April 6, 2021

spinal anaesthesia in pregnancy

by Admin

The ultrasound imaging technique can be a reliable guide to facilitate spinal anesthesia, especially in obese parturients. With the development of newer needles and bevel designs and methods whereby the incidence of hypotension can be minimized, spinal anaesthesia is making a reappearance in obstetrical anaesthesia spheres. Spinals are pain medications delivered via the spinal column in one dose. Ultrasound for spinal anesthesia in pregnancy. The definition of prematurity was altered to distinguish between the preterm infant, born before the thirty-seventh week of gestation, and the small-for-gestational-age infant, who may be born at term but whose weight is more than 2 standard deviations below the mean. If clotting abnormalities exist, blood components and fresh frozen plasma, cryoprecipitate, and platelet concentrates may be required. However, the tachycardia associated with an intravenous test dose of epinephrine is not a reliable indicator of intravascular injection during labor because it may be confounded coincident with a painful uterine contraction. Materials and Methods: A total of 100 ASA Grade I patients undergoing elective cesarean section under spinal anesthesia with a normal singleton pregnancy beyond 36 weeks gestation were randomly allocated into two groups of 50 each. The total maternal body clearance of amide local anesthetics is prolonged in preeclampsia, and repeated administration of these drugs can lead to higher blood concentrations than in normotensive patients. General anesthesia is rarely necessary but may be indicated for uterine relaxation in some complicated deliveries. Elevation of the diaphragm occurs with an increase in the size of the uterus. Before offering a patient spinal anesthesia, an anesthesiologist not only must be aware of the indications and contraindications of spinal anesthesia but also must be able to weigh the risks and benefits of performing the procedure. However, more recent studies using radiographic, ultrasound, and dye dilution techniques have demonstrated that gastric emptying of liquid and solid materials does not decrease at any time during pregnancy. Non-Obstetric Surgery During Pregnancy. The woman may still feel some pressure but not pain. Pain relief properties of ketamine prescription were assessed in women with elective cesarean section who underwent spinal anesthesia with low dose intravenous ketamine and midazolam and intravenous midazolam alone.Sixty pregnant women scheduled for spinal anesthesia for cesarean section were randomized into two study groups. Rapid control of the airway is essential, and endotracheal intubation may be necessary to ensure oxygenation without aspiration. Regional anesthesia (also called epidural, spinal, or systemic anesthesia) is the most common and effective pain relief. Repeated administration can result in high maternal blood concentrations, depending on the dose and frequency of reinjection, in addition to the kinetic characteristics of the drug. Russell et al. The effects of systemically administered meperidine on the course of labor are controversial. Regional analgesia can benefit the fetus by eliminating maternal hyperventilation with pain, which often leads to a reduced fetal arterial oxygen tension owing to a leftward shift of the maternal oxygen–hemoglobin dissociation curve. No significant side effects were observed. The diagnosis of abruptio placentae is based on the presence of uterine tenderness, hypertonus, and vaginal bleeding of dark, clotted blood. Caution has been exercised with sedatives before block placement because of several reports describing a specific rela-tionship between diazepam and oral clefts; however, other stud-ies have not confirmed this. For cesarean section delivery, the sensory level of regional anesthesia must extend to T3–4, making adequate fluid therapy and left uterine displacement even more vital. These changes are caused by increased extracellular fluid and vascular engorgement. Pregnancy and parturition are considered high risk when accompanied by conditions unfavorable to the well-being of the mother or fetus, or both. Peripheral nerve injury as a result of instrumentation, lithotomy position, or compression by the fetal head may occur even in the absence of neuraxial technique. However, repeated intrathecal injections may be required for a long labor, thus increasing the risk of postdural puncture headache. It has been suggested that bupivacaine may be implicated as a possible cause of neonatal jaundice because of its high affinity for fetal erythrocyte membranes, resulting in a decrease in filterability and deformability rendering subjects more prone to hemolysis. This is injected through a tube into the epidural space situated in the lower back. Prophylactic antibiotics are not recommended because gastric contents are sterile. Pathophysiology and consequences of hypotension during spinal anaesthesia. Spinal Anesthesia and Maternal Hypotension. In early labor, only the lower thoracic dermatomes (T11–T12) are affected. High, or total, spinal anesthesia is a rare complication of intrathe-cal injection in modern-day practice. One common side effect of spinal anesthesia is maternal hypotension, or low blood pressure (sometimes this is also referred to as a hypotensive crisis).Maternal hypotension may cause nausea and vomiting in the mother . The choice of anesthetic for a woman with placental abruption depends on maternal and fetal condition and how urgently the procedure needs to be performed. Generally speaking, with regional techniques, the duration of antepartum anesthesia does not affect neonatal outcome, provided that there is no protracted aortocaval compression or hypotension. Spinal anesthesia, also known as a spinal or intradural block, is one of the most common. Spinal anesthesia is a safe technique, widely used and tested in the gynecological field, so as to be considered the first choice technique in cesarean section, which allows to quickly obtain a valid sensor and motor block. They were subsequently withdrawn when found to be associated with neurologic deficits, possibly related to maldistribution of local anesthetic in the cauda equina region. The establishment of invasive monitoring (arterial line, central venous catheter) and blood volume replacement via a 14- or 16-gauge catheter is usually required. Alterations in maternal anatomy and physiology induced by pregnancy have clinical anesthetic implications and present potential hazards for the mother and fetus undergoing anesthesia. The anesthetic management should be the same as for the nonpregnant patient with an aneurysm, except that a pregnant patient is actually two . However, in two recent studies, the incidence of hypotension, perioperative fluid and ephedrine administration, and neonatal conditions were found to be similar in preeclamptic women who received either epidural or spinal anesthesia for cesarean delivery. Spinal anaesthesia in pregnant patients Spinal anaesthesia in pregnant patients Edmondson, L.; Erwin, D.C. 1987-06-01 00:00:00 sufentanil. The goals of anesthesia during pregnancy are to ensure recovery of the mother and normal continuation of the pregnancy without damage to the fetus. Neuro-anaesthesia may be indicated during pregnancy for procedures such as intracranial surgery, spinal surgery and diagnostic and therapeutic interventions. Delivery is indicated in refractory cases or if the pregnancy is close to term. Anticoagulant therapy during pregnancy is widely used due to the increasing awareness of maternal hypercoagulability. Most women experience moderate to severe pain during labor and delivery, often requiring some form of pharmacologic analgesia. The patient’s ability to handle a glucose load is decreased, and the transplacental passage of glucose may stimulate fetal secretion of insulin, leading, in turn, to neonatal hypoglycemia in the immediate postpartum period. Spinal anaesthetic. 86 The optimal analgesic for labor provides pain relief for first- and second-stage labor but otherwise has minimal effect on the mother or baby. Currently, diazepam is not a proven teratogen. Spinal anaesthetic spread . II. Spinal Anesthesia and Maternal Hypotension. Fetal regional blood flow changes can also affect the amount of drug taken up by individual organs. Anesthesiology 91: 1159, 1999]. Spinal anaesthetic - this is the most common; Epidural - you might have your epidural topped up if you've had one for labour; Spinal anaesthetic and epidural together; More about epidurals. Some clinicians do not advocate the CSE analgesia technique for labor because of the concern for an “unproven” epidural catheter that may need to be used emergently for cesarean section delivery. Ketamine is a potent analgesic. The addition of adjuvants, such as clonidine and neostigmine, has been disappointing. Perioperative analgesia may be enhanced by the addition of fentanyl 20 mcg or preservative-free morphine 0.1 mg to the local anesthetic solution. Various agents have been used to suppress uterine activity (tocolysis), such as ethanol, magnesium sulfate, prostaglandin inhibitors, β-sympathomimetics, and calcium channel blockers. Potential risk factors identified from these cases are entry-point infections from usual causative organisms (eg, Staphylococcus aureus), possible systemic sources of infection, poor aseptic technique, and prolonged catheterization. During labor and delivery, fetal malpresentation (eg, breech, transverse lie), placental abruption, compression of the umbilical cord (eg, prolapse, nuchal cord), precipitous labor, or intrauterine infection (eg, prolonged rupture of membranes) may increase the risk to the mother or fetus. Welcome back, Want to sign up? The origin of preeclampsia-eclampsia is unknown, but all patients manifest placental ischemia. Regional anesthesia can be success-fully used, with nitroglycerin available for uterine relaxation if needed. The panel was convened to address an ongoing issue where obstetric patients with thrombocytopenia are often denied neuraxial anesthesia due to risk of spinal epidural hematoma. LaparoscopyLaparoscopy Left uterine displacement maintaining ETCO2 32-34 mmHg maternal BP within 20% of baseline Limit insufflation pressure to 12-15 mmHg O'Rourke N. Kodali BS. 15,16 Additionally, abnormal fetal heart tones during labor are seen in about 10% to 20% of patients with regional . The potential exists for epidurally administered drug to leak intrathecally through the dural puncture, particularly if large volumes of drug are rapidly injected. The lack of proper psychological preparation combined with fear and anxiety can greatly enhance the patient’s sensitivity to pain and further add to the discomfort during labor and delivery. Decrease in vascular resistance in the uterine, renal, and other vascular beds. This is mostly a result of a 40% increase in tidal volume and a small increase in respiratory rate. Table 3 lists local anesthetics and the dosages commonly used for cesarean section delivery with subarachnoid block. Delayed respiratory depression may occur with the use of morphine; hence, the patient must be monitored carefully in the postoperative period. Stenotic valvular heart lesions Severe spinal deformity Controversial: Prior back surgery Inability to communicate with the patient Complicated surgeries that may involve a prolonged amount of time to perform, major blood loss, and maneuvers that may compromise respiration. The severe manifestation of the disease occurs in approximately 1:10.000 cases (8). Bleeding time, prolonged in approximately 25% of patients with normal platelet counts, is no longer considered a reliable test of clotting. This may occur even if the total plasma drug concentration in the mother exceeds that in the fetus, because there is lower protein binding in fetal plasma. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Regional anesthesia greatly reduces or eliminates pain throughout the birthing process. Fentanyl 1–2 mcg/mL or sufentanil 0.3–0.5 mcg/mL may be added. If the initial block is not adequate, concern exists regarding a repeat spinal injection and the potential for inadvertent high spinal anesthetic. One of the most serious side effects was the occurrence of seizures both from the primary drug effect and from the drug’s metabolite, normeperidine. Before ambulation, women should be observed for 30 minutes after intrathecal or epidural drug administration to assess maternal and fetal well-being. Note: For more information on thrombocytopenia in pregnancy including etiologies and management, see ‘Related ObG Topics’ below, Neuraxial Anesthesia: Thrombocytopenia-Related Spinal Henatoma, We found no evidence from RCTs or non‐randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter, …clinicians and patients should engage in shared decision-making about the perceived competing risks/benefits of proceeding with or withholding neuraxial anesthesia in cases of severe thrombocytopenia and concurrent aspirin use, The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients with Thrombocytopenia, SOAP Thrombocytopenia Consensus Statement FINAL, Cochrane Review: Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia, Already an ObGFirst Member? Chorioamnionitis without sepsis is not a contraindication to central neuraxial blockade. Unintentional intrathecal administration of epidural medication as a result of dural puncture or catheter migration may also result in this complication. Regional anesthesia may be associated with hypotension, which is related to the degree and rapidity of local anesthetic–induced sympatholysis. Similar results have been reported in another study involving lidocaine administration to human infants in a neonatal intensive care unit. Their predominant effect is β2 receptor stimulation, which results in myometrial inhibition, vasodilation, and bronchodilation. Trimethaphan, a ganglion blocking agent, is useful in hypertensive emergencies when cerebral edema and increased intracranial pressure are a concern because it does not cause vasodilation in the brain. Spinal anesthesia is used during childbirth to reduce and relieve pain. The fetus can excrete local anesthetics back into the maternal circulation after the concentration gradient of the free drug across the placenta has been reversed. Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. Human placental lactogen and cortisol increase the tendency toward hyperglycemia and ketosis, which may exacerbate preexisting diabetes mellitus. The objective of this study was to evaluate the safety and feasibility of minimally invasive spinal anesthesia in parturients with anticoagulation therapy undergoing cesarean section. She will still be able to help push the baby out during delivery. However, hypotension and sedation have been reported with spinal clonidine and may limit its routine use. Although they are potent, their usefulness during labor is limited by their short duration of action. Several factors influence the placental transfer of drugs, including the physicochemical characteristics of the drug itself, maternal drug concentrations in the plasma, properties of the placenta, and hemodynamic events within the fetomaternal unit.Highly lipid-soluble drugs, such as local anesthetics, cross biologic membranes more readily, and the degree of ionization is important because the nonionized moiety of a drug is more lipophilic than the ionized drug. An emergency hysterectomy may be required because of severe hemorrhage, even after the delivery of the placenta, because of uterine atony. The main aim of epidural anesthesia is to relieve pain. It is easy to confuse a spinal block and spinal epidural because they are both . Other agents that have been used to control maternal blood pressure include α-methyldopa, nitroglycerine, and, now more frequently, labetalol. If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Ketamine (30 mg) + midazolam (1 mg = 2CC) or 1mg midazolam (2CC . The On the maternal side, the dose administered, the mode and site of administration, and the use of vasoconstrictors can influence fetal exposure. Rapid injection of 1 mL of air with simultaneous precordial Doppler monitoring appears to be a reliable indicator of intravascular catheter placement. For example, a single IV injection of fentanyl, up to 1 mcg/kg, results in prompt pain relief without severe neonatal depression but for a short period of time. It can be used only epidurally, can last up to 48 hours, and the patient must be monitored for delayed respiratory depression. Fortunately, in a recent multi-institutional study, no cases of neurologic symptoms occurred after the use of 28-gauge microcatheters for continuous spinal analgesia in laboring women. Petechial hemorrhages are common after the onset of convulsions. In the pregnant patient at risk for seizures—that is, with pregnancy-induced hypertension or preeclampsia—confusing the picture by the administration of a drug known to cause seizures complicates patient care. Spinal anaesthesia in pregnancy Decreased dose requirement due to • Mechanical factor : compression of IVC causes shunting of blood to the venous plexus in the vertebral canal- decreased vertebral canal space and CSF volume • Hormonal factor - higher progesterone levels 72. In severe cases, aggressive management should continue for at least 24–48 hours after delivery. Recent studies using spinal ropivacaine have shown less hypotension and faster recovery but a slower onset compared to bupivacaine. Paracervical block is a useful technique to provide analgesia for uterine curettage. For example, during asphyxia and acidosis, a greater proportion of the fetal cardiac output perfuses the fetal brain, heart, and placenta. However, most drugs used in anesthesia exhibit low to moderate degrees of binding in the fetal serum: approximately 50% for bupivacaine, 25% for lidocaine, 52% for meperidine, and 75% for thiopental.In selecting the anesthetic drugs and techniques for delivering a preterm infant, concerns regarding drug effects on the newborn are far less important than preventing asphyxia and trauma to the fetus. A small dose of local anesthetic, lidocaine 45 mg or bupivacaine 5 mg, produces a readily identifiable sensory and motor block if injected intrathecally. Epidural and Spinal Anesthesia During Labor. The choice of anaesthesia for caesarean section in patient with severe preeclampsia remains controversial- [2]. Edema and small foci of degeneration have been attributed to hypoxia. References The efficacy of prophylactic nonparticulate antacids is diminished by inade-quate mixing with gastric contents, improper timing of administration, and the tendency for antacids to increase gastric volume. The maternal uptake and elimination of inhalational anesthetics are enhanced because of the increased alveolar ventilation and decreased FRC. However, it would seem prudent that treatment of a pregnant woman intoxicated with bupivacaine should include the administration of lipid emulsion early on in the resuscitation. Tulay Sahin 1, Onur Balaban 1, Levent Sahin 2, Mine Solak 1 & Kamil Toker 1 Journal of Anesthesia volume 28, pages 413-419 (2014)Cite this article The greater cardiotoxicity of bupivacaine (and etidocaine) compared with other amide local anesthetics has been well established.When using potent long-acting amide local anesthetics, fractioning the induction dose is critical. The plasma buffer base decreases from 47 to 42 mEq; consequently, the pH remains practically unchanged. In a recent meta-analysis, the onset of analgesia for CSE was significantly faster than with an epidural technique (2–5 minutes vs. 10–15 minutes). It has been demonstrated that for effective prevention of hypotension, the blood volume increase from preloading must be sufficient to result in a significant increase in cardiac output. In the fetus, this difference was attributed to placental clearance of drug into the mother and better maintenance of blood gas tensions during convulsions, whereas in the newborn lamb, a larger volume of distribution was probably responsible for the higher doses needed to induce toxic effects. It has also become an alternative to general anesthesia for emergency cesarean section. Leighton et al. Preterm labor and delivery present a significant challenge to the anesthesiologist because both the mother and the infant may be at risk. Advantages of Regional Anesthesia in the Obstetric Patient. In patients who have undergone prior uterine surgery, particularly prior cesarean delivery, the risk of severe hemorrhage is even greater, owing to a higher incidence of placenta acreta (penetration of the myometrium by placental villi). This is called ion trapping. Proteinuria, a sign of preeclampsia, is also attributed to placental ischemia, which leads to local tissue degeneration and a release of thromboplastin with subsequent deposition of fibrin in constricted glomerular vessels. However, severe spasmodic back pain has been described after epidural injection of large volumes of Nesacaine-MPF in surgical patients, but not in parturients. The disadvantages of general anaesthesia in this type of patients have been discussed extensively [3] [4]. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately. Repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective cesarean section Rakesh Kumar, Kunal Singh, Ganga Prasad, Nishant Patel Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India With spinal anesthesia, the local anesthetic concentration required to block sufficient sodium channels to affect motor, sensory, and sympathetic function is less than that needed for the better-protected nerves found in the epidural space; thus, a wider band of differential blockade occurs during spinal anesthesia than during epidural anesthesia. Placenta previa occurs in 0.11% of all pregnancies, resulting in up to a 0.9% incidence of maternal and a 17–26% incidence of perinatal mortality. This causes superficial placental implantation, resulting in decreased placental perfusion and ischemia related to stiff, muscular spiral arteries. Antepartum hemorrhage occurs most commonly in association with placenta previa (abnormal placental implantation on the lower uterine segment and partial to total occlusion of the internal cervical os) and abruptio placentae.

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