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Non obstetric surgery during pregnancy is rare with maternal malignancy being one of the most common causes. Sporadic pregnancy related desmoid tumours are even more uncommon and optimal management of this tumour is complex. Complete surgical excision is the most commonly accepted treatment. Surgery during pregnancy is challenging as it demands taking into consideration requirements for both the mother and the foetus. The choice of anaesthetic plan must take into account surgical and patient specificities, and the effects of anaesthesia on the foetus. We report the perioperative management of a pregnant woman in the second trimester of pregnancy who underwent complete excision of a desmoid tumour under regional anaesthesia. Intraoperative change of surgical plan posted an additional challenge.&nbsp, A cirurgia não obstétrica durante a gravidez é rara, sendo uma das causas mais comuns a excisão de tumores maternos. Tumores desmóides esporádicos na gravidez, constituem uma causa ainda mais rara, sendo o tratamento ideal complexo. A excisão cirúrgica completa é atualmente o tratamento mais aceite. A cirurgia durante a gravidez é um desafio uma vez que requer ter em consideração ambos a mãe e o feto. A escolha de um plano anestésico requer ter em linha de conta especificidades cirúrgicas e da paciente, bem como os efeitos da própria anestesia no feto. Este caso clínico relata o manuseio perioperatório de uma grávida no segundo trimestre de gravidez que foi submetida a uma excisão completa de um tumor desmóide sobre anestesia loco regional. A alteração intraoperatória do plano cirúrgico constituiu um desafio adicional.

Résumé La pandémie de COVID-19 n’a pas épargné les femmes enceintes. Le tableau clinique et biologique est peu spécifique mais la littérature n’a pas retrouvé de susceptibilité accrue des parturientes, à l’infection virale, notamment aux formes graves, ayant comme principale conséquence une prématurité induite et les complications qui en résultent. La pandémie a fait revoir l’organisation de la prise en charge des femmes enceintes, avec une généralisation de la téléconsultation et une réduction d’accès des d’accompagnants en salle de travail comme en suite de couche. La décision du mode d’accouchement est restée uniquement dépendante de l’évaluation obstétricale dans les formes mineures ou asymptomatiques, de même que le mode d’anesthésie à privilégier pour le travail ou la césarienne est resté l’anesthésie locorégionale périmédullaire, en prenant soins de vérifier l’hémostase du fait de l’impact du virus, notamment sur le taux de plaquettes. D’autres situations spécifiques, comme la prise en charge de la fièvre ou de l’hypertension artérielle du péri-partum, n’ont pas été modifiées par le statut viral des parturientes. Le post-partum est la période qui a fait l’objet du plus grand nombre de modifications avec l’administration plus large d’anticoagulants et une utilisation restreinte des AINS. Le point clé de la prise en charge obstétricale en cette période de pandémie a finalement été la coopération interdisciplinaire, impliquant anesthésiste-réanimateur, gynécologue et pédiatres.

Background and purpose: While remifentanil can be used either during labour or fetal surgery, more should be known about the transplacental transfer of this opioid. The aim of this study was to investigate the placental transfer and haemodynamic effects of remifentanil after i.v. administration to pregnant ewes. Experimental approach: Seven pregnant ewes received a continuous infusion of remifentanil (0.33 mu g.kg(-1).min(-1)) for 1 h, and maternal and fetal arterial blood samples were drawn at regular intervals during and up to 1 h after the discontinuation of the infusion. Haemodynamic parameters were monitored continuously. Blood gas samples were drawn at baseline and once during the infusion. Key results: Peak maternal remifentanil plasma levels of 4.0 +/- 0.9 ng.mL(-1) (mean +/- SD) and peak fetal plasma levels of 0.4 +/- 0.3 ng.mL(-1) were obtained. Remifentanil plasma levels dropped rapidly after the discontinuation of the infusion. The continuous infusion of remifentanil did not result in significant maternal or fetal haemodynamic changes. Conclusions and implications: Remifentanil rapidly passes through the placenta of pregnant ewes and although remifentanil concentrations stay significantly lower in the fetus compared with those in the mother, remifentanil can be detected in significant amounts in the fetus. British Journal of Pharmacology (2010) 161, 1472-1476; doi:10.1111/j.1476-5381.2010.00783.x

The aims of antenatal anaesthetic assessment are to: identify problems or potential problems; arrange investigations; refer to specialists for advice and/or treatment; institute treatment; discuss options for analgesia in labour and/or anaesthesia for operative delivery; formulate a management plan; and highlight special requirements (e.g. latex-free equipment, extra staff, intensive care bed). In the UK, few, if any, units have the manpower to assess every pregnant woman, therefore attention is targeted at high-risk patients. •The number of parturients with pre-existing disease is thought to be increasing owing to better management of their underlying condition and of their pregnancy and delivery. It is important to tailor a plan to their individual needs and this is best done antenatally. •Arrangements for antenatal anaesthetic assessment vary from ad hoc calls from the antenatal clinic to regular, formal, anaesthetic clinics. Some units have combined clinics with obstetricians and other specialists. Setting up and running an antenatal anaesthetic assessment service is discussed and a sample antenatal anaesthetic assessment record is provided. •A checklist is given of those who should be referred for antenatal anaesthetic assessment. Women may have musculoskeletal problems, ranging from back pain to scoliosis, and may be concerned about having an epidural. Other problems covered include cardiac disease, haematological problems, previous anaesthetic problems, neurological conditions, respiratory problems (e.g. asthma), allergic reactions, obesity and needle phobia.

La analgesia epidural es hoy día el método de elección para el tratamiento del dolor del trabajo de parto, el expulsivo y el alumbramiento. Sin embargo, esta técnica puede fallar y aliviar de forma inadecuada (o nula) a la parturienta. En el presente artículo se revisan los factores de riesgo, las posibles causas y las alternativas terapéuticas posibles a la analgesia inadecuada, ya sea mediante terapias farmacológicas (neuroaxiales, bloqueos periféricos o administración de analgésicos vía intravenosa o inhalatoria) o no farmacológicas (técnicas de relajación, psicológicas o mecánicas). En todos los casos posibles se revisan la eficacia y las indicaciones de las terapias alternativas en función de la literatura publicada, especialmente desde el punto de vista de la medicina basada en la evidencia. Se insiste en la necesidad de aplicar una aproximación terapéutica multifactorial a la embarazada, no limitándonos solo a eliminar el dolor del parto. Epidural analgesia is now the method of choice for the treatment of pain in labour and delivery. However, this technique may fail and provide inadequate or null alleviation to the mother. This paper reviews the risk factors, possible causes and possible therapeutic alternatives to inadequate analgesia, whether pharmacological therapies (neuroaxial, peripheral blocks or analgesic administration via intravenous or inhalational routes) or non-pharmacological ones (relaxation techniques, psychological or mechanical). In all possible cases the efficacy and indications of alternative therapies based on the published literature are reviewed, especially from the point of view of evidence-based medicine. The need is underscored of a multifactorial therapeutic approach to the pregnant woman, not just restricting ourselves to eliminating the pain of childbirth.

Spinal anaesthesia has been used since the 1800s but, due to a number of complications, the popularity of this technique has waxed and waned. In the 1950s, it was the most widely used method of anaesthesia and analgesia in obstetrics but it fell out of fashion with the arrival of the epidural technique which allowed a continuous method of delivering analgesia with relatively few complications. Hypotension and the high incidence of postdural puncture headaches were two reasons for the decline in the popularity of spinal anaesthesia in the young, otherwise healthy pregnant population. With the development of newer needles and bevel designs and methods whereby the incidence of hypotension can be minimized, spinal anaesthesia is making a reappearance in obstetrical anaesthesia spheres. The purpose of this article is to review the history, effects, technique, indications, contraindications and complications of this method of anesthesia as it applies to the obstetrical patient.

The purpose of this study was to determine the availability of regional anaesthesia for Caesarean section, of epidural opioids and patient-controlled analgesia after Caesarean section, and of epidural and other forms of analgesia in labour. A mail survey was sent to the "Head Nurse, Department of Obstetrics" at each of the 142 hospitals in Ontario with designated obstetric beds. Responses were obtained from 100% of hospitals. For Caesarean Section, general anaesthesia was used in all hospitals, and was the only option in seven. Epidural anaesthesia was used in 93% of hospitals, and spinal anaesthesia in 48%. Postoperatively, patient-controlled analgesia was used in 31% of hospitals and spinal opioids in 28%. In 66 hospitals, im or iv opioids were the only types of analgesia available. For analgesia in labour, im or iv opioids were used in 96% of hospitals, nitrous oxide was used in 75%, epidural analgesia in 75%, transcutaneous electrical nerve stimulation in 52% and patient-controlled analgesia in 10%. The overall epidural rate was 38%. Although the average rate in the 73 hospitals with fewer than 500 births per year was only 6%, 14 large hospitals had an epidural rate of 60% or higher. It is concluded that regional techniques for peripartum analgesia have been widely accepted. Analgesia after Caesarean section could be improved. Epidural analgesia should be more widely available, especially in the many small hospitals in Ontario.

Background and purpose: While remifentanil can be used either during labour or fetal surgery, more should be known about the transplacental transfer of this opioid. The aim of this study was to investigate the placental transfer and haemodynamic effects of remifentanil after i.v. administration to pregnant ewes. Experimental approach: Seven pregnant ewes received a continuous infusion of remifentanil (0.33 mu g.kg(-1).min(-1)) for 1 h, and maternal and fetal arterial blood samples were drawn at regular intervals during and up to 1 h after the discontinuation of the infusion. Haemodynamic parameters were monitored continuously. Blood gas samples were drawn at baseline and once during the infusion. Key results: Peak maternal remifentanil plasma levels of 4.0 +/- 0.9 ng.mL(-1) (mean +/- SD) and peak fetal plasma levels of 0.4 +/- 0.3 ng.mL(-1) were obtained. Remifentanil plasma levels dropped rapidly after the discontinuation of the infusion. The continuous infusion of remifentanil did not result in significant maternal or fetal haemodynamic changes. Conclusions and implications: Remifentanil rapidly passes through the placenta of pregnant ewes and although remifentanil concentrations stay significantly lower in the fetus compared with those in the mother, remifentanil can be detected in significant amounts in the fetus. British Journal of Pharmacology (2010) 161, 1472-1476; doi:10.1111/j.1476-5381.2010.00783.x

Background: Cardiopulmonary distress during obstetrical anaesthesia may result from a drug-induced allergic reaction, but, in the obstetrical setting, allergic anaphylaxis may be inseparable from amniotic fluid embolism in terms of the clinical presentation. Further investigations, using allergy tests and other laboratory analyses, are then needed to pursue a diagnostic clarification. Methods: Twelve women suspected of having developed anaphylaxis during obstetrical anaesthesia underwent allergy follow-up investigations and further serological tests with the amniotic fluid embolism marker sialyl Tn and complement factors (C3 and C4) in an attempt to differentiate amniotic fluid embolism from drug-induced allergic anaphylaxis. Results: The diagnostic programme revealed one case of probable amniotic fluid embolism and four cases of probable drug-induced allergic anaphylaxis. Of the remaining seven cases, there were two cases that, by diagnostic exclusion, could be classified as possible cases of amniotic fluid embolism. The cause of the reactions remained unresolved in five cases. Conclusions: It can be difficult to differentiate between anaphylaxis and amniotic fluid embolism, especially amongst survivors. Diagnostic markers that can be applied on peripheral blood samples are promising, but larger studies are needed to validate their use in the diagnosis of causes of cardiopulmonary distress during obstetrical anaesthesia.

Purpose: Randomized controlled trials (RCTs) are suitable for meta-anal,/sis and systematic reviews provided they are of high quality and are easy to retrieve. We determined these attributes of RCTs in obstetrical anaesthesia in a sample of available joumals that are indexed in MEDLINE. Source: Randomized controlled trials published between January 1985 and December 1994 in seven anaesthetic and three obstetric journals were identified by a P1EDUNE search, and by handsearch of the same journals. Each RCT was assigned a quality score by a blinded rater using a reliable and validated scale. The quality of each RCT was described and compared over time and by journal. The comparative yield of MEDLINE and handsearch was evaluated. Principal s Three hundred and forty RCTs were retTieved by MEDLINE and handsearch. Two hundred and twenty seven (6596) were identified by the MEDLINE search and 333 by the handsearch (98%). The median quality score was 3/5. There was no difference in score over time. AnesthesJolo~ had the highest median score. Anoesthesaa had the lowest (P

The administration of anaesthesia to the obstetrical patient is an extremely important aspect of our speciality. Awareness of changes and advances in obstetrics and neonatology are important for the anaesthetist so that he or she can anticipate problems and provide optimal care for both the mother and her infant.

The effects of intravenous metoclopramide (Maxolon) on the lower oesophageal sphincter (LOS) were studied in three groups of patients, one group being normal control and the other two being pregnant females, one without heartburn and the other with. Metoclopramide increases the LOS pressure 20.5, 15.2 and 10.2 cm H2 O respectively (p These findings suggest that for patients undergoing elective or emergency obstetrical anaesthesia, intravenous metoclopramide may help reduce the incidence of regurgitation of gastric contents.

Obstetrical anaesthesia is a rewarding section of our specialty for many anaesthetists; it is studiously avoided by some, and at times provokes terror in all. Most patients have safe and often pain-free deliveries because of the specialized techniques available in obstetrical anaesthesia. It is a mistake, however, for anaesthetists to treat these patients in a casual manner. Close monitoring, close observation, and a careful respect for sudden disasters are of paramount importance when providing anaesthesia or analgesia for the obstetrical patient.

A report is presented of a questionnaire survey of obstetrical anaesthesia practice patterns, academic structure, resident teaching and research programmes in Canadian University Departments of Anaesthesia. Replies were received from 13 of the 16 departments, representing 24 university-affiliated hospitals. It is apparent that the majority of these hospitals do not have adequate obstetrical anaesthesia coverage. In most instances the delivery suite is covered by the anaesthetists on duty in the operating rooms. While epidural analgesia is widely used during labour, there are some hospitals where it still has a limited use, or is not used at all. Caesarean sections are still largely done under general anaesthesia in most reporting hospitals, with a few institutions reporting an increasing use of regional (mainly epidural) anaesthesia. Resident training in this branch of anaesthesia is felt to be deficient, based on the reports from many hospitals that resident staff are frequently not in attendance at deliveries; and on the evident failure in the majority of institutions to utilize their clinical material for teaching purposes. Research programmes in obstetrical anaesthesia are rare. The most common reason cited was the difficulty experienced in obtaining research funds. It is suggested that the major problems in obstetrical anaesthesia service, teaching and research are: It is recommended that consideration be given to

The use of trifluoroethylvinyl ether (fluroxene, Fluoromar®) for obstetrical anaesthesia and analgesia has been described. This agent is potent, non-toxic, and acceptable to the patients. It offers specific advantages over other agents in certain obstetrical complications.

We found the advantages of the Analgizer to be the following: 1. It is simple to administer. 2. It produces a high percentage of satisfactory results (i.e. 80 per cent in our study). 3. It may be given to several patients simultaneously. 4. It allows labour to progress normally. 5. All vital signs remained normal in the mother, the baby, or the injured patient. 6. It is disposable, thus preventing the risk of cross infection and eliminating the need for cleaning and sterilization. 7. It is safe over a prolonged period of time. 8. The patient, after a brief explanation, takes to it quite readily.

This paper presents a comparison between the anti-emetic properties of Fluothane, Trilene, and cyclopropane during obstetrical anaesthesia in 250 unselected deliveries.

(1) Gwathmey anaesthesia produced no fœtal nor maternal complications, and the 2.4% failures were apparently due to faulty technique. (2) In this series, and in the experience of others, it gives safe and almost certain relief, and can be carried out by a nurse, according to instructions. (3) The method affords the most perfect,prolonged obstetrical anaesthesia at our disposal at the present time, and is applicable in over 70% of all labours. (4) It is far preferable to “twilight sleep,” as there is no danger to the infant and the method is more certain in its action.

Between 1956 and 1959, in the Royal Victoria Hospital, Montreal, 1,601 vaginal deliveries have been managed with nitrous oxide, oxygen, and Fluothane anaesthesia.

Decamethonium Bromide and Succinyl Choline have been used in combination with nitrous oxide anaesthesia to produce muscular relaxation for the vaginal delivery of 591 obstetrical patients. There has been no evidence of placental transmission of these drugs to the baby. The use of these drugs has made possible the employment of lighter general anaesthesia, smaller episiotomies, and control of precipitate delivery. Advantages have accrued to the baby, and the mother, and to the obstetrician and the anaesthetist.

During the past four years halothane has been used for obstetrical anaesthesia in the great majority of cases. It was cur choice for 3657 deliveries and 138 Caesarean sections, approximately 65 per cent of our confinements and 44 per cent of our Caesareans. The use of this anaesthetic agent began in the early part of 1959 With the advent of the Fluotec vaporizer, mounted on the Boyle apparatus as standard equipment, halothane began to occupy a definite sphere of usefulness in our delivery room. This device was effective in giving us accurate percentages of N2O, O2, and halothane, thus making the administration of this gas easy for the trained anaesthetist, and for the residents as well. The hazards of uterine haemorrhage, and resuscitation difficulties in the newborn, which were sounded as a warning note m earlier publications, did not occur in the course of our numerous anaesthetics with this agent, and we have no untoward incidents to report with halothane in the course of our present series of cases. In conclusion, we are still of the opinion that halothane is a potent and serviceable agent for obstetrical anaesthesia. It is recommended that care be taken never to exceed the optimal level of vapour concentration, in order to avoid cardiovascular collapse or atonia uteri. Undesirable side-effects both for the mother and the foetus were minimal, and compared very favourably with those of the other anaesthetic agents.

Prolonged suxamethonium-induced apnoea was observed after obstetrical anaesthesia in a 30 year old woman with abnormal plasma cholinesterases (homozygous Ea1-Ea1). Flaccidity and apnoea in the child required controlled ventilation for 30 min. Possible mechanisms underlying prolonged apnoea after the use of suxamethonium for obstetrical anaesthesia are discussed. Atypical pseudocholinesterases were identified using quantitative dosage of enzymatic activity and inhibition of atypical pseudocholinesterases by dibucaine, fluoride, chloride, scoline and urea. This was carried out in the patient, her baby and family, thus identifying the genotype of the different family members.

Ľexperience de ľanesthesie obstetricale du Women’s Hospital de Winnipeg de 1975 a 1983 est revue (n = 22,925 enfants). Ľutilisation des narcotiques pour Ľanalgesie lors du travail diminua de 38.7 a 18.3 pour cent. Pour ľanalgesie lors de ľaccouchement vaginal spontane, ľanesthesie epidurale augmenta de 6.0 a 24.0 pour cent, ľanalgesie par agent ďinhalation diminua de 53.7 a 3.2 pour cent alors que pour le groupe ou aucune intervention anesthesique nefut necessaire le pourcentage augmenta de 40.3 a 72.8 pour cent. Ľutilisation de ľanesthesie epidurale pour les cesariennes augmenta de 58.7 a 82.6 pour cent. Les complications aigues les plus communes de ľanesthesie furent ľhypotension et la ponction involontaire de la dure-mere lors de la catheterisation de ľespace epidural. Ľincidence de ľhypotension diminua de 26.3 a 17.4 pour cent au cours de cette periode de neuf ans. La ponction de la duremere diminua de 4.7 a 1.1 pour cent pour toute injection epidurale. Les plaintes en periode de postpartum (qu’on pense reliees a ľanesthesie) etaient surtout les maux de tete, les dorsalgies et les maux de gorge. Ľincidence de ces plaintes diminuerent aussi a travers la periode de ľetude.

A questionnaire was designed to determine the type of personnel that provide obstetrical anaesthesia care and the techniques used in the provision of this care. All seven hospitals with an obstetrical unit affiliated with the University of Toronto and seven community hospitals responded. All anaesthetics were given by physicians. Ninety-two per cent of those in University affiliated hospitals and 63 per cent of those in the community hospitals had obtained their specialty qualification. Standards for preoperative assessment and communication with the patients should be similar to those applied to patients receiving anaesthesia for other reasons. It was clear from our survey that pre-anaesthetic assessment of obstetrical patients differs from that advocated for other surgical patients. For vaginal deliveries, epidural analgesia was clearly the preferred choice, Subarachnoid block was rarely used. The majority of anaesthetists did not use a test dose. Eleven per cent in University-affiliated hospitals and 50 per cent in community hospitals sometimes conducted surgical anaesthesia without tracheal intubation for vaginal delivery. More than 60 per cent routinely encouraged their patients to accept general anaesthesia for Caesarean section. The doctors providing neonatal resuscitation may require further training. Surveys such as this are important if standards of anaesthetic practice are to be established.

Methoxyflurane was used to produce anaesthesia and analgesia for 645 obstetrical cases. The low concentrations used afforded good results and absence of side-effects. The method and the results are discussed.

Methoxyflurane has been used for general anaesthesia in 500 unselected consecutive cases of vaginal deliveries. The outstanding features of the drug are the rapidity of induction, high level of analgesia under a light plane of anaesthesia, very low incidence of vomiting, minimal depression of uterine contractions, minimal respiratory depression of the foetus, quiet and rapid recovery. In our opinion, it is the drug of choice in obstetrical anaesthesia. We are at the moment experimenting with the use of Penthrane in Caesarean sections and present data show it to be a promising agent. Nous avons analyse les resultats obtenus avec l’anesttnesie generale au methoxyflurane dans 500 cas d’accouchements. Nous avons decrit en premier lieu les techniques d’utilisation du Penthrane avec l’inhalateur a Trilene, avec le goutte a goutte et dans le vaporisateur a meche Heidbrink no. 8. Nous soulignons ensuite les avantages generaux de son utilisation en obstetrique. Nous etudions en dernier lieu les effets du methoxyflurane sur la mere et sur l’enfant. Le methoxyflurane se signale par sa facilite et sa rapidite d’induction, son haut degre d’analgesie a un plan leger d’anesthesie et par le reveil calme qu’il assure. Ses effets cardiovasculaires sont negligeables et il reduit au minimum les vomissements per-anesthesiques (2.4%). Aucune complication pulmonaire n’est survenue dans notre serie de cas. Employe a faible concentration, il deprime tres peu la contraction uterine. L’atonie et l’hemorrhagie uterines sont exceptionnelles, peu marquees, et reagissent tres bien aux ocytociques. Dans ses effets sur l’enfant, le Penthrane se signale par un absence quasi complete de depression respiratoire et cardiaque. C’est l’anesthesique general de choix en obstetrique. We are grateful to the Medical Department, Abbott Laboratories Limited, Montreal, for making available to us supplies of Penthrane (methoxyflurane).