Background: In this study, we evaluated the performance of the Baska Mask^® , a new extraglottic airway device (EAD) for use in anesthesia in adult patients undergoing a variety of surgical interventions. Materials and Methods: The self-recoiling membrane distally open cuff silicone mask consists of an anatomically curved airway tube with: (1) a bite block over the full length of the airway; (2) a self-sealing membranous variable-pressure cuff which adjusts to the contours of the mouth and pharynx; (3) a large sump cavity with two aspiratable gastric drain tubes; together with a number of special features such as (4) a tab for manually curving the mask to ease insertion; and (5) a suction elbow integral to one port with a second port acting as a free air flow access. The cuff of the Baska Mask^® is not an inflatable balloon, but a membrane which inflates on every breath during intermittent positive pressure ventilation (IPPV) to achieve a superior seal when opposed to the larynx. An increase in IPPV pressure increases the oropharyngeal seal. With existing extraglottic airway devices, an increase in IPPV merely increases the leak. Results: Fifty patients with American Society of Anesthesiologists (ASA) physical status I-III were enrolled. We evaluated the "first attempt" and "overall insertion" success rates, insertion time, ease of insertion and removal of the device, oropharyngeal leak pressure, and anatomical position at fiberoptic view. The "first attempt" success rate was high (88%) and "overall insertion" success rates was considered "easy" to "very easy" by the operators in 92% of patients. Removal of the device was considered easy in all cases. The oropharyngeal leak pressure was above 30 cm H ₂ O in all patients and the maximum of 40 cm H ₂ O was achieved in 82% of the patients. In two patients, no adequate capnogram was obtained, so a smaller size mask was inserted with correction to adequate function. At fiberoptic evaluation of the anatomical position of the masks, the vocal cords could be seen, except in six patients (12%), where only the epiglottis could be visualized. Conclusion: The new EAD Baska Mask^® has many novel features which should improve safety when used in both spontaneously breathing and IPPV anesthesia.

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Dexmedetomidine is a highly selective α-2 agonist, which when used in recommended dose in the form of an infusion, has several desirable properties like sedation, anxiolysis, sympatholysis, analgesia, decreased anesthetic requirements, maintains cardiovascular stability and provides a smooth recovery. Anesthesiologists have used this drug with great reluctance in parturients due to possible uteroplacental transfer, thereby, causing undesirable effects in the baby. However, literature shows that as dexmedetomidine has a high placental extraction, it doesn't ge transferred to the baby. We tried to review the available literature so as to find in what circumstances it has been used in parturients and in future what are the possible indications of its use in labor analgesia, cesarean section, and non-obstetric surgeries.

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Neuraxial blocks in parturients with scoliosis and/or previous back surgery have traditionally been avoided due to concerns such as difficulty, increased complications, and decreased efficacy. Recent studies suggest that with attention to proper anesthetic technique and improvements in surgical procedures the success rate of neuraxial blocks is improved. The use of ultrasound may also improve the success rate of neuraxial blocks and should be considered. We review the recent literature and suggest practical approaches to neuraxial blocks in these parturients.

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In vitro fertilization (IVF) is one of the most recent advances in the treatment of infertility. The availability and utilization of this technology are increasing by the hour. IVF procedures are usually performed on an outpatient basis under day care surgery units. Various anesthetic modalities and analgesic regimens have been tested in different studies, but no definite conclusion so far been made regarding the preferred technique for anesthesia and pain relief for these procedures. Many anesthetic drugs have been detected in the oocyte follicular fluid and may potentially interfere with oocyte fertilization and implantation. The ideal anesthetic technique for IVF should provide good surgical anesthesia with minimal side effects, a short recovery time, high rate of successful pregnancy, and shortest required duration of exposure. The preferred method of anesthesia and analgesia should be individualized as at present there are no perfect answers.

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Peripartum cardiomyopathy (PPCM) is a disease affecting the parturient during late pregnancy or immediately after delivery. This unique disorder not just endangers the life of mother and progeny but is also a financial burden to the health system due to its potential to cause prolonged and persistent cardiac function insufficiency in the mother. The hallmark of the disease is onset of decreased cardiac ejection fraction either in the late pregnancy or early puerperium. Over the last few decades, the disease has been extensively researched and investigated to formulate diagnostic guidelines and therapeutic approaches. Many theories regarding its pathophysiology have also been proposed. The clinical presentation and the basic and intensive interventional strategies of the disease are more or less similar to that of dilated cardiomyopathy due to any other cause; however, at all points of time the pregnant or lactating state of mother and the subsequent effect of the medication and therapeutic interventions on the fetus or neonate needs to be considered. Apart from intensive care management, these patients may also require anaesthetic intervention for management of painless labor and/or either vaginal or operative delivery. Favorable maternal and fetal outcome require that the basic hemodynamic goals be always kept in mind while choosing the techniques and drugs to provide anaesthesia to the patients with PPCM. Literature search of the anaesthetic management of patients with diagnosis of PPCM undergoing operative delivery reveals both general and regional anaesthesia being used with comparable outcomes.

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Headache in the postpartum period is common and multifactorial in origin. Apart from primary causes such as tension headaches and migraine, secondary headaches such as post-dural puncture headache (PDPH) are increasingly common because of increasing use of regional anaesthesia and analgesia during childbirth. Preventive measures for PDPH include the use of smaller gauge pencil-point needles for spinal blocks; epidural needles of 18 G or less; using saline rather than air for epidural space identification and the use of ultrasound guidance, especially for difficult cases such as morbid obesity and spinal deformities. In case of accidental dural puncture (ADP), the choice is between inserting the catheter in an adjacent space or intrathecal catheterization. Current evidence seems to be in favour of inserting the epidural catheter into the subarachnoid space and using the intrathecal catheter for analgesia/anaesthesia after prominently labelling it as intrathecal, to prevent misuse. It should be removed after at least 24 hours and a 10 ml bolus of saline injected before removal of catheter may be helpful. Either way, having written protocols for the management of accidental dural puncture helps to reduce the incidence of PDPH. PDPH can be disabling in severity and can mar the whole experience of childbirth. In addition, severe untreated PDPH can cause complications such as nerve palsies, subdural hematoma and cerebral venous thrombosis. Conservative methods of treatment should be tried first such as adequate hydration, paracetamol, caffeine, sumatriptan or ACTH/hydrocortisone. Epidural blood patching is the most effective treatment for PDPH. It is more effective if done 24-48 hours after dural puncture. It is an invasive procedure with its own complications as well as a failure rate of up to 30%, so that a second or even third patch may be necessary. Both these facts should be intimated to the patient beforehand. Meticulous follow-up and evaluation of these patients is an important responsibility of the obstetric and anaesthetic team. Persistent headache, loss of the postural nature of the headache, altered sensorium, onset of focal neurological deficits and seizures are all features necessitating further investigation including neuroradiological imaging.

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A syncopal attack is a sudden loss of consciousness and muscle tone that may be due to various reasons. Vasovagal attack is one of the reason that leads to an unanticipated syncopal attack. A case is described in which a high level of anxiety and pain during insertion of the spinal needle caused a vasovagal attack. A 36-year-old female patient was posted for exploratory laparotomy. During the insertion of a 25-gauge spinal needle she became unconscious with the loss of muscle tone. The spinal needle got bent when it was still present inside the patient. The spinal needle was removed immediately with restoration of airway and circulation. A patient undergoing elective surgery with adequate anxiolysis can still have a rare chance of a syncopal attack.

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Background: Minimum effective concentration of local anesthetics for providing optimal labor epidural analgesia and the strategies aiming to reduce their consumption are continuously being searched. Objectives: The objective of this study was to evaluate the efficacy of 0.125% and 0.2% ropivacaine both mixed with fentanyl 2 mcg/ml for epidural labor analgesia. Materials and Methods: A total of 80 parturients in active labor were randomly assigned to two groups of 40 each, to receive an epidural injection of 15 ml ropivacaine 0.125% with fentanyl (2 mcg/ml) in group R1 and 15 ml of ropivacaine 0.2% with fentanyl (2 mcg/ml) in group R2 as initial bolus dose. Same dose regimen was used as subsequent top-up dose on patients demand for pain relief. The duration and quality of analgesia, motor block, top-up doses required consumption of ropivacaine and fentanyl and feto-maternal outcome in both groups were compared. Results: Effective labor analgesia with no motor blockade was observed in both groups with no failure rate. Onset of analgesia was significantly faster in group R2 (75% parturients in 0-5 min) as compared to group R1 (25% parturients in 0-5 min), P < 0.001. Duration of analgesia after initial bolus dose was also significantly longer in group R2 (132 ± 56.81 min) than in group R1 (72.25 ± 40.26 min), P < 0.001. Mean VAS scores were significantly less in group R2 than in group R1 at 5, 60, and 90 min, P < 0.01. Requirement of top-up doses was significantly less in group R2 (0.05 ± 0.22) as compared to group R1 (0.80 ± 0.65), P < 0.001. Consumption of ropivacaine was comparable in both the groups (33.75 ± 12.16 mg in group R1 and 31.50 ± 6.62 mg in group R2 P > 0.05), but consumption of fentanyl was significantly more in group R1 (54.00 ± 19.45) as compared to group R2 (31.50 ± 6.62), P < 0.001. There were no significant changes in hemodynamics, nor adverse effects related to neonatal or maternal outcomes in both groups. Conclusion: We conclude that both the concentrations of ropivacaine (0.2% and 0.125%) with fentanyl are effective in producing epidural labor analgesia. However, 0.2% concentration was found superior in terms of faster onset, prolonged duration, lesser breakthrough pain requiring lesser top-ups, and hence a lesser consumption of opioids.

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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.

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Management of a parturient with systemic lupus erythematosus (SLE) requires a multidisciplinary approach. Although the ideal treatment strategy has not been formulated, certain management principles are recommended. We discuss the perioperative course and anesthetic management of five parturient with history of SLE who underwent cesarean section.

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Background: Maternal hemodynamic changes are common during spinal anesthesia for cesarean delivery. Many agents are used for treating hypotension. In this study we compared the efficacy of ephedrine and phenylephrine in preventing and treating hypotension in spinal anesthesia for cesarean section and their effect on fetal outcome. Materials and Methods: A total of 100 ASA Grade I patients undergoing elective cesarean section under spinal anesthesia with a normal singleton pregnancy beyond 36 weeks gestation were randomly allocated into two groups of 50 each. Group I received prophylactic bolus dose of ephedrine 10 mg IV at the time of intrathecal block with rescue boluses of 5 mg. Group II received prophylactic bolus dose of phenylephrine 100 μg IV at the time of intrathecal block with rescue boluses of 50 μg. Hemodynamic variables like blood pressure and heart rate was recorded every 2 minutes up to delivery of baby and then after every 5 minutes. Neonatal outcome was assessed using Apgar score at 1 and 5 minutes and neonatal umbilical cord blood pH values. Results: There was no difference found in managing hypotension between two groups. Incidence of bradycardia was higher in phenylephrine group. The differences in umbilical cord pH, Apgar score, and birth weight between two groups were found statistically insignificant. Conclusion: Phenylephrine and ephedrine are equally efficient in managing hypotension during spinal anesthesia for elective cesarean delivery. There was no difference between two vasopressors in the incidence of true fetal acidosis. Neonatal outcome remains equally good in both the groups.

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Since a century, we have been using magnesium sulfate for prophylaxis and treatment of eclamptic seizures. There are various regimens followed throughout the world. Although the efficacy is of no doubt, side effects remain a problem. Here, we present a rare case of magnesium toxicity with normal serum magnesium levels.

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We report the anesthetic management of a case of Guillain-Barre syndrome in the 34 ^th week of gestation coming for an emergency Cesarean section. The perioperative anesthetic challenges have been discussed with emphasis on the medical and anesthetic management which includes the use of plasma-pheresis, intravenous gamma-globulin, and the safety of preservative free 0.75% isobaric ropivacaine, which was administered intrathecally in this difficult medical condition with excellent hemodynamic, maternal, and fetal outcome. The sensory and motor blocks achieved were well suited to the clinical risks and conditions.

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Mitral stenosis in pregnancy is poorly tolerated because of the pregnancy induced physiological changes in the cardiovascular system. Our patient had presented with cardiac failure in 5 ^th month of gestation due to valve area of 0.8 cm ² . She underwent commissurotomy and was asymptomatic with valve area of 1.6 cm ² until term when she developed lower respiratory tract infection. Anesthetic management of emergency caesarean section in this patient is discussed where neuraxial block is not well-tolerated, and general anesthesia is associated with increased morbidity in the presence of reactive airways.

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Amniotic fluid embolism (AFE) is a rare complication of pregnancy carrying a high mortality rate. The exact pathogenesis of the condition is still not known. Diagnosing AFE needs a high suspicion as it is essentially a clinical diagnosis of exclusion. Patients with AFE are best-managed in a critical care unit by a multidisciplinary team and management is largely supportive. This review compiles the currently available information on AFE.

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The advancements in medicine have made early detection and management of medical diseases possible especially during the pregnancy. The physiologic alterations of pregnancy have important implications for renal structure and functions, which may possibly lead to diagnostic dilemmas and wrong interpretation of various investigations carried out during the gestational period. Renal diseases are extremely challenging to treat during pregnancy as various drugs can have adverse effect on the pregnancy outcome. In general, these patients may either progress to normal delivery or may have to undergo surgical delivery under anesthesia. Apart from these anticipated challenges, many other renal problems can develop during the pregnancy in patients with normal renal functions such as urinary tract infections, acute kidney injury or renal trauma. Planning of pregnancy in renal diseases is also associated with increased potential risks especially in patients on dialysis as well as in patients who had undergone renal transplantation.

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Background : The present audit was initiated to evaluate the knowledge, attitude, perception and acceptance of women toward labor analgesia and caesarean section, in a Medical College Hospital in Udaipur, India. Materials and Methods : A semi-structured interview of 200 antenatal women was conducted, to assess the knowledge, attitude and perception regarding labor analgesia and caesarean section (CS) and to estimate the correlation of awareness and acceptability with demographic variables. The data were analyzed using Epi Info 6 and the Likert type scale (0 - 10), as also the chi square test, to calculate the statistical significance. Results : Most of the patients (n = 181, 90.50%) were unaware of labor analgesia. When the option of labor analgesia was offered, only 23% (n = 46) accepted it and the most significant reason for refusal was to experience natural child birth (n = 114 / 154, 74.03%). An educational status of the graduate level had a positive impact on knowledge about labor analgesia (P = 0.0001). When the option for CS was offered, 73.50% women (n = 147; P = 0.008) refused and the most common reasons for refusal were fear of operation (53.06%, n = 78) and delay in resuming household work (46.26%, n = 68). Educational status up to the graduate level and previous surgical experience of CS had a positive correlation with preference for CS (P = 0.0092 and P = 0.0001, respectively). Conclusions : Awareness and acceptance for labor analgesia was relatively low among the prospective parturients. A higher level of education had a significant impact on their decisions regarding delivery.

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Antiphospholipid antibody syndrome is an autoimmune disorder characterized by venous and/or arterial thromboses. When present in women of reproductive age, it is associated with recurrent loss of pregnancy. This case report summarizes the perioperative course and anaesthetic management in a patient with bad obstetrics history who had to undergo emergency caesarean section.

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Critically ill obstetric patients present a unique challenge as outcome of indwelling life is dependent upon the maternal well-being. Optimal patient management involves early detection and the multidisciplinary treatment by obstetricians, pediatricians, and anesthesiologists based on knowledge of physiological and pathophysiological alterations. This article aims to provide a comprehensive review of the available literature for the management of critically ill obstetric patient and recent update on commonly encountered situations.

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Background: Upper airway obstruction can present with stridor or wheeze and is sometimes misdiagnosed as asthma. As asthma is common amongst pregnant women, upper airway obstruction can remain hidden. Case: We describe the case of goitre-related life threatening upper airway obstruction which was initially thought to be poorly controlled asthma in a pregnant woman. Careful history, high clinical suspicion and directed imaging was required to make the diagnosis. A multi-disciplinary team and meticulous planning was required to safely treat the parturient. Conclusion: As asthma has an incidence of 3%-12% among pregnant woman; wheezing is likely to be diagnosed as asthma. Our case illustrates the importance of detailed history, examination and imaging in the parturient who presents with wheeze. It also highlights the added complexity of managing a patient with a life threatening airway problem while she is pregnant.

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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.

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