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New predictors of difficult intubation in obstetric patients: A prospective observational study

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... We suggest that spinal anesthesia can be safe for COVID-19 infected pregnant women, even in patients with pneumonia [5,21]. However, general anesthesia remains risky in obstetric patients because of difficult airway management and the risk of contamination of healthcare workers [22,23]. ...
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Introduction: Pregnant women are vulnerable to SARS-CoV2 infection, particularly with the Delta variant. The aim of our study is to describe the COVID-19 syndrome among non-vaccinated pregnant women during the delta wave and to investigate risk factors for severe forms. Methods: In this study, we included all non-vaccinated pregnant women who tested positive for COVID-19 and who required hospital admission at any stage of gestation during the Delta wave in the maternity of Sfax, Tunisia. Patients were divided into 2 groups according to the mode of delivery in case of completed pregnancies and according to the severity of the disease. Severe COVID-19 is considered when the pregnant woman requires advanced oxygen support or intensive care unit referral. We performed univariate and multivariate logistic regression models to investigate the predictors of severe maternal outcomes among infected pregnant women. The significance level was set top ≤ 0.05. Results: one hundred patients were included. Severe adverse outcomes were observed in 23 patients (group1). The mortality rate during the Delta wave was 6%. The mode of delivery had not influenced the maternal and perinatal outcomes. Age >35 years old [OR 3.16, 95% CI 1.13- 8.84], BMI>30 kg/m2 [OR 2.63, 95% CI 1.0 -6.95], preeclampsia [OR 4.0, CI 95% 1.04- 15.32], dyspnea [OR 7.55, 95% CI 2.62- 21.7], cytolysis [ OR 4.6, 95% CI 1.48- 14.2], and lung injury in CT Scan > 50% [OR9.6, 95%CI 1.48-62.1] were significantly associated with an increased risk of severe maternal outcomes. Conclusions: During the delta wave in Tunisia, non-vaccinated pregnant women seem to be at higher risk of severe maternal outcomes and maternal deaths. The main risk factors for severe outcomes were age 35, obesity, preeclampsia, cytolysis, and severe lung damage in the CT scan.
... Early in the pandemic, cesarean section was a very common practice [13,14] with COVID-19 status alone being a common indication [4]. Some physicians thought that a cesarean would avoid an emergency cesarean section under general anesthesia and tracheal intubation [15], which is M a n u s c r i p t a c c e p t e d f o r p u b l i c a t i o n 8 risky for the pregnant woman [16]. Moreover, there was a debate on the risk of vertical transmission in vaginal delivery [5,17]. ...
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Objective: The aim of this study was to assess the maternal and fetal outcomes in pregnant women with COVID-19 infection at birth and the impact of the mode of delivery on the prognosis of these patients. Material and Methods: This is a multicenter observational study including pregnant women delivering while infected with COVID-19 from January 2021 to June 2022 in 3 regions in the south of Tunisia. To assess the impact of the mode of delivery among patients included, they were divided into 2 groups: • Group 1: included patients who had cesarean delivery. • Group 2: included patients who had vaginal delivery. The maternal and fetal outcomes were compared between the 2 groups. Multivariable logistic regression was performed to assess the association between the mode of delivery and maternal and fetal adverse outcomes. Results: We included 201 patients: 129 cesarean deliveries and 72 vaginal deliveries. Demographic parameters and the severity of COVID-19 signs before delivery were comparable in both groups. We noted higher rates of increased need for oxygen, maternal complications, and intensive care unit referral in the cesarean group (p<0.001).Cesarean birth was significantly associated with the risk of clinical deterioration (aOR=12.9, 95% CI: 4.89-34.4, p<0.001), maternal death (aOR= 3.84, 95% CI: 0.839-17.5, p=0.042), and an increased risk of neonatal intensive care unit admission (aOR=3.72; 95%CI: 1.63-8.48, with p= 0.001). Conclusions: Cesarean delivery may worsen the prognosis of pregnant women with COVID-19. It was also associated with adverse fetal outcomes.
... 4 Anatomical and physiological changes that occur during pregnancy increase the likelihood of difficult or failed intubation, 5 which may be up to eight times higher than in the general surgical population. [6][7][8][9] Maternal deaths from difficult airway management have been highlighted in two reports of the Confidential Enquiries into Maternal Deaths in the United Kingdom (2006-2008 and 2000-2002). 10,11 The American Society of Anaesthesiologists' Closed Claims in obstetrics database revealed that maternal deaths were more frequently associated with general than regional anaesthesia, and that 16% of the anaesthetic claims were due to critical events involving the airway and respiratory system. ...
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Background: In Africa, maternal mortality after caesarean delivery is 50 times greater than in high-income countries. In South Africa, more than 50% of anaesthesia-related maternal mortality is attributed to failure to protect the airway. We implemented an obstetric airway management registry, to facilitate future improvements in management and outcomes. Methods: A prospective electronic registry was established at three obstetric sites in Cape Town, recording airway management for all general anaesthetics from 20 weeks gestation to seven days post-partum. Perioperative descriptive data are entered using a web-based smartphone-enabled platform. To quantify the reliability of capture, we compared the first 200 records in the registry to theatre logbooks. We used summary statistics to describe our obstetric anaesthesia population, and details relevant to airway management. Results: The first 200 cases were recorded from September 2018 to January 2019. According to theatre logbooks, this represented 80% of cases performed. Major indications for general anaesthesia included severe fetal distress/bradycardia (21%), failed neuraxial technique (19%), coagulopathy (19%), and abnormal placentation (12%). A third of patients had hypertensive disorders of pregnancy, and 6% had imminent/confirmed eclampsia. Forty per cent were in active labour. On airway assessment, Mallampati grade was 3 or 4 in 29% of patients, and mouth opening, thyromental distance and mandibular protrusion limited in 10%, 8% and 8% respectively. Cormack-Lehane grade IIb and III views were encountered in 6% and 2% respectively, with no grade IV views. Desaturation below 90% occurred in 12% of patients. There were two cases (1%) of failed intubation with supraglottic airway rescue, and no emergency surgical airways performed. Conclusion: An obstetric airway management registry was successfully implemented. Clinically significant hypoxaemia occurred commonly during general anaesthesia, with a high incidence of difficult intubation predictors and desaturation. The registry will guide research aimed at improving safety during general anaesthesia in obstetrics. The full article is available at https://doi.org/10.36303/SAJAA.2020.26.4.2423 or http://www.sajaa.co.za/index.php/sajaa/article/view/2423 (Open Access)
Article
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care, Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
Article
Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.
Article
Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.
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