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Gerber C, Bishop DG, Dyer RA, Maswime S, Rodseth RN, van Dyk D, Kluyts HL, Mbwele B, Tumukunde JT, Madzimbamuto FD, Elkhogia AM, Ndonga AK, Ngumi ZWW, Omigbodun AO, Amanor-Boadu SD, Zoumenou E, Basenero A, Munlemvo DM, Coulibaly Y, Ndayisaba G, Antwi-Kusi A, Gobin V, Forget P, Rakotoarison S, Samateh AL, Mehyaoui R, Patel-Mujajati U, Sani CM, Madiba TE, Pearse RM, Biccard BM. Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study. Anesth Analg 2024; 138:1275-1284. [PMID: 38190343 DOI: 10.1213/ane.0000000000006750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.
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Affiliation(s)
- Carmen Gerber
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - David G Bishop
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Robert A Dyer
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- World Federation of the Societies of Anaesthesiologists Obstetric Anaesthesia Committee, London, United Kingdom
| | - Salome Maswime
- Division of Global Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Reitze N Rodseth
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Dominique van Dyk
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
| | - Hyla-Louise Kluyts
- Department of Anaesthesiology, Sefako Makgatho Health Sciences University, South Africa
| | - Bernard Mbwele
- Department of Epidemiology, Biostatistics and Clinical Research, University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Mbeya, Tanzania
| | | | - Farai D Madzimbamuto
- Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Abdulaziz M Elkhogia
- Department of Anaesthesia and Intensive Care, Tripoli University Hospital, Tripoli, Libya
| | - Andrew K Ndonga
- Department of General and Gastrosurgery, Mater Hospital, Nairobi, Kenya
| | - Zipporah W W Ngumi
- Department of Anaesthesia, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Akinyinka O Omigbodun
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Eugène Zoumenou
- Department of Surgery, Clinique Universitaire Polyvalente d'Anesthésie-Réanimation Centre National Hospitalier et Universitaire HKM de Cotonou, Cotonou, Benin
| | - Apollo Basenero
- Quality Management Programme, Ministry of Health and Social Services Namibia, Windhoek, Namibia
| | - Dolly M Munlemvo
- Department of Anaesthesia, University Hospital of Kinshasha, Kinshasha, Democratic Republic of Congo
| | - Youssouf Coulibaly
- Service des urgences, d'anesthésie et de Réanimation polyvalente, Faculté de médicine de Bamako, Bamako, Mali
| | - Gabriel Ndayisaba
- Department of Surgery, Kamenge Teaching Hospital, Bujumbura, Burundi
| | - Akwasi Antwi-Kusi
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Veekash Gobin
- Department of Anaesthesia, Ministry of Health and Quality of Life, Jawaharlal Nehru Hospital, Rose Belle, Mauritius
| | - Patrice Forget
- Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Department of Anaesthesia, NHS Grampian, Aberdeen, United Kingdom
| | | | - Ahmadou L Samateh
- Department of Surgery, Edward Francis Small Teaching Hospital, Banjul, The Gambia
| | - Ryad Mehyaoui
- Department of Anesthesiology and Intensive Care in Cardiovascular Surgery, Algiers University, Algiers, Algeria
| | | | - Chaibou M Sani
- Department of Anesthesiology, Intensive Care and Emergency, National Hospital of Niamey, Niamey, Republic of Niger
| | | | - Rupert M Pearse
- Critical Care and Perioperative Medicine Research Group, Queen Mary University of London, United Kingdom
| | - Bruce M Biccard
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
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Fernandes NL, Lilaonitkul M, Subedi A, Owen MD. Global obstetric anaesthesia: bridging the gap in maternal health care inequities through partnership in education. Int J Obstet Anesth 2023; 55:103646. [PMID: 37211512 DOI: 10.1016/j.ijoa.2023.103646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/20/2023] [Indexed: 05/23/2023]
Abstract
Maternal mortality rates are unacceptably high globally. Low- and middle-income countries (LMICs) face challenges of an inadequate anaesthesia workforce, under-resourced healthcare systems and sub-optimal access to labour and delivery care, all of which negatively impact maternal and neonatal outcomes. In order to effect the changes in surgical-obstetric-anaesthesia workforce numbers advocated by the Lancet Commission on Global Surgery to support the UN sustainable development goals, mass training and upskilling of both physician and non-physician anaesthetists is imperative. The implementation of outreach programmes and partnerships across organisations and countries has already been shown to improve the provision of safe care to mothers and their babies, and these efforts should be continued. Short subspecialty courses and simulation training are two cornerstones of modern obstetric anaesthesia training in poorly resourced environments. This review discusses the challenges to accessing quality maternal healthcare in LMICs and the use of education, outreach, partnership and research to protect the most vulnerable women from coming to harm in the peripartum period.
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Affiliation(s)
- N L Fernandes
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - M Lilaonitkul
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - A Subedi
- Department of Anesthesiology and Critical Care, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - M D Owen
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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van Dyk D, Dyer RA, Fernandes NL. Preeclampsia in 2021-a Perioperative Medical Challenge for the Anesthesiologist. Anesthesiol Clin 2021; 39:711-725. [PMID: 34776105 DOI: 10.1016/j.anclin.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors provide a review of recent advances in the understanding of pathophysiology and perioperative management of preeclampsia and eclampsia, from the perspective of the anesthesiologist. This review includes aspects of assessment of severity of disease, hemodynamic monitoring, peripartum anesthesia care, and postpartum management. The perioperative management of patients with eclampsia is also discussed.
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Affiliation(s)
- Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Nicole L Fernandes
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
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