Severe fetal bradycardia in a pregnant surgical patient despite normal oxygénation and blood pressure

PURPOSE: To report and discuss a case of fetal bradycardia in a parturient under anesthesia for cholecystectomy despite normal maternal oxygenation and arterial blood pressure. CLINICAL FEATURES: A 27-yr-old woman (gravida 2 para 1), with a fetus of 34 weeks gestation, received general anesthesia for cholecystectomy. After anesthesia induction and tracheal intubation, anesthesia was maintained with oxygen, sevoflurane and iv remifentanil infusion. While preparing for surgery, the fetal heart rate decreased within about half a minute to 70 beats x min(-1) and remained at that level. The maternal blood pressure, heart rate and oxygen saturation were normal. An emergency Cesarean delivery was performed. The infant had Apgar scores of 1 at one minute, 5 at five minutes, 7 at ten minutes and required resuscitation after birth. CONCLUSION: Ideally, women having non-obstetric surgery during the third trimester of pregnancy will have intraoperative fetal heart rate monitoring.     

Anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia

PURPOSE: To describe the anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia. CLINICAL FEATURES: A 28-yr-old parturient with a history of thrombocytopenia was admitted with signs of pre-eclampsia (blood pressure of 140/90 mmHg, heavy proteinuria and moderate bilateral ankle edema) at 25 weeks of gestation. Laboratory studies revealed pancy-topenia (hemoglobin 6.4 g.dL(-1), white cell count 3.43 x 10(9).L(-1), platelet count 20 x 10(9).L(-1)) and bone marrow biopsy showed hypoplastic anemia. As pre-eclampsia worsened, a Cesarean delivery was performed at 27 weeks with prophylactic platelet transfusion and meticulous blood pressure control. The procedure was uneventful, conducted under general anesthesia with an estimated blood loss of around 600 mL and a live female baby was delivered. Postoperatively her blood pressure and neurological symptoms improved but thrombocytopenia remained at discharge. CONCLUSIONS: Hypoplastic anemia is rare in pregnancy but it poses an increased risk for both mother and fetus. The mother is at risk of life-threatening episodes of bleeding and infection and a multidisciplinary team approach (obstetrician, anesthesiologist, hematologist and pediatrician) is essential. An accurate assessment of the hematological condition should be made and abnormalities corrected before surgery. Regional anesthesia may not be possible in this circumstance.     

Emergency Cesarean delivery for umbilical cord prolapse: the head-down, knee-chest prone position for spinal anesthesia

OBJECTIVE: Umbilical cord prolapse in a parturient is an emergency, where the need for immediate fetal delivery may conflict with maternal anesthetic risk factors. We describe the anesthetic management of a parturient who was rushed to the operating room, in the knee-chest prone position, because of cord prolapse with variable decelerations of fetal heart rate. CLINICAL FEATURES: A 28-yr-old multiparous patient presented at 37 weeks gestation. Her co-morbidities included morbid obesity and asthma. She had a Mallampati class IV airway. She required emergency Cesarean delivery, in view of umbilical cord prolapse, with evidence of fetal compromise. In light of the airway concerns, the urgency to proceed with delivery, and the presence of a palpable umbilical cord pulse in this position, we performed a spinal anesthetic in the knee-chest prone position, and immediately thereafter turned the patient supine, with lateral uterine displacement. Fetal heart rate was monitored throughout the procedure. The spinal anesthetic required less than five minutes to perform, from the time of skin preparation, until readiness for surgery. The subsequent surgical and anesthetic course was unremarkable. CONCLUSIONS: Performing spinal anesthesia in the knee-chest prone position served as an innovative solution for emergency Cesarean delivery in this case. Both the head-down lateral, and the head-down knee-chest prone positions, are compatible with spinal anesthesia, and the maternal position that achieves relief of cord compression, determined by the presence of a palpable umbilical cord pulse, may be the most important factor to determine the optimal approach to spinal anesthesia.     

Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta

Purpose

We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.

Clinical features

A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35⁺³ weeks due to suspected placenta accreta. Her body mass index was 21?kg·m^?2 and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800?mL, colloid 1,500?mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient??s cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta.

Conclusion

A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.     

The effect of colloid and crystalloid preloading on thromboelastography prior to Cesarean delivery

PURPOSE: Fluid preloading with colloids reduces hypotension after spinal anesthesia for Cesarean delivery more effectively than crystalloids. However, the effects of fluid preloading regimens on coagulation in pregnant patients remain unresolved. The aim of this study was to compare the effects on coagulation of fluid preloading with 6% hydroxyethyl starch (HES) and lactated Ringer's (LR) solution using thromboelastography (TEG) with kaolin-activated whole blood in healthy pregnant patients prior to spinal anesthesia for Cesarean delivery. METHODS: After obtaining Ethics committee approval, 30 parturients were prospectively randomized prior to spinal anesthesia for elective Cesarean delivery to receive fluid preloading with either 1500 mL LR or 500 mL 6% HES over 30 min. Thromboelastography was performed immediately prior to and after fluid preloading. Standard TEG parameters were analyzed in terms of r time (min), k time (min), alpha angle (degrees) and maximum amplitude (mm). RESULTS: Group HES had statistically significant longer reaction times (r) and clot formation times (k) after fluid loading compared to baseline values (P < 0.05 respectively), although these post-fluid loading TEG parameters remained within a normal reference range. No significant differences in TEG values were seen after preloading within the LR group. CONCLUSION: Fluid preloading with 500 mL 6% HES in healthy parturients produced mild coagulation effects, as measured with TEG, prior to spinal anesthesia for Cesarean delivery. No significant effects on coagulation with TEG were observed following preloading with 1500 mL LR.     

Anesthesia for cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord

PURPOSE: Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case. CLINICAL FEATURES: The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia. CONCLUSIONS: Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.     

Pregnancy, labour and delivery in a Jehovah’s Witness with esophageal varices and thrombocytopenia

PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness. CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery. CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.     

Intrathecal anesthesia for cesarean delivery via a subarachnoid drain in a woman with benign intracranial hypertension

A 26-year-old primiparous patient with intractable benign intracranial hypertension treated by cerebrospinal fluid drainage through an indwelling spinal catheter was expecting twins. At 30 weeks she presented for emergent cesarean delivery secondary to a non-reassuring fetal condition. In consultation with the neurosurgical team, spinal anesthesia for the cesarean delivery was induced successfully through the spinal catheter. Cesarean delivery proceeded uneventfully with a favorable neonatal outcome.     

Type A aortic dissection during late pregnancy in a patient with Marfan syndrome

Purpose

To report the management of a 38-yr-old patient with known Marfan syndrome who presented with acute Stanford type A dissection of the aorta in the 34^th week of pregnancy.

Clinical features

A Cesarean delivery was performed under deep general anesthesia with high-dose opioid administration to avoid tachycardia and hypertension during tracheal intubation and obstetric surgery. Delivery took place less than five minutes after induction of anesthesia, and tracheal intubation of the newborn was required due to opioid-induced hypoventilation. Subsequently, aortic arch repair was performed in the mother after connection to extracorporal bypass. Despite extensive replacement of coagulation factors, severe vaginal bleeding persisted after weaning from extracorporal bypass, and the bleeding stopped only after a hysterectomy was performed. Postoperatively, after a short period in the intensive care unit, mother and child were discharged from hospital in excellent condition ten days after surgery.

Conclusion

Deep general anesthesia for emergency Cesarean delivery while accepting the risk of respiratory depression in the newborn is a viable option for the anesthetic management of life-threatening events such as Stanford type A dissection.     

Excessive blood loss during operation in the patient treated with propylthiouracil

A case of bleeding during operation due to propylthiouracil-induced thrombocytopenia is reported. A 55 year old male who had been treated with Propylthiouracil for two months before operation underwent otherwise uneventful cervical laminectomy. Perioperatively he was transfused seven units of whole blood, two units of packed red cells, six units of platelets and two units of fresh frozen plasma for the estimated blood loss of 5500 ml. The patient underwent thyroidectomy without incident 45 days after withdrawal from Propylthiouracil. The value of the preoperative coagulation studies of the patient treated with Propylthiouracil is discussed.     

Assessment of Changes in Coagulation in Parturients with Preeclampsia Using Thromboelastography

Background: Preeclampsia is associated with a risk of abnormal hemostasis that occurs most commonly secondary to thrombocytopenia. Thromboelastography measures whole blood coagulation and has been used to manage coagulation defects in obstetric patients. The authors conducted this investigation in a large number of preeclamptic women to assess changes in coagulation using thromboelastography.

Methods: Thromboelastography and platelet counts were performed in 52 healthy pregnant women, 140 mild preeclamptic women, and 114 severe preeclamptic women in active labor using disposable plastic cups and pins and native whole blood. In preeclamptic patients with a platelet count <100,000/mm3, conventional coagulation tests were also performed. Epidural analgesia was provided in some women when they requested pain relief.

Results: Fifteen percent of all preeclamptic women (38 of 254) and 2% (1 of 52) of healthy pregnant women had a platelet count <100,000/mm3. The incidence of thrombocytopenia <100,000/mm3 was 3% (4 of 140) and 30% (34 of 114) in mild preeclamptic patients and severe preeclamptic patients, respectively. Severe preeclamptic patients with a platelet count <100,000/mm (3) were significantly hypocoagulable when compared to the other study groups. Ten severe preeclamptic women with a platelet count <100,000/mm3 had a maximum amplitude <54 mm (the lower limit of maximum amplitude in healthy pregnant women enrolled in this investigation). None of the mild preeclamptic women had a maximum amplitude <54 mm. Five severe preeclamptic women with a platelet count <100,000/mm3 had an abnormal coagulation profile, whereas all four mild preeclamptic women with a platelet count <100,000/mm3 had a normal coagulation profile.     

General anesthesia for cesarean delivery in a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia

Pregnancy in patients with paroxysmal nocturnal hemoglobinuria (PNH) increases the risk of complement activation, hemolysis, and thrombosis. We describe the anesthetic management of a patient with PNH who underwent general anesthesia for cesarean delivery. Steroids, heparin, and blood products were administered early to minimize the likelihood of a hematologic emergency. IMPLICATIONS: Pregnancy in patients with paroxysmal nocturnal hemoglobinuria increases the risk of hemolysis, thrombosis, anemia, and thrombocytopenia. We describe the anesthetic management of a patient with paroxysmal nocturnal hemoglobinuria and thrombocytopenia who underwent general anesthesia for cesarean delivery.     

The management of Cesarean delivery in a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia

PURPOSE: To describe the anesthetic and peripartum management of a parturient with paroxysmal nocturnal hemoglobinuria complicated by severe preeclampsia, review the pathophysiology of this condition, rationale for thromboembolic prophylaxis, and its implications on the choice of labour analgesia and anesthesia. CLINICAL FEATURES: A 35-yr-old primigravida was diagnosed with paroxysmal nocturnal hemoglobinuria at 18 weeks gestation following new onset pancytopenia. Venous thromboembolic prophylaxis with low molecular weight heparin (LMWH) was started, and continued despite a persistent thrombocytopenia. At 34 weeks, labour was induced after she developed signs of severe preeclampsia, and intravenous magnesium sulfate therapy was commenced. The use of a twice daily dosing regime of LMWH, along with severe thrombocytopenia contraindicated neuraxial anesthesia. As a result, labour analgesia was provided with an intravenous patient-controlled analgesia system with fentanyl. The patient subsequently had an uneventful Cesarean delivery under general anesthesia. Anticoagulation with LMWH was restarted postoperatively, and continued for six weeks postpartum. She was discharged home on day 20 postpartum, on oral prednisolone under the care of the hematologists. CONCLUSION: Paroxysmal nocturnal hemoglobinuria is associated with an increased risk of venous thromboembolism, and so anticoagulation therapy assumes primary importance. The use of LMWH for prophylaxis in combination with thrombocytopenia may contraindicate neuraxial anesthesia. General anesthesia should be aimed at preventing or exacerbating complement mediated intravascular hemolysis.     

Value of preoperative coagulation tests: reappraisal of major noncardiac surgery

In a retrospective case-control review, we evaluated preoperative coagulation testing in patients undergoing major noncardiac operations to determine if routine testing benefits this group of patients. The platelet count (PC), prothrombin time (PT), and activated partial thromboplastin time (aPTT) in all patients undergoing major noncardiac surgery over a 22-month period were reviewed. The review was done both manually and by the computerized hospital information system. Major surgery was defined as procedures usually associated with significant bleeding. For each patient with abnormal results, another two control patients undergoing the same surgery and matched for age and gender were identified. Case and control patients were compared regarding a change in the management plan, use of blood products, blood loss, and bleeding complications by detailed chart review. A total of 828 patients undergoing nine different surgeries were reviewed. The incidence of abnormal PCs was 2.2% [95% confidence interval (CI) 1.2-3.2%] and that of abnormal PT/aPTTs was 2.1% (95% CI 1.1-3.1%). There were only two cases each of thrombocytopenia and prolonged PT/aPTT where the coagulation tests were not indicated clinically. Although (compared to controls) patients with abnormal tests had more changes in their anesthesia plan (36% vs. 2%, p < 0.001) and platelet or fresh frozen plasma transfusions (50% vs. 9%, p < 0.001), blood loss and the incidence of bleeding complications were not different. We conclude that the use of preoperative coagulation tests in patients undergoing major noncardiac surgery should still be guided by clinical assessment. The surgical procedure itself does not constitute an indication for testing.     

Cesarean section in a patient with Wolfe-Parkinson-White syndrome

A 30 year old woman with abnormal fetal presentation was scheduled for emergency cesarean section. The patient had been a known case of Wolff-Parkinson-White syndrome, and appeared exceedingly anxious. She was given diazepam 5 mg and sufentanil 15 microgram as premedication following which routine and conventional general anesthesia was administered. The perioperative course was uneventful, and both the patient and the child were discharged fully well on the 5th postoperative day.     

Amyloidosis associated bleeding diatheses in the surgical patient

The coagulopathies associated with amyloidosis have not been widely appreciated. We encountered a patient with amyloidosis and mildly abnormal coagulation studies who presented for an emergency laparotomy for acute bowel obstruction. Upon gentle manipulation of the bowel, an unexpected bleeding diathesis was manifested by the formation of several large haematomas resulting in a large amount of blood loss (approximately 800 ml). Numerous defects of platelet function and coagulation have been associated with amyloidosis, including abnormal platelet aggregation, increased vascular fragility, factor IX and X deficiencies, decreased levels of alpha-2-plasmin inhibitor, and increased levels of plasminogen. Intraoperative therapy for our patient included the rapid administration of four units of fresh frozen plasma and ten units of platelet concentrate. A review of the pathology and therapeutic modalities for this potentially life-threatening complication is presented.     

Cerebral venous thrombosis complicating severe preeclampsia in the postpartum period: a diagnostic challenge

A 26 year old primigravida with preeclampsia was diagnosed with a cerebral venous thrombosis 6 days following Cesarean section. The diagnosis was initially challenging due to the patient’s history of migraines, the preeclampsia, multiple attempts at spinal anesthesia for Cesarean section, and a dural puncture while performing epidural blood patch.     

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.     

General anesthesia with remifentanil for Cesarean section in a patient with HELLP syndrome

HELLP syndrome is a severe complication of pre-eclampsia characterised by hemolysis, elevated liver enzymes and a low platelet count. It is associated with an increased risk of adverse outcome for both the mother and the fetus. Patients with HELLP syndrome are also at greater risk of pulmonary edema, adult respiratory distress syndrome, abruptio placentae, intracerebral hemorrhage, eclamptic convulsions, disseminated intravascular coagulation, ruptured liver hematomas and acute renal failure. Perinatal mortality is equally high. Before delivery, aggressive obstetric management is directed toward stabilization of the affected organ systems, if possible, and interruption of the pregnancy in the early phase of the accelerated disease progression. Definitive therapy is delivery. Parturients HELLP syndrome often require general anesthesia for Cesarean section delivery. The anesthetic technique is critical for these patients with a high risk of uncontrollable hypertension, bleeding and multiple organ failure. Remifentanil is increasingly used as a very short analgesic agent providing cardiovascular stability in high-risk patients. We report the management of a patient presenting in labor with HELLP syndrome, and describe the successful use of remifentanil as part of the anesthetic technique for her subsequent Cesarean section.     

The anesthetic management for cesarean delivery in a patient with Shone's syndrome

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.