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Obstetric Anesthesia and Uncommon Disorders,
2nd edition

This new edition of Obstetric Anesthesia and Uncommon Disorders
provides a convenient resource for practitioners suddenly faced with
a parturient who has an unusual medical or surgical condition.
The book considers the impact of a condition on pregnancy, labor
and delivery, or the fetus and the impact of pregnancy on a
condition, or the effect of therapy for the disorder on the fetus or
Case reports and experience from the world literature, and clinical
advice from many specialists, have been drawn together by an inter-
national team of editors and contributors who are leading experts in
the field. Clear, concise management guidelines and algorithms are
provided, and each chapter is written from the viewpoint of the
obstetric anesthesiologist.
Fully updated, with new chapters on Chronic pain in pregnancy and
Malignancy and pregnancy, Obstetric Anesthesia and Uncommon
Disorders continues to be an invaluable resource for any anesthesiol-
ogist involved in the clinical management of these complex patients.

Reviews of the first edition:

˜˜very well written and comprehensive. . . and an excellent value-for-
money textbook for all anesthesiologists interested in obstetric
anesthesia.™™ Anesthesiology

˜˜. . . any practitioner of obstetric anesthesia will find occasion to refer
to this useful and practical book.™™
International Journal of Obstetric Anesthesia

˜˜. . . covering conditions as diverse as cystic fibrosis, acute severe
asthma, rheumatoid arthritis, and transplants. . . it is a must for
every delivery suite.™™ British Journal of Anaesthesia

D A V I D R . G A M B L I N G is a Staff Anesthesiologist at Sharp Mary Birch
Hospital for Women, San Diego and Associate Clincal Professor of
Anesthesiology at University of California, San Diego, USA.

M . J O A N N E D O U G L A S is the Clinical Professor of Anesthesiology,
Pharmacology and Therapeutics at the University of British
Columbia, Canada.

R O B E R T S . F . M C K A Y is the Clinical Professor and Chair of the
Department of Anesthesiology at the University of Kansas School of
Medicine, Wichita, USA.
Obstetric Anesthesia and
Uncommon Disorders
2nd edition
Edited by

David R. Gambling
M. Joanne Douglas
Robert S. F. McKay
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
Information on this title:

© Cambridge University Press 2008

This publication is in copyright. Subject to statutory exception and to the provision of
relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published in print format 2008

ISBN-13 978-0-511-38804-0 eBook (NetLibrary)

ISBN-13 978-0-521-87082-5 hardback

Cambridge University Press has no responsibility for the persistence or accuracy of urls
for external or third-party internet websites referred to in this publication, and does not
guarantee that any content on such websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and up-to-
date information which is in accord with accepted standards and practice at the time of
publication. Although case histories are drawn from actual cases, every effort has been
made to disguise the identities of the individuals involved. Nevertheless, the authors,
editors and publishers can make no warranties that the information contained herein is
totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors and publishers therefore disclaim all liability
for direct or consequential damages resulting from the use of material contained in this
publication. Readers are strongly advised to pay careful attention to information provided
by the manufacturer of any drugs or equipment that they plan to use.

List of plates page vi 12 Chronic pain in pregnancy
List of contributors vii 229
Hector J. Lacassie and Holly A. Muir
Preface ix
Section 4 Metabolic disorders 239
Section 1 Cardiovascular and respiratory disorders 1
13 Disorders of intermediary metabolism
1 Structural heart disease in pregnant women 239
Stephen Halpern and Bhadresh Shah
Brendan Carvalho and Ethan Jackson
14 Liver and renal disease
2 Disorders of cardiac conduction 249
M. J. Paech and K. Scott
Jean E. Swenerton, Ravishankar Agaram, and Victor F. Huckell
15 Malignant hyperthermia
3 Vascular diseases 269
M. Joanne Douglas
David R. Gambling
16 Rare endocrine disorders
4 Respiratory disorders in pregnancy 275
J. M. Mhyre and L. S. Polley
John Philip and Shiv K. Sharma
Section 5 Other disorders 293
Section 2 Musculoskeletal disorders 101
17 Blood disorders
5 Myopathies 293
M. Joanne Douglas and Penny Ballem
Chantal Crochetiere
18 Infectious diseases in pregnancy
6 Parturients of short stature 321
Gabriela Rocha Lauretti and Robert S. F. McKay
Andrea J. Fuller, Sheila E. Cohen, and Emily F. Ratner
19 Dermatoses
7 Disorders of the vertebral column 343
Robert S. F. McKay and John E. Schlicher
Edward T. Crosby
20 Psychiatric disorders in pregnancy
8 Miscellaneous skeletal and connective tissue disorders 363
Timothy J. G. Pavy
in pregnancy
145 21 Malignancy and pregnancy
Caroline Grange
Holly A. Muir, Michael Smith, and David R. Gambling
Section 3 Nervous system disorders 167
22 Pregnancy and transplantation
9 Disorders of the central nervous system in pregnancy
Kerri M. Robertson
J. Martinez-Tica and R. B. Vadhera

23 Autoimmune diseases
10 Spinal cord disorders
Caroline Grange
Roanne Preston

Index 423
11 Peripheral neuropathy
Felicity Reynolds


Plate section between pages 278 and 279

Figure 14.1 page 262

Figure 17.1 296

Figure 17.3 305

Figure 17.4 307

Figure 19.1 346

Figure 19.2 349


Ravishankar Agaram, MBBS, MD (Anes), FRCA David R. Gambling, MB, BS, FRCPC
Specialist Registrar Clinical Associate Professor
Department of Anaesthetics Department Anesthesiology, University of California, San Diego
Glasgow Royal Infirmary San Diego, CA, USA
Glasgow, UK Staff Anesthesiologist, Sharp Mary Birch Hospital for Women

Penny Ballem, BSc, MSc, MD, FRCPC Caroline Grange, MBBS
Clinical Professor Consultant Anaesthetist
Department of Medicine Nuffield Department of Anaesthetics
School of Hematology The John Radcliffe Hospital
Faculty of Medicine Oxford, UK
University of British Columbia
Stephen Halpern, MD, MSc, FRCPC
Vancouver, BC, Canada
Professor, Department of Anesthesia
Brendan Carvalho, MB, BCh, FRCA University of Toronto
Department of Anesthesia Director of Obstetrical Anesthesia
Stanford University School of Medicine Sunnybrook and Women™s College Health Sciences Centre
Stanford, CA, USA Toronto, Ontario, Canada

Sheila E. Cohen, MB, ChB, FRCA Victor F. Huckell, MD
Professor of Anesthesia and of Obstetrics and Gynecology Clinical Professor of Medicine
Department of Anesthesia University of British Columbia
Stanford University School of Medicine Vancouver, BC, Canada
Stanford, CA, USA
Ethan Jackson, MD
Chantal Crochetiere, MD, FRCPC Clinical Assistant Professor of Cardiothoracic Anesthesia
Assistant Professor Director of Intraoperative Transesophageal Echocardiography,
University of Montr´ al
e and Division Chief of Adult Congenital Cardiothoracic Anesthesia
Department of Anesthesiology Stanford University Medical Center and
Sainte-Justine Hospital Lucille Packard Children™s Hospital at Stanford University.
Chemin Cote-Ste-Catherine Stanford, CA, USA
Montr´ al QC, Canada
Hector J. Lacassie, MD
Edward T. Crosby, MD, FRCPC Associate Professor
Department of Anesthesiology Anesthesiology Department
Ottawa Hospital “ General Campus Pontificia Universidad Cat´ lica de Chile and
Ottawa, Ontario, Canada Visiting Associate, Duke University Medical Center
Durham, NC, USA
M. Joanne Douglas, MD, FRCPC
Gabriela Rocha Lauretti, MD, PhD
Department of Anesthesia
BC Women™s Hospital Professora Associada (Anestesiologista)
Vancouver, Canada Universidade de S˜ o Paulo
Faculdade de Medicina de Ribeir˜ o Preto
Andrea J. Fuller, MD Av. Bandeirantes
Northern Colorado Anesthesia Professional Consultants Ribeir˜ o Preto-SP, Brasil
Staff Physician
J. Martinez-Tica, MD
Fort Collins, CO, USA
Associate Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA

List of contributors

Robert S. F. McKay, MD Felicity Reynolds, MB BS, MD, FRCA, FRCOG ad eundem
Clinical Professor and Chair Emeritus Professor of Obstetric Anaesthesia
Department of Anesthesiology St Thomas™s Hospital
University of Kansas School of Medicine “ Wichita London, UK
Wichita, KS, USA
Kerri M. Robertson, MD
J. M. Mhyre, MD Associate Clinical Professor
Robert Wood Johnson Clinical Scholar Chief, GVTCCM Division
Lecturer, Department of Anesthesiology Chief, Liver Transplantation
Division of Obstetrical Anesthesiology Department of Anesthesiology
Duke University Medical Center
Holly A. Muir, MD Durham, NC, USA
Vice Chair Clinical Operations Department of Anesthesiology
John E. Schlicher, MD, FAAD
Chief, Division of Women™s Anesthesia
Duke University Medical Center Private Practice Dermatologist
Durham, North Carolina, USA Beatrice Keller Clinic
Sun City West, AZ, USA
M. J. Paech, MB
K. Scott, BM, FRCA
School of Medicine and Pharmacology
The University of Western Australia Specialist Registrar in Anaesthesia
Department of Anaesthesia and Pain Medicine Oxford Radcliffe Hospitals NHS Trust
King Edward Memorial Hospital for Women Oxford, UK
Subiaco, Western Australia
Bhadresh Shah, MB, BS, MD
Timothy J. G. Pavy, MBBS, FANZCA, FRCA, FFPMANZCA, DA, DIP, Fellow in Obstetrical Anesthesia
MID, COG Sunnybrook and Women™s College Health Sciences Centre
Staff Specialist Anaesthetist and Head of Department Toronto, Ontario, Canada
Department of Anaesthesia and Pain Medicine
Shiv K. Sharma, MD, FRCA, Professor
King Edward Memorial Hospital
Subiaco, Western Australia Department of Anesthesiology and Pain Management
Obstetric Division
John Philip, MD, Associate Professor University of Texas Southwestern Medical Center
Department of Anesthesiology and Pain Management Dallas, TX, USA
University of Texas Southwestern Medical Center
Michael Smith, MD
Dallas, TX, USA
Chief Resident in Anesthesiology
L. S. Polley, MD Department of Anesthesiology
Associate Professor of Anesthesiology University of Kansas School of Medicine “ Wichita
Director, Obstetric Anesthesiology Wichita, KS, USA
University of Michigan Health System
Jean E. Swenerton, MD, FRCPC
F3900 Mott Children™s Hospital
Ann Arbor, MI, USA Clinical Associate Professor
Division of Obstetric Anesthesia
Roanne Preston, MD, FRCPC Faculty of Medicine
Department of Anesthesia The University of British Columbia
BC Women™s Hospital Canada
Vancouver, BC, Canada
R. B. Vadhera, MD, FRCA, FFARCSI
Emily F. Ratner, MD, DABMA Director, OB Anesthesia
Associate Professor Department of Anesthesiology
Co-Director, Division of Medical Acupuncture University of Texas Medical Branch
Department of Anesthesia Galveston, TX, USA
Stanford University School of Medicine
Stanford, CA, USA


It has been almost ten years since the first edition of Obstetric This book is dedicated to my wife Kimberley and children
Anesthesia and Uncommon Disorders was published. Over the Carwyn, Jake, and Samantha. David R. Gambling
past few years colleagues have asked the editors when they
This book is dedicated to my family: my mother, Bill, Matthew,
could expect to see a new edition. We had some hesitation, not
Sheila, Erin, and Mark, who fill my life with joy.
least of which was because we felt that many practioners could
M. Joanne Douglas
find most of this information for themselves using the internet or
subspecialty journals. Upon reflection, we recognized that there We dedicate this book to the many anesthesiologists who work
is no substitute for a textbook that contains information gathered long hours to provide safe care to mothers and babies, and to their
and carefully reviewed by a number of devoted specialists. Hence, families who make the sacrifices that allow their loved one to
spurred on by those requests for a second edition it was decided provide this care. Thank you Susan, Lindsey, and Katie.
to create a revision that provides more recent references and Robert S. F. McKay
reflects some of the changes in obstetric anesthesia practice
To the memory of Dr Clive Meintjies a wonderful friend, mentor
that have occurred over the past ten years. With the assistance
and doctor.
of a third editor, Robert S. F. McKay, we recruited some outstand-
ing new contributors from around the world and created a second
edition that we trust the reader will find useful. We have contin-
ued to use chapters based on body systems and diseases. We have
consolidated some chapters, split others, and added two new
chapters, namely ˜Chronic pain in pregnancy™ and ˜Malignancy
and pregnancy™. There are now 23 chapters each illustrated with
figures, tables, and photographs, and each chapter is accompa-
nied by a comprehensive list of updated references.
We thank our new publishers, Cambridge University Press, for
giving us the opportunity to produce this revision, and we would
like to thank each and every contributor for their hard work and
commitment to this project.
Finally, we want to thank our families for their patience while
we spent hours, too numerous to count, fine tuning each chapter.

Brendan Carvalho and Ethan Jackson

Introduction Pregnancy exerts a progressive cardiovascular stress that peaks
at approximately 28“32 weeks of gestation.9 Cardiac output (CO)
This chapter will outline the physiological changes, hemodynamic
starts to increase by the tenth week of gestation and continues to
goals, management, and anesthetic options with regards to patients
rise to a peak of 30“50% above baseline by 32 weeks™ gestation.
with acquired or congenital structural heart disease during preg-
The increase in CO is due to increased stroke volume (SV) “ up to
nancy, labor, and delivery. There is no consensus as to the optimal
30% above baseline “ in the first half of pregnancy. This is in
anesthetic technique for the conditions being discussed. General
contrast to the latter half of pregnancy when CO is maintained
and regional anesthesia can have significant cardiovascular effects
by an increase in heart rate (HR) “ up to 15% above baseline “ in
on a parturient with cardiac disease. In addition, many pharmaco-

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