A retrospective audit of anaesthesia for caesarean section in parturients with eclampsia at a tertiary referral hospital in Cape Town

Abstract

Background: Anaesthesia for caesarean section (CS) in women with eclampsia is a major clinical challenge, and there are limited data concerning the rationale for the choice of technique, and short-term outcomes. A retrospective audit was performed on practice at a tertiary referral centre in Cape Town. Methods: The primary outcome of the audit was the proportion of patients with eclampsia receiving either spinal anaesthesia (SA) or general anaesthesia (GA) for CS, and an assessment of the rationale for the choice of method. In addition, short-term maternal and neonatal outcomes were recorded. Results: There were 11 exclusions in 100 patient records screened, therefore 89 were analysed. Seven/89 (7.9%) patients received SA and 82/89 (92.1%) GA. Overall, 63/89 (70.8%) patients had a preoperative GCS < 14, and 26/89 (29.2%) ≥ 14. Seven/26 patients with GCS ≥ 14 had SA; the remaining 19/26 received GA. GA was performed because there was no platelet count available in three, pulmonary oedema in two, difficult airway due to a bitten tongue in two, fetal bradycardia in two, HELLP syndrome in one, renal failure in one, and patient refusal in one patient. In seven women, there was no clear reason for GA. Median (IQR) Apgar scores at 1 minute in SA patients (8 [8–9]) were higher than those in GA patients with GCS ≥ 14 (5 [3–6]) and < 14 (4 [2–6]), p = .008 and .001 respectively. At five minutes, neonates of SA patients had median scores of 10 [9–10], compared with 8 [7–8] in those of GA patients with GCS ≥ 14, and 8 [7–9] in those with GCS < 14, p = .007 and .019 respectively. There were two stillbirths and two neonatal deaths in the GA group. Patients with GCS ≥ 14 receiving GA required mechanical ventilation for 0 [0–1] days, and those with GCS < 14 were ventilated for 1 [1–2] days. No patients receiving SA required postoperative ventilation, compared with 5/19 (26.3%) patients with GCS ≥ 14 who received GA. Seven/63 patients with GCS < 14 had cerebral oedema, and two had a cerebral infarct. There were two maternal deaths. Conclusions: The small percentage of women with eclampsia who received SA for CS, experienced good maternal and fetal outcomes, and more patients could have safely received SA. Larger prospective audits in high- and low-resource environments are required to establish factors influencing the context-sensitive choice of method of anaesthesia, and risk versus benefit of GA versus SA for CS in women with eclampsia.

The power of marginal gains in obstetric anaesthesia

“…Jordaan and colleagues add to the knowledge base with their retrospective study comparing outcomes in eclamptic women who received either general or spinal anaesthesia for caesarean delivery. 21 Jordaan's findings confirm what is perhaps already generally accepted, that general anaesthesia in women who have suffered an eclamptic seizure is associated with higher neonatal and maternal morbidity and mortality, and spinal anaesthesia can be used safely in many patients. The authors highlight the concept of a woman with 'stable eclampsia' .…”

Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study

“…It is debatable whether this practice is appropriate. In a recent audit of practice by Jordaan et al 12 in Cape Town, only 7 of 89 (7.9%) of eclamptic patients were deemed suitable for SA. The majority were excluded due to Glasgow Coma Scale (GCS) <14 (70.8%).…”