Anesthesia technique and postpartum hemorrhage: a prospective cohort study.

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.

Insulinoma and pregnancy: anesthesia and perioperative management / Insulinoma e gestação: anestesia e manejo perioperatório

Abstract Insulinoma is a functional neuroendocrine tumor derived from beta cells of the pancreatic islets of Langerhans, usually solitary, benign, and curable with surgery (enucleation). It rarely occurs during pregnancy and is clinically manifested by hypoglycemia, particularly in the first trimester of pregnancy. During pregnancy, both conservative therapeutic measures (medication) and surgical treatment are challenging regarding the impossibility of studies on drug teratogenicity as well as the maternal-fetal repercussions during surgery, such as hypoglycemia and changes due to stress. Case report: A 33-year primiparous woman, 86 kg, 1.62 m, BMI 32.7 kg·m-2, at 15 weeks' gestation, physical status ASA III, investigated for a reduced level of consciousness. Laboratory tests showed: hypoglycemia (45 mg.dL-1) associated with hyperinsulinemia (24 nUI.mL-1), glycosylated hemoglobin (4.1%); other laboratory findings and physical examination were normal. Magnetic resonance imaging showed a 1.1 cm nodule in the pancreatic tail with suspected insulinoma. Due to the difficult glycemic control with bolus and continuous infusion of glucose, laparotomy was performed for tumor enucleation under total intravenous anesthesia combined with epidural block. Monitoring, central and peripheral venous access, radial artery catheterization, diuresis, and glucosimetry were recorded every 15 minutes. Intraoperatively, there was severe hypoglycemia while handling the tumor and shortly before its enucleation, which was controlled through continuous infusion of 10% glucose balanced crystalloid solution (100-230 mL.h-1). The patient's postoperative evolution was uneventful, with resolution of hypoglycemia and total withdrawal of glucose intravenous infusion.

Resumo O insulinoma é um tumor neuroendócrino funcional de células beta das ilhotas de Langerhans pancreáticas, geralmente solitários, benignos, curáveis com cirurgia (enucleação). Raramente ocorre durante a gravidez e se manifesta clinicamente por hipoglicemia, principalmente no primeiro trimestre da gravidez. Durante a gestação as condutas terapêuticas conservadoras (medicamentosas) e o tratamento cirúrgico constituem desafios tendo em vista a impossibilidade de estudos sobre teratogenicidade de fármacos, assim como as repercussões materno-fetais durante intervenções cirúrgicas, como a hipoglicemia e alterações decorrentes do estresse. Relato de caso: Paciente com 33 anos, 86 Kg, 1,62m, IMC 32,7 kg.m-2, primigesta, 15 semanas de idade gestacional, estado físico III da ASA, investigada por rebaixamento do nível de consciência. Aos exames laboratoriais constataram-se: hipoglicemia (45 mg.dL-1) associada à hiperinsulinemia (24 nUI.mL-1) e hemoglobina glicosilada (4,1%); demais exames laboratoriais e exame físico normais. A ressonância magnética mostrou nódulo de 1,1 cm em cauda de pâncreas com hipótese de insulinoma. Devido ao difícil controle glicêmico com infusão em bolus e contínua de glicose, foi feita laparotomia para enucleação do tumor sob anestesia venosa total associada a bloqueio peridural. Monitoração, acesso venoso central e periférico, cateterização de artéria radial, diurese, glicosimetria a cada 15 minutos. No intraoperatório, observou-se hipoglicemia acentuada nos momentos de manipulação e imediatamente antes da enucleação do tumor, controlada com infusão contínua de solução cristaloide balanceada glicosada a 10% (100 a 230 ml.h-1). A evolução no pós-operatório seguiu sem intercorrências, com resolução dos quadros de hipoglicemia e retirada total da infusão venosa de glicose.

[Insulinoma and pregnancy: anesthesia and perioperative management]. / Insulinoma e gestação: anestesia e manejo perioperatório.

Insulinoma is a functional neuroendocrine tumor derived from beta cells of the pancreatic islets of Langerhans, usually solitary, benign, and curable with surgery (enucleation). It rarely occurs during pregnancy and is clinically manifested by hypoglycemia, particularly in the first trimester of pregnancy. During pregnancy, both conservative therapeutic measures (medication) and surgical treatment are challenging regarding the impossibility of studies on drug teratogenicity as well as the maternal-fetal repercussions during surgery, such as hypoglycemia and changes due to stress. CASE REPORT: A 33-year primiparous woman, 86kg, 1.62m, BMI 32.7kg.m-2, at 15 weeks of gestation, physical status ASA III, investigated for a reduced level of consciousness. Laboratory tests showed: hypoglycemia (45mg.dL-1) associated with hyperinsulinemia (24 nUI.mL-1), glycosylated hemoglobin (4.1%); other laboratory findings and physical examination were normal. Magnetic resonance imaging showed a 1.1cm nodule in the pancreatic tail with suspected insulinoma. Due to the difficult glycemic control with bolus and continuous infusion of glucose, laparotomy was performed for tumor enucleation under total intravenous anesthesia combined with epidural block. Monitoring, central and peripheral venous access, radial artery catheterization, diuresis, and glucosimetry were recorded every 15minutes. Intraoperatively, there was severe hypoglycemia while handling the tumor and shortly before its enucleation, which was controlled through continuous infusion of 10% glucose balanced crystalloid solution (100-230ml.h-1). The patient's postoperative evolution was uneventful, with resolution of hypoglycemia and total withdrawal of glucose intravenous infusion.