Changes in Compression Pressure of Elastic Stockings for the Lower Limbs During Cesarean Section: A Prospective Observational Study.

Background Postpartum peripheral nerve injuries can impact recovery. Elastic stockings are recommended for thromboembolism prevention, although concerns about entrapment neuropathy exist. In this prospective observational study, we investigated the differential compressions caused by wearing elastic stockings before and after anesthesia, as well as changes in the diameters of the lower leg and ankle in parturient women undergoing spinal anesthesia for elective cesarean section (CS). Methods Eighteen pregnant women, classified by the American Society of Anesthesiologists as having physical status 2, underwent lower leg measurements taken before a CS. Elastic stockings were applied, and compression pressure was measured at pre-anesthesia, post-surgery, and six hours post-return to a hospital room. Fluid, blood loss, urine output, and neuropathy presence were recorded. For all parameters, changes at the three time points were compared for the primary analysis. For secondary analysis, participants were categorized as having intraoperative blood loss greater than (group P) or less than 1,000 g (group N), and factors were compared with pre-anesthesia and six hours post-return to a room. Data were analyzed and presented using a one-way analysis of variance with Bonferroni correction for multiple comparisons or unpaired two-tailed t-tests for pairwise comparison. Results None of the women had postoperative entrapment neuropathy. Six patients had >1,000 g of blood loss. Compression significantly increased from pre-anesthesia (left 13.6 ± 2.4, 95% CI: 12.18 to 14.52; right 13.4 ± 2.4, 95% CI: 12.41 to 14.69) to post-surgery (left, 17.4 ± 2.6, 95% CI: 15.68 to 18.12; right, 16.9 ± 2.6, 95% CI: 16.20 to 18.70) (p < 0.01). Compression pressure at post-surgery differed significantly between group P (left, 15.3 ± 1.3; right, 14.7 ± 1.8; 95% CI: -4.98 to -0.32) and group N (left, 18.1 ± 2.9; right, 17.8 ± 2.4; 95% CI: -5.38 to -0.26) (p < 0.05). The results are expressed as mean ± standard deviation, with P-values <0.05 indicating statistical significance. Conclusions In this study, no neuropathy occurred; however, over-compression risk with elastic stockings, especially when exceeding recommended pressure levels, was highlighted. Balancing thromboembolism prevention and over-compression risks is crucial for patients undergoing CSs with spinal anesthesia.

Venoarterial extracorporeal membrane oxygenation as an early treatment for amniotic fluid embolism with cardiac arrest: A case report.

Amniotic fluid embolism (AFE) is a rare but fatal obstetric complication, characterized by sudden cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation. Maternal mortality associated with AFE is high, making early recognition and prompt treatment important. In AFE with cardiac arrest, survival following acute cardiopulmonary dysfunction is crucial. In recent years, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has attracted attention as an aggressive treatment for AFE with cardiac arrest. A 40-year-old woman experienced sudden cardiac arrest due to AFE during cesarean section. Cardiopulmonary resuscitation and VA-ECMO (also called percutaneous cardiopulmonary support) were initiated early. Finally, she recovered without any complications. VA-ECMO can provide temporary respiratory and hemodynamic support until cardiopulmonary function improves after a few days in intensive care. VA-ECMO should be considered as an early treatment for AFE with cardiac arrest.

First Report of Spinal Anesthesia for Cesarean Delivery in a Parturient With Jeune Syndrome: A Case Report.

Jeune syndrome, also known as asphyxiating thoracic dystrophy, is a rare form of autosomal recessive skeletal dysplasia. Respiratory distress due to thoracic and lung dysplasia is the primary complication associated with this disorder in neonates. Women with Jeune syndrome seldom conceive and give birth, as only a few survive until adulthood. Herein, we report the world's first case of a cesarean delivery under spinal anesthesia in a pregnant woman with Jeune syndrome with a history of chest wall reconstruction and spinal fusion surgeries.

The concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in Japanese parturients.

Background: The accurate identification of an intervertebral lumbar level is essential to avoid neuraxial anesthesia and analgesia-related spinal cord injury. It has been shown that estimation of L3/4 intervertebral lumbar level based on the intercristal line determined by palpation (palpated L3/4) is often inaccurate. However; studies evaluating intervertebral lumbar level concordance based on palpation vs. ultrasonography were conducted in Western populations (i.e. in North America and/or Europe). Radiological studies suggest that the intercristal line intersects at a lower level of the spine in Japanese women than in Western women. Therefore, we hypothesized that differences exist in intervertebral levels based on the palpated intercristal line between Asian and Western women. Herein we present the results of the first study in Japan comparing the concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in pregnant Japanese women.Study objective: The objective of this study was to evaluate the accuracy of palpated L3/4 in Japanese parturients assessed by ultrasonography (US).Design: A prospective, observer-blinded study.Setting: Labor and delivery room at the Kitasato University Hospital, Sagamihara, Kanagawa, Japan.Patients: Sixty-three term parturients underwent induction of labor and requested neuraxial labor analgesia.Interventions: With the patients in the sitting position, an attending anesthesiologist marked the intervertebral space estimated as L3/4 based on intercristal line with palpation. Another attending anesthesiologist who was blinded to the marker performed US to identify L3/4.Results: The overall agreement rate of palpated and US L3/4 was 69.8% (44/63). Palpated L3/4 was US L2/3 in 8/63 (12.7%) and US L4/5 in 11/63 (17.5%). In comparison with women with palpated L3/4 agreed with US L3/4, women with palpated L3/4 agreed with US L2/3 were more frequently multiparous (52 vs. 100%, p < .05) and women with palpated L3/4 identified as L4/5 were younger (36 ± 4 years vs. 33 ± 4 yrs, p < .05) and gained less weight during pregnancy (10 ± 4 kg vs. 7 ± 4 kg, p < .05). The patients whose palpated L3/4 were found to be US L2/3 were all multiparous.Conclusion: The accuracy rate of palpated L3/4 intervertebral lumbar level in pregnant women included in our study was 69.8%. Pregnancy-related weight gain, parity, and maternal age can all influence an estimation of L3/4 intervertebral lumbar level by palpation. In addition, we believe that this is the first study to analyze the correlation between maternal parity and interspace estimation by palpation in pregnant women.

A systematic review of massive transfusion protocol in obstetrics.

Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.

A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150µg.

INTRODUCTION: Delayed respiratory depression is a feared complication of intrathecal morphine in patients undergoing cesarean delivery. The incidence, timing and risk factors for hypoxia in this population are not known. METHODS: Patients undergoing cesarean delivery under spinal anesthesia at a tertiary care center from October 2012 to March 2016 were included in the study. The Berlin sleep apnea Questionnaire was completed before surgery. Oxygen saturation was recorded every second for 24hours after the initiation of spinal anesthesia. Desaturation events were defined as a median saturation of <90% (mild) or <85% (severe) across a 30-s period. Multivariable logistic regression was used to determine predictors of a desaturation event. RESULTS: A total of 721 patients were included in the analysis. Within this cohort, 169 women (23%) experienced at least one mild desaturation event, 91 (13%) experienced two or more mild desaturations, and 26 (4%) suffered a severe desaturation event. After the administration of intrathecal morphine, the median times to first mild or first severe desaturation were 7.4 (IQR 4.1-13.5)h and 12.0 (IQR 5.4-19.6)h, respectively. Patients who screened positive for sleep apnea had increased odds of having a mild desaturation event (OR 2.31, 95% CI 1.40 to 3.79, P=0.001), as did patients who were obese (OR 1.80, 95% CI 1.05 to 3.09, P=0.033). CONCLUSIONS: Mild hypoxemia occurred frequently in women receiving intrathecal morphine 150µg for post-cesarean analgesia. Desaturations were observed most frequently 4-8hours after administration of intrathecal morphine. Obesity and a positive Berlin Questionnaire were risk factors for hypoxemic events.

Continuous spinal labor analgesia for two deliveries in a parturient with severe subvalvular aortic stenosis.

Various degrees of left ventricular outflow tract (LVOT) obstruction have been seen in patients with subvalvular aortic stenosis (SAS). Regional analgesia during labor for parturients with SAS is relatively contraindicated because it has a potential risk for hemodynamic instability due to sympathetic blockade as a result of vasodilation by local anesthetics. We thought continuous spinal analgesia (CSA) using an opioid and minimal doses of local anesthetic could provide more stable hemodynamic status. We demonstrate the management of a 28-year-old pregnant patient with SAS who received CSA for her two deliveries. For her first delivery (peak pressure gradient (∆P) between LV and aorta was approximately 55 mmHg), intrathecal fentanyl was used as a basal infusion, but we needed a small amount of bupivacaine to provide supplemental intrathecal analgesia as labor progressed. Although there were mild fluctuations in hemodynamics, she was asymptomatic. For her second delivery (∆P between LV and aorta was approximately 90 mmHg), minimal doses of continuous bupivacaine were used as a basal infusion. For her additional analgesic requests, bolus co-administration of fentanyl was effective. There were no fluctuations in her hemodynamics. Although her SAS in her second pregnancy was more severe than in the first, her hemodynamics exhibited less fluctuation during the second delivery with this method. In conclusion, CSA using fentanyl combined with minimal doses of bupivacaine provided satisfactory analgesia and stable hemodynamics in parturient with severe SAS.

[Retrospective Review of Labor Analgesia for Parturients with Moyamoya Disease.]

BACKGROUND: Moyamoya disease (MD) is an occlu- sive cerebrovascular disease with risks of cerebral ischemia or hemorrhage. Although cesarean section (CS) is the prevailing delivery mode for these parturi- ents to stabilize cerebral circulation, the preferable mode remains controversial. We have conducted vagi- nal delivery with neuraxial analgesia (NA) because safety with the procedure is equivalent to that with CS. The aim of this study is to investigate peripartum outcomes, particularly delivery mode and occurrence of cerebrovascular events, in women with MD. METHODS: We retrospectively analyzed the data of parturients with MD for the previous 8 years. RESULTS: Among 13 pregnancies during this period, eight were vaginal deliveries with NA, while CS was executed in five cases according to obstetric indica- tions. Instrumental deliveries were conducted in five among eight vaginal delivery cases. No cerebrovascular event occurred during delivery. A transient ischemic attack in one case of vaginal delivery and cerebral ischemia in CS were noted in the postpartum period. CONCLUSIONS: We successfully managed vaginal deliveries in the eight patients with MD using NA. NA provides pain relief and assures maternal hemody- namic and respiratory stability during delivery. Instru- mental delivery plays a key role in reducing the dura- tion of the second stage of labor.

[A Case of Preeclampsia Diagnosed with CADASIL after Emergency Cesarean Section].

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a rare inherited disease which begins with migraine and later develops repeated cerebral subcortical infarction and dementia. We present an anesthetic experience of an undiagnosed CADASIL woman complicated with preeclampsia. She developed headache, slurred speech, cognitive dysfunction and restlessness at 35 weeks' gestation and was diagnosed as hypertensive encepha- lopathy. Urgent cesarean section was decided. After ruling out meningitis by physical examination, and intracranial hemorrhage, cerebral swelling and hydro- cephalus by brain CT, spinal anesthesia was chosen. Mild sedation was necessary because the patient became restless and uncooperative during surgery. The anesthetic course was uneventful otherwise. She was either restless or lethargy and had hallucinatory episodes on 1st post-operative day. The neurologist suspected CADASIL because of multiple lacunar infarct lesions on MRI and her family history. The diagnosis was confirmed by skin biopsy and a genetic test.

Vaginal Delivery under Epidural Analgesia in Pregnant Women with a Diagnosis of Moyamoya Disease.

BACKGROUND: Moyamoya disease more commonly occurs in young people and women, so patients with this disease may experience pregnancy and delivery. Cesarean section (CS) is often chosen as the mode of delivery for these patients in Japan. No appropriate mode of delivery has yet been established for pregnant women with moyamoya disease in terms of stroke prevention. We have used vaginal delivery under epidural analgesia (EA) in such patients unless CS has been indicated for the maternal or fetal reasons. This study retrospectively analyzed our patients with moyamoya disease who gave birth to confirm the safety of vaginal delivery under EA. METHODS: Twelve consecutive patients diagnosed with moyamoya disease had 14 deliveries at our hospital between September 2004 and January 2013. The incidences of intrapartum stroke were compared between cases of vaginal delivery under EA and CS cases. RESULTS: Ten vaginal deliveries under EA and 4 elective CSs were performed. No intrapartum stroke was observed during either vaginal delivery under EA or CS. Among the patients who underwent vaginal delivery under EA, 1 parturient who experienced 2 deliveries suffered transient ischemic attack during both postpartum periods. All 14 infants were healthy without sequelae. CONCLUSIONS: Vaginal delivery under EA is an option for patients with moyamoya disease, provided that close cooperation with neurosurgeons, obstetricians, and anesthesiologists is assured.

[The first labor analgesia with drug was performed in late Meiji Period (1868-1912). Hypnosis also attracted attention as a method of labor analgesia in mid-Meiji Period].

Ether or chloroform, was in use for ambulatory surgery after 1861 in Japan. An inhalational anesthetic, especially chloroform, was administered for cesarean section in early Meiji Period (from 1868) up to 1897. According to an article in 1903, chloroform was recommended as a strategy for internal cephalic version. However, it is uncertain whether inhalational anesthetic had been utilized for vaginal deliveries before 1903. There is evidence that hypnosis had attracted attention as a method of labor analgesia around that time.

Transversus abdominis plane block provides postoperative analgesic effects after cesarean section: additional analgesia to epidural morphine alone.

AIM: The aim of our study was: (i) to investigate whether transversus abdominis plane (TAP) block confers additional analgesic effects to epidural morphine alone; and (ii) to determine plasma levels of local anesthetics after TAP block in post-cesarean women. MATERIAL AND METHODS: The subjects were parturients undergoing cesarean section under combined spinal-epidural anesthesia. Morphine (2 mg) was administered to the epidural space close to the end of surgery. Women who desired TAP block were allocated to the TAP group. Women who did not undergo TAP block were allocated to the control group. In the TAP group, 20 mL of either 0.375% ropivacaine or 0.3% levobupivacaine was infused to both sides of the transversus abdominis plane after surgery. All patients were placed on a patient-controlled i.v. analgesia regimen with morphine after surgery. Time to the first morphine request and amount of morphine consumption within 24 h after surgery were compared in patients with and without TAP block. Plasma concentrations of local anesthetics were determined at 15, 30 and 60 min after TAP block. RESULTS: Forty and 54 patients were allocated to the control and TAP group, respectively. The median time to the first morphine request was longer (555 vs 215 min), and the median cumulative morphine consumption within 24 h was lower (5.3 vs 7.7 mg) in the TAP group than in the control group. The maximum median concentrations of ropivacaine and bupivacaine after TAP block were 784 and 553 ng/mL, respectively. CONCLUSION: TAP block had additional analgesic effects to epidural morphine alone.

[The first labor analgesia with drug was already performed in late Meiji-Period (1868-1912): trace of opioid-scopolamine which was used in Akiko Yosano, back to its origins].

There have been some records of labor analgesia with intravenous or rectal anesthetics in early Showa-period (1926-1989). However, the author found that labor analgesia had been already attempted for some women in late Meiji-period (1868-1912). One of agents used was pantopon, a water-soluble opioid without serious respiratory depression as morphine. The drug was developed and produced in Germany. Some doctors applied this agent with scopolamine to labor analgesia in Europe. They also reported that this combination also conferred excellent analgesic effects without any serious complications in the mother and fetus. This combination was originally used for general surgery with inhaled anesthesia at that period. It remains uncertain how Japanese doctors got pantopon scopolamine from Germany.

Laparoscopy versus open distal gastrectomy by expert surgeons for early gastric cancer in Japanese patients: short-term clinical outcomes of a randomized clinical trial.

BACKGROUND: Short-term outcomes of laparoscopy-assisted distal gastrectomy (LADG) and open DG (ODG) have been investigated in previous clinical trials, but operative techniques and concomitant treatments have evolved, and up-to-date evidence produced by expert surgeons is required to provide an accurate image of the relative efficacies of the treatments. The purpose of this study was to compare laparoscopic versus ODG with respect to specific primary and secondary short-term outcomes. METHODS: From October 2005 to February 2008, a total of 64 patients with early gastric cancer were randomly assigned to the LADG or the ODG group. One patient was excluded due to concurrent illness unrelated to the intervention, so the data from 63 patients were analyzed. The primary short-term outcome was the 4-day postoperative use of analgesics. Secondary short-term outcomes were postoperative residual pain, complications, days hospitalized, blood data, days with fever, and days to first flatus. RESULTS: There was a significant difference in favor of LADG for postoperative use of analgesics (P = 0.022). Unexpectedly, there was no significant difference in degree of pain in the immediate postoperative period, putatively due to the optimal use of analgesics. Of the secondary outcomes, residual pain at postoperative day 7 (P = 0.003) and days to first flatus (P = 0.001) were significantly better with LADG. Postoperative complications, number of days hospitalized, and number of days with fever were also better with LADG, but the differences were not significant. Blood data representing inflammation (WBC and CRP) showed marked differences, especially on postoperative day 7 (P = 0.0016 and P = 0.0061, respectively). CONCLUSIONS: LADG performed by expert surgeons results in less postoperative pain accompanied by decreased surgical invasiveness and is associated with fewer postoperative inconveniences. No preliminary suggestions of changes in long-term curability were observed. LADG for early gastric cancer is a feasible and safe procedure with short-term clinical results superior to those of ODG.

[Prompt resuscitation by obstetric anesthesiologists saved a parturient with amniotic fluid embolism: a case report].

Amniotic fluid embolism (AFE) is a disorder with a high mortarity rate, because it often causes sudden respiratory failure, circulatory collapse and disseminated intravascular coagulation (DIC). We present a case of AFE in which an obstetric anesthesiologist promptly initiated resuscitation of a parturient and saved her without any sequelae. Her fetus was diagnosed as intrauterine fetal demise on 25th gestational week and vaginal delivery under epidural analgesia was planned. One hundred and five minutes after induction of labor with prostaglandine E1, sudden tetanic convulsion occurred with a loss of consciousness. An obstetric anesthesiologist immediately started to resuscitate her and her consciousness was restored. However, noncoagulable vaginal bleeding followed. As the hemorrhage persisted, AFE was suspected. Anesthesiologists gave effective massive transfusion therapy, and she recovered from coagulopathy. Total blood loss was 5,524 g. This case was diagnosed as AFE with high serum sialyl-Tn antigen and zinc-coproporphyrin. The obstetric anesthesiologists are one of the best groups of physicans for resuscitation because they have skills in managing obstetric emergencies such as AFE. In this case, the crucial points for successful resuscitation were prompt obstetric anesthesiologist involvement and good communications with obstetricians and midwives.

[Emergency cesarean section].

There are abundant cases of obstetric emergencies demanding prompt intervention. Emergency cesarean sections are classified into stable, urgent and immediate surgeries, although there is significant overlap between three groups. Stable emergency cesarean sections are performed in patients with stable maternal and fetal physiology, but who need surgery before unstability occurs. Urgent cesarean sections refer to situations in which maternal and/or fetal physiology is unstable, whereas the immediate cesarean section is used for life-threatening condition such as sustained fetal bradycardia, maternal cardiopulmonary arrest. In most cases the key to proper management is the prompt communication between obstetricians and anesthesiologists. Anesthesiologists must have a clear understanding of certain obstetric emergencies. In the event of sustained fetal bradycardia caused by placental abruption, cord prolapse, uterine rupture etc, delivery by immediate cesarean section within 25 minutes improve long-term neonatal neurologic outcome. Although cardiopulmonary arrest in pregnancy is very uncommon, peripartum cesarean section should be considered within 5 minutes not only for maternal resuscitation but for neonatal survival. Only a well-coordinated teamwork of all involved specialities will guarantee optimal prognosis of mother and fetus.

[Akiko Yosano, the famous Japanese poet and writer, is the first lady who experienced labor analgesia in Japan?].

There have been some records of labor analgesia with intravenous or rectal anesthetics since 1925. It is widely believed that labor epidural analgesia in Japan started to become popular after the World War II (1939-1945). However, the author found that Akiko Yosano, a well-known Japanese female poet and writer, had labor analgesia for her 5th son as early as 1916. She was given a mixture of an opioid alkaloid and scopolamine and had painless labor and delivery. She took this experience as a pleasant surprise and described "Never once, had I screamed or feel sweaty during my labor". She loved this comfortable and easy labor so much that she had it again for her 6th son in 1917. Her obstetrician was Dr. Yuzo Ohmi, who had studied in Munich University from 1910 to 1913. He brought this miracle painkiller from Germany to Japan and gave it to her for the first time in Japan. Akiko's husband, Tekkan Yosano, met Dr. Ohmi on a ship to Marseilles in 1911. Then, they and Akiko promoted friendship in Munich and Japan. Her labor experience and friendship with Dr. Ohmi are described in her collected essays "Warera-naniwo-motomuruka? (What do we long for?)" and "Ai-Risei-oyobi-yuhki (Love, Reason, and Bravery)". Dr. Ohmi's wife became a pupil of Akiko.

[Preoperative oral hydration for pregnant women].

Preoperative oral hydration is an important component of "enhanced recovery after surgery" strategies. This was originally developed for patients undergoing colon surgery. The Obstetric Anesthesia Practice Guideline issued by American Society of Anesthesiologists states that intake of minimum amount of clear fluid 2 hours prior to surgery may be safe. However, anesthesiologists have to consider physiological changes that parturients undergo during pregnancy, such as increased risk of aspiration and impaired glucose tolerance. We also have to consider the potential effect of glucose loading on neonates. Mothers are more likely to develop ketosis by glucose loading. It also stimulates insulin release in the fetus, which can result in neonatal hypoglycemia. In addition, sodium overloading may deteriorate intra-vascular dehydration and cause lung edema to mothers. On the other hand, oral hydration can alleviate a sense of thirst and increase maternal satisfaction. Our data showed that maternal urinal ketone body at delivery tended to decrease with oral hydration during labor. Moreover, some articles suggest that oral hydration may improve utero-placental perfusion. Therefore, we have to balance risks and benefits of oral hydration in parturients. Further investigations are needed among this specific subgroup of patients in order to establish the safe application of preoperative oral hydration.