Novel approaches facilitating neuraxial anesthesia placement in pregnant women with morbid obesity: case descriptions.

Clinical management of pregnant women with morbid obesity poses challenges in performing neuraxial anesthesia as well as positioning for cesarean delivery. Occupational injuries are also known to occur while caring for patients with morbid obesity. We describe two novel approaches to assist neuraxial anesthesia administration and positioning for cesarean delivery. With the assistance of the Institution's Safe Patient Handling and Mobility Team, a universal high-back sling can be placed to lift the patient into a sitting position before neuraxial anesthesia procedure. After placement of combined spinal epidural anesthesia, the ceiling lift is used to lift the patient into a seated position and then rotate to the appropriate location on the operating room table to facilitate supine positioning. The lifting system reduces shearing of the patient's posterior and compromising the epidural site. Team members also report reduced effort required when positioning patients from seated to supine on the operating room table. The second approach is the application of TraxiTM abdominal pannus retractor to retract fat folds encroaching on the epidural placement site in pregnant women with morbid obesity. This is particularly useful when the traditional taping of fat folds away from the site is inadequate. The pannus retractor results in a flatter surface facilitating epidural placement. We have introduced these two approaches into our clinical practice for pregnant women with morbid obesity requiring cesarean delivery under neuraxial anesthesia.

Mechanical ventilation and prone positioning in pregnant patients with severe COVID-19 pneumonia: experience at a quaternary referral center.

BACKGROUND: We present the care of 17 consecutive pregnant patients who required mechanical ventilation for Coronavirus Disease 2019 (COVID-19) pneumonia at a quaternary referral center in the United States. We retrospectively describe the management of these patients, maternal and fetal outcomes, as well as the feasibility of prone positioning and delivery. METHODS: Between March 2020 and June 2021, all pregnant and postpartum patients who were mechanically ventilated for COVID-19 pneumonia were identified. Details of their management including prone positioning, maternal and neonatal outcomes, and complications were noted. RESULTS: Seventeen pregnant patients required mechanical ventilation for COVID-19. Thirteen patients received prone positioning, with a total of 49 prone sessions. One patient required extracorporeal membrane oxygenation. All patients in this series survived until at least discharge. Nine patients delivered while mechanically ventilated, and all neonates survived, subsequently testing negative for SARS-CoV-2. There was one spontaneous abortion. Four emergent cesarean deliveries were prompted by refractory maternal hypoxemia or non-reassuring fetal heart rate after maternal intubation. CONCLUSIONS: Overall, maternal and neonatal survival were favorable even in the setting of severe COVID-19 pneumonia requiring mechanical ventilation. Prone positioning was well tolerated although the impact of prone positioning or fetal delivery on maternal oxygenation and ventilation are unclear.

Accidental dural puncture during labor analgesia and obstetric outcomes in nulliparous women.

BACKGROUND: The effect of accidental dural puncture during labor epidural analgesia on obstetric outcomes remains unexplored. In this retrospective cohort study, we tested the hypothesis that accidental dural puncture is associated with prolonged second stage of labor. METHODS: Anesthetic and obstetric data from nulliparous parturients who suffered an accidental dural puncture at term labor (n=89) during the years 2006-2012 were compared with randomly selected parturients with uncomplicated epidural analgesia (n=232). The primary outcome was the proportion of parturients with prolonged second stage of labor: secondary outcomes were the proportion of instrumented and cesarean deliveries. Statistical analysis included student t-test for continuous variables, chi-square test for binary variables, and logistic regressions for associations between accidental dural puncture and outcomes. RESULTS: Demographic and obstetric characteristics of parturients were comparable except for a non-significant increase in prolonged second stage of labor in the accidental dural puncture group (27% vs. 17%, P=0.06). After adjusting for known potential confounders, multivariate logistic regression analyses revealed a significant association between accidental dural puncture and prolonged second stage of labor (adjusted risk ratio [aRR] 1.99, 95% CI 1.04 to 3.82; P=0.037). This was not accompanied by an increase in instrumented (aRR 0.57, 95% CI 0.27 to 1.21; P=0.15) or cesarean delivery (aRR 1.83, 95% CI 0.89 to 3.77; P=0.10). CONCLUSION: Accidental dural puncture during labor analgesia was associated with prolonged second stage of labor in nulliparous parturients. Prospective studies are needed to assess the relationship between the quality of neuraxial block after accidental dural puncture and obstetric outcomes.

Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications.

BACKGROUND: The aim of this study was to evaluate labor and delivery outcomes in parturients with inadvertent dural puncture managed by either insertion of an intrathecal catheter or a resited epidural catheter. METHODS: This was a retrospective cohort review of 235 parturients who had an inadvertent dural puncture during epidural placement over a six-year period. The primary outcome was the proportion of women with a delayed second stage of labor. Secondary outcomes were the proportion of cesarean deliveries, the proportion of cases resulting in post-dural puncture headache, and the incidence of failed labor analgesia. RESULTS: Baseline characteristics such as age, body mass index and parity were similar between the two groups. Among the 236 cases of inadvertent dural puncture, 173 women (73%) had an intrathecal catheter placed while 63 women (27%) had the epidural catheter resited. Comparing intrathecal with epidural catheters, there was no observed difference in the proportion of cases of prolonged second stage of labor (13% vs. 16%, P=0.57) and the overall rate of cesarean deliveries (17% vs. 16%, P=0.78). However, we observed a lower rate of post-dural puncture headache in women who had cesarean delivery compared to vaginal delivery (53% vs. 74%, P=0.007). A greater proportion of failed labor analgesia was observed in the intrathecal catheter group (14% vs. 2%, P=0.005). CONCLUSION: The choice of neuraxial technique following inadvertent dural puncture does not appear to alter the course of labor and delivery. Cesarean delivery decreased the incidence of post-dural puncture headache by 35%. Intrathecal catheters were associated with a higher rate of failed analgesia.

Establishing an obstetric neuraxial service in low-resource areas.

The proportion of laboring women utilizing neuraxial techniques for labor analgesia has steadily increased over the past decades in North America, the UK and parts of Europe. Anesthesiologists in many other countries may want to introduce an obstetric neuraxial service but may lack the knowledge and experience necessary to ensure its safety. The focus of this article is to address the necessity, benefit and challenges of establishing such a service in a resource-limited environment. Even successful financial institutions may be considered resource-limited if critical components necessary for an obstetric neuraxial service are missing due to either perceived unimportance or non-availability. There is a need to deploy a culture of safety by ensuring the availability of resuscitation equipment, developing protocols and training, fostering communication among members of the care team and initiating quality-control measures. Patient education and satisfaction are additional key components of a successful service. Even in financially low-resource settings, proper safety measures must be adopted so that the neuraxial procedure itself does not contribute to morbidity and mortality. A viable and safe neuraxial service can be developed using innovative strategies based on local constraints.

Laparoscopic splenectomy in a pregnant patient with immune thrombocytopenic purpura.

We describe the perioperative management of a pregnant woman at 19 weeks' gestation with idiopathic thrombocytopenic purpura requiring laparoscopic splenectomy. The preoperative platelet count ranged between 1 and 5 x 10(9)/L and did not respond to conventional medical therapy. To reduce the risk of intracerebral hemorrhage, platelets were transfused before induction of anesthesia to maintain platelet count closer to 20 x 10(9)/L. The blood pressure was monitored continuously via an arterial line and remifentanil was infused to prevent a hypertensive response to induction/intubation, carbon dioxide insufflation, and surgery. After the splenic artery was clamped, additional platelet units were transfused to assure surgical hemostasis.

Effect of amniotic fluid on coagulation and platelet function in pregnancy: an evaluation using thromboelastography.

Amniotic fluid embolism is a rare obstetric complication. The exact pathogenesis of this syndrome remains unknown and significant controversy exists whether coagulopathy should always be present. We used thromboelastography to assess the effect of amniotic fluid on coagulation and platelet function in pregnant women. Different volumes of amniotic fluid (10-60 microl) were added to blood (330 microl) from pregnant women and thromboelastography variables determined. There were three important findings. R time, reflecting time to first clot formation, was significantly decreased with the addition of 10 microl amniotic fluid; platelet function, as determined by Reopro-TEG technique, was increased with the addition of 30 microl of amniotic fluid; and there was no evidence of fibrinolysis in any samples studied. In conclusion, our study substantiates the hypothesis that coagulation profile changes are invariable accompaniments of amniotic fluid embolism.