An anesthetic experience with cesarean section in a patient with vasovagal syncope -A case report-

Syncope in pregnancy, immediate pregnancy outcomes, and offspring long-term neurologic health

BACKGROUND

There are limited data regarding the perinatal consequences of maternal syncope during pregnancy, and even less is known about the potential long-term effect on offspring health.

OBJECTIVE

This study aimed to examine perinatal outcomes as well as long-term offspring neurologic morbidity associated with prenatal maternal syncope, and the possible differential effect by trimester of first syncope episode.

STUDY DESIGN

A retrospective cohort study was conducted, including all singleton deliveries occurring between 1991 and 2021 at a large tertiary medical center. Multivariable analyses were applied to study the associations between prenatal maternal syncope and various perinatal outcomes as well as offspring neurologic morbidity up to the age of 18 years, while adjusting for clinically relevant factors. Analyses were further conducted by trimester of first syncope episode.

RESULTS

The study population included 232,475 pregnancies, 774 (0.3%) were affected by maternal syncope, which most frequently first occurred during the second trimester (44.5%), followed by the first trimester (31.8%) and finally the third trimester (27.7%). Maternal syncope was independently associated with increased risk for intrauterine growth restriction (adjusted odds ratio, 1.52; 95% confidence interval, 1.01-2.29), which appeared to be mainly driven by first trimester syncope occurrence; as well as with increased risk for cesarean delivery (adjusted odds ratio, 1.33; 95% confidence interval, 1.10-1.61), and for long-term offspring neurologic morbidity (adjusted hazard ratio, 1.79; 95% confidence interval, 1.65-2.08), regardless of the trimester of syncope occurrence.

CONCLUSION

Prenatal maternal syncope is an independent risk factor for intrauterine growth restriction, cesarean delivery, and for long-term offspring neurologic morbidity.

The use of tenoxicam to prevent symptoms of discomfort induced by vagotonia during uterus manipulation in cesarean sections

PURPOSE

Symptoms such as nausea, vomiting, tightness of the chest, bradycardia, and shoulder or abdominal discomfort, caused by vagotonia occurring during uterus manipulation, have concerned healthcare professionals for some time. Patients sometimes report these symptoms when undergoing spinal anesthesia for cesarean sections (CSs). We designed a prospective, double-blind study to investigate the effectiveness of tenoxicam in preventing these symptoms of discomfort.

METHODS

A total of 105 American Society of Anesthesiologists (ASA) class I-II nulliparous pregnant women, who were scheduled for a CS, were enrolled into this prospective, double-blind study. Spinal anesthesia was conducted to reach a peak dermatome level of no more than T3. The 100 patients were randomly divided into 2 groups having completed study course: Group T (N = 50) received a 20 mg dose of tenoxicam in 5 mL of normal saline (NS) immediately after skin incision and Group N (N = 50) only received 5 mL NS. The incidence and severity of the symptoms experienced by the patients were recorded by a nurse anesthetist who was blinded to the injection regimen the patients were receiving. A chi-square test was used for statistical analysis t test and P < .05 was defined as significant.

RESULTS

The incidence and degree of severity of nausea and vomiting were same in both the groups. The incidence and degree of severity of bradycardia, nausea, vomiting, tightness of the chest, shoulder discomfort, and abdominal discomfort were lower in Group T than in Group N.

CONCLUSION

Tenoxicam might theoretically block the parasympathetic vagus pathway and decrease the visceral pain or visceral-specific symptoms, alleviating the symptoms caused by vagotonia. However, the prophylactic effect of tenoxicam in reducing the incidence and severity of nausea and vomiting was not statistically significant. This could be because nausea and vomiting are not solely caused by vagotonia, but also by other mechanisms.

Pneumocephalus during cervical transforaminal epidural steroid injections: a case report

A cervical transforaminal epidural injection of anesthetic and corticosteroids (CTFESI) is a frequently used procedure for cervical radiculopathy. Most cases of pneumocephalus after an epidural block occur when using an interlaminar approach with the loss-of-resistance technique. The authors present the first case of pneumocephalus after cervical transforaminal epidural injection of anesthetic and corticosteroids. A 64-yr-old woman with left C7 radiculopathy was undergoing C6-7 transforaminal epidural injection of anesthetic and corticosteroids. The epidural spread of contrast was checked by fluoroscope, and 5 mg of dexamethasone in 4 ml of 0.1875% ropivacaine was injected. She lost consciousness 5 mins after the procedure and regained awareness after manual ventilation. She subsequently complained of nausea and headache, and a computed tomography brain scan revealed pneumocephalus. After carefully assessing the fluoroscopic images, the authors believe that the needle may have punctured the dura mater of the nerve root sleeve, allowing air to enter the subdural space. Thus, fluoroscopic images should be carefully examined to reduce dural puncture when performing cervical transforaminal epidural injection of anesthetic and corticosteroids, and air should be completely removed from the needle, extension tube, and syringe.