International journal of obstetric anesthesia最新文献

Clinical management of pregnant women with morbid obesity poses challenges in performing neuraxial anesthesia as well as positioning for cesarean delivery. Occupational injuries are also known to occur while caring for patients with morbid obesity. We describe two novel approaches to assist neuraxial anesthesia administration and positioning for cesarean delivery. With the assistance of the Institution’s Safe Patient Handling and Mobility Team, a universal high-back sling can be placed to lift the patient into a sitting position before neuraxial anesthesia procedure. After placement of combined spinal epidural anesthesia, the ceiling lift is used to lift the patient into a seated position and then rotate to the appropriate location on the operating room table to facilitate supine positioning. The lifting system reduces shearing of the patient’s posterior and compromising the epidural site. Team members also report reduced effort required when positioning patients from seated to supine on the operating room table. The second approach is the application of Traxi^TM abdominal pannus retractor to retract fat folds encroaching on the epidural placement site in pregnant women with morbid obesity. This is particularly useful when the traditional taping of fat folds away from the site is inadequate. The pannus retractor results in a flatter surface facilitating epidural placement. We have introduced these two approaches into our clinical practice for pregnant women with morbid obesity requiring cesarean delivery under neuraxial anesthesia.

Introduction

Prophylactic vasopressor administration reduces spinal hypotension during cesarean delivery, however the effects of vasopressor administration on neonatal acidemia remain uncertain. We examined the occurrence of neonatal acidemia in the setting of non-urgent cesarean delivery and compared outcomes between cases receiving prophylactic phenylephrine infusion versus cases treated with boluses of phenylephrine.

Methods

Retrospective cohort study with ethical approval, comparing non-urgent cesarean delivery cases performed under spinal anesthesia (2016 to 2021), receiving either prophylactic phenylephrine infusion or boluses as needed.

Data were collected from anesthesia and labor ward electronic medical records. Records with missing pH or missing blood pressure data were excluded. The independent variable was prophylactic phenylephrine administration, a strategy implemented following international recommendations in 2018. The main outcome was neonatal acidemia, defined as umbilical artery pH < 7.1. The secondary outcome was maternal hypotension, defined as at least one systolic blood pressure (SBP) measurement below 100 mmHg or below 80% baseline.

Results

A total of 4392 patients were included in the final analysis; 1318 (30.0%) received prophylactic phenylephrine infusion. Neonatal acidemia (umbilical artery pH < 7.1) occurred in 28 (2.1%) cases receiving prophylactic phenylephrine versus 50 (1.6%) treated with boluses as needed (p = 0.188). Prophylactic phenylephrine infusion was not associated with occurrence of neonatal acidemia (aOR 0.83; 95% CI 0.52 to 1.33, p = 0.435). Prophylactic phenylephrine infusion was associated with a reduced spinal hypotension rate when defined as SBP < 100 mmHg (OR 0.47; 95% CI 0.37 to 0.57; p < 0.001), with similar results when hypotension was defined as a drop below 80% or 90% of baseline SBP.

Conclusion

In this pragmatic study, prophylactic phenylephrine infusion was associated with a reduction in maternal spinal hypotension, but not reduced neonatal acidemia.

Background

Severe upper back/interscapular, neck and shoulder pain during labor epidural analgesia (PLEA) is not uncommon. The objective of this quality initiative was to evaluate the incidence, demographic associations and management of PLEA.

Methods

An eight-month, single-center quality improvement initiative was performed for the detection and management of PLEA. After survey-based consensus among obstetric anaesthetist attendings and fellows, a three-step PLEA treatment protocol with interventions and numeric rating scale (NRS, 0 – 10 scale) pain assessments was introduced. Demographic data and outcomes were compared among parturients with and without PLEA.

Results

Among 2888 women who received labor epidural analgesia from October 2022 through May 2023, 36 (1.2% [95% CI 0.9% to 1.7%]) reported PLEA. Women with PLEA were younger, more likely to be nulliparous, and had a higher body mass index (BMI) than women without PLEA (p < 0.05 for all). A total of 72.2% (26/36) of women with PLEA received at least one protocol treatment. Twenty-three women received first-line therapy, with pain relief in 91.3% (21/23). The median NRS score decreased from 9 [IQR 8–10] to 3 [1–4]. Women with PLEA had a higher incidence of cesarean delivery (CD) and a longer interval between epidural placement and delivery; 52.8 vs. 17.5% (p < 0.001) and 16.5 vs. 6.9 hours (p < 0.001), respectively.

Conclusions

The incidence of PLEA was higher than previously reported. Patients with PLEA were younger, more commonly nulliparous, had higher BMI, longer epidural infusion times and higher CD rates. A three-step treatment protocol was successful in managing PLEA.

Pregnancy in patients with dilated cardiomyopathy carries a significantly increased risk of maternal mortality or severe morbidity, and pregnancy is typically considered contraindicated for patients with severely reduced ventricular function. Nonetheless, anesthesiologists will still encounter patients with cardiomyopathy requiring delivery or termination care. This review describes how NT-ProBNP testing and echocardiography can help with early recognition of heart failure in pregnancy, and describes a suggested approach to anesthetic management of patients with cardiomyopathies or acute heart failure, including hemodynamic goals, use of vasoactive medications and mechanical support. Vaginal delivery, with effective neuraxial anesthesia is the preferred mode of delivery in most patients with cardiomyopathy, with cesarean delivery reserved for maternal or fetal indications. The Pregnancy Heart Team is vital in coordinating the multidisciplinary care necessary to safely support these patients through pregnancy.