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The prevalence of anaphylaxis occurring during pregnancy is approximately 3 cases per 100,000 deliveries. The management of anaphylaxis occurring during the third trimester of pregnancy may be challenging because of the additive effects of aortocaval compression and cardiovascular disturbances of anaphylaxis. In this review, we identify the clinical signs of anaphylaxis occurring during labor and cesarean delivery, discuss the more common allergens that cause anaphylaxis during this clinical setting, and develop a rational approach to the identification of the offending allergen. We also suggest strategies for the management of anaphylaxis occurring during the third trimester of pregnancy, including the prompt administration of epinephrine and emergency cesarean delivery in cases of severe reactions. Evidence is limited to case reports and extrapolation from nonfatal and fatal cases, interpretation of pathophysiology, and consensus opinion.

A 30-year-old African woman was admitted in labour at 37 weeks’ gestation of her fifth pregnancy for emergency cesarean delivery. This was her first assessment for the current pregnancy at this hospital. She had a cesarean delivery with each of her previous pregnancies. On examination, she was

Penetrating trauma during pregnancy is mainly the result of gunshot and stab wounds. When you have to deal with an injured pregnant patient, you have to be aware of the changes in its physiology and anatomy, because subsequent management adaptations are required. Also, the patterns of injury in pregnancy give you much valuable information. Remember there are two patients to treat. When you must proceed with an emergency cesarean delivery? What you have to do on the surgical table? And finally, is there any space for non-operative management?

Objective The purpose of this study was to report optical coherence tomography (OCT) and angiographic findings in a patient with pregnancy-induced hypertension (PIH). Case report A 39-year-old woman, who was diagnosed with PIH, reported blurred and distorted vision at 5 days after an emergency cesarean delivery. OCT revealed a large serous retinal detachment (SRD) that included areas in the macula, along with an increased choroidal thickness noted in both eyes. Indocyanine green angiograms indicated delayed filling of the choroidal circulation in the early phase but choroidal hyperpermeability in the mid-phase. The SRD was gradually resolving without any treatment except for antihypertensive drugs. At 40 days after the initial examination, OCT revealed both the disappearance of the SRD and marked improvement of the choroidal thickening. Conclusion Ophthalmologists need to be aware that PIH can cause choroidal ischemia, a breakdown of the outer blood–retinal barrier, and lead to the development of SRD.

Cardiac diseases in pregnancy pose a multitude of challenges to both anesthesiologists and obstetricians. Peripartum cardiomyopathy is one of the rare causes of dilated cardiomyopathy in parturients with a great diagnostic difficulty. High degree of suspicion along with good clinical experience is needed for its diagnosis. Unfortunately, mortality from this ranges from 35% to 50%. We report a case of 21-year-old female parturient presenting at 37 weeks of gestation for emergency cesarean delivery with undiagnosed peripartum cardiomyopathy. She developed cardiac arrest soon after giving spinal anesthesia. She was successfully resuscitated and shifted to ICU for further management. Bedside echocardiography was conducted, which showed dilated cardiomyopathy with an ejection fraction of 32%.

Placental abruption is one of the major life-threatening obstetric conditions. The fetomaternal outcome of a severe placental abruption depends largely on prompt maternal resuscitation and delivery. A case of severe preterm placental abruption with intrauterine fetal death. Following a failed induction of labor with a deteriorating maternal condition despite resuscitation, emergency cesarean delivery was offered with good maternal outcome. Cesarean delivery could avert further disease progression and possible maternal death in cases of severe preterm placental abruption where vaginal delivery is not imminent. However, further studies are necessary before this could be recommended for routine clinical practice.

The objective of this study was to evaluate the effect of the current guideline of 30-minute decision-to-incision interval (D-I) in emergent cesarean delivery (ECD) on neonatal and maternal outcomes. A retrospective chart review was conducted of pregnant women who underwent ECDs between January 1999 and December 2001. The overall median D-I was 20 minutes (range, 5 to 57 minutes). In 83 women (group I), D-I was < or = 30 minutes, and in 28 women (group II), it exceeded 30 minutes. Group I had more neonates with cord pH < 7.00, seizures, encephalopathy, and lower Apgar scores at 1 and 5 minutes than group II, but were not statistically significant. There was no significant difference in neonatal admission to the neonatal intensive care unit or length of stay between the two groups. Maternal complications were higher in group I, but not statistically significant. Although it was achieved in most of the ECDs, the guideline of 30-minute D-I does not seem to improve neonatal nor worsen maternal outcomes.

Vaginal birth after cesarean delivery (VBAC) has been promoted as a method to reduce overall cesarean delivery rates. The benefits of successful VBAC in North American centers reportedly outweigh risks in most women with a prior low transverse cesarean delivery. Many women come to our center specifically to attempt VBAC since we offer this option for delivery following one lower segment cesarean section. Emergency cesarean delivery is possible within 15 min of decision making. We monitor all women attempting VBAC with continuous electronic monitoring and if required use oxytocin for labor induction and augmentation. We do not routinely explore the uterus after delivery. During the study period prostaglandin E2 gel (0.5 mg) was used for cervical ripening when required. (excerpt)

Cesarean delivery in a patient with pulmonary hypertension poses significant risks, particularly if the maternal status is decompensating. We present the first report of emergency use of cardiopulmonary bypass for cesarean delivery in a patient whose status was deteriorating.

THE Airtraq (Prodol Meditec S.A., Vizcaya, Spain), a new disposable intubating device, was designed to provide a view of the glottis without alignment of the oral and pharyngeal axes. The Airtraq laryngoscope (AL) has recently been used in patients with normal airways 1 and in simulated difficult airways, 2 but no study has assessed its performance in difficult airway patients. After training on a manikin, five senior staff anesthesiologists covering the obstetric anesthesia unit of our university hospital performed the clinical learning process with the AL. Because of its efficiency in the case of difficult tracheal intubation, the AL was incorporated into our emergency difficult airway management algorithm as a second-step airway device in the case of failed tracheal intubation using a standard Macintosh laryngoscope. We report two cases of emergency cesarean delivery parturients in whom the trachea was rapidly intubated using the AL after failed direct laryngoscopy. We discuss the place of the AL in a difficult airway management algorithm in parturients.

The American College of Obstetricians and Gynecologists (ACOG), in 1995, recommended that, before starting cesarean delivery for fetal distress, a scalp pH be obtained if feasible and intrauterine resuscitation attempted with tocolytic agents or amnioinfusion. It was further proposed that, if fetal heart rate (FHR) abnormalities persisted, the skin incision for cesarean delivery be made within 30 minutes of the decision to operate. In 1998, the ACOG determined that, because most newborn infants delivered for fetal distress are in good condition, the term nonreassuring fetal status is preferable. Practitioners have been slow to accept these recommendations. The authors undertook a PubMed search of the English-language literature from 1990 to 2000 to estimate compliance with the ACOG guidelines. There were 169 relevant publications. In 3 relevant reports, scalp blood pH was determined in 5% of 1128 emergency cesarean section deliveries. Three reports found that tocolytics were used for intrauterine resuscitation in 16% of 1261 cases. Five reports found that the interval between the decision to operate and the incision was less than 30 minutes in 59% of 446 cases. In 5 reports of 340 cases in which the cord blood pH was determined, the umbilical arterial pH was less than 7.00 in 10% of instances. Little attention has been given in the recent obstetric literature to compliance with the ACOG guidelines concerning how best to manage emergency cesarean delivery for fetal distress. The authors conclude from this review of the recent literature that compliance is infrequent and incomplete.

Dexmedetomidine is a highly selective α-2 agonist which has recently revolutionized our anesthesia and intensive care practice. An obstetric patient presented for emergency cesarean delivery under general anesthesia, with pre-eclampsia and postpartum hemorrhage. In carefully selected cases with refractory hypertension and postpartum hemorrhage, dexmedetomidine can be used for improving overall patient outcome. It was beneficial in controlling both the blood pressure and uterine bleeding during cesarean section in our patient. Resumo: Dexmedetomidina é um α2-agonista altamente seletivo que recentemente revolucionou a nossa prática de anestesia e tratamento intensivo. Uma paciente obstétrica foi admitida para cesariana de emergência sob anestesia geral, com pré-eclâmpsia e hemorragia pós-parto. Em casos cuidadosamente selecionados com hipertensão refratária e hemorragia pós-parto, dexmedetomidina pode ser usada para melhorar o resultado geral da paciente. O fármaco foi benéfico no controle tanto da pressão arterial quanto do sangramento uterino durante cesariana em nossa paciente. Keywords: Dexmedetomidine, Obstetric anesthesia, Pregnancy-induced hypertension, Post-partum hemorrhage, Emergency cesarean section, Palavras-chave: Dexmedetomidina, Anestesia obstétrica, Hipertensão induzida pela gravidez, Hemorragia pós-parto, Cesariana de emergência