2023.1 Day 2 VIVA 3

Its 10am on a weekday morning when you are on-call for anaesthesia. You are called by a midwife on the labour ward to provide an epidural for Sarah.

Sarah’s details are:

• 39-year woman who has recently moved to the area.

• G3 P1 previous emergency caesarean • Has a new partner

• Her current gestation is 39 weeks.

• This is an IVF pregnancy.

• She has a BMI of 38 calculated this week.

• She has just arrived in the labour ward in spontaneous labour.

• Her last BP was 145/110.

Her recent bloods:

	Booking	30 Week	38 Week	Today 39 Week
Hb	110	112	108	95
WCC	11.1	10.2	10.3	15.2
Platlets	330	327	334	101

What are your main concerns?

Main Issues:

• Hypertension (BP 145/110) – risk of pre-eclampsia (PET) and eclampsia.

• BMI of 38 – increased risk of difficult airway, epidural failure, obstructive sleep apnoea (OSA), and obstetric complications.

• Previous emergency caesarean – history of uterine scarring, potential risk for uterine rupture in labour or subsequent caesarean.

• Thrombocytopaenia – monitor for platelet drop as a complication of pre-eclampsia, which affects neuraxial anaesthesia safety.

• IVF pregnancy – increased risk of multiple pregnancy (check for multiple gestation), possible placenta praevia, or placenta accreta.

• Emerging infection (WCC 15)

• Past medical history:

  • Possible kidney issues (due to hypertension and pregnancy) – assess renal function and electrolytes.

How would you proceed with the anaesthetic assessment?

• Review obstetric and medical history:

  • Clarify previous anaesthesia experience, any complications with the prior caesarean, and current symptoms of PET (e.g., headaches, visual disturbances).

• Physical examination:

  • Airway assessment: Look for mallampati score, teeth, jaw mobility for potential difficulty.

  • Spine examination: Check for lumbar spine mobility or any anatomical abnormalities that could complicate epidural placement.

  • Focused CVS/resp: Assess for signs of heart failure, fluid overload, or breathing difficulties that may impact anaesthesia.

• Check for signs of pre-eclampsia:

  • Proteinuria, oedema, reflexes, and clonus.

  • Platelet count – obtain a repeat platelet count before proceeding with epidural anaesthesia to check for a precipitous drop.

How would you assess and manage the risk of pre-eclampsia and thrombocytopaenia?

• Confirm pre-eclampsia diagnosis:

  • Request urine dipstick or 24-hour urine collection for proteinuria.

  • Blood tests: Check for liver function (ALT, AST), renal function (urea, creatinine), and platelet count.

  • If platelets <100,000, hold neuraxial anaesthesia and consider alternative options like general anaesthesia.

• Monitor BP:

  • Antihypertensive treatment with labetalol (preferred due to beta-adrenergic blockade and alpha-receptor antagonism).

  • Consider hydralazine or nifedipine if labetalol is ineffective.

• Discuss with obstetric team for delivery planning and fetal monitoring.

• If signs of severe PET or HELLP syndrome (high liver enzymes, low platelets), transfer to a tertiary centre with appropriate care.

What should be included in the epidural consent process for this patient?

Explain procedure and risks:

• Risks of epidural anaesthesia (e.g., failed block, hypotension, infection, nerve injury, PDPH).

• Hypotension as a side effect, and potential need for vasopressors to maintain maternal and fetal well-being.

• Thrombocytopaenia and risk of spinal haematoma if platelets are too low.

• Alternatives: General anaesthesia, especially if platelets <100,000 or other complications arise.

Discuss benefits: Epidural provides excellent analgesia during labour, with less neonatal respiratory depression than systemic opioids.

Monitor for any changes in the patient’s condition (e.g., sudden drop in platelets or worsening BP) and discuss backup plans for GA if required.

How would you manage an eclamptic seizure in this patient?

Immediate action:

• Call for help, ensure a clear airway, administer 100% oxygen via mask.

• Magnesium sulfate: Administer 4g IV bolus, followed by 1-2g/hour infusion to prevent further seizures.

• Ensure adequate ventilation and maintain normal oxygenation.

BP management:

• Use labetalol (or hydralazine) to control hypertension.

• Fluid balance: Careful with fluids to avoid fluid overload.

Delivery plan:

• Urgent discussion with obstetric team for early delivery, as eclampsia may be a sign of imminent fetal compromise.

• Prepare for caesarean section under general anaesthesia or epidural if platelets are safe

How would your RSI for GA during a caesarean differ in this patient?

Induction:

• Avoid high-dose propofol (due to hypotension), consider ketamine (0.5-1 mg/kg) for its hemodynamic stability.

• Fentanyl (50-100 mcg) for analgesia.

• Succinylcholine (1-1.5 mg/kg) for rapid intubation, with cricoid pressure.

Maintenance:

• Consider sevoflurane or TIVA (if avoiding inhalational agents for more control).

Vasopressors:

• Ensure phenylephrine or ephedrine is available to counteract hypotension.

Post-intubation management:

• Careful fluid management and continue magnesium sulfate to prevent further seizures.

• Post-operative analgesia: Consider regional blocks or opioids, depending on the patient's condition.

How would you manage the patient's post-operative recovery in PACU if she is hypertensive or showing signs of eclampsia?

• Monitor BP closely and treat with labetalol or hydralazine to control hypertension.

• Magnesium sulfate infusion should continue to prevent further seizures, monitor reflexes and urine output.

• Monitor for signs of pulmonary oedema or fluid overload (especially in a patient with pre-eclampsia).

• Fetal monitoring post-delivery if the baby is premature.

• Plan for transfer to ICU/HDU if ongoing haemodynamic instability or need for closer monitoring.