Seminars in perinatology
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Ultrasound has permeated the practice of anesthesiology and is becoming an essential tool for the obstetric anesthesiologist in the labor and delivery suite. The most common applications include guidance for neuraxial (epidural and spinal) anesthesia and acute pain nerve blocks, as well as guidance for central and peripheral vascular access. Obstetric anesthesiologists are becoming increasingly familiar with diagnostic applications, including transthoracic echocardiography (TTE) and lung and gastric ultrasound. There is intense interest in developing standard curricula for achieving competency in ultrasound skills during residency training and expanding the role of ultrasound in education and research.
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Seminars in perinatology · Oct 2014
ReviewAnesthesia implications of coagulation and anticoagulation during pregnancy.
Coagulation is an organized and well-orchestrated process that depends on the intrinsic balance between procoagulants, anticoagulants, and fibrinolytic systems. During pregnancy, this balance is affected in various ways and becomes more critical due to the physiologic changes and obligate hemorrhage after delivery. In some instances, this equilibrium will be disrupted. In this article, we describe the anesthetic implications of bleeding disorders, thrombophilias, and anticoagulation for the safe management of the parturient, with an emphasis on how this impacts decision-making by the anesthesiologist.
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Seminars in perinatology · Oct 2014
ReviewPost-dural puncture headache: the worst common complication in obstetric anesthesia.
Ever since the first spinal anesthetic in the late 19th century, the problem of "spinal headache" or post-dural puncture headache (PDPH) has plagued clinicians, and more importantly, patients. It has long been realized that the headache and other symptoms that often occur after the entry of a needle into the subarachnoid space is somehow related to fluid loss, although the exact pathophysiology of the headache has really never been defined. ⋯ In this article, we will discuss the current state of knowledge in this area, suggesting that the PDPH syndrome is more severe and often more long-lasting, with some potentially life-threatening complications (cerebral hemorrhage) than usually appreciated or admitted. While prevention and treatment options are still limited, with the only clearly effective treatment being the epidural blood patch, recognition of the PDPH syndrome in postpartum women by anesthesiologists and obstetricians, with aggressive follow-up and treatment, may help limit the associated morbidity and mortality.
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The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. ⋯ Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.
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Seminars in perinatology · Oct 2014
ReviewNeurologic disease with pregnancy and considerations for the obstetric anesthesiologist.
Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. ⋯ In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.