BACKGROUND:Preeclampsia is a multisystem disorder associated with adverse maternal and fetal outcomes. A previous study in patients with late-onset preeclampsia (LOPE), showed an association between pulmonary interstitial syndrome (PIS), detected by lung ultrasound, and elevated left ventricular end-diastolic pressure (LVEDP), measured by transthoracic echocardiography (TTE). In early onset preeclampsia (EOPE); however, the cardiopulmonary status remains poorly characterized. METHODS:This prospective observational cohort study enrolled women with EOPE with severe features. Point of care ultrasound (POCUS) assessments included lung ultrasound, TTE, and sonographic assessment of the optic nerve sheath diameter (ONSD). PIS was defined as the presence of bilateral B-lines on lung ultrasound. An ONSD >5.8 mm was considered compatible with raised intracranial pressure. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and albumin levels were measured. The primary aim was to assess the association between PIS and elevated LVEDP in EOPE. Secondary aims included assessing the prevalence of POCUS abnormalities in EOPE and their association with serum NT-proBNP and albumin levels, and comparing the results with historical data from patients with LOPE. RESULTS:Sixty-4 patients completed the study. There was no association between PIS and elevated LVEDP ( P = .53). PIS, diastolic dysfunction, systolic dysfunction, and elevated LVEDP were observed in 23% (95% CI, 14.4-35.4%), 52% (95% CI, 39.3-63.8%), 30% (95% CI, 19.9-42.5%), and 35% (95% CI, 24.2-47.6%) of women, respectively. Increased ONSD was noted in 2 women (3%). Median (IQR) NT-proBNP levels were significantly elevated (278 [119-678] ng/L) and associated with PIS ( P = .015) and elevated LVEDP ( P = .003). Using a threshold for NT-proBNP of 125 ng/L, the sensitivity and specificity for predicting PIS were 93.3% and 34%, and for increased LVEDP, 90.5% and 40%, respectively. Receiver operating characteristic analysis showed limited diagnostic value of NT-proBNP for PIS (AUC = 0.78) and for elevated LVEDP (AUC = 0.68). No association was found between serum albumin and PIS, systolic dysfunction, or elevated LVEDP. The prevalence of systolic dysfunction was significantly higher ( P < .01) and raised ONSD lower ( P < .01) than in historical controls with LOPE. CONCLUSIONS:Lung ultrasound and TTE showed a high prevalence of PIS, systolic dysfunction, and raised LVEDP in women diagnosed with EOPE. PIS was not associated with elevated LVEDP. NT-proBNP level was significantly associated with PIS and elevated LVEDP, however clinical predictive value was limited. Women with EOPE had a higher prevalence of systolic dysfunction than those with LOPE.

Background: Core temperature changes during obstetric spinal anaesthesia are likely underestimated because monitoring is challenging and often not performed. This study aimed to describe the incidence and severity of perioperative hypothermia in patients undergoing caesarean delivery under spinal anaesthesia in a resource-limited setting. Methods: We performed a prospective observational study of parturients undergoing either elective or emergency caesarean delivery under spinal anaesthesia in a South African regional hospital. We used dual-sensor heat flux technology to monitor their core temperature during the perioperative period. The primary outcome was the incidence of clinically relevant hypothermia (defined as core temperature decrease from baseline of > 1 degrees C) following spinal anaesthesia. Smoothing splines were used to estimate maximum changes in core temperature. Results: We included 166 patients in our analysis. A decrease of > 1 degrees C occurred in 49% of participants (95% CI 40-63%) while hypothermia (temperature < 36 degrees C) occurred in 67% (49-78%). Discharge from recovery room with core temperature < 35 degrees C occurred in 26% (20-34%) of the participants. There was a higher incidence of vomiting in those participants who experienced temperature decreases of > 1 degrees C (18% vs 6%, p = 0.03). Conclusion: In this resource-constrained environment, clinically relevant hypothermia during obstetric spinal anaesthesia occurred in half of participants. Hypothermia was often severe and participants did not recover by the time of discharge from anaesthesia care. Monitoring of a patient's core temperature should be a standard of care, and further research into the clinical impact of perioperative hypothermia and warming strategies in these settings is warranted.

BACKGROUND:Mothers in Africa are 50 times more likely to die after cesarean delivery (CD) than in high-income countries, largely due to hemorrhage. It is unclear whether countries across Africa are adequately equipped to prevent and treat postpartum hemorrhage (PPH) during and after CD. METHODS:This was a cross-sectional survey of anesthesiologists and obstetricians across the African Perioperative Research Group (APORG). The primary objective was to determine readiness of the hospital system to implement the World Health Organization (WHO) recommendations for prevention and treatment of PPH during and after CD. The secondary objectives were to evaluate the availability of blood products, skilled human resources and establish available postoperative care after CD. Survey question format was close-ended or Likert scale, with options "always," "sometimes," or "never." RESULTS:Responses were analyzed from 1 respondent from each of 140 hospitals from 29 low- and middle-income countries across Africa. Most respondents completed every data field on the case report form. Regarding WHO recommendations on prevention of PPH, oxytocin and misoprostol were available in 130/139 (93.5%) and 101/138 (73.2%) hospitals, respectively. There was limited access to heat-stable carbetocin (12/138 [8.7%]) and ergometrine (35/135, [25.9%]). Controlled cord traction for removal of placenta was always performed in 133/135 (98.5%) hospitals. Delayed cord clamping when neonatal resuscitation was not indicated, was not performed universally (86/134 [64.2%]). Regarding the treatment of PPH, crystalloids were always available in 133/139 (95.7%) hospitals, and the preferred initial resuscitation fluid (125/138 [90.6%]). Uterine massage was always performed in 117/139 (84.2%) hospitals. Tranexamic acid was always available in 97/139 (69.8%) hospitals. The availability of intrauterine balloon tamponade devices was limited. Most had immediate access to theater (126/139 [90.6%]). Responses concerning organizational recommendations showed that 113/136 (83.1%) hospitals had written protocols for the treatment of PPH. Protocols for patient referral and simulation training were limited. Most hospitals had access to emergency blood (102/139 [73.4%]). There was limited access to blood component therapy, with platelets available at 32/138 (23.2%), cryoprecipitate at 21/138 (15.2%) and fibrinogen at 11/139 (7.9%) hospitals. In-person specialist cover was reduced after-hours. CONCLUSIONS:Important WHO-recommended measures to reduce hemorrhage during and after CD, are not currently available in many hospitals across Africa. It is likely that the lack of a combination of factors leads to failure to rescue mothers in Africa from postoperative complications. These findings should facilitate codesign of quality improvement initiatives to reduce hemorrhage related to CD.

Open AccessBalancing haemodynamic priorities in obstetrics: back to basics DG Bishop, RA Dyer and M Crowther DG Bishop1 https://orcid.org/0000-0001-9861-3646 , RA Dyer2 https://orcid.org/0000-0002-8165-9098 and M Crowther2 https://orcid.org/0009-0004-6072-7735 Affiliations 1Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, South Africa 2Department of Anaesthesia and Perioperative Medicine, University of Cape Town, South Africa Published Online:1 May 2024https://doi.org/10.36303/SAJAA.3163https://hdl.handle.net/10520/ejc-medsajaa_v30_n3_a1SectionsPDFAbstract ToolsAdd to favouritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InRedditGMailOutlookCopy LinkMendeley AboutAbstractThe case presented by Davies and Hofmeyr illustrates the consequences of systems failure to patient care.1 A patient with severe preeclampsia and an uncorrected cardiac lesion (in this case, Tetralogy of Fallot [TOF]) should be managed in a tertiary/ quaternary setting, by a multidisciplinary team including a specialist obstetrician, anaesthesiologist, and cardiologist. The underlying cardiac condition should have resulted in early antenatal discussion regarding the threat of pregnancy to maternal life, including whether termination of pregnancy should be recommended. This complex decision was precluded by late booking of the pregnancy. The patient subsequently missed a high-risk clinic appointment, further preventing timely access to the specialised care she required. This is regrettably a common occurrence in South Africa. The NCCEMD report (2020–2022) showed that 57% of maternal deaths were deemed potentially preventable during this triennium.2 The major causes of death included obstetric haemorrhage (16%), hypertensive disorders of pregnancy (15%), and medical and surgical disorders (14%).2 It should be self-evident that when these conditions coexist, mortality risk increases significantly. In Africa, while the complication rate following caesarean delivery is 2–3 times higher than in high-income countries, the risk of dying is 50 times higher.3IntroductionThe case presented by Davies and Hofmeyr illustrates the consequences of systems failure to patient care.1 A patient with severe preeclampsia and an uncorrected cardiac lesion (in this case, Tetralogy of Fallot [TOF]) should be managed in a tertiary/ quaternary setting, by a multidisciplinary team including a specialist obstetrician, anaesthesiologist, and cardiologist. The underlying cardiac condition should have resulted in early antenatal discussion regarding the threat of pregnancy to maternal life, including whether termination of pregnancy should be recommended. This complex decision was precluded by late booking of the pregnancy. The patient subsequently missed a high-risk clinic appointment, further preventing timely access to the specialised care she required. This is regrettably a common occurrence in South Africa. The NCCEMD report (2020–2022) showed that 57% of maternal deaths were deemed potentially preventable during this triennium.2 The major causes of death included obstetric haemorrhage (16%), hypertensive disorders of pregnancy (15%), and medical and surgical disorders (14%).2 It should be self-evident that when these conditions coexist, mortality risk increases significantly. In Africa, while the complication rate following caesarean delivery is 2–3 times higher than in high-income countries, the risk of dying is 50 times higher.3The patient presented at 33 weeks gestation with severe preeclampsia and uncorrected TOF. Management of concurrent cardiac conditions should ideally be guided by experienced senior clinicians, with access to specialised monitoring equipment, drugs, cardiovascular support devices, and critical care services. Key principles in such complex cases include immediate referral to the anaesthesia provider within the hospital. In this case, there was an unfortunate delay until complications occurred. If experienced clinicians are unavailable on site, there should at least be telephonic discussion. This case represents a scenario that could be faced by practitioners at any level in the South African health system, as both preeclampsia and unrecognised or uncorrected cardiac pathology are relatively common problems. Anaesthetists must have an approach to balancing the haemodynamic priorities of each condition. The clinical team is to be congratulated on their astute clinical management of this vulnerable patient. Her subsequent in-hospital demise due to COVID-19 infection was indeed tragic.It may be useful to consider in isolation each of the conditions that affected the cardiovascular system, before discussing an approach to the coexistence of all this pathology.The expected haemodynamic changes associated with the four underlying conditions are as follows:1. Cardiovascular changes in normal pregnancyThe physiological changes of advanced pregnancy are an important aspect to consider in any patient presenting for anaesthesia. During normal pregnancy, the heart increases in size, secondary to increased blood volume and increased stretch and force of contraction.4 Left ventricular hypertrophy results in a 5–10% increase in mass,5 and is accompanied by increased annular diameters of the mitral, tricuspid and pulmonary valves, such that 94% of women have some evidence of tricuspid and pulmonary regurgitation.4 Heart rate increases by almost 25%, stroke volume by 20%, and the cardiac output consequently increases to 50% of pre-pregnancy values. This may be accompanied by a mild degree of diastolic dysfunction. Aortocaval compression in the supine position may also lead to hypotension, mainly secondary to preload reduction. This may have particular clinical significance when there is multiple cardiac pathology.2. Pregnancy – specific cardiovascular disease; preeclampsiaPreeclampsia is a common condition in pregnancy in South Africa, which results in increased vascular tone and an increased sensitivity to vasoconstrictors.4 It is usually a hyperdynamic state, with normal to increased cardiac output and moderately increased systemic vascular resistance.4 Concentric ventricular hypertrophy and diastolic dysfunction often occur.6 Transthoracic echocardiography in the typical case of uncomplicated preeclampsia with severe features, has shown what has been termed an "inovasoconstrictor state," with increased left ventricular mass, increased inotropy, normal to increased cardiac output, and an elevated systemic vascular resistance.7 This may uncommonly progress to severe systolic dysfunction, even precipitating low ejection fraction cardiac failure. Early onset disease is more likely to show evidence of systolic dysfunction and severe diastolic dysfunction.8 For the majority of patients, haemodynamic management priorities focus on afterload reduction, accompanied by fluid restriction and seizure prophylaxis.3. Congenital heart disease: Tetralogy of FallotThis is the commonest cyanotic congenital heart disease, and the authors have correctly dealt with the relevant background information.1 With surgical correction, most patients tolerate pregnancy reasonably well, although a proportion will still have cardiac pathology, such as pulmonary regurgitation and right ventricular dysfunction.9 In the unrepaired TOF, patients present with a ventricular septal defect, an overriding aorta, right ventricular outflow tract obstruction (infundibular, valvular, or both) and right ventricular hypertrophy. In addition to the haemodynamic consequences of the cardiac lesion, these patients are also at increased risk of arrhythmias and infective endocarditis. The unrepaired form is rarely seen in adults in high-income countries, and in these patients pregnancy is not recommended due to significant maternal risk.4 The key goal of management is to prevent right-to-left shunt across the ventricular septal defect, by maintaining sufficient afterload. High filling pressures should be maintained in order to enhance right ventricular output, especially in the presence of right ventricular compromise. Tachycardia is also poorly tolerated due to right ventricular outflow tract obstruction. Management priorities are, therefore, to maintain the preload, and in particular the afterload, while avoiding tachycardia.4. Postpartum haemorrhageHaemorrhage results in a decreased intravascular volume, leading to diminished preload and an initial sympathetic response, causing an increase in heart rate and myocardial contractility. Failure to correct hypovolaemia may result in multicomponent shock, with vasodilatation and impaired myocardial contractility. Treatment goals rely on rapid restoration of the blood volume with fluids, ideally including blood component therapy. Pharmacological support may be required while attending to the cause of bleeding and the replacement of blood loss, and ephedrine and adrenaline are the most suitable agents for this purpose. Phenylephrine is theoretically a less suitable choice given its alpha receptor selectivity. However, animal studies have suggested that this agent may assist with mobilisation of splanchnic venous blood in the shocked state, suggesting that it may be used to supplement the β inotropic effects of adrenaline.10Uterine atony is suspected to have contributed to this particular patient's postpartum haemorrhage, with a resultant coagulopathy. It is unclear from the case report if there were contributing surgical factors. The medical management strategies for uterine atony are limited in this case. Rapid oxytocin administration can cause hypotension and arrhythmias, and preeclampsia precludes the use of ergometrine. Misoprostol would have been a reasonable agent to consider.Balancing haemodynamic goalsAnaesthetic teaching often focuses cardiovascular priorities on individual components: heart rate, rhythm, preload, contractility, and afterload. In this case, the focus should be on preload, afterload and heart rate. This patient presented with hypertension (BP 157/103 mmHg), and a reasonably stable clinical condition. An echocardiogram done a week before had confirmed the cardiac lesion, and suggested that the ejection fraction was preserved. The systolic blood pressure was below the immediate target of 160 mmHg, recommended in the national guidelines.11 At this point, the focus should have been on preventing eclampsia (using magnesium) while attempting to preserve afterload, given the uncorrected TOF. This required careful titration in a monitored setting. However, she was administered two further medications that cause afterload reduction: methyldopa and nifedipine. The dramatic reduction in afterload likely precipitated increased right-to-left shunt, hypoxaemia, and ultimately impaired myocardial contractility – which then worsened the shunt in a vicious cycle. Following the development of hypotension and hypoxaemia, the patient suffered a seizure, compounding the clinical deterioration.The choice to do a general anaesthetic in this case was appropriate. Both severe preeclampsia and eclampsia may be managed under regional anaesthesia, provided preconditions are met.12,13 Similarly, uncorrected TOF may also be managed under regional anaesthesia in specialist settings, using methods such as titrated epidural anaesthesia with strict preservation of the afterload.14 However, when these conditions occur concurrently, and especially given the hypoxia and haemodynamic instability, general anaesthesia is preferred. Additionally, the use of positive pressure ventilation may have augmented myocardial contractility, and the use of positive end expiratory pressure would have improved hypoxia in the setting of pulmonary congestion. It is interesting that the attending anaesthetists chose to extubate the patient at the end of surgery; an argument could be made for at least a brief period of postoperative ventilation, particularly considering the risk of pulmonary oedema in eclampsia, and the probability of further haemorrhage.How should clinicians approach cardiovascular assessment in these dynamic scenarios with complex cardiac pathology? While clinical acumen remains important, point-of-care cardiac ultrasound (either transthoracic or transoesophageal) is invaluable, as are other cardiac output monitors. However, this equipment and the clinical skills required to correctly interpret these devices are not routinely available outside specialist centres. A general strategy, prior to the onset of haemorrhage, might have incorporated the following management objectives: High afterload, but maintain blood pressure below 160/110 mmHg.Preserve intravascular volume.Avoid tachycardia, aiming for heart rate < 80 beats per minute.Maintain cardiac contractility and sinus rhythm where possible.Postpartum haemorrhage changed the emphasis in management. In this case, the clinicians were limited by unavailability of the full range of blood component therapy, in particular cryoprecipitate to correct hypofibrinogenaemia, and platelet transfusion.In the absence of cardiac output monitors, anaesthetists need to use all available clinical information. Fluid restriction, although recommended in preeclampsia,15 no longer applies when there is acute hypovolaemia. Estimation of intravascular volume status requires an assessment of the overall symptom complex.16 Heart rate and blood pressure are relatively late markers of hypovolaemia in obstetrics, but response to fluid administration remains an important clinical sign. Peripheral perfusion, acid-base status, urine output, and lactate level all provide further information.In terms of invasive monitoring, the measurement of systolic pressure variation (SPV) and/or stroke volume variation (SVV) on the arterial trace in the ventilated patient are critical.16,17,18 It is unclear whether a central venous catheter was inserted. Given the need for inotropic support, this would have been reasonable. Modern teaching is that central venous pressure (CVP) measurement is of little value in the assessment of volume status.16,19 However, in the setting of rapid haemorrhage, a persistently low CVP would have further supported fluid administration. Finally, although not without risk, veno-arterial extra-corporeal membrane oxygenation (VA ECMO)20 and/ or resuscitative endovascular balloon occlusion of the aorta (REBOA)21 are increasingly being employed in high-resource environments for the management of haemodynamic instability in patients with complex obstetric cardiovascular pathology, and fulminant postpartum haemorrhage. However, in limited resource environments, the patient remains dependent on the astute clinical judgement of the anaesthesia provider in urgently deciding on the clinical priorities for cardiovascular intervention in these vulnerable patients.1. Davies AHofmeyr R "Anaesthesia for caesarean section in a patient with uncorrected Tetralogy of Fallot complicated by eclampsia" Southern African Journal of Anaesthesia and Analgesia2024 3038992 Google Scholar2. NCCEMDSaving Mothers: Executive summary 2020-2022: Includes data for COVID-19 pandemic2023 Google Scholar3. Bishop DDyer RAMaswime SRodseth RNet al. "Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study" Lancet Glob Health2019 74e513e22 Google Scholar4. Chestnut DHWong CATsen LCNgan Kee WDet al.Chestnut's Obstetric Anesthesia: Principles and Practice6thElsevier2020 Google Scholar5. Curtis SLBelham MBennett Set al. "Transthoracic echocardiographic assessment of the Heart in pregnancy - a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society" Echo Res Pract2023 1017 DOI: https://doi.org/10.1186/s44156-023-00019-8 Google Scholar6. Van Dyk DDyer RAFernandes NL "Preeclampsia in 2021 - a perioperative medical challenge for the anesthesiologist" Anesthesiol Clin2021 39471125 DOI: https://doi.org/10.1016/j.anclin.2021.08.005 Google Scholar7. Dennis AT "Transthoracic echocardiography in women with preeclampsia" Curr Opin Anaesthesiol2015 28325460 DOI: https://doi.org/10.1097/ACO.0000000000000182 Google Scholar8. Castleman JSGanapathy RTaki Fet al. "D. echocardiographic structure and function in hypertensive disorders of pregnancy: a systematic review" Circ Cardiovasc Imaging2016 99 DOI: https://doi.org/10.1161/CIRCIMAGING.116.004888 Google Scholar9. Baris LLadouceur MJohnson MRet al. "Pregnancy in Tetralogy of Fallot data from the ESC EORP ROPAC registry" International Journal of Cardiology Congenital Heart Disease 20212100059 DOI: https://doi.org/10.1016/j.ijcchd.2020.100059 Google Scholar10. Cannesson MJian ZChen GVu TQHatib F "Effects of phenylephrine on cardiac output and venous return depend on the position of the heart on the Frank-Starling relationship" J Appl Physiol19852012 11322819 DOI: https://doi.org/10.1152/japplphysiol.00126.2012 Google Scholar11. Moodley JSoma-Pillay PBuchmann EPattinson RC "Hypertensive disorders in pregnancy: 2019 National Guideline" S Afr Med J2019 109912723 Google Scholar12. Reed ARJordaan MCloete EDyer RA "A retrospective audit of anaesthesia for caesarean section in parturients with eclampsia at a tertiary referral hospital in Cape Town" Southern African Journal of Anaesthesia and Analgesia2020 2641927 DOI: https://doi.org/10.36303/SAJAA.2020.26.4.2406 Google Scholar13. Seymour LMFernandes NLDyer RAet al. "General anesthesia for cesarean delivery for thrombocytopenia in hypertensive disorders of pregnancy: findings from the obstetric airway management registry" Anesthesia & Analgesia2022 DOI: https://doi.org/10.1213/ANE.0000000000006217 Google Scholar14. Parker JAGrange C "Anaesthetic management of a parturient with uncorrected Tetralogy of Fallot undergoing caesarean section" Int J Obstet Anesth2015 2418890 DOI: https://doi.org/10.1016/j.ijoa.2014.10.002 Google Scholar15. Pretorius Tvan Rensburg GDyer RABiccard BM "The influence of fluid management on outcomes in preeclampsia: a systematic review and meta-analysis" Int J Obstet Anesth2018 348595 DOI: https://doi.org/10.1016/j.ijoa.2017.12.004 Google Scholar16. Joubert I "The assessment of intravascular volume" Southern African Journal of Anaesthesia and Analgesia2007 135336 DOI: https://doi.org/10.1080/22201173.2007.10872503 Google Scholar17. Parry-Jones AJDPittman JAL "Arterial pressure and stroke volume variability as measurements for cardiovascular optimisation" International Journal of Intensive Care20036772 Google Scholar18. De Backer DVincent JL "Should we measure the central venous pressure to guide fluid management? Ten answers to 10 questions" Crit Care2018 22143 DOI: https://doi.org/10.1186/s13054-018-1959-3 Google Scholar19. Gelman S "Venous function and central venous pressure: a physiologic story" Anesthesiology2008 108473548 DOI: https://doi.org/10.1097/ALN.0b013e3181672607 Google Scholar20. Wong MJBharadwaj SGaley JLet al. "Extracorporeal membrane oxygenation for pregnant and postpartum patients" Anesth Analg2022 135227789 DOI: https://doi.org/10.1213/ANE.0000000000005861 Google Scholar21. Stensaeth KHCarlsen MISLovvik TSet al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjunct treatment in life threatening postpartum hemorrhage: Fourteen years' experience from a single Norwegian center" Acta Obstet Gynecol Scand2024 10359659 DOI: https://doi.org/10.1111/aogs.14767 Google Scholar Next article FiguresReferencesRelatedDetails Volume 30, Issue 3 | May 2024 AccreditationDepartment of Higher Education and Training (DHET)LanguagesEnglish InformationCopyright © 2024, Medpharm PublicationsLicensesThis work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.PDF download Disclosure The authors confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. The authors confirm that they have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. Ethical conduct of research The authors state that they have obtained appropriate institutional review board outlined in the Declaration of Helsinki for all human or animal experimental investigations. A signed informed consent document has been obtained from all participants included in the study.

BACKGROUND:The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS:This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS:Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS:Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.

Hypothermia during obstetric spinal anaesthesia is a common and important problem, yet temperature monitoring is often not performed due to the lack of a suitable, cost-effective monitor. This study aimed to compare a noninvasive core temperature monitor with two readily available peripheral temperature monitors during obstetric spinal anaesthesia. We undertook a prospective observational study including elective and emergency caesarean deliveries, to determine the agreement between affordable reusable surface temperature monitors (Welch Allyn SureTemp® Plus oral thermometer and the Braun 3-in-1 No Touch infrared thermometer) and the Dräger T-core© (using dual-sensor heat flux technology), in detecting thermoregulatory changes during obstetric spinal anaesthesia. Predetermined clinically relevant limits of agreement (LOA) were set at ± 0.5 °C. We included 166 patients in our analysis. Hypothermia (heat flux temperature < 36 °C) occurred in 67

( Anesth Analg . 2024;138(6):1275-1284. doi: 10.1213/ANE.0000000000006750) A key finding of the African Surgical Outcomes Study (ASOS) was that general anesthesia (GA) was linked to higher maternal and neonatal risk and that cesarean delivery (CD) in Africa was 50 times higher than in high-income countries. The ASOS recruited consecutive patients 18 years or older who had inpatient surgery in 183 hospitals in 22 African countries over a 7-day period between February 2016 and May 2016. This ASOS substudy of the obstetric cohort was designed primarily to estimate the association between preoperative risk factors and the outcome of the type of anesthesia administered. The secondary aim was to estimate the association between the method of anesthesia and maternal and neonatal outcomes.

(Anesth Analg. 2023;136:992–998) In Africa, maternal morality following cesarean delivery is 50× more likely compared to morality rates in high-income countries, and spinal anesthesia (SA) is the preferred anesthetic method during cesarean delivery. For parturient patients with hypertensive disorders (ie, preeclampsia, eclampsia, or gestational hypertension), there is an increased risk for adverse outcomes, including spinal epidural hematoma following SA, so thrombocytopenia should be excluded before neuraxial blockade. An accurate platelet count is necessary before SA in emergent situations of fetal distress, which can be complicated when laboratory services are unavailable or off-site. The primary aim of this study was to determine which patients received general anesthesia (GA) when the presence of thrombocytopenia was known versus suspected. The secondary aim was perioperative platelet counts of patients with suspected thrombocytopenia to determine how often GA may have been avoided in favor of SA if platelet count was known.

Learning objectivesBy reading this article, you should be able to:•Discuss the impact of resource limitation on the practice of obstetric anaesthesia.•Identify patients at high risk for adverse maternal outcomes in these settings.•Outline key areas where context-sensitive management might improve maternal outcomes.Key points•Perioperative maternal mortality rates are significantly higher in low- and middle-income countries than in high-income countries.•Evidence-based practice from these settings is limited and data are lacking.•The lack of trained anaesthetists is a key barrier to safe obstetric anaesthesia.•Identifying high-risk patients in advance may enable better use of limited resources.•Context-sensitive management may prevent complications in an accessible and safe manner. By reading this article, you should be able to:•Discuss the impact of resource limitation on the practice of obstetric anaesthesia.•Identify patients at high risk for adverse maternal outcomes in these settings.•Outline key areas where context-sensitive management might improve maternal outcomes. •Perioperative maternal mortality rates are significantly higher in low- and middle-income countries than in high-income countries.•Evidence-based practice from these settings is limited and data are lacking.•The lack of trained anaesthetists is a key barrier to safe obstetric anaesthesia.•Identifying high-risk patients in advance may enable better use of limited resources.•Context-sensitive management may prevent complications in an accessible and safe manner. Maternal and neonatal outcomes in low- and middle-income countries (LMICs) remain poor, despite gradual improvement. The global maternal mortality ratio (MMR) has declined from 339 to 223 deaths per 100,000 live births during the period 2000 to 2020, an annual reduction of 2.1% per year.1World Health OrganizationTrends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization, Geneva2023Google Scholar However, the MMR in sub-Saharan Africa in 2020 was 545 (from 807 in 2000), with a lifetime risk of maternal death of 1 in 40 (compared to 1 in 16,000 in Australia and New Zealand). In 2020, sub-Saharan Africa still accounted for 70% of the global mortality. These poor outcomes are the result of complex and multifactorial health systems deficiencies. A recent review in this journal outlined the causes and contributors to higher MMRs in LMICs.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar It discussed elements that are still relevant today, including the 3-delays model (transport, training and treatment), challenges related to systems and infrastructure, and the choice of anaesthesia for Caesarean section (CS), and methods for labour analgesia.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar The safe provision of anaesthesia remains a key goal to improve maternal and neonatal outcomes, although it is just one aspect within a complex, interconnected and interdependent obstetric healthcare system. There may be marked differences between the levels of accessible care even within LMIC. For example, in South Africa major referral hospitals provide suitable care for complex obstetric anaesthesia, but in peripheral areas, there are often inadequate anaesthesia skills and resources to provide routine care during CS. Labour epidural rates remain unacceptably low in state hospitals, even in referral centres.3van Zyl S.F. Burke J.L. Increasing the labour epidural rate in a state hospital in South Africa: challenges and opportunities.South Afr J Anaesth Analg. 2017; 23: 156-161Crossref Scopus (5) Google Scholar Similarly, there may be considerable differences in resources between countries classified as LMIC. This article focuses on specific anaesthesia practices that may contribute to improved outcomes, rather than the systems-level issues covered previously in this journal.2Pelland A. George R.B. Safe obstetric anaesthesia in low- and middle-income countries.BJA Educ. 2017; 17: 194-197Abstract Full Text Full Text PDF Google Scholar Although we concentrate on Africa, we believe that the underlying principles and contextual similarities make these suggestions globally applicable to resource-limited settings. Literature informing practice in LMICs originates from vastly different contexts.4du Toit L. Bougard H. Biccard B.M. The developing world of pre-operative optimisation: a systematic review of Cochrane reviews.Anaesthesia. 2019; 74: 89-99Crossref Scopus (7) Google Scholar Although this is to be expected given resource constraints that may preclude labour-intensive research, it highlights the need for context-sensitive solutions developed in conjunction with clinicians in that setting. We will discuss clinical anaesthetic approaches to LMIC concerns, based on the limited research available. We will also provide an update on anaesthesia-related morbidity and mortality in LMICs, including data from the South African National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD).5NCCEMD. SavingMothers 2011–2013: Sixth Report on the Confidential Enquiries into Maternal Deaths in South Africa. Compiled by the National Committee for Confidential Enquiry into Maternal Deaths, 2014Google Scholar,6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Many high-income countries (HICs) have processes that evaluate maternal outcomes, through confidential enquiries into maternal deaths. Until recently, South Africa was the only country that conducted this process in Africa. Kenya completed its first report in October 2016 (relating to deaths in 2014), although <15% of the actual deaths were reported and only half of these were assessed. The South African and the Kenyan processes highlighted similar problems: poor antenatal care, and a high number of avoidable deaths, particularly driven by obstetric haemorrhage and hypertensive disorders. Limited analysis of anaesthesia-related outcomes was available in the Kenyan report.7Mgamb E. Maua J.M. Okoro D. et al.Lives Saving Mothers 2017First Confidential Report into Maternal Deaths in Kenya.2017Google Scholar In contrast the 2017–2019 South African data suggested that anaesthesia contributed to 205/921 (22%) of maternal deaths after CS. In 66/921 (7%) of patients, deaths resulted primarily from complications of anaesthesia, whereas in a further 139/921 (15%), anaesthesia was contributory (mortality from another cause, such as obstetric haemorrhage, but action or inaction by the anaesthetist might have contributed significantly to the death or events ultimately leading to death).6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Thus anaesthesia contributed to one in five perioperative maternal deaths, often including an avoidable component such as delayed or poor resuscitation, delay in recognition of complications and inappropriate method of anaesthesia. The African Surgical Outcomes Study (ASOS) showed that many regions in Africa have inadequate workforce density, and maternal and neonatal mortality remain unacceptably high, driven largely by haemorrhage and anaesthesia complications.8Biccard B.M. Madiba T.E. Kluyts H.-L. et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar,9Bishop D. Dyer R.A. Maswime S. et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Whereas the complication rate of CS is only two to three times higher in women in Africa, maternal mortality is 50 times higher than in their HIC counterparts. This illustrates the concept of ‘failure-to-rescue’: when perioperative complications occur, the ‘rescue’ of these patients requires resources that are lacking, such as monitoring, skilled practitioners, blood products and intensive care support. The prevention and early detection of complications, in tandem with context-sensitive management solutions, are therefore a key priority. Poor maternal outcomes are compounded by inadequate CS rates, which should be up to 19%,10Molina G. Weiser T.G. Lipsitz S.R. et al.Relationship between Cesarean delivery rate and maternal and neonatal mortality.JAMA. 2015; 314: 2263-2270Crossref PubMed Google Scholar but are <10% in more than half of African countries, indicating a deficiency in access to surgery.11Sobhy S. Arroyo-Manzano D. Murugesu N. et al.Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis.Lancet. 2019; 393: 1973-1982Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar There is also an increased morbidity and mortality that occurs in the absence of adequate numbers of trained anaesthesia providers.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar In LMICs, obstetric anaesthesia deaths occur at rate of 1.2 per 1000, and represent 13.8% of all deaths after CS—compared with 3.8–6.5 per million in the USA. Anaesthesia is responsible for 2.8% of all maternal deaths in LMICs, with general anaesthesia (GA) resulting in a five-fold higher mortality rate than spinal anaesthesia.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar In Malawi, poorly trained anaesthesia providers have been found to have almost three times higher maternal mortality rates compared with trained anaesthesia providers.13Fenton P.M. Whitty C.J. Reynolds F. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality.BMJ. 2003; 327: 587Crossref PubMed Google Scholar A lack of robust data makes it impossible to determine whether non-physician anaesthesia providers (NPAPs) are associated with worse maternal outcomes than physician anaesthesia providers (PAPs) within any particular jurisdiction.12Sobhy S. Zamora J. Dharmarajah K. et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Abstract Full Text Full Text PDF PubMed Google Scholar An inflection point regarding optimal number of anaesthetists has been described, below which maternal mortality increases precipitously.14Davies J.I. Vreede E. Onajin-Obembe B. Morriss W.W. What is the minimum number of specialist anaesthetists needed in low-income and middle-income countries?.BMJ Glob Health. 2018; 3e001005Crossref Scopus (31) Google Scholar The authors suggest that a minimum of four specialist anaesthetists per 100,000 of the population are required to achieve a minimum standard of healthcare. Only five African countries have more than one PAP per 100,000 of the population (Fig. 1), and HICs have 90 times the number of PAPs compared with low-income countries (LICs).15Kempthorne P. Morriss W.W. Mellin-Olsen J. Gore-Booth J. The WFSA global anesthesia workforce survey.Anesth Analg. 2017; 125: 981-990Crossref PubMed Scopus (168) Google Scholar Despite the fact that this proportion is exceeded in South Africa, the South African confidential enquiry process confirmed that in some areas, unqualified junior doctors and clinical associates were providing anaesthesia care in unsupervised settings, and that in 2.5% of deaths the designated anaesthetist was also an assistant at surgery.6Lundgren A.C. Trends in maternal deaths associated with anaesthesia in the triennium 2017–2019.O&G Forum. 2020; 30: 46-47Google Scholar Workforce deficiencies usually coexist with poor operative capacity. One study in LMICs, including three African countries, suggested that one-third of hospitals do not have access to reliable electricity, one-quarter do not have access to oxygen, three-quarters do not have pulse oximetry for routine monitoring and half of hospitals do not have a recovery area.16LeBrun D.G. Chackungal S. Chao T.E. et al.Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.Surgery. 2014; 155: 365-373Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar A survey conducted in referral hospitals in East Africa showed that none of the hospitals had all the necessary requirements to provide safe obstetric anaesthesia (based on the availability of drugs, equipment, monitoring and anaesthesia machines), and only 7% reported adequate staffing.17Epiu I. Tindimwebwa J.V. Mijumbi C. et al.Challenges of anesthesia in low- and middle-income countries: a cross-sectional survey of access to safe obstetric anesthesia in East Africa.Anesth Analg. 2017; 124: 290-299Crossref PubMed Scopus (66) Google Scholar Providing guidance to inexperienced anaesthetists is challenging in the absence of these minimum standards. Single-shot spinal anaesthesia remains the safest choice for CS in most patients in LMICs. However, it is probably true that spinal anaesthesia is performed inappropriately in many patients in variable resource countries, resulting from concerns about the ability to perform a safe general anaesthetic, because of the lack of availability of trained staff or basic equipment. Data from Africa have shown that spinal anaesthesia is often performed in patients with conditions such as abnormal placentation or even a ruptured uterus, or eclampsia associated with a low Glasgow Coma Scale (GCS).9Bishop D. Dyer R.A. Maswime S. et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Most practitioners are comfortable with performing spinal anaesthesia in healthy patients, but often cannot manage complications should they arise, whether in healthy or compromised patients.Clinical scenario 1In a district hospital in Uganda, a woman is scheduled for CS as a result of obstructed labour. She is assessed by an NPAP, who decides to perform spinal anaesthesia. The patient has a mild tachycardia and is experiencing uterine contractions while the spinal anaesthetic is performed. Soon after commencement of surgery, the patient complains of numbness in the hands, and subsequently becomes drowsy. The NPAP notices a slow heart rate, but the blood pressure is undetectable, and there is no pulse oximetry available. After checking the blood pressure cuff and restarting the machine, the NPAP notices that the patient is unconscious and is not breathing. Mask ventilation is commenced, but the patient quickly progresses to a cardiac arrest. The surgeon (a general practitioner) assists with a full resuscitation. Following treatment with adrenaline (epinephrine) and fluids there is a return of spontaneous circulation, but both the mother and neonate have suffered significant neurological injury. In a district hospital in Uganda, a woman is scheduled for CS as a result of obstructed labour. She is assessed by an NPAP, who decides to perform spinal anaesthesia. The patient has a mild tachycardia and is experiencing uterine contractions while the spinal anaesthetic is performed. Soon after commencement of surgery, the patient complains of numbness in the hands, and subsequently becomes drowsy. The NPAP notices a slow heart rate, but the blood pressure is undetectable, and there is no pulse oximetry available. After checking the blood pressure cuff and restarting the machine, the NPAP notices that the patient is unconscious and is not breathing. Mask ventilation is commenced, but the patient quickly progresses to a cardiac arrest. The surgeon (a general practitioner) assists with a full resuscitation. Following treatment with adrenaline (epinephrine) and fluids there is a return of spontaneous circulation, but both the mother and neonate have suffered significant neurological injury. Spinal hypotension is usually a consequence of sympathectomy, and rarely may result from a high spinal anaesthetic (manifesting as hypotension, bradycardia and a high spinal sensory level to the cervical dermatomes). Guidelines for the management of high spinal anaesthesia are available, which include suggestions for emergency inotrope infusions in the absence of a syringe pump (adrenaline [epinephrine] 1 mg in 1 L modified Ringer's lactate solution).18van Rensburg G. van Dyk D. Bishop D.G. et al.The management of high spinal anaesthesia in obstetrics: suggested clinical guideline in the South African context.South Afr J Anaesth Analg. 2016; 22: S1-S5Google Scholar Pattern recognition should be taught of the haemodynamic presentations of all the causes of spinal hypotension. This is particularly important where anaesthesia providers with minimal experience are practicing without supervision by a senior anaesthetist.19van Dyk D. Dyer R.A. Bishop D.G. Spinal hypotension in obstetrics: context-sensitive prevention and management.Best Pract Res Clin Anaesthesiol. 2022; 36: 69-82Crossref PubMed Scopus (0) Google Scholar It is crucial that spinal anaesthesia is given only to appropriate patients, avoiding patients in whom a sympathectomy could cause rapid decompensation, such as those with hypovolaemia, or when major haemorrhage is present or expected. Unexplained tachycardia (heart rate >120–140 beats min−1) should be a relative contraindication to spinal anaesthesia and requires discussion with the best qualified anaesthesia provider, and further investigation as indicated. The management of spinal hypotension should include fluids and early initiation of appropriate vasopressor drugs, optimally phenylephrine if available, or other agents such as ephedrine, etilefrine, metaraminol or adrenaline.20Heesen M. Carvalho B. Carvalho J.C.A. et al.International consensus statement on the use of uterotonic agents during caesarean section.Anaesthesia. 2019; 74: 1305-1319Crossref PubMed Scopus (71) Google Scholar In the setting of precipitous hypotension unresponsive to phenylephrine or ephedrine, adrenaline boluses may be required (10–50 μg), in conjunction with airway management if needed. Hypotension during routine spinal anaesthesia is both likely and predictable and should be managed proactively if possible. Given that hypotension occurs in >70% of patients and is severe in >20%, the use of prophylactic vasopressor infusions is advised. A titrated phenylephrine infusion remains the gold standard,21Kinsella S.M. Carvalho B. Dyer R.A. et al.International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia.Anaesthesia. 2018; 73: 71-92Crossref PubMed Scopus (247) Google Scholar but fixed-rate, low-dose infusions have been shown to be effective in variable resource settings in the hands of junior doctors.22Bishop D.G. Cairns C. Grobbelaar M. Rodseth R.N. Prophylactic phenylephrine infusions to reduce severe spinal anesthesia hypotension during Cesarean delivery in a resource-constrained environment.Anesth Analg. 2017; 125: 904-906Crossref Scopus (23) Google Scholar Where infusion pumps are unavailable, adding vasopressor (phenylephrine 500 μg) to the first litre of fluid after spinal anaesthesia may also be safe and effective.23Buthelezi A.S. Bishop D.G. Rodseth R.N. Dyer R.A. Prophylactic phenylephrine and fluid co-administration to reduce spinal hypotension during elective caesarean section in a resource-limited setting: a prospective alternating intervention study.Anaesthesia. 2020; 75: 487-492Crossref Scopus (5) Google Scholar A recent review of these practices in LMICs deals with the subject in more detail.19van Dyk D. Dyer R.A. Bishop D.G. Spinal hypotension in obstetrics: context-sensitive prevention and management.Best Pract Res Clin Anaesthesiol. 2022; 36: 69-82Crossref PubMed Scopus (0) Google Scholar Regardless of how they are given, the early use of vasopressors is recommended. Recently, there has been considerable research in HICs into noradrenaline (norepinephrine) for both prophylaxis and treatment of spinal hypotension, predominantly motivated by the mild beta-adrenergic activity of noradrenaline. However, research has been conducted predominantly in resource-rich contexts. Current evidence is unconvincing even in HICs for any clinically significant benefits of potent agents such as noradrenaline. In LMICs this agent should be avoided as clinicians are unfamiliar with the drug and unable to monitor for adverse effects. In addition, syringe pumps are often unavailable, and the risk of catastrophic dose error is significant. In the rare situation in which phenylephrine is associated with bradycardia and hypotension, small doses of anticholinergic agents or ephedrine would suffice. Spinal anaesthesia may require conversion to GA, either because of complete or partial failure of the block, protracted surgery, or haemodynamic instability. The decision to convert to GA because of pain should be guided by the risk associated with GA in that context. This is likely increased in proportion to the shortage of equipment available to anaesthesia providers, and their lack of training. Recent guidelines have been published for the management of intraoperative pain and include modifications for variable resource countries.24Plaat F. Stanford S.E.R. Lucas D.N. et al.Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach.Anaesthesia. 2022; 77: 588-597Crossref PubMed Scopus (17) Google Scholar Conversion to GA either for protracted surgery or haemodynamic instability requires a higher level of anaesthesia expertise, particularly with respect to airway management. Tracheal intubation may be technically more challenging in a patient draped and prepared for surgery. Whereas exact details of the practice of GA for CS in Africa are unavailable, in Sierra Leone, the use of ketamine without intubation is commonly performed.25Lonnee H.A. Taule K. Knoph Sandvand J. et al.A survey of anaesthesia practices at all hospitals performing caesarean sections in Sierra Leone.Acta Anaesthesiol Scand. 2021; 65: 404-419Crossref Scopus (1) Google Scholar It is likely that i.v. or i.m. ketamine is often used without definitive airway management. Recently, a prospective case-series from Kenya analysed 401 emergency CS that were conducted by 54 non-anaesthesia providers using ketamine-based anaesthesia (ESM-Ketamine), in circumstances where no anaesthetist was available.26Burke T.F. Mantena S. Opondo K. Orero S. Rogo K. A ketamine package for use in emergency cesarean delivery when no anesthetist is available: an analysis of 401 consecutive operations.Int J Gynaecol Obstet. 2022; 158: 377-384Crossref Scopus (3) Google Scholar There were no serious adverse maternal events and all mothers survived to hospital discharge. Further data related to the prevalence and safety of the various practices used for GA in LMICs are urgently required, and currently under investigation in the ASOS studies. Following the World Health Organization's recommendation to use tranexamic acid early in the management of obstetric haemorrhage at CS, there has been a concerning increase in the number of intrathecal tranexamic acid injections, associated with a high mortality.27Moran N.F. Bishop D.G. Fawcus S. et al.Tranexamic acid at caesarean delivery: drug error deaths.Am J Obstet Gynecol. 2023; 228: 1-4Abstract Full Text Full Text PDF PubMed Google Scholar Clinical presentation typically follows initial failure of the spinal anaesthesia, proceeding to a seizure and sympathetic hyperactivity, which may be mistaken for eclampsia. This arises because of a drug error caused by similarities in the size and appearance of tranexamic acid and bupivacaine ampoules, compounded by storage of the two drugs in close proximity to each other. Systems are necessary that allow for timely use of tranexamic acid, but reduce the risk of drug error. Improved procedures for checking of ampoules, and ultimately re-design of the ampoules so that they are clearly distinguishable, are recommended. Tranexamic acid should be stored in a separate location to bupivacaine, either in a sealed box containing drugs used specifically for obstetric haemorrhage, or just outside the operating theatre, where the drug can be accessed quickly for use when required.27Moran N.F. Bishop D.G. Fawcus S. et al.Tranexamic acid at caesarean delivery: drug error deaths.Am J Obstet Gynecol. 2023; 228: 1-4Abstract Full Text Full Text PDF PubMed Google Scholar With the increased use of spinal anaesthesia for CS, it is possible that junior clinicians have become less proficient in the management of the obstetric airway, as a consequence of a lack of regular exposure. Hypoxaemia (Spo2 <90%) is a relatively common event during the management of the obstetric airway in anaesthesia departments in South Africa, occurring in one in six patients.28Tomlinson J.M.B. Bishop D.G. Hofmeyr R. Cronje L. Rodseth R.N. The incidence and predictors of hypoxaemia during induction of general anaesthesia for caesarean delivery in two South African hospitals: a prospective, observational, dual-centre study.South Afr J Anaesth Analg. 2020; 26: 180-187Google Scholar Guidelines exist for the management of the difficult airway in obstetric anaesthesia.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Calls for the availability of a videolaryngoscope in all obstetric theatres are unlikely to be realised because of cost restraints. In addition, training in their use is in short supply. However, many of the basic principles of modern airway management are available and accessible in variable resource countries through education and training. These include the following practices29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar:•Adequate preoperative assessment of the airway•Elevation of the head by 25°•Ramping (horizontal alignment between the external auditory meatus and the sternal notch)•Preoxygenation (end-tidal oxygen fraction >0.9)•Apnoeic insufflation by face mask before tracheal intubation•Considering early mask ventilation at pressures ≤20 cmH2O during induction of anaesthesia, if there is a high risk of hypoxaemia, or in the event of difficult intubation Amendments to traditional rapid-sequence induction should be taught routinely, including the early release of cricoid pressure if laryngoscopy is difficult, and the use of low-pressure mask ventilation.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Appropriate teaching of the use of the Macintosh blade is essential, and should be supplemented with online teaching and simulation where necessary. These principles are essential in ensuring that an ‘easy airway’ is not converted to a ‘difficult airway’ through deficiencies in technique and positioning. Early use of a rescue airway such as the supraglottic airway device should be encouraged, as indicated in the most recent difficult airway algorithm.29Mushambi M.C. Kinsella S.M. Popat M. et al.Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.Anaesthesia. 2015; 70: 1286-1306Crossref PubMed Scopus (338) Google Scholar Hypertensive disorders of pregnancy are a leading cause of mortality in LMICs.30van Dyk D. Dyer R.A. Fernandes N.L. Preeclampsia in 2021—a perioperative medical challenge for the anesthesiologist.Anesthesiol Clin. 2021; 39: 711-725Abstract Full Text Full Text PDF PubMed Google Scholar Late presentation and delayed treatment often compound the severity of this multisystem disorder. In preeclampsia with severe features, rapid clinical deterioration is possible, particularly where cardiovascular involvement is present. Point-of-care ultrasound evaluation of the heart and lungs has utility in the assessment of disease severity and strategic anaesthesia choices. However, although handheld devices are becoming more affordable and increasingly used in variable resource countries, this equipment and experience are unlikely to be routinely available in many LMICs. In the absence of a reliable measurement of stroke volume responsiveness, fluid restriction is likely the safer general strategy. Adequate control of the blood pressure on admission and before

BACKGROUND:Current guidelines recommend prophylactic vasopressor administration during spinal anesthesia for cesarean delivery to maintain intraoperative blood pressure above 90% of the baseline value. We sought to determine the optimum baseline mean arterial pressure (MAP) reading to guide the management of spinal hypotension. METHODS:We performed a secondary analysis of data collected from normotensive patients presenting for elective cesarean delivery in a tertiary care institution from October 2018 to August 2020. We compared the magnitude of hypotension in patients who reported nausea versus those who did not, using a case-control design. Baseline MAPs at last office visit, morning of surgery, or operating room (pre-spinal) were determined. We calculated the duration and degree of hypotension using the area under the curve (AUC) when the MAP of the respective patient was below 90% of each baseline. RESULTS:The patients who experienced nausea (n=45) had longer and more profound periods of hypotension than those who did not develop nausea (n=240). A comparison of AUC using MAP baseline at the last office visit or on the morning of surgery showed a statistically significant between-group difference, P=0.02, and P=0.005, respectively, and no significant between-group difference when 90% of the MAP baseline in the operating room was used. CONCLUSIONS:Patients had the highest preoperative MAP in the operating room and the AUC was similar for those with and without nausea when the pre-spinal MAP baseline was used. Therefore, maintaining higher intraoperative blood pressure using individual pre-spinal MAP as baseline should reduce intraoperative maternal nausea.

South Africa is classified as a low-and middle-income country, with a complex mixture of resource-rich and resource-limited settings. In the major referral hospitals, the necessary skill level exists for the management of complex challenges. However, this contrasts with the frequently-inadequate skill levels of anaesthesia prac-titioners in resource-limited environments.In Japan, obstetricians administer anaesthesia for 40% of caesarean deliveries and 80% of labour analgesia. Centralisation of delivery facilities is now occurring and it is expected that obstetric anaesthesiologists will be available 24 h a day in centralised facilities in the future.In China, improvements in women's reproductive, maternal, neonatal, child, and adolescent health are crit-ical government policies. Obstetric anaesthesia, especially labour analgesia, has received unprecedented atten-tion. Chinese obstetric anaesthesiologists are passionate about clinical research, focusing on efficacy, safety, and topical issues.The Latin-American region has different landscapes, people, languages, and cultures, and is one of the world's regions with the most inequality. There are large gaps in research, knowledge, and health services, and the World Federation of Societies of Anaesthesiologists is committed to working with governmental and non-governmental organisations to improve patient care and access to safe anaesthesia.Anaesthesia workforce challenges, exacerbated by coronavirus disease 2019, beset North American health-care. Pre-existing struggles by governments and decision-makers to improve health care access remain, partly due to unfamiliarity with the role of the anaesthesiologist. In addition to weaknesses in work environments and dated standards of work culture, the work-life balance demanded by new generations of anaesthesiologists must be acknowledged.

BACKGROUND: In resource-limited environments, spinal anesthesia (SA) is preferred for cesarean delivery. In women at risk of spinal epidural hematoma, particularly those with hypertensive disorders of pregnancy, thrombocytopenia should be excluded before neuraxial blockade. In the context of emergency surgery for fetal distress, this investigation may be hampered by laboratory services being unavailable or off-site. METHODS: The Obstetric Airway Management Registry (ObAMR) is currently active across all anesthesia training institutions affiliated with the University of Cape Town. This multicenter observational study aimed to estimate the proportion of patients receiving general anesthesia (GA) for either confirmed or suspected thrombocytopenia, which was not excluded due to unavailability of laboratory results. To establish the number of GA uses that may have been avoided if platelet counts were available, we retrospectively searched for subsequent platelet counts in patients for whom thrombocytopenia was suspected. An algorithm was proposed, including a simple decision aid for estimating risk versus benefit of SA versus GA, to be followed in the setting of hypertensive disorders of pregnancy and thrombocytopenia. RESULTS: Thrombocytopenia was the indication for GA in 100 of 591 patients (16.9%) captured in the registry. In total, 48 of 591 (8.1%) had confirmed thrombocytopenia, and 52 of 591 (8.8%) had suspected thrombocytopenia. Of these patients, 91 of 100 had a hypertensive disorder of pregnancy. In the confirmed thrombocytopenia group, the indication for GA was a platelet count <75 × 109/L. In the suspected thrombocytopenia group, 46 of 52 (88.5%) platelet counts could be retrospectively traced. The median (interquartile range) platelet count was 178 × 109/L (93 – 233 × 109/L), and platelets exceeded 75 × 109/L in 41 of 46 patients (89.1%). In the 5 of 46 patients with retrospectively confirmed thrombocytopenia, 2 had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, 2 had antepartum hemorrhage with preeclampsia, and 1 had isolated thrombocytopenia with preeclampsia. CONCLUSIONS: In 17% of patients, the indication for GA was thrombocytopenia. Of these, 52 of 100, or nearly 9% of the total of 591, received GA because a platelet count was unavailable at the time of surgery. The importance of early laboratory assessment, when available, should be emphasized. Overall, 41 of 591 (6.9%) had a platelet count >75 × 109/L and would not have needed GA if their platelet count had been known. After following the constructed algorithm and applying the decision aid to assess risk and benefit, there may be circumstances in which the clinician justifiably opts for SA when a platelet count is indicated but unavailable.

Background: The ease of administration and relative safety of spinal anaesthesia have made this the preferred technique for both elective and many emergency caesarean sections. Complications include incomplete sensory block, resulting in intraoperative breakthrough pain, which is commonly associated with a successful medicolegal claim. If documentation of the spinal anaesthesia technique was found to be inadequate during the course of the medicolegal proceedings, it is likely that the decision would be against the anaesthetist. The purpose of this study was to evaluate documentation by anaesthetists relating to the establishment of surgical anaesthesia utilising subarachnoid block. Methods: A retrospective folder analysis was conducted at Mowbray Maternity Hospital in Cape Town, South Africa. One hundred consecutive spinal anaesthesia charts, each completed by a different anaesthetist, either a registrar or specialist, were analysed. Starting from 31 December 2018 and proceeding retrospectively in time, charts were included until the desired sample size was achieved. Results: Of the 100 cases of spinal anaesthesia for caesarean section analysed, 68 were emergency and 32 were elective operations. Following a literature review, 12 variables were identified that required documentation so that adequate information would be available in the event of medicolegal action. Of these variables, 7 and 8 were recorded in 23% and 32% of the charts, respectively. Ninety per cent of the anaesthesia charts had inadequate documentation, defined as information on fewer than 10 of the specified variables. Conclusion: The quality of documentation of both the procedure and block level during spinal anaesthesia for caesarean section was inadequate. National guidelines should be drafted and standardised to improve the quality of these records, both for quality of care and medicolegal purposes.

Spinal hypotension during caesarean section remains a common complication, with important attendant maternal and fetal adverse outcomes. Research elucidating the mechanisms of spinal hypotension has led to the development and refinement of effective management strategies, with a particular emphasis on prophylactic vasopressor administration. This has proved effective in well-resourced settings, with maternal comfort and the elimination of nausea now considered the primary aim of treatment. In resource-limited settings, sophisticated strategies are not feasible due to insufficient equipment, staff, and expertise. Therefore, in these areas spinal hypotension remains an important cause of maternal and fetal morbidity and mortality. Translational, context-sensitive research in resource-limited settings has shown promise in implementing pragmatic strategies based on research from resource-rich environments. We review the current best practice for the prevention and treatment of spinal hypotension, with a special emphasis on effective strategies in resource-limited settings. We further suggest a research agenda to address the knowledge gap in specific contexts.

BACKGROUND:In South Africa, hypertensive disorders of pregnancy are the leading cause of maternal mortality. More than 50% of anaesthesia-related maternal deaths are attributed to complications of airway management. We compared the prevalence and risk factors for hypoxaemia during induction of general anaesthesia in parturients with and without hypertensive disorders of pregnancy. We hypothesised that hypertensive disorders of pregnancy are associated with desaturation during tracheal intubation.METHODS:Data from 402 cases in a multicentre obstetric airway management registry were analysed. The prevalence of peri-induction hypoxaemia (SpO2 <90%) was compared in patients with and without hypertensive disorders of pregnancy. Quantile regression of SpO2 nadir was performed to identify confounding variables associated with, and mediators of, hypoxaemia.RESULTS:In the cohort of 402 cases, hypoxaemia occurred in 19% with and 9% without hypertension (estimated risk difference, 10%; 95% CI 2% to 17%; P=0.005). Quantile regression demonstrated a lower SpO2 nadir associated with hypertensive disorders of pregnancy as body mass index increased. Room-air oxygen saturation, Mallampati grade, and number of intubation attempts were associated with the relationship.CONCLUSIONS:Clinically significant oxygen desaturation during airway management occurred twice as often in patients with hypertensive disorders of pregnancy, compounded by increasing body mass index. Intermediary factors in the pathway from hypertension to hypoxaemia were also identified.

The authors provide a review of recent advances in the understanding of pathophysiology and perioperative management of preeclampsia and eclampsia, from the perspective of the anesthesiologist. This review includes aspects of assessment of severity of disease, hemodynamic monitoring, peripartum anesthesia care, and postpartum management. The perioperative management of patients with eclampsia is also discussed.

Background. The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in sub-Saharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. Objectives. To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. Methods. This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. Results. Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 mL/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5%, respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years. Conclusions. The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients’ CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.

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-par tum. 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.