1. Obstetrics Nuala Lucas OAA

2. What we knew before NAP6
Had received very limited prospective examination
available knowledge case reports/series & reviews
Scottish Confidential Audit of Severe Maternal Morbidity
3/100,000 births
Retrospective US review
2.7 / 100,000 deliveries
UK Obstetric Surveillance System
1.6 / 100,000 maternities

3. Specific concerns for obstetrics
Two ‘patients’
Broad differential diagnosis
Latex allergy?

4. Obstetric cases 8 cases identified
NAP6 Activity Survey estimated 233,886 obstetric anaesthetics are administered PA in UK
Incidence of severe obstetric perioperative anaphylaxis of 3.4 per 100,000 (95% CI per 100,000)
6 cases associated with neuraxial anaesthesia, 2 cases associated with general anaesthesia

5. Numerical analysis Operative procedure Category 1 CS Category 3 CS
EUA/PPH
Unknown 2 4 1

6. Mon-Fri ‘daytime hours’
Numerical analysis
Operative procedure
Category 1 CS
Category 3 CS
EUA/PPH
Unknown 2 4 1
Timing
Mon-Fri ‘daytime hours’
Out of hours 3 5

7. Mon-Fri ‘daytime hours’
Numerical analysis
Operative procedure
Category 1 CS
Category 3 CS
EUA/PPH
Unknown 2 4 1
Timing
Mon-Fri ‘daytime hours’
Out of hours 3 5
Anaesthetist
Consultant
NCCG
Trainee 3 2

8. Mon-Fri ‘daytime hours’ Anaesthetist for resus
Numerical analysis
Operative procedure
Category 1 CS
Category 3 CS
EUA/PPH
Unknown 2 4 1
Timing
Mon-Fri ‘daytime hours’
Out of hours 3 5
Anaesthetist for resus
Consultant
Unknown 7 1

9. Presentation
4/6 patients who developed anaphylaxis assoc with neuraxial anaesthesia complained of feeling unwell prior to the onset of hypotension or other clinical signs
‘New’hypotension
In 4 cases (both GA and 2/6 neuraxial cases) there was prompt recognition of the clinical event
Only one case (neuraxial anaesthesia) was the event promptly recognised as anaphylaxis

10. ‘New’ hypotension

11. Management Chlorphenamine 5/8 Hydrocortisone 6/8
Fluid mx appropriate ?
Anaphylaxis pack
2/8

12. Management Chlorphenamine 5/8 Hydrocortisone 6/8
Fluid mx appropriate ?
Anaphylaxis pack
2/8

13. Outcomes Post event Aftercare Baby 5/6 caesarean section cases
No cardiac arrests
Aftercare
ITU/Recovery/Operating theatre/Observation bay on LW – 2/2/2/2
3/5 delayed hospital discharge
One woman reported anxiety re future anaesthetics
Baby
5/6 caesarean section cases
– onset after delivery of baby
1/6 onset immediately before delivery of baby

14. Culprits

15. Recommendations Individual Institutional
An allergy history should be taken even when there is extreme urgency to deliver the baby
Anaesthetists should be vigilant to non-obstetric causes of hypotension in obstetric patients
Anaphylaxis should be actively considered where the cause of maternal hypotension or collapse is unclear, and mast cell tryptase levels should be measured
Anaphylaxis in obstetric patients should be managed following the same principles as in non-obstetric patients.
Anaesthetists should be aware that hypotension due to anaphylaxis can be exacerbated by neuraxial blockade and or aortocaval compression
Institutional
Obstetric units should ensure immediate availability of anaesthetic anaphylaxis treatment and investigation packs wherever general or regional anaesthesia is administered

16. Other findings - choice of induction agent

17. Any questions?