International journal of obstetric anesthesia
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Int J Obstet Anesth · May 2022
ReviewThe venous system during pregnancy. Part 1: physiologic considerations on the venous system.
An essential contributor to the hemodynamic responses observed during pregnancy, the venous system is affected by hormones, blood volume, flow rates, and an enlarging uterus. The venous system is a dynamic reservoir for blood volume, within which a virtual point of conversion between unstressed volume (Vu) and stressed volume (Vs) exists. The physiologic importance of the venous system during pregnancy is best understood when the basic concepts, functional characteristics, and alterations in pregnancy are reviewed.
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Int J Obstet Anesth · May 2022
Meta AnalysisThe effect of two groups of intrathecal fentanyl doses on analgesic outcomes and adverse effects in parturients undergoing cesarean delivery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.
Variable doses of intrathecal fentanyl (ITF) have been used for peri-operative analgesia during cesarean delivery (CD). We conducted a systematic review and meta-analysis to compare lower doses (LD; ≤12.5 µg) and higher doses (HD; >12.5 µg) of ITF in parturients undergoing CD. ⋯ In women undergoing CD, doses of ITF >12.5 µg reduced the requirement for intra-operative analgesic supplementation and prolonged the time to first rescue analgesia compared with smaller doses, but increased pruritus. On revising the cut-off to 15 µg, no significant difference was found.
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Int J Obstet Anesth · Feb 2022
Review Case ReportsPostpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports.
Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block. ⋯ The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.
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Int J Obstet Anesth · Nov 2021
ReviewRefractory uterine atony: still a problem after all these years.
Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. ⋯ Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.
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Int J Obstet Anesth · Nov 2021
ReviewTranexamic acid and obstetric hemorrhage: give empirically or selectively?
Antifibrinolytic agents such as tranexamic acid (TXA) inhibit the fibrinolytic pathway and protect blood clots from being degraded, thereby promoting hemostasis. They have been used to reduce blood loss in various settings including obstetrics. Based on current evidence, TXA can be considered as a therapeutic adjunct to control postpartum hemorrhage (PPH) after vaginal and cesarean deliveries, with earlier administration preferred. ⋯ As a proposed prophylactic agent to prevent PPH, the level of evidence is currently insufficient to recommend the routine use of TXA to prevent blood loss after vaginal and cesarean deliveries. The results of large new multicenter studies assessing the impact of TXA on maternal blood loss-related outcomes after cesarean delivery are awaited. While most studies to date have focused on empirical and one-size-fit-all dosing of TXA, more selective and individualized treatment protocols (possibly guided by functional coagulation assays) are needed to pave the way for safer and more effective use of this inexpensive and widely used medication.