Maternal Sedation Research Articles

Respiratory patterns in spontaneously breathing near-term lambs delivered by caesarean section under spinal anaesthesia.

The transition to newborn life has typically been studied in intubated and mechanically ventilated newborn lambs delivered via caesarean section (CS) under general anaesthesia. As a result, little is known of the spontaneous breathing patterns in lambs at birth, particularly those at risk of developing respiratory distress (RD). We have developed a method for delivering spontaneously breathing near-term lambs to characterise their breathing patterns in the immediate newborn period. At 137-8 days gestation (2-3 days prior to delivery; term ∼147 days), fetal lambs (n = 7) were partially exteriorised for instrumentation (insertion of catheters and flow probes) before they were returned to the uterus. At 140 days, lambs were delivered via CS under light maternal sedation and spinal anaesthesia. Lambs were physically stimulated and when continuous breathing was established, the umbilical cord was clamped. Breathing patterns were assessed by measuring intrapleural and upper-tracheal pressures during the first four hours after birth. Newborn lambs display significant heterogeneity in respiratory patterns in the immediate newborn period that change with time after birth. Seven distinct breathing patterns were identified including: (i) quiet (tidal) breathing, (ii) breathing during active periods, (iii) breathing during oral feeding, (iv) tachypnoea, (v) expiratory braking manoeuvres, (vi) expiratory pauses or holding, and (vii) step changes in ventilation. We have described normal respiratory behaviour in newborn lambs, in order to identify respiratory behaviours that are indicative of RD in term newborn infants.

Quantitative measurements and morphological evaluation of fetal cardiovascular structures with fetal cardiac MRI

PurposeFetal cardiac magnetic resonance imaging (FCMR) can be used as an imaging modality in fetal cardiovascular evaluation as studied in recent years. We aimed to evaluate cardiovascular morphology using FCMR and to observe the development of cardiovascular structures according to gestational age (GA) in pregnant women. MethodIn our prospective study, 120 pregnant women between 19 and 37 weeks of gestation in whom absence of cardiac anomaly could not be excluded by ultrasonography (US) or, who were referred to us for magnetic resonance imaging (MRI) for suspected non-cardiovascular system pathology, were included. According to the axis of the fetal heart, axial, coronal, and sagittal multiplanar steady-state free precession (SSFP) and 'real time' untriggered SSFP sequence, respectively, were obtained. The morphology of the cardiovascular structures and their relationships with each other were evaluated, and their sizes were measured. ResultsSeven cases (6.3%) contained motion artefacts that did not allow the assessment and measurement of cardiovascular morphology, and three (2.9%) cases with cardiac pathology in the analysed images were excluded from the study. The study included a total of 100 cases. Cardiac chamber diameter, heart diameter, heart length, heart area, thoracic diameter, and thoracic area were measured in all fetuses. The diameters of the aorta ascendens (Aa), aortic isthmus (Ai), aorta descendens (Ad), main pulmonary artery (MPA), ductus arteriosus (DA, superior vena cava (SVC), and inferior vena cava (IVC) were measured in all fetuses. The left pulmonary artery (LPA) was visualised in 89 patients (89%). The right PA (RPA) was visualised in 99 (99%) cases. Four pulmonary veins (PVs) were seen in 49 (49%) cases, three in 33 (33%), and two in 18 (18%). High correlation values were found for all diameter measurements performed with GW. ConclusionIn cases where US cannot achieve adequate image quality, FCMR can contribute to diagnosis. The very short acquisition time and parallel imaging technique with the SSFP sequence allow for adequate image quality without maternal or fetal sedation.

Analysis of intrathecal clonidine as an adjuvant in the subarachnoid block on post-operative analgesia and safety profile in obstetric surgeries: A randomised controlled trial

Background: Clonidine has long been considered an 'off-label' medication for use in obstetrics. Different doses of clonidine are studied and it is found that higher doses are associated with sedation and haemodynamic instability. Hence, we analysed a mini dose of intrathecal clonidine of 30 μg for its impact primarily on post-operative analgesia and secondarily on the quality of spinal anaesthesia, haemodynamics, sedation and neonatal outcomes in caesarean sections.Methods: One hundred participants were randomised them to receive the interventions. Group B received 11 mg of 0.5% hyperbaric bupivacaine (2.2 mL) and Group C received 10 mg of 0.5% hyperbaric bupivacaine with 30 μg of clonidine (2.2 mL). Motor, sensory and haemodynamic characteristics with time to rescue analgesics were observed in both the groups and analysed using univariate analysis.Results: Time to rescue analgesics (P < 0.001), visual analogue scores in the post-operative period and time to grade 0 Bromage (P = 0.002) were statistically significant in Group C. Time to T6 dermatomal level and time to grade 4 Bromage were similar in both the groups. Apgar scores were comparable and no adverse events were noted in both the groups.Conclusions: A low dose of intrathecal clonidine (30 μg) can prolong the duration of post-operative analgesia in caesarean section with comfortable maternal sedation and good neonatal outcome without significant complications.(Clinical Trials Registry- India, number CTRI/2018/08/015250)

Survey about the current use of fetal MRI in Spain

In June 2019 in Seville, at the first course in fetal MRI, endorsed by the Spanish Society of Medical Radiology (SERAM) and the Spanish Society of Pediatric Radiology (SERPE), the Spanish fetal MRI group was founded. To establish this group, a questionnaire was designed for radiologists dedicated to prenatal imaging in Spain and disseminated to the SERAM’s members. The questions were related to the type of hospital, to MRI studies (magnetic field, gestational age, use of sedation, number of studies per year, proportion of fetal neuroimaging studies), and to teaching and research about fetal MRI. A total of 41 responses were received from radiologists in 25 provinces (88% working in public hospitals). Very few radiologists in Spain perform prenatal ultrasonography (7%) or prenatal CT. MRI is done in the second trimester (34%) or in the third trimester (44%). In 95% of centers, fetal brain MRI studies predominate. In 41% of the centers, studies can be done on 3 T MRI scanners. Maternal sedation is used in 17% of centers. The number of fetal MRI studies per year varies widely, being much higher in Barcelona and Madrid than in the rest of Spain.

Perioperative pharmacological interventions for fetal immobilisation during fetal surgery and invasive procedures.

Developments in ultrasound assessment of pregnancy has resulted in the increasing diagnosis of antenatal fetal issues. Many structural fetal conditions as well as complications associated with multiple pregnancies have the potential for in-utero treatment to improve both pregnancy and neonatal outcomes. Procedures such as laser ablation for twin-twin syndrome or cord occlusion for selective fetal termination require fetal immobilisation. Immobilisation of the fetus can occur through administration of medication to the mother or directly to the fetus. This improves procedural success and reduces the ongoing risk to the pregnancy. Evidence regarding the best medication and mode of delivery helps to ensure the optimal decision is made for both the mother and the fetus. To assess the effects of perioperative pharmacological interventions for fetal immobilisation during fetal surgery and invasive procedures on fetal, neonatal, and maternal outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 May 2021), and reference lists of retrieved studies. We included randomised controlled trials (RCTs) and quasi-RCTs (including published abstracts) which compared different classes of medication administered to the mother or fetus to allow in-utero procedures to be performed. We also included cluster-randomised trials but excluded cross-over trials. We used the standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. One study with three trial reports met the inclusion criteria. This involved 54 women with a multiple pregnancy. The study was conducted in a tertiary European hospital maternal-fetal medicine unit and compared remifentanil to diazepam for fetal immobilisation and maternal sedation during fetoscopic surgery. Low-certainty evidence suggested that remifentanil may reduce fetal movement more than diazepam for two outcomes of fetal movement, one of fetal immobilisation at 40 minutes using a visual analogue score (VAS) (where 0 = immobile and 100 = baseline mobility), and one of gross body and limb movements (score was absolute number of movements), both assessed by a sonographer evaluating a taped ultrasound sequence (mean difference (MD) -65.00, 95% confidence interval (CI) -69.38 to -60.62 and MD -10.00, 95% CI -11.62 to -8.38; 1 study, 50 women). Surgeons may also report being more satisfied with the procedure when using remifentanil rather than diazepam (risk ratio (RR) 2.88, 95% CI 1.60 to 5.15; 1 study, 50 women; low-certainty evidence). However, maternal respiratory rate may decrease more during the surgical procedure with remifentanil compared with diazepam (MD -6.00, 95% CI -8.29 to -3.71; 1 study, 50 women; low-certainty evidence). Maternal sedation may also be worse with remifentanil compared with diazepam (RR 0.09, 95% CI 0.01 to 0.65; 1 study, 50 women; low-certainty evidence) measured using an observer assessment of alertness/sedation (where a score of < 4 equates to profound sedation and > 4 equates to insufficient sedation). Perinatal mortality and time taken to perform the procedure were not reported in the trial. We prespecified 20 outcomes and planned to use GRADE for 6 of them, all other outcomes were not able to be reported against for the purpose of meta-analysis due to data not being provided or unable to be interpreted. We assessed the included study at low risk of selection bias (appropriate random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (outcome assessors were blinded), attrition bias (incomplete outcome data minimal), and reporting bias. Our GRADE assessment for certainty of the evidence indicates that there is low certainty of the evidence. We were only able to include one study with a small number of women, from a single centre, a European tertiary hospital. This study was published in 2005 with an abstract of this trial published in 2004. This study evaluated two intravenous medications administered to the mother - remifentanil and diazepam. This study reported our prespecified primary outcome but only evaluated several of our secondary outcomes, which limited further assessment.Low-certainty evidence suggested that remifentanil may be better at reducing fetal movements and surgeons were more satisfied with the procedure. However, maternal sedation and depression of breathing may be worse with remifentanil. Further high-quality RCTs assessing both fetal and maternal medications are required to evaluate their efficacy for fetal immobilisation as well as safety for both mother and fetus.

A Comparison Between Dexmedetomidine and Clonidine as Adjuvants to Levobupivacaine in Labour Analgesia.

BackgroundThe epidural analgesia technique is effective for labor analgesia and combinations of various local anesthetics with lipophilic opioids like fentanyl are used. However, fentanyl can cause an increased incidence of pruritus, urinary retention, nausea, vomiting, giddiness, shivering, and respiratory depression. Dexmedetomidine and clonidine are selective alpha 2 agonists with analgesic properties and have been used via the neuraxial route with local anesthetics for the same without the side effects of fentanyl. Thus, the primary objective was to assess and compare the analgesic efficacy of the two-drug combinations by the visual analog scale (VAS) score.MethodsFifty-four primigravida women were randomly allocated in two groups of 27 each and were given an initial bolus of 10 mL of 0.125% levobupivacaine with dexmedetomidine 0.5 ug/kg in Group A and with clonidine 1 μg/kg in Group B. Subsequently, each patient received a background infusion rate of 10 mL/h, a bolus dose of 5 ml, and a lock-out interval of 10 min via a patient-controlled-analgesia (PCA) pump. The blood pressure, heart rate, and severity of pain using VAS were assessed. Durations of the stages of labor, rate of instrumental delivery, and cesarean section, side effects, maternal sedation, and neonatal Apgar scores were also recorded.ResultsVAS scores in both the groups progressively decreased to <3 by 15 min with significant differences at five, 10, 15, and 120 min being lower in group A. Onset of analgesia and time for maximum analgesia was significantly shorter in group A. There was a significant decrease in hemodynamic parameters from baseline in both groups. The fall in heart rate was significantly greater in Group A and at almost all the time intervals after baseline, diastolic blood pressure (DBP) was also lower in group A. Maternal motor blockade scores, the intensity of maternal sedation, the incidence of maternal complications, the duration of the first and second stage of labor, the rate of instrumental delivery and cesarean section, total analgesic dose and PCA bolus requirement, and neonatal Apgar scores did not show a significant difference between the two groups.ConclusionBoth dexmedetomidine and clonidine provide hemodynamically stable labor with a fall in heart rate and maternal blood pressure in the initial hours. Dexmedetomidine has the advantage of faster onset of analgesia and time for maximum analgesia.

Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network

Introduction: A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques. Methods: We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet). The survey included details of fetal interventions performed in 2018, anesthesia staffing models, anesthetic techniques, fetal monitoring, and postoperative management. Results: There was a 92% response rate. Most FTCs are located within an adult hospital and employ a small team of anesthesiologists. There is heterogeneity when evaluating anesthesiology fellowship training and staffing, indicating there is a multidisciplinary specialty team-based approach even within anesthesiology. Minimally invasive fetal interventions were the most commonly performed. The majority of FTCs also performed ex utero intrapartum treatment (EXIT) and open mid-gestation procedures under general anesthesia (GA). Compared to FTCs only performing minimally invasive procedures, FTCs performing open fetal procedures were more likely to have a pediatric surgeon as director and performed more minimally invasive procedures. Conclusions: There is considerable variability in anesthesia staffing, caseload, and anesthetic techniques among FTCs in NAFTNet. Most FTCs used maternal sedation for minimally invasive procedures and GA for EXIT and open fetal surgeries.

Encuesta sobre la situación actual de la resonancia magnética fetal en España

In June 2019 in Seville, at the first course in fetal MRI, endorsed by the Spanish Society of Medical Radiology (SERAM) and the Spanish Society of Pediatric Radiology (SERPE), the Spanish fetal MRI group was founded. To establish this group, a questionnaire was designed for radiologists dedicated to prenatal imaging in Spain and disseminated to the SERAM's members. The questions were related to the type of hospital, to MRI studies (magnetic field, gestational age, use of sedation, number of studies per year, proportion of fetal neuroimaging studies), and to teaching and research about fetal MRI. A total of 41 responses were received from radiologists in 25 provinces (88% working in public hospitals). Very few radiologists in Spain perform prenatal ultrasonography (7%) or prenatal CT. MRI is done in the second trimester (34%) or in the third trimester (44%). In 95% of centers, fetal brain MRI studies predominate. In 41% of the centers, studies can be done on 3 T MRI scanners. Maternal sedation is used in 17% of centers. The number of fetal MRI studies per year varies widely, being much higher in Barcelona and Madrid than in the rest of Spain.

The Effects of Pre-emptive Single Dose Oral Pregabalin on Maternal Anxiety and Stress Response to Laryngoscopic intubation During Caesarean Section

ABSTRACT Background: Parturients scheduled to elective cesarean section usually develop higher anxiety and stress symptoms. Pregabalin decreases preoperative anxiety and intubation stress response; however, its effects on mother and newborn have not been investigated yet. The primary aim of this study was to investigate the effect of single-dose oral pregabalin on preoperative maternal anxiety, and the secondary aims were to assess its effect on attenuating the stress response to laryngoscopic intubation, maternal sedation, and neonatal clinical outcomes in parturients undergoing cesarean section. Methods: A prospective double-blind randomized-controlled clinical study. Sixty minutes before induction of anesthesia, 74 parturients scheduled for elective cesarean section under general anesthesia were randomly allocated into two groups: Group A (n = 37) received single oral pregabalin 150 mg capsule and Group B (n = 37) received oral multivitamin capsule. Results: Group A showed statistically significant lower number of parturients with moderate and high anxiety [11(29.73%) and 2(5.41%)], respectively, and increasing number of parturients with low anxiety [24(64.86%)] using STAI compared to [13(35.13%) and 14(37.84%)] for moderate and high anxiety, respectively, and [10(27.03%)] for low anxiety in group B and to basal numbers (p = 0.001). Rise in mean (heart rates and arterial blood pressures) from baseline values in both groups at 0 min (at intubation) and both groups were comparable at all measured time points (p > 0.05). Also, rising of mean serum glucose and cortisol levels at 10 min post-intubation from basal in both groups and both groups were comparable (p > 0.05). Mean APGAR scores were normal and both groups were comparable. All parturients were alert by AVPU score and no side effects were detected in both groups. Conclusion: Pre-emptive single oral 150 mg pregabalin is effective in decreasing maternal anxiety with good neonatal outcomes, but has no effect on stress response of laryngoscopic intubation during cesarean section.

Transversus abdominis plane block compared with wound infiltration for postoperative analgesia following Cesarean delivery: a systematic review and network meta-analysis

This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration. We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes. Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed. In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

Severe COVID-19 during pregnancy and the subsequent premature delivery

Severe COVID-19 during pregnancy and the subsequent premature delivery

European overview of current practice of fetal imaging by pediatric radiologists: a new task force is launched.

A new task force dedicated to prenatal imaging was created in 2018 by the European Society of Pediatric Radiology. In order to establish a network of European prenatal imaging practice, we sent a questionnaire to radiologists practicing prenatal imaging in Europe. The questions were related to the type of institution, the local legislation for termination of pregnancy, the type of imaging modality and the following items regarding magnetic resonance imaging (MRI): magnetic field, gestational age at which it is performed, use of maternal sedation, number of examinations per year, proportion of cerebral versus body indications and proportion of repeated examinations. We collected responses from 20 European countries, 52 cities and 67 institutions (82% public). In most countries, the upper gestational age limit for termination of pregnancy is 24weeks of gestation. In some countries, it is earlier and in other countries, there is no limit. Very few radiologists practice fetal ultrasonography and computed tomography. In some countries, fetal MRI is mainly performed before 24weeks of pregnancy, while in others, it is mainly performed in the third trimester. Neurological indications are by far predominant and 30% of the institutions have access to a 3-tesla (T) unit for fetal MRI. Maternal sedation is rarely used. The number of scans per year is highly variable with an average of 140, which is not necessarily correlated to the size of the population.

Acute Maternal Fasting or Fluid Abstention Does Not Significantly Affect the Macronutrient Composition of Human Milk: Clinical and Clinical Research Relevance.

There are guidelines on lactation following maternal analgo-sedative exposure, but these do not consider the effect of maternal fasting or fluid abstention on human milk macronutrient composition. We therefore performed a structured search (PubMed) on ‘human milk composition’ and screened title, abstract and full paper on ‘fasting’ or ‘abstention’ and ‘macronutrient composition’ (lactose, protein, fat, solids, triglycerides, cholesterol). This resulted in six papers and one abstract related to religious fasting (n = 129 women) and observational studies in lactating women (n = 23, healthy volunteers, fasting). These data reflect two different ‘fasting’ patterns: an acute (18–25 h) model in 71 (healthy volunteers, Yom Kippur/Ninth of Av) women and a chronic repetitive fasting (Ramadan) model in 81 women. Changes were most related to electrolytes and were moderate and mainly in the chronic repetitive fasting model, with no clinical significant changes in macronutrients during acute fasting. We therefore conclude that neither short-term fasting nor fluid abstention (18–25 h) affect human milk macronutrient composition, so that women can be reassured when this topic was raised during consulting. Besides the nutritional relevance, this also matters, as clinical research samples—especially estimating analgo-sedative exposure by lactation—are commonly collected after maternal procedural sedation and maternal fasting. Based on these results, it is reasonable to assume stable human milk composition when such data are used in physiology-based pharmacokinetic (PBPK) models.

Duration of labor, delivery mode and maternal and neonatal morbidity after remifentanil patient-controlled analgesia compared with epidural analgesia.

ObjectiveThe objective of this study was to compare duration of active labor, delivery mode, maternal and neonatal morbidity and women’s satisfaction with delivery after intravenous remifentanil patient-controlled analgesia (PCA) or standard epidural analgesia (EDA). Based on clinical observations, we hypothesized that women with PCA would have shorter labor.Study designAn observational study at a university hospital in Sweden 2009–16. Maternal and neonatal outcomes with PCA (n = 69) and EDA (n = 138) were compared.ResultsWomen with PCA had shorter active labor 5.6 ± 3.3 compared to 8.5 ± 4.4 h (p < 0.001) with EDA, and a higher rate of spontaneous delivery 94% (65/69) compared to 65% (n = 90/138) with EDA (p < 0.001). Intrapartum temperature >38 °C (p = 0.001) and signs of fetal asphyxia (p < 0.001) were less common with PCA. No maternal or neonatal sedation was observed. The rates of transient oxygen desaturation <95%, bleeding > 1000 mL and women’s satisfaction with delivery did not differ between the groups.ConclusionPCA had several advantages over EDA, as it was associated with shorter active labor and a higher rate of spontaneous delivery without worsening maternal or neonatal morbidity or women’s satisfaction with delivery. Therefore, we suggest an increased availability of PCA for labor analgesia. We recommend continuous one-to-one care and oxygen saturation monitoring for all women during active labor.

Intravenous Remifentanil Patient-controlled Analgesia Versus Intramuscular Pethidine for Pain Relief in Labour (RESPITE): An Open-label, Multicenter, Randomized Controlled Trial

(Lancet. 2018;392:662–672) While pethidine (meperidine) is widely used for pain relief during labor, there are unfavorable side effects, such as nausea/vomiting, maternal sedation, and possible neonatal depression. In addition, more than a third of women receiving pethidine ultimately request epidural labor analgesia. Remifentanil is a potential alternative to pethidine for labor pain relief. Its rapid onset and short duration of action provide some benefits although its short duration requires administration via intravenous (IV) patient controlled analgesia (PCA). It is not commonly used in maternity units in the United Kingdom, however, as previous trials evaluating remifentanil versus pethidine yielded low-quality evidence. Stronger evidence was required to evaluate the efficacy and safety of remifentanil as compared with pethidine for labor pain management. The RESPITE trial primary outcome compared IV remifentanil PCA with intramuscular pethidine looking at the need to convert to epidural analgesia with secondary outcomes evaluating visual analog scale (VAS) pain scores, mode of delivery and adverse maternal or neonatal outcomes.

The Combined Use of Ultrasound and Fetal Magnetic Resonance Imaging for a Comprehensive Fetal Neurological Assessment in Fetal Congenital Cardiac Defects: Scientific Impact Paper No. 60.

Heart problems are common in newborn babies, affecting approximately 5-10 in 1000 babies. Some are more serious than others, but most babies born with heart problems do not have other health issues. Of those babies who have a serious heart problem, almost 1 in 4 will have heart surgery in their first year. In the UK, pregnant women are offered a scan at around 20weeks to try and spot any heart problems. In most cases there is not a clear reason for the problem, but sometimes other issues, such as genetic conditions, are discovered. In recent years the care given to these babies after they are born has improved their chances of surviving. However, it is recognised that babies born with heart problems have a risk of delays in their learning and development. This may be due to their medical condition, or as a result of surgery and complications after birth. In babies with heart problems, there is a need for more research on ultrasound and magnetic resonance imaging (MRI) to understand how the brain develops and why these babies are more likely to have delays in learning and development. This paper discusses the way ultrasound and MRI are used in assessing the baby's brain. Ultrasound is often used to spot any problems, looking at how the baby's brain develops in pregnancy. Advances in ultrasound technologies have made this easier. MRI is well-established and safe in pregnancy, and if problems in the brain have been seen on ultrasound, MRI may be used to look at these problems in more detail. While it is not always clear what unusual MRI findings can mean for the baby in the long term, increased understanding may mean parents can be given more information about possible outcomes for the baby and may help to improve the counselling they are offered before their baby's birth.

Dexmedetomidine infusion during caesarean section under general anaesthesia: Evaluation of maternal awareness using BIS, maternal and neonatal outcomes

Study objectivesThe present study investigated the effect of dexmedetomidine infusion on bispectral index and hemodynamic values for patients undergoing cesarean section under general anesthesia as well as the postoperative maternal and fetal outcomes.Design and settingThis is randomized controlled study done in operating rooms and postoperative recovery area.Patients44 Adult healthy pregnant females scheduled for elective Caesarian section delivery under general anesthesia were divided randomly in to two equal groups. Dexmedetomidine group and control group.InterventionsUnlike control group, Dexmedetomidine group: patients were given intravenous loading dose of DEX 1 mcg/kg before induction of anesthesia then intravenous infusion of DEX 0.4 mcg kg−1 hr−1 throughout surgery.MeasurementsThe BIS values; heart rate, blood pressure and MAC were monitored at 15 designated points of sequential events during anesthesia. The maternal sedation in the first postoperative hour was reported every 15 min. Apgar score of the neonates was assessed by the pediatrician 1 min and 5 min interval. All patients were asked about awareness or recall at the time of discharge and 6 h after.ResultsBIS values, blood pressure, heart rate and MAC were significantly lower in DEX group at most different time intervals. Both groups of the study were matched as regard as Apgar score at 1 min. and 5 min. Alderete score was significantly lower in DEX group 15 min after extubation. However, both groups were matched 30 min after extubation. Sedation score was higher in Dex group at 5 and 15 min postoperatively. 10 patients in the control group needed extra dose of fentanyl.ConclusionsDexmedetomidine is useful adjuvant during general anesthesia for CS as it attenuates hemodynamic responses to surgical stress, reduces needs for analgesic and anesthetic drugs together with favorable maternal and neonatal outcome.

Magnetic resonance imaging of the fetal brain at 3 Tesla: Preliminary experience from a single series.

To report our preliminary experience with cerebral fetal magnetic resonance imaging (MRI) with a 3 Tesla (3T) scanner. We assessed feasibility, time of acquisition, and possibility to establish a diagnosis.Fifty-nine pregnant women had fetal MRI performed during the third trimester of pregnancy due to clinical or sonography concern of a central nervous system anomaly. No fetal or maternal sedation was used. The MRI protocol consisted of T2 turbo-spin-echo images in 3 planes of space. No T1-weighted images were performed. All images were analyzed by 2 pediatric neuroradiologists, who evaluated spatial resolution, artifacts, time of acquisition, and possibility to establish a diagnosis suspected by sonography.Examinations were performed safely for all patients. The images required longer time of acquisition (approximately 75 seconds for each plane in the space). The specific absorption rate was not exceeded in any fetus. Cerebral fetal MRI was normal in 22 cases. The spectrum of diagnostics included isolated ventriculomegaly, posterior fossa malformation, corpus callosum malformation, gyration anomalies, craniosynostosis, tuberous sclerosis, microcephaly, external hydrocephaly, midline arachnoid cyst, cerebral lesions, and persistent hyperplastic primitive vitreous.In our series, 3 T MRI of fetal brain was feasible and able to establish a diagnosis but required longer time of acquisition.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.

492: Brain volumetric assessment by magnetic resonance imaging in fetuses that underwent a prenatal neural tube defect repair using a fetoscopic or open approach

To assess volumetric brain composition using Magnetic Resonance Imaging (MRI) performed 6 weeks after surgery on fetuses that underwent a prenatal neural tube defect (NTD) repair via either a fetoscopic or open approach Longitudinal retrospective cohort study on two groups of fetuses diagnosed with NTD that underwent a prenatal repair: Fetoscopic (n=10) and Open (n=10). The fetal NTD repair was performed at a comparable gestational ages (GA). MRI studies were performed six weeks after surgery in a 1.5T scanner without maternal sedation. To create a single 3D volume absent of artifact from inherent motion and intensity corruption, a super resolution (SR) reconstruction was obtained by co-registering the three orthogonal T2 weighted image stacks and iteratively performing voxel- based intensity matching. SR images were post-processed for volumetric analyses by performing manual segmentation. Supratentorial brain parenchyma, ventricular system, brain stem and cerebellar volumes were assessed. The addition of all of these individual volumes constituted “Total brain volume”. All volumes were compared between the two groups. GA at surgery was similar in the two groups, as was the level of the lesion and the GA at time of MRI scan. The degree of ventriculomegaly, both prior to surgery and at the time of the MRI was comparable between the two groups. There were no significant differences detected in any of the studied brain volumes. These results suggest that fetoscopic NTD repair, with its attendant CO2 exposure, has no obvious effects on select fetal brain volumes at six weeks post, when compared with cases repaired using the open histerotomy technique, and as such increase the available data supporting the safety of this technique.View Large Image Figure ViewerDownload Hi-res image Download (PPT)