Japanese parturient body mass index and the role in initial nerve block height of women undergoing cesarean delivery with spinal anesthesia.

The present retrospective cohort study was designed to determine body mass index (BMI) at the delivery in women undergoing cesarean section in a Japanese urban area, and whether the nerve block height after spinal anesthesia upon the cesarean delivery relates to the lower maternal BMI, less gestational age, or underweight fetus at birth in the population.A total of 401 pregnant women undergoing cesarean delivery with spinal anesthesia were evaluated retrospectively. We examined background differences, including BMI at the delivery, gestational age, and fetal birth weight between the cases with and without the adequate initial nerve block height less than the sixth thoracic vertebral level (Th6) after the spinal dose administration.The data demonstrated advanced maternal age pregnancy (median 35.5 years) and normal BMI (median 24.7) at the delivery in the population. The patients with the inadequate initial nerve block height immediately after the spinal dose administration documented significantly lower block height compared with those with adequate block height (Th8 [n = 55] vs Th4 [n = 346], P < 0.001). There was a risk of the low initial block height caused by either preoperative BMI <23, gestational age <37 weeks, or fetal birth weight <2500 g in the population.In a Japanese urban area, parturient median BMI undergoing cesarean delivery is in the normal range. Such lower BMI, in addition to less gestational age or underweight fetus, seems one of the factors causing the low initial block height upon spinal anesthesia.

Anesthesia management in 14 cases of cesarean delivery in renal transplant patients-a single-center retrospective observational study.

BACKGROUND: The aim of this study was to investigate anesthesia management for cesarean delivery in renal transplant patients. METHODS: The details of anesthesia management, patient characteristics, surgical information, and renal and maternal outcomes were retrospectively investigated in 14 post-renal transplant patients who underwent cesarean delivery at a single university hospital between January 1, 2014, and August 31, 2018. RESULTS: Five patients were managed under general anesthesia, and nine cases were under regional anesthesia. Nine cases were emergency surgeries. The mean (SD) age was 35.5 (4.4) years, pregnancy body weight was 56.8 (10.0) kg, and gestational age was 33.3 (4.1) weeks. Nine cases were preterm deliveries. Five cases showed hypertension prior to pregnancy, and 13 patients showed hypertension before cesarean delivery. The preoperative creatinine level was 1.49 (0.53) mg/dL. The intraoperative maximum systolic/diastolic blood pressure was 170 (20)/102 (15) mmHg, and the intraoperative minimum systolic/diastolic blood pressure was 97 (13)/49 (12) mmHg. A total of six patients had either mean arterial pressure < 65 mmHg or required vasopressors. Serum creatinine remained unchanged after surgery compared with the preoperative level. CONCLUSION: Cesarean delivery was often performed in post-renal transplant patients for preterm delivery or as emergency surgery, with a higher ratio of regional anesthesia to general anesthesia. Since both hypertension and hypotension are most likely to occur during cesarean delivery, circulation management can be difficult, and anesthesia should be managed so as to maintain sufficient renal perfusion and ensure postoperative renal function.

A case of chronic hepatitis B merged with acute fatty liver of pregnancy with severe coagulopathy.

BACKGROUND: Acute fatty liver of pregnancy (AFLP) is a life-threatening disorder, and its relevance to viral hepatitis B (HB) remains unknown. This case presents an initial experience of treating a patient with HB progressing to AFLP throughout pregnancy; anesthesiologists should also recognize its clinical feature for perioperative management. CASE PRESENTATION: A 28-year-old parturient was diagnosed as chronic HB (CHB) at 21 weeks gestation. Liver and kidney dysfunction appeared rapidly at 34 weeks gestation, suspected as acute exacerbation of either CHB or AFLP. Emergency cesarean section was carried out, after which maternal disseminated intravascular coagulation and hypothermia persisted. With multidisciplinary management, the patient and infant were discharged on postpartum days 64 and 12, respectively. CONCLUSIONS: Active CHB develops into AFLP. Antiviral therapy should be considered for parturient patients with CHB, particularly for those with high viral load. The most favorable outcome is prompt and accurate diagnosis to establish suitable termination method.

A case of left frontal high-grade glioma diagnosed during pregnancy.

BACKGROUND: As pregnancy accelerates glioma growth, therapeutic abortion has been recommended prior to tumor resection. Additionally, it has also been suggested that the extent of glioma resection is closely correlated with patient survival. CASE PRESENTATION: A 162-cm, 61.4-kg, 30-year-old, right-handed primigravida was referred to our institution at 21 weeks gestation to obtain a second opinion. At 18 weeks gestation, the patient developed new-onset generalized convulsive seizures (GCSs), which were poorly controlled by anticonvulsant polytherapy, early in the second trimester. A 6-cm lesion located in her left frontal supplementary motor area (SMA) was suspected as a grade III glioma, classified according to the World Health Organization (WHO) guidelines. Due to the limited evidence on the use of adjuvant therapy during pregnancy, tumors causing neurological symptoms and seizures must be treated, in order to stabilize the maternal condition and enable a safe birth. In the case of pregnant patients, awake craniotomy using intraoperative magnetic resonance imaging (iMRI) is considered advantageous, achieving gross total resection with a reduction of direct cortical stimulation, which may induce seizure, and so reducing fetal exposure to anesthetics. The "Asleep-Awake-Asleep" technique was performed at 27 weeks and 2 days gestation. As use of propofol in pregnant patients is prohibited, general anesthesia was maintained through administration of sevoflurane and remifentanil until the first scan of iMRI, and was subsequently re-induced with dexmedetomidine when tumor removal had been accomplished. A supraglottic airway (SGA) was used until the patient's cranium was opened. There were no complications during either the procedure or the post-operative period. At 35 weeks gestation, the patient delivered a healthy baby of 2317 g. Pathological examination of the patient, revealed an anaplastic astrocytoma, thus radiotherapy and chemotherapy began 2 months post-delivery. There is no evidence of tumor recurrence in the patient and the child did not show any medical or developmental concerns at the point of the 17-month follow-up. CONCLUSIONS: Since evidence on the use of adjuvant therapy during pregnancy is limited, extensive resection with functional monitoring is recommended if a brain tumor is presumed to be malignant. Awake craniotomy is considered advantageous to pregnant patients because subjective movement preserves the patient's motor function and reduces fetal exposure to anesthetics. Therefore, providing multidisciplinary discussion takes place within the decision-making process, as well as careful perioperative preparation, awake craniotomy should be considered, even in the case of pregnant patients.

Outcomes of labor epidural analgesia among women aged over 40: A single-institution retrospective study.

AIM: The purpose of this study was to investigate the effects of labor epidural analgesia (LEA) on maternal and neonatal outcomes among parturients aged 40 years or older. METHODS: We retrospectively reviewed medical records of all laboring, singleton and cephalic deliveries at ≥36 weeks' gestation at the Saitama Medical Center from April 2003 to September 2012. Women aged ≥40 years who received LEA (≥40 with LEA group) were compared with women aged ≥40 years who delivered without LEA (≥40 without LEA group) and women <40 years who received LEA (<40 with LEA group). Extracted outcomes included mode of delivery, oxytocin augmentation, duration of labor, amount of estimated blood loss, umbilical artery pH, Apgar scores, and neonatal intensive care unit admission. RESULTS: This study included 4441 women. There were 74 women in the ≥40 with LEA group, 369 in the ≥40 without LEA group, and 601 in the <40 with LEA group. The maternal outcomes of emergency cesarean delivery rate (9.5%, 12.5%, 9.0%), instrumental delivery rate (33.8%, 10.3%, 28.3%), duration of labor (521 min, 321 min, 565 min), and estimated blood loss (524 g, 351 g, 412 g) were reported for the ≥40 with LEA, ≥40 without LEA, and <40 with LEA groups, respectively. Neonatal outcomes were not different between these groups. LEA use was not associated with emergency cesarean delivery in the multivariable analysis. CONCLUSION: Our study showed that parturients aged ≥40 with LEA can expect similar LEA-associated labor outcomes to younger parturients with LEA.