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.

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.

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.

Autonomic dysreflexia in a parturient with spinal cord injury.

Autonomic dysreflexia (ADR) is a syndrome of imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) at or above the level of splanchnic sympathetic outflow (T6). We present the case of a 29 year-old, gravida 3, para 1 Caucasian female at 28 weeks gestation, with a history of T3 SCI secondary to a gunshot wound 9 years prior, who developed ADR during preterm labor and received epidural anesthesia during 6 days of labor followed by spinal anesthesia for cesarean section. Spinal anesthesia may be superior to epidural anesthesia for providing hemodynamic protection against ADR during cesarean section.

The effect of hydroxyethylstarch infusion on bupivacaine pharmacokinetics in rats.

BACKGROUND: Bupivacaine is the agent most often used for labor analgesia. However, the risk of accidental intravascular injection of this drug and consequent acute systemic toxicity is ever-present. Although hydroxyethylstarch (HES) is preferred over crystalloid for prevention of hypotension during regional anesthesia, the pharmacokinetics of bupivacaine during fluid preloading has not been studied. METHODS: Twenty-four awake Sprague-Dawley rats were randomly allocated to receive the continuous intravenous infusion of HES 70K, 200K or 400K, or normal saline (NS). After 1 hour of prehydration all animals received bupivacaine, 1mg kg(-1), bolus, followed by a continuous infusion, 0.4mg kg(-1) min(-1) for 15 minutes. After the completion of bupivacaine infusion serial arterial blood samples to determine the plasma bupivacaine concentration were obtained. The plasma concentration-time profile of bupivacaine was fitted to a two-compartment open model, and the estimated intercepts and slopes were used for calculation of standard pharmacokinetic parameters. RESULTS: The mean peak bupivacaine concentration during HES 400K infusion was significantly lower than during NS infusion (1488 +/- 302 ng ml(-1) vs 2388 +/- 582 ng ml(-1)). Mean volume of distribution in each of the three HES groups was greater than in NS group. Mean area under curves (AUC) during HES 200K and HES 400K infusions were significantly lower than during NS infusion (32534 +/- 4180 and 29619 +/- 4431 min ng ml(-1), respectively, vs 39802 +/- 6268 min ng ml(-1)). Mean total clearance of bupivacaine during HES 200K and HES 400K infusions was significantly higher than during NS infusion (115 +/- 14 and 132 +/- 15 ml min(-1) kg(-1), respectively, vs 92 +/- 14 ml min(-1) kg(-1)). CONCLUSION: Our results suggest that the increased volume of distribution during HES infusion could be counterbalanced by the increased total clearance, resulting in unchanged half-life or elimination rate constant of bupivacaine.

Trauma during pregnancy: a situation pregnant with danger.

Trauma in pregnancy is currently a leading cause of non-pregnancy-related maternal death, and maternal death remains the most common cause of fetal demise. The most common etiologies of trauma in pregnancy include transportation accidents, falls, violent assaults, and burn injuries. Head and neck injuries and hemorrhagic shock account for most maternal deaths secondary to trauma. Women of childbearing age are among the population at greatest risk for trauma. The pregnant trauma victim presents a unique spectrum of challenges to the health care team. Expeditious maternal resuscitation is the most effective method of fetal resuscitation. The management of pregnant trauma victims requires the anesthesiologist, the obstetrician and the trauma surgeon to consider and understand the unique changes in anatomy and physiology that take place during pregnancy. This article reviews the current considerations for the optimal perioperative management of pregnant trauma victims.

Herbal ecstasy: cardiovascular complications of khat chewing in pregnancy.

Chewing fresh leaves of the Khat plant (Catha edulis Celestrasae) is a widespread habit (also practiced by women, even during pregnancy) with a deep-rooted tradition in East Africa and the Arabian Peninsula. With the influx of immigrants from East Africa and the Arabian Peninsula khat chewing has been imported into other countries including Europe the United States. The major pharmacologically active constituent of the fresh khat leaves is cathinone. Khat (also known as herbal ecstasy) is chewed for its central nervous system stimulant properties, which resemble amphetamine. Cardiovascular complications from cathinone use may therefore be similar to those of amphetamine. I herein present the first reported case of a pregnant patient who developed chest pain, tachycardia, and hypertension following khat-chewing session.

[Delleman syndrome: anesthetic considerations]. / Syndrome de Delleman: prise en charge anesthésique.

We herein report a case of a 5-year-old patient with Delleman Syndrome, a rare congenital disorder affecting the eyes, skin, and central nervous system, who underwent general anesthesia for conjuctivoplasty. This is only the second report of the anesthetic management of a patient with this condition. We attempt to summarize some of the anesthetic implications of this syndrome.

Cocaine abuse in pregnancy--anesthetic implications.

Substance abuse, including that of cocaine, has crossed social, economic and geographic borders and remains one of the major problems facing society today. The prevalence of cocaine abuse in young adults (including women) has increased markedly over the past two decades. Nearly 90% of cocaine-abusing women are of childbearing age. Consequently it is not surprising to find pregnant women who abuse this drug, and numerous case reports of cocaine abuse in pregnancy have been published. The diverse clinical manifestations of cocaine abuse combined with physiologic changes of pregnancy, and pathophysiology of coexisting pregnancy-related disease might lead to life-threatening complications and significantly impact the practice of obstetric anesthesia. A complete understanding of the physiology of pregnancy, pathophysiology of pregnancy-specific disorders and anesthetic implications of cocaine abuse in pregnancy is essential to tailor a safe anesthetic plan for this high-risk group of patients.

Anesthetic management of a parturient with congenital cavernous transformation of the portal vein and chronic thrombocytopenia.

Cavernous transformation of the portal vein is a rare disorder resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation. We report a case of a pregnant patient with congenital cavernous transformation of the portal vein associated with persistent consumptive coagulopathy and chronic thrombocytopenia. Single dose spinal anesthesia was safely conducted for an uneventful cesarean delivery.

Cesarean section and Ehlers-Danlos syndrome: choice of anesthesia.

Ehlers-Danlos syndrome is a rare genetically transmitted connective tissue disorder, non-specific to pregnancy. Because of multi-organ involvement and varied presentations of this disease, no uniform anesthetic recommendations can be made. We report a case of a parturient with Ehlers-Danlos syndrome who presented in active labor with spontaneous rupture of membranes and footling breech presentation. She received single dose spinal anesthesia for an uneventful emergency cesarean section.

Cesarean section in a parturient with HIV and recent cocaine and alcohol intake: anesthetic implications.

We present a case of a human immunodeficiency virus (HIV) positive, poly-substance abusing parturient who presented for an emergency cesarean section following recent cocaine and alcohol intake. Spinal anesthesia was selected for the abdominal delivery. 4 min after delivery of the fetus, the patient developed hypotension, intermittent runs of ventricular tachycardia, premature ventricular complexes and ST-segment elevation. Induction of general anesthesia, endotracheal intubation, intravenous lidocaine and phenylephrine were required to restore stability. At the end of surgery the patient was stable and was extubated. The ST-segment elevation returned to normal 45 min postoperatively. Her postoperative course was uneventful.

Marijuana in pregnancy.

INTRODUCTION: The prevalence of recreational drug abuse among young adults, including women, has increased markedly over the last 2 decades. Nearly 90 % of these women are of childbearing age. Marijuana remains the drug most commonly used for recreational purposes in pregnancy. However, there appears to be an absence of uniform guidelines for obstetric and anaesthetic management of pregnant patients with a history of marijuana abuse. MATERIALS AND METHODS: A Medline search for articles highlighting drug abuse in pregnancy, with particular emphasis on marijuana abuse in pregnancy, the drug 's impact on the fetus and implications for administration of obstetrical anaesthesia was performed. RESULTS: Because the pharmacological actions of marijuana are complex and include a unique blend of effects, the clinical picture could be very unpredictable, the diagnosis often difficult, and management at times controversial. CONCLUSION: In the absence of uniform anaesthetic guidelines for pregnant patients with a history of drug abuse, including abuse of marijuana, the decision regarding administration of peripartum analgesia or anaesthesia should be individualised and conducted on a case-by-case basis.

Ambulation with combined spinal-epidural labor analgesia: the technique.

The combined spinal-epidural labor analgesia technique (CSEA) has attained wide spread popularity in obstetric anesthesia worldwide. The onset of analgesia is rapid and reliable, and maternal satisfaction is high. While there still remains some concern about dural puncture, the CSEA technique offers many advantages to the parturient. For ambulatory labor analgesia the CSEA technique offers the possibility of combining rapid onset of subarachnoid analgesia with the flexibility of continuous epidural analgesia. This approach with the application of low-dose local anesthetic and/or opioid can provide a very selective sensory block with minimal motor blockade, allowing parturients to ambulate. This article will attempt to assess the validity of some strongly held opinions of whether CSEA offers any advantages for ambulatory labor analgesia as well as highlight some selected technical aspects and controversies of the CSEA specifically applicable to ambulatory labor analgesia.

Amphetamine abuse in pregnancy: anesthetic implications.

The prevalence of recreational substance abuse amongst young adults (including women in child-bearing age) has markedly increased over the past two decades and it remains one of the major problems facing our society today--worldwide. 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. The following case report illustrates the problems that may arise during anesthesia in the parturient with recent amphetamine intake.