Author: Neelam Maurya

Do cesarean section [Ref- Dutta 7/e p. 227-232, COGDT 10/e p. 32-25; Williams Ohs 23/e p. 729]

• This is case of preeclampsia at 37 weeks.
• For management purpose preeclampsia is divided into two categories i.e., mild preeclampsia and severe preeclampsia.
• Severe and mild preeclampsia are managed differently.
• But this categorization does not matter in this case because of the gestational age of the patient.

– “The gestational age of the patient is 37 weeks and any case of preeclampsia 37 weeks gestational age is delivered immediately irrespective of the severity of the preeclampsia”.

• The main concern here is the mode of delivery

-The patient presents with unfavourable cervix and a history of previous LS.C.S.

– The best mode of delivery in such a patient with mild preeclampsia is performing an L.S.C.S.

Eisenmenger syndrome Eisenmenger’s syndrome

• Maternal mortality rate in Eisenmenger’s syndrome is 30-40%

– Because of high maternal mortality rate patient should he counselled to avoid pregnancy and if pregnant consider termination of pregnancy.

– Because of high maternal mortality rate abortion is the t/t of choice.

If any pregnancy continues upto term in Eisenmenger’s syndrome, there is no evidence to support the choice of either vaginal or cesarean delivery.

• Maternal mortality rate with normal delivery is 34% and with cesarean section is 75%.

Mitral regurgitation

• Mitral regurgitation is usually tolerated well during pregnancy. The marked decrease in systemic vascular resistance that occurs during pregnancy alleviates the abnormal physiologic stress imposed by this lesion. Rarely, reactive pulmonary hypertension and severe right heart failure may ensue.
• There are no specific recommendations for the management of mitral regurgitation during labour and delivery. Prior to labour, symptoms may be managed with diuretics and vasodilators. During labour, regional anaesthesia is usually well tolerated. However, in complicated NYHA class 3-4 cases, cesarean section and general anaesthesia may be required.

Aortic stenosis

• In general the symptoms of aortic stenosis are masked by progressive left ventricular hypertrophy and are thus easily missed. Overall, patients who were asymptomatic prior to pregnancy usually tolerate pregnancy relatively uneventfully.
• Echocardiographic determination of valve area is the best guide to severity of aortic stenosis. The hyperdynamic circulation of pregnancy frequently leads to overestimation of the degree of stenosis.
• These patients tolerate tachycardia, hypovolaemia and systemic vasodilatation poorly, since coronary perfusion is critically dependent upon maintaining aortic diastolic pressure. General anaesthesia and caesarean section, with the aid of invasive haemodynamic monitoring, appears to be the safest means of successful delivery.

Aggressive maintenance of systemic blood pressure with vasopressors (e.g. phenylephrine), is paramount to the avoidance of severe hypotension, acute left ventricular failure and cardiac arrest.

• Spinal anaesthesia is generally contraindicated in these patients. There are reports of the successful management of vaginal delivery under carefully introduced and limited epidural analgesia, but this should be restricted to very experienced hands.

Aortic regurgitation

• Aortic regurgitation also reduces both cardiac output and coronary blood flow. Like M.R. it is well tolerated in pregnancy. The preferred mode of delivery in A.R. vaginal delivery unless obstetrical indications for cesarean exist. The crux is

i) Both Aortic regurgitation and mitral regurgitation are well tolerated during pregnancy. Vaginal delivery is the preferred mode of termination of pregnancy unless there are obstetrical indications for cesarean section.

ii) Aortic stenosis carries more risk than the above two disorders and the preferred mode of delivery is cesarean section.

iii)  Eisenmenger syndrome carries great risk in pregnancy. The maternal mortality reaches 50%. So, ideally pregnancy should be terminated in patients with Eisenmenger syndrome.

We are not sure, if we have got the correct question.

Pain due to prolonged labour may lead to hyperventilation and resultant respiratory alkalosis.

This will cause a decrease in the level of free ionized calcium in the ECF,

resulting in hypocalcemia and precipitating carpopedal spasm.

Ref: Primer on The Metabolic Bone Diseases and Disorders of Mineral Metabolism Edited By Clifford J. Rosen, 7th Edition, Page 354 ; Nutrition Therapy and Pathophysiology By Marcia Nahikian Nelms, 2007, Page 196 ; Essentials of Medical Pharmacology By KD Tripathi, 5th Edition, Page 479

Caudal anaesthesia may be used for perenial operations.

It is not indicated in Lower segment caesarian section.

 Further it is associated with potential risk of penetrating the fetal head in obstetric practice.

Ref:Textbook of Anaesthesia By Aitkinhead, 4th Edition, Pages 568, 641, 643

Non reassuring FHR is a Relative indication for C-section.

Prior classical or T-shaped uterine incisions are considered contraindications to labor.

The highest risks of uterine rupture are present with prior vertical incisions extending into the fundus such as the classical incision.

Women with a transverse scar confined to the lower uterine segment have the lowest risk of symptomatic scar separation during a subsequent pregnancy. 

• One previous prior low-transverse cesarean delivery
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery
• Availability of anesthesia and personnel for emergency cesarean delivery

• Severe degree placenta previa (type-II (marginal), type-III (incomplete or partial central), type-4 (central or total).
•  Lesser degree of placenta previa where amniotomy fails to stop bleeding or fetal distress appears.
• Complicating factors associated with lesser degrees of placenta previa where vaginal delivery is unsafe.

Vaginal delivery usually is reserved for patients with a marginal implantation and a cephalic presentation. If vaginal delivery is elected, the membranes should be artificially ruptured prior to any attempt to stimulate labor (oxytocin given before amniotomy is likely will cause further bleeding).

Cephalopelvic disproportion is an absolute indication for Caesarean section. Other absolute indications includes central placenta praevia, pelvic mass causing obstruction (cervical or broad ligament fibroid), advanced cervical carcinoma and vaginal obstruction (as in atresia, stenosis).

• Previous caesarean delivery
• Non reassuring FHR
• Dystocia due to relatively large fetus, small pelvis or inefficient contractions
• Antepartum hemorrhage
• Malpresentation
• Failed surgical induction of labour, failure to progress in labour
• Bad obstetric history
• Hypertensive disorders
• Medical gynecological disorders

Indications of C section after a previous caesarean section includes: contracted pelvis, previous two casesarean sections, features of scar dehiscence and previous classical caesarean section.

Upper uterine segment

Caesarean section

Coarctation of aorta

Ans. is ‘c^‘ i.e., Interlobar fissure effusion

Ans. is ‘a’ i.e., Transient tachypnea of newborn

o Respiratory distress, which resolves within 24 hours without any respiratory support and fluid in interlobar fissure on chest X-ray suggest the diagnosis of TTN.

B i.e. Atracurium

You might be thinking that this Q has never been asked, but think a while and try to understand that around which concept the Q is based. In other words, they are trying to ask that which muscle relaxant will not require reversal? I think now you need no explanation 

– In pancuronium reversal is often required d/ t its longer duration of action

– Ve/Ro-curonium seldom require reversal unless repeated doses have been given

– In atracurium & cis-atracurium reversal is mostly not required due to its unique feature of spontaneous non eyzmatic degradation (Hoffmann elimination) Q.

C i.e. General anesthesia

In coarctation of aorta any decrease in cardiac output or cardiac return is deleterious to the fetus because the placental circulation is already comprised on account of coarctation. So any anesthetic procedure/drug which causes hypotension should be avoided.

Regional anaesthic procedure such as spinal anesthesia and epidural anesthesia should be avoidedQ in these patients because hypotension is the most common side effect of these procedure.

General anesthesia is technique of choiceQ for performing cesarian section in a patient with coarctation of aorta, as it has advantage of – rapid induction, better airway & ventilation and less hypotension.

Ans. B: Isoflurane should not be used as it causes placental insufficiency

General anaesthesia for CS:

It is given for fetal distress/if there is contraindication for spinal anaesthesia.

• Prophylaxis against aspiration should be taken.
• Intubation with Sellick’s manoeuvre (cricoid pressure)
• Give drugs in minimum doses
• Avoid premedication
• Induction by thiopentone in minimum doses
• All inhalational agent relax the uterus and cause post-partum hemorrhage in dose related manner.
• Isuflurane is the agent of choice as it maintains the cardiac output thus minimally compromising the fetal circulation.

Ans. B i.e. Type IV placenta previa

Caesarean section

Indications of classical caesarean section

• Previous classical cesarean section
• Neglected shoulder with anhydramnios
• Structural abnormality making approach to lower segment difficult
• Constriction ring due to neglected labor
• Fibroids in lower segment
• Anterior placenta accreta and praevia
• Very preterm fetus, where lower segment is poorly formed.

Ans. B: Caesarean Section

An initial assessment to determine the status of the mother and fetus is required.

It is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.

In cases of fetal distress, associated complicating factors like malpresentation, elderly primigravidae, pregnancy with a previous caesarean section and contracted pelvis, a caesarean section is indicated.

Caesarean section is contraindicated in cases of disseminated intravascular coagulation.

Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery

Ans. D: Placenta accreta

Most important risk factors for placenta accreta are the placenta praevia and prior caesarean delivery It complicates 3^rd stage of labour (haemorrhage, shock, infection and rarely inversion of the uterus) Other types of placenta:

• Biscoidal placenta: Placenta have 2 discs
• Lobed placenta: Placenta divided into lobes
• Placenta succenturita: Small part of placenta separated from the rest
• Febestrated: Placenta having a hole in centre
• Circumvallate: Edge of placenta is covered by circular fold of decidualis

Ans: A i.e. 1%

Incidence of scar rupture in lower segment CS is less (0.5-1.5%) whereas there is more risk of scar rupture in classical CS (4-9%).

Ans. C: 4-8%

Classical caesarean section carries more risk of scar rupture (4-8%) Scar rupture in lower segment CS is less (0.5-1.5%)