Intrapartum ultrasound monitoring of malposition and malrotation during labor neuraxial analgesia: maternal outcomes.

Objective: This study analyzes the important role of ultrasonography (IUS) related to the maternal outcomes in women with fetal persistent occiput posterior position (POPP) and asynclitism (A) in labor neuraxial analgesia (LNA).Study design: Prospective assessment of 148 primiparous women diagnosed with the prolonged second stage of labor. Transabdominal and transperineal IUS were used to detect fetal head position and to evaluate the angle of progression (AOP) and pubic arch angle (PAA). Statistical data about maternal aspects, modalities of delivery and maternal outcomes were observed.Results: In all parturients included in the study, the operative delivery rate was 73%. In patients delivered via cesarean section, the PAA was ≤ of 96.5°. There was statistical correlation between doses of LNA and Apgar score at first minute (r0.8).Conclusions: There is a greater frequency of Fetal POPP and asynclitism related with maternal complications. The results of our study confirmed the importance of determination of angle of progression (AoP) and PAA in the prolonged second stage of labor. Unfavorable AoP and PAA, in presence of POPP and A, are related with high percentage of operative delivery. If the prolonged labor and delivery in these patients exceed time limit proposed by American College of Obstetricians and Gynecologists guidelines, it may be viewed as a possible malpractice. In cases of POPP with asynclitism, in the second stage of labor detected by IUS it is advisable to discontinue the anesthetic drugs administration in LNA; because the labor pain is related to the dystocia, an operative delivery is necessary to avoid maternal and fetal complications.

Coagulation abnormalities and severe intraventricular hemorrhage in extremely low birth weight infants.

BACKGROUND: The association between intraventricular hemorrhage (IVH) and coagulation in infants has been a subject of controversy. Only few publications assessing risk factors for development of IVH reported results of coagulation studies. OBJECTIVES: To evaluate the levels of coagulation and fibrinolysis systems in ELBW infants and determine their influence on IVH. PATIENTS AND METHODS: Following IRB approval coagulation status of 38 ELBW infants was evaluated on first and second day of life. Severity of IVH assessed by cerebral ultrasonography was graded according to Papile classification. Newborns were assigned to either Group A--Grade III or IV, or Group B--Grade I-II, or no IVH. RESULTS: Neonates with Grade III/IV IVH had significantly lower plasma Factor VII (FVII) level on first day of life and FVII differed significantly between Groups A and B with sensitivity of 100%, specificity 41% for a cut-off value of< 7%. In Group A there was no improvement of prothrombin and activated partial thromboplastin times on Day 2. A significant decline of platelet count was also observed. CONCLUSIONS: High-grade IVH coincides with severe derangement of coagulation in ELBW infants with FVII level being the most sensitive, it is not clear what the reason for such low FVII concentration is. Further studies are indicated.

Postpartum convulsions and acute hemodynamic instability in the parturient with recent amphetamine intake.

Amphetamine is one of the most common substances abused in pregnancy and one of the most potent sympathomimetic amines with respect to stimulatory effects on the central nervous system. I present a case of an amphetamine abusing parturient who developed postpartum convulsions and acute hemodynamic instability initially mistaken for eclampsia.

Running an obstetric anesthesia training program: words of wisdom.

Obstetric anesthesia, by definition, is a subspecialty of anesthesia dedicated (devoted) to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and labor and delivery nurse to ensure the high-quality care for the parturient and her baby. Communication skills and exchange of information in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The anesthesiologist's unique skills in acute resuscitation combined with experience in critical care make members of this subspecialty of anesthesiology particularly valuable in peripartum care of the high-risk patients, extending the anesthesiologist's role well beyond the routine provision of intrapartum anesthesia or analgesia.