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Background and objective During the past few years, an increased number of postpartum hemorrhages have been noticed, even in high-income countries. It has been suggested that this escalation could be associated with increased obstetric interventions. Among such interventions, anesthesia is one of the most prevalent. The present study aimed to investigate the influence of peripartum anesthesia on total blood loss during the 24 hours after delivery. Methods We performed a complementary analysis from a prospective cohort study that evaluated postpartum bleeding within 24 hours after birth. The study was performed between February 1st, 2015 and March 31st, 2016 at the Women’s Hospital at the Universidade Estadual de Campinas, Brazil. Postpartum bleeding was measured using a calibrated drape and summing the blood contained in the compresses and pads used for 24 hours. We calculated means, percentages, and standard deviation and performed Mann-Whitney analysis for the relation of anesthesia with Postpartum Hemorrhage (PPH) and logistic regression for drugs used in the anesthesia with PPH, using SAS 9.4 software. Results We included 270 women in the study; of these, 168 received anesthesia for delivery and almost 50% of them had spinal and epidural anesthesia. The mean blood loss within 24 hours after delivery did not show differences between those who did and those who did not receive obstetrical anesthesia (579.0 ± 361.6 vs. 556.6 ± 360.6; p = 0.57). Logistic regression showed that anesthesia, the type of anesthesia, and the drug used did not influence the PPH above 500 mL and above 1000 mL within 2 hours (p > 0.05). Conclusion Anesthesia did not influence postpartum bleeding after vaginal delivery.

Patients with placenta previa are at risk for intra- and postpartum massive blood loss as well as increased risk of placenta accreta, a type of abnormal placental implantation. This condition can lead to serious obstetric complications, including maternal mortality and morbidity. The risk factors for previa include prior cesarean section, multiparity, advanced maternal age, prior placenta previa history, prior uterine surgery, and smoking. The prevalence of previa parturients has increased due to the rising rates of cesarean section and advanced maternal age. For these reasons, we need to identify the risk factors for previa and identify adequate management strategies to respond to blood loss during surgery. This review evaluated the diagnosis of placenta previa and placenta accreta and assessed the risk factors for previa-associated bleeding prior to cesarean section. We then presented intraoperative anesthetic management and other interventions to control bleeding in patients with previa expected to experience massive hemorrhage and require transfusion.

Purpose Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients. Methods This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to 'spend' $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them. Results Two hundred twentyquestionnaires were completed (105 antenatal, 115 postpartum). 'Achieving desired pain relief' was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). 'Overall satisfaction with the pain management,''experiencing a short time to achieve pain relief,'and 'experiencing a short duration of labor' received more money than avoiding various LEA-related side effects. The postpartum cohort ranked 'experiencing a short time to achieve pain relief' as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)). Conclusions Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.

Pulmonary embolism (PE) is the most serious type of venous thromboembolism, and pregnancy related PE, while uncommon, is likely to be fatal [1]. PE is one of the main causes of maternal death in high-income countries. At present, there are a limited number of reports about the entire process of PE- it is thought that PE is caused by vein thrombosis and detachment of a thrombus, which can be detected by echocardiography [2, 3].

We present a case of difficult anesthesia for obstetrical surgery. The case involved a morbidly obese patient requiring anesthesia for a cesarean section and was punctuated by difficult and ultimately failed neuraxial anesthesia, semi-urgent induction of general anesthesia, and management of the difficult airway.

Background Maternal early warning systems reduce maternal morbidity. We developed an electronic maternal surveillance system capable of visually summarizing the labor and delivery census and identifying changes in clinical status. Automatic page alerts to clinical providers, using an algorithm developed at our institution, were incorporated in an effort to improve early detection of maternal morbidity. We report the frequency of pages generated by the system. To our knowledge, this is the first time such a system has been used in peripartum care. Methods Alert criteria were developed after review of maternal early warning systems, including the Maternal Early Warning Criteria (MEWC). Careful consideration was given to the frequency of pages generated by the surveillance system. MEWC notification criteria were liberalized and a paging algorithm was created that triggered paging alerts to first responders (nurses) and then managing services due to the assumption that paging all clinicians for each vital sign triggering MEWC would generate an inordinate number of pages. For preliminary analysis, to determine the effect of our automated paging algorithm on alerting frequency, the paging frequency of this system was compared to the frequency of vital signs meeting the Maternal Early Warning Criteria (MEWC). This retrospective analysis was limited to a sample of 34 patient rooms uniquely capable of storing every vital sign reported by the bedside monitor. Results Over a 91-day period, from April 1 to July 1, 2017, surveillance was conducted from 64 monitored beds, and the obstetrics service received one automated page every 2.3 h. The most common triggers for alerts were for hypertension and tachycardia. For the subset of 34 patient rooms uniquely capable of real-time recording, one vital sign met the MEWC every 9.6 to 10.3 min. Anecdotally, the system was well-received. Conclusions This novel electronic maternal surveillance system is designed to reduce cognitive bias and improve timely clinical recognition of maternal deterioration. The automated paging algorithm developed for this software dramatically reduces paging frequency compared to paging for isolated vital sign abnormalities alone. Long-term, prospective studies will be required to determine its impact on patient outcomes.

Introduction: during the scheduled cesarean section, the main side effect of the spinal anesthesia is the spinal anesthesia-induced hypotension (SAIH). Objective: to identify the course of action with regard to the use of fluids and vasopressors for the prevention and management of the SAIH during the cesarean section in healthy women. Methods: a survey by means of e-mail address was carried out to the members of the Sociedad Colombiana de Anestesiología y Reanimación (SCARE) in April in 2012, with the objective to determine their strategies for the prevention and management of the SIAH with regard to the use of fluids and vasopressors. This survey was created by the authors and without the validation process. Results: of 2113 anesthesiologists, just 491 (23.2%) answered the survey. 61.7% of the participants used fluids as prevention strategies of the SAIH. Of them, 60% administered it only as precharge and the other ones as adjuvant. 10.2% of all the participants combined intravenous fluids and vasopressors. 3.7% used only vasopressors and the 24.4% did not use any of those measures as prevention of the SAIH. The crystalloids were used by more than 99% of the survey respondents that administer fluids in a routine way, being the doses of preference between 500 and 1000 cc. Just the 14% of the survey respondents use vasopressors in a prophylactic way, from which the 53% uses etilefrine, the majority in intravenous bolus. The majority of the survey respondent use vasopressors just in a therapeutic way, being preferred by 65% the etilefrine, followed by the ephedrine, both administered mainly in intravenous bolus. Conclusions: the etilefrine is the most used agent by a group of Colombian anesthesiologists belong to the SCARE, mainly in intravenous bolus, as prophylactic and therapeutic measure for the SAIH in cesarean section. Rev.cienc.biomed. 2014;5(2):263-271. KEYWORDS Hypotension, Obstetrical anesthesia, Spinal anesthesia, Vasoconstrictor agents

The occurrence of broken spinal and epidural needles has been reported. However, most case reports have focused primarily on prevention rather than on management. A broken spinal needle fragment was left in a patient before it was removed one month later due to back pain.

The addition of opioids to bupivacaine for spinal anesthesia has been shown to improve quality of anesthesia by the action of fentanyl, and extend postoperative analgesia by the effect of morphine. Side effects, particularly respiratory depression, have prevented their widespread use. Studies are not consistent regarding the incidence of respiratory depression due to the variety of definitions of this complication and the doses of opioids used. Low dose regimens currently used do not produce further respiratory depression than parenteral opioids. The high levels of progesterone, a potent respiratory stimulant, makes safe the use of neuroaxial opioids in scenarios such as obstetrical anesthesia or analgesia, hence their use should not be overlooked.

ResumenLa adición de opiáceos a la bupivacaína para la anestesia raquídea ha demostrado mejorar la calidad de esta por la acción del fentanilo y prolongar la analgesia postoperatoria por el efecto de la morfina. Los efectos secundarios, en particular la depresión respiratoria, han impedido la generalización de su uso. Los estudios no son consistentes en cuanto a la incidencia de depresión respiratoria por la variedad de definiciones sobre esta complicación y las dosis de opiáceos empleadas. Las bajas dosis utilizadas actualmente no producen mayor depresión respiratoria que los opiáceos parenterales. Los altos niveles de progesterona, un potente estimulante respiratorio, hacen seguro el empleo de opiáceos neuroaxiales en escenarios como la anestesia o la analgesia obstétricas, por lo que no deberían omitirse.AbstractThe addition of opioids to bupivacaine for spinal anesthesia has been shown to improve quality of anesthesia by the action of fentanyl, and extend postoperative analgesia by the effect of morphine. Side effects, particularly respiratory depression, have prevented their widespread use. Studies are not consistent regarding the incidence of respiratory depression due to the variety of definitions of this complication and the doses of opioids used. Low dose regimens currently used do not produce further respiratory depression than parenteral opioids. The high levels of progesterone, a potent respiratory stimulant, makes safe the use of neuroaxial opioids in scenarios such as obstetrical anesthesia or analgesia, hence their use should not be overlooked.

Epidural analgesia is assumed to be the technique of choice for the relief of pain in labor. Multiple adverse neurological effects have been reported, one of which is the so-called Horner syndrome (ptosis, myosis, anhidrosis). Its evolution is usually benign and does not require specific management, except clinical monitoring for the more than probable cephalic spread of local anesthetic. Most of the cases that exist in the literature are isolated; in our work we present a series of 3 clinical cases and review the pathogenesis and management in the obstetric patient. La analgesia epidural supone la técnica de elección para el alivio del dolor del parto. Se han descrito múltiples efectos adversos a nivel neurológico, uno de ellos es el llamado Síndrome de Horner (ptosis,miosis, anhidrosis), suele presentar evolución benigna y no requiere manejo especifico, salvo vigilancia clínica por la más que probable difusión cefálica del anestésico local. La mayor parte de los casos existentes en la literatura son aislados, en nuestro trabajo presentamos una serie de 3 casos clínico y repasamos su etiopatogenía y manejo en la paciente obstétrica.

ResumenIntroducciónEn gestantes acondroplásicas se recomienda el parto por cesárea con anestesia general; sin embargo, recientemente se ha reportado el uso de técnicas conductivas con resultados adecuados.ObjetivoDescribir el manejo anestésico de una paciente con acondroplasia programada para cesárea utilizando anestesia combinada espinal-epidural.Métodos y resultadosMostramos el caso de una primigestante acondroplásica con 110cm de estatura y embarazo de 37 semanas, en quien se realizó cesárea con anestesia conductiva guiada por ecografía, empleando una mezcla titulada de anestésico local y opiáceo, con buenos resultados para la madre y el hijo.ConclusionesLa anestesia conductiva es una alternativa en la cesárea de pacientes con acondroplasia. Aunque no existen recomendaciones claras para orientar el acceso seguro al neuroeje ni para administrar medicamentos anestésicos a este nivel, se puede considerar el uso de la ecografía y la administración titulada de fármacos neuroaxiales (epidural, epidural-espinal y espinal continua) para mejorar la seguridad y la eficacia de la técnica en este tipo de pacientes.AbstractIntroductionCesarean section under general anesthesia is recommended in achondroplastic pregnant patients; however, the use of conductive techniques has been recently reported, with acceptable results.ObjectiveTo describe the anesthesia management in an achondroplastic patient scheduled for C-section under combined spinal-epidural anesthesia.Methods and resultsWe present the case of a first pregnancy in a patient with achondroplasia, height 110cm and 37 weeks of gestation. The patient underwent cesarean section under ultrasound-guided conductive anesthesia, using a titrated mixture of local anesthetic and opiate, with good results for the mother and child.ConclusionsConductive anesthesia is an option in C-section in patients with achondroplasia. Although there are no clear recommendations to guide a safe access to the neuroaxis or to administer anesthetic agents at this level, ultrasound and the titrated administration of neuraxial drugs (epidural, epidural-spinal and continuous spinal) for improved safety and efficacy of the technique in this type of patients may be considered.

Introducción: En gestantes acondroplásicas se recomienda el parto por cesárea con anestesia general; sin embargo, recientemente se ha reportado el uso de técnicas conductivas con resultados adecuados. Objetivo:Describir el manejo anestésico de una paciente con acondroplasia programada para cesárea utilizando anestesia combinada espinal-epidural. Métodos y resultados:Mostramos el caso de una primigestante acondroplásica con 110 cm de estatura y embarazo de 37 semanas, en quien se realizó cesárea con anestesia conductiva guiada por ecografía, empleando una mezcla titulada de anestésico local y opiáceo, con buenos resultados para la madre y el hijo. Conclusiones: La anestesia conductiva es una alternativa en la cesárea de pacientes con acondroplasia. Aunque no existen recomendaciones claras para orientar el acceso seguro al neuroeje ni para administrar medicamentos anestésicos a este nivel, se puede considerar el uso de la ecografía y la administración titulada de fármacos neuroaxiales (epidural, epidural-espinal y espinal continua) para mejorar la seguridad y la eficacia de la técnica en este tipo de pacientes. Introduction:Cesarean section under general anesthesia is recommended in achondroplastic pregnant patients; however, the use of conductive techniques has been recently reported, with acceptable results. Objective: To describe the anesthesia management in an achondroplastic patient scheduled for C-section under combined spinal-epidural anesthesia. Methods and results:We present the case of a first pregnancy in a patient with achondroplasia, height 110 cm and 37 weeks of gestation. The patient underwent cesarean section under ultrasound-guided conductive anesthesia, using a titrated mixture of local anesthetic and opiate, with good results for the mother and child. Conclusions:Conductive anesthesia is an option in C-section in patients with achondroplasia. Although there are no clear recommendations to guide a safe access to the neuroaxis or to administer anesthetic agents at this level, ultrasound and the titrated administration of neuraxial drugs (epidural, epidural-spinal and continuous spinal) for improved safety and efficacy of the technique in this type of patients may be considered.

The aim of the 2012 "What's new in obstetric anesthesia?" review is to highlight important scientific and medical advances in the fields of obstetric anesthesiology, obstetrics and perinatology from literature published in 2011. This review will consider advances in the prevention and treatment of important obstetric and obstetric anesthesia-related morbidities, research relevant to the course of labor and electronic fetal monitoring, and advances in neuraxial analgesia and anesthesia for obstetric patients.

Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate “imperfect” neuraxial anesthesia once fetal considerations are removed.

In this study, we sought to determine the long-term effect of the additional year of anesthesia residency (postgraduate year [PGY]-4) instituted in 1989 by the American Board of Anesthesiology on the number of individuals who pursued 12-mo subspecialty anesthesia training. We tested the hypothesis that extending education by a year would decrease the number of anesthesia subspecialty trainees. Surveys were collected from approved anesthesia residency training programs in the United States from 1989 to 2001. The questionnaires determined the number of individuals pursuing subspecialty training during PGY-4 and PGY-5. The subspecialties included cardiac anesthesia, pediatric anesthesia, pain management, obstetrical anesthesia, neuroanesthesia, outpatient anesthesia, intensive care medicine, and research. The number of anesthesiology residents (PGY-5) pursuing 12-mo subspecialty training increased over this period. The specific subspecialty distribution of fellows changed, with the largest increase in number and percentage occurring in pain management. The largest declines occurred in critical care medicine and research. Our data do not indicate a decrease in the number of anesthesiology subspecialists. Factors other than the duration of training appear responsible for the selection of subspecialty education.

Introducción y objetivos: La anestesia regional brinda una excelente anestesia y analgesia en pacientes obstétricas, pero existe el potencial de complicaciones tales como la cefalea pospunción dural y lesión neurológica permanente o transitoria. El presente estudio pretende describir la incidencia de la cefalea pospunción dural y daño neurológico en la población obstétrica de un hospital universitario que fue tratada con bloqueo neuroaxial, en comparación con la literatura mundial e identificar los factores de riesgo. Material y métodos: Se hizo una cohorte retrospectiva incluyendo los datos recolectados a partir de los registros de consultas posanestesia durante el año 2010. El análisis central se hizo en función de las quejas de déficit neurológico periférico y cefaleas reportadas por los pacientes, el tipo de anestesia y el procedimiento quirúrgico realizado. Se aplicó un análisis de regresión múltiple para investigar la relación entre el inicio de parestesias de las extremidades inferiores y el tiempo en que permanecieron estas pacientes en posición ginecológica y otras variables. Resultados: Se evaluaron en total 2399 pacientes embarazadas tratadas con bloqueo neuroaxial. Las complicaciones neurológicas que se presentaron en estas pacientes se dividieron en parestesias de las extremidades inferiores (0,3%), irritación radicular transitoria (0,1%) y cefalea pospunción dural (3%). Las pacientes que permanecieron más de 60 min en posición ginecológica mostraron un índice de probabilidades (odds ratio) de evolución con parestesia de las extremidades inferiores de 1,75, y las pacientes que estuvieron más de 120 min mostraron un índice de probabilidades de 2,1, pero sin significación estadística. Conclusiones: Las pacientes que se sometieron a bloqueo neuroaxial y se colocaron en posición ginecológica tenían mayores probabilidades de evolucionar con parestesias de las extremidades inferiores por el tiempo que permanecieron en esta posición. Introduction and objectives: Regional anesthesia provides excellent anesthesia and analgesia in obstetric patients, but has potential for complications such as post-dural puncture headache and permanent or transient nerve damage. This study aimed to describe the incidence of post-dural puncture headache and nerve damage in the obstetric population of auniversity hospital that was submitted to neuraxial blockades, comparing with the world literature, and identify risk factors. Materials and methods: A retrospective cohort was performed including data collected in the records of post-anesthetic consults conducted during the year 2010. The main analysis was performed on the complaints of peripheral neurological deficits and headaches reported by patients, type of anesthesia and performed surgical procedures. A multiple regression analysis was performed to investigate the association between the onset of lower limb paresthesias and the length of stay of these patients in the gynecological position and other variables. Results: A total of 2399 pregnant patients who had undergone neuraxial blockade were eva-luated. Neurologic complications that occurred in these patients were divided into lower limb paresthesias (0.3%), transient radicular irritation (0.1%), and post-dural puncture headache (3%). The patients who stayed more than 60 min in gynecological position showed an odds ratio of evolution with lower limb paresthesias of 1.75 and patients who stayed more than 120 min showed an odds ratio of 2.1, but without statistical significance. Conclusions: Patients submitted to neuraxial blockades and placed in gynecological position were more likely to evolve with lower limb paresthesias related to duration of this position.

Fetal safety is a permanent priority during anesthetic practice for obstetrics. This review is intended to analyze the scientific evidence available on the potential fetal and neonatal impact of intrapartum anesthetic procedures. An online search (PubMed) was conducted. Relevant references were selected and reviewed. Compared to regional techniques, intravenous analgesia with opioids is associated with higher incidence of fetal bradycardia and decreased fetal heart rate variability, lower Apgar score, greater base deficit and higher incidence of neonatal respiratory depression. These effects are accentuated if there is prior fetal distress and are similar to those induced by general anesthesia for cesarean section. The choice of opioid for intravenous analgesia should be based on the pharmacology of each agent and on the progression of labor. Remifentanil offers good cost-effectiveness and a security profile among intravascular opioids. It is important not to underestimate the potential for secondary injury associated to regional techniques, namely by maternal hypotension and uterine hypertonicity, with resulting uteroplacentar hypoperfusion. There is no evidence on the ideal regional technique. It should be tailored to maternal and fetal characteristics, considering onset and duration of its analgesic or anesthetic effect as well as its influence on maternal hemodynamic and uterine hypertonicity. Inhalational analgesia with N2O may constitute an alternative to regional techniques., A segurança fetal é uma prioridade constante na prática anestésica em Obstetrícia. Constituem objectivos desta revisão, uma análise da evidência científica sobre as potenciais repercussões fetais e neonatais dos procedimentos anestésicos intraparto. Procedeu-se a uma pesquisa bibliográfica on-line (PubMed). As referências consideradas relevantes foram selecionadas e revistas. Comparativamente com as técnicas regionais, a analgesia de trabalho de parto com opioides intravasculares tem maior incidência de bradicardia fetal, redução da variabilidade da frequência cardíaca fetal e, tal como a anestesia geral para cesariana, associa-se a menor índice de Apgar, maior défice de bases e maior incidência de depressão respiratória neonatal. Esses efeitos são acentuados se existe sofrimento fetal prévio. A escolha do opioide para analgesia intravascular deve basear-se na farmacologia de cada agente e na evolução do trabalho de parto, constituindo o remifentanil uma solução com relação custo-eficácia favorável e com maior segurança fetal, dentro deste grupo de agentes. É importante não minimizar os potenciais efeitos secundários fetais das técnicas regionais, através da hipotensão materna e da hipertonicidade uterina, com consequente hipoperfusão uteroplacentar. Não há evidência sobre a técnica regional ideal, devendo esta ser adaptada às circunstâncias materno-fetais e ponderada em função do início e duração do efeito anestésico ou analgésico, da repercussão hemodinâmica materna e do risco de hipertonicidade uterina. A analgesia inalatória com protóxido de azoto (N2O) constitui uma alternativa válida às

Los desórdenes del desarrollo del tubo neural son el segundo mayor grupo de malformaciones congénitas conocidas y con una incidencia de 1/1000 nacidos vivos. El meningomielocele es una de las malformaciones más frecuentes. Se define como una falla en el cierre del tubo neural con herniación de meninges y elementos neurales. El embarazo en estas pacientes es complicado por las deformidades físicas y complicaciones neurológicas secundarias, pudiendo dificultar la técnica anestésica neuroaxial en el trabajo de parto y operación cesárea. Existen escasos reportes de pacientes con meningomielocele en trabajo de parto y analgesia neuroaxial. Presentamos una revisión de esta patología y las técnicas anestésicas utilizadas en el trabajo de parto y operación cesárea de pacientes con antecedente de meningomielocele, basados en un caso clínico del cual participamos. Neural tube defects are the second most common type of congenital birth defects with an incidence of 1/1000 newborns. Meningomyelocele is one of the most common clinical presentations. It is defined as a failed closure of the neural arch with herniation of the meninges and neural elements. Pregnancy among these patients can be complicated with physical deformity and coexisting neurological defects, which may challenge neuroaxial anesthetic technique in obstetric labor and cesarean delivery. There are few reports involving patients with meningomyelocele in obstetric labor and neuroaxial anesthesia. We discuss some key points of this disease and the anesthetic technique of choice in obstetric labor and cesarean delivery in patients with history of meningomyelocele, based on a case in which we participated.

La obesidad es una epidemia a nivel mundial, con más de 2.000 millones de adultos con sobrepeso u obesidad, por lo que cada vez es más probable enfrentarse a una embarazada obesa en la práctica clínica del equipo obstétrico. La obesidad incrementa los cambios fisiológicos del embarazo a nivel cardiovascular, respiratorio, metabólico y gastrointestinal, lo que tiene implicancias clínicas que aumentan los costos en salud y la morbimortalidad materna y fetal. Las embarazadas obesas son un constante desafío para el equipo obstétrico, anestesiológico y de salud, debiendo ser enfrentadas de forma multidisciplinaria para la obtención de mejores resultados obstétricos y perinatales. El anestesiólogo debe tener especial cuidado en el manejo analgésico del trabajo de parto y en la técnica anestésica para la operación cesárea. El objetivo central de la siguiente revisión es explicar, analizar y desarrollar las principales implicancias anestésicas a las cuales se ve enfrentado el especialista en una embarazada obesa. Obesity is a global epidemic, with more than 2,000 million overweight or obese adults, so it is very likely to have an obese pregnant in the clinical practice of the anesthesiologist. Obesity increases the physiological changes of pregnancy in the cardiovascular, respiratory, metabolic and gastrointestinal system, which has clinical implications that increase health care costs and maternal and fetal morbidity and mortality. Obese pregnant are a constant challenge for the obstetric, anesthesiology and health team, and must be considerate in a multidisciplinary way to obtain better maternal and perinatal outcomes. The anesthesiologist should take special care in the labor analgesia and anesthetic technique for caesarean section. The focus of the following review is to present and develop the main anesthetic implications to which the anesthesiologist is confronted in obese pregnant patient.

This article is intended for readers seeking an update on current obstetric analgesic/anesthetic techniques, and selected problems and controversies currently of interest to those committed to improving their ability to provide safe and effective maternal analgesia and anesthesia for labor, vaginal and instrumental delivery, and related obstetric procedures. It is assumed that the reader has familiarity with fundamental obstetric anesthetic techniques and principles. Practitioners who provide obstetric anesthesia should be familiar with several important recently published documents. The most recent standards for obstetric anesthesia care are included in a joint statement from the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists, approved in 1998, entitled "Optimal Goals for Anesthesia Care in Obstetrics," and in the ASA's "Guidelines for Regional Anesthesia in Obstetrics," last amended in 1991. These may be obtained from the ASA directly or via http://www.asahq.org/standards. Another important document is the report prepared by the ASA Task Force on Obstetrical Anesthesia, entitled "Practice Guidelines for Obstetrical Anesthesia."46

T HE DEVELOPMENT of standards (rules or minimum requirements) and guidelines (recommendations) for obstetric anesthesia has usually been fraught with controversy. Obstetric anesthesia practices are among the most variable in our specialty: everyone has their own method of clinical care, administrative organization, daytime and call coverage, and even billing for labor analgesia time. ~'2 In 1988, the American Society of Anesthesiologists (ASA) House of Delegates approved "Standards for Conduction Anesthesia in Obstetrics" as developed by the ASA Committee on Obstetric Anesthesia. These standards generated intense and heated discussion and in 1990 were "downgraded" to guidelines and retitled "Guidelines for Regional Anesthesia in Obstetrics. ''3 They underwent review in 1998 at the request of th6 ASA president and were reapproved with no changes. In October 1998, the ASA House of Delegates approved a practice parameter entitled "Practice Guidelines for Obstetrical Anesthesia." Because the titles of these separate guidelines are so similar, they are frequently confused, but the topics they cover are quite different. Although these are the primary ASA documents pertaining to obstetric anesthesia, other standards and guidelines contain statements relating to care in the labor and delivery suite. These include "Guidelines for Patient Care in Anesthesiology," "The Anesthesia Care Team," "Statement on Regional Anesthesia," and "Optimal Goals for Anesthesia Care in Obstetrics" (American College of Obstetritians and Gynecologists [ACOG]/ASA Joint Statement). "Guidelines for Regional Anesthesia in Obstetrics" can be found in the ASA Directory of Members (page 473 in the 1999 edition) as can all other statements and guidelines.

Rapid detection of hemostatic defects presents a challenge for the anesthesiologist who must balance anesthetic and surgical considerations for maintaining adequate platelet and coagulant factors, while keeping allogenic blood exposure to a minimum. The Clot Signature Analyzer®, a point-of-care device capable of rapid response and easy interpretation is described here. Its applicability in two obstetrical patients with platelet dysfunction is discusssed.

Computerization of the medical record in various outpatient settings has been successful but for anesthesiologists, the preoperative visit differs significantly. This study implemented a computerized version of a structured pre-anesthetic evaluation questionnaire that we had previously developed and which provided a starting point for developing a suitable vocabulary and workflow. Using the computerized version, pre-anesthetic evaluations were performed on 26 obstetric patients over a 20-week period. The introduction of a computer into the physician-patient relationship did not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), captured far more detail than found in our previously dictated and handwritten notes and provided immediately available data for quality assurance activities.

Study Objective To determine the impact of the plica mediana dorsalis (PMD) on injected contrast media spread in the epidural space. Design Prospective interventional study. Setting Academic medical center. Patients 30 chronic pain patients ranging in age from 37 to 71 years, undergoing epidural steroid injection. Interventions and Measurements Epidurograms were evaluated for the 1) presence or absence of a PMD and 2) bilateral differential density and the extent of contrast spread on either side of the midline, horizontally and vertically. Results The PMD (defined as midline radiolucency in epidurograms) was observed in (80%) 24/30 patients based on the epidurograms that were evaluated. Denser contrast spread on one side was found in (79%) 19/24 patients who had the PMD and in (33%) 2/6 patients who did not have the PMD ( P = 0.03). Horizontal and vertical asymmetrical spread of the contrast was observed in (67%) 16 of 24 patients with the PMD and in (50%) 3 of 6 of patients without the PMD in each direction independently. Conclusion The difference in density of contrast spread on either side of the midline carries important clinical implications in understanding the pathogenesis of inadequate epidural analgesia and/or unilateral excessive motor weakness or numbness.

Unlike the epidural analgesia (EA), the combined spinal-epidural analgesia (CSE) hasn't been studied enough to be able to draw real conclusions on its consequences on the mother, the son and the labor. This thesis aims at finding if the EA and the CSE are compatible on this point. We have realise the prospective study at two centres. The maternity of Port-Royal and Neker, from may 2010 to january 2011. We set up a survey in the delivery room, and we have gathered data from the obstetrical folder. Thirty five records were collected. The results of the study and the analysis of the literature don't highlight any significative difference between the two groups regarding the repercussions on the mother the child and work. On the other hand the results showed a rather faster relief of pain with the EA based on smaller morphemic dosses and local anaesthetic ones. This dissertation allows us to assert that the EA and the CSE are two comparable methods. Regarding the repercussions on work development, on the neonative part and the side effects. It showed that a midwife can take care of a patient under EA and CSE.; Contrairement à l'APD, la PRC n'a pas fait l'objet d'un assez grand nombre d'études pour tirer de réelles conclusions sur ses conséquences sur la mère, l'enfant et le travail. Ce mémoire vise à déterminer si la PRC et l'APD sont comparables sur ce point. Nous avons réalisé une étude prospective sur deux centres : la maternité de Port-Royal et celle de Necker, de mai 2010 à janvier 2011. Nous avons mis en place un questionnaire en salle de naissance et nous avons rassemblé des données du dossier obstétrical. Nous avons recueilli 35 dossiers. Les résultats de l'étude et l'analyse de la littérature ne mettent pas en valeur de différence significative entre les deux groupes au niveau des répercussions sur la mère, l'enfant et le travail, mais retrouvent un soulagement de la douleur significativement plus rapide avec la PRC avec des doses d'anesthésique local et de morphinique plus faibles. Ce mémoire nous permet d'affirmer que la PRC et l'APD sont deux méthodes d'anesthésie comparables en terme de répercussions sur le déroulement du travail, sur l'état néonatal, ainsi qu'en terme d'effets secondaires. Il nous a permis de montrer qu'une sage-femme peut suivre une patiente sous PRC au même titre qu'une patiente sous APD.

A parturient presented at 35 weeks' gestation with worsening neurological symptoms caused by syringomyelia. She underwent urgent cesarean delivery. The etiology and anesthetic considerations for an obstetrical patient with syringomyelia are discussed.

An international investigation was undertaken into practices of pre-anesthetic evaluation provided for obstetrical patients in outpatient clinics. A questionnaire was completed by 21 36 (58%) obstetric units. Only 5 (23%) had an outpatient clinic for pre-anesthetic evaluation of the obstetric patient, but in 10 (37%) anesthetists take part in the prenatal examinations and give advice in cases of complicated pregnancy.

To provide a current review of the literature regarding airway problems in pregnancy and management.Obstetrical anesthesia is considered to be a high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Failure to appropriately manage a difficult or failed intubation increases the risk of hypoxemic cardiopulmonary arrest and/or pulmonary aspiration, resulting in a high probability of maternal morbidity and mortality.Anesthesia is the seventh leading cause of maternal mortality in the United States. Anatomic and physiologic changes during pregnancy place the parturient at increased risk for airway management problems. It is essential to perform a thorough preanesthetic evaluation and identify the factors predictive of difficult intubation. Airway devices such as the laryngeal mask airway, ProSeal, intubating laryngeal mask airway, Combitube, and laryngeal tube are described and have been used during failed intubation in pregnant patients.Teamwork between an anesthesiologist and an obstetrician is absolutely essential for the safety of both the mother and baby. Most of us tend to agree that airway emergencies have a way of occurring at the worst possible times. It is essential that all anesthesia care practitioners must have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.

Obstetrical anesthesia is considered by many to be a high-risk subspecialty of anesthesia practice that is laden with clinical challenges and medico-legal liability. Anesthesia-related complications are the sixth leading cause of pregnancy-related maternal mortality in the United States.Difficult or failed intubation following induction of general anesthesia for cesarean delivery remains the major contributory factor to anesthesia-related maternal complications.Communication skills and exchange of information (between anesthesiologists, obstetricians, and nurses) in an ever changing environment of labor and delivery are essential for a perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The safe provision of labor anesthesia and/or analgesia requires appropriate staff, facilities, and equipment for proper patient safety.This article is intended for obstetricians and reviews the current guidelines for the administration of obstetrical anesthesia and analgesia.

This study measures the association between health insurance and the likelihood of receiving different obstetrical anesthesia protocols among 121,351 singleton live births in upstate New York during 1992. Mothers receiving a cesarean under Medicaid were approximately twice as likely to receive general anesthesia as those with traditional private coverage. Those receiving a cesarean under an HMO were least likely to receive general anesthesia with adjusted odds of 0.73 (confidence interval [CI] = 0.68-0.79), compared to those with traditional private insurance. Those delivering vaginally under Medicaid, HMO, or no coverage had adjusted odds of receiving an epidural of 0.45 (CI = 0.43-0.48), 0.68 (CI = 0.64-0.71), and 0.44 (CI = 0.38-0.52), respectively, compared to those under traditional private insurance. Although there was some differences by race, the strongest determinant of anesthesia remained insurance type. Insurance-mediated disparities in obstetrical anesthesia care are evident in upstate New York and warrant further study nationally.

To report the management of a multigravida presenting with preeclampsia, HELLP syndrome and acute cortical blindness for Caesarean section.A 39-yr-old woman, with three past uncomplicated pregnancies presented at 33 wk with acute cortical blindness. Based on clinical and laboratory assessment, a diagnosis of preeclampsia with HELLP syndrome was made. A CT scan of her head demonstrated ischaemic lesions of her basal ganglia, extending superiorly to involve both posterior parietal and occipital regions. Infusions of magnesium sulphate and hydralazine were started and an urgent Caesarean section was performed under subarachnoid anaesthesia after insertion of an arterial line and intravenous hydration. The course of anaesthesia and surgery was uneventful and she delivered a live 1540 g female infant. By the following morning, she had recovered some vision and visual recovery was complete by 72 hr postpartum. She underwent an MRI with angiography on the first postpartum day. Ischaemic lesions were confirmed in the same sites identified on CT scan but all major cerebral vessels were patent and no significant vascular abnormality was noted. Her postoperative course was uneventful and she was discharged home seven days postpartum after being prescribed labetalol for continued hypertension.The anaesthetic management of a parturient with acute cortical blindness and HELLP syndrome is modeled on the underlying preeclamptic condition. Invasive monitoring is not routinely indicated but is specifically indicated in some cases. Provided that it is not contraindicated because of prohibitive risk to the mother, regional anaesthesia has particular advantage in these patients. In particular, the use of spinal anaesthesia, which has been discouraged by some for this patient population, should be re-evaluated.

Cavernous transformation of the portal vein (CTPV) is a rare disorder resulting from extrahepatic portal vein thrombosis and development of collateral venous circulation.I herein present the first reported case of a pregnant patient with CTPV associated with persistent consumptive coagulopathy and chronic thrombocytopenia.Single-dose spinal anesthesia was safely conducted for an uneventful cesarean delivery.

Background: Data on the effects of general anesthesia on the fetal and neonatal brain are limited. Animal studies demonstrated that anesthetic agents leave their consequences in the form of learning and memory deficits. The effects of propofol on the fetal neurodevelopment are not clear yet. Materials and Methods: This is a telephone-based questionnaire survey that addressed the effect of general anesthesia by propofol during cesarean section at term with no perinatal complications on the psychosocial behavior of children at 8-10 years of age compared with children having same characteristics except for delivery under neuraxial anesthesia using the Pediatric Symptom Checklist as a score. Results: A total of 187 children were born at term between January 1, 2002 and December 31, 2004 with no perinatal distress under induction of general anesthesia by propofol. 66 children (35.3%) were lost to follow-up and parents of two children (1.1%) refused to participate. A total of 189 children were included in the study: 119 were born by cesarean section under general anesthesia and 70 were born by cesarean section under neuraxial block. The incidence of psychosocial behavior impairment at 8-10 years of age was not found to be affected by the mode of anesthesia during delivery by cesarean section nor by neonatal nor parental characteristics. Conclusion: Exposure to propofol as an induction agent for general anesthesia or cesarean section does not seem to increase the psychosocial behavior disorder development risk at 8-10 years of age.

s of free papers presented at the Obstetric Anaesthetists' Association: Basel 265 epidural bupivacaine infusions does indeed increase the incidence of maternal hypoxaemic episodes during the second stage of labour. The higher inci- dence of hypoxaemia in the active phase compared with the passive phase may result from breath- holding while pushing. The fentanyl group may push harder or respiratory drive between pushing may be diminished. We have found no evidence that this degree of hypoxia is harmful to the baby. References 1. Deckardt R, Fembacher P M, Schneider K T M, Graeff H. Maternal arterial oxygen saturation during labor and delivery: Pain-dependent alterations and effects on the newborn. Obstetrics & Gynecology 1987; 70: 21-25. 2. Huch A, Huch R, Schneider H, Rooth G. Continuous transcutaneous monitoring of fetal oxygen tension during labour. British Journal of Obstetrics and Gynaecology 1977; 84 (Supp. 1): 1-39. 3. Griffin R P, Reynolds E Maternal hypoxaemia during labour and delivery: the influence of analgesia and effect on neonatal outcome. Anaesthesia 1995; 50: 151-156. FORTHCOMING MEETINGS Obstetric Anaesthetists' Association (OAA) 11-12 April 1996 Glasgow, UK Call for papers Abstracts (3 copies) should be submitted on one side of a single sheet of A4 paper with a 1.5 inch margin down the left hand side. The title of the work, the authors, institution and address should be given at the head of the page. Conventional titles (introduc- tion, methods, results, conclusion, references) are advisable. References should conform to the style of the International Journal of Obstetric Anesthesia. Please state if you have a preference for oral or poster presentation. If you wish your abstract to be considered for inclusion in the International Journal of Obstetric Anesthesia, please send an additional copy double spaced. The abstract should not be published else- where, but this does not preclude publication as a full paper at a later date. Contact: OAA Registration, PO Box 3219, London SW13 9XR, UK. Tel: (44) 0181 741 1311 Fax: (44) 0181 741 0611. Abstracts should be submitted by 26 January 1996 to: Dr J.A. Reid, Department of Anaesthetics, Western Infirmary, Dumbarton Road, Glasgow G11 6NT, UK. Tel: (44) 0141 211 2069 Fax: (44) 0141 211 1806.s should be submitted by 26 January 1996 to: Dr J.A. Reid, Department of Anaesthetics, Western Infirmary, Dumbarton Road, Glasgow G11 6NT, UK. Tel: (44) 0141 211 2069 Fax: (44) 0141 211 1806. 10-11 April 1997 Guildford, UK Contact: Dr P. Moore Department of Anaesthetics, Royal Surrey Hospital, Guildford, UK. April 1998 Leeds, UK Contact: Dr G. Lyons Department of Anaesthetics, St James Hospital, Leeds, UK. RPMS Institute of Obstetrics and Gynaecology 31 October 2 November 1995 Contact: O A A Registration, Royal College of Obstetrics and Gynaecology, PO Box 3219, London SW13 9XR, UK. London, UK Tel: (44) 0181 741 1311 A three-day course in obstetric anaesthesia and Fax: (44)0181 741 0611. analgesia. Society for Obstetric Anesthesia and Perinatology (SOAP) 28th Annual Meeting 1-4 May 1996 Tucson, Arizona Richmond, VA 23230-1086, USA. Contact: SOAP Tel: (1) 804 282 5051 1910 Byrd Avenue, Suite 100, PO Box 11086, Fax: (1)804 282 0090. Sol M. Shnider Obstetrical Anesthesia: 21-24 March 1996 The annual obstetrical anesthesia course will again be held in San Francisco. It is now named in honor of the late Dr. Sol M. Shnider, the original organizer of this course. The course will be held at the Grand Hyat t on Union Square. Call (1) 415-398-1234 for room reservations. Course brochures or registration 1996 information requests should be addressed to Dr. Samuel C. Hughes, University of California, San Francisco General Hospital, Department of Anesthesia, Room 3C-38, 1001 Portrero Avenue, San Francisco, CA 94110, USA. Fax (1) 415 206 6014.