An Assessment of Neonatal Status Using Apgar score: Pipecuronium Bromide Used as an Anaesthesia Drug during Caesarian-Section

Dhruv V.K.¹, Sahu A.² Bansal A.K.³, Shashikala Dhruv (Thakur)⁴, Shrivastav P.K.³, Baghel B.², Viswanadham K. K.² and Sharma S.⁵

Dept. of Anaesthesia¹, Paediatrics², Community Medicine³, Pathology⁴ and Pharmacology⁵, Govt. Medical College, Jagdalpur (BASTAR) -494001 -INDIA

ABSTRACT:

Objectives: To know the effects of Pipecuronium Bromide used as general anaesthesia during caesarian section on neonates, if any? Material and Methods: Eighty five mothers who have undergone Caesarian Section were included in the study (sixty five in study and twenty in control group). Statistical analysis: Chi-square tests, Proportion etc. were used for statistical analysis. Results: 85% had an average apgar score of 9.19 and 9.92 at 1 minute and 5 minutes interval. Only 15% had an average Apgar score of 5.77 to 8.0. Preoperative foetal distress and prematurity were the two factors leading to a poor scoring. Conclusion: It was concluded that pipecuronium Bromide can be used safely during Caesarian Section without any adverse effects on Neonates.

KEYWORDS: Apgar score, Caesarian-Section, New-borne.

INTRODUCTION:

For Caesarean Section (C-section) to provide optimal anaesthesia, causing least trespass in to the existing patho-physiology of the mother and the child, needs the use of such techniques and drug, which have minimal side effects. The Anaesthesiologist has to be sound as regards the changes in the mother during pregnancy and labour, direct or indirect effect of the drug on mother and neonate, the benefit and rest of various anaesthetic technique and drugs for the proper anaesthetic management of the C-section. There is a long list of drugs and recently pipecuronium bromide has been added to this list of non depolarizing muscle relaxants having longer duration of action than the existing ones. As no and /or very face reports of clinical study of this drug on foetal out come after C-section is available in literature and in 1957 a study group of World Health Organization W.H.O. has expressed the view that in order to get a comprehensive picture of disease (drug used) more and more studies have to be conducted Garg Narendra K. (1). This prompted us to undertake this study which is primarily aimed at assessing safety of pipecuronium bromide as a muscle relaxant in balanced general anaestesia during C-section vis - a – vis foetal (Neonate) out come by using APGAR SCORE .

MATERIAL AND METHODS:

The present study was conducted in the Dept. of Anaesthesiology, G.M. Hospital and S.S. Medical College, Rewa, 85 patients were divided in to two groups, study and control. In study group 65 patients and in control 20 patients were included. All the patients were weight beforehand to determine the dose of drug /Kg. body weight.

The study group received Pipecuronium 0.08 mg /Kg. of body weight and control group spinal anaesthesia, Xylocaine 5%, 1 – 2 ml.

APGAR SCORING SYSTEM: - This scoring system was developed by VIRGINIA 1953. Since then it has been widely used to decide in whether immediate resuscitation is required or not. It is a practical method of systematically assessing the newborn infant immediately after birth.

The principal of giving a score to a patient as sum total of several objective finding is not new and has been used recently in judging the treatment of drugs addition. The end point which has been used previously in field of resuscitation is breathing time, defined as the time from delivery to the establishment of a satisfactory cry.

A list was made of all the objective signs which pertained in any way to the condition of the infant at birth. Of these five signs which could be determined easily and without interfering with the care of the infant were considered useful, a rating of zero, one or two, was given to each sign depending, whether it is absent or present. A score of ten indicated baby in the best possible condition.

These ratings have been included in the present series.

The signs are used as follows:-

1. Heart rate: This was found to be the most important diagnostic and prognostic of the five signs. A heart rate of 100-140 was considered good and given a score of two. A rate under 100 received a score of one, and if no rate could be seen, felt or heard the score was zero. The epigastrium or precordium can be observed for visible heart beat, while palpation of the cord about two inches from the umbilicus is the most satisfactory method for determining the heart rate quickly.

2. Respiratory Effort: An infant who was apnoeic at 60 seconds after birth received a score of zero. While one who breathed and cried lustily received a two rating. All other type of respiratory effort such as irregular, shallow ventilation was scored one. An infant who had gasped once in thirty or fourty five seconds after birth, and who then became apnoeic, received zero.

3. Reflex Irritability: This term refers to the response to some form of stimulation. The usual testing method was suctioning the oropharynx and nares with a soft rubber catheter which called forth a response of facial grimace, sneezing or coughing.

4. Muscle Tone : This was an easy sign to judge, for a completely flaccid infant received a zero score and one with good tone and spontaneously flexed arms and legs which resisted extension were rated two point .We are unable to agree with flagg’s descripition of spasticity as a sign of asphyxiation of the infant. The use of analeptics in the baby did not influence this score because of the standardized early time of observation and rating.

5. Color: This is by the most unsatisfactory sign and caused the most discussion among the observers. All infants are obviously cyanotic at birth because of their high capacity for carrying oxygen and their relatively low oxygen content and saturation. The disappearance of cyanosis depends directly on two sign previously considered respiratory effort and heart rate.

Comparatively few infant were given a full score of two for this sign, and many received zero. The foreign material so often covering the skin of the infant at birth interfered with interpreting this sign, as did the inherited pigmentation of the skin of colored children, and an occasional congenital defect.

Thus each criterion is given a score of 0, 1, or 2 based on whether the response to testing that criterion is absent or grossly abnormal - 0, mediocre or slightly abnormal - 1; or normal - 2. Therefore the maximum possible score is 40.

RESULTS:

On analysis of collected data it has been revealed that the mean weight of the infants in both groups was approximately same. Apgar score 7 to 10 was considered to be vigorous infant, in the both group there was an insignificant difference in the Apgar at 5 minutes (P< 0.01) (Table – 1). It has been further revealed that there was no statistical significant difference in mean Apgar score at 1and 5 minute interval of both group (<0.01). Regarding newborn cry, again an insignificant difference was noted in both group (P < 0.01).

Table No. – I Mean birth weight, Newbornes crying time and Apgar scores.

S. No.	Data	Study Group	Control Group
1	Mean birth weight	2.83 ± .56	2.66 ± 2.31
2	New-bornes crying time (in sec. ± mean S.D.)	14.21 ± 4.46	14.12 ± 4.31
3	Mean Apgar Score ± S.D.
	at 1 min.	8.86 ± 1.61	8.72 ± 1.32
	at 5min.	9.63 ± 1.66	9.8 ± .63
4	Apgar score (7-10)
	at 1 min.	78.6%	92%
	at 5min.	100%	100%

Table further reveals that the mean Apgar score at 1 minute and 5 minutes interval of both (Study and Control) group, there is no statistically significant difference in the Apgar score of both the group (P<0.01). Table also shows 14.21 ± 4.46 in study group was comparable with the control group 14.21 ± 4.31 the P value of this was P<0.01 showing an insignificant difference in both groups.

Neonatal Outcome: - No evidence of adverse effect on neonates with pipecuronium were found in this study and also no clinical evidence of myoneural blockade in infant, whose mothers had received pipecuronium bromide before delivery. These conclusions were based on Apgar scores and general observations.

Table No. – II Apgar score at 1 min., 5 min. used of pancuronium, Vecuronium, Atracuonium study drug pipecurinum in C.S.

S. N.	Author	Year	Drug studied and its dose	Apgar at min. ± S.D.	Apgar at 5 min. S.D.
1.	Spiers et. al	1972	Pancuronium 0.07-0.1mg./ kg	--	9 ± 0.4
2.	Neel et. al.	1973	Pancuronium 0.87 mg./ kg	7.2 ± 1.9	9 ± 0.4
3.	Booth et. al.	1977	Pancuronium 0.08-0.01 mg./ kg	6.1	9.6
4.	Duraldest in et. al.	1978	Pancuronium0.05-0.08 mg./ kg	8.5 ± 08	9.8 + 0.1
5.	Mazumder et. al.	1983	Pancuronium 1 mg./ kg	8.12 ± 1.2	9.24 ± 0.91
6.	Baraka et. al.	1983	Vecuronium 0.05 mg./ kg	100% > 7	100% > 7
7.	Dailey et. al.	1984	Pancuronium 0.04 mg./ kg	57% > 8	100% > 8
8.	Dailey et. al.	1984	Vecuronium 0.04 mg./ kg	45% > 8	91% > 8
9.	Flynn	1984	Atracuronium 0.03 mg./ kg	7.77	9.6
10.	Dixit et. al.	1986	Pencuronium 4 mg./ kg	8.1	9
11.	Baijal P.K.	1988	Atracuronium 0.3 mg./ kg	--	81.1% scored 10
12.	Mayak et. al	1988	Atracuronium 0.5 mg./ kg	86% scored 9	86% scored 10
13.	Shearea et. al.	1991	Atracuronium 0.3 mg./ kg	8.3 ± 1.67	9.6 ± 0.59
14.	Chatterjee	1991	Vencuronium 0.1 mg./ kg	9	10
15.	Chatterjee	1991	Atracuronium 0.1mg./ kg	8.5	10
16.	Present study	1996	Piperacuronium	8.68 ± 1.61	9.23 ± 1.66

In the present study 9 cases showing having foetal distress pre-operative because of some reason or others had an Apgar score less than 7 in 1 minutes and less than 10 in 5 minutes.

DISCUSSION:

Spiral et al (3) studied effect of pancuronium 0.07 – 0.1 mg/kg. and found the Apgar score at 5 minutes to be 9 ± 0.4. Neld et al (1973) suxamethonium with pancuronium sequence reported mean Apgar score at 1 minutes, 5 minutes to be 7.2 ± 1.9 and 9 ± 0.8 Booth et al (1977) used pancuronium 0.1 mg./kg. Followed by suxamethonium and reported Apgar scores of 6.1 and 9.6 at 1 minute and 5 minutes.

Muzumdar et al (5) utilized 0.1 mg./kg. of pancuronium for intubation and maintainence of anaesthesia obtained an Apgar score of 8.12 at 1 minute and 9.24 at 5 minutes Barka et al (14) reported Apgar score more than 7 minutes in all neonates using vecuronium 0.05 mg./kg/ following suxamethonium for intubation. In the study by Dailey et al (16) using pancuronium 0.04 mg./kg. similarly vercuronium 0.04 mg./kg. was used and 45% neonate scored more than 8 at 1 minute, 91% scored at 8-10 at 5 minutes in the same study.

Flynn et al (15) reported use of Atrcurium 0.3 mg./kg., for caesarean section resulting in mean Apgar scores of 7.7 at 1 minute and 9.6 at 5 minutes, Howkins et al (1990) reported 70% infants scoring more than 7 at 1 minute and all the neonates scoring more than 7 at 5 minutes, after use of vercuronium 0.1 mg./kg for intubation and maintenance.

The Apgar score obtained in our study are 8.68 ± 1.61 at 1 minute, 9.63 ± 1.66 at 5 minutes. It is comparable to the above studies.

From the above study it was concluded that Pipecuronium can be used safely during caesarean section without any adverse effect on the neonate for elective & emergency L.S.C.S.

ACKNOWLEDGEMENT:

The authors express their cordial thanks to Mr. Anand Singh Kanwar, Lab-Technician, Dept. of Community Medicine, Govt. Medical College, Jagdalpur (C.G.) for his neat and excellent typing.

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Received on 24.02.2011

Modified on 18.04.2011

Accepted on 04.07.2011

Research J. Science and Tech. 3(4): May-June. 2011: 189-191