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Q1. Perioperative Plan for Eclamptic Patient Posted for Caesarean Section (10 Marks)

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A. PREOPERATIVE ASSESSMENT

1. History

• Onset and frequency of seizures; last seizure episode
• Current magnesium sulfate therapy - dose, duration, any toxicity signs
• Antihypertensive medications in use (labetalol, hydralazine, nifedipine)
• Obstetric history: gestational age, fetal wellbeing, last oral intake
• Symptoms of end-organ damage: headache, visual disturbance, RUQ pain (hepatic capsule distension), oliguria

2. Airway Assessment (CRITICAL)

• Eclampsia causes significant airway oedema - anticipate difficult intubation
• Mallampati scoring, mouth opening, neck movement, thyromental distance
• Assess for pharyngeal and laryngeal oedema (stridor, hoarse voice)
• Always have video laryngoscope, LMA rescue, and a failed intubation plan ready

3. Cardiovascular Assessment

• BP: target <160/110 mmHg before proceeding
• Signs of pulmonary oedema (tachypnoea, SpO2, crackles)
• ECG if severe hypertension or electrolyte disturbance
• IV access: two large-bore cannulas (16G minimum)

4. Laboratory Investigations

5. Fetal Assessment

• CTG monitoring - magnesium reduces FHR variability (ensure not hypoxic)
• Placental abruption must be excluded

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B. PREMEDICATION & PREPARATION

• Aspiration prophylaxis (all parturients are full stomach risk):
  • Sodium citrate 30 mL PO immediately preop
  • Ranitidine 150 mg PO / IV the night before and morning of surgery
  • Metoclopramide 10 mg IV (reduces gastric volume, increases tone)
• Antihypertensive control before induction:
  • Labetalol IV 10-20 mg boluses (repeat up to 300 mg/day)
  • Hydralazine IV 5 mg boluses (every 20-40 min)
  • Nifedipine 10-20 mg PO (30-min intervals)
• Continue magnesium sulfate: ACOG recommends continuing the infusion through delivery; 4 g IV loading dose, then 1-2 g/hr maintenance
• IV fluid restriction: limit to 80-100 mL/hr total (risk of pulmonary oedema due to low colloid oncotic pressure and endothelial damage)
• Monitoring: Pulse oximetry, ECG, IBP (arterial line if severe), urine output via catheter (target >0.5 mL/kg/hr)

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C. ANAESTHESIA

Choice: Regional Anaesthesia Preferred

"Regional anesthesia has become the preferred technique for women with preeclampsia with severe features and eclampsia for labor and delivery." - ACOG (Creasy & Resnik's Maternal-Fetal Medicine)

SPINAL ANAESTHESIA (preferred for C-section)

• Spinal is NOW considered safe - earlier concerns about severe hypotension are unfounded
• Women with preeclampsia actually have less hypotension after spinal vs. healthy women (17% vs 53%) due to vasoconstriction from vasospasm
• Drug: Hyperbaric bupivacaine 0.5% (10-12.5 mg) + fentanyl 10-25 µg + intrathecal morphine 0.1-0.15 mg (for postop analgesia)
• Block level: T4 dermatome required
• Vasopressors must be immediately available (phenylephrine preferred over ephedrine in this setting - alpha agonist better than ephedrine which can cause maternal tachycardia)
• Minimal or NO fluid preload - conservative fluid management

EPIDURAL ANAESTHESIA (if labour epidural already sited, or CSE)

• Allows titration, avoids sudden sympathectomy
• Convert labour epidural to surgical block with 15-20 mL lignocaine 2% + adrenaline
• Advantages: slower onset = more cardiovascular stability

PLATELET COUNT AND NEURAXIAL DECISION

• Platelet count >80,000/mm³ and stable: neuraxial safe in most centres
• Many anaesthesiologists proceed with platelets >70,000/mm³ if stable and no clinical bleeding
• TEG/ROTEM if available - no single cutoff value is absolute
• HELLP syndrome increases risk: spinal hematoma incidence 1:200,000 in obstetrics

GENERAL ANAESTHESIA (reserve for: failed regional, emergency, severe coagulopathy, uncontrolled seizures, airway emergency)

1. Hypertensive response to laryngoscopy - attenuate with:
   • Remifentanil 1 µg/kg IV bolus (most effective), OR
   • Esmolol 1-2 mg/kg IV, OR
   • Labetalol 0.25 mg/kg IV, OR
   • Lignocaine 1.5 mg/kg IV
2. Rapid sequence induction (RSI): Propofol 2 mg/kg + Succinylcholine 1.5 mg/kg (or Rocuronium 1.2 mg/kg with sugammadex reversal plan)
3. Magnesium + non-depolarising relaxants: Synergistic - reduce rocuronium dose, monitor NMB with nerve stimulator, difficult extubation possible
4. Difficult airway plan: Video laryngoscope first line; LMA as rescue; cricothyrotomy plan
5. Maintenance: low-dose volatile + N2O (avoid high-dose volatile - causes uterine atony)
6. Have misoprostol and carboprost ready (magnesium causes uterine relaxation - oxytocin alone may be insufficient)

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D. POSTOPERATIVE ANALGESIA & MONITORING

• Intrathecal morphine 0.1-0.15 mg (if spinal used): 12-18 hours of excellent analgesia
• Paracetamol 1 g IV/PO 6-hourly (safe, avoid NSAIDs if renal impairment)
• Avoid NSAIDs in severe preeclampsia (worsen renal function, raise BP)
• Epidural morphine 2-4 mg PRN if epidural in situ
• IV PCA fentanyl if no neuraxial opioid

• BP q15 min for first 4 hours, then hourly
• Urine output (oliguria = <30 mL/hr is high risk - may need fluid challenge vs. diuretics)
• SpO2 and respiratory rate (pulmonary oedema peak risk at 24-48 hrs postpartum as fluid mobilises)
• Magnesium continued for 24 hours postpartum
• Platelet trend - remove epidural catheter when platelets stable and trending up
• One-third of eclamptic seizures occur postpartum - remain vigilant

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Q2. Labour Analgesia and Pain Pathways

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PAIN PATHWAYS IN LABOUR

First Stage of Labour (Cervical Dilatation - Visceral Pain)

• Pain impulses travel in visceral afferent type C fibres (slow, unmyelinated)
• These fibres accompany sympathetic nerves
• Pathway: Uterine/cervical nociceptors → Uterovaginal plexus → Inferior hypogastric plexus → Enter spinal cord at T10-L1 nerve roots
• Early (latent) phase: T11-T12 dermatomes
• Active phase: expands to involve T10-L1 dermatomes
• Pain referred to lower abdomen, lumbosacral area, gluteal region, thighs

"The visceral afferent fibers responsible for labor pain travel with sympathetic nerve fibers first to the uterovaginal plexus, then through the inferior hypogastric plexus, before entering the spinal cord with the T10-L1 nerve roots." - Morgan & Mikhail's Clinical Anesthesiology

Second Stage of Labour (Fetal Descent - Somatic + Visceral Pain)

• Pudendal nerve (S2-S4) - somatic afferents
• Total coverage: T10 to S4 dermatomes in second stage
• Pain is more intense, acute, well-localised (somatic component)

Summary Table

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METHODS OF LABOUR ANALGESIA

1. Non-Pharmacological

• Prepared childbirth (Lamaze technique) - breathing patterns, focus distraction
• Continuous labour support (doula/support person) - reduces analgesia need, shorter labour
• Hydrotherapy (water baths) - reduced pain scores
• TENS (transcutaneous electrical nerve stimulation)
• Intradermal water injections (sterile water, 4 sites on lower back)
• Acupuncture, hypnosis

2. Systemic (Parenteral) Analgesia

• Meperidine (Pethidine): 50-100 mg IM or 10-25 mg IV; avoid if delivery imminent (peak effect: 1-3 hrs IM, 10-20 min IV); neonatal respiratory depression
• Fentanyl IV PCA: 50 µg bolus, 10-min lockout; superior to meperidine, less neonatal depression
• Remifentanil IV PCA: Ultra-short acting, most effective parenteral opioid for labour; requires continuous SpO2 monitoring (maternal apnoea risk)
• Morphine: Less commonly used in labour
• Nitrous oxide (Entonox 50% N2O/O2): Inhaled at onset of contraction; partial analgesia, minimal neonatal effects, self-administered

3. Neuraxial Analgesia (GOLD STANDARD)

A. Epidural Analgesia

• Most common method; placed at L2-3 or L3-4
• First stage: 10 mL bupivacaine 0.125% + fentanyl 50-100 µg (or sufentanil 5-10 µg) into lumbar epidural space; blocks T10-L1
• Maintenance: Bupivacaine 0.0625-0.1% + fentanyl 1-2 µg/mL
  • Continuous infusion: 10-12 mL/hr
  • PCEA (patient-controlled epidural analgesia): 5-10 mL bolus, 10-20 min lockout - better satisfaction, less motor block
  • PIEB (programmed intermittent epidural bolus): newer, better drug distribution, lower total dose
• Converted to surgical block for C-section if needed

B. Combined Spinal-Epidural (CSE)

• Epidural needle identifies space → pencil-point spinal needle through it → intrathecal injection → epidural catheter sited
• Intrathecal: Fentanyl 10-25 µg ± bupivacaine 1.25-2.5 mg → profound analgesia 90-120 minutes
• Spinal opioid alone: excellent for latent phase (no motor block, can ambulate = "walking epidural")
• Local anaesthetic added for active phase
• Then maintain with epidural PCEA/PIEB
• Risk: fetal bradycardia (uterine tachysystole from rapid catecholamine drop)

C. Dural-Puncture Epidural (DPE)

• CSE technique without intrathecal drug injection
• Dural puncture enhances epidural drug spread
• Avoids fetal bradycardia risk of CSE; better onset than standard epidural

D. Spinal Analgesia (Single Shot)

• Rarely used for pure labour analgesia (short duration)
• Useful in multiparous women close to delivery

4. Regional Blocks

• Paracervical block: Blocks uterine afferents at T10-L1; only 1st stage; risk of fetal bradycardia - rarely used now
• Pudendal nerve block: Blocks S2-4; perineal analgesia for 2nd stage, episiotomy, instrumental delivery; 10 mL lignocaine 1% each side

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Q3. RECENT PPH MANAGEMENT - FLOWCHART

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┌─────────────────────────────────────────────────────────────────────┐
│              POSTPARTUM HAEMORRHAGE (PPH) MANAGEMENT               │
│     Definition: Blood loss >500 mL (vaginal) / >1000 mL (C/S)     │
│         Severe PPH: >1000 mL with haemodynamic compromise          │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
                           ▼
┌─────────────────────────────────────────────────────────────────────┐
│                     IMMEDIATE RECOGNITION                           │
│   • Quantitative Blood Loss (QBL) - weighing sponges + visual aid  │
│   • ACOG recommends QBL over visual estimation (prevents delays)   │
│   • Call for help - Multidisciplinary team (OB, anaesthetist,      │
│     midwife, neonatologist, blood bank)                             │
│   • Move to OT if still in labour room                              │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
                           ▼
┌─────────────────────────────────────────────────────────────────────┐
│                    IDENTIFY THE CAUSE: "4 Ts"                       │
│  TONE (Atony 80%) │ TRAUMA │ TISSUE (retained) │ THROMBIN (coag)  │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
              ┌────────────┴────────────┐
              ▼                         ▼
    ┌──────────────────┐     ┌────────────────────────────────────────┐
    │ RESUSCITATION     │     │         TREAT THE CAUSE                │
    │ Simultaneously   │     │                                        │
    │ • O2 15L/mask    │     │ TONE: Bimanual uterine massage         │
    │ • 2 large-bore   │     │ TRAUMA: Repair lacerations/haematoma   │
    │   IV (16G+)      │     │ TISSUE: Manual removal of placenta     │
    │ • Bloods: FBC,   │     │ THROMBIN: Correct coagulopathy         │
    │   coag, G&S, LFT │     └────────────────────────────────────────┘
    │ • Catheter       │
    │ • Warm IV fluids │
    └──────────────────┘
                           │
                           ▼
┌─────────────────────────────────────────────────────────────────────┐
│            STEP 1: UTEROTONICS (First-line - UTERINE ATONY)        │
│                                                                     │
│  1st line: OXYTOCIN                                                 │
│    • 3-5 IU slow IV bolus (NOT rapid bolus - causes hypotension)   │
│    • Then infusion: 10-40 IU in 500 mL over 4-8 hrs               │
│    (WHO: 20 IU in 1L crystalloid after C/S)                        │
│                                                                     │
│  2nd line (if oxytocin fails):                                      │
│    • METHYLERGONOVINE 0.2 mg IM (Ergometrine)                      │
│      ⚠ CONTRAINDICATED in hypertension, cardiac disease            │
│    • CARBOPROST (PGF2α) 0.25 mg IM q15 min (max 8 doses/2 mg)    │
│      ⚠ Caution: Asthma (bronchospasm), pulmonary hypertension      │
│    • MISOPROSTOL (PGE1) 600-800 mcg oral/SL/rectal/vaginal        │
│      Especially useful when oxytocin unavailable/desensitised      │
│                                                                     │
│  ⭐ TRANEXAMIC ACID (TXA) 1 g IV over 10 min                       │
│    • Give EARLY once PPH diagnosed (within 3 hours of delivery)    │
│    • WOMAN trial (n=20,060): Reduces death from bleeding           │
│      RR 0.69 (95%CI 0.52-0.91) when given within 3 hours          │
│    • 2nd dose of 1 g IV if bleeding continues after 30 min        │
│    • ACOG: Consider when initial medical therapy fails             │
│    • Clamp cord before administering (crosses placenta)            │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
              Is bleeding controlled?
              NO ──────────▼
┌─────────────────────────────────────────────────────────────────────┐
│              STEP 2: PHYSICAL/MECHANICAL TAMPONADE                  │
│                                                                     │
│  • Bimanual uterine compression                                     │
│  • Uterine packing / gauze packing                                  │
│  • Intrauterine Balloon Tamponade (Bakri balloon)                  │
│    - Fill with 300-500 mL saline                                    │
│  • ⭐ JADA SYSTEM (novel vacuum-induced haemorrhage control device) │
│    - Successful in >90% of PPH from atony (median time 3 min)      │
│  • Aortic compression                                               │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
              Still bleeding?
              NO ──────────▼
┌─────────────────────────────────────────────────────────────────────┐
│             STEP 3: SURGICAL INTERVENTIONS                          │
│                                                                     │
│  Conservative Surgery (uterus-sparing):                             │
│  • B-Lynch compression suture (uterine brace suture)              │
│  • Bilateral uterine artery ligation                                │
│  • Bilateral utero-ovarian ligament ligation                        │
│  • Bilateral internal iliac artery ligation                         │
│                                                                     │
│  Interventional Radiology (if available + haemodynamically stable): │
│  • Uterine artery embolisation (UAE)                                │
│                                                                     │
│  Definitive: PERIPARTUM HYSTERECTOMY                                │
│  • If all else fails or placenta accreta spectrum                   │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
                           ▼
┌─────────────────────────────────────────────────────────────────────┐
│             STEP 4: MASSIVE TRANSFUSION PROTOCOL (MTP)             │
│                    Trigger: >1500-2000 mL blood loss               │
│                                                                     │
│  • Activate MTP: RBCs : FFP : Platelets = 1:1:1 ratio             │
│  • CRYOPRECIPITATE / FIBRINOGEN CONCENTRATE early                  │
│    (fibrinogen drops early in obstetric haemorrhage)               │
│  • Target fibrinogen >2 g/L                                         │
│  • Point-of-care testing: TEG / ROTEM - guide product choice       │
│  • Cell salvage (leukocyte filter) if available                     │
│  • Factor VIIa: NOT universally recommended (FDA adverse events)   │
│  • Warm all products; calcium replacement                           │
│                                                                     │
│  MONITORING:                                                        │
│  • Arterial line (continuous BP + bloods)                           │
│  • Central line (CVP monitoring)                                    │
│  • Serial FBC, coag, fibrinogen, Ca2+, lactate, ABG               │
│  • Target MAP >65 mmHg, Hb >8 g/dL, Platelets >50,000            │
└──────────────────────────┬──────────────────────────────────────────┘
                           │
                           ▼
┌─────────────────────────────────────────────────────────────────────┐
│                    PLACENTA ACCRETA SPECTRUM (PAS)                  │
│              (Increasing with rising C/S rates)                     │
│                                                                     │
│  Antenatal planning (multidisciplinary team <34 weeks):            │
│  • Anesthesiology + MFM + Neonatology + Urology/Gyn Oncology       │
│  • Planned C/S + hysterectomy at tertiary centre                   │
│  • Interventional radiology (iliac balloons)                        │
│  • Massive transfusion protocol pre-activated                       │
│  • Arterial line + large-bore IV preoperatively                     │
│  • CSE (spinal for delivery, epidural/GA for hysterectomy)         │
└─────────────────────────────────────────────────────────────────────┘

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Key Recent Updates in PPH Management

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