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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Aims: The aim of this study was to evaluate the onset, duration of sensory and motor block, hemodynamic effects (if any), duration and quality of postoperative analgesia, and adverse effects of magnesium or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine in patients with mild preeclampsia undergoing elective caesarean sections. Materials and Methods: A total of 60 women with mild preeclampsia undergoing elective cesarean section were included in a prospective, double-blind, controlled trial. Patients were randomly assigned to receive spinal anesthesia with 2 mL 0.5% hyperbaric bupivacaine with 12.5 μg fentanyl (Group F) or 0.1 mL of 50% magnesium sulfate (50 mg) (Group M) with 0.15 ml preservative free distilled water. Onset, duration and recovery of sensory and motor block, time to maximum sensory block, duration of spinal anesthesia and postoperative analgesia requirements were studied. Statistical comparison was carried out using the Chi-square or Fisher's exact tests and independent Student's t-test where appropriate. Results: The onset of both sensory and motor block was slower in the magnesium group. The duration of spinal anesthesia (246 min ± 11 min vs. 284 min ± 15 min; P < 0.001) and motor block (186.3 ± 12 min vs. 210 ± 10 min; P < 0.001) were significantly longer in the magnesium group. Total analgesic dose requirement was less in Group M. Hemodynamic parameters were comparable in the two groups. Intrathecal magnesium caused minimal side effects. Conclusions: The addition of magnesium sulfate 50 mg to bupivacaine for sub-arachnoid block in patients with mild preeclampsia undergoing elective cesarean section prolongs the duration of analgesia and reduces postoperative analgesic requirements without additional side effects and adverse neonatal outcomes

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Eisenmenger's syndrome, although uncommon, has a plethora of literature available on its anesthetic management for caesarean sections. Options of management have varied from general anesthesia to continuous spinal to epidurals. However, management without the essential invasive monitoring devices poses a formidable challenge to the anesthetist. We present a case of a 26-year-old primigravida with Eisenmenger's syndrome with pulmonary hypertension in labor who underwent an emergency cesarean section under epidural anesthesia in a hospital that lacked agents to maintain the cardiovascular stability as well as monitoring equipment - a situation not so uncommon in low resourced areas. The intra-operative course was uneventful but tragically she died on the 3 ^rd postoperative day.

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Background: Hypothermia, shivering, nausea and vomiting are frequent perioperative events in patients undergoing cesarean delivery under spinal anesthesia. Apart from physical warming for shivering many drugs have also been used for prevention of these events. Objectives: We conducted a randomized double-blinded clinical trial to evaluate the effect of a single drug, granisetron on prevention of shivering, nausea and vomiting during cesarean section performed under spinal anesthesia. Materials and Methods: One hundred American Society of Anesthesiologists I-II patients undergoing elective cesarean section under spinal anesthesia were randomly allocated into two groups, control saline (n = 50) or granisetron groups (n = 50). Warmed (37°C) lactated ringer's solution was infused over 15 min before anesthesia. Spinal block was performed with the same technique in both groups. In the saline group 3 ml of 0.9% saline and in granisetron 3 mg (3 ml) granisetron was injected intravenously after intrathecal injection at identical times. Shivering, maximum and minimum level of spinal block, core body temperature, nausea and vomiting and need to treat shivering with intravenous pethidine and neonates APGAR scores were all recorded. Results: Demographic data, median of sensory block level and mean core body temperature were not statistically different in groups. Eight percent (4/50) of patients in granisetron and 54% (27/50) of patients in the saline group had shivering during the perioperative period that was treated with pethidine (P = 0.001). Ten patients (20%) in granisetron and 30 patients (60%) in saline group had nausea (P = 0.002). No patients in both groups needed rescue medication. 1 ^st and 5 ^th minutes APGAR scores of neonates were not statistically different in the groups. Ten patients (20%) in granisetron and 30 patients (60%) in saline group had nausea (P = 0.002). Conclusions: Granisetron is an effective way to prevent shivering, nausea and vomiting during cesarean delivery under spinal anesthesia with no effect on APGAR score.

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Background: Spinal anesthesia is a widely practiced anesthetic technique for cesarean delivery. Record charting and keeping during obstetric spinal anesthesia demand accuracy and completeness for patient's safety, medico-legal and research purposes. This study was conducted to evaluate the effect of teaching on improving audit of the anesthetic record charts for spinal anesthesia in obstetrics. Materials and Methods: We retrospectively reviewed 100 anesthetic charts for spinal anesthesia in the obstetric theatre of our hospital. This was followed by a lecture given by a consultant anesthetist on the importance of the anesthesia record keeping with emphasis on obstetric spinal anesthesia. Immediately after the lecture, post teaching intervention audit of 400 anesthetic charts for obstetric spinal anesthesia in four consecutive periods of 100 charts each were done. Data collected were analyzed with SPSS version 16.0. Results: A total of 500 anesthetic record charts were studied. Average percentage completion of anesthetic charts before the lecture (pre-intervention); first, second, third and fourth audit (post-intervention) were 56.1%, 70.1%, 78.1%, 81.3% and 87.7%, respectively. The level of improvement in the filling of the charts pre- and post-teaching intervention in the elective cases (54.72 vs. 83.69) and emergency cases (48.67 vs. 82.27) were statistically significant respectively (P < 0.05). Conclusion: There was a significant improvement in the adequacy of documentation of anesthetic record chart for obstetric spinal anesthesia after a teaching intervention.

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To provide optimal medical care to our patients, it is crucial that all members of operating room team have clear understanding of patients' medical needs and the risks associated with their upcoming surgeries. Multi-disciplinary meetings to establish the best treatment options regarding patient care are not new to medicine. We hereby present a case in which an obstetric patient with a rare combination of two bleeding diathesis was managed using a similar multi-disciplinary approach. A 21-year-old pregnant patient with known von Willebrand's disease type I and platelet storage pool disorder (dense granule deficiency type: Decreased number of granules per platelet) presented to her hematologist for counseling regarding her current pregnancy. Decision was made to convene a multi-disciplinary conference with the panel inclusive of personnel from anesthesiology, adult hematology, pediatric hematology, pediatrics, maternal fetal medicine, obstetrics, pathology and blood bank services along with the patient and her family. The primary concerns of anesthesiologists were whether the patient with rare bleeding diathesis combination can have neuraxial analgesia-anesthesia and how likely the patient may have severe bleeding complications requiring massive blood transfusion protocol. As patient's von Willebrand factor activity was normal (>150%) secondary to pregnancy but platelet function was impaired, the hematologist's recommendations were that patient should receive transfusion of 5 units random donor platelets prior to labor epidural catheter insertion and 5 units random donor platelets prior to removal of epidural catheter left-in-situ for 24 h postdelivery. Anesthesiologists as perioperative physicians are in a unique position to actively participate in multi-disciplinary approach to perioperative patient care. Complex patient scenarios wherein multiple clinicians are concurrently managing these patients can benefit the most from this approach.

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We are presenting the management of a patient posted for elective caesarean delivery who conceived after ovulation induction and in vitro fertilisation, 20 years after postsurgical hypopituitarism. She had uneventful pregnancy and delivered a healthy baby by caesarean section under general anaesthesia.

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