Obstetrik Anestezi ve Analjezide Yenilikler ve Postoperatif Ağrı Yönetimi
Özet
Obstetrik anestezi; vajinal doğum, sezaryen, emzirme ve anne resüsitasyonu gibi geniş alanları kapsayan multidisipliner bir uzmanlık dalıdır. Son yıllarda bu alandaki teknolojik ve farmakolojik gelişmeler, anne güvenliğini artırırken komplikasyon yönetimini kolaylaştırmıştır. Gebelerde rutin preoperatif değerlendirme; özellikle zor havayolu riski, yandaş hastalıklar ve nöroaksiyel yöntemler için sırt muayenesini içermelidir. Güncel Obstetrik ASA sınıflaması ve antikoagülan kullanım kılavuzları, hasta yönetiminde kritik rol oynamaktadır. Doğum analjezisinde dural ponksiyon epidural (DPE) gibi yeni yöntemler, geleneksel epidural ve kombine spinal-epidural tekniklere etkili alternatifler sunmaktadır. Sezaryen operasyonlarında tek doz spinal anestezi, hızı ve etkinliği nedeniyle altın standart olmaya devam etmektedir. Postoperatif dönemde ise multimodal ağrı yönetimi; nöroaksiyel morfin, NSAİİ'ler ve uygun durumlarda transversus abdominis plane (TAP) gibi periferik blokların kullanımıyla hem analjezik etkinliği artırmakta hem de yan etkileri minimize etmektedir. Ayrıca, COVID-19 pandemisi sürecinde viral yükü azaltmak adına genel anestezi yerine nöroaksiyel tekniklerin tercih edilmesi vurgulanmıştır. Sonuç olarak, güncel literatürün takibi ve multidisipliner yaklaşım, obstetrik hastaların perioperatif bakım kalitesini ve konforunu iyileştirmektedir.
Obstetric anesthesia is a multidisciplinary field encompassing various areas such as vaginal delivery, cesarean section, breastfeeding, and maternal resuscitation. In recent years, technological and pharmacological advancements in this field have enhanced maternal safety while facilitating complication management. Routine preoperative evaluation in pregnant women must include airway assessment due to the risk of difficult airways, comorbid diseases, and back examination for neuraxial methods. Current Obstetric ASA classifications and anticoagulant use guidelines play a critical role in patient management. In labor analgesia, new methods such as dural puncture epidural (DPE) offer effective alternatives to traditional epidural and combined spinal-epidural techniques. Single-dose spinal anesthesia remains the gold standard for cesarean operations due to its speed and efficacy. In the postoperative period, multimodal pain management—utilizing neuraxial morphine, NSAIDs, and peripheral blocks like the transversus abdominis plane (TAP) when appropriate—increases analgesic efficacy while minimizing side effects. Additionally, during the COVID-19 pandemic, the preference for neuraxial techniques over general anesthesia to reduce viral load was emphasized. In conclusion, following current literature and adopting a multidisciplinary approach continuously improves the quality and comfort of perioperative care for obstetric patients.
Referanslar
Butterworth J.F., Mackey D.C., Wasnick J.D. Morgan & Mikhail Klinik Anesteziyoloji (6.Baskı) (F.Handan CUHRUK, Çev. Ed.). Ankara: Güneş Kitapevleri; 2021.
Grace L., Francesca L. F., Naveen N. et al. A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes. Anesthesiology. 2018 Jul; 129(1): 192–215. doi: 10.1097/ALN.0000000000002182.
American Society of Anesthesiologists Physical Status Classification System. Committee of Oversight: Economics. (21.02.2022 tarihinde https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system adresinden ulaşılmıştır) .
Türk Anesteziyoloji ve Renanimasyon Derneği. Sezaryende Güncel Anestezi Protokolü Ve Yenilikler 2021. (21.02.2022 tarihinde http://www.tard.org.tr/akademi/?p=kilavuz-detay&bID=40&session=13977228303072-27954456606144 adresinden ulaşılmıştır) .
The American College of Obstetricians and Gynecologists . Obstetric Analgesia and Anesthesia, ACOG Practice Bulletin, Committee on Practice Bulletins—Obstetrics, 2019. (21.02.2022 tarihinde https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/obstetric-analgesia-and-anesthesia adresinden ulaşılmıştır) .
Palmerola KL, D'Alton ME, Brock CO et al. A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines. BJOG. 2016;123: 2157–2162.
Terese T. H., Vandermeuelen E., Kopp S. et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition), Reg Anesth Pain Med 2018;43: 263–309
Norris MC. Patient variables and the subarachnoid spread of hyperbaric bupivacaine in the term parturient. Anesthesiology. 1990; 72:478–82.
Wahba Z. Bakhet. A randomized comparison of epidural, dural puncture epidural, and combined spinal epidural without intrathecal opioids for labor analgesia. Anaesthesiol Clin Pharmacol. 2021 Apr-Jun; 37(2): 231–236. doi: 10.4103/joacp.JOACP_347_19
Wong, CA. Epidural and Spinal Analgesia/Anesthesia for Labor and Vaginal Delivery, Obstetric Anesthesia: Principles and Practice. Chestnut, DH., editor. Mosby: 2014. p. 490
George RB, Allen TK, Habib AS. Intermittent epidural bolus compared with continuous epidural infusions for labor analgesia: a systematic review and meta-analysis. Anesth Analg. 2013; 116:133–44.
Weiniger CF, Carvalho B, Stocki D. et al. Analysis of Physiological Respiratory Variable Alarm Alerts Among Laboring Women Receiving Remifentanil. Anesth Analg. 2017; 124:1211–1218.
Saravanakumar K, Garstang JS, Hasan K. Intravenous patient-controlled analgesia for labour: a survey of UK practice. Int J Obstet Anesth. 2007; 16:221–5.
Aaronson J, Abramovitz S, Smiley R. et al. A Survey of Intravenous Remifentanil Use for Labor Analgesia at Academic Medical Centers in the United States. Anesth Analg. 2017; 124:1208–1210.
Likis FE, Andrews JC, Collins MR. et al. Nitrous oxide for the management of labor pain: a systematic review. Anesth Analg. 2014; 118:153–67.
Ngan Kee WD, Khaw KS, Tan PE. et al. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009; 111:506–12.
Dyer RA, Emmanuel A, Adams SC. et al. A randomised comparison of bolus phenylephrine and ephedrine for the management of spinal hypotension in patients with severe preeclampsia and fetal compromise. Int J Obstet Anesth. 2017.
Sutton CD, Carvalho B. Optimal Pain Management After Cesarean Delivery. Anesthesiol Clin. 2017; 35:107–124.
Lim Y, Jha S, Sia AT, Rawal N. Morphine for post-caesarean section analgesia: intrathecal, epidural or intravenous? Singapore Med J. 2005; 46:392–6.
Abdallah FW, Halpern SH, Margarido CB. Transversus abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis. Br J Anaesth. 2012; 109:679–87.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth. 2012; 59:766–78.
Bauer M., Bernstein K., Dinges E. et al. Obstetric Anesthesia During the Coronavirus Disease 2019 Pandemic Anesth Analg. 2020 Apr 20 : 10.1213/ANE.0000000000004856. doi: 10.1213/ANE.0000000000004856
Narang K., Enninga E.A.L, Madugodaralalage D.S.K. et al. SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review Mayo Clin Proc. 2020 Aug; 95(8): 1750–1765. doi: 10.1016/j.mayocp.2020.05.011 PMCID: PMC7260486
Ashokka B., Loh M., Tan C. et al. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. Am J Obstet Gynecol. 2020 Jul; 223(1): 66–74.e3. doi: 10.1016/j.ajog.2020.04.005 PMCID: PMC7151436
D’Angelo R, Smiley RM, Riley ET et al. Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2014;120: 1505–12.
Chestnut DH, Wong CA, Tsen LC, Ngan Kee WD, Beilin Y, Mhyre JM, et al, editors. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th ed. Philadelphia (PA): Elsevier Saunders; 2014.
