Key points Pdb
Control of blood pressure in hypertension is important in pregnancy, whether or not it is pregnancy related. Headaches are not always due to dural puncture. Pregnancy is not a contraindication to neurosurgery. Regional analgesia or anaesthesia is usually indicated unless there is significant neurological impairment. Eggert SM, Eggers, KA. Subarachnoid haemorrhage following spinal anaesthesia in an obstetric patient. Br J Anaesth 2001 86 442-4. James AH, Bushnell CD, Jamison MG, Myers ER....
Inhalational analgesia
1847 James Young Simpson, Professor of Midwifery at Edinburgh University, administered the first obstetric general anaesthetic using ether. Considerable opposition came from religious leaders for going against the Bible and from medical authorities for compromising safety. Simpson went on to advocate chloroform in preference to ether, having used it the same year. He was a major influence in British obstetrics and also designed obstetric forceps, which bear his name. 1853 John Snow, London...
Management options Ylz
Early conservative management is appropriate if bleeding is not excessive and vital signs are stable. An intravenous infusion of oxytocics may be started, and putting the baby to the breast for suckling sometimes stimulates delivery of the placenta. Turning the woman into the left lateral position is anecdotally reported to assist spontaneous placental delivery, and emptying the bladder may also be helpful. Surgical removal of the placenta should take place in theatre, not in the delivery room....
Key points Dhu
It is difficult to provide complex information to a woman in painful labour. Antenatal education makes this task much easier. The risks and benefits discussed with the patient should always be recorded. A pregnant woman's autonomy is not affected by the fact that she is carrying a fetus. Association of Anaesthetists of Great Britain and Ireland. Information and Consent for Anaesthesia. London AAGBI, 2005. Bethune L, Harper N, Lucas DN, et al. Complications of obstetric regional analgesia how...
Problemsspecial considerations Pje
Rapid onset of widespread vasodilatation coupled with the effect of aortocaval compression means that hypotension is an almost inevitable accompaniment to spinal anaesthesia in the mother unless specific precautions are taken. Avoidance of the supine position, frequent blood pressure measurement and instant availability of intravenous fluid and vasopressors are prerequisites for the safe use of this technique. Careful assessment of the level of block is essential before starting the operation....
Side effects of epidural analgesia
Epidural local anaesthetics cause sympathetic blockade and hypotension. Administration of intravenous fluids, vasopressor agents, or a combination of both, can prevent and or treat this. Currently used low-dose combinations of local anaesthetic and opioid cause minimal haemodynamic disturbance, but it is mandatory to establish venous access before initiating epidural analgesia, although the need for routine preloading with intravenous fluids has been questioned. Local anaesthetics also cause...
Key points Idt
Acute fatty liver of pregnancy occurs in about 1 in 10 000 pregnancies and potentially has a very high mortality unless diagnosed and treated promptly. Some cases are caused by long-chain-3-hydroxyacyl-CoA dehydrogenase LCHAD deficiency and have an increased risk of recurrence. Delivery of the fetus is the only definitive treatment. Acute liver failure and multiorgan derangement can occur rapidly. Regional analgesia and anaesthesia are usually contraindicated because of abnormal clotting...
Key points Tdm
Regional analgesia is particularly indicated in malpresentation. Prolapsed cord is often associated with breech and transverse presentations and preterm delivery. Early multidisciplinary communication will help optimise management. FURTHER READING Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term a randomised multicentre trial. Lancet. 2000 356 1375-83. External cephalic version ECV is a procedure performed to convert...
Key points Oqg
Thrombophilias are a significant cause of fetal loss in pregnancy. The adverse effects on maternal and fetal health are treatable. The risks and benefits of regional analgesia and anaesthesia should be considered antenatally if possible. Kujovich JL. Thrombophilia and pregnancy complications. Am J Obstet Gynecol 2004 191 412-24. Ralph CJ. Anaesthetic management of parturients with the antiphospholipid syndrome a review of 27 cases. Int J Obstet Anesth 1999 8 249-34. Ringrose DK. Anaesthesia...
Tocolytic drugs
There are several different groups of drugs that have been used or studied as tocolytics. As with many areas of obstetric practice, their value and even efficacy in some cases is controversial. b2-Adrenergic agonists these act on uterine p2-receptors causing relaxation of myometrium. Although the most commonly prescribed tocolytics for premature labour, improvement in outcome has not been conclusively proven. The emphasis of therapy has shifted away from long-term prolongation of pregnancy...
Key points Irb
Anaesthetists may be involved in the assessment and management of postpartum spinal cord lesions. Knowledge of the appropriate anatomy is crucial. In acute spinal cord compression, delay in decompression beyond 6-8 hours may result in permanent disability. Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth 2000 9 99-124. Horlocker TT, Wedel DJ. Neurologic complications of spinal and epidural anesthesia. Reg Anesth Pain Med 2000 25...
Key points Iug
Although at least 80 of kyphoscoliosis is idiopathic, association with other diseases such as neurofibromatosis and familial dysautonomia should not be forgotten. Uncorrected progressive kyphoscoliosis leads to severe restrictive pulmonary disease and pulmonary hypertension. The major anaesthetic problem in pregnant women with corrected kyphoscoliosis is provision of regional anaesthesia and analgesia. Spinal techniques offer several advantages over epidural. When no previous X-ray films or...
Key points Onx
Women with multiple pregnancies are an 'at-risk' group. The anaesthetist should be actively involved with the care of these women whether they are in labour or not. Special care is required to avoid aortocaval compression. There is increased likelihood of premature or prolonged labour, instrumental delivery and postpartum haemorrhage. Wen SW, Demissie K, Yang Q, Walker MC. Maternal morbidity and obstetric complications in triplet pregnancies and quadruplet and higher-order multiple...
Acquired thrombophilia
The antiphospholipid syndrome is the most common cause of acquired thrombo-philia. Identified autoantibodies include lupus anticoagulant and anticardiolipin antibodies. However, there is some evidence that other as yet unidentified auto-antibodies may cause thrombosis and fetal loss in pregnancy. The lupus anticoagulant is so called because it causes a prolongation of the activated partial thromboplastin time even when diluted because the autoantibody binds to phospholipid in the assay ....
Obstetric Anaesthetists Association OAA
The OAA was formed in 1969 to promote the highest standards of anaesthetic practice in the care of the mother and baby and has an international membership in the order of 2000. It provides a focus for all anaesthetists who want to improve the care and safety of women in childbirth. The Association has charitable status, supports a research fellowship and offers annual research grants 163 Obstetric anaesthetic organisations and bursaries. It also offers prizes for trainees for research presented...
Management options Ieu
Early antenatal assessment is vital, and preconception counselling may be desirable. If pregnancy has occurred unexpectedly, expert advice should be sought about the relative risks of teratogenicity of immunosuppressive drugs, and the patient counselled appropriately. Many women with connective tissue disorder have multisystem involvement. Detailed history and examination are necessary, with particular reference to drug treatment and symptoms or signs suggestive of cardiac or pulmonary disease....
Key points
Oocyte retrieval may involve laparoscopy requiring general anaesthesia, although intravenous sedation and regional anaesthesia are suitable for transvaginal ultrasound-directed techniques. Couples are usually very anxious and require constant reassurance. Tidmarsh MD, May AE. Spinal analgesia for transvaginal oocyte retrieval. Int J Obstet Anesth 1998 7 157-60. Viscomi CM, Hill K, Johnson J, Sites C. Spinal anaesthesia versus sedation for transvaginal oocyte retrieval reproductive outcome,...
Section 1 Preconception and Conception
There have been rapid developments in the treatment of infertility. The anaesthetist may be involved in many aspects of the patient's treatment, which may be complex. The harvesting of oocytes needs to take place within a defined period of time, or ovulation will have occurred and oocytes will be lost. Couples presenting for infertility treatment are generally anxious and often the women are emotional at the time of oocyte retrieval. It is therefore particularly important for the anaesthetist...
Problemsspecial considerations
All of the techniques involve extraction of oocytes from the follicles, either laparoscopically or, with the development of transvaginal ultrasonography, via the transvaginal route ultrasound directed oocyte retrieval, UDOR . The techniques differ in the site of fertilisation and or replacement of the gamete zygote In vitro fertilisation IVF fertilisation occurs in the laboratory and the developing embryo is transferred into the uterus via the cervix, usually 48 hours after oocyte retrieval....