Influence of prenatal corticosteroid therapy on neonatal vitality and utility as a labor-inducing agent in Santa Inês ewes

Since the 1970s, maternal corticosteroid therapy has been used successfully to induce labor. This allows for better monitoring of parturients and provision of first aid to neonates, improving neonatal viability, as this treatment induces maturation in a variety of fetal tissues, thereby reducing morbidity and mortality. Although the effects of corticosteroids are well known, few studies have investigated the influence of this therapy in Santa Inês sheep. This study aimed to evaluate the efficacy of dexamethasone at two doses (8 and 16 mg) to induce lambing in Santa Inês ewes at 145 days of gestation and assess its effects on neonatal vitality. For this study, 58 ewes raised in an extensive system were investigated. Pregnancy was confirmed after artificial insemination at a set time or after controlled mounting. Ewes were separated into three groups: an untreated control group (G1: 0 mg) and groups treated with two doses of dexamethasone (G2: 8 mg and G3: 16 mg). In total, 79 lambs were born. Their vitality was assessed based on their Apgar score, weight, temperature, and postnatal behavior. SAS v9.1.3 (SAS Institute, Cary, NC) was used to analyze data, considering a 5% significance level for all analyses. The births in the induced groups occurred 48.4 ± 22.1 h after induction, while the ewes that underwent non-induced labor gave birth 131.96 ± 41.9 h after placebo application (p < 0.05), confirming the efficacy of dexamethasone to induce and synchronize labor. The induced and non-induced neonates had similar Apgar scores, temperatures, weights, and postnatal behavioral parameters (p > 0.05). This study showed that inducing labor in Santa Inês ewes at 145 days of gestation with a full (16 mg) or half dose (8 mg) of dexamethasone is an effective technique and does not compromise neonate vitality.

Experiences of childbirth care in Lithuania and Romania: Insights from the European Babies Born Better survey

BACKGROUND

Data on experience and satisfaction of users are essential for improvement of health care, especially in the field of childbirth. The aim of this study was to compare childbirth care experiences in Lithuania and Romania.

METHODS

Data derived from the EU Babies Born Better online survey were analyzed. Parturients from Lithuania (N = 373) and Romania (N = 359) who had given birth within the last 5 years were included. Participants were asked to (1) describe the best things in childbirth care and (2) suggest changes in the care received at their birthplace. Qualitative data were analyzed using a previously developed deductive coding framework.

RESULTS

In agreement with previous findings from Austria, positive experiences mainly addressed care experienced at an individual level (in particular healthcare practitioners' competence and personality traits) and suggested changes mainly addressed services at birthplace (issues related to infrastructure, information and counseling, and empowerment). Responses not initially included in the coding framework addressed aspects such as informal payment (in both countries), desire for home birth (particularly in Lithuania), or mistreatment of parturients (particularly in Romania).

CONCLUSIONS

We conclude that similar trends in childbirth care exist in Lithuania and Romania with regard to parturients' personal experiences and psychosocial needs and that addressing the needs of parturients is important for improving service provision.

Prevalence and factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth: a prospective multicentre cohort study

BACKGROUND

This multicentre prospective observational study sought to determine the prevalence and the factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth, and to identify the clinical situations in which ultrasound assessment of gastric contents would be most helpful (i.e. when the prevalence of high-risk gastric contents is close to 50%).

METHODS

Ultrasound assessments of gastric contents were performed within the first hour after admission to the maternity unit. The prevalence of high-risk gastric contents was calculated and variables associated with high-risk gastric contents were identified using logistic regression analyses.

RESULTS

A total of 1003 parturients were analysed. The prevalence of high-risk gastric contents was 70% (379/544; 95% confidence interval: 66-74%) in women admitted in spontaneous labour and 65% (646/1003; 95% confidence interval: 61-67%) in the whole cohort. Lower gestational age, increased fasting duration for solids, and elective Caesarean delivery were independently associated with reduced likelihood of high-risk gastric contents. In women admitted in spontaneous labour and in the whole cohort, the prevalence of high-risk gastric contents ranged from 85% to 86% for fasting duration for solids <6 h, 63%-68% for fasting 6-8 h, 54%-55% for fasting 8-12 h, and 47%-51% for fasting ≥12 h.

CONCLUSIONS

Around two-thirds of parturients had high-risk gastric contents within the first hour after admission to the maternity unit. Our results suggest that gastric emptying for solids continues in labouring women, and that gastric ultrasound would be most helpful when fasting duration is ≥8 h.

The diagnostic accuracy of preoperative perfusion index as a predictor of postspinal anesthesia hypotension in parturients undergoing cesarean delivery: A prospective non-blinded observational study

Background and Objectives

Spinal anesthesia is the technique of choice for elective cesarean section with a prominent side effect of postspinal anesthesia hypotension (PSH). This needs an early prediction to avoid feto-maternal complication. This study aimed to assess the diagnostic accuracy of perfusion index (PI) and inferior vena cava collapsibility index (IVCCI) in the prediction of PSH.

Material and Methods

Thirty parturients of American Society of Anesthesiologists Physical Status (ASA-PS) 1 and two undergoing cesarean delivery participated in the study. IVCCI, PI, baseline systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR) were noted in the preoperative period. The fall of MBP by 20% from baseline or below 65 mm Hg was considered PSH. After spinal anesthesia, SBP, DBP, MBP, and HR were noted again for diagnosing PSH.

Results

It did not show any statistical difference when comparing the PI between the PSH and non-PSH groups in both the PSH definition groups. IVCCI was significantly higher when PSH was considered MBP <65 mm Hg (P = 0.01). However, IVCCI was found to be statistically insignificant if PSH was considered a 20% reduction in baseline MBP. The correlation matrix between IVCCI and PI showed Pearson's r-value of 0.525, indicating a substantial relationship between the two (P = 0.003). Multivariate logistic regression analysis had shown that neither IVCCI nor PI was a good predictor of PSH in parturients for both definition groups for PSH.

Conclusion

Although there is a modest correlation between PI and IVCCI, both cannot be used to predict postspinal hypotension in parturients undergoing elective lower-segment cesarean section (LSCS).

High psychological stress levels related to delivery can increase the occurrence of postpartum mental disorders

Objective

The study sought to explore the relationship between high psychological stress levels related to delivery and postpartum mental disorders.

Methods

A total of 284 parturients were included in the study from July 2021 to January 2022. The stress level at 1 month postpartum was assessed by the Impact of Event Scale-Revised (IES-R). Parturients with an IES-R score ≤ 9 were included in the low psychological stress level group, and those with an IES-R score > 9 were included in the high psychological stress level group. The Edinburgh Postnatal Depression Scale (EPDS), Union Physio-Psycho-Social Assessment Questionnaire (UPPSAQ-70), Symptom Checklist-90 (SCL-90) and Mini-International Neuropsychiatric Interview (M.I.N.I.) were conducted at 42 ± 7 days postpartum to assess the mental health of parturients.The parturients' mental health after birth was assessed by the EPDS, UPPSAQ-70, and SCL-90. Semi-structured diagnostic interviews were conducted at 42 ± 7 days postpartum by using the M.I.N.I.

Results

The incidence rate of postpartum mental disorders was 20.42% (58/284), the incidence rates of postpartum depression, anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder were 17.96% (51/284), 11.97% (34/284), 4.58% (13/284) and 1.41% (4/284), respectively, and the comorbidity rate was 58.62% (34/58). A history of mental disorders and pregnancy complications were risk factors for postpartum depression (p = 0.028, p = 0.040, respectively); a history of mental disorders, a lack of physical exercise, partner violence and pregnancy complications were risk factors for postpartum anxiety disorders (p = 0.003, p = 0.007, p = 0.031, p = 0.048, respectively); and the delivery of female infants was a risk factor for postpartum obsessive-compulsive disorder (p = 0.022).The risk of postpartum depression, anxiety disorders and obsessive-compulsive disorder was 9.125 times (95% CI = 3.900 ~ 21.349, p < 0.01), 7.310 times (95% CI = 2.588 ~ 20.649, p < 0.01) and 6.259 times (95% CI = 1.347 ~ 29.093, p < 0.01) higher in postpartum women with high psychological stress levels related to delivery than in those with low psychological stress levels, respectively.

Conclusion

The incidence of postpartum mental disorders is high and has a positive correlation with the level of psychological stress. This may lead to a new perspective of the effect of psychological stress on postpartum mental disorders and attract more attention to other mental disorders in addition to postpartum depression.

Characteristics and outcomes of parturients with COVID-19, admitted to a critical care unit: A single-center retrospective observational study

Background

Data on outcomes of coronavirus disease 2019 (COVID-19) in pregnancy are scarce, although they represent a unique physiological state affecting both the mother and child. We present collated data from a tertiary care center in North India, encompassing the outcome, clinical characteristics, and management of these patients.

Materials and Methods

Parturients ≥ 18 years old, with COVID-19 reverse transcriptase polymerase chain reaction positive for severe acute respiratory syndrome coronavirus 2, requiring intensive care unit (ICU) admission at a tertiary care hospital were included. Data were retrospectively collected from April 2020 to November 2021.

Results

In all, 26 parturients were admitted to ICU with COVID-19. Five patients were admitted during the first wave, and all were asymptomatic. Twenty-one patients presented during the second wave (March 2021 onward), among which four were asymptomatic and 17 symptomatic (all with severe pneumonia). Three patients presented in the second trimester, all with critical disease, out of which one did not survive. Two patients had twin gestation, and others were singleton pregnancies. Seven patients (27%) were primigravida, and five patients (19.2%) had more than third pregnancy. Twenty critically ill women (77%) delivered during the hospital stay. Six patients died during the second wave, and four deaths (66.7%) were because of COVID-19 acute respiratory distress syndrome (ARDS).

Conclusions

The number of admissions and mortality related to COVID-19 ARDS was higher in the second wave than in the first. We report the safe use of remdesivir and tocilizumab in our patients.

Epidural Anesthesia for Cesarean Section for Parturient with Recently Diagnosed Asymptomatic Chiari Malformation Type I: A Case Report

Description Chiari malformations (CMs) are congenital defects of the brain and skull that result in inferior displacement of the cerebellum. There are four types of CMs distinguished by the severity of the anatomic defects and parts of the brain that protrude beyond the foramen magnum. Of these types, CM Type I (CMI) is the least severe. It is characterized by the downward displacement of the cerebellar tonsils beyond the foramen magnum by more than 5 millimeters and goes into the cervical spinal canal. CMI is the most common type with an incidence of 0.1-0.5% in the general population and a predominance in females. Given its relatively benign nature, CMI is often found incidentally or in adulthood when symptoms such as a headache or neck pain are present. It can be associated with syringomyelia or, less commonly, hydrocephalus. Although surgical decompression can be performed, most patients do not require surgical treatment. CMs present a unique challenge for anesthesiologists providing care to parturients. Since a majority of patients do not have a history of surgical decompression or ventriculoperitoneal shunting, it is difficult to evaluate for hydrocephalus when the patient is in labor. Therefore, many patients with diagnosed CMI are scheduled for an elective cesarean section. Numerous case reports and literature reviews have documented the successful use of spinals, epidurals and combined spinal-epidurals (CSEs) in these patients without neurologic sequelae. The patient in this case presented with CMI, which was diagnosed one year prior to our encounter, without any treatment. At the time of labor, she was asymptomatic. Although she had two prior vaginal deliveries under epidural anesthesia, she was scheduled for an elective cesarean section this time given the new diagnosis. This case report demonstrates the safe and successful use of epidural anesthesia for a parturient with CMI.

Comparison of three neuraxial anesthesia approaches in parturient women with obesity and pregnancy-induced hypertension who underwent cesarean section

OBJECTIVE

To compare the effectiveness of different approaches of neuraxial anesthesia in parturient women with obesity and pregnancy-induced hypertension (PIH) who undergo cesarean section (CS).

METHODS

We retrospectively analyzed data from 108 parturient women with obesity and PIH who underwent CS. All women were divided into the following three groups according to the neuraxial anesthesia approach: spinal anesthesia (SA), epidural anesthesia (EA), and combined spinal-epidural anesthesia (CSE). Clinical variables were compared.

RESULTS

The mean age of the patients was 27.3 ± 2.2 years. Women in the CSE group had a longer duration from puncture to surgery, smaller intraoperative change in mean arterial pressure, higher Apgar scores at 1 and 5 minutes, shorter surgery time, lower rates of nausea and vomiting, and lower rate of intraoperative hypotension compared with those in the SA and EA groups.

CONCLUSION

CSE takes longer to administer in parturient women with obesity and PIH who undergo CS compared with those who have SA or EA. However, CSE has several advantages over SA or EA, including a shorter surgery time, more stable intraoperative mean arterial pressure, lower rates of nausea, vomiting, and intraoperative hypotension, and better Apgar scores at 1 and 5 minutes.

The interrelation between body mass index and post-dural puncture headache in parturient women

Background and Aims

Post-dural puncture headache is seen more frequently in pregnant women due to stress, dehydration, intra-abdominal pressure, and insufficient fluid replacement after delivery. Obesity protects against post-dural puncture headache in pregnant women; increased intra-abdominal fat tissue reduced cerebrospinal fluid leakage by increasing the pressure in the epidural space. Therefore, this study investigated the influence of body mass index on post-dural puncture headache in elective cesarean section patients in whom 27G spinal needles were used.

Material and Methods

The study included 464 women who underwent elective cesarean section under spinal anesthesia. Dural puncture performed with a 27G Quincke spinal needle at the L3-4 or L4-5 intervertebral space and given 12.5 mg hyperbaric bupivacaine intrathecally. The patients were questioned regarding headache and low back pain 6, 12, 24, and 48 h after the procedure, and by phone calls on days 3 and 7.

Results

Post-dural puncture headache developed in 38 (8.2%) patients. Of the patients who developed post-dural puncture headache, 23 (60.5%) had a body mass index <30 and 15 (39.5%) had a body mass index ≥30. Of the patients who did not develop post-dural puncture headache, 258 (60, 6%) had a body mass index <30 and 168 (39, 4%) had a body mass index ≥30.

Conclusion

This prospective study found the body mass index values did not affect post-dural puncture headache in the elective cesarean section performed under spinal anesthesia.

Incidence and associated factors of postdural puncture headache for parturients who underwent cesarean section with spinal anesthesia at Debre Tabor General Hospital, Ethiopia; 2019

Introduction and Objective

Postdural puncture headache is one of the most frequent late complications of spinal anesthesia. There are different factors that might predispose for postdural puncture headache. Therefore, the main aim of this study was to assess the incidence of postdural puncture headache and its associated factors for parturients who gave birth by cesarean section under spinal anesthesia.

Methods

Hospital-based longitudinal study was conducted on mothers who underwent cesarean section with spinal anesthesia. Descriptive analysis and chi-square test were employed. Bivariable and multivariable logistic regression were used to measure the association of factors with the presence of postdural puncture headache. A p-value of ⩽0.05 was used to decide statistical significance for multivariable logistic regression.

Result

A total of 119 parturients were participated in this study. The incidence of postdural puncture headache was 20.2%. According to multivariable logistic regression, having previous spinal anesthesia (adjusted odds ratio = 7.028; 95% confidence interval = 2.377-20.781; p = 0.0001), using 20- and 22-gauge needle (adjusted odds ratio = 4.206; 95% confidence interval = 1.247-14.187; p = 0.021), and repeated attempt (adjusted odds ratio = 4.699; 95% confidence interval = 1.594-13.872; p = 0.05) had statistically significant association with postdural puncture headache.

Conclusion

Larger gauge needle size, repeated attempt, and previous spinal anesthesia might increase the incidence of postdural puncture headache.

Investigation Regarding Early Cognitive Function of Women in the Postpartum Period and the Analysis of Influencing Factors

Objective

The present study aims to assess the cognitive function of healthy full-term puerperae and compare it with the cognitive function of healthy non-pregnant women in order to analyze possible influencing factors.

Methods

The study subjects were divided into two groups: the maternal (case) group (n = 80) and the control group (n = 30). A total of 50 healthy single-birth full-term primiparous women and 30 women undergoing a second pregnancy were assigned to the maternal group, while 30 non-pregnant women matched by general data were assigned to the control group. Subject cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) (Beijing version) and the Birmingham Cognitive Screen (BCoS) (Mandarin version); related influencing factors were analyzed.

Results

In the maternal group, the results showed a MoCA score of 26.52 ± 2.13 points and a cognitive impairment incidence of 26% in primiparous women, along with a MoCA score of 25.83 ± 2.49 points and a cognitive impairment incidence of 36.7% in women undergoing a second pregnancy. All scores were lower in the maternal group than in the control group, which had a MoCA score of 27.47 ± 1.28 points and cognitive impairment incidence of 6.7% (p < 0.05). The differences in MoCA score and cognitive impairment incidence between the primiparous sub-group and the second pregnancy sub-group were not statistically significant (p > 0.05). The visual space and executive function MoCA scale scores were lower in the maternal group than in the control group (p < 0.01). Furthermore, the scores were lower in the maternal group than in the control group in the following BCoS items: instant story recall, total apple deletion number, auditory attention, rule conversion, and gesture imitation (p < 0.05).

Conclusion

Women in the postpartum period may develop cognitive dysfunction; however, the difference in cognitive impairment incidence between the primiparous sub-group and the second pregnancy sub-group in this study was not statistically significant. The educational level, labor analgesia, and total labor time (min) were found to be influencing factors in the postpartum cognitive function decline (p < 0.05).

Reliability of a clinical method in estimating foetal weight and predicting route of delivery in term parturient monitored at a voluntary agency hospital in Southwest Nigeria

BACKGROUND

The antepartum estimation of foetal weight is a major determinant of the route of delivery and this has become vital in modern day obstetrics. The limitations to the use of obstetric ultrasonography, considered as the gold standard in estimating foetal weight, make clinical estimation methods attractive alternatives, especially in resource- constrained settings where many un-booked women may report for delivery.

AIM

To determine the reliability of intrapartum clinical foetal weight estimation in predicting the actual birth weight (ABW) and route of delivery among term parturient.

SETTING

The study was conducted at the Sacred Heart Hospital, Lantoro, a voluntary mission agency hospital in Southwest Nigeria.

METHODS

This cross-sectional study was conducted among 291 term parturient recruited by systematic random sampling between June and September 2017. The clinical estimation of foetal weight was carried out using Johnson's formula.

RESULTS

The accuracy of Johnson's formula to predict the ABW was 59.5%; while for the mode of delivery, it was 130 (75.1%) for spontaneous vaginal delivery (SVD) and 43 (24.9%) for caesarean section (CS). The sensitivity of the accuracy of Johnson's formula to predict the mode of delivery was 75.1%, with a specificity of 35.6%, a positive predictive value (PPV) of 63.1%, and a negative predictive value (NPV) of 49.4%.

CONCLUSION

The intrapartum clinical foetal weight estimation at term determined by Johnson's formula was reliably predictive of ABW and SVD, but it was unreliable in predicting the need for a CS.

Performance of the Surgical Pleth Index and Analgesia Nociception Index in Healthy Volunteers and Parturients

Various commercially available nociception devices have been developed to quantify intraoperative pain. The Surgical Pleth Index (SPI) and Analgesia Nociception Index (ANI) are among the analgesic indices that have been widely used for the evaluation of surgical patients. This study aimed to evaluate the clinical performance of the SPI and ANI in conscious healthy volunteers and parturients. Ten healthy volunteers and 10 parturients participated in this study. An algometer was used to induce bone pain in the volunteers until they rated their pain as five on the numerical rating scale (NRS); this procedure was repeated during the administration of remifentanil or normal saline. The study comprised two periods, and the volunteers were infused with different solutions in each period: normal saline during one period and remifentanil during the other in a randomized order. The parturients’ SPI and ANI data were collected for 2 min when they rated their pain levels as 0, 5, and 7 on the NRS, respectively. Both the SPI and ANI values differed significantly between NRS 0 and NRS 5 (P < 0.001) in the volunteers, irrespective of the solution administered (remifentanil or normal saline). At NRS 5, the SPI showed similar values, irrespective of remifentanil administration, while the ANI showed significantly lower values on remifentanil administration (P = 0.028). The SPI and ANI values at NRS 5 and NRS 7 did not differ significantly in the parturients (P = 0.101 for SPI, P = 0.687 for ANI). Thus, the SPI and ANI were effective indices for detecting pain in healthy volunteers and parturients.

Peripartum cardiomyopathy with preeclampsia in a parturient: A case report with literature review

Peripartum cardiomyopathy (PPCM) is a rare disease of unknown cause that affects women of childbearing age. A high index of suspicion should be maintained in the pregnant and peripartum woman who presents with sudden cardiac decompensation without any prior history of cardiac disease. The diagnosis can be confirmed with echocardiographic evidence of global left ventricular dysfunction. Timely diagnosis and institution of therapy for heart failure can avoid adverse outcomes in a parturient with PPCM. In this case report, we describe the management of primigravida presenting to the hospital's emergency department with acute cardiac failure and respiratory distress due to PPCM. The case also highlights that though preeclampsia and PPCM are two separate entities, these can coexist in the same parturient due to the common pathophysiological mechanism. In the review, the recommended medical management of heart failure in PPCM with the “BOARD” (Bromocriptine, Oral heart failure drugs, Anticoagulants, Vasorelaxing agents, and Diuretics) scheme is discussed.

Protocolized approach to a COVID-19 parturient undergoing a cesarean section - A case report

The health care workers working in the operation theater (OT) face many unique challenges to deal with the corona virus disease (COVID-19) patients undergoing surgery. We hereby report the management of a COVID-19 parturient undergoing cesarean section in the dedicated COVID health center. Patient care of this special and vulnerable subset of population with least exposure of COVID-19 to health care worker was the cornerstone of the management. We have summarized some of the important precautionary measures which were taken during cesarean section to minimize exposure and genuine use of resources in this pandemic. To conclude, despite Personal Protective Equipment (PPE), precautionary measures and strategies are of utmost importance and should be opted so as to lower the virus contagion risk.

Development and Validation of a Rating Scale of Pain Expression during Childbirth (ESVADOPA)

One of the most representative symptoms during childbirth is pain, which is one of the most prominent concerns of pregnant women. There are different instruments to assess pain, all of which require interrupting the woman, thus interfering with the intimacy of childbirth. This study seeks to develop and validate a rating scale of the expression of childbirth pain that does not require the mother’s attention and respects her privacy during labor. The study was conducted at a regional hospital in a border town in southern Spain between November 2018 and September 2019. Scale items were developed following a review of the scientific literature, and experts judged the content validity. After a pilot test, the scale was psychometrically evaluated. The psychometric tests consisted of internal consistency analysis, exploratory factor analysis, and determination of the content, construct, and convergent validity. The scale was evaluated by 36 experts in the field and was then applied to 55 women during the active phase of childbirth. The final version of the Rating Scale of Pain Expression during Childbirth (in Spanish, Escala de Valoración de la Expresión del Dolor durante el Trabajo de Parto—ESVADOPA) consists of six items in two dimensions. The scale had a Cronbach’s alpha coefficient of 0.78, and the content validity measured by Aiken’s V co-efficient was also 0.78. The exploratory factor analysis yielded two dimensions that explained 68.08% of the total variance. For convergent validity, a comparison was made with the visual analogue scale, yielding a medium–high value of 0.641. As indicated by the internal consistency and by the content and construct validity outcomes, the ESVADOPA successfully measures pain expression during childbirth and represents a suitable tool for pain expression during birth without the need for intervention or the need for the mother to speak the same language as the midwife.

Evaluation of 2 ultrasonic indicators as predictors of difficult laryngoscopy in pregnant women: A prospective, double blinded study

BACKGROUND

Ultrasonic measurements of tongue thickness and condylar translation were recently introduced to predict difficult laryngoscopy in non-obstetric patients. We designed the present study to evaluate the performance of these two ultrasonic indicators in predicting difficult laryngoscopy in healthy parturients.

METHODS

The 119 parturients undergoing elective cesarean delivery were enrolled. Tongue thickness and condylar translation measured by ultrasonography, and Modified Mallampati test (MMT) score, inter-incisor distance (IID) and modified Cormack-Lehane grading system (MCLS) were measured and recorded before anesthesia. The primary outcome was difficult laryngoscopy defined as MCLS 3 or 4. The association between these variables and difficult laryngoscopy were analyzed by using multivariable logistic regression and receiver operating characteristic (ROC) curve.

RESULTS

Compared to the Easy Laryngoscopy Group, the tongue thickness was significantly higher and the condylar translation and IID were significantly lower in the Difficult Laryngoscopy Group. Tongue thickness and condylar translation but not MMT score and IID were proved to be two independent predictors for difficult laryngoscopy by multivariate logistic regression, with the odds ratios of 2.554 (95% confidence interval (CI), 1.715 to 3.802) and 0.457 (95% CI, 0.304 to 0.686). The area under the ROC curve to predict difficult laryngoscopy for tongue thickness was 0.93 (95% CI, 0.88-0.98) and for condylar translation was 0.77 (95% CI, 0.67-0.86), which were significantly higher than those for MMT score (0.67, 95% CI, 0.56-0.77) and IID (0.65, 95% CI, 0.55-0.76).

CONCLUSIONS

Compared with MMT and IID, tongue thickness and condylar translation measured by ultrasonography appear to be better indicators for predicting difficult laryngoscopy in parturients.The trial was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org), registration number ChiCTR-ICR-1800019991.

Pharmacokinetics and Placental Transfer of Bupivacaine Enantiomers in HIV-Infected Parturient Women on Antiretroviral Therapy

Bupivacaine, a local anesthetic, is commercialized as a racemic mixture of R-bupivacaine and S-bupivacaine enantiomers. HIV infection increases the expression of placental P-glycoprotein (P-gp), and antiretroviral (ARV) therapy inhibits cytochrome P450 3A and P-gp. The present study evaluates the kinetic disposition of bupivacaine enantiomers in HIV-infected parturient women on ARV therapy. In this study, HIV-infected parturient women (n = 10) treated with zidovudine, lamivudine, lopinavir, and ritonavir were investigated. Anesthesia and/or analgesia was achieved by the administration of 0.5% racemic bupivacaine hydrochloride with 1:200000 epinephrine in the epidural space at doses of 2.5 to 22.5 mg. Maternal serial blood samples were obtained at the time immediately before and 5, 15, 30, 45, and 60 minutes and 2, 4, 6, 8, 10, 12, and 14 hours after administration of the bupivacaine. At the time of delivery, samples of maternal and umbilical cord vein blood were also collected. The results suggest that bupivacaine pharmacokinetics are enantioselective, revealing higher maternal plasma concentrations of the R-bupivacaine enantiomer (area under the total plasma concentration-time curve was calculated by the trapezoid method with extrapolation to infinity/dose_(S)/(R) = 0.91; P < .05). The plasma unbound fraction of the drug (0.09 vs 0.06) and the umbilical cord vein/maternal plasma ratio (0.47 vs 0.39) were higher for the R-bupivacaine enantiomer than the S-bupivacaine enantiomer (P < .05). ARV therapy with ritonavir confers an enantioselective interaction between the enantiomers of bupivacaine and placental P-gp, producing greater inhibition of efflux transport of the R-bupivacaine enantiomer. Possible changes in the well-being of the fetuses of mothers under analgesia may be a consequence of the increased placental transfer of bupivacaine enantiomers to the fetal circulation.

Anesthetic challenges in a pregnant patient with post mitral valve replacement, complete heart block, and coagulopathy coming for emergency cesarean section: A case report

A 24-year-old primigravida with a history of rheumatic heart disease and prosthetic mitral valve on oral anticoagulation who was lost follow-up during the third trimester presented with premature rupture of membranes. On evaluation, she had new-onset complete heart block. She was temporarily paced but developed cardiac failure. Anesthetic challenges and management of this parturient with post mitral valve replacement, complete heart block, and warfarin-induced coagulopathy for emergency cesarean delivery are discussed in this case report. Ours is the first case report of a pregnant patient with new onset of complete heart block during pregnancy several years after mitral valve replacement.

Herbal medicines and pregnancy: A narrative review and anaesthetic considerations

The use of herbal medicines by pregnant women varies among different countries, ranging from 4.3% in Sweden to 69% in Russia. The aim of this narrative review is to evaluate the benefits and safety of common herbal medicines used during pregnancy. A systematic literature search (from 1995 to February 2018) was performed using a variety of electronic databases. The levels of evidence of the clinical studies were graded using the Oxford Centre for Evidence-Based Medicine levels of evidence guidelines. From the 736 articles retrieved, 69 articles were used for this review. Ginger has been investigated extensively and has been consistently found to decrease nausea and vomiting associated with pregnancy (Level 2). There is insufficient evidence concerning the efficacy of other herbal medicines such as garlic, cranberry and raspberry in pregnancy (Level 3–4). Much of the literature is based on case reports with limited pharmacodynamic/kinetic studies. There are no clear data on the adverse herb–drug interactions during anaesthesia. As the risks of these interactions are unknown, it would be prudent for anaesthetists to explicitly ask their patients about their use of herbal medicines before surgery and prior to labour and birth. The European Society of Anaesthesiology and American Society of Anesthesiologists recommend that patients cease taking herbal medicines two weeks before surgery.

Evidence for Congenital Zika Virus Infection From Neutralizing Antibody Titers in Maternal Sera, Northeastern Brazil

Reliable diagnosis of congenital Zika virus (ZIKV) infection is challenging. Here, we assessed ZIKV-specific neutralizing antibodies in 28 mothers of children with microcephaly (cases) and 122 controls from northeastern Brazil using plaque reduction neutralization tests. ZIKV-specific antibody titers were significantly higher in cases than in controls (t test, P < .0001). We identified a putative case of congenital Zika syndrome retrospectively by unusually high ZIKV-specific antibody titers. High ZIKV-specific antibody titers in cases were unrelated to prior dengue virus infection. Our data suggest a strong immunological stimulus from prolonged placental or transplacental ZIKV shedding and potential utility of maternal antibody titers to corroborate congenital ZIKV infection.

Management of major obstetric haemorrhage

One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases.

Exhaustive TORCH Pathogen Diagnostics Corroborate Zika Virus Etiology of Congenital Malformations in Northeastern Brazil

The Latin American 2015-2016 Zika virus (ZIKV) outbreak was associated with an increase in microcephaly predominantly in northeastern Brazil. To comparatively investigate infectious causes of congenital malformations, we performed a nested case-control study in 32 mothers of cases of suspected congenital Zika syndrome (CZS) and 160 age-matched controls from Bahia, northeastern Brazil. We collected clinical and imaging data and assessed past exposure to ZIKV, Chikungunya virus (CHIKV), dengue virus, and 8 established TORCH (Toxoplasma gondii, Treponema pallidum, rubella virus, cytomegalovirus, herpes simplex virus 1 [HSV-1] and HSV-2, varicella-zoster virus, parvovirus B19) pathogens using multiple serological tests. Heterogeneous symptoms prevented unequivocal diagnosis of CZS on clinical grounds. Only ZIKV and CHIKV seroprevalence rates differed significantly between cases and controls (93.8% versus 67.8% for ZIKV [Fisher's exact text, P = 0.002] and 20.7% versus 8.2% for CHIKV [χ2, P = 0.039]). High ZIKV seroprevalence rates in cases could not be explained by previous dengue virus infections potentially eliciting cross-reactive antibody responses affecting ZIKV serological tests. In conditional logistic regression analyses, only ZIKV was significantly associated with congenital malformations (P = 0.030; odds ratio, 4.0 [95% confidence interval, 1.1 to 14.1]). Our data support an association between maternal ZIKV exposure and congenital malformations. Parallels between the discrepant ZIKV and CHIKV seroprevalence rates between cases and controls and similar seroprevalence rates between cases and controls for the sexually transmitted T. pallidum and HSV-2 may suggest the occurrence of predominantly vector-borne transmission in our study population. High seroprevalence of TORCH pathogens suggests that exhaustive diagnostics will be necessary in the aftermath of the ZIKV outbreak and provides baseline data for longitudinal studies on ZIKV pathogenesis.IMPORTANCE The Latin American Zika virus (ZIKV) outbreak had a major impact on reproductive health worldwide. The reasons for the massively increased reports of neonatal microcephaly in northeastern Brazil are still unclear. Beyond the technical limitations of laboratory diagnostics, unambiguous diagnosis of ZIKV as the cause of congenital malformations is hampered by similar clinical pictures elicited by other pathogens known as TORCH pathogens. We performed a case-control study comparing mothers of children with congenital malformations to age-matched controls from Salvador, Brazil, one of the areas most extensively affected by the ZIKV outbreak. The ZIKV and Chikungunya virus seroprevalence rates differed significantly, whereas the levels of maternal exposure to TORCH pathogens were similar between cases and controls. Our data support a link between maternal ZIKV infection and congenital malformations and suggest the occurrence of predominantly vector-borne ZIKV transmission in these cases. In addition, some highly prevalent TORCH pathogens may be misinterpreted as representative of ongoing ZIKV activity in the absence of exhaustive diagnostics in northeastern Brazil.

Maternal and Fetal Outcomes With Early Neuraxial Engagement in Obese Parturients

Research indicates the combination of obesity and pregnancy is correlated with increased morbidity, mortality, and healthcare costs. The clinical inquiry of this study was: Does early neuraxial placement in obese parturients decrease the rate of cesarean delivery, decrease use of general anesthesia, and improve fetal Apgar scores? A retrospective analysis of 212 obese parturients with neuraxial anesthesia based on cervical dilation at time of placement and low-intervention delivery was conducted to evaluate the impact of early neuraxial intervention. The study site was a university-affiliated women and children's hospital in the US Midwest. Appropriate statistical analysis tests were performed to compare maternal and fetal outcomes of early, late, and no neuraxial anesthesia. Maternal outcomes included type of delivery, surgical anesthesia, and complications associated with the delivery. Fetal outcomes were Apgar scores and umbilical artery pH. Results of the retrospective analysis showed that early neuraxial placement was associated with a higher incidence of cesarean deliveries, successful conversion of laboring epidural to surgical epidural, avoidance of general anesthesia, potential loss of airway, and death. No significant differences were noted in Apgar scores based on neuraxial anesthesia timing. Further research regarding the risks and benefits of early neuraxial anesthesia in obese parturients is recommended.

Anesthetic management of a parturient with Kearns-Sayre syndrome, dual-chamber and VVI implantable defibrillator pacemaker/defibrillator, and preeclampsia for cesarean delivery: A case report and review of the literature

Kearns–Sayre syndrome (KSS), a rare form of mitochondrial myopathy, is a triad of chronic progressive external ophthalmoplegia, bilateral pigmentary retinopathy, and cardiac conduction abnormalities. In this report, we show how a combined spinal epidural anesthesia can be useful for cesarean delivery, as we illustrate in a dual-chamber and VVI implantable defibrillator pacemaker/defibrillator parturient with a KSS and preeclampsia.

Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia

BACKGROUND

Arnold-Chiari malformation Type 1 (ACM-1) in parturients is a topic of ongoing discussion between obstetricians and anesthesiologists. The primary unanswered question remains; How should the anesthesia provider proceed with labor analgesia and anesthesia for cesarean section when confronted with an advanced, asymptomatic, or minimally symptomatic case of ACM-1 during labor?

CASE DESCRIPTION

A 24-year-old, ASA II, G1P0 full-term parturient presented to Labor and Delivery for vaginal delivery. A diagnosis of ACM-1 was made 12 years ago when a brain magnetic resonance imaging (MRI) was performed for right-sided numbness following a rear-end motor vehicle collision. The patient had been asymptomatic since then and had been seen by an outside neurologist frequently for the past 10 years. During the anesthesia evaluation, it was noted that she had an exaggerated patellar reflex, and a questionable left-sided Babinski; subsequently, an MRI study was requested. Review of a brain MRI demonstrated an advanced form of ACM with a 1.7 cm transtonsillar herniation and a large syrinx extending from C1 down to C5. Following a discussion with the patient, family, and primary OB team, a plan for elective cesarean section was made per neurosurgical recommendations. This was conducted uneventfully under general anesthesia. The patient had no complaints in the post-anesthesia care unit.

CONCLUSION

Unfamiliarity of health care providers with regards to ACM-1 parturients can be countered by increasing awareness of this condition throughout medical specialties involved in their care. The Ghaly Obstetric Guide to Arnold-Chiari malformation Type 1, along with proper training of anesthesia care providers regarding the specificities of ACM-1 parturients aids in better management and understanding of this complex condition.

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics

The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H₂O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO₂ should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

[Determinants of neonatal serum calcium in a peripheral maternity in Abidjan]

Introduction

Le transfert du calcium de la mère au nouveau-né est nécessaire pour la constitution de la charpente osseuse. L'hypocalcémie néonatale reste peu documentée en Afrique. En 1993, il a été observé au service de néonatologie du Centre hospitalo-universitaire de Yopougon à Abidjan une proportion d'hypocalcémie asymptomatique de 26.9%. L'objectif de ce travail était de préciser la prévalence de l'hypocalcémie néonatale dans une maternité périphérique de Yopougon et en déterminer les facteurs de risque.

Méthodes

Une étude transversale a été menée à la formation sanitaire de de Yopougon de février à mai 2012 auprès de 145 parturientes et leurs nouveau-nés. Les caractéristiques des mères et des nouveau-nés ont été recueillies. Les prélèvements de sang maternel et du cordon ont permis le dosage des paramètres du métabolisme phosphocalcique. Une régression linéaire multiple a été faite pour apprécier les éléments de prédilection de la calcémie néonatale.

Résultats

Les valeurs moyennes étaient de 2,271 mmol/l pour la calcémie, 1,169 mmol/l pour le phosphore, 0,735 mmol/l pour le magnésium et 69 g/l pour les protides totaux chez les mères. La durée moyenne du travail était de 499 minutes. L’âge gestationnel moyen était de 39 semaines. Les constantes anthropométriques et cliniques des nouveau-nés étaient normales. Les paramètres phosphocalciques étaient en moyenne normaux (calcémie = 2,52 mmol/l, phosphorémie = 1,668 mmol/l, magnesémie = 0,777 mmol/l, protidémie = 63 g/l). Six gestantes (4,1%) étaient hypocalcémiques contre 12 nouveau-nés (8,1%). La durée du travail influençait la calcémie néonatale (p = 0,02). En analyse multivariée, 34% de la variabilité de la calcémie néonatale était expliqué par la calcémie maternelle et la durée du travail.

Conclusion

L'hypocalcémie néonatale est rare en zone tropicale. Dans cette étude, la proportion était de 8,1%. La durée du travail influençait la calcémie néonatale. Aussi, nous recommandons de poursuivre les investigations en dosant, en plus, la vitamine D et le Parathormone de la naissance à J7 de vie et préciser les étiologies de ces hypocalcémies.

Prevalence of low back pain experienced after delivery with and without epidural analgesia: A non-randomised prospective direct and telephonic survey

BACKGROUND AND AIMS

The most frequent concern of patients receiving epidural analgesia for labour pain relief is post-partum back pain. This survey was designed to assess the prevalence of post-partum backache with and without epidural analgesia among post-partum women.

METHODS

The study was conducted at a university teaching hospital and women presenting to labour room for labour and delivery formed the target population. A total of 482 women were recruited during the study period. Response rate was 95.4% and these cases were included in our statistical analysis. Two forms were designed for data collection before and after delivery; form I was filled by one of the investigators while form II was filled by a research assistant to prevent bias which included follow-up of back pain. The primary outcome variable was backache quantified with visual analogue scale score. Out of 460 women, 230 women received epidural analgesia for labour and 230 women had not.

RESULTS

The prevalence of post-partum back pain in epidural analgesia versus non epidural analgesia groups was 40.9% versus 40% on day one and 32.2% versus 35.2% after 1 week. However, after one and 3(rd) months follow-up, backache prevalence was less in epidural analgesia group (unadjusted odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.39-0.99) and (unadjustedd OR: 0.32; 95% CI: 0.15-0.69) respectively. The adjusted odd ratio was 0.59 at 1st month and 0.25 at 3rd month. There was no significant difference between the two groups in pain scores.

CONCLUSION

There was no association between the epidural analgesia and post-partum back pain.

Epidural anesthesia for cesarean delivery in a morbidly obese parturient with spinal meningioma

We report our experience with epidural anesthesia for cesarean section in a morbidly obese parturient with progressive paraplegia from a spinal meningioma. Epidural anesthesia may represent a safe anesthetic choice in such clinical situations.

Epidural anesthesia for repeat cesarean delivery in a parturient with Klippel-Feil syndrome

A patient with Klippel-Feil syndrome, morbid obesity, and scoliosis required cesarean delivery. Her previous cesarean deliveries were performed under general anesthesia. She desired a regional technique. Following aspiration prophylaxis and placement of standard monitors, ultrasound was used to identify midline and L_2-3 interspace. Unintentional dural puncture occurred at 10 cm, with an inability to advance the catheter. On second attempt, an epidural catheter was placed easily. After negative test dose, 18 ml of 2% lidocaine with epinephrine was administered to the patient. A T4 level was achieved. The patient tolerated surgery well. Complete block resolution occurred at 4 hours with no neurologic sequelae.

What is new?

The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with “what is new?” in obstetric anaesthesia.

Anaesthetic considerations for the hiv positive parturient

The HIV epidemic in children parallels that among women on account of perinatal transmission. A combination of antiretroviral therapy and elective caesarean section reduces the rate of vertical transmission to <2%. Elective caesarean section independent of antiretroviral therapy decreases the risk of HIV vertical transmission from mother to baby. However, a caesarean section is a major surgical intervention that has well-reported complications. Women infected with HIV have been reported to be more susceptible to such complications. The multi-organ nature of HIV poses challenges at the time of surgery and anesthesia. Preoperative evaluation will allow a good prediction for the perioperative risk of the HIV-patient. The anesthesiologist should be aware of the possible toxic side effects or the possible interaction of antiretroviral drugs with the anesthetics. Some of these adverse effects may mimic signs and symptoms of the HIV disease itself. Regional anesthesia has been shown to be associated with reduced morbidity and mortality in a wide range of patients, including HIV positive parturients. Finally, the possibility of transmission in the health care setting highlights the need for anesthetists to enforce rigorous infection control policies to protect themselves, other health workers and their patients.