INTERFASCIAL PLANE BLOCKS IN OBSTETRIC AND GYNECOLOGIC SURGERY.

Introduction: Interfascial plane blocks (IPB) are truncal blocks with local anesthetic injected into space between two muscle layers. IPBs are easy to learn, simple to perform, provide satisfactory analgesia up to 24 hours, having a minimal risk of complications. Methods: We present a retrospective analysis of the patients who had IPB as a part of postoperative pain management plan following either CD or hysterectomy in Leskovac General Hospital, Serbia during the period April 2017 - February 2022. Results: We had 131 patients who had IPB perioperatively. Bilateral QLB type 1 was performed in 53 patients after CD and in 68 patients after hysterectomy. Bilateral ESPB T10-11 was done following one CD case and in 9 patients before hysterectomy. Patients had both acetaminophen and nonsteroidal anti-inflammatory drug for postoperative pain control. Decreased usage of fentanyl and sevoflurane was noticed in the cases where IPB was performed preoperatively. Almost all patients had well-controlled pain, and were very satisfied with pain score of 0-4/10 at numeric rating scale during 24 hours after surgery, with no opioid use. There were no complications regarding block performance. Conclusion: QLB and ESPB have great potential to improve and facilitate postoperative pain management in obstetric and gynecologic surgery.

Preeclampsia Among African American Pregnant Women: An Update on Prevalence, Complications, Etiology, and Biomarkers.

IMPORTANCE: Preeclampsia is a devastating disease of pregnancy associated with increased risk of fetal and maternal complications. African American pregnant women have a high prevalence of preeclampsia, but there is a need of systemic analyses of this high-risk group regarding complications, etiology, and biomarkers. OBJECTIVE: The aim of this study was to provide a synopsis of current research of preeclampsia specifically related to African American women. EVIDENCE ACQUISITION: A comprehensive search was performed in the bibliographic database PubMed with keywords "preeclampsia" and "African American." RESULTS: African American women with preeclampsia were at an increased risk of preterm birth, which resulted in low-birth-weight infants. Intrauterine fetal death among African American preeclamptic patients occurs at twice the rate as in other races. On the maternal side, African American mothers with preeclampsia have more severe hypertension, antepartum hemorrhage, and increased mortality. Those who survive preeclampsia have a high risk of postpartum cardiometabolic disease. Preexisting conditions (eg, systemic lupus erythematosus) and genetic mutations (eg, sickle cell disease in the mother, FVL or APOL1 mutations in the fetus) may contribute to the higher prevalence and worse outcomes in African American women. Many blood factors, for example, the ratio of proteins sFlt/PlGF, hormones, and inflammatory factors, have been studied as potential biomarkers for preeclampsia, but their specificity needs further investigation. CONCLUSIONS: Further studies of preeclampsia among African American women addressing underlying risk factors and etiologies, coupled with identification of preeclampsia-specific biomarkers allowing early detection and intervention, will significantly improve the clinical management of this devastating disease.

Post Partum Death in a Patient Diagnosed With COVID-19.

Background: There are few case reports describing maternal mortality and intensive care of the pregnant patient with COVID-19 infection. Case: A 27-year-old patient at 34 weeks of gestation was admitted for the evaluation of cough, fever, tachypnea, and oligohydramnios. The day of admission she underwent cesarean delivery for a non-reassuring fetal heart rate tracing. Over the next 6 days her clinical condition deteriorated, she developed multi organ system failure, and died despite aggressive supportive care. Conclusion: Although mortality related to COVID-19 in pregnancy has been rarely reported to date, we describe a case of progressive clinical deterioration postpartum despite aggressive supportive care. Management strategies specific for pregnant women have not been developed. In timing delivery, the obstetrician must consider the possibility that the inflammatory response associated with CD may increase the risk for multiorgan system failure in parturients with COVID-19 while recognizing that risks to the fetus may be higher in patients with COVID-19 than in other critically ill parturients. Vertical transmission of infection to the neonate did not occur in our case and has not been demonstrated in other pregnancies with COVID-19 disease.

A Review of the Quadratus Lumborum Block and ERAS.

The use of truncal nerve blocks has been described since 2001. Since then, there have been many studies trying to understand the ideal clinical scenarios for its use. Since 2001, the transversus abdominis plane block has evolved in many ways including from landmark based technique to ultrasound guided and more recently, into the quadratus lumborum (QL) block. Its anatomical placement, concentration of local anesthetic, volume of local anesthetic, and anatomic placement have all been raised as clinical questions. This article will discuss the literature of the QL block in an effort to understand how it is best used in a variety of clinical scenarios.

Continuous Spinal Anesthesia for Obstetric Anesthesia and Analgesia.

The widespread use of continuous spinal anesthesia (CSA) in obstetrics has been slow because of the high risk for post-dural puncture headache (PDPH) associated with epidural needles and catheters. New advances in equipment and technique have not significantly overcome this disadvantage. However, CSA offers an alternative to epidural anesthesia in morbidly obese women, women with severe cardiac disease, and patients with prior spinal surgery. It should be strongly considered in parturients who receive an accidental dural puncture with a large bore needle, on the basis of recent work suggesting significant reduction in PDPH when intrathecal catheters are used. Small doses of drug can be administered and extension of labor analgesia for emergency cesarean delivery may occur more rapidly compared to continuous epidural techniques.

Increasing Regional Anesthesia Use in a Serbian Teaching Hospital through an International Collaboration.

Many low- and middle-income countries (LMICs) report low rates of regional anesthesia (RA) use for cesarean delivery (CD), despite its association with lower maternal major morbidity and mortality. Also, the prevalence of neuraxial analgesia for labor (NAL) is often low in LMICs. We report on the results of a collaboration in clinical education over a multi-year period between Kybele Inc., an international non-profit organization, and Klinicki Centar Vojvodine (CCV), a teaching hospital in Novi Sad, Serbia, to increase RA use for CD and NAL at CCV. From late 2011 through 2015, teams from Kybele participated in annual to biannual didactic conferences and week-long bedside teaching efforts involving obstetric and anesthesia staff from CCV and surrounding hospitals. Ongoing contact occurred at least weekly between Kybele and the host to discuss progress. De-identified quality improvement data on total deliveries, numbers of elective and non-elective CDs, number of vaginal deliveries, type of anesthesia for CD, and the number of NALs were collected. RA use for CD increased to 25% in year 2015 versus 14% in base year 2011 [odds ratio (OR): 2.05; 95% confidence interval (CI): 1.73,2.42; p < 0.001]. NAL increased to 10.5% of laboring women in 2015 versus 1.2% in 2011 (OR: 9.6; 95% CI: 7.2, 12.8; p < 0.001). Greater increases for RA use during non-elective CD were observed between 2011 and 2015 (1.4 versus 7.5% of total CD; OR: 5.52; 95% CI: 2.63, 8.41; p < 0.001) relative to elective CD (12.5 versus 17.5% of total CD; OR: 1.48; 95% CI: 1.23, 1.77; p < 0.001). Overall, RA for CD increased during the 4 year collaboration but was not as great as reported in other countries with similar health-care demographics utilizing a similar program. Detailed descriptions of program interventions and barriers to change at CCV are presented.

Complement factor B activation in patients with preeclampsia.

Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. Bb, the active fragment of complement factor B (fB), has been reported to be a predictor of preeclampsia. However, conflicting results have been found by some investigators. We hypothesized that the disagreement in findings may be due to the racial/ethnic differences among various study groups, and that fB activation is significant in women of an ethnic minority with preeclampsia. We investigated the maternal and fetal levels of Bb (the activated fB fragment) in pregnant women of an ethnic minority with or without preeclampsia. We enrolled 291 pregnant women (96% of an ethnic minority, including 78% African-American). Thirteen percent of these were diagnosed with preeclampsia. Maternal venous blood was collected from all participants together with fetal umbilical cord blood samples from 154 deliveries in the 291 women. The results were analyzed using the Mann-Whitney U test and multivariate analyses. Maternal Bb levels were significantly higher in the preeclamptic group than in the nonpreeclamptic group. Levels of Bb in fetal cord blood were similar in both groups. Subgroup analyses of African-American patients' results confirmed the study hypothesis that there would be a significant increase in Bb in the maternal blood of the preeclamptic group and no increase in Bb in the fetal cord blood of this group. These results suggest that a maternal immune response through complement fB might play a role in the development of preeclampsia, particularly in African-American patients.

Peripartum cardiomyopathy and cesarean section: report of two cases and literature review.

INTRODUCTION: The anesthetic management of labor and delivery in patients with peripartum cardiomyopathy is not well defined. Using continuous spinal anesthesia with bupivacaine or combined spinal epidural anesthesia with ropivacaine in such rare clinical situations has not been previously reported. CASE REPORT: We present two cases in which parturients with the diagnosis of peripartum cardiomyopathy presented in congestive heart failure for emergent Cesarean section. Continuous spinal anesthesia and combined spinal-epidural anesthesia were successfully employed as the anesthetic techniques for the procedures. Both patients remained hemodynamically stable during surgery and were discharged home on postoperative days 5 and 4 respectively.

Patient-controlled epidural analgesia for labor and delivery in a parturient with chronic inflammatory demyelinating polyneuropathy.

OBJECTIVE: The anesthetic management of labor and delivery in patients with any form of chronic inflammatory demyelinating polyneuropathy (CIDP) is not well defined. Using patient-controlled epidural analgesia (PCEA), or epidural analgesia, in such a rare clinical situation has not been previously reported. CASE REPORT: A 32-year-old, gravida 3, para 2, woman with a 2(1/2) year history of CIDP was admitted for labor and delivery at 38 weeks of pregnancy. At the time she presented for labor analgesia, she complained of bilateral hand and foot weakness and tingling. PCEA with 0.1% ropivacaine and fentanyl 2 microg/mL was used for labor analgesia. The patient was pain free during labor and delivery and had an uneventful postpartum course. CONCLUSION: PCEA had no apparent detrimental affect on the patient's disease and may be a reasonable option for patients with CIDP presenting for labor and delivery.