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Journal: International journal of obstetric anesthesia

166

We describe the case of a 29-year-old parturient who, after undergoing elective cesarean delivery, displayed symptoms of lower extremity weakness and sensory deficit. Her past medical history was significant for asymptomatic Arnold Chiari Type I malformation and asthma. She had received spinal anesthesia that failed to achieve an adequate surgical level requiring conversion to general anesthesia. After tracheal extubation, she exhibited bilateral leg weakness that did not resolve over the next 4-6h. An urgent magnetic resonance imaging scan revealed a normal spine with no evidence of hematoma. The lower extremity paresis persisted and a neurologist diagnosed psychogenic paresis, a type of conversion disorder. Interestingly, the patient’s postoperative leg paresis was not her first occurrence of neurological dysfunction after dural puncture. At 27weeks of gestation, she had similar lower extremity symptoms after a lumbar puncture, performed to exclude meningitis for severe headache symptoms. Psychogenic paresis is not commonly reported in the medical literature and we found no reports of psychogenic paresis after spinal anesthesia in a parturient or recurrent psychogenic paresis. We review the various risk factors, etiology, neurological signs and symptoms, types, therapy and future management of a patient with recurrent conversion disorder.

Concepts: Medicine, Childbirth, The Canon of Medicine, Neurology, Anesthesia, Epidural, Caesarean section, Arnold-Chiari malformation

166

BACKGROUND: Thromboelastography (TEG®) is a point of care monitor of whole blood coagulation and has previously demonstrated hypercoagulability in both pregnant and obese populations. However, the individual and combined contribution of pregnancy and obesity on coagulation status has not been defined. We carried out a study to assess the effect of both pregnancy and body mass index (BMI) on blood coagulation using laboratory tests of coagulation and thromboelastography. METHODS: This was a prospective study of 96 women divided into four equal groups; non-pregnant lean (NPL) BMI <25kg/m2, pregnant lean (PL) BMI <25kg/m2, non-pregnant obese (NPO) BMI >35kg/m2 and pregnant obese (PO) BMI >35kg/m2. Women were of either >36weeks of gestation presenting for elective caesarean delivery; non-pregnant women with BMI >35kg/m2 presenting for bariatric surgery; or non-pregnant volunteers with BMI <25kg/m2. Eligible women were then allocated to a group based on BMI and pregnancy status. TEG® analysis, full blood count and coagulation profiles were performed on all patients. The main outcome measures were TEG® profile (including r time, k time, α angle, maximum amplitude and coagulation index), platelet count, activated partial thromboplastin time, prothrombin time, and fibrinogen levels. RESULTS: The coagulation index was significantly higher in the obese patient groups compared with the lean groups (NPL -4.5 vs. NPO 1.9, P<0.001; PL -4.3 vs. PO 2.5, P<0.001). However, comparisons between the pregnant and non-pregnant groups when matched for BMI demonstrated no significant difference in coagulation. CONCLUSIONS: The combined effect of pregnancy and obesity on coagulation has not previously been investigated. Thromboelastographic comparison of pregnant and non-pregnant females separated into low or high BMI cohorts in the current study suggests that obesity correlates more with a hypercoagulable state than with pregnancy, particularly in pregnant patients at the extremes of low and high body weight.

Concepts: Childbirth, Blood, Obesity, Coagulation, Platelet, Body mass index, Blood tests, Prothrombin time

25

We set out to validate the accuracy of gravimetric quantification of blood loss during simulated major postpartum haemorrhage and to evaluate the technique in a consecutive cohort of women experiencing major postpartum haemorrhage. The study took part in a large UK delivery suite over a one-year period. All women who experienced major postpartum haemorrhage were eligible for inclusion.

Concepts: Childbirth, Blood, Bleeding

24

Preeclampsia is associated with greater narrowing of the airway than normal pregnancy, but it is not known if these changes worsen during labor and delivery. The aim of the study was to evaluate the airway during and after labor in women with or without preeclampsia.

Concepts: Pregnancy, Childbirth, Experimental design, Uterus, Obstetrics, Case-control study, Woman, Caesarean section

23

The optimal fluid management strategy to ensure best outcomes in preeclamptic patients remains a controversial issue, with little evidence to support any one approach.

22

Ultrasound measurements of optic nerve sheath diameter (ONSD) and optic disc height (ODH) measured outside pregnancy correlate with intracranial hypertension. Data on the usefulness of ocular ultrasonography in preeclampsia are limited.

22

This study set out to compare the onset and duration of rocuronium-induced neuromuscular blockade in second trimester pregnant women and non-pregnant women receiving general anesthesia.

Concepts: Pregnancy, Childbirth, Trimester

4

Accidental awareness during general anaesthesia (AAGA) is a complex and rare outcome to investigate in surgical patient populations, particularly obstetric patients. We report the protocol of the Direct Reporting of Awareness in Maternity patients (DREAMY) study, illustrating how the research was designed to address practical and methodological challenges for investigating AAGA in an obstetric cohort.

4

BACKGROUND: The decision to use, or not use, neuraxial analgesia is complex and likely multi-factorial. The objectives of this study were to understand parturients' concerns about neuraxial analgesia, and the reasons for not anticipating the use of neuraxial analgesia using qualitative methodology. METHODS: English-speaking, term parturients, who had not requested or received labor analgesia, were recruited for this mixed-methods study. In addition to a quantitative survey, the results of which have been published elsewhere, women were asked open-ended questions regarding concerns about neuraxial analgesia and reasons for not anticipating its use. Answers were recorded verbatim and analyzed using qualitative methodology. RESULTS: Interviews were conducted with 509 women. Thirty-nine percent of patients expressed some concern about neuraxial analgesia. These concerns were thematically represented by misunderstandings about neuraxial analgesia, general fears about the procedure, and lack of trust in providers. Many of the concerns were misunderstandings that were not supported by the medical literature. Of the 129 patients who did not anticipate using neuraxial analgesia, 23% stated that this was because they desired a natural childbirth and/or control over their labor experience, whereas 46% cited concerns about the procedure and its complications as the basis for their decision. CONCLUSION: Many women who anticipate not using neuraxial analgesia may be basing their decision on an inaccurate understanding of the risks of the procedure. Improved patient education and counseling that target specific areas of concern may address these misunderstandings.

Concepts: Scientific method, Childbirth, Educational psychology, Qualitative research, Woman, Quantitative research, Midwifery, Natural childbirth

3

We reviewed the literature on obstetric failed tracheal intubation from 1970 onwards. The incidence remained unchanged over the period at 2.6 (95% CI 2.0 to 3.2) per 1000 anaesthetics (1 in 390) for obstetric general anaesthesia and 2.3 (95% CI 1.7 to 2.9) per 1000 general anaesthetics (1 in 443) for caesarean section. Maternal mortality from failed intubation was 2.3 (95% CI 0.3 to 8.2) per 100000 general anaesthetics for caesarean section (one death per 90 failed intubations). Maternal deaths occurred from aspiration or hypoxaemia secondary to airway obstruction or oesophageal intubation. There were 3.4 (95% CI 0.7 to 9.9) front-of-neck airway access procedures (surgical airway) per 100000 general anaesthetics for caesarean section (one procedure per 60 failed intubations), usually carried out as a late rescue attempt with poor maternal outcomes. Before the late 1990s, most cases were awakened after failed intubation; since the late 1990s, general anaesthesia has been continued in the majority of cases. When general anaesthesia was continued, a laryngeal mask was usually used but with a trend towards use of a second-generation supraglottic airway device. A prospective study of obstetric general anaesthesia found that transient maternal hypoxaemia occurred in over two-thirds of cases of failed intubation, usually without sequelae. Pulmonary aspiration occurred in 8% but the rate of maternal intensive care unit admission after failed intubation was the same as that after uneventful general anaesthesia. Poor neonatal outcomes were often associated with preoperative fetal compromise, although failed intubation and lowest maternal oxygen saturation were independent predictors of neonatal intensive care unit admission.

Concepts: Childbirth, Intensive care medicine, Obstetrics, Anesthesia, Endotracheal tube, Intubation, Caesarean section, Pulmonary aspiration