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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Background: There is a constant endeavor for newer, safer anesthetic agents providing effective block characteristics and having minimal side effects. Hyperbaric bupivacaine is the most frequently used anesthetic agent for cesarean section. Levobupivacaine is less toxic to the heart and central nervous system, but there are few studies of its use in cesarean section, hence the present study was undertaken to compare the quality of sensory and motor block and side effects if any, following intrathecal levobupivacaine and hyperbaric bupivacaine, in parturients undergoing elective cesarean section. Materials and Methods: Sixty American Society of Anesthesiologists I or II parturients for the elective cesarean section were enrolled in this prospective randomized, double-blind study. Using computer generated codes, the parturients were randomly assigned to two groups with patients in Group L (n = 30) and Group B (n = 30). Subarachnoid block was performed with 2 ml of 0.5% isobaric levobupivacaine in Group L and 2 ml of 0.5% hyperbaric bupivacaine in Group B. Characteristics of sensory and motor block were assessed with pinprick and Bromage scale, respectively. Side effects such as hypotension, bradycardia, nausea, and vomiting were recorded. Results: Both the duration of sensory and motor block were shorter in parturients in Group L than those in Group B (80.03 ± 8.12 vs. 103.47 ± 10.18 min and 64.37 ± 7.42 vs. 94.70 ± 9.18 min), the difference being highly significant (P < 0.001). None of the patients required analgesic supplementation intraoperatively. The maximum sensory block height achieved in Group L was significantly lower than Group B (P = 0.003). The incidence of side effects (hypotension, bradycardia, nausea, and vomiting) was lower in Group L as compared to Group B (10% vs. 33.3%, 3% vs. 16%, 6.6% vs. 26% and 0% vs. 3.3%); with P < 0.05 for hypotension and nausea. Conclusion: Adequate surgical anesthesia can be achieved with both levobupivacaine and hyperbaric bupivacaine as tested by the loss of pinprick sensation in both groups. Levobupivacaine given intrathecally can provide safe and effective analgesic choice for parturients undergoing elective cesarean section as the incidence of side effects with its use was significantly lower in comparison to hyperbaric bupivacaine.

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Background: Ketofol is a combination of ketamine and propofol in a single syringe which can be prepared in any desired concentration. Several gynecological procedures like tubal sterilization are of short duration and just require analgesia and moderate sedation. A study was conducted to compare two different proportions of ketofol, with reference to the duration and level of sedation, quality of analgesia, hemodynamic and respiratory profiles, and to compare all the above effects with the well-tried propofol-fentanyl combination. Materials and Methods: This prospective randomized double-blind study was conducted on 60 adult females scheduled for elective tubal sterilization by minilaparotomy. Patients received a slow bolus injection followed by small aliquots of ketofol containing ketamine: Propofol (1:1) (group A), ketamine: Propofol (1:2) (group B), and fentanyl: Propofol (group C) to a predetermined sedation level using Ramsay Sedation Scale. Vital signs, oxygen saturation, and incidence of any side effects were recorded. Results: Ketofol in groups A and B was comparable in onset of sedation (A: 1.59 ± 0.58 min, B: 1.60 ± 0.72 min), intraoperative sedation scores (A: 5.60 ± 0.5, B: 5.85 ± 0.3), and recovery times (A: 4 ± 1 min, B: 3.5 ± 0.67 min). There was no significant difference in the hemodynamic and respiratory profile of ketofol in groups A, B, and C. Considering the onset of sedation, intraoperative sedation score, and recovery time, group C (fentanyl-propofol) patients were less sedated than their counterparts in ketofol group A and B. Furthermore, considering the verbal rating scale for pain at 15 min postoperatively, group C patients had poor analgesia compared to group A and B. Conclusion: Though ketofol in a ratio of 1:2 provides better sedation level compared to the other groups, both ketofol ratios (1:1 and 1:2) were similar in terms of providing hemodynamic and respiratory stability and producing adverse effects.

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The effects of various anesthetic techniques used for transvaginal ultrasound-guided oocyte retrieval (TUGOR) on reproductive outcomes remain controversial. Some studies have reported adverse effects due to nitrous oxide, propofol, and other general anesthetic drugs, whereas others have found them to be safe. The aim of the current meta-analysis is to pool the data available from studies comparing effects of a loco-regional technique against general anesthesia (GA)/intravenous sedation on reproductive outcomes when used for TUGOR. We searched PubMed, EMBASE, Cochrane Register, Google Scholar, and Scopus for studies that evaluated loco-regional anesthesia against GA and reported data on fertilization rate, cleavage rate, and pregnancy rate. A total of eight studies involving 1416 women undergoing TUGOR were identified. The risk of bias was high in most studies, and only two were randomized controlled trials. The loco-regional and the general anesthetic techniques used in these studies varied widely. Pooled odds ratio comparing general versus loco-regional groups for the fertilization rate was 0.939 (95% confidence interval [CI] 0.812-1.086; P > 0.05) and for the cleavage rate was 1.046 (95% CI 0.902-1.213; P > 0.05). Loco-regional anesthesia was found to be favorable to GA with regard to the pregnancy rate (pooled odds ratio was 0.701 (95% CI 0.543-0.905; P < 0.05). No serious complication was reported. Though the pregnancy rate was found to be higher in the loco-regional group, the superiority of one technique over the other cannot be confirmed based on the available quality of evidence and requires further well-conducted trials.

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This case describes a 39-year-old G3P2 parturient with a history of the antiphospholipid syndrome (APS), who experienced severe hemorrhage during her cesarean section (CS) delivery of twins. At 36 weeks gestation, the patient was being treated prophylactically with Lovenox and acetylsalicyclic acid. In preparation for delivery, her medications were discontinued 24 h prior to admission. Due to breech presentation, the patient required delivery by CS. The patient received epidural anesthesia and successfully delivered two healthy babies. Following delivery, the patient became hypotensive and unresponsive and experienced uterine atony with profuse bleeding. Based on the patient's clinical symptoms and history of APS, hemorrhage was suspected. Airway patency was immediately established using rapid sequence intubation, and the patient was placed under general anesthesia for removal of her atonic uterus. Following massive fluid resuscitation and correction of her coagulopathy, the patient stabilized and was transferred to the surgical intensive care unit. Four days later, she was discharged from the hospital without further complications.

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Objective: Electrocardiographic (ECG) changes and chest symptoms suggestive of myocardial ischemia have been reported in healthy women during cesarean section under regional anesthesia. This study aimed to determine the incidence of ECG changes and find any relation between the changes and subjective chest symptoms, hemodynamic variables, oxytocin, and ephedrine administration. Materials and Methods: ECG changes were recorded in 237 term parturients during elective cesarean section done under spinal anesthesia. ST-T depression of ≥1 mm and elevation of ≥2 mm for at least 1-min were considered as significant. Timing of hypotension, bradycardia, tachycardia, ECG changes, and chest symptoms were recorded. Pearson correlation coefficient was used to determine the association between ST changes and subjective chest symptoms, hemodynamic variables, oxytocin, or ephedrine administration. Results: Of 237 patients, 71 (30%) had significant ST-T depression, and 83 (35%) complained of chest symptoms (pressure, squeezing, pain, or dyspnea). Of 71, 42 had chest symptoms. Chest symptoms were also experienced by 30 (18%) patients where no change in ECG was seen (166/237). The changes were more commonly noted at delivery or 3-10 min after oxytocin administration. No correlation was found between ECG changes and chest symptoms, hemodynamic variables, and ephedrine, but there was moderate positive relation with oxytocin. Conclusion: Chest symptoms and ECG changes consistent with myocardial ischemia were observed in about 1/3 healthy parturients during cesarean section. An association between oxytocin and ECG changes was found in half of the patients. The symptoms were short lived and required no treatment.

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Placenta accreta is a life-threatening obstetric complication with an ever-increasing incidence. Between 1982 and 2002, the reported incidence of placenta accreta was 1/533 pregnancies, nearly 4 times its incidence in the 1980s and 8 times its incidence in the 1970s. As Cesarean sections (C/S) become more common, so does placenta accreta, as prior C/S is a risk factor. Placenta accreta requires emergent treatment and unique anesthetic considerations. However, little research discusses the anesthetic protocol to treat this condition. This report details the anesthetic procedure used to successfully treat a patient with placenta accrete diagnosed 15 days post-C/S.

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A young lady with Takayasu's arteritis was scheduled for cesarean section in view of precious pregnancy and intrauterine growth retardation. She was successfully managed under spinal anesthesia as the blood pressure difference between the upper and lower limbs was not significant and as she had no co-morbidities apart from hypertension.

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