Where is obstetric anesthesiology heading in the next decade? An Eastern European perspective.

European countries of "Eastern Block" origin took different healthcare and economic development trajectories after the Berlin Wall fell. Despite decreased maternal and neonatal mortality in the last two decades, healthcare disparities exist between the various countries. Minimum standards for obstetric anesthesia are not available for every maternity patient. Lack of equity in access to healthcare for maternity patients is multifactorial and includes differences in systems of care and health economics, and shortages of medical personnel. The war in Ukraine generates additional challenges for healthcare systems in the region, resulting from a significant increase in the number of refugees, some of whom are pregnant and require maternity services, including obstetric anesthesia and analgesia and maternal critical care. The next decade's challenges comprise the implementation of evidence-based medicine advances in the field of obstetric anesthesia and analgesia, and of maternal critical care at national levels, including access to neuraxial opioids, the broad implementation of enhanced recovery after cesarean section protocols, and more frequent use of labor epidural analgesia. Further, there needs to be improvement in medical education provided in the national language, so that healthcare providers, patients, and their families can build and provide a safe environment for maternity patients. In addition, better provision of services and access to healthcare providers who have been well trained and are dedicated to dealing with obstetric patients. These measures will hopefully enhance the quality of care for maternity patients, focusing on further reduction of maternal and neonatal morbidity and mortality, which is a priority and a highly desirable long-term outcome.

Epidural hematoma following low molecular weight heparin prophylaxis and spinal anesthesia for cesarean delivery.

Epidural hematoma is a very uncommon complication of spinal anesthesia. Its incidence has been reported to be between 1:200 000-250 000 in the obstetric population following neuraxial anesthesia. Cesarean delivery increases the risk of maternal venous thromboembolism significantly and recommendations to decrease its incidence and morbidity have been developed. Strategies to decrease venous thromboembolism include pharmacologic prophylaxis with unfractionated or low molecular weight heparin. We report a case of spinal-epidural hematoma occurring in a parturient who received spinal anesthesia for a planned, repeat cesarean delivery after low molecular weight heparin thromboprophylaxis.

[Prolonged apnea after administration of succinylcholine]. / Produzena apneja posle davanja sukcinilholina.

INTRODUCTION: Succinylcholine is a depolarizing muscle relaxant that has been used for five decades in clinical practice. It is decomposed by enzyme acetylcholinesterase, which is synthesized in posed by enzyme acetylcholinesterase, which is synthesized in the liver. This process lasts a few minutes, and is prolonged in the case of hepatic failure of the liver function, in normal pregnancy and puerperium, in persons with lack of this enzyme or genetic anomaly in its composition. CASE REPORT: The patient, a 31 years old woman, was exposed to diagnostic biopsy of endometrium during treatment of primary infertility. She received classic short-term general anaesthesia and 1 mg/kg (50 mg) of succinylcholine. Breathing was completely restored after 90 minutes. Eventually we found out that in previous three anaesthesias she showed the same dysfunction. It was laboratory proven that she had a decrease in contents of acetylcholinesterase in plasma (20 mukat/l). The possibility of genotype investigation does not exist in our country. The patient was introduced in detail with the nature of her disability. DISCUSSION: The activity of enzyme acetylcholinesterase depends on functional state of the liver, as well as the therapy with some drugs (cyclophosphamide, ecothiopate etc.). For the anaesthetic practice the most important is the presence of abnormal acetylcholinesterase. The incidence of recessive homozygotes is 1:1500-1:3000 cases in the total population and the apnea lasts for 1-2 hours, and sometimes even 4-8 hours. Every apnea over 15 minutes requires maximal attention of the anesthesiologist. First it is necessary to eliminate other possible causes of apnea. The therapy is based on oxygenation with 100% O2 blood transfusion or transfusion of fresh frozen plasma or preparation of human acetylcholinesterase. CONCLUSION: The case of the patient with prolonged postsurgical apnea indicates the decisive significance of comprehensive preanaesthetic anamnesis, both in serious surgical and in clinical interventions. Since there is no adequate substitution for succinylcholine, nowadays it is still in use in clinical practice.