Preeclampsia and anaesthesia

Comparison of Ropivacaine versus Bupivacaine in Spinal-Induced Hypotension in Preeclampsia Patients: A Randomized Control Trial

Background

Spinal anesthesia is considered to be the safest method of anesthesia for cesarean sections in patients with preeclampsia. Patients with preeclampsia are at an increased risk of experiencing severe hypotension following spinal anesthesia, which could have more profound and deleterious effects on both the fetus and the mother. However, bupivacaine, the most commonly used drug, can induce severe hypotension even at low doses. The purpose of this study is to minimize post-spinal hypotension in both the mother and the fetus.

Objectives

To determine and compare the reduction in hypotension following spinal anesthesia in patients with preeclampsia between the ropivacaine and bupivacaine groups.

Methods

In a randomized clinical trial, a total of 90 parturients with preeclampsia undergoing spinal anesthesia were enrolled and randomly divided into 2 groups: One receiving ropivacaine and the other receiving bupivacaine. The dose of spinal ropivacaine was 15 mg of a 0.5% solution, and the dose of bupivacaine was also 15 mg of a 0.5 % solution. Hemodynamic parameters, including systolic and diastolic blood pressure and heart rate, were recorded following the administration of spinal anesthesia. Pain scores and the time until the return of motor movement were also documented.

Results

For statistical analysis, the t-test, Chi-square, and ANOVA tests were utilized to compare the groups. Demographic variables, including maternal age, gestational age, parity, and gravidity, were not significantly different between the 2 groups. The trend of mean systolic blood pressure (SBP) was significantly lower in the bupivacaine group compared to the ropivacaine group at all measured time points in the study (P < 0.05). The amount of ephedrine used after spinal anesthesia was significantly different at 2 and 4 minutes in the ropivacaine group compared to the bupivacaine group (P = 0.012, P = 0.025). Post-operative pain scores at 1 hour in recovery were not significantly different between the ropivacaine and bupivacaine groups (P = 0.015). The time to knee movement was also significantly shorter in the ropivacaine group compared to the bupivacaine group (P < 0.001).

Conclusions

Ropivacaine reduces the incidence of hypotension in spinal anesthesia compared to bupivacaine for cesarean section in patients with preeclampsia. This is attributed to a lower occurrence of spinal-induced hypotension, improved hemodynamic control, reduced ephedrine usage, and faster patient ambulation. A future study could focus on investigating different dosages of both drugs with a larger number of participants.

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Comparison of Supreme laryngeal mask airway versus endotracheal intubation for airway management during general anesthesia for cesarean section: a randomized controlled trial

Background

The obstetric airway is a significant cause of maternal morbidity and mortality. Endotracheal intubation is considered the standard of care but the laryngeal mask airway (LMA) has gained acceptance as a rescue airway and has been incorporated into the obstetric airway management guidelines. In this randomized controlled equivalence trial, we compared the Supreme LMA (SLMA) with endotracheal intubation (ETT) in managing the obstetric airway during cesarean section.

Methods

Parturients who underwent elective cesarean section under general anesthesia were randomized to receive either an SLMA or ETT as their airway device. Our primary outcome was first-attempt insertion success. Successful insertion was defined as adequate bilateral air entry with auscultation and the presence of end-tidal carbon dioxide on the capnogram. The first-attempt insertion success rate was compared using the Chi-Square test. Secondary outcomes included time-to-ventilation, seal pressure, ventilation/hemodynamic parameters, occurrence of clinical aspiration, fetal outcomes, and maternal side effects associated with the airway device.

Results

We recruited 920 parturients (460 SLMA, 460 ETT) who underwent elective cesarean section under general anesthesia. Patient characteristics were similar between the groups. First attempt success was similar (Odds Ratio--OR_SLMA/ETT: 1.00 (95%CI: 0.25, 4.02), p = 1.0000). SLMA was associated with reduced time to effective ventilation (Mean Difference--MD -22.96; 95%CI: − 23.71, − 22.21 s) compared to ETT group (p <  0.0001). Ventilation parameters, maternal and fetal outcomes were similar between the groups, and there was no aspiration.

Conclusions

SLMA could be an alternative airway management technique for a carefully selected low-risk obstetric population, with similar insertion success rates, reduced time to ventilation and less hemodynamic changes compared with ETT. Our findings are consistent with the airway guidelines in recommending the second-line use of LMA in the management of the obstetric airway.

Trial registration

The study was registered at http://www.clinicaltrials.gov, identifier: NCT01858467, retrospectively registered. Date of registration: May 21, 2013.

Type of obstetric anesthesia administered and complications in women with preeclampsia in low- and middle-income countries: A systematic review

BACKGROUND

Delivery is often expedited with cesarean section, necessitating anesthesia, to prevent complications in women with preeclampsia. Anesthesia-associated risks in these women from low- and middle-income countries (LMICs) are not known.

METHODS

We searched major databases (until February 2017) for studies on general vs. regional anesthesia in women with preeclampsia. We summarized the association between outcomes and type of anesthesia using a random effects model and reported as odds ratio (OR) with 95% confidence intervals (95% CIs).

FINDINGS

We included 14 studies (10,411 pregnancies). General anesthesia was associated with an increase in the odds of maternal death sevenfold (OR 7.70, 95% CI 1.9 to 31.0, I² = 58%) than regional anesthesia. The odds of pulmonary edema (OR 5.16, 95% CI 2.5 to 10.4, I² = 0%), maternal intensive care unit admissions (OR 16.25, 95% CI 9.0 to 29.5, I² = 65%), and perinatal death (OR 3.01, 95% CI 1.4 to 6.5, I² = 56%) were increased with general vs. regional anesthesia.

CONCLUSION

General anesthesia is associated with increased complications in women with preeclampsia undergoing cesarean section in LMIC.

Premedication with midazolam prior to cesarean delivery in preeclamptic parturients: A randomized controlled trial

Background:

Anxiety is a concern in obstetrics, especially in preeclamptic mothers. Sedation is not commonly used in parturients for fear of adverse neonatal effect. We investigated maternal and neonatal outcome of midazolam as an adjuvant to spinal anesthesia for elective cesarean delivery.

Methods:

A prospective randomized controlled trial, in which eighty preeclamptic parturients received either an intravenous dose of 0.035 mg/kg of midazolam or an equal volume of normal saline, 30 min before spinal anesthesia. Maternal anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS); postoperative maternal satisfaction was assessed using Maternal Satisfaction Scale for Cesarean Section (MSSCS). Newborns were assessed using Apgar score, Neonatal Neurologic and Adaptive Capacity Score (NACS), and umbilical artery blood gases.

Results:

Mothers premedicated with midazolam showed a lower level of preoperative anxiety and a higher degree of postoperative satisfaction than the control group. There were no between-group differences regarding the neonatal outcome.

Conclusion:

Preeclamptic parturients premedicated with midazolam (0.035 mg/kg) before spinal anesthesia have lower anxiety and higher postoperative satisfaction levels, with no adverse effects on the newborns.

Spontaneous acute subdural hematoma and intracerebral hemorrhage in a patient with thrombotic microangiopathy during pregnancy

Preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low-platelet count), and acute fatty liver of pregnancy are the main causes of thrombotic microangiopathy and severe liver dysfunction during pregnancy and represent different manifestations of the same pathological continuum. The case of a 35-week pregnant woman who was admitted to an intensive care unit immediately after a Cesarean section due to fetal death and the presence of nausea, vomiting, and jaundice is reported. Postpartum preeclampsia and acute fatty liver of pregnancy were diagnosed. The patient developed an acute subdural hematoma and an intracerebral hemorrhage, which were subjected to neurosurgical treatment. The patient died from refractory hemolytic anemia and spontaneous bleeding of multiple organs. Preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy might overlap and be associated with potentially fatal complications, including intracranial hemorrhage, as in the present case. Early detection and diagnosis are crucial to ensure appropriate management and treatment success.

A clinical characteristic analysis of pregnancy-associated intracranial haemorrhage in China

Intracerebral haemorrhage (ICH) occurring during pregnancy and the puerperium is an infrequent but severe complication with a high mortality and poor prognosis. Until recently, previous studies have mainly focused on the effect of different treatments on prognosis. However, few studies have provided solid evidence to clarify the key predisposing factors affecting the prognosis of ICH. In the present study, based on a unique sample with a high ICH incidence and mortality rate, we described the main clinical characteristics of ICH patients and found that the prognosis of patients who underwent surgical intervention was not better than that of patients who received other treatment modalities. However, pre-eclampsia patients had higher maternal and neonatal mortality rates than other aetiology groups. Furthermore, univariate regression analysis identified onset to diagnosis time (O-D time) and pre-eclampsia as the only factors showing independent correlation with poor maternal outcomes (modified Rankin Scale, mRS ≥ 3), and only O-D time was identified as a predictor of maternal mortality. These results revealed that the aetiology of ICH and O-D time might be crucial predisposing factors to prognosis, especially for patients with pre-eclampsia. The study highlighted a novel direction to effectively improve the prognosis of pregnancy-associated ICH.

Anesthetic management of labor and delivery in patients with elevated intracranial pressure

The anesthetic management of labor and delivery in patients with elevated intracranial pressure is complex. This review discusses the etiologies of diffuse and focal pathologies which lead to elevated intracranial pressure in pregnancy. The role of neuraxial and general anesthesia in the management of labor and delivery is also examined. Finally, a comprehensive review of strategies to minimize increases in intracranial pressure during general anesthesia for cesarean delivery is presented.

Prevention of peri-induction hypertension in preeclamptic patients: a focused review

Many medications have been used to prevent the hypertensive response to the induction of general anesthesia and laryngoscopy in preeclamptic patients, with varying results. In this focused review, we summarize the available data and pharmacologic profiles of these drugs. Several different drug classes may be used safely; however, magnesium bolus, lidocaine, calcium channel antagonists other than nicardipine, and hydralazine are not recommended. Further research is warranted into the hemodynamic impact of varying the induction drug dose or combining different classes of drugs.

Pre-eclampsia part 2: prediction, prevention and management

An antiangiogenic state might constitute a terminal pathway for the multiple aetiologies of pre-eclampsia, especially those resulting from placental abnormalities. The levels of angiogenic and antiangiogenic proteins in maternal blood change prior to a diagnosis of pre-eclampsia, correlate with disease severity and have prognostic value in identifying women who will develop maternal and/or perinatal complications. Potential interventions exist to ameliorate the imbalance of angiogenesis and, hence, might provide opportunities to improve maternal and/or perinatal outcomes in pre-eclampsia. Current strategies for managing pre-eclampsia consist of controlling hypertension, preventing seizures and timely delivery of the fetus. Prediction of pre-eclampsia in the first trimester is of great interest, as early administration of aspirin might reduce the risk of pre-eclampsia, albeit modestly. Combinations of biomarkers typically predict pre-eclampsia better than single biomarkers; however, the encouraging initial results of biomarker studies require external validation in other populations before they can be used to facilitate intervention in patients identified as at increased risk. Angiogenic and antiangiogenic factors might also be useful in triage of symptomatic patients with suspected pre-eclampsia, differentiating pre-eclampsia from exacerbations of pre-existing medical conditions and performing risk assessment in asymptomatic women. This Review article discusses the performance of predictive and prognostic biomarkers for pre-eclampsia, current strategies for preventing and managing the condition and its long-term consequences.

Magnesium Therapy in Pre-eclampsia Prolongs Analgesia Following Spinal Anaesthesia with Fentanyl and Bupivacaine: An Observational Study

BACKGROUND

Magnesium has anti-nociceptive effects and potentiates opioid analgesia following its systemic and neuraxial administration. However, there is no study evaluating the effects of intravenous (IV) magnesium sulphate (MgSO4) therapy on spinal anaesthesia characteristics in severely pre-eclamptic patients.

AIMS

The aim of this study was to compare spinal anaesthesia characteristics in severely pre-eclamptic parturients treated with MgSO4 and healthy preterm parturients undergoing caesarean section. Thus, our primary outcome was regarded as the time to first analgesic request following spinal anaesthesia.

STUDY DESIGN

Case-control Study.

METHODS

Following approval of Institutional Clinical Research Ethics Committee and informed consent of the patients, 44 parturients undergoing caesarean section with spinal anaesthesia were enrolled in the study in two groups: Healthy preterm parturients (Group C) and severely pre-eclamptic parturients with IV MgSO4 therapy (Group Mg). Following blood and cerebrospinal fluid (CSF) sampling, spinal anaesthesia was induced with 9 mg hyperbaric bupivacaine and 20 μg fentanyl. Serum and CSF magnesium levels, onset of sensory block at T4 level, highest sensory block level, motor block characteristics, time to first analgesic request, maternal haemodynamics as well as side effects were evaluated.

RESULTS

Blood and CSF magnesium levels were higher in Group Mg. Sensory block onset at T4 were 257.1±77.5 and 194.5±80.1 sec in Group C and Mg respectively (p=0.015). Time to first postoperative analgesic request was significantly prolonged in Group Mg than in Group C (246.1±52.8 and 137.4±30.5 min, respectively, p<0.001; with a mean difference of 108.6 min and 95% CI between 81.6 and 135.7). Side effects were similar in both groups. Group C required significantly more fluids.

CONCLUSION

Treatment with IV MgSO4 in severe pre-eclamptic parturients significantly prolonged the time to first analgesic request compared to healthy preterm parturients, which might be attributed to the opioid potentiation of magnesium.

Anesthetic considerations in pregnant women at advanced maternal age

OBJECTIVE

To evaluate anesthetic considerations in pregnancy for women at advanced maternal age (≥40 years).

METHODS

A retrospective cohort study of laboring women aged 40 years or above comparing women aged 40-44 years old with those aged ≥45 years, in a single, tertiary, university affiliated medical center.

RESULTS

Overall, 39,006 women delivered in our institution during the study period, of them 376 (1%) were eligible for analysis: 278 (74%) were 40-44 years old (control group) and 98 (26%) were 45 years old and above (study group). No differences were found between the groups with regards to analgesia or anesthesia management during labor. Differences were found in obstetrical characteristics such as higher rates of primiparity, preeclampsia, need for magnesium sulphate therapy and chronic hypertension among parturients aged ≥45 years. Of note, parturients aged ≥ 45 years had an approximately eight-fold risk for postpartum hemorrhage.

CONCLUSION

Anesthesia management of parturients aged 45 years and above is comparable to the management of women aged 40-44 years. However, parturients≥45 are more susceptible to bleeding complications.

Balancing the benefits and risks: lessons learned from the therapeutic interventions of a case with severe preeclampsia

BACKGROUND AND OBJECTIVE

Preeclampsia is a multiple organ dysfunction syndrome (MODS) for its typical and atypical manifestations including hypertension, proteinuria, HELLP syndrome, hypertensive encephalopathy and coagulopathy. Optimal management for such patients is determined from an assessment of the balance between benefits and risks of anesthetic and obstetric therapeutic strategies.

CASE REPORT

A 35-year-old pregnant woman, with one past uncomplicated pregnancy presented at 29 weeks to our medical institute as an emergency with dizziness, chest distress, palpitation, blurred vision and vaginal bleeding. After physical examination and laboratory tests, the patient was diagnosed with severe preeclampsia, HELLP syndrome, placental abruption, and MODS. The patient also presented spinal and pelvic deformity, fixation of articulus mandibularis, and tracheal displacement because of a traffic accident 11 years ago. Therefore, urgent cesarean section was performed under general anesthesia with nasal tracheal intubation using a guide wire. The patient was discharged directly home from the obstetric intensive care unit on the 7(th) postoperative day with normal blood pressure and full recovery of organic function.

CONCLUSIONS

This case merits further discussion on the anesthesia considerations concerning how to make a clinical decision when treating such a patient. Neuraxial block is the first choice for preeclampsia patients undergoing cesarean section when a moderate but not progressive thrombocytopenia exists. When general anesthesia is decided, adequate sedation and analgesia is needed to better control the stress response to intubation especially in patients with neurological signs, and to prevent major cerebral complications.

Chronic subdural haematoma associated with pre-eclampsia: case report and review of the literature

Pre-eclampsia complicates approximately 5-8% of all pregnancies and may have adverse long-term effects on both mother and child. Chronic atraumatic subdural haematoma as a complication of severe pre-eclampsia, in the absence of clotting factor abnormalities, is a very rare condition. We present the case of a 30-year-old Moroccan woman who had a pregnancy 10 years previously, with an uneventful delivery. She presented with pre-eclampsia complicating a 29-week-old pregnancy. A few days preceding maternity unit admission the patient complained of headaches and malaise. Her blood pressure at admission was 150/120mmHg and subsequently was treated with doses of methyldopa and magnesium sulphate. Her condition worsened with a loss of consciousness 24 hours later and was transferred to the neurosurgical unit. A brain computerized tomography (CT) scan revealed a left-sided subdural haematoma and the patient underwent surgery, with a good postoperative outcome. This article highlights the occurrence of neurological complications due to pre-eclampsia/eclampsia that require particular neurosurgical attention, its treatment and prognosis. We also review the literature regarding this pathology.

[New aspects of obstetric anesthesia]

BACKGROUND

The risk profile of patients in obstetric anesthesia has substantially changed. Even more so than other disciplines, obstetric anesthesia is therefore in the true sense of the word dependent on the close coordination of all concerned and a good interdisciplinary cooperation.

AIM

This article explains the important anesthesiological risks connected with parturition and presents the corresponding concepts for prevention, diagnosis and management of peripartum complications.

MATERIAL AND METHODS

The increase in the number of high risk pregnancies, which are mostly due to an increase in obesity, require clearly defined guidelines and interdisciplinary concepts which are described and discussed in this article. The neuraxial block is still the most effective procedure for treatment of birth pain and offers a promising new method with the programmed intermittent epidural boluses presented in this article. Finally, the German speaking countries Germany, Austria and Switzerland have developed a treatment algorithm for the management of postpartum hemorrhage which is presented here.

RESULTS

The anesthesiological components of a risk pregnancy must be recognized early and include obesity, preeclampsia and drug-induced coagulopathy. Epidural analgesia is the most effective analgesic procedure in obstetrics. Patient-controlled remifentanil analgesia currently represents the best alternative in cases of contraindications for a neuraxial procedure.

CONCLUSION

In risk situations, such as pre(eclempsia), emergency cesarean section, massive blood loss or other peripartum emergency situations, optimal interdisciplinary cooperation between midwives, obstetricians and anesthetists is required. However, not only emergency situations require a good interdisciplinary cooperation. Just as important is the cooperation to recognize risk pregnancies and a timely joint planning of the approaching birth.

Focused review: spinal anesthesia in severe preeclampsia

Spinal anesthesia is widely regarded as a reasonable anesthetic option for cesarean delivery in severe preeclampsia, provided there is no indwelling epidural catheter or contraindication to neuraxial anesthesia. Compared with healthy parturients, those with severe preeclampsia experience less frequent, less severe spinal-induced hypotension. In severe preeclampsia, spinal anesthesia may cause a higher incidence of hypotension than epidural anesthesia; however, this hypotension is typically easily treated and short lived and has not been linked to clinically significant differences in outcomes. In this review, we describe the advantages and limitations of spinal anesthesia in the setting of severe preeclampsia and the evidence guiding intraoperative hemodynamic management.

Platelet Counts and Coagulation Tests Prior to Neuraxial Anesthesia in Patients With Preeclampsia

This retrospective, descriptive study aimed to assess hematologic testing practices in 100 patients with preeclampsia undergoing neuraxial blockade (NB). Prior to NB, platelet (PLT) count was performed in 61 (98%) of 62 women in labor and in 37 (97%) of 38 women undergoing cesarean delivery (CD). No patients had a pre-NB PLT count <70 × 109/L. Pre-NB tests for prothrombin time (PT) and activated partial thromboplastin time (APTT) were less common and varied among laboring patients (15 [24%] of 62) and patients prior to CD (18 [47%] of 38). Prior to NB, PT and APTT values were within normal limits in all patients. The time intervals between laboratory testing and NB ranged from <2 to >12 hours. The lack of consistency in pre-NB coagulation testing and the variable time intervals between laboratory tests and NB may be due to a lack of consensus among anesthesiologists for determining “safe” hemostatic conditions for NB placement in patients with preeclampsia.

Fluid and vasopressor management for Cesarean delivery under spinal anesthesia: continuing professional development

PURPOSE

The purpose of this Continuing Professional Development module is to review the physiology of maternal hypotension induced by spinal anesthesia in pregnant women, and the effects of fluids and vasopressors.

PRINCIPAL FINDINGS

Maternal hypotension induced by spinal anesthesia is caused mainly by peripheral vasodilatation and is not usually associated with a decrease in cardiac output. Although the intravenous administration of fluids helps to increase cardiac output, it does not always prevent maternal hypotension. Three strategies of fluid administrations are equivalent for the prevention of maternal hypotension and a reduced need for vasopressors: (1) colloid preload; (2) colloid coload; and (3) crystalloid coload. Crystalloid preload is not as effective as any of those three strategies. Unlike phenylephrine, ephedrine can cause fetal acidosis. Therefore, phenylephrine is recommended as first line treatment of maternal hypotension. A phenylephrine infusion (25-50 μg x min(-1)) appears to be more effective than phenylephrine boluses to prevent hypotension, and nausea and vomiting. In pre-eclamptic patients, spinal anesthesia produces less hypotension than in normal pregnant women and fluid volumes up to 1,000 mL are usually well tolerated. Therefore mild to moderate intravascular volume loading is recommended, keeping in mind the increased risk for pulmonary edema in this population. In pre-eclamptic patients, hypotension can be treated either with ephedrine or phenylephrine, and phenylephrine infusions are not recommended.

CONCLUSION

A volume loading regimen other than crystalloid preload should be adopted. A phenylephrine infusion during elective Cesarean delivery is beneficial for the mother and safe for the newborn.

Invasive versus non-invasive monitoring of acute severe hypertension in women with pre-eclampsia

OBJECTIVE

To compare the accuracy of two non-invasive methods of blood-pressure measurement with intra-arterial measurement in women with pre-eclampsia and acute severe hypertension.

METHODS

This descriptive, cross-sectional study prospectively enrolled 23 women with pre-eclampsia and acute severe hypertension for continuous intra-arterial blood-pressure monitoring. Simultaneous monitoring was performed with a manual and an automated, non-invasive device during episodes of severe hypertension. The paired T-test was used to compare measured values. The accuracy of a MAP⩾125mmHg in detecting a systolic blood pressure⩾160mmHg was determined.

RESULTS

There was a weak correlation between intra-arterial and automated as well as intra-arterial and manual systolic values (r=0.34, p<0.01; r=0.41, p<0.00, respectively). Better correlation was found amongst diastolic values. The differences between the mean intra-arterial (94±11mmHg) and automated (96±12mmHg) diastolic values as well as intra-arterial and manual diastolic measurements (94±14mmHg) were not significant (p=0.20, 0.65, respectively). A mean arterial pressure⩾125mmHg was not accurate in detecting a systolic value⩾160mmHg, with low sensitivities (17.2-35.9%) and specificities (0-50%) for all three methods.

CONCLUSIONS

When compared to intra-arterial monitoring, the automated and manual methods showed weak correlation with systolic but better correlation with diastolic values. A mean arterial pressure⩾125mmHg was not accurate in detecting systolic peaks. When protection against cerebral haemorrhage is paramount, intra-arterial measurement of systolic values is best.

The role of platelet counts in the assessment of inpatient women with preeclampsia

OBJECTIVE

Platelet count has been proposed as a screening test for generalized coagulopathy in women with preeclampsia. We performed this study to determine the relationship between platelet counts and the risk of abnormal coagulation and adverse maternal outcomes in women with preeclampsia.

METHODS

We used data from women in the PIERS (Pre-eclampsia Integrated Estimate of RiSk) database. Abnormal coagulation was defined as either an international normalized ratio result greater than and/or a serum fibrinogen level less than the BC Women's Hospital laboratory's pregnancy-specific normal range. The relationship between platelet counts and adverse maternal outcomes was explored using a logistic regression analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of platelet counts in identifying abnormal coagulation or adverse maternal outcomes were calculated.

RESULTS

Abnormal coagulation occurred in 105 of 1405 eligible women (7.5%). The odds of having abnormal coagulation were increased for women with platelet counts < 50 × 10(9)/L (OR 7.78; 95% CI 3.36 to 18.03) and between 50 and 99 × 10(9)/L (OR 2.69; 95% CI 1.44 to 5.01) compared with women who had platelet counts above 150 × 10(9)/L. Platelet counts < 100 × 10(9)/L were associated with significantly increased odds of adverse maternal outcomes, most specifically blood transfusion. A platelet count of < 100 × 10(9)/L had good specificity in identifying abnormal coagulation and adverse maternal outcomes (92% [95% CI 91% to 94%] and 92% [95% CI 91% to 94%], respectively), but poor sensitivity (22% [95% CI 15% to 31%] and 16% [95% CI 11% to 23%], respectively).

CONCLUSION

A platelet count < 100 × 10(9)/L is associated with an increased risk of abnormal coagulation and maternal adverse outcomes in women with preeclampsia. However, the platelet count should not be used in isolation to guide care because of its poor sensitivity. Whether or not a platelet count is normal should not be used to determine whether further coagulation tests are needed.

Endothelial dysfunction in the human umbilical artery due to preeclampsia can be prevented by sildenafil

OBJECTIVES

We aimed to determine the effects of sildenafil in human umbilical artery preparation taken from preeclamptic or normal pregnant women, also to investigate underlying mechanisms in these effects.

STUDY DESIGN

Eighteen pregnant women with preeclampsia and 18 healthy pregnant women were involved. Relaxation responses of sildenafil in presence and absence of nitric oxide (NO) synthase inhibitor, N-[omega]-nitro-L-arginine methyl ester (L-NAME), and soluble guanylyl cyclase inhibitor, 1H-[1,2,4] oxadiazolo [4,3-a]quinoxalin-1-one (ODQ), were compared between the preeclampsia group and control group.

RESULTS

Sildenafil-induced relaxation responses were significantly attenuated in the presence of preeclampsia, L-NAME or ODQ, but not totally abolished. Interestingly, except with ODQ incubation, in all set of experiments maximal relaxation response was achieved by sildenafil.

CONCLUSION

These data indicate that sildenafil might effect vascular responsiveness of human umbilical artery through the involvement of NO/cyclic guanosine monophosphate (cGMP)-dependent and -independent pathways. Further investigations are needed to clarify the exact mechanisms.

Anaesthesia for lower-segment caesarean section: Changing perspectives

The number of caesarean sections has increased over the last two decades, especially in the developed countries. Hence, it has increasingly become a greater challenge to provide care for the parturient, but this has given obstetric anaesthetists a greater opportunity to contribute to obstetric services. While caesarean deliveries were historically performed using general anaesthesia, there is a recent significant move towards regional anaesthesia. Unique problems that patients with obesity and pre-eclampsia present will be discussed in the present article. New medications and devices now used in obstetric anaesthesia will change the practice and perspectives of our clinical practice.

Inverted takotsubo-like left ventricular dysfunction with pulmonary oedema developed after caesarean delivery complicated by massive haemorrhage in a severe preeclamptic parturient with a prolonged painful labour

Inverted takotsubo cardiomyopathy (TTC), a variant of stress-induced cardiomyopathy, features transient myocardial dysfunction characterized by a hyperdynamic left ventricular apex and akinesia of the base. Herein, we describe a 38-year-old primigravida with severe preeclampsia who had active labour for 4 h followed by an emergency caesarean delivery. She developed postpartum haemorrhage due to uterine atony complicated by pulmonary oedema, which was managed with large-volume infusion and hysterectomy. Her haemodynamic instability was associated with cardiac biomarkers indicative of diffuse myocardial injury and echocardiographic findings of an “inverted” TTC. The patient was almost fully recovered one month later. Our case shows that a reversible inverted TTC may result from a prolonged painful labour. TTC should be listed in the differential diagnosis of the patient presenting with pulmonary oedema of unknown origin, especially in patients with severe preeclampsia.

Critical care management of obstetric emergencies

Obstetric cases are normally well managed on the labour suite. However, emergencies are not uncommon, and when they occur, they can be major. It is vital that rapid assessment and management are put in place. Critical care doctors are often called upon to do so.

Diagnosis and management of pre-eclampsia: an update

Pre-eclampsia is a significant, multifactorial, multiorgan disease affecting 5%-8% of all pregnancies in the US where it is the third leading cause of maternal mortality. Despite improvements in the diagnosis and management of pre-eclampsia, severe complications can occur in both the mother and the fetus, and there is no effective method of prevention. Early detection and identification of pregnant women most at risk of developing the disease have proven challenging, but recent efforts combining biochemical and biophysical markers are promising. Efforts at prevention of pre-eclampsia with aspirin and calcium have had limited success, but research on modifiable risk factors, such as obesity surgery, are encouraging. Obstetric management of severe pre-eclampsia focuses on medical management of blood pressure and prevention of seizures using magnesium sulfate, but the ultimate cure remains delivery of the fetus and placenta. Timing of delivery depends on several factors, including gestational age, fetal lung maturity, and most importantly, disease severity. Anesthetic management includes regional anesthesia with careful evaluation of the patient's airway, volume status, and coagulation status to reduce morbidity and mortality. The potential complications of general anesthesia, including intracranial hemorrhage, in these patients make regional anesthesia the preferred choice in many cases. Nevertheless, it is important to be aware of the contraindications to neuraxial anesthesia and to prepare always for the possibility of encountering a difficult airway.

[Anesthesia for procedures other than neurosurgery in the adult with epilepsy]

Epilepsy is a common disease affecting between 1% and 2% of the general population. The incidence increases with age. Given the complicated etiology and pathogenesis of this disease, epileptic patients of all ages may require anesthesia. The perioperative care of these patients involves a number of special considerations, although the main issues to deal with are pharmacologic. This review gives an overview of the etiopathogenesis and pathophysiology of epilepsy and describes the general characteristics of antiepileptic drug therapy. The anesthetic implications of chronic treatment with antiepileptic agents and the interactions between these drugs and common anesthetics are discussed in more detail.