Rates of opioid prescribing are at historically high levels, and, as opioid exposure increases, the number of women of childbearing age with opioid use disorder is rising. Despite this growing population, the optimal management of pain for parturients maintained on medical-assisted therapy (MAT, i.e., methadone or buprenorphine) is unknown. This systematic review is intended to evaluate patient outcomes associated with pain management strategies for parturients on MAT. Literature databases EMBASE, MEDLINE, and the Cochrane Library were searched up to September 2017. Articles were included if they discussed peripartum analgesic options for pregnant women with opioid dependence. The search identified 1,814 articles, of which, nine matched all inclusion criteria and were selected for data extraction and analysis. Articles were a mix of case series, retrospective case reviews, retrospective cohorts, and randomized controlled trials. They showed various responses ranging from no difference in analgesic requirements between MAT and non-MAT patients to MAT patients requiring higher amounts of opioids after a cesarean section. Parturients on MAT present a number of challenges for obstetric anesthesiologists, but various approaches can be used to achieve satisfactory analgesia. It is important to practice an individualized yet multidisciplinary approach to ensure the delivery of optimal patient care.

Background and Objective: Epidural analgesia is the most commonly practiced method for labor analgesia. It provides effective pain relief, less maternal stress response, better parturient satisfaction and the ability to provide anesthesia when required. We conducted this study to evaluate the efficacy of Magnesium Sulphate as an adjunct to ropivacaine and fentanyl for labor analgesia. Materials and Methods: 60 primi parturients, aged more than 18 years, ASA physical status class II, in active labor, requesting labor analgesia were included in this prospective randomised double blind study. Patients in Group F received 7.5 ml 0.2% Ropivacaine + 50 mcg Fentanyl + Normal Saline to make a total volume of 10 ml and in Group FM received 7.5 ml 0.2% ropivacaine + 50 mcg fentanyl + 50 mg MagnesiumSulphate + Normal Saline to make a total volume of 10 ml. Pain was assessed using Visual Analogue Scale (VAS). Time of onset, quality of analgesia and duration of analgesia of bolus dose were noted. Results: Epidural single dose Magnesium Sulphate added to ropivacaine and fentanyl resulted in significantly early onset (2.9 ± 0.7 min v/s 5.2 ± 1.1 min, P < 0.001) and longer duration of epidural analgesia (107.2 ± 20.1 min v/s 89.9 ± 21.3 min, P = 0.002) as compared to those patients who received ropivacaine and fentanyl only. There was no significant effect on neonatal outcome (assessed by APGAR Score) and no maternal side effects were recorded. Conclusion: Magnesium sulphate added to ropivacaine and fentanyl for labor analgesia resulted in early onset of analgesia and longer duration of action without any significant side effects.

Context: Following cesarean section, pain is anticipated. An important component of pain after cesarean section is from abdominal wall incision. Transverse abdominis plane (TAP) block can be used as a part of multimodal analgesia for cesarean section. Aims: To assess the analgesic efficacy and safety of ultrasound-guided TAP block in postcesarean section patients. Methods: Sixty patients undergoing cesarean section under spinal anesthesia were included in this randomized control study. They were divided into three equal groups, A, B, and C. All patients received diclofenac suppository 100 mg 12^th hourly and intravenous paracetamol 1g 8^th hourly after surgery. Group A patients underwent TAP block after the surgery using a total of 40 ml of 0.25% bupivacaine bilaterally. Group B patients underwent TAP block using 20 ml of 0.25% bupivacaine with clonidine 2 μg/kg. Group C patients did not undergo any block. Postoperative blood pressure, heart rate, nausea, vomiting, sedation, and pain score were noted. Kruskal–Wallis test, Chi-square test, and Mann–Whitney test were used for statistical analysis. Results: Patients who received TAP block had prolonged analgesia. The mean time to rescue analgesia was 8.6 ± 2.8, 7.9 ± 3.8, and 3.5 ± 3.1h for groups A, B, and C, respectively. The pain scores in group A and B were less than group C. Comparison of pain score between group A and B did not show any statistical difference. Conclusion: Ultrasound-guided TAP block is a safe and effective method of providing postoperative analgesia in caesarean patients. Addition of clonidine does not provide any additional benefit.

Context: Spinal anesthesia is the preferred anesthetic technique for cesarean section. Lateral and sitting positions are commonly used for performing subarachnoid block in parturients. Maternal positioning affects the spread of local anesthetic drugs and affects the onset and level of block. Faster onset of block is associated with hemodynamic changes having detrimental effects in parturients. Aims: The aim of our study is to evaluate the effectiveness of two maternal positions – lateral and sitting. Materials and Methods: This prospective randomized control study was conducted on 100 parturients undergoing elective cesarean section under spinal anesthesia. They were randomly assigned into two groups. Group L received spinal anesthesia in lateral and group S in sitting position. Time to achieve T5 blockade, hemodynamics, motor blockade, fetal pH, and Apgar score were noted. Independent sample 't' test, Chi-square test, and paired t test were used for statistical analysis. Results: Time to achieve T5 dermatomal level was less in group L which was statistically significant (2.60 ± 0.535 vs. 4.34 ± 0.745 min, P < 0.001). Number of attempts required and time taken for giving spinal was significantly more in group L. The drop in mean arterial pressure and requirement of phenylephrine was more in lateral position. Conclusion: Adoption of sitting position while performing subarachnoid block for cesarean section was found to be superior to lateral position in view of better hemodynamic stability, need for fewer attempts, and better maternal comfort, though time to achieve T5 block was longer.

Background: Labor pain is an inevitable experience for parturients with choice for labor analgesia depending on awareness, parturients' education, availability, cost and adverse effects of the analgesic materials. Methods: All pregnant women attending booking clinics in the obstetric units of our hospital were recruited into an open-label randomized control trial for a period of 3 months into either intervention or control group. The pregnant women in the intervention group were shown a video demonstration on epidural labor analgesia in addition to distribution of epidural information leaflets with verbal explanation on pain management in labour. The control group had the same exposure except the video demonstration. An interviewer semi-structured questionnaire was used to collect information on biodata, knowledge of pain management in labor, previous labor pain experience, willingness to receive epidural labor analgesia in the current pregnancy and factors associated with willingness to receive epidural labor analgesia. Data were analyzed using descriptive and inferential statistics with P < 0.05 accepted as statistically significant. Results: Out of the 199 expectant mothers that participated in the study, 95 (47.7%) were in the intervention group and 104 (52.3%) in the control group with 18 (18.9%) and 5 (4.8%) patients had prior knowledge of epidural labor analgesia respectively. A higher proportion of 41 (43.2%) of participants in the intervention group were willing to receive epidural analgesia in the current pregnancy, when compared with 13 (12.5%) in the control group (P = 0.001). Conclusion: Addition of video demonstration to epidural leaflet information with verbal explanation in the intervention group increased the willingness of pregnant women to request for epidural pain relief in the current pregnancy compared to the control group.

Background and Aims: The management of post-cesarean delivery pain is of utmost importance to prevent undesirable outcomes. Local anesthetic wound infiltration and bilateral ilioinguinal-iliohypogastric (ILIH) nerve block are two potential techniques to provide better postoperative analgesia. In this study, these two techniques have been compared for the management of postoperative pain in the elective cesarean section. Materials and Methods: After approval from the institutional ethics committee and informed consent from patients, this study was conducted on 150 patients who underwent elective cesarean section under spinal anesthesia. Patients were allotted into three groups: group C (postoperative sham injection), group L (postoperative infiltration of incision site with 20 mL of 0.5% ropivacaine), and the group I (postoperative bilateral ILIH block with 10 mL of 0.5% ropivacaine on each side under ultrasound guidance). The objectives of our study were to evaluate the duration of analgesia, visual analog scale (VAS) score, and the cumulative analgesic requirement for pain relief and a number of analgesic demands. Student t-test and Mann-Whitney U test were used to compare the analgesic parameters among the groups. Results: Group I had a significantly longer duration of analgesia (515.64 ± 82.87 min) compared to group L (280.87 ± 39.47 min), and group C (246.89 ± 37.85 min). Group I had significantly lower VAS scores compared to the groups L and C. Group I (1.72 ± 0.68) had lower analgesic demands compared to group L (3.26 ± 0.64) and group C (4.62 ± 0.65). The cumulative analgesic requirement was significantly lower in group I. Conclusion: ILIH nerve block has a longer duration of postoperative pain relief in cesarean delivery patients compared to local infiltration and placebo.

Introduction: Hypotension is a common complication after spinal anesthesia for cesarean delivery which is caused by sympathetic block 1. This can result in adverse maternal and fetal outcomes. Hence prevention and early treatment of spinal hypotension early has been a key research area in obstetric anesthesia. Intermittent non-invasive blood pressure measurement is the standard practice that fails to detect episodes of hypotension in a timely fashion. Methods: Noninvasive PI and blood pressure were measured in 109 healthy parturients undergoing elective cesarean section under spinal anesthesia. Results: PI appeared to increase significantly and more quickly in parturients with significant hypotension. Discussion: Findings may be due to the thoracic sympathetic blockade. Conclusion: Perfusion index can be a useful tool to early predict hypotension following spinal anesthesia for cesarean section. Response to ephedrine can be quickly assessed by the change in the PI which helps to decide on further boluses of ephedrine. Effect on the vascular tone by oxytocin is significant with 5IU bolus, though it does not cause a significant blood pressure drop.

28-year-old G1P0 at 33 weeks gestation presented with abdominal pain, elevated blood pressures and worsening edema. Laboratory workup revealed abnormal transaminases and hypofibrinogenemia. Diagnoses of disseminated intravascular coagulation (DIC) and acute fatty liver of pregnancy (AFLP) were made and out of concern for placental abruption, an emergency cesarean section was planned. Preoperatively, cryoprecipitate and fresh frozen plasma (FFP) were administered. Cesarean delivery was performed under general anesthesia. Postoperatively, her course was complicated by ongoing metabolic derangements and acute liver failure. She was transferred to a liver transplant facility and remained hospitalized for several months with gradual clinical improvement.

Leukemia is a very rare condition in pregnancy. The pathology itself poses a great challenge to the anesthesiologist due to the inherent risks such as blast crisis, tumor lysis syndrome, anemia, and thrombocytopenia. The authors present the case of a 30-year-old G3P2002, complicated by profound thrombocytopenia refractory to platelet transfusion who underwent general anesthesia for cesarean section.

Spontaneous pneumothorax during pregnancy is a rare condition. Only 56 cases have been reported in the English literature. A primigravida at 32 weeks pregnancy presented with breathing difficulty, left chest pain, and cough for 2 days. She was diagnosed to have left primary spontaneous pneumothorax and multiple unruptured blebs and bullae of the right lung. A left chest tube was inserted which relieved her symptoms. However, after 3 weeks, she again developed breathing difficulty so she was planned for an emergency cesarean section. The anesthesia was challenging as she could lie down only in the 60° propped-up position. With spinal anesthesia, desired level of block could not be achieved. General anesthesia also could not be given as it will cause further rupture of blebs and bullae. Therefore, the operation was performed under epidural anesthesia using injection ropivacaine in the same 60° propped-up position.

Asymptomatic lung cysts in prepregnant state can have its first manifestation during pregnancy due to altered respiratory physiology. They offer special challenge due to difficult diagnosis and definite treatment during pregnancy. We report case of a 26 years old parturient, G2P1L0 at 36 weeks period of gestation who presented as non resolving pneumothorax which was later diagnosed as a giant lung cyst for cesarean section.

Achondroplasia is a genetic disorder where there is underdevelopment and shortening of the long bones formed by endochondral ossification without abnormalities of cartilage formation. Patients with achondroplasia can exhibit various manifestations: spinal abnormalities; thorao-lumbar kyphoscoliosis, respiratory and cardiac abnormalities; obstructive sleep apnea; and changes of the head and the midface. In women with achondroplasia, cesarean delivery is inevitable because the pelvis is invariably small. Anesthetic management for cesarean section in this population is controversial; the choice of anesthetic technique depends on the benefits and risks of each technique. Emergency cesarean is another factor to consider for the choice of anesthetic technique. We report the case of a 34-year-old Moroccan primipara with achondroplasia who had a cesarean delivery under Spinal anesthesia. Other possible anaesthetic techniques used for cesarean sections in such patients are also discussed.

Sheehan's syndrome (SS) or adenohypophyseal insufficiency is a rare but known complication of postpartum hemorrhage (PPH). It develops as result of ischemic pituitary necrosis secondary to a brutal and extended shock due to obstetric hemorrhage. The clinical presentation of this syndrome is variable and marked with abrupt or insidiously developing pituitary insufficiency. We report a case of 35-year-old female scheduled for laparoscopic appendicectomy under general anesthesia who developed delayed recovery. Proper history revealed that patient had history of severe PPH and was amenorrheic after that for last 4 years. Investigation revealed that pan hypopituitarism and neuroimaging (magnetic resonance imaging) showed reduced pituitary size. Replacement of deficient hormone leads to recovery and weaning from mechanical ventilation.