|KOPS AWARD ABSTRACTS: OBSTETRIC ANAESTHESIA
|Year : 2020 | Volume
| Issue : 13 | Page : 15-21
KOPS Award Abstracts: Obstetric Anaesthesia
|Date of Web Publication||6-Feb-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. KOPS Award Abstracts: Obstetric Anaesthesia. Indian J Anaesth 2020;64, Suppl S1:15-21
| Abstract ID: ISAP125: Effects of labetalol alone versus labetalol with magnesium sulphate on intraoperative haemodynamics in preeclamptic patients following spinal anaesthesia: A cohort analysis.|| |
Manjusree Guha, Santanu Ghosh
North Bengal Medical College And Hospital
Background and aims: The hypotensive potential of spinal anaesthesia is less in severe pre-eclampsia compared to normal healthy parturients. There is substantial lack of literature on the effects of adding labetalol and magnesium sulphate to these patients on their haemodyanamic changes following spinal anaesthesia. This study was aimed to compare the changes in the haemodyanamics of the patients who received only labetalol versus when given magnesium sulphate with labetalol.
Methods: A prospective cohort analytical study was conducted in North Bengal Medical College And Hospital. Assuming p value<0.05 to be significant, we got n=30. Ninety parturients [30 normal (1), 30 who received only labetalol (2) and 30 received labetolol and magnesium sulphate (3)] of ASA grade 1, 2 and 3 were accepted in this study with written consent. Spinal anaesthesia induced with 10 mg 0.5% hyperbaric bupivacaine with 25 μg fentanyl. Intraoperative and postoperative haemodynamic variables, onset of sensorial and motor block,offset of motor block, Bromage scores, consumptions of intraoperative analgesic and phenylephrine were measured and recorded. The intervention was decided on the discretion of the obstetrician.
Results: The total doses of IV phenylephrine for treating hypotension was lower in patients receiving only labetalol (141±51 mcg) compared to other two groups (magnesium sulphate and labetalol group=208±100 mcg, healthy parturient= 403±126 mcg). The onset of motor block was longer in group magnesium sulphate and labetalol than other 2 groups(p<0.05).
Conclusion: It is thus concluded that adding magnesium sulphate to labetalol induces some haemodyanamic derrangements compared to labetalol alone but less remarkable than healthy parturients.
- Dyer RA, Piercy JL, Reed AR, Lombard CJ, Schoeman LK, James MF. Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2008 May 1;108(5):802-11.
- Atcı M, Unlugenç H, Guneş Y, Burgut R, Isık G, Hatipoglu Z, Turktan M. The Effect of Intravenous Magnesium Sulphate Treatment on the Spinal Anaesthesia Produced by Bupivacaine in Pre-eclamptic Patients. Turkish journal of anaesthesiology and reanimation. 2015 Feb;43(1):13.
| Abstract ID: ISAP154: Efficacy of different infusion rates of oxytocin for maintaining uterine tone during non-elective caesarean section in labouring patients – a randomized, double - blind controlled trial|| |
Sheeba Siddiqui, Medha Mohta, Geetanjali Chilkoti
University of College of Medical Sciences and GTB Hospital
Background and aims: Low-dose oxytocin is effective and safe in initiating adequate uterine contractions. However, it should be followed by an infusion for maintenance of adequate uterine tone. There is no randomized trial in current literature to establish an optimal oxytocin infusion rate for maintenance of adequate uterine tone during caesarean section in labouring patients.
Methods: Following institutional ethics committee approval and written informed consent, 105 labouring healthy term parturients undergoing non-elective caesarean section under spinal anaesthesia, were randomly divided into three groups using computer-generated random number table. Following administration of oxytocin 3 IU over one minute at the time of umbilical cord clamping, infusion was started @ 2.5 IU/hr (Group 2.5), 5 IU/hr (Group 5) or 10 IU/hr (Group 10) for 4 hours. Primary outcome measure was intraoperative estimated blood loss (EBL). Uterine tone was assessed at regular intervals and additional uterotonics administered, if required. Occurrence of any oxytocin related side-effects were noted.
Results: Patients in group 10 had minimum EBL (p<0.001) and lowest requirement for additional uterotonics (p<0.001). However, incidence of hypotension and nausea/vomiting was higher than other groups. Group 2.5 showed maximum EBL and highest requirement of rescue uterotonics. Results in group 5 were intermediate.
Conclusion: Oxytocin infusion @ 5 IU/hr is recommended for maintenance of adequate uterine tone after initial 3 IU slow bolus in labouring patients undergoing non-elective caesarean section under spinal anaesthesia as it results in intermediate EBL and uterotonic requirements with lower incidence of hypotension and other oxytocin related side-effects than 10 IU/hr.
- Balki M, Ronayne M, Davies S, Fallah S, Kingdom J, Windrim R, Carvalho JC. Minimum oxytocin dose requirement after cesarean delivery for labor arrest. Obstet Gynecol 2006;107:45–50.
- Lavoie A, McCarthy RJ, Wong CA.The ED90 of prophylactic oxytocin infusion after delivery of the placenta during cesarean delivery in laboring compared with nonlaboring women: an up-down sequential allocation dose-response study. Anesth Analg 2015;121:159-64.
| Abstract ID: ISAP250: Effect of intraabdominal pressure on maximum sensory block level following intrathecal hyperbaric or plain local anesthetic for caesarean sectionn: A PRELIMINARY RANDOMIZED CONTROLLED TRIAL|| |
Jubin Jakhar, Asha Tyagi, A K Sethi
UCMS & GTB HOSPITAL, New Delhi
Background & Aims: Increase in Intra Abdominal Pressure (IAP) may cause intrathecal dose sparing effect and consequently higher sensory level in pregnancy. There is very little actual data evaluating the relationship. Relationship is likely to depend on time of measurement of IAP viz., before or after a spinal block; and baricity of intrathecal drug. Thus we aimed to evaluate association between IAP and maximum sensory block level following intrathecal injection of hyperbaric versus plain (isobaric) local anesthetic.
Methods: It was randomized controlled blinded trial. Pregnant women aged 18-40 years, scheduled for elective cesarean section under single shot subarachnoid block were included. After randomisation they received either intrathecal hyperbaric bupivacaine (group H) or plain (isobaric) levobupivacaine (group P) (n = 40 each). IAP was measured prior to the spinal (IAPprespinal) and after it (IAPpostspinal), using recommended intravesical technique via indwelling Foley. Maximum sensory block level and the IAPs.
Results: There was no significant correlation of IAPprespinal with maximum level of sensory block for group H (P = 0.334; rs = -0.157); or group P (P = 0.637; rs = -0.078). Similarly, there was no significant correlation of the IAPpostspinal either: group H (P = 0.370; rs = -0.145); and group P (P = 0.714; rs = -0.061). Both group H and group P had similar IAPprespinal (15.9 [14.3-18.2] and 15.3 [14.3-17.4] mmHg respectively) (P = 0.474); as well as IAPpostspinal (15.2 [13.8-17.2] and 14.6 [13.4-16.0] mmHg respectively) (P = 0.239).
Conclusion: Despite IAP being increased in pregnant patients scheduled for cesarean section, it does not relate to a greater intrathecal drug spread.
| Abstract ID: ISAP286: Relationship between preoperative maternal abdominal circumference measurement and the level of sensory block in spinal anaesthesia in cesarean section: A prospective observational study.|| |
Vyshnavi N Rao, Ramachandraiah R
Bangalore Medical College and Research Institute, Bangalore.
Background and aims: Inferior venacaval compression during pregnancy causes extradural venous engorgement which may reduce the lumbar cerebrospinal fluid volume. A subsequent greater cephalad spread of sensory block is observed. We hypothesized that maternal abdominal circumference measurement can reflect the compressive effect of uterus and investigated the relationship between maternal abdominal circumference and the level of sensory block, the maximum level of sensory block, incidence of hypotension, nausea and vomiting, requirement of ephedrine in term parturients undergoing cesarean section under spinal anasethesia.
Methods: Abdominal circumference of 40 term parturients undergoing cesarean section were measured before performing subarachnoid block. 0.5% hyperbaric bupivacaine (2ml, 2.2ml ,2.4ml) was injected into L3-L4 subarachnoid space according to parturients height. The level of sensory block was assessed at 1minute, 5minutes, 10minutes, 15minutes and 20minutes after subarachnoid block. The statistical tests applied were One way anova, product moment correlation and independent sample T Test.
Results: The correlation coefficient between abdominal circumference and the level of sensory block was significantly positive at 1minute, 5minutes, 10minutes,15minutes and 20minutes after spinal anaesthesia(p<0.05). There was a positive correlation between abdominal circumference and highest level of sensory block. No significant correlation was found between abdominal circumference and incidence of hypotension, requirement of ephedrine, nausea and vomiting after spinal anaesthesia(p>0.05). There was a significant positive correlation between BMI and the level of sensory block (p<0.05).
|Figure 1: RELATIONSHIP BETWEEN ABDOMINAL CIRCUMFERENCE AND THE LEVEL OF SENSORY BLOCK AT VARIOUS TIME INTERVALS|
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Conclusion: Parturients with greater abdominal circumference value have a higher level of sensory blockade after spinal anaesthesia. Abdominal circumference cannot predict the incidence of hypotension, nausea , vomiting and the dose of ephedrine required.
- Kuok CH, Huang CH, Tsai PS, Lee WS, Hsu YW, etal. Perioperative measurement of maternal abdominal circumference relates to initial sensory block level of spinal anaesthesia for cesarean section: An observational study. Taiwanese J of Obsterics and Gynecology 2016;810-14.
- Zhou QH, Xiao W P, Shen Y Y. Abdominal girth, vertebral column length and spread of spinal anaesthesia in 30 minutes after plain bupivacaine 5 mg/ml. AnesthAnalg 2014;119:203-6.
| Abstract ID: ISAP340: A study to evaluate perfusion index as a predictor of hypotension following spinal anaesthesia for caesarean section|| |
Shweta Bhardwaj, Jatin Lal, Teena Bansal, Pardeep Kumar
PT BD Sharma PGIMS, Rohtak
Background and aims: Perfusion index (PI) is a marker of peripheral perfusion and is a non-invasive and continuos method for predicting the degree of hypotension during spinal anaesthesia (SA) for lower segment caesarean section (LSCS). This study was conducted to evaluate the efficacy of PI as a predictor of hypotension after spinal anesthesia in caesarean sections and to find out the correlation between baseline PI and incidence of hypotension.
Methods: In this prospective observational study, 60 parturients undergoing elective LSCS under SA, were divided into two groups based on their baseline PI. Group I included patients with baseline PI≤3.5 (n=30) and group II included patients with baseline PI >3.5 (n=30). SA was given with 10mg of 0.5% hyperbaric bupivacaine in sitting position at L3-L4 interspace. Hypotension was defined as decrease in systolic blood pressure by more than 20% or less than 80mmHg. Haemodynamic variables including PI were measured at regular intervals. Statistical analysis was performed using chi square test, student t-test, Mann-whitney test. Spearman's rank correlation coefficient was done for correlation between PI and hypotension. ROC curve was also used between PI and incidence of hypotension.
Results: The incidence of hypotension in group I was found to be 40% as compared to 73.3% in group II. There was a positive correlation between the episodes of hypotension and baseline PI (r= -0.236 p=0.210). The ROC curve yielded baseline PI 3.79 as an appropriate cut-off with a sensitivity and specificity of 73.3% and 76.6% respectively.
Conclusion: Baseline PI >3.5 can be used to identify parturients with high risk of hypotension following SA in LSCS.
| Abstract ID: ISAP387: Assesment of vertebral level of tuffier's line using ultrasonography- comparison between full term pregnant women and non-pregnant women|| |
Akhil M R, Kavita Lalchandani, M R Upadhyay
Government medical college & SSG Hospital, Vadodara.
Background and aims: Tuffier's line also known as intercristal line is an imaginary transverse line connecting the tips of iliac crests. Generally it intersects the spine at L4-L5 intervertebral space. Full term pregnant women undergo various physical changes, therefore Tuffier's line may shift one or two segments higher. Our aim of the study was to compare the exact vertebral level of Tuffier's line in full term pregnant women with non pregnant women using ultrasonography.
Methods: Total 120 females including 60 full term pregnant women posted for elective LSCS and 60 non pregnant women were taken for study. In pre-operative area sitting position was given and then intercristal line was drawn horizontally. After that ultrasonography of spine was done by curvilinear probe and spaces were marked from L5-S1 to L2-L3 vertebral level. The vertebral level corresponding to intercristal line was considered as the exact vertebral level of Tuffier's line.
Results: In full term pregnant women 35 % have Tuffier's line corresponding to L4-L5 level, 58.33 % have L3-L4 level and 6.66% have at L2-L3 level, while in non pregnant women 85 % have Tuffier's line corresponding to L4-L5 and 15 % have at L3-L4 level.
Conclusion: Study results shows that the Tuffier's line tends to shift one or more segments cephalad compared to non-pregnant women, it's mainly due to various physiological and anatomical changes during pregnancy.
- Kim SH, Kim DY, Han JI, Baik HJ, Park HS, Lee GY et al. Vertebral level of Tuffier's line measured by ultrasonography in parturients in the lateral decubitus position. Korean J Anesthesiol. 2014 Sep;67(3):181-5.
- Dhanger S, Vinayagam S, Vaidhyanathan B, Rajesh IJ, Tripathy DK. Comparison of landmark versus pre-procedural ultrasonography-assisted midline approach for identification of subarachnoid space in elective caesarean section: A randomised controlled trial. Indian J Anaesth. 2018;62(4):280–284.
| Abstract ID: ISAP454: Comparision of preoperative gastric volume using ultrasonogram between women with term gestational diabetes and normal term pregnant women undergoing elective cesarian section|| |
Madhura M, Shobha D
Bangalore Medical College and Research Institute, Bangalore
Background and aims : In recent years the usage of bedside ultrasonogram in estimating gastric volume perioperatively has emerged as a potential point of care in determining aspiration risk. This study aims to describe the qualitative and quantitative ultrasound assessment, comparison of gastric volume prior to anaesthetic procedure and evaluate the risk of pulmonary aspiration in the term pregnant women with and without gestational diabetes mellitus (gdm). Aim was to evaluate and compare the pre operative gastric volume in term parturients with and without gestational diabetes mellitus, in order to assess the risk of aspiration prior to the anaesthetic procedure using ultrasonogram
Methods: Group A term pregnant women & group B term pregnant women with GDMwere examined after a minimum period of overnight fasting before their scheduled caesarean delivery, a standardized ultrasound examination of the gastric antrum was performed. Based on the qualiltative assessment in supine and right lateral decubitus position, women were classified using a 3 point grading system (grade 0, grade 1 and grade 2). A quantitative assessment of antral cross sectional area was performed using still images in right lateral decubitus position and in supine position.
Results: There was no significant difference between group A and group B in cross sectional area of the antrum in right lateral decubitus position ( 8.77±0.33 vs 8.94± 0.40, p= 0.088) and in supine position (8.40±0.29 vs 8.55±0.45,p= 0.119). gastric volume(121.45± 7.05 vs 122.52 ± 7.63 p=0.585).
Conclusion: Preoperative gastric volume assessment using ultrasonogram in women with term gestational diabetes and women with normal term pregnancy showed no significant difference.
- Arzola, C., Perlas, A., Siddiqui, N. and Carvalho, J. (2016). Bedside gastric ultrasonography in Term Pregnant Women Before Elective Cesarian Delivery. Obstetric Anaesthesia Digest, 36(3), pp.146-147.
- Hong, J. (2006). Comparison of Preoperative Gastric Contents between Gestational Diabetic and Normal Pregnant Women Undergoing Elective Cesarean Delivery. Korean Journal of Anesthesiology, 50(6), p.S25.
| Abstract ID: ISAP469: Prediction of post spinal hypotension in cesaerean section by using femoral vessel doppler studies|| |
Lakshmi.K.Nair, J.Edward Johnson.
Kanyakumari Government Medical College
Background and aims: Hypotension is a common complication after spinal anaesthesia. Predicting intraoperative hypotension can be useful in determining high risk patients and initiate methods to prevent it. We hypothesized that measuring a change in femoral vessel area following positional variation from supine to left lateral position can be used to predict post spinal hypotension in caesarean section.
Methods: After institutional ethical board approval and written informed consent, 35 term parturient belonging to ASA class II were observed for NIBP, pulse rate and pulse wave Doppler (peak systolic velocity, end diastolic velocity, pulsatility index, resistance index, femoral artery area, femoral vein velocity and area) in supine and left lateral position with a time interval of three minutes each before caesarean section. The difference between the femoral vessel Doppler parameter in supine and left lateral was noted and correlated to patients with intraoperative hypotension. Hypotension was monitored every minute from the time of subarachnoid block till the delivery of the baby.
Results: Demographic and baseline hemodynamic parameters were comparable. Change in femoral artery area >0.04 cm2 seems to be the best predictor of post spinal hypotension in parturient posted for caesarean section with a sensitivity of 80% and specificity of 95%. The incidence of supine hypotension was found to be 11.4% .
|Table 2: Correlation of change in femoral vessel doppler parameters with intraoperative hypotension|
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Conclusion: A change in femoral vessel doppler characteristics from supine to left lateral position can be used to predict intraoperative hypotension in term parturient undergoing caesarean section.
- Kundra, P., Velraj, J., Amirthalingam, U., Habeebullah, S., Yuvaraj, K., Elangovan, S. and Venkatesan, V. (2012). Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients. Anaesthesia 2012; 67(8):889-893.
- Moore, A & Koeva, V & Shan, Pi & Elbahrawy, Aly & Hatzakorzian, Roupen & Schricker, & Corriveau, M. Positional and Spinal Anesthesia Induced Changes in Femoral Vein Blood Flow in Term Parturients Undergoing Cesarean Section. Middle East journal of anaesthesiology. 2017; 24: 49-55.
| Abstract ID: ISAP527: Comparative study of effect of different vasopressors for treatment of post spinal hypotension in caesarean deliveries on fetal acid base balance.|| |
Surbhi Saini, Ranju Singh, Sushma Nangia, Ratna Biswas
Background and aims: Spinal anaesthesia (SA) is technique of choice for caesarean deliveries (CD). However, post-spinal hypotension is common problem. There is wide consensus that phenylephrine (PE) is drug of choice to treat post-spinal hypotension. Recently low dose norepinephrine (NE) has been proposed as an effective alternative with advantage of less depression of maternal heart rate, cardiac output and good neonatal outcome. The objective of our study is to identify most appropriate and safe drug for treatment of post-spinal hypotension.
Methods: This was prospective observational study including women scheduled for CD under SA and divided into group PE (100 μg) or group NE (8 μg) when systolic blood pressure was below 20% of baseline. Primary objective was to study the difference in umbilical artery pH with use of PE & NE. The secondary objectives were to compare maternal haemodynamics, number of boluses required and neonatal outcome.
Results: Total 593 patients enrolled, out of which 226 patients (38%) who developed post-spinal hypotension were analysed, 106 patients received PE and 120 patients received NE. Umbilical artery pH was similar in both groups but in CD for fetal distress, umbilical artery pH was acidotic in both groups with a greater dip with PE than NE. Incidence of bradycardia was significantly higher in group PE and number of boluses was greater in group NE. No difference observed in number of episodes of hypotension and neonatal outcome.
Conclusions: When used to treat post-spinal hypotension, fetal pH was effectively maintained within normal range with both NE and PE but in CD for fetal distress, fetal pH was acidotic in both groups but better maintained with NE than PE. Norepinephrine is as effective as PE with significantly lower incidence of bradycardia and have similar neonatal outcome.
|Table 4: Umbilical artery acid-base balance in the fetal distress subgroup|
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- Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009 Sep;111(3):506-12. doi: 10.1097/ALN.0b013e3181b160a3.
- Reynolds, F. and Seed, P.T. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis*. Anaesthesia. 2005; 60: 636-653. doi:10.1111/j.1365-2044.2005.04223.x
| Abstract ID: ISAP755: Effect of addition of neostigmine to ropivacaine –fentanyl combination on dose requirements of ropivacaine and duration of labour during epidural labour analgesia|| |
Archana Dande, Bala Subramanya.H, S Bala Bhaskar, Devanand.B
Vijayanagar Institute of Medical Sciences(VIMS), Ballari
Background and aims: Labour may be the most painful experience many women ever encounter. Different methods are chosen to relieve pain. Central neuraxial analgesia is the most versatile and the gold standard technique for labour analgesia. This study is taken up to determine the effect of adding epidural Neostigmine to Ropivacaine-Fentanyl combination on dose requirements of Ropivacaine 0.1% and duration of labour in laboring patients receiving lumbar epidural analgesia.
Methods: After ethical committee approval and trial registration (REF/2017/12/016574), a prospective, randomized, double blinded study was conducted in 50 primiparous patients in active phase of labour over period of 1 year. Patients were randomized into 2 groups. Group A- received 0.1%Ropivacaine with Fentanyl 2μg/ml (10 ml), Group B- received 0.1%Ropivacaine with Fentanyl 2μg/ml and Neostigmine500μg (10 ml).Analgesia maintained by top up of 5 ml 0.1%Ropivacaine and Fentanyl 2μg/ml with NRS≥4.The primary objective was to compare the total dose requirement of Ropivacaine per hour in both groups, and secondary objectives were duration of labour, labour outcomes, fetal outcomes, maternal hemodynamic changes, and maternal satisfaction. Data analysed using SPSS software version 20.0. A p value of <0.05 considered statistically significant.
Results: Mean total dose requirement of ropivacaine per hour in group A 6.52 mg and in group B 5.68 mg, was statistically significant (p value<0.001). Mean duration of labour in group A 191.2 mins and group B 177.8 mins, was also statistically significant (p value 0.004)
Conclusion:Addition of Neostigmine during epidural labour analgesia reduces the dose requirement of Ropivacaine0.1% and duration of labour.
- Hawkins JL, Harry JGM. Crijns, Maarten P. Van den Berg. Epidural analgesia for labour and delivery. The New England Journal of Medicine 2010;362:1503-10
- AP Cossu, L.M.De.Giudici ,D.Piras, P.Mura, M.Scanu, M Cossu, et al. A systematic review of the effects of adding neostigmine to local anesthetics for neuraxial administration in obstetric anesthesia and analgesia. International Journal of Obstetric Anaesthesia 2015; 24(3):237-246.
[Table 1], [Table 2], [Table 3], [Table 4]