Fetal heart rate changes associated with general anesthesia

The Importance of Fetoplacental Doppler Velocimetry for Fetal Surveillance During General Anesthesia for Non-obstetric Surgery

Fetal heart rate monitoring during general anesthesia for non-obstetric surgery at viable gestational ages is recommended to evaluate fetal well-being during the intervention. Alteration induced by anesthetic drugs could mimic fetal acute hypoxia, leading to pointless Cesarean sections. We report a case of a pregnant woman in the third trimester undergoing neurosurgical surgery. The continuous heart rate registration showed a non-reassuring pattern, potentially inducing the multidisciplinary team to expedite the delivery. The seriate fetoplacental Doppler evaluations were reassuring about normal fetal conditions, suggesting that ultrasound surveillance could be more reliable than intraoperative heart rate monitoring.

Ten Rules for the Management of Moderate and Severe Traumatic Brain Injury During Pregnancy: An Expert Viewpoint

Moderate and severe traumatic brain injury (TBI) are major causes of disability and death. In addition, when TBI occurs during pregnancy, it can lead to miscarriage, premature birth, and maternal/fetal death, engendering clinical and ethical issues. Several recommendations have been proposed for the management of TBI patients; however, none of these have been specifically applied to pregnant women, which often have been excluded from major trials. Therefore, at present, evidence on TBI management in pregnant women is limited and mostly based on clinical experience. The aim of this manuscript is to provide the clinicians with practical suggestions, based on 10 rules, for the management of moderate to severe TBI during pregnancy. In particular, we firstly describe the pathophysiological changes occurring during pregnancy; then we explore the main strategies for the diagnosis of TBI taking in consideration the risks related to mother and fetus, and finally we discuss the most appropriate approaches for the management in this particular condition. Based on the available evidence, we suggest a stepwise approach consisting of different tiers of treatment and we describe the specific risks according to the severity of the neurological and systemic conditions of both fetus and mother in relation to each trimester of pregnancy. The innovative feature of this approach is the fact that it focuses on the vulnerability and specificity of this population, without forgetting the current knowledge on adult non-pregnant patients, which has to be applied to improve the quality of the care process.

Neural correlates of inhibitory control are associated with stimulant-like effects of alcohol

Poor inhibitory control and heightened feelings of stimulation after alcohol are two well-established risk factors for alcohol use disorder (AUD). Although these risk factors have traditionally been viewed as orthogonal, recent evidence suggests that the two are related and may share common neurobiological mechanisms. Here we examined the degree to which neural activity during inhibition was associated with subjective reports of stimulation following alcohol. To assess neural changes during inhibition, moderate alcohol drinkers performed a stop signal task during fMRI without drug. To assess subjective responses to alcohol they ingested alcohol (0.8 g/kg) or placebo beverages under double-blind conditions and provided subjective reports of stimulation and sedation. Feelings of stimulation following alcohol were inversely associated with activity in the supplementary motor area, insula, and middle frontal gyrus during inhibition (successful stop trials compared to go trials). Feelings of sedation did not correlate with brain activation. These results extend previous findings suggesting that poor inhibitory control is associated with more positive subjective responses to alcohol. These interrelated risk factors may contribute to susceptibility to future excessive alcohol use, and ultimately lead to neurobiological targets to prevent or treat AUD.

Intraoperative fetal heart monitoring for non-obstetric surgery: A systematic review

Limited data are available on fetal monitoring during non-obstetric surgery in pregnancy. We performed a systematic review to evaluate the incidence of emergent cesarean delivery performed for non-reassuring fetal heart rate patterns during non-obstetric surgery. Electronic databases were searched from their inception until October 2018 without limit for language. We included studies evaluating at least five cases of intraoperative fetal heart rate monitoring -either with ultrasound or cardiotocography- during non-obstetric surgery in pregnant women at ≥22 weeks of gestation. The primary outcome was the incidence of intraoperative cesarean delivery performed for non-reassuring fetal heart rate monitoring. Non-reassuring fetal heart rate monitoring was defined by attendant personnel, meeting NICHD criteria for category II or III patterns. Data extracted regarded type of study, demographic characteristics, maternal and perinatal outcomes. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. Of 120 studies identified, 4 with 41 cases of intraoperative monitoring met criteria for inclusion and were analyzed. Most (66%) surgeries were indicated for neurological or abdominal maternal issues and were performed under general anesthesia (88%) at a mean gestational age of 28 weeks. Minimal or absent fetal heart variability was noted in most cases and a 10-25 beats per minutes decrease in fetal heart rate baseline was observed in cases with general anesthesia. No intraoperative cesarean deliveries were needed. The incidence of non-reassuring fetal heart rate monitoring was 4.9% (2/41) and were limited to fetal tachycardia during maternal fever. Two (4.9%) cases of non-reassuring fetal heart rate monitoring were noted within the immediate 48 h after surgery, necessitating cesarean delivery. A single case of intrauterine fetal demise occurred four days postoperatively in a woman who had neurosurgery and remained comatose. In conclusion, limited data exist regarding the clinical application of fetal heart rate monitoring at viable gestational ages during non-obstetric surgical procedures. Fetal heart rate monitoring during non-obstetric surgery at ≥22 weeks was not associated with need for intraoperative cesarean delivery, but two (4.9%) cesarean deliveries were performed for non-reassuring fetal heart rate monitoring within 48 h after surgery.

Unnecessary emergency caesarean section due to silent CTG during anaesthesia?

We present a case of a probably unnecessary Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia. A 27-yr-old patient in her 30th week of an uneventful, normal first pregnancy presented with a deep venous thrombosis in the pelvic region. She was to undergo an emergency thrombectomy under general anaesthesia. During the operation, the CTG showed a lack of beat-to-beat heart rate variation (silent pattern CTG) with normal fetal heart rate. This silent CTG pattern was probably a result of the effect of general anaesthesia on the fetus. The CTG pattern was interpreted as indicating fetal distress, and an emergency Caesarean section was performed after the thrombectomy. The infant was apnoeic and had to be resuscitated and admitted to the neonatal intensive care unit. The pH at delivery was 7.23 and the baby was extubated 2 days later. Mother and child recovered without short-term sequelae. In the absence of alternative explanations, reduced fetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.