Anesthesia for cesarean section in a patient with Holt-Oram syndrome

Holt-Oram syndrome is a rare genetic disorder affecting the heart and upper limbs (atriodigital dysplasia). The manifestations of the limb defects may vary in severity from subtle carpal bone defects and triphalangeal thumb to digit aplasia and upper extremity phocomelia. Cardiac abnormalities include atrial and/or ventricular septal defects, anomalies in pulmonary venous return and various dysrhythmias. We present the anesthetic management of a parturient with this syndrome who underwent elective cesarean section and tubal ligation, conducted under combined spinal-epidural anesthesia with a low dose of intrathecal bupivacaine. Our goal was to avoid an excessively high sympathetic block or excessive sympathetic stimulation accompanied by potential deleterious effects on cardiac rhythm. Cardiac monitoring was continued in the postoperative period for 6 h because of the possibility of dysrhythmia.     

Anesthesia for combined cesarean section and extra-adrenal pheochromocytoma resection: a case report and literature review

Pheochromocytoma during pregnancy is unusual, with approximately 250 cases now reported in the literature. The current case describes the anesthetic management of a patient with a large extra-adrenal pheochromocytoma who underwent a combined cesarean section and tumor removal in which perioperative hemodynamic control was difficult despite high-dose a-adrenergic blockade. In this case it is believed that difficulty in perioperative hemodynamic management was related to mechanical stimulation of the tumor by the gravid uterus. Review of published case reports since 1980 reveals that a pheochromocytoma during pregnancy may be diagnosed in an extra-adrenal location relatively more commonly compared to non-pregnant patients. Established criteria exist for the adequacy of alpha- and beta-adrebergic blockade for the management of pheochromocytoma in the non-pregnant patient. We discuss how these criteria apply to pregnant patients with pheochromocytoma, and suggest possible modifications to the criteria.     

Anesthesia for cesarean section in a patient with Ebstein's anomaly]

A 30-year-old woman with Ebstein's anomaly was scheduled for Cesarean section at 38 week gestation because of latent fetal distress. After arterial and central venous catheters were inserted, general anesthesia was started. Anesthesia was induced smoothly and rapidly through intravenous route. Following induction, her hemodynamics was stable until post-operative period. The baby weighed 1564g and had an Apgar score of 8 at 1 minute. A patient with Ebstein's anomaly during pregnancy and anesthesia has potential for a variety of hemodynamic disturbances. This case illustrates the importance of careful attention to the preoperative findings and the perioperative hemodynamic parameters.     

Anesthesia for cesarean section in patients with fetal anomaly

Twenty-two cases of Cesarean section due to fetal anomaly diagnosed prenatally were reviewed in terms of the anesthetic managements. In 6 cases, diazepam 0.3 mg.kg-1, which provides fetal anesthesia for surgery scheduled immediately after birth, was administered intravenously to the mothers with/without fentanyl (2 general anesthesia and 4 regional anesthesia). The diagnosis of their fetuses was congenital diaphragmatic hernia, congenital cystic adenomatoid malformation of the lung, gastroschisis or omphalocele. No fetal anesthesia was performed in the other 16 cases (15 spinal anesthesia and 1 general anesthesia). Seven of their fetuses were diagnosed as hydrops. Since the general condition of the diseased newborn is known to be deteriorated after receiving various stress and aerophagia, fetal anesthesia in Cesarean delivery has the advantage of stress reduction and prevention of aerophagia. When the newborn is considered to need immediate neonatal resuscitation or intensive care including surgery, fetal anesthesia may be a choice of anesthetic technique.     

Anesthesia for 15 morbidly obese parturients undergoing cesarean section

From 1994 to June 2001, 15 parturients weighing more than 100 kg underwent cesarean section at our institution. Their medical and anesthetic records were reviewed retrospectively. They consisted of 10 primiparous and 5 multiparous patients. Mean body weight was 108.4 +/- 6.3 kg (mean +/- SD) and body mass index (weight in kilograms/[height in meters]2) was 41.6 +/- 2.8 kg.m-2 (min 36.6, max 49.7). Maternal complications included preeclampsia (n = 7, 46.7%), diabetes mellitus (n = 6, 40%) and asthma (n = 1). Of 15 patients, cesarean section was performed under spinal anesthesia in 11 patients and under epidural anesthesia in 4, and none received general anesthesia. All the patients gave live births. Intraoperative complications included hypotension (n = 6) and nausea (n = 3). All of them were free from the morbid postoperative complications except wound dehiscence occurring in four patients.     

Anesthesia for an achondroplastic dwarf presenting for urgent cesarean section

Achondroplasia is a physeal dysplasia which leads to dwarfism secondary to a decrease in the proliferation of cartilage in the growth plate. This, coupled with normal persistent bone formation, leads to the development of short tubular bones. Achondroplastic dwarfism is among the more common types of dwarfism and is inherited as an autosomal dominant trait. Its incidence is reported as 1 in 26,000 live births. Most achondroplastic dwarfs have a normal life span. The selection and management of anesthesia for the achondroplastic dwarf must take into account a variety of anatomic deformities. The physiologic and hormonal changes of pregnancy further complicate anesthetic administration. We report the safe use of a continuous lumbar epidural anesthetic in an achondroplastic dwarf who presented for urgent cesarean section.     

Anesthesia for cesarean section in two patients with brain tumours

PURPOSE: To describe two patients with brain tumours where general anesthesia was used for cesarean sections under emergency and urgent conditions. CLINICAL FEATURES (CASE #1): The first patient presented at 38 wk gestation with an acute intracranial tumour herniation, requiring emergency craniotomy and simultaneous cesarean section. General anesthesia was induced with thiopental and vecuronium, maintained with enflurane 1% in O2 100%. Maternal P(ET)CO2 was maintained at 25 mmHg. After delivering a healthy infant, she was given syntocinon, mannitol and dexamethasone i.v. anesthesia was maintained with fentanyl, nitrous oxide 50% in O2 and isoflurane 1% during frontal-lobe tumour resection. CLINICAL FEATURES (CASE #2): The second patient presented at 37 wk gestation for urgent cesarean section because of placental insufficiency. She had had a brain tumour resection four years earlier. An increase in intracranial pressure necessitated craniotomy for decompression at 20 wk gestation. She was further treated with dexamethasone, carbamazepine and radiation for control of cerebral oedema at 34 wk. Cesarean section was performed under general anesthesia; rapid-sequence-induction with thiopental and succinylcholine, followed by isoflurane 1% in O2 100%. Syntocinon, fentanyl and atracurium i.v. were administered after delivery of a healthy infant. Although neurosurgeons stood by, their intervention was unnecessary. CONCLUSION: General anesthesia remains safe and dependable for operative delivery in parturients with intracranial tumour. Tracheal intubation allows maternal hyperventilation thereby controlling raised intracranial pressure. Hemodynamic stability is readily achieved to maintain cerebral perfusion. However, a multidisciplinary-team approach is critical for successful patient management.     

Anesthesia for cesarean section in a parturient taking risperidone and haloperidol

We report a case of anesthesia for cesarean section in a schizophrenic patient. Her psychiatric symptoms were well controlled with low doses of risperidone until 35 weeks' gestation, when she suddenly developed psychotic manifestations. Risperidone 6 mg x day(-1) and haloperidol 12 mg x day(-1) PO were given for 3 weeks before delivery. Elective cesarean section was performed under spinal anesthesia at 38 weeks. The parturient showed good psychiatric condition during and after the surgery. The neonate did not show any symptoms which antipsychotics could have caused. Maternal and umbilical blood concentrations of risperidone and haloperidol are reported.     

Anesthesia for cesarean section in a patient with cor triatriatum

Cor triatriatum is a rare congenital cardiac anomaly, in which left ventricular filling is impeded by obstructive membrane in the left atrium. We administered spinal anesthesia for cesarean section in a patient with cor triatriatum (type III A1) with congestive heart failure. We optimized hemodynamics with the aid of pulmonary artery cathter. In general, cor triatriatum involves similar hemodynamic profiles to mitral stenosis and thus tachycardia should be avoided during anesthesia. However, in our patient, increasing the heart rate to 80-90 beats x min(-1) was beneficial in maintaining adequate systemic blood pressure and cardiac output. Spinal anesthesia could be a method of choice for cesarean section in a patient with cor triatriatum when adequate hemodynamic monitoring is available.