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Background: To compare the efficacy and safety of prophylactic intravenous infusions of phenylephrine (0.1 μg/kg/min) and norepinephrine (NE) (0.05 μg/kg/min) for the management of maternal hypotension under spinal anesthesia for cesarean delivery. Methods: A prospective randomized comparative interventional study was conducted on 100 pregnant patients who underwent elective/emergency cesarean section under the sub-arachnoid block. The study patients were randomly allocated into two equal groups comprising of Group P (n = 50): who received phenylephrine 0.1 μg/kg/min infusion prophylactically and Group N (n = 50): who received norepinephrine 0.05 μg/kg/min infusion prophylactically. The data of outcome measures were compared among the two groups by SPSS ver 21.0. Results: A significant difference was seen in the incidence of bradycardia between groups P and N (20% vs 4%, P value = 0.028). The blood pressure was significantly higher in Group N (systolic-120.5 vs 104 mm of Hg, P = 0.026; diastolic-66 vs 61 mm of Hg, P = 0.019). Group N patients had no complications whereas Group P patients experienced nausea (8%) and vomiting (4%), P = 0.027. Neonatal outcomes in terms of Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score and umbilical arterial/venous blood gases were similar among the two groups (P > 0.05). Conclusion: In conclusion, the study results show that NE is better in maintaining the hemodynamic parameters (BP and HR) during spinal anesthesia for cesarean delivery with minimal side effects. It can be suggested that NE may be advantageous in pregnancies especially those complicated with pregnancy-induced hypertension.

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Pregnancy in a patient with Marfan syndrome is associated with risks, including cardiovascular complications. The hemodynamic changes of pregnancy during delivery are deleterious to Marfan syndrome patients. This case describes a Marfan syndrome parturient with dilated aortic root >45 mm who underwent neuraxial anesthesia and cesarean delivery. Anesthetic management focused on reducing hypertension and shear forces on the ascending aorta. A combined spinal-epidural with a reduced dose of hyperbaric bupivacaine was utilized for cesarean delivery. Multidisciplinary approaches are vital in the management of Marfan syndrome pregnancy and cardiovascular complications must be considered when planning for delivery and postpartum management. Anesthetic management must consider the hemodynamic changes in pregnancy and severity of Marfan syndrome cardiovascular involvement in the parturient as well as neonatal risks. Guideline development concerning anesthetic management for both the timing of delivery and aortic repair postpartum would be beneficial to Marfan syndrome parturients.

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Enhanced recovery after cesarean delivery (ERAC) is an evidence-based interdisciplinary protocol with an aim to improve quality of care and patient satisfaction while lowering health care cost by reducing length of hospital stay. It is an approach that combines several evidence-based perioperative care components to hasten patient recovery. ERAC uses multidisciplinary approach with inclusion of all stakeholders including anesthesiologists, obstetricians, pediatricians, nurses, pharmacists, patients, and hospital administration. Therefore, institutional support, local infrastructure, and compliance of all supporting systems are necessary for the successful implementation of ERAC. The role of anesthesiologists in implementation of standardized care cannot be disregarded as they are involved in the provision of perioperative services to improve maternal outcomes and healthcare quality. The purpose of this narrative review is to explore the components and guidelines from the enhanced recovery after surgery for caesarean delivery, highlight the responsibility of anesthesiologists in the existing and emerging ERAC programs and the difficulties associated with implementing the ERAC in resource-constrained environments.

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Objective: Preoperative identification of women at greater risk of post-cesarean pain might allow more intensive analgesic interventions. This study aimed to assess the effect of age of a parturient on post-cesarean section (CS) pain. Methods: 100 pregnant females were enrolled and divided into 4 groups: group A (age 18–24 years), group B (25–30 years), group C (31–35 years), and group D (≥36 years). Patient-controlled epidural analgesia was started postoperatively in all patients. Pain on a 0- to 10-point visual analog scale (VAS), a number of attempts tried for patient-activated dose delivery of ropivacaine, and successful delivery of patient-activated dose of ropivacaine were recorded for 72 hours. Breastfeeding was initiated as early as possible. The effect of breastfeeding on post-CS pain was observed for 72 hours in terms of increase, decrease, or no change in VAS scores with breastfeeding. Results: The peak VAS scores over 72 hours were 4.10 ± 0.60, 4.00 ± 0.67, 3.75 ± 0.45, and 3.42 ± 0.67, respectively, in groups A, B, C, and D, showing a significant declining trend (P = 0.007). The mean VAS scores decreased from 4.08 to 1.69 (group A, P < 0.0001), from 4.00 to 1.64 (group B, P < 0.0001), from 3.67 to 1.25 (group C, P < 0.0001), and from 3.33 to 1.50 (group D, P < 0.0001) over 72 hours. A statistically significant decline in patient-activated rescue drug delivery attempts, the number of times the rescue analgesic was delivered, and 24-h cumulative ropivacaine dose requirement was seen. Conclusions: In this study, it was found that post-cesarean pain decreases significantly with increasing age, as evidenced by reduced pain scores, reduced attempts at rescue drug delivery, and reduced rescue analgesic requirements.

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Background: Labor pain and child birth entail a number of physiological consequences that may lead to deleterious effects on the mother and fetus. Implication of a neuraxial technique is being appreciated in labor. Fetal prognosis and maternal consent and its satisfaction are key to labor analgesia. Method: The primary objectives were to determine the visual analog scale (VAS), total duration of labor analgesia, patient-controlled analgesia demand, sensory and motor block, and hemodynamics. The secondary objectives were to determine obstetrics parameters such as maternal satisfaction, cervical dilation, membrane, APGAR score, and complications such as hypotension, bradycardia, and vomiting. A randomized prospective comparative, interventional study including 50 parturients was conducted, where they were divided into two equal groups of 25 each, and epidural analgesia was given by 0.2% ropivacaine with 2 mcg/ml fentanyl and 0.2% ropivacaine without fentanyl. Observation and Results: Analgesia was more in the RF group compared to the R group. The maternal satisfaction was more in the RF group than in the R group. Clinical hemodyamics, VAS score, Bromage score, and APGAR score were appreciable in the RF group as compared to the R group. Conclusion: We concluded that 0.2% ropivacine with fentanyl gives more analgesia and maternal satisfaction than ropivacine alone.

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Purpose: Management of delivery in pregnant women with coronavirus disease 2019 (COVID-19) is mainly based on extrapolated evidence or expert opinion. This study aimed to assess the clinical manifestations and maternal and perinatal outcomes of COVID-19 during pregnancy. Methods: We retrospectively reviewed the cases of 20 pregnant women infected with the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Their demographic data and clinical characteristics, including symptoms, laboratory examination, and imaging findings, were evaluated. We also assessed the delivery method and timing and clinical courses of mothers, including oxygenation and treatment for COVID-19, as well as neonatal outcomes. Results: The most common symptoms were fever (65%) followed by cough (45%). Seven cases (35%) of preterm birth were observed. Eight patients (40%) required oxygen administration during pregnancy. Among them, two patients (10%) required a high-flow nasal cannula, and one patient (5%) required venovenous extracorporeal membrane oxygenation (VV-ECMO). No maternal death was observed; however, one instance of severe neonatal asphyxia and one intrauterine fetal death were observed. Conclusion: Although most pregnant women with COVID-19 were discharged without any major complications, some cases became severe. Therefore, the timing and method of delivery should be considered for each case to control maternal and infant respiratory conditions.

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Background: Intrathecal magnesium sulfate is now emerging as a safe and effective adjuvant for spinal anesthesia (SA). The aim of the present study was to compare the efficacy of two doses of intrathecal magnesium in parturients with pre-eclampsia. Methods: This prospective randomized double-blind study was conducted on 105 parturients undergoing elective cesarean section (CS) who were randomized into three groups of 35 each: Group C, M₅₀, and M₇₅. Group M₅₀ and group M₇₅ received 50 mg of 50% (0.1 ml) and 75 mg of 50% (0.15 ml) magnesium sulfate, respectively. All of the groups received 10 mg of 0.5% heavy bupivacaine with normal saline accordingly to make a total volume of 2.2 ml. The sensory and motor block characteristics, visual analogue scale (VAS) score, post-operative analgesic requirements, hemodynamic parameters, and adverse effects were compared. Results: The sensory and motor block characteristics were significantly delayed in group M₇₅ compared to group M₅₀ and the control group (P < 0.05). VAS scores were significantly high in the control group up to 6 h as compared to group M₅₀ and group M₇₅ (P < 0.05). The time to first rescue analgesia was significantly extended in group M₇₅ (222.86 ± 12.502 min) as compared to group M₅₀ (221.14 ± 13.671 min) and the control group (127.43 ± 11.464 min) (_P < 0.05). Conclusion: Intrathecal magnesium sulfate at doses of 50 mg and 75 mg in pre-eclamptic parturients undergoing elective CS results in prolonged duration of analgesia, decreased VAS scores and also delays the first rescue analgesic requirement with a favorable adverse effect profile in terms of decreased incidence of nausea and shivering.

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Background: Current research promotes opioid-sparing analgesia as an approach to enhanced recovery after cesarean (ERAC). In developing countries, non-opioid-based analgesia is routinely practiced in obstetric settings, as opioids are not freely accessible. There are no randomized trials evaluating intravenous diclofenac and acetaminophen for postoperative analgesia following elective cesarean section. Methods: Women scheduled for elective cesarean delivery under subarachnoid block were enrolled if they fulfilled the inclusion criteria. They were randomized to receive either intravenous diclofenac or intravenous diclofenac-acetaminophen combination at the end of surgery and at predefined time intervals during the 24-hour postoperative period. The primary outcome measure of our study was 24-hour rescue analgesic (tramadol) consumption. Secondary outcome measures included time to first request for rescue analgesia, postoperative pain at rest and on movement, episodes of nausea, retching, and vomiting during the 24-hour postoperative period and overall patient satisfaction. Results: The 24-hour rescue analgesic consumption was significantly lesser in the diclofenac-acetaminophen group compared to the diclofenac group (56.25 ± 47.73 mg vs. 92.86 ± 50.83 mg; P = 0.00). Time to first request for rescue analgesia was earlier in the diclofenac group compared to the diclofenac-acetaminophen group (3.96 ± 2.40 h vs. 5.64 ± 3.58 h, P = 0.01). Parturients given a combination of intravenous diclofenac and acetaminophen used 40% less tramadol in the first 24 hours following cesarean section and were more satisfied with their pain management when compared to those given intravenous diclofenac alone. Conclusion: Following cesarean section, intravenous diclofenac-acetaminophen combination provides superior analgesia with significantly lesser opioid consumption and higher patient satisfaction when compared to intravenous diclofenac alone. This combination is effective, easy to administer, opioid-sparing and is compatible with ERAC regimens.

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Background and Aims: Surgical procedures performed using spinal anesthesia techniques present a special challenge to anesthesiologists, because patients are awake and exposed to multiple anxiety-provoking visual and auditory stimuli. Therefore, this study was carried out to define the effect of music on the level of cortisol and anxiety in patients under spinal anesthesia undergoing elective lower-segment cesarean section (LSCS). Methods: The study was conducted on 60 patients undergoing LSCS under spinal anesthesia. The patients were divided into two groups containing 30 patients each. Group A received music through headphones and group B did not receive any music. Blood samples for serum cortisol and visual analog score for anxiety (VASA) were evaluated in both groups in pre-operative and post-operative periods. Results: Student's t-test was used for comparison of serum cortisol levels. The mean cortisol levels in group A were 32.44 ± 14.42 μg/dl in the pre-operative and 33.59 ± 12.74 μg/dl in the post-operative period (P = 0.583). However, in group B, the mean cortisol levels were 25.24 ± 13.54 μg/dl in the pre-operative period and 30.22 ± 17.04 μg/dl in the post-operative period. The difference was highly significant (P = 0.023). The mean VASA 1 score in group A as 5.22 ± 0.73 and in group B was 6.00 ± 0.82. The difference was not significant (P = 0.608). However, VASA 2 in group A was 4.90 ± 0.66 and group B was 5.89 ± 0.99. This difference was highly significant (P = 0.0001). Conclusion: This study's results showed that listening to music during surgery under spinal anesthesia significantly reduces cortisol levels (P = 0.023) as well as anxiety score (P = 0.0001).

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Background and Aims: Post-dural puncture headache (PDPH) is one of the complications of the subarachnoid block (SAB), and the incidence of PDPH is influenced by various factors related to either patients or the type of spinal needle used. This study observed the incidence and severity of PDPH in relation to non-modifiable factors in the patients scheduled for surgeries under SAB. Methods: The study enrolled 302 obstetric and non-obstetric patients, aged 20–60 years, American Society of Anesthesiologists (ASA) I/II having body mass index (BMI) 18.5–29.9 kg.m^-2 scheduled for surgeries under SAB utilizing 26 G Quincke spinal needle. Primary outcome was the incidence of PDPH in obstetric and non-obstetric patients. The secondary outcomes included onset, severity of PDPH, and association of age, BMI, and gender to PDPH. Results: The total incidence of PDPH was 5.6%, eight (7%) patients in obstetric and nine (4.8%) patients in non-obstetric group (P = 0.597). The onset of PDPH was comparable in obstetric 17.25 ± 3.69 and non-obstetric patients 18.0 ± 6.02 h (P = 0.663). None of the patient had severe PDPH. The BMI of the patients was not associated with the incidence of PDPH. The female patients among non-obstetric group had higher incidence of PDPH (P = 0.0002). The six patients having PDPH in non-obstetric group belonged to age-group of 31–40 yrs as compared to two above 40 years (P = 0.0173). Conclusion: Obstetric population had comparable incidence of PDPH to non-obstetric population. In the subgroup analysis of non-obstetric patients, the higher incidence of PDPH was observed in the female and younger patients.

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Objectives: Increase in Intra-Abdominal Pressure (IAP) is commonly accepted as a cause for intrathecal dose sparing and consequently higher level of sensory block during pregnancy. There is however very little actual data evaluating the relationship. Thus, we aimed to evaluate association between IAP and maximum level of sensory block following intrathecal injection of hyperbaric bupivacaine as well as plain levobupivacaine for cesarean section. Methods: Preliminary randomized controlled blinded trial included females aged 18-40 years, scheduled for elective cesarean section under single-shot subarachnoid block. After randomization, they received either intrathecal hyperbaric bupivacaine (group H) or plain (isobaric) levobupivacaine (group P) in a dose of 12.5 mg (n = 40 each). IAP was measured before and after the spinal block, using the recommended intravesical technique. The maximum level of sensory block and the IAPs were measured in each patient. Results: There was no significant correlation of IAP_prespinal with maximum level of sensory block for group H (P = 0.334; r_s = -0.157) or group P (P = 0.637; r_s = -0.078). Similarly, there was no significant correlation of the IAP_postspinal: group H (P = 0.370; r_s = -0.145); and group P (P = 0.714; r_s = -0.061). Both group H and group P had similar IAP_prespinal (15.9 [14.3-18.2] and 15.3 [14.3-17.4] mmHg, respectively) (P = 0.474); as well as IAP_postspinal (15.2 [13.8-17.2] and 14.6 [13.4-16.0] mmH, g respectively) (P = 0.239). Among ancillary observations, duration of sensory block was significantly longer for group P versus group H (133.6 ± 24.2 and 103 ± 23.4 mins; P < 0.000). However, the maximum levels of sensory and motor block, respective times required to achieve them, as well as incidences of intraoperative hypotension and bradycardia were statistically similar between group H and group P (P > 0.05). Conclusions: The IAP was raised to the level of conventionally defined intra-abdominal hypertension (>12 mmHg) in patients scheduled for elective cesarean section. However, despite being increased, the IAP_prespinal or IAP_postspinal did not show any significant association with the maximum level of sensory block (P > 0.05).

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Pituitary apoplexy in a pregnant woman is a devastating condition that develops secondary to a massive increase in the size of the pituitary gland and hyperplasia of lactotroph cells caused by high estrogen levels of pregnancy. The resultant sudden hemorrhage or infarction into the pituitary gland or a tumor leads to gland destruction with serious consequences like acute adrenal insufficiency, circulatory shock, neurological deterioration, and visual loss. Prompt handling of complications is necessary to prevent maternal and fetal mortality. Resuscitation is aimed at the early correction of hemodynamic instability, fluid-electrolyte abnormalities, hormone deficiencies, and intracranial hypertension. Urgent decompressive pituitary surgery may be required if the patient has rapidly declining vision and neurological status. Management of such patients is challenging and requires multi-disciplinary collaboration. We describe here the emergency handling of pituitary apoplexy in a pregnant woman.

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Sjogren syndrome is a slowly progressive autoimmune disease with lymphocytic infiltration of exocrine glands, peri-epithelial and extra-epithelial tissues. In light of better diagnostic modalities and improved treatment options, patients with Sjogren syndrome are now commonly encountered by anaesthetist for various surgeries. Here, we would like to describe an anaesthetic management of a parturient with bad obstetric history who was diagnosed with Sjogren syndrome and was planned for caesarean delivery. This article also reviewed anaesthetic problems faced due to inherent disease pathology and concurrent alterations in treatment modalities.

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Background: The pregnant patients undergoing anesthesia are at increased risk of aspiration due to decreased lower esophageal sphincter tone and mass effect of gravid uterus on gastric antrum. Ultrasound used as a noninvasive bedside imaging tool to measure gastric volume in term pregnant patients immediately before elective caesarian section (CS) may help in reducing aspiration induced morbidity and mortality. Methods: This observational prospective case--control study was conducted in 33 nonlaboring term pregnant patients immediately before elective CS and 30 nonpregnant patients immediately before elective surgeries, enrolled according to inclusion and exclusion criteria. A 2-5 MHz curvilinear probe was used to scan the participants in supine and right lateral decubitus (RLD) position in pre-recovery room. Visibility, qualitative grading (0,1, 2), anteroposterior (AP), and craniocaudal (CC) diameter, and cross-sectional area (CSA) of gastric antrum was measured. Gastric volume was derived from CSA using equations formulated by previous investigators. Results: Gastric antrum was visible in 27 (82%) of pregnant and 30 (100%) of nonpregnant patients in supine position (P = 0.014). In RLD position, 25 (75.7%) pregnant and 29 (96.7%) nonpregnant patients had antrum visible (P = 0.018). The qualitative grading was comparable (P = 0.064) in both the groups. In supine position, (P = 0.615), CSA in cm² was 3.37 ± 1.31 and 3.54 ± 1.33, while in RLD position (P = 0.012), CSA was 3.98 ± 1.13 and 5.09 ± 1.85, in pregnant and nonpregnant patients, respectively. Conclusion: Gravid uterus sometimes impedes visualization of antrum by ultrasound in term pregnant patients immediately before elective CS and shows clinically similar gastric CSA when compared to nonpregnant patients, though statistically different in RLD position. Trial registration number- NCT03380637

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Background: In the spinal anesthetic technique, local anesthetic dose (concentration and volume) is the main determinant of its adequacy and success of block to be achieved. The lack of pain during surgical intervention rather than on dermatome sensory block level is considered to be an appropriate indicator of surgical anesthesia. Spinal anesthesia is the most common anesthetic technique to provide anesthesia for the elective or emergent cesarean section (CS). However, spinal block-induced maternal hypotension is the most common adverse effect during single-shot spinal anesthesia. In our study, we aim to study the height-adjusted dose of 0.5% Bupivacaine Heavy (BH) in achieving surgical anesthesia and its effect on maternal hypotension. Participants and Method: One hundred parturients scheduled for elective CS were enrolled and were compared to the parallel arms of parturients receiving conventional BH. Fifty parturients in each group were included. In the conventional group (B), participants received spinal block with 12 mg of 0.5% BH, and in the height adjusted-dose group (H), participants received a dose of 0.5% BH in 0.06 mg per centimetre height. A sensory block level of T6 dermatome or higher was consider adequate to start surgery. The adequate surgical anesthesia is considered to be achieved if cesarean delivery can be performed without supplementary analgesia. The need of supplementary analgesia, conversion to general anesthesia, or no block till 15 min of intrathecal BH is considered spinal failure. Results: 4% of the height-adjusted dose group have a low block level. Two cases complained of pain, and of them, one received supplementary analgesia and one was converted to general anesthesia. Systolic hypotension of a maternal blood pressure of less than 90 mm Hg was found in 19 (38%) and 10 (20%) in the conventional group and HAD group, respectively, which was highly significant statistically (p value 0.001%). Conclusion: Intrathecal hyperbaric bupivacaine in height adjusted 0.06 mg per cm height of patient can achieve surgical anesthesia with maintainance of systolic blood pressure. However, low dosing of intrathecal BH has higher cases of block failure in comparison to the conventional fixed dose regime of spinal anesthesia.

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Background: Currently, spinal anesthesia for cesarean section is the anesthetic technique of choice for women with preeclampsia in the absence of contraindications to neuraxial anesthesia. Recently, norepinephrine has been introduced for prevention and treatment of hypotension associated with spinal anesthesia; however, only a couple of studies have compared norepinephrine infusion and bolus. Aims: This study aims to compare primarily the efficacy and safety of norepinephrine bolus given therapeutically and norepinephrine infusion given prophylactically for management of hypotension and effects on other hemodynamic parameters in parturients with preeclampsia undergoing cesarean section under spinal anesthesia and secondarily to determine the effects of study drugs on neonatal Apgar score and arterial blood gas analysis of neonatal blood. Methods: In this prospective randomized study, 100 singleton full-term pregnant females of ASA grade II, aged 18–35 years, diagnosed with preeclampsia (controlled on single antihypertensive drug with BP ≤140/90), scheduled for elective cesarean section under spinal anesthesia were randomly divided into two groups. Group A: Received therapeutic norepinephrine bolus (4 μg) only when hypotension (fall in SBP to ≤20% of baseline) was detected after spinal anesthesia. Group B: Received prophylactic intravenous norepinephrine infusion (4 μg/min) immediately after induction of spinal anesthesia. Results: Heart rate, systolic, diastolic, and mean blood pressure had statistically significant difference at 3,4,5,6,7,8,9, and 10 mins of surgery. Number of episodes of hypotension and number of norepinephrine boluses used in Group A were higher and statistically significant (p-value < 0.001) than Group B. Apgar score at 1 and 5 minutes as well as umbilical artery parameters in two groups was comparable and statistically insignificant (p-value 0.301 for Apgar at 1 min and P value 0.562 for Apgar at 5 mins). Conclusion: Although both norepinephrine bolus and infusion doses are an effective way to treat spinal anesthesia-related hypotension in patients with preeclampsia undergoing cesarean section with comparable maternal and fetal side effects, infusion dose of norepinephrine is better in maintaining hemodynamics of parturients with insignificant changes in neonatal outcomes.

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Background and Aims: Obstetric airway guidelines recommend preoxygenation before the induction of general anesthesia to achieve an end tidal oxygen concentration of ≥90%. Recently, high flow nasal oxygenation (HFNO) has been evaluated as a technique for delivering a high concentration of oxygen using high flow rates to patients. We evaluated the use of HFNO as a technique for preoxygenation in full-term pregnant women. Methods: A cross-sectional observational study was conducted on 100 term pregnant women. They underwent preoxygenation using HFNO for 4 minutes (30 L/min for 30 secs followed by 50 L/min for 210 secs) and end tidal oxygen concentration (ETO₂) was measured at the end of preoxygenation. The primary outcome was the percentage of women who achieved an expired oxygen concentration of ≥90% for the first expired breath. The secondary outcome was the acceptability and comfort of HFNO as compared to facemask preoxygenation using a 4-point Likert scale. Results: The percentage of women who achieved expired oxygen concentration of ≥90% after 4 minutes of HFNO preoxygenation was 32% [95% confidence interval (CI):22.7-41.3%] with the mean end tidal oxygen (SD) being 86.67 (3.4). 71% [mean (SD): 2.94 (0.92)] found nasal cannula and 56% [mean (SD): 2.67 (1.21)] found facemask comfortable and acceptable for preoxygenation (P value, 0.05). Conclusion: Although HFNO is a comfortable technique, when used for preoxygenation for 4 minutes, it did not achieve an acceptable level of preoxygenation (ETO₂ ≥90% in 95% of individuals). Therefore, it is an inadequate technique for preoxygenation in term pregnant women.

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Pneumomediastinum was reported as a complication of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia in the general population. Data concerning the association of this complication with pregnancy are rare. We report a case of a parturient who presented with SARS-CoV-2 pneumonia complicated with pneumomediastinum. The management of Acute respiratory distress syndrome (ARDS) and obstetric approach are also discussed.

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The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily.

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Introduction: Placenta accreta is a general term, when part of the placenta or the entire placenta invades and is inseparable from the uterine wall. The incidence is considerably higher in women with both a previous caesarean delivery and placenta praevia, occurring in around 1 in every 20 such women. Resorption of the retained, poorly perfused placenta can be augmented by concurrent treatment with methotrexate when fertility is desired. In cases where operative measures are required, placement of Internal Iliac artery (IIA) balloons preoperatively and their inflation intraoperatively, reduces maternal morbidity and mortality. Materials and Methodology: We present a case series of 14 patients with placenta accreta diagnosed preoperatively, 7 of whom had IIA balloons placed before undergoing Caesarean section and 7 did not have such an intervention. The maternal and foetal morbidity and mortality were studied, including the need for blood and blood product transfusions. Results: Internal Iliac Balloon placements did not change the requirement for blood and blood product transfudion in both groups. The group who had IIA balloon placed preoperatively had better maternal and fetal outcome as compared to the group who had no such intervention.

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We present a case of a 28-year-old pregnant patient in labor with two prior cesarean sections with a history of both successful and failed spinal anesthesia in her first and second pregnancies, respectively. This time, attempts at spinal anesthesia failed twice despite ruling out the common causes such as technical or drug error. Surgery was ultimately performed under general anesthesia uneventfully. While technical factors may contribute substantially to failure of spinal anesthesia, the sequence of events in this case, viz. one successful subarachnoid block followed by two unsuccessful ones three and seven years apart, supported by investigative evidence, indicates a possible acquired resistance to local anesthetics.

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Paraganglioma is a neuroendocrine tumor characterized by small organs comprising neuroendocrine cells that can produce catecholamines. Because of the nature of such tumors, hemodynamic instability can pose a management challenge. This condition can influence the provision of medical care across different clinical settings. The aim of this case report is to highlight anesthesia management in parturient patients with abdominopelvic paraganglioma, particularly during an emergency cesarean section. At 34 weeks of gestation, the 33-year-old female patient with three pregnancies and two past deliveries had a known case of inoperable large pelvic and lower abdominal retroperitoneal paraganglioma and poor radiotherapy response. The 15.5 × 4.2 × 22 cm tumor encased the aorta, inferior vena cava, and bilateral iliac vessels, compressing the lumbar vertebrae. The patient had an uneventful and successful cesarean delivery with a multidisciplinary team effort. Paragangliomas are rarely reported in a parturient and its optimization course. Despite being interrupted by an emergency cesarean section, which was handled safely and effectively, both mother and fetus had a safe delivery and postoperative recovery without complications.

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Parturient with kyphoscoliosis poses a major challenge in the administration of spinal anaesthesia owing to changes in the anatomy of the spine and physiological changes associated with pregnancy. Recently, ultrasound guidance has proved to be a boon for regional anaesthesia techniques. We report the successful anaesthetic management of a 43 year-old primigravida with kyphoscoliosis who was posted for emergency caesarean section using an ultrasound-guided subarachnoid block.

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