Intrapartum sonography of fetal head in second stage of labor with neuraxial analgesia: a literature review and possible medicolegal aftermath.

OBJECTIVE: Intrapartum ultrasound (IU) is a valid support to obstetric management of fetal head progression in the second stage of labor in nulliparous with neuraxial labor analgesia (NLA). Nulliparous with NLA may have a prolonged the second stage of labor. The aim of this literature review was to evaluate the mode of delivery, as well as maternal and fetal morbidities associated with missed progression of fetal head detected with IU in the second stage of labor in nulliparous women with NLA. MATERIALS AND METHODS: The literature review was performed using PubMed, Cochrane, Medline, EMBASE, Scopus, Google Scholar and book chapters searches to identify relevant articles from 2001 to 2019, evaluating the mode of delivery and morbidities of the second stage of labor. Search terms used were "Intrapartum ultrasound", "dystocia", "prolonged labor", "neuraxial analgesia", "persistent occiput posterior position", "asynclitism", "second stage of labor", "medico-legal aftermath". Prolonged second stage was defined as three hours and more. Retrospective case series of women with prolonged second stage of labor with NLA were identified. The primary outcome was the incidence of operative vaginal delivery (OVD) and cesarean delivery (CS). RESULTS: The use of NLA may determine a prolonged second stage of labor (PSSL). IU when compared to the traditional vaginal digital examination (VDE) demonstrated the highest degree of diagnostic accuracy. CONCLUSIONS: The use of IU during NLA can aid in the diagnosis of fetal head progression, station or malposition and malrotation, alerts obstetrician on the possibility of dystocic labor, indicating to stop the drug administration in NLA and shift to OVD or CS. Extending the second stage of labor beyond current American College of Obstetricians and Gynecologists (ACOG) recommendations is beneficial. The ISUOG guidelines recommended the clinical application of IU to diagnose the persistent occiput posterior position (POPP) and asynclitism (A) in dystocic labor and produce photographic evidence of the case. Maternal and neonatal complications, medicolegal consequences and litigation can decrease if the IU device is used as good practice.

Management of pregnancy-related emergencies: what do Polish anesthesiologists know?

BACKGROUND: Emergencies can occur at any time during pregnancy. In addition to obstetricians and midwives, anesthesiologists should also be familiar with pregnancy-related emergencies. The aim of this study was to assess the basic and advanced knowledge regarding the management of pregnancy-related emergencies of anesthesiologists. METHODS: An anonymous questionnaire was distributed to anesthesiologists at two conferences (S1, n = 87; S2, n = 35), and to other groups comprising doctors during specialization (DS, n = 28) and postgraduate doctors (PD, n = 130). Ultimately, 280 doctors were included in the survey. The first part of the questionnaire collected demographics, and a second one evaluated both their basic and advanced knowledge by taxonomy. RESULTS: Basic knowledge regarding the management of pregnancy-related emergencies of the tested group was poorer compared with advanced knowledge. The DS group had better basic management skills than anesthesiology specialists and the PD group. Significantly worse results of the tested group were obtained on the questions about maneuvers for choking pregnant women and time to cesarean section during cardiopulmonary resuscitation. The specialists and the DS group had results on advanced level questions better than the PD group. CONCLUSIONS: Older specialists in anesthesiology did not know how to properly manage pregnancy-related emergencies at the basic level; however, anesthesiologists were familiar with advanced management. No relationship between recalling and using such knowledge in difficult situations was observed. The teaching process of acute obstetric emergencies must be improved through implementation of compulsory nationwide courses and verification of knowledge every few years.

Peripartum implications of caffeine intake in pregnancy: is there cause for concern?

Maternal use of "social drugs" such as caffeine, ethanol and tobacco in pregnancy is on increase- -worldwide. Caffeine is probably the most frequently ingested pharmacologically active substance in the world. It is found in common beverages (coffee, tea, soft drinks), in products containing cocoa or chocolate, and in medications. Because of its wide consumption at different levels by most segments of the population, the public and the scientific community have expressed interest in the potential for caffeine to produce adverse effects on human health. Reproductive-aged and pregnant women are 'at risk' subgroups of the population who may require specific advice on moderating their daily caffeine intake. This article highlights the implications of caffeine intake in pregnancy, reviews the latest evidence-based information available on this subject, and offers recommendations (practical advice) for anesthesiologists and obstetrician-gynecologists proving peripartum care to these potentially complicated pregnancies.

Cyclic supraventricular tachycardia in the parturient: to treat or not to treat?

Cardiac arrhythmias are more common in pregnant women than in non-pregnant women. In the asymptomatic pregnant patient with a stable fetus, watchful waiting might be the best strategy. Herein, we describe the first reported case of a pregnant patient who developed cyclic supraventricular tachycardia during labor. No treatment was prescribed, with a good maternal and fetal outcome.

Anesthetic considerations for cesarean section in the parturient with familial cardiomyopathy.

Dilated cardiomyopathy (DCM) is a heart muscle disease characterized by ventricular dilatation and impaired systolic cardiac function. DCM is defined by the presence of: a) fractional myocardial shortening less then 25% (> 2 SD) and/or ejection fraction less than 45% (> 2 SD); and b) left ventricular end diastolic diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Familial dilated cardiomyopathy (FDC) accounts for 20-48% of all DCM cases, and is defined by the presence of two or more affected relatives with DCM meeting the above diagnostic criteria or a relative of a DCM patient with unexplained sudden death before the age of 35 years. We herein present the first reported case in the literature of a parturient with FDC undergoing urgent Cesarean section (secondary to worsening cardiac function) and briefly highlight anesthetic considerations for parturients with this heart condition.

Peripartum care of the parturient with acute fatty liver of pregnancy.

Acute fatty liver of pregnancy (AFLP) is a rare, but serious life-threatening clinical entity, the etiology of which is unknown. The clinical presentation of this disease is varied and timely diagnosis often difficult. Since multiorgan involvement (and dysfunction) complicates diagnosis, no uniform peripartum obstetric and anesthetic recommendations can be made. Still, once the diagnosis of AFLP is established, prompt delivery is indicated. We herein present a case of acute fatty liver and hepatic failure that developed during the third trimester of pregnancy. Favorable maternal and fetal outcome was accomplished.

The use of potent inhalational agents for the ex- utero intrapartum treatment (exit) procedures: what concentrations?

The anesthetic management of a parturient undergoing ex-utero intrapartum treatment (EXIT) procedures for airway control of a newborn with a potentially life-threatening difficult airway is complex and often challenging. We herein report on the successful anesthetic management of the EXIT procedure in a 30-year-old primigravida carrying a fetus with large cervical lymphangioma. General anesthesia was maintained with sevoflurane 2%, combined with continuous infusion of nitroglycerine (TNG). Although the use of high concentrations of potent inhalational agents (to keep the uterus fully relaxed) is currently recommended we believe that the use of low concentrations of potent inhalational anesthetics with continuous infusion of TNG may be a safer anesthetic strategy for these operations.