Intrapartum Emergencies

Anesthetic management for emergency cesarean section in a patient with status epilepticus: A case report

RATIONALE

The presence of clinically significant repeated maternal epilepsies during pregnancy increases the risk of adverse maternal, fetal and neonatal outcomes. However, there are few guidelines for anesthesiologists to deal with this situation.

PATIENT CONCERNS AND DIAGNOSES

A 28-year-old primigravida was transferred to the operating room for emergency cesarean section. Based on the patient's complaints and clinical appearance, provisional diagnosis of preeclampsia at 33 weeks' gestation as well as frequent and repeated grand mal convulsions at 14 years of age were considered. The anesthetic modalities of the disease are also discussed.

INTERVENTIONS AND OUTCOMES

Because the usual antiepileptic therapy had failed, the patient with status epilepticus underwent surgery under general anesthesia. The newborn was handed to the pediatrician and the patient was transferred to the intensive care unit for further observation and discharged 4 days later. No peri-operative or anesthetic complications were observed.

LESSONS

Providing anesthesia to patients undergoing cesarean section poses major challenges for anesthesiologists. Close monitoring and proper treatment can help reduce risks for both the mother and baby.

Pulmonary Disorders Complicating Pregnancy: An Overview

Awareness of pulmonary complications and the timely execution of appropriate interventions are critical to maintaining adequate oxygenation for the pregnant woman and the fetus. Clinicians have an opportunity during prenatal visits to provide women with education regarding pulmonary complications during pregnancy to promote positive maternal and fetal outcomes. The pulmonary conditions to be addressed in this article include asthma, tuberculosis, cystic fibrosis, and pneumonia. The purpose of this manuscript is to provide an overview of specific pulmonary conditions, as well as interventions related to each disorder and its impact on pregnancy.

A model for educational simulation of the evolution of uterine contractions during labor

Electronic fetal monitoring remains an important tool in labor ward settings, providing continuous information on fetal heart rate and maternal uterine contractions. A prompt detection of abnormalities in these signals is essential for the timely resolution of situations that may put both mother and fetus at risk. Uterine contraction signals provide information that is important to evaluate the onset and progress of labor, as well as the significance of certain fetal heart rate abnormalities. We present a model for educational simulation of the spontaneous evolution of uterine contractions during labor, which combines a previously published signal generator with literature-based pre-programmed scripts for educationally relevant scenarios. This model is an essential component of a high-fidelity simulator of intrapartum emergencies, aimed to improve the competency of healthcare providers. Real and simulated tracings were presented to three independent clinical experts who judged simulated signals to be indistinguishable or negligibly different from real tracings.

Diagnosis of acute foetal distress does not preclude banking of umbilical cord blood units

Clinical diagnosis of acute foetal distress (AFD) is based on several parameters such as abnormal foetal heart rate (FHR) pattern and/or meconium liquid staining (MLS). Standards for cord blood (CB) banking indicate that AFD should be considered as exclusion criteria for CB collection, but precise guidelines on how to proceed with CB collection in the presence of AFD signs during labour are not available. We evaluated whether the presence of FHR abnormality and/or MLS during labour 1) reduced the CB collection activity; 2) were associated with the infant's acidaemia or asphyxia and 3) deteriorated the biological characteristics of CB units. Thirty-three units of CB were evaluated for biological parameters, gas values and newborn's Apgar score. The results were compared with a control group of 33 consecutive units previously banked. No differences were observed between the two groups and all but one newborn showed normal Apgar score and absence of metabolic acidaemia. The results showed that 1) AFD reduced the CB collection activity by 10% each year; 2) the majority of CB units collected in the presence of abnormal FHR and/or meconium have biological characteristics eligible for banking; 3) FHR alterations or meconium in the presence of normal gas analysis do not represent certain diagnosis of AFD.

Perianesthesia care following obstetric emergencies at risk for multisystem organ dysfunction

Perianesthesia care provided to obstetric patients is on the rise due to current obstetric practice habits, changes in the maternal population, and the increased desire for scheduled childbirth. Both scheduled and emergent cesarean deliveries create risk, yet the use of general anesthesia increases maternal morbidity and mortality significantly. Obstetric emergencies make up the majority of emergent cesarean deliveries. Detrimental events during pregnancy and childbirth may be categorized into hemorrhagic, septic, or anaphylactic shock. Excessive loss of circulating volume with subsequent loss in oxygenation creates an environment for multisystem organ dysfunction syndrome (MODS). Both MODS and pregnancy are hyperdynamic and hypermetabolic states. Close monitoring is needed to differentiate pregnancy for the progression of organ dysfunction. Caring for pregnant women with the intent that pregnancy is a normal, physiologic state can lead to complacency and the risk of misdiagnosis. The purpose of this article is to review current obstetric emergencies that place the obstetric population at risk for MODS and offer management options to perianesthesia providers.