key: cord-0077684-1e0iflm9
authors: Ito, Y.; Machineni, V.
title: P.186 Anaesthetic management of a woman with renal transplant rejection for category 3 caesarean section
date: 2022-05-03
journal: Int J Obstet Anesth
DOI: 10.1016/j.ijoa.2022.103482
sha: dfdd31523672309b080317c87f1f3a2e58b5be40
doc_id: 77684
cord_uid: 1e0iflm9

nan

tachycardic but oxygen saturations were 100% on air. There were no recent blood results available. A successful single-shot spinal anaesthetic was performed and her baby was delivered in good condition and the operation was uncomplicated. She was discharged home day 2 post CS, but deteriorated day 10 of her COVID-19 illness with worsening hypoxia secondary to COVID-19 pneumonitis. She was admitted to ICU for invasive ventilation and proning. Unfortunately she was not deemed a candidate for extracorporeal membrane oxygenation (ECMO), and after a superimposed bacterial infection, deteriorated precipitously and passed away after three weeks in ICU. Discussion: We carried out regional anaesthesia in this patient after risk-benefit analysis. Despite the potential risks of thrombocytopenia and disseminated intravascular coagulopathy with COVID-19, we felt the benefits of spinal anaesthesia in a patient with malignant hyperthermia, fetal compromise and potential postoperative respiratory decompensation outweighed these risks [1] . Prior handover from the high-risk clinic enabled preparation for total intravenous anaesthesia at short notice. She tolerated the spinal anaesthetic well and was able to spend time with her baby immediately after. This case is important as the management of patients for operative delivery with COVID-19 is becoming more important with increasing prevalence and low number of pregnant patients vaccinated. Introduction: Thrombocytopenia occurs in one-third of patients with COVID-19 infection compared with 7-12% of non-COVID pregnant patients [1] . We describe the anaesthetic management of a patient with COVID-19 undergoing an elective caesarean section presented with moderate thrombocytopenia. Case Report: A 28-year-old nulliparous woman at 39 + 4 weeks of gestation was listed for an elective caesarean section due to breech presentation. Her past medical history included mild anxiety. At 28 weeks the platelet count was 111 × 10 9 /L and 72 × 10 9 /L at term. Preeclampsia had been excluded. Asymptomatic COVID-19 infection was incidentally discovered a week before delivery. The agreed anaesthetic plan was to request platelets to be available as they take 75 minutes to procure. Spinal anaesthetic was planned as per the current COVID-19 guidelines. There were concerns regarding the risk of epidural haematoma due to thrombocytopenia. A pool of platelets was given preoperatively as per the recommendation of the haematologist. The post-transfusion platelet count was 86 × 10 9 /L. Spinal anaesthetic was performed with a 25G Sprotte needle. Hyperbaric bupivacaine 12.5 mg with diamorphine 300 μg was used. It was an uneventful caesarean section with an estimated blood loss of 500 mL. The woman's platelet count 6 hours postoperatively was 87 × 10 9 /L and increased to 96 × 10 9 /L after 2 days. Discussion: Thrombocytopenia during pregnancy affects 5-10% of patients [2] . Aetiologies include gestational/immune thrombocytopenia, preeclampsia, and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. Mild thrombocytopenia was recorded in a third of non-pregnant patients with COVID-19. Thrombocytopenia is frequently associated with moderate to severe coronavirus disease. Many observations show that moderate to severe thrombocytopenia can exist in asymptomatic COVID-19. Thrombocytopenia was found in 2 of 14 cases (14%) of COVID-19 patients undergoing neuraxial procedures with the lowest reported platelet count of 81 × 10 9 /L [1] . A platelet count of 70 × 10 9 /L carries a low risk for neuraxial anaesthesia, especially for those at high risk for general anaesthesia [1] . We opted for transfusion of one platelet pool preoperatively considering the borderline platelet count and the progressive course of thrombocytopenia. Appropriate monitoring of the platelet count is essential to enable safe discharge. Good communication between clinical teams and haematologist ensured a positive outcome for our patient and her baby. Case Report: Marsh and Minto target-controlled infusion models were used for propofol and remifentanil, respectively. Processed electroencephalogram ( pEEG) monitoring (Bispectral index(BIS)) was used in all. Effect-site concentration (Ce) of propofol remained between 4 and 8 μg/mL, whilst Ce of remifentanil was between 2 and 7 ηg/mL. BIS values were 30-56 throughout, and were 34-41 at surgical incision. Time interval between anaesthetic induction and delivery ranged between four and 14 minutes. All received a 5U bolus of Syntocinon followed by a 40 U infusion. Case three required a second-line uterotonic (ergometrine). All remained haemodynamically stable. Postoperative nausea occurred in case two only. One baby (case two) required ventilatory support. Discussion: General anaesthesia (GA) is used in a minority of CDs in the UK. In our case series, all had a coagulopathy precluding them from having regional anaesthesia. Traditionally, an obstetric GA is a rapid sequence induction and maintenance with an inhalational agent. The anaesthetist chose to perform TIVA in each case for the intended benefit of avoiding effects of inhalational agents on uterine tone [1] . No case bled to excess despite a coagulopathy. TIVA has been shown to have a superior profile on postoperative recovery indicators in nonpregnant patients -less nausea and vomiting, smooth emergence and physical comfort [2] . pEEG use and uninterrupted anaesthetic delivery may reduce the incidence of accidental awareness. No detrimental neonatal effects were seen. One required ventilatory support attributed to prematurity.

P.188 Anaesthetic management of a parturient with DAO enzyme deficiency, postural orthostatic tachycardia syndrome and joint hypermobility L. Borg Xuereb, S. Halder

Introduction: Diamine Oxidase is the main enzyme in histamine metabolism, and its deficiency occurs in 1% of the population, causing histamine intolerance. Pharmacological agents can trigger acute syndromes [1] . Postural orthostatic tachycardia syndrome (POTS) is characterized by chronic orthostatic intolerance and compensatory tachycardia [2] . In Joint hypermobility syndromes, local anaesthetic resistance is common. We describe the anaesthetic management in a parturient suffering from a combination of the three disorders in labour.

Case Report: A 34 year old G1P0 parturient presented at 39 + 4 weeks gestation for induction of labour. Her past medical history included DAO enzyme deficiency, POTS and joint hypermobility syndrome. Epidural analgesia was instigated early to attenuate the stress response of labour. This was initiated after an adequate fluid preload to minimize hypotension and tachycardia. Epidural insertion was uneventful. The epidural loading was carried out gradually, a total of 20 mL of bupivacaine 0.1% with fentanyl 2 μg/mL was administered. Patient-controlled epidural analgesia was then initiated as per hospital protocol. Further boluses of 10 mL 0.125% bupivacaine were required every two hours to maintain patient comfort. Haemodynamics were closely monitored. A decision was taken for instrumental delivery due to slow progress in the second stage. The epidural provided effective analgesia during labour and delivery. The patient had no evidence of haemodynamic compromise during her inpatient stay, recovery was uneventful and she was discharged home on day one postpartum. Discussion: Histamine intolerance is characterised by hypotension, arrhythmias, airway obstruction and facial flushing. Alterations in histamine metabolism is commonly dietary but can also be secondary to pharmacological agents(1). These include thiopental, atracurium, suxamethonium and non-steroidal analgesic agents. In POTS, inadequate vasoconstriction and a compensatory tachycardia occurs, which can be more profound in labour due to pain and exacerbated especially in response to neuraxial technique(2) In joint hypermobility syndrome, partial or complete failure to local anaesthetic drugs is a known phenomenon. To our knowledge, this is the first report of successful provision of epidural anaesthesia in a patient with all three syndromes. There is a delicate balance between the risk of cardiovascular instability with DAO deficiency and POTS and the resistance to local anaesthetic drugs in hypermobility syndromes. 

Neuraxial procedures in COVID-19 positive parturient: a review of current reports

Thrombocytopenia in pregnancy

Risk factors for obstetric morbidity in patients with uterine atony undergoing Caesarean delivery

Type of anaesthesia and patient quality of recovery: A randomized trial comparing propofolremifentanil total i.v. anaesthesia with desflurane anaesthesia