Advances in the surgical technique, safer anesthetic agents, improved hemodynamic monitoring, better pre-operative optimization of cirrhotic patients and postoperative critical care facilities have led to drastic improvement in the outcomes following orthotopic liver transplantation (OLT). Reproductive dysfunction in patients with end-stage liver disease can be corrected within months of successful orthotopic liver transplantation. Consequently, there is a worldwide increase in the number of women of childbearing potential after orthotopic liver transplantation. Successful pregnancies are now increasingly being reported in these patients. These are high-risk pregnancies as increased medical and obstetric complications and adverse maternal and fetal effects of immunosuppressant medications are likely to be encountered in these patients following liver transplantation. Optimal antenatal and perioperative management in these parturients warrant a multidisciplinary approach and meticulous planning. There is little evidence available regarding anesthetic concerns in this high-risk pregnant population. This review is aimed at addressing important perioperative issues in parturients, who have undergone a successful liver transplantation.

Context: Neuraxial analgesia and walking epidural is the popular method of practicing labor analgesia. The combination of local anesthetic and opioid is advantageous as it prolongs the duration of labor analgesia. Ropivacaine is the newer local anesthetic agent having lesser motor effects and toxic effects hence would be preferred for labor analgesia. Aims: The primary objective of the study was to assess the duration of analgesia of the intrathecal drug. The secondary objective was the assessment of onset, fixation of analgesia, motor weakness, ambulation, sedation, incidence of side-effects, maternal, and neonatal outcomes. Settings and Design: This is prospective, randomized, controlled, double-blinded, study of 120 patients consenting for labor analgesia. Subjects and Methods: A total of 120 primiparas with a singleton pregnancy in active labor who were given combined spinal epidural (CSE) were included in the study. These patients were randomly allocated to three groups of 40 each and received CSE. Group F-received 25 μcg fentanyl intrathecally. Group BF-received 25 μcg fentanyl with 2.5 mg isobaric bupivacaine intrathecally. Group RF-received 25 μcg fentanyl with 2.5 mg isobaric ropivacaine intrathecally. Statistical Analysis Used: Correlations among different measurements were assessed using Pearson's correlation coefficients, P <0.05 was considered to be statistically significant. Results: The three groups show comparable demographic data and obstetric parameters. The duration of spinal analgesia was significantly greater with Group RF 106.63 ± 17.99 min and Group BF 111.75 ± 23.58 min than the control Group F which was 60 ± 10.39 min with P = 0.001, but were comparable for Group BF and RF. The secondary outcome was comparable in all the three groups. Conclusions: The addition of bupivacaine or ropivacaine to fentanyl intrathecally increased duration and quality of analgesia, did not affect ambulation and bearing down. The incidence of side-effects, maternal and neonatal outcomes and maternal satisfaction were comparable in all groups. Hence, the effect of both the local anesthetics with fentanyl intrathecally has similar effects, and there was no added advantage of ropivacaine over bupivacaine.

Context: Pain is subjective and labor pain perception is said to be influenced by personality, culture, parity, educational status and maternal weight. Objectives: This study assessed the Igbo Women's perception of labor pain and evaluated factors influencing their perception of labor pain as well as ascertained the level of utilization of obstetric analgesia by parturients. Materials and Methods: This was a cross-sectional study that spanned 6 months (January 1, to June 30, 2011) and involved parturients of Igbo extraction who delivered by vaginal route in 3 different referral hospitals. They were interviewed with self-administered questionnaires within the first 24-48 hours postpartum. Labor pains were rated using a 3-pont verbal rating scale (VRS). Data were analysed with MathCAD 7 statistical soft ware package. Results: A total of 530 parturients were interviewed but only 500 were analysed. Fifty-two percent of parturients rated labor pain as severe. While 67.6% of parturients desired labor pain alleviation, only 38% actually requested for analgesia, and only 27% of parturients received pain relief during labor. The commonest pain relief available was intramuscular injection of Pentazocine Hydrochloride (92.6%) The influence of age, parity, educational status, maternal weight and companionship, on pain perception was statistically significant. Conclusion: Though most Igbo women found labor painful, they tend to cope with it. Most Igbo parturients did not request for pain relief and only a fraction of those who did request received it. Adequate antenatal preparation for the birthing process is necessary.

Background: Spinal block provides excellent anesthesia for cesarean section, but it is frequently accompanied by hypotension, which if untreated can pose serious risks to mother and baby. Over the years, many interventions have been tried to prevent hypotension, but no single technique has proven to be effective and reliable. This study was carried out with the aim to find if wrapping the legs with elastic crepe bandage in addition to traditional methods was effective in preventing post spinal hypotension. Materials and Methods: A total of 60 full-term parturients with an uncomplicated pregnancy belonging to American Society of Anesthesiologists I or II were allocated randomly (30 in each group) to have their legs wrapped with elastic crepe bandage or no wrapping was done. All patients received intravenous (IV) crystalloid (20 ml/kg) 15 min prior to spinal injection and were placed in left lateral position. Electrocardiography and oxygen saturation was monitored continuously and heart rate, blood pressure was measured every 2 min until delivery of baby and every 5 min thereafter until end of cesarean section. Significant hypotension was treated with IV phenylephrine 50 µg bolus doses. Results: The frequency of hypotension was significantly less (P = 0.009) in Group B (legs wrapped group) 3 (10%) patients when compared with Group A (nonleg wrapped) 13 (43.33%). In Group A 10 (33.33%) patients and in Group B 3 (10%) patients required rescue dose with phenylephrine which was statistically significant (P = 0.0003). Difference in the "mean change of arterial pressure" between Group A and B was highly significant (P < 0.001) recorded at 4, 6, and 8 min. Conclusion: Incidence of hypotension can be reduced by wrapping the legs with elastic crepe bandage with a subsequent reduction in the use of potent vasopressor. Since leg wrapping with crepe bandage is cheap, easy, readily available, noninvasive, and nonpharmacological method, it can be recommended for preventing post spinal hypotension in a developing country like ours.

Context: The study was to compare the analgesic efficacy of three different epidural solutions - ropivacaine, ropivacaine fentanyl mixture, and ropivacaine buprenorphine mixture - for cesarean section. Materials and Methods: This was a prospective, randomized, controlled, double blind study carried out in primi parturients undergoing elective cesarean section with singleton fetus. A total of 102 parturients in the age group of 20-35 years, American Society of Anesthesiologists (ASA) I or II scheduled for elective cesarean under continuous epidural anesthesia were divided into three groups using a computer-generated random number list. The test dose (3 ml 2% lignocaine with 15 μg adrenaline) and 0.75% ropivacaine 12 ml were given to all parturients. In addition, normal saline 1 ml, fentanyl 50 μg, and buprenorphine 300 μg were given to Group I, II, and III respectively. Sensory block, motor block, analgesia, maternal effects, fetal outcome, and surgeons' and parturients' satisfaction were evaluated. Results: Onset of sensory block was faster in the fentanyl and buprenorphine groups compared to ropivacaine group (9.94 ± 0.48, 10.72 ± 0.26 versus 14.59 ± 0.34). Duration of sensory block was prolonged in buprenorphine group as compared to fentanyl and ropivacaine groups (120.41 ± 4.31) versus (95.68 ± 3.28, 98.28 ± 3.42). Duration of analgesia was prolonged in buprenorphine group compared to fentanyl and ropivacaine groups (516.38 ± 29.14 versus 327.06 ± 12.41, 285.78 ± 10.10). It proved to be safe for mother and fetus. The surgeon and the parturients were satisfied with the mode of anesthesia. Conclusion: Ropivacaine 0.75%, ropivacaine 0.75% with fentanyl 50 mg, or buprenorphine 300 mg provided safe anesthesia when given extradurally for cesarean section. Addition of both fentanyl and buprenorphine to ropivacaine hastened the onset of sensory block, while addition of buprenorphine provided prolonged excellent postoperative analgesia.

A heterogeneous group of inherited disorders of the connective tissue, characterized by skin hyperextensibility, joint hypermobility and tissue fragility, is defined as Ehlers-Danlos syndrome (EDS). The clinical manifestations vary depending on the type of disease. This syndrome may be associated with numerous pregnancy complications, ranging from mild articular discomfort to maternal death. We report the anesthetic management and the literature review of a parturient with EDS undergoing elective cesarean section.

Neurofibromatosis is a multisystem genetic disorder that is associated with cutaneous, neurologic and orthopedic manifestations. Type 1 neurofibromatosis is characterized by dermatological lesions, such as benign neurofibromas of the skin and cafι-au-lait spot, and is more common than type 2 neurofibromatosis. Anesthesiologists must be aware of and consider each of the multisystemic complications of the disorder when evaluating and managing patients for surgical procedures. Anesthesia for the pregnant patient with neurofibromatosis is not well documented. We report a successful case of spinal anesthesia for cesarean section in a parturient with type 1 neurofibromatosis.

This report describes a woman presenting for an elective caesarean section, with undiagnosed valvular heart disease. She had recent hospital admissions for respiratory dysfunction. Soon after the initial surgical incision, she became asystolic for 20-30 s with an un-recordable blood pressure. She was treated with anticholinergics and became cardiovascularly stable enough for the procedure to continue. However, she had deteriorating respiratory function. A transthoracic echocardiogram in recovery demonstrated mixed mitral valve (MV) disease, moderate mitral stenosis, and severe mitral regurgitation with evidence of severe pulmonary hypertension. She had a dilated left atrium, dilated right ventricle with pulmonary artery systolic pressures of 100 mmHg. She underwent a period of medical optimization followed by a mechanical MV replacement 6 weeks postdelivery. This case attempts to highlight the diagnostic dilemma of unknown maternal cardiac disease. The growing popularity of echocardiography as a diagnostic tool among anaesthetists and critical care physicians proved pivotal in this case.

Subdural hematoma (SDH) is a rare but serious complication of spinal anesthesia. We report a case of intracranial SDH in a patient developing 11 days after spinal anesthesia for cesarean section. The patient complained of headache on the 2^nd post-operative day that was relieved by analgesics, bed rest and hydration. Later she presented with severe headache, vomiting, dizziness, dysarthria, irritability and somnolence. Diagnosis of the left sided SDH was confirmed radiologically and treated surgically. The patient recovered completely. The report highlights the need of considering the possibility of SDH in patients when postdural puncture headache is prolonged or recurs after a headache free period with neurological symptoms.

The present case report describes an unreported complication of self limiting unilateral ptosis after uneventful lumbar epidural analgesia followed by anaesthesia for caesarean section.

Posterior reversible encephalopathy syndrome (PRES) is a recently described clinicoradiologic entity that is associated with several medical conditions like hypertensive encephalopathy and eclampsia. It presents with rapid onset of symptoms including headache, seizures, altered consciousness, and visual disturbance. It is often, but not always associated with high blood pressure. We present a case of 23-year-old patient, with unremarkable antenatal period, who developed convulsions in the immediate postpartum period following elective cesarean delivery of her triplets performed under regional anesthesia. The magnetic resonance imaging brain revealed vasogenic edema suggestive of PRES. She was managed with supportive treatment including mechanical ventilation in the intensive care unit. She recovered completely without neurological sequelae and discharged on the 8 ^th postoperative day. This case report highlights the importance of awareness, prompt diagnosis and treatment to improve the outcome in this potentially life-threatening, but reversible condition.

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinicopathological syndrome associated with various clinical conditions presenting with headache, encephalopathy, seizure and cortical visual disturbances. Radiological findings in PRES are thought to be due to vasogenic edema predominantly in posterior cerebral hemispheres and are reversible with appropriate management. We present a case of post partum PRES,A 29 year old primigravida of 33 weeks 3 days period of gestation who presented to our hospital with painless bleeding per vagina and breathlessness. A provisional diagnosis of Ante partum Haemorrhage due to Marginal Placenta Previa was made and she was admitted for safe confinement. Caesarean section was performed for APH under subarachnoid block which was uneventful. On the fourth post operative day patient developed headache and generalised tonic clonic seizures. The provisional diagnosis of Postpartum PRES was made and confirmed with MRI. All other causes of postpartum seizures were ruled out. Patient was successfully treated with anticonvulsants, corticosteroids and supportive treatment Postpartum PRES is a rare clinical condition mostly associated with hypertension, Preeclampsia and vasculitis .Early recognition and treatment can lead to complete recovery of the condition