are widely used for pain management. Recently, they have emerged as a novel type of potent antipruritic agents. The purpose of this study was to investigate the effects of dezocine with ropivacaine on epidural analgesia during labor. A total of 120 parturients were randomly divided into two groups (60 cases each). The group D received 0.1% ropivacaine with dezocine 0.2mg/mL for epidural analgesia while the control group received 0.1% ropivacaine with sufentanil 0.4μg/mL for epidural analgesia. The systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were monitored. The onset time and duration of analgesia, pain intensity, Bromage scores, delivery outcome, neonatal Apgar scores, and adverse events of mothers and neonates were recorded. Pain intensity was assessed using visual analogue scale (VAS). Umbilical arterial blood was collected for analysis. The incidence of itching was lower in the group D than the control group (0% vs. 10%, P = 0.036). The duration of analgesia was longer in the group D (76.1 ± 9.7 vs. 72.1 ± 10.5min, P = 0.032), and numbers of boluses were fewer in the group D (median, 2 vs.3, P = 0.018). The onset time of analgesia and VAS values were similar between the two groups (all P > 0.05). There were no significant differences in terms of hypotension, bradycardia, motor block, respiratory depression, fetal acidosis, nausea and vomiting between the two groups. This study indicated that the epidural use of dezocine increased the analgesic effect, prolonged the duration of analgesia and decreased the incidence of itching during labor without increasing adverse events of mothers and neonates. https://www.chictr.org.cn, identifier ChiCTR2000035341.

Objective: The frequency of maternal hypotension after spinal anesthesia in Caesarean section (CS) may be as high as 90%. The aim of this study was to investigate the effect of the use of the combination of ephedrine and norepinephrine on maternal hemodynamics, neonatal APGAR and acidosis in CS delivery under spinal anesthesia. Methods: This prospective, randomized, double-blind study included pregnant patients aged 18 - 45 years, evaluated as ASA class I-II for surgery, who underwent elective CS under spinal anesthesia. The clinical and laboratory findings, umbilical blood gases, maternal blood pressure and heart rate were also analyzed. The patients were randomly separated into 3 groups: Ephedrine (E), Ephedrine+Norepinephrine (EN), and Norepinephrine (N). Results: Umbilical cord venous blood pH and HCO3 was lower in Group EN than the other groups. APGAR score was lower in Group E. Heart rate in Groups EN and N decreased up to the middle of surgery, then was slightly elevated until the end of surgery. Heart rate persistently decreased in Group E from the beginning to the end of the surgery. SBP decreased significantly at the end of the surgery compared to basal levels in Group EN and N, and did not decrease significantly in Group E. Conclusion: These findings suggest that the addition of norepinephrine to ephedrine might increase the risk of fetal acidosis and affect the APGAR score. The longer duration of action and the higher number of bolus of ephedrine might be associated with a lesser decrease in maternal blood pressure after the middle of the surgery.

Fetal arrhythmias have been described with intrapartum hypoxemia; however, they cannot be accurately diagnosed with currently used fetal heart rate (FHR) monitoring systems due to low resolution and signal averaging. We used a Holter device to record electrocardiogram (ECG) at 250 Hz in term sheep fetuses that developed severe metabolic acidosis induced by intermittent umbilical cord occlusions (UCOs), mimicking human labor contractions. We hypothesized that UCOs leading to worsening fetal metabolic acidosis provoke distinct fetal arrhythmias that could indicate impending fetal death. Thirteen pregnant sheep (gestational age 133-135/145 days) were instrumented under general anesthesia. Three electrodes were placed on the fetal chest and connected to a Holter device for continuous ECG recording at a sampling rate of 250 Hz. The fetal axillary artery was catheterized and an inflatable occluder was placed around the umbilical cord. After a 4-5 day recovery, complete UCOs were induced by inflating the occluder for 1 min, followed by deflation for 2 min, until the fetal arterial pH dropped <7.0 and/or base excess (BE) <-16. Thereafter, an emergency cesarean section was performed to deliver the fetus. Eight sheep fetuses were included in the final analysis. All fetuses had normal baseline arterial blood gases and lactate values. During the first two UCOs, all fetuses demonstrated isolated benign arrhythmias. Three fetuses that developed severe metabolic acidosis after five UCOs showed persistent atrioventricular (AV) conduction abnormalities during the last UCO and its release, requiring cardiopulmonary resuscitation (CPR) at birth. One fetus with third-degree AV block had no detectable QRS complexes at birth, developed ventricular tachycardia and fibrillation (VT/VF) during CPR, and was successfully defibrillated. Five fetuses tolerated ≥10 UCOs before developing severe metabolic acidosis, and none of these showed any persistent AV-conduction abnormalities, though one fetus died after developing VT/VF after the 10th UCO. Metabolic acidemia induced by intermittent UCOs in term sheep fetuses is associated with various arrhythmias, some of which may be life-threatening. Continuous intrapartum fetal ECG recording at a sample rate of ≥250 Hz coupled with a software capable of automatically detecting significant arrhythmias could enhance intrapartum fetal monitoring in the future.

Evaluation of scalp sampling practice and methods before and after training in intrapartum monitoring

Diabetic ketoacidosis in pregnancy is a rare but serious complication caused by insulin deficiency. Hyperglycemia is considered a hallmark sign of diabetic ketoacidosis; however, physiologic changes of pregnancy predispose pregnant women to developing euglycemic diabetic ketoacidosis, where the plasma glucose level is normal or near normal. Euglycemic diabetic ketoacidosis during pregnancy poses many challenges to diagnosis including signs and symptoms that can be attributed to pregnancy, rapid progression of signs and symptoms, and near-normal glucose levels. Fetal acidosis also develops as a result of the maternal disease process. The fetal heart rate tracing in diabetic ketoacidosis often features minimal to absent variability, fetal tachycardia, or recurrent or late decelerations. Treatment should focus on correcting maternal acidosis and electrolyte imbalances. Despite the state of the fetal heart rate tracing, birth is not typically indicated as fetal status should improve over time after correcting maternal acidosis. To improve outcomes and prevent worsening complications, early diagnosis and intervention is vital for patients with diabetic ketoacidosis. A collaborative, multidisciplinary approach to these patients can facilitate timely diagnosis and initiation of treatment. We present a case study of a patient diagnosed with euglycemic diabetic ketoacidosis secondary to influenza A that required emergency cesarean birth due to worsening maternal and fetal status despite corrective interventions.

Background: Anaesthesia to a parturient is not only unique but also requires highest degree of care because the anaesthesiologist has to look after two individuals, the mother and fœtus. Hypotension during spinal anaesthesia for caesarean delivery can have detrimental effects on both mother and neonate. These effects include decreased utero-placental blood flow, impaired foetal oxygenation with asphyxial stress and foetal acidosis and maternal symptoms of low cardiacoutput such as nausea, vomiting, dizziness and decreased consciousness. Vasopressor like Ephedrine, Mephentermine, Phenylephrine, are used for treating the hypotension. In this study we compared the efficacy of Ephedrine, Mephentermine and Phenylephrine in treating the hypotension for caesarean section and their desirable side effects. Materials and Methods: In this prospective randomised controlled study, 90 patients of ASA physical status I and II belonging to age group of 18-35 years undergoing elective or emergency LSCS under sub-arachnoid block were randomly allocated into 3 groups of 30patients each, Group E (Ephedrine) and Group M (Mephentermine) and Group P (Phenyephrine). Group E received Inj Ephedrine 6 mg IV bolus, Group M received Inj Mephentermine 6 mg IV bolus and Group P received Inj Phenylephrine 100 microgram IV bolus for spinal anaesthesia. The changes in hemodynamic parameters, neonatal outcome, side-effects and usage of rescue vasopressor were compared between the groups. Results: The mean age in group P was 24.2 years, in group E 25.7 years and in group M was 25.7 years, which was similar across the groups. The time between induction and delivery was 87.8 sec in group P, 89.4 sec in group E and 89.6 sec in group M. The time at which 1st vasopressor dose given was 5.2 min in group P, 4.8 min in group E and 4.87 min in group M. The mean heart rate was lower in group P at all the points of study after episode of hypotension. The bolus drug requirement was highest in group P with mean of 3.52 followed by group M with mean of 2.86 and group E with mean of 2.55. The group E required rescue analgesia 73% of time, group M 70% of time and group P also 70% of time in study. The mean APGAR score at 1 minute was 8.2 in group P, 8.4 in group E and 8.6 in group M. Conclusion: During subarachnoid block for cesarean delivery, all three of the study's vasopressors— phenylephrine, ephedrine, and mephentermine—effectively maintained arterial blood pressure and were safe to use in the treatment of hypotension. Compared to ephedrine and mephentermine, phenylephrine significantly lowered heart rate, which may be helpful for cardiac patients or those in whom tachycardia is not desired