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Journal of Obstrectic Anaesthesia and Critical Care
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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 11 | Issue 2
Page Nos. 53-133

Online since Friday, October 1, 2021

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EDITORIALS  

A ten-year-old obstetric anaesthesia journal: Musings of an editor p. 53
Anjan Trikha
DOI:10.4103/JOACC.JOACC_86_21  
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“Too powerful to push”: A rise in “on demand” caesarean section p. 56
Ketan S Parikh, Sunil T Pandya
DOI:10.4103/JOACC.JOACC_42_21  
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REVIEW ARTICLES Top

Pathophysiologic and anaesthetic considerations in iron deficiency anaemia and pregnancy; An update p. 59
Sunanda Gupta, Karuna Sharma, Charu Sharma, Alka Chhabra, Lalita Jeengar, Nalini Sharma
DOI:10.4103/JOACC.JOACC_46_21  
Anaemia is common during pregnancy, especially in low- and middle-income countries, and iron deficiency is the most common cause of anaemia worldwide. Symptoms relating to iron deficiency can be diverse, which relate to the depletion of cellular Fe function in different tissue organs and may exist long before Fe deficiency restricts erythropoiesis and anaemia develops. It is important to understand the pathophysiological and adaptation changes occurring during anaemia as long-standing changes affect the various organ systems and may impact both maternal and neonatal outcomes. There is growing evidence linking maternal IDA with subsequent neonatal cognitive and neurobehavioral outcomes, which makes it imperative that IDA should be treated early in pregnancy. Preoperative optimization with iron therapy (oral or parenteral) and erythropoiesis-stimulating agents vs replenishing O2-carrying capacity by transfusion must always be balanced against transfusion-associated risks. The anaesthetic management in parturients with severe anaemia depends on a multitude of factors, such as severity of iron deficiency anaemia, co-morbid diseases, extent of physiological compensation, and type and nature of anticipated haemorrhagic loss. This review summarizes the pathophysiological changes and adaptations consequent to oxygen delivery and iron homeostasis, therapeutic management, and anaesthetic challenges in pregnancy with IDA. It is based on electronic search strategies from Ovid Medline, Ovid Embase and PubMed (up to June 2021) along with relevant college and society web-based resources, including Royal College of Obstetricians and Anaesthesiologists, National Institute for Health and Clinical Excellence College and Society (NICE), Patient Blood Management Guidelines and American College of Obstetricians and Gynaecologists (ACOG) practice bulletins.
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Sickle cell disease in pregnancy and anaesthetic implications: A narrative review Highly accessed article p. 70
Yudhyavir Singh, Alka Chabra, Vineeta Venkateswaran, Anjan Trikha
DOI:10.4103/JOACC.JOACC_76_21  
Sickle cell disorder (SCD) is a genetic disorder of haemoglobin with a wide spectrum of severity and manifestations. It is a significant global public health problem and is mainly widespread among many tribal populations. Sickle cell disease (SCD) in pregnancy poses a unique challenge due to the physiological changes in pregnancy, the multitude of various organs involved, and its complications. The databases of PubMed, MedLine ResearchGate, EMbase, Scopus and Google Scholar were searched for literature about SCDs published up to 2021. Search terms and phrases used were 'sickle cell disease', 'sickle cell disease and pregnancy', 'anaesthesia and analgesia in sickle cell disease' and 'transfusion in sickle cell disease'. Original articles, guidelines, review articles, case reports, letters to editor and abstracts were reviewed with particular focus on pathophysiology and anaesthetic implications of sickle cell anaemia with pregnancy. While ample literature is available on SCDs, there is a paucity of literature on SCDs with pregnancy. In this review, we have attempted to present the relevant literature in a comprehensible manner.
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Pregnancy in thalassemia, anesthetic implication and perioperative management- A narrative review p. 81
Abhishek Singh, Karuna Sharma, Vineeta Venkateswaran, Anjan Trikha
DOI:10.4103/JOACC.JOACC_77_21  
Advancement in the treatment of thalassemia has increased the life span of female patients, with the result that they are reaching the reproductive age group and expecting childbirth. Anesthesia is challenging in such patients due to ineffective erythropoiesis and multiple system involvement as a result of iron overload and chelation therapy. Careful management of the preconception phase, various conception strategies, and multidisciplinary management of pregnancy and childbirth can lead to a healthy and successful outcome of pregnancy. This review provides an overview of the pathophysiology and clinical manifestation of alpha and beta-thalassemia in pregnancy and its successful management. All available literature related to thalassemia was searched in major databases like PubMed, Embase, Scopus, and Google Scholar. Original articles, review articles, book chapters, guidelines, case reports, and correspondence were reviewed for pathophysiology, clinical manifestations, and anesthetic management of thalassemia during pregnancy with keywords like thalassemia, Cooley's anemia, thalassemia and pregnancy, anesthetic management of thalassemia, labor analgesia in thalassemia, and transfusion in thalassemia.
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ORIGINAL ARTICLES Top

Airway changes before & after delivery-does labour has any effect on the modified mallampati score? p. 90
Akshaya Kumar Das, Nikki Sabharwal, Meenakshi Kumar
DOI:10.4103/joacc.JOACC_89_20  
Background: Changes in modified mallampati grade occur with the progress of pregnancy, labor, and delivery due to various reasons. This could lead to unanticipated difficulties in airway management, especially if the parturient were to undergo a surgical procedure in the postpartum period. Our study aimed to evaluate the change in airway parameters after delivery in parturient undergoing lower segment cesarean section (LSCS) under spinal anesthesia. Materials and Methods: This study was conducted at Vardhaman Mahavir (VMMC) and Safdarjung Hospital over a period of 18 months. A total of 160 patients posted for either elective or emergency cesarean section under spinal anesthesia were enrolled in the study (80 in each group). Airway parameters including modified mallampati grade (MMPG) were measured at various time intervals – before cesarean section (T1) and 2 h (T2), 6 h (T3), 24 h (T4), 48 h (T5), and 72 h (T6) after delivery and analyzed statistically. Results: Changes in MMPG occurred in 71.25% of cases in the emergency group as compared with 40% of cases in the elective group (P = 0.0001). The mean MMPG was significantly higher from 2 h up to 72 h after LSCS in the emergency group (having more patients in active labor). (P = 0.0001). Maximum changes in MMPG occurred 6 h after delivery in both groups. Normalization of MMPG to its precesarean value occurred earlier in elective patients (P = 0.0005). An association was found between the duration of labor and normalization of changes in MMPG to its preoperative value (P = 0.023). Conclusion: Airway changes in pregnant women are seen to worsen after emergency LSCS under spinal anesthesia and are affected by prolonged labor. Therefore, the maternal airway should be reassessed after the delivery of the baby, for any surgical procedure thereafter.
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Sequential organ failure assessment score for predicting outcome of severely ill obstetric patients admitted to intensive care unit p. 96
Uma Srivastava, Yogita Dwivedi, Shiva Verma, Ashish K Kannaujia, Suruchi Ambasta, Israel Lalramthara
DOI:10.4103/JOACC.JOACC_15_21  
Background and Aim: Severe maternal illness is a life-threatening condition for pregnant women and often requires admission into the ICU. The aim was to evaluate the performance of maximum sequential organ failure assessment (SOFA) score to predict the outcome of patients admitted to ICU. Material and Methods: This prospective study was done on 121 consecutive women with severe obstetric illness admitted to the ICU during one year. Basic demographic, obstetrical data, indication of admission to ICU and interventions done were noted. SOFA score was evaluated according to the worst score for each of its six components every 24 hr till discharge or death in ICU. The receiver-operator characteristic (ROC) curve was constructed to predict the outcome of ICU. For analysis, patients were categorized as survivors and non-survivors. Results: Out of 121 patients admitted, 65 survived and 56 died with mortality rate of 45.9%. There were no differences among survivor and non-survivor patients regarding demographic data, obstetrical data and interventions done, but anaemia and inadequate ante natal care was more common in non survivors. ICU utilisation rate of obstetric patients was 1.9%. Most patients were admitted due to obstetric causes (87.6%), mainly for hypertensive disorders (46%) and were post caesarean (84.29%). Total maximum SOFA scores were higher in non-survivors than in survivors (14.09 ± 5.53 vs 7.47 ± 4.58, P < 0.001). Area under curve (AUC) for SOFA score was 0.859, standard error 0.035, P < 0.001, showing good discriminatory power for predicting mortality in ICU. Conclusion: SOFA score is an effective tool to predict outcome of severely ill obstetric patients admitted to ICU.
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Effect of implementation of perineal tear pain management programme on pain scores p. 101
Karunakaran Ramaswamy, Nicolas Hooker, Zofia Kotyra, Saravanan Solai Dhanashekaran, Sam Soltanifar, Niamat Aldamluji
DOI:10.4103/JOACC.JOACC_45_21  
Background: Perineal tear (PT) occurs in more than 85% of the women undergoing vaginal birth and up to 11% of these can be third- and fourth-degree tears and the majority suffer from pain. Poorly managed pain can impact the mother and her capacity to look after the baby. The institution introduced a PT pain management programme (PPP) as part of a quality improvement programme. This paper is a retrospective analysis to determine the effect of this implementation on the pain scores and patient satisfaction. Objective: Does the PT pain management programme improve pain scores at rest 12 and 24 h post-repair? Does the programme improve maternal satisfaction? Methods: A pain management protocol had been implemented for women with PT from January 1, 2020. To assess the effectiveness of the protocol, data were retrieved from electronic medical records (Cerner Millennium) of 100 women who had a PT from January 1, 2019, to March 31, 2019 (pre-PPP), and 96 women who had a PT from April 1, 2020, to July 31, 2020 (post-PPP). We included consecutive women who had second-, third- and fourth-degree tears. Results: A significant difference in the pain scores at 12 h (mean ± SD [difference of means], 95% CI) (2.17 ± 1.11 vs. 4.5 ± 1.65 [2.33], 1.93–2.73, t (194) = 11.54, P < 0.0001) and 24 h (2.17 ± 1.11 vs. 4.32 ± 1.44 [2.15], 1.79–2.52, t (194) = 11.67, P < 0.0001) was found after the introduction of the PPP. The patient satisfaction scores after the programme were improved (8.13 ± 1.35 vs. 5.11 ± 1.72, t (194) = 13.6, P < 0.0001). Conclusions: The implementation of a pain programme for PT is associated with improvements in the pain scores and patient satisfaction. These improvements suggest that pain management protocols should be considered for women with a PT. Further prospective evaluations and work to confirm this finding would be useful in the other institutions.
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CASE REPORTS Top

Caesarean section in a case of acute coronary syndrome - A case report p. 106
Neha Mehta, Kalpesh Shah, Yogen Bhatt
DOI:10.4103/joacc.JOACC_94_20  
Acute coronary syndrome (ACS) during pregnancy is a rare event and can be a significant contributor to maternal and foetal mortality. We present here one such case of a 40-year-old primigravida posted for elective caesarean section at 36 weeks of pregnancy with a history of acute myocardial infarction (AMI) and left ventricular failure which was treated conservatively.
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Ultrasonography in aid of spinal anaesthesia in lumbar lipomas not infallible p. 109
Nita D'souza, Tasnim Karachiwala, Pratiksha Kulkarni
DOI:10.4103/joacc.JOACC_40_20  
Lipomas are benign tumours which are frequently seen, however there is no specific mention regarding the incidence of lumbar lipomas. Literature does not describe challenges of anaesthesia technique in patients with lumbar lipomas without neuro deficit. An ultrasound examination of the spine using a low frequency probe contributes to screening for the path for passage of the needle.
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Management of kyphoscoliotic pregnant patient presenting with impending respiratory failure – A case report p. 112
Shashikiran, Renu Bala
DOI:10.4103/joacc.JOACC_92_20  
Pregnancy with kyphoscoliosis is relatively a rare condition. Cardiopulmonary compromise due to mechanical restriction associated with spine deformity is exacerbated by pregnancy-related respiratory changes. We successfully managed a pregnant patient with kyphoscoliosis who reported to us in her third trimester with impending respiratory failure.
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Relapsing polychondritis in a primiparous women for elective lower segment caesarean section p. 115
Chi Ho Chan, Anqi Lu, May Un Sam Mok
DOI:10.4103/JOACC.JOACC_24_21  
Relapsing polychondritis is a rare multisystem autoimmune disorder characterized by recurrent, progressive inflammation and destruction of cartilaginous tissue. Respiratory involvement is the major cause of morbidity and mortality. Airway management during anaesthesia in these patients can be challenging and may result in failed oxygenation and death. Increased physiological demand during pregnancy further complicates anaesthesia planning. Collaborative management under a multidisciplinary team of obstetricians, obstetric anaesthetists, rheumatologist, and pulmonologist is essential. We report a case of a parturient with relapsing polychondritis and severe respiratory involvement for caesarean section under combined epidural-spinal anaesthesia and discuss the anaesthetic management based on current literature.
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Case series of perimortem caesarean delivery during maternal cardiac arrest: Our initial experience and audit p. 118
Manjot Kaur, Richa Jain, Aayushi Gulati, Ashima Taneja, Sahil Sardana, Anju Grewal
DOI:10.4103/JOACC.JOACC_35_21  
Cardiac arrest in pregnancy is a rare, catastrophic condition that can lead to major morbidity and mortality for both mother and baby. Prompt high-quality resuscitative measures need to be employed keeping in mind the altered maternal anatomy and physiology, presence of a compromised fetus, and an urgent need to deliver the baby for optimizing maternal and fetal outcomes. Therefore, it is important that health care facilities make appropriate systems in consonance with the latest recommendations of cardiopulmonary resuscitation (CPR) for this special group of parturients. Despite protocols and training, the clinical scenario often is emotionally overwhelming and brings forth an enormous cognitive load of resuscitating two lives along with the performance of perimortem cesarean delivery (PMCD) or resuscitative hysterotomy. We report five cases of maternal cardiac arrest referred to our tertiary care hospital, wherein PMCD was performed as part of ongoing high-quality CPR with manual left uterine displacement. Two mothers had a return of spontaneous circulation (ROSC), whereas ROSC could not be achieved in three. One neonate had an Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score of 8. Four neonates needed CPR, and ROSC was achieved in two of these. Underlying causes were mainly severe hemorrhagic shock, eclampsia, severe pre-eclampsia, and anaphylactic reactions. Poor survival rates in our initial experience of setting up a maternal code blue mechanism as per the guidelines reflect the need for reinforcement of early PMCD, use of cognitive aids, and retraining using mock drills and simulation for better outcomes in the future. In addition, awareness of modified obstetric warning signs in peripheral hospitals is essential so that timely referral to tertiary care centers can help salvage precious lives.
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Accidental Dural Puncture With An Introducer Needle (18 G) For Elective Caesarean Section: A case report p. 122
Omar Rajab, Saleh Kanawati, Mohamad Ali Barada, Zoher Naja, Loubna Sinno
DOI:10.4103/JOACC.JOACC_59_21  
A 23-year-old parturient with a body mass index of 20.8 kg/m2 at term was admitted for elective caesarean section. Spinal anaesthesia was done using a 27-G pencil-point needle without an introducer guide, with the usage of a separate 18-G introducer needle. After the introduction of the introducer at the level of L4–L5, accidental free flow of cerebrospinal fluid (CSF) was seen. The introducer was withdrawn and inserted at the level of L3–L4, followed by the spinal needle. CSF backflow was seen; an anaesthetic mixture was given. Block was successful and caesarean section was done with no intraoperative complications.
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Acute fatty liver of pregnancy leading to a delayed hepatic failure necessitating liver transplantation: A case report p. 124
Patriot Yang, Rutuja R Sikachi, Madina Gerasimov, Judith Aronsohn, Gregory Palleschi
DOI:10.4103/JOACC.JOACC_16_21  
Acute fatty liver of pregnancy (AFLP) is a potentially fatal metabolic disorder in pregnant patients that requires urgent delivery and aggressive medical and aesthetic management of maternal complications associated with acute liver failure. A 41-year-old female (79 kg) G1P0 at 31 weeks gestation presented with nausea, vomiting, pruritus, and jaundice. A diagnosis of severe liver dysfunction secondary to AFLP was made. We proceeded with urgent delivery under general anaesthesia. The patient had an uncomplicated caesarean section and gave birth to female infant with Apgar scores of 7 and 8. The patient remained stable for the following 2 weeks, however, given the lack of further recovery of hepatic function, a transjugular liver biopsy was performed, revealing persistent AFLP. She received N-acetylcysteine infusion and 4 cycles of plasma exchange with no improvement. Over the next few days her mental status worsened and her liver functions further deteriorated. She was listed for a deceased liver donor transplant and underwent successful orthotopic liver transplantation. She was discharged on post-operative day (POD) 14 of liver transplant.
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LETTERS TO EDITOR Top

Pseudodextrocardia delaying the diagnosis of peripartum cardiomyopathy p. 127
Anjishnujit Bandyopadhyay, Neeru Sahni, Gorla Deep Kanth
DOI:10.4103/joacc.JOACC_27_21  
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Implications of active infective endocarditis with pregnancy and its management p. 128
Parmeet Bhatia, Deepak Dwivedi, Alok R Gautam, Shalendra Singh
DOI:10.4103/JOACC.JOACC_10_21  
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Extension of labor epidural analgesia for emergency cesarean section: A survey of practice in the United Kingdom p. 130
Thomas E Potter, Neel Desai
DOI:10.4103/JOACC.JOACC_36_21  
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Failure of resuscitative hysterotomy to rescue peripartum cardiac arrest p. 131
Isha Kunagpa, Bharti Sharma, Prerna Verma, Sujata Siwatch, G R V. Prasad, Kajal Sharma
DOI:10.4103/JOACC.JOACC_30_21  
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