The obstetrical anaesthesia assessment clinic: a review of six years experience

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Remote Obstetric Anesthesia: Leveraging Telemedicine to Improve Fetal and Maternal Outcomes

In the United States, the prevalence of pregnancy-related deaths has risen significantly over the past 20 years. Pregnant women at high risk for peripartum complications should undergo anesthesia consultation before delivery so that a management plan can be created between the obstetrician, anesthesiologist, and patient to ensure optimal outcomes for both the mother and newborn. However, few hospitals outside of major, urban, academic medical centers have dedicated anesthesiologists specially trained in obstetric anesthesia and the resources available to expedite optimization of high-risk parturient comorbidities. Telemedicine is a valuable tool by which evaluation, triaging, and multidisciplinary coordination can be provided for high-risk obstetric patients living in remote or rural communities without access to specialized, maternal care medical facilities. This review examines the existing literature regarding telemedicine use in preoperative anesthesia and antenatal obstetrics and identifies areas for future research. Furthermore, the benefits and potential barriers of implementing a telemedicine program specifically dedicated to obstetric anesthesia are discussed.

Antenatal anaesthesia clinics - the way forward?

Specialist antenatal clinics are increasingly being used to enable anaesthetists to evaluate pregnant women with co-morbidities and those at high risk of obstetric complications. In this journal a team from Israel describe the process of setting up and running such a clinic over a 14 year period. One of the challenges they identify was the limited referral of high risk women. Based on UK and US literature, the use of structured referral tools, clear criteria for referral and regular antenatal multidisciplinary meetings may help to address this.

Five years' experience in an anesthesiology antenatal clinic for high-risk patients

INTRODUCTION

The aim, of this study is to describe our approach and outcomes in an outpatient anesthesia/analgesia antepartum clinic among ambulatory high-risk obstetric patients.

METHODS

This was a retrospective evaluation of the activity of the anesthesiology antenatal clinic from its inception in 2010 until 2016 (a 5-year period). The clinic works in collaboration with the Department of Obstetrics and Gynecology. The catchment area of the study University Affiliated Hospital attends a multiethnic population characterized by high parity.

RESULTS

There were 241 referrals over the 5 years, each of whom was discharged with a consult and a delivery management plan and 228 (95%) of which were performed as planned. Mean gestational age at consultation was 34.4 weeks (range: 20-37). There were no preconceptional consultation. No limitations regarding mode of anesthesia/analgesia was considered for 47% of the referrals. Nulliparous women accounted for 50% of the referrals and 17% were in their second pregnancy. The greatest number of referrals (30%) was for musculoskeletal conditions. No maternal death encountered. The mode of delivery was vaginal in 139 (65%) women; elective cesarean section in 44 (21%) women; and emergent cesarean section in 30 (14%) women. The neonatal outcomes were unremarkable; 210 (87%) in hospital births, 97.1% had an a 5' Apgar score of 9.

CONCLUSION

Our findings reveal the need for high-risk obstetric patients consult with a dedicated obstetric anesthesiologist to devise a management plan for labor and delivery that is tailored to their comorbidity and obstetric status, to ensure an optimum outcome for mother and child.

Concurrent medical conditions among pregnant women - ignore at their peril: report from an antenatal anesthesia clinic

Background

Care of pregnant women with concurrent medical conditions can be optimized by multidisciplinary antenatal management. In the current study we describe women with concurrent medical conditions who attended our antenatal anesthesia clinic over a 14-year period, 2002–2015 and, based on the findings, we suggest new policies, strategies and practices to improve antenatal care.

Methods

In 2002, an antenatal anesthesia clinic was established in Hadassah Medical Center. Each consultation focused on the concurrent medical condition. A written anesthesia strategy according to the medical condition and its anesthesia considerations was discussed and given to the patient. Data regarding clinic visits were recorded.

Results

A total of 451 clinic women attended the antenatal anesthesia clinic. Maternal age was 31.7 ± 6.0 years (mean ± SD), with gestational age of pregnancy 33.0 ± 5.4 weeks at the clinic visit. Musculoskeletal conditions (23% of all the women seen) were the most frequent concurrent conditions, followed by anesthesia related concerns 20%, neurologic conditions 19%, and cardiac conditions 15%. Women were provided plans that were deliberated carefully rather than being concocted during labor.

Conclusions

A wide range of concurrent medical conditions was seen in the antenatal anesthesia clinic, however fewer women attended the clinic than expected according to known population frequencies of concurrent medical conditions. Women with concurrent medical conditions should have labor and anesthesia plans considered during the nine months of pregnancy, prior to delivery, and hospitals should have a means of obtaining this information in a timely manner. Finally, there is a need to develop additional antenatal anesthesia clinics.

Occult Spinal Dysraphism in Obstetrics: A Case Report of Caesarean Section with Subarachnoid Anaesthesia after Remifentanil Intravenous Analgesia for Labour

Neuraxial techniques of anaesthesia and analgesia are the current choice in obstetrics for efficacy and general low risk of major complications. Concern exists about neuraxial anaesthesia in patients with occult neural tube defects, regarding both labour analgesia and anaesthesia for Caesarean section. Recently, remifentanil infusion has been proposed as an analgesic technique alternative to lumbar epidural, especially when epidural analgesia appears to be contraindicated. Here, we discuss the case of a pregnant woman attending at our institution with occult, symptomatic spinal dysraphism who requested labour analgesia. She was selected for remifentanil intravenous infusion for labour pain and then underwent urgent operative delivery with spinal anaesthesia with no complications.

General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update

BACKGROUND

Complications from general anesthesia for cesarean delivery are a leading cause of anesthesia-related mortality. As a consequence, the overall use of general anesthesia in this setting is becoming less common. The impact and implications of this trend are considered in relation to a similar study performed at our institution 10 years ago.

METHODS

The hospital database for all cesarean deliveries performed during six calendar years (January 1, 2000 through December 31, 2005) was reviewed. The medical records of all parturients who received general anesthesia were examined to collect personal details and data pertinent to the indications for cesarean delivery and general anesthesia, mode of airway management and associated anesthetic complications.

RESULTS

Cesarean deliveries accounted for 23.65% to 31.51% of an annual total ranging from 8543 to 10091 deliveries. The percentage of cases performed under general anesthesia ranged from 0.5% to 1%. A perceived lack of time for neuraxial anesthesia accounted for more than half of the general anesthesia cases each year, with maternal factors accounting for 11.1% to 42.9%. Failures of neuraxial techniques accounted for less than 4% of the general anesthesia cases. There was only one case of difficult intubation and no anesthesia-related mortality was recorded.

CONCLUSION

The use of general anesthesia for cesarean delivery is low and declining. These trends may reflect the early and increasing use of neuraxial techniques, particularly in parturients with co-existing morbidities. A significant reduction in exposure of trainees to obstetric general anesthesia has been observed.

Small dose spinal bupivacaine for Cesarean delivery does not reduce hypotension but accelerates motor recovery

BACKGROUND

Maternal hypotension occurs in 60-94% of Cesarean deliveries with 10-15 mg spinal bupivacaine. Reduced doses of bupivacaine may decrease the incidence of hypotension, nausea, and vasopressor use. The primary objective of this study was to compare 4.5 mg and 12 mg doses of intrathecal bupivacaine on maternal hemodynamics. The secondary objective was to determine if anticipated reductions in side effects were reflected in increased patient satisfaction.

METHODS

Following Research Ethics Board approval and informed consent 52 term parturients undergoing elective Cesarean delivery were randomly assigned to isobaric bupivacaine 4.5 mg or hyperbaric bupivacaine 12 mg for spinal anesthesia. All patients received fentanyl 50 microg and morphine 200 microg intrathecally. Intravenous fluid and vasopressor administration were standardized. Maternal hemodynamics, and sensorimotor levels were recorded at regular intervals. Side effects and patient satisfaction were documented.

RESULTS

Median cepahalad sensory block was C8 in both groups (NS) but the intensity of motor block was significantly less (P < 0.001) and of shorter duration (P < 0.001) with bupivacaine 4.5 mg. The proportion of patients requiring ephedrine (> 70%) and the quantities of ephedrine used were similar in both groups (NS). Use of supplemental analgesia, side effects, and measures of patient satisfaction were comparable in both groups.

DISCUSSION

Intrathecal bupivacaine 4.5 and 12 mg yielded similar sensory block and side effects during Cesarean delivery. Patients receiving 4.5 mg did, however, experience significantly less motor blockade of shorter duration.

Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice

BACKGROUND

Anaesthetists are frequently involved in the management of high-risk pregnancy. Antenatal referral permits time to prepare an appropriate management plan for labour and delivery. This survey looked at current methods of referral in the UK and the role of a formal clinic.

METHOD

A postal questionnaire was sent to lead consultant anaesthetists of 256 UK obstetric units enquiring into methods of referral for high-risk pregnancy.

RESULTS

Replies were received from 196 units (response rate 77%). Only 30% of units that responded ran a formal anaesthetic pre-assessment clinic, the remaining 70% relying on ad hoc referrals of high-risk cases. Larger units were more likely to run formal clinics. Some units wishing to introduce a formal clinic had not been able to do so because of financial constraints.

CONCLUSION

Most hospitals were satisfied with current arrangements for referral of high-risk pregnancy. A mechanism for anaesthetic referral of high-risk pregnancy is vital, but in many units is not via a formal clinic.

Planning for hemorrhage. Steps an anesthesiologist can take to limit and treat hemorrhage in the obstetric patient

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

Epidural haematoma after dural puncture in a parturient with neurofibromatosis

A case of epidural analgesia in a parturient with neurofibromatosis (von Recklinghausen's disease) complicated by dural puncture and epidural haematoma is described and the management of the case is discussed. The case emphasizes the need for antenatal assessment of parturients with neurofibromatosis in order that the necessary investigations can be arranged and informed consent for analgesia and anaesthesia can be obtained.

Cardiac disease and pregnancy

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Caesarean section using a combined spinal epidural technique in a patient with arthrogryposis multiplex congenita

A case of a woman with arthrogryposis multiplex congenita presenting for elective caesarean section is reported. A combined spinal epidural anaesthetic technique was used. Aetiology and anaesthetic considerations for patients with arthrogryposis multiplex congenita are discussed. The importance of early referral to the anaesthetic team of patients with intercurrent disease or congenital syndromes is emphasised.

Epidural anaesthesia and neural tube defects

This is a retrospective record of the analgesic management during labour of 16 patients with spina bifida seen at Leicester Royal Infirmary Maternity Hospital between March 1994 and February 1996. The information highlights the potential difficulties in providing epidural analgesia for this patient group, and demonstrates how an antenatal pre-anaesthetic clinic can help to optimize pain management by providing the opportunity to formulate a realistic analgesic plan, which can be documented in the notes.