International Journal of Obstetric Anesthesia

Editorial Board

2010-01-01

Chronic pain after vaginal and cesarean delivery: a reality questioning our daily practice of obstetric anesthesia

Patricia Lavand’homme — 2009-12-03

The prevalence of chronic pain in our society reaches 35%, higher in women than men (40% vs. 31%). Looking at risk factors associated with chronic pelvic pain in the female population, a history of gynecological surgery and more particularly previous cesarean delivery is frequently highlighted. Indeed, 20% of the patients seen in pain clinics report that a surgical procedure caused their pain. Thanks to several publications over the last decade, chronic pain is now recognized as an important outcome of surgery and a prevalent healthcare problem. However, it is of interest that the first paper on persistent pain after the most common operation worldwide, i.e. cesarean delivery, was published as recently as 2004.

A new editorial structure for IJOA

Robin Russell, Lawrence Tsen — 2009-11-30

To keep pace with IJOA’s increasing popularity, 2010 sees significant modification to its editorial structure. Since its launch in 1991, IJOA has had two Co-Editors. With the numbers of submissions increasing four-fold, it has become difficult both to handle submissions promptly and to provide our readers with up-to-date information. Consequently, we are expanding the editorial structure, with one Editor-in-Chief, Robin Russell, working with three Associated Editors and an Editorial Board of international experts. This, combined with Elsevier’s electronic editorial system introduced in 2008, will, we hope, reduce editorial response times and expedite publication of accepted papers.

Persistent pain after caesarean section and vaginal birth: a cohort study

J.P. Kainu, J. Sarvela, E. Tiippana, E. Halmesmäki, K.T. Korttila — 2009-09-04

Abstract: Background: Although persistent pain has been described to occur after various types of surgery, little is known about this entity following caesarean section or vaginal birth. We sought to examine the association between mode of delivery and development of persistent pain, as well as the nature and intensity of the pain.Methods: A questionnaire was sent to 600 consecutive Finnish-speaking women within one year of their giving birth. The survey recorded the women’s health history, obstetric history, previous pain, details of the caesarean section or vaginal birth, and a description of their pain, if present.Results: Persistent pain one year after delivery was significantly more common after caesarean section (42/229, 18%) than after vaginal birth (20/209, 10%: P=0.011, OR 2.1 with 95% CI 1.2-3.7). The persistent pain was mild in 55% of the patients in both groups, and intense or unbearable for four caesarean sections and six vaginal births. Persistent pain was significantly more common in women with previous pain (P=0.013), previous back pain (P=0.016), and any chronic disease (P=0.016). The women with persistent pain recalled significantly more pain on the day after caesarean section (P=0.004) and vaginal birth (P=0.001) than those who did not report persistent pain.Conclusion: Persistent pain is more common one year after a caesarean section than after vaginal birth. A history of previous pain and pain on the day after delivery correlated with persistent pain.

Analgesic requirements and postoperative recovery after scheduled compared to unplanned cesarean delivery: a retrospective chart review

B. Carvalho, L. Coleman, A. Saxena, A.J. Fuller, E.T. Riley — 2009-12-02

Abstract: Background: Studies examining the effects of various analgesics and anesthetics on postoperative pain following cesarean delivery conventionally use the scheduled cesarean population. This study compares postoperative analgesic requirements and recovery profiles in women undergoing scheduled cesarean compared to unplanned cesarean delivery following labor. We postulated that unplanned cesarean deliveries may increase postoperative analgesic requirements.Methods: We conducted a retrospective chart review of 200 cesarean deliveries at Lucile Packard Children’s Hospital, California. We examined the records of 100 patients who underwent scheduled cesarean delivery under spinal anesthesia (hyperbaric bupivacaine 12 mg with intrathecal fentanyl 10 μg and morphine 200 μg) and 100 patients that following a trail of labor required unplanned cesarean under epidural anesthesia (10–25 mL 2% lidocaine top-up with epidural morphine 4 mg after clamping of the umbilical cord). We recorded pain scores, analgesic consumption, time to first analgesic request, side effects, and length of hospital stay.Results: We found no differences in postoperative pain scores and analgesic consumption between scheduled and unplanned cesarean deliveries for up to five days postoperatively. There were no differences in treatment of side effects such as nausea, vomiting, or pruritus (P>0.05).Conclusion: The results indicate that women experience similar pain and analgesic requirements after scheduled compared to unplanned cesarean delivery. This suggests that the non-scheduled cesarean population may be a suitable pain model to study pain management strategies; and that alterations in pain management are not necessary for the unplanned cesarean delivery population.

A randomised comparison of regular oral oxycodone and intrathecal morphine for post-caesarean analgesia

N.J. McDonnell, M.J. Paech, R.M. Browning, E.A. Nathan — 2009-08-25

Abstract: Background: Primary post-caesarean analgesia based on oral opioid has not been adequately studied. This approach may show a good side-effect profile and high satisfaction and avoid neuraxial complications.Methods: In a double-blind, double-dummy, placebo-controlled clinical trial 120 women were randomised to receive either sustained-release oral oxycodone 20mg in the recovery room followed by immediate-release oxycodone 10mg 6-hourly for the first 24h (group O) or intrathecal morphine 100μg at the time of spinal anaesthesia (group I). All women received regular postoperative diclofenac, paracetamol and standardised supplemental analgesia.Results: One hundred and eleven women completed the study. The area under the curve for pain scores to 24h did not differ significantly between groups for pain at rest (P=0.465) or on movement (P=0.533). Numerical pain scores were low and similar, except at rest at 12h (group I 1 [0-2] vs. group O 2 [1-3]; P=0.030). The time to first analgesic request was similar but additional postoperative analgesics were required more often in group O (82% vs. 63%, P=0.034). Group O more frequently reported high worst pain scores (score 4-10 in 87% vs. 64%, P=0.007). Pruritus was more common and more severe in group I (87% vs. 56%, P=0.001). At 24h maternal satisfaction with the analgesic regimen was lower in group O (P=0.010).Conclusion: Oral oxycodone produced comparable postoperative pain relief to intrathecal morphine with a lower incidence of pruritus, but was associated with a lower satisfaction score.

Maternal and neonatal effects of bolus administration of ephedrine and phenylephrine during spinal anaesthesia for caesarean delivery: a randomised study

S. Prakash, V. Pramanik, H. Chellani, S. Salhan, A.R. Gogia — 2009-08-10

Abstract: Background: Maternal haemodynamic changes and neonatal well-being following bolus administration of ephedrine and phenylephrine were compared in 60 term parturients undergoing elective caesarean delivery under spinal anaesthesia.Methods: In a randomised double-blind study, women received boluses of either ephedrine 6 mg (group E; n=30) or phenylephrine 100 μg (group P; n=30) whenever maternal systolic pressure was ⩽80% of baseline.Results: Changes in systolic pressure were comparable in the two groups. There were no differences in the incidence of bradycardia (group E: 0% vs. group P: 16.7%; P>0.05), nausea (group E: 13% vs. group: P 0; P>0.05) and vomiting (group E: 3.3% vs. group P: 0; P>0.05). Umbilical artery (UA) pH (group E: 7.29 ± 0.04 vs. group P: 7.32 ± 0.04; P=0.01) and venous pH (group E: 7.34 ± 0.04 vs. group P: 7.38 ± 0.05; P=0.002) were significantly greater in group P than in group E. UA base excess was significantly less in group E (-2.83 ± 0.94 mEq/L) than in group P (-1.61 ± 1.04 mEq/L; P<0.001). Apgar scores at 1, 5 and 10min and neurobehavioural scores at 2-4 h, 24 h and 48 h were similar in the two groups (P>0.05).Conclusions: Phenylephrine 100 μg and ephedrine 6 mg had similar efficacy in the treatment of maternal hypotension during spinal anaesthesia for elective caesarean delivery. Neonates in group P had significantly higher umbilical arterial pH and base excess values than those in group E, which is consistent with other studies.

Satisfaction, control and pain relief: short- and long-term assessments in a randomised controlled trial of low-dose and traditional epidurals and a non-epidural comparison group

G.M. Cooper, C. MacArthur, M.J.A. Wilson, P.A.S. Moore, A. Shennan — 2009-11-30

Abstract: Background: Childbirth is an important life event for which a positive experience is important to many women.Methods: As secondary outcomes from the randomised controlled Comparative Obstetric Mobile Epidural Trial, various aspects of satisfaction were assessed in women who had one of three types of regional analgesia (two of which were low-dose techniques and a high-dose control using 0.25% epidural bupivacaine) and a comparison group who did not have epidural analgesia, shortly after delivery and 12 months later.Results: The predominant finding was satisfaction with spontaneous vaginal delivery whatever the mode of analgesia. The overall immediate and long-term satisfaction was similar for all three neuraxial techniques. Satisfaction with the speed of pain relief and the amount of mobility were significantly greater for the combined spinal-epidural technique compared with the low-dose infusion (P<0.001). The degree of control felt by women who had combined spinal-epidural analgesia was greater than with the high-dose (P<0.05). Women in the non-epidural comparison group did not report a greater feeling of control. Among those who delivered spontaneously, more women in the combined spinal-epidural group (30%) felt in full control compared with the high-dose group (17%) (P<0.05). By comparison 22% in the low-dose infusion group and only 15% who had no epidural felt in full control.Conclusions: Whilst satisfaction with the experience of childbirth appears intimately related to the attainment of a spontaneous delivery, mobile epidurals enhance women’s feeling of control in labour and are popular for future choice of regional analgesia.

Obstetric epidural catheter-related infections at a major teaching hospital: a retrospective case series

L.K. Green, M.J. Paech — 2009-11-30

Abstract: Background: Clinically overt infections of the epidural catheter skin entry site occur in approximately 1-5% of patients after a few days of catheterization but serious complications such as deep tissue infection or epidural abscess appear rare in the obstetric population. In recent years, sporadic reports and small series suggest that the incidence may be higher than previously estimated.Methods: A retrospective chart review was conducted to identify epidural catheter-related infections occurring between January 2002 and December 2005 in a tertiary referral maternity hospital delivering between 4000 and 6000 women per annum. Cases were identified using International Statistical Classification of Diseases coding.Results: In total 9482 women (52.8%) who delivered had an epidural catheter inserted. There were 258 cases with the relevant code identified and 49 (0.52%, 95% CI 0.37-0.66%) had epidural catheter-related infection. Four women had deep tissue infection (incidence 0.04%, 95% CI 0.01-0.11%; rate 1 in 4741), represented by paraspinous and epidural abscess formation (incidence of both 0.02%, 95% CI 0-0.08%; rate 1 in 2371). Three of the cases are described.Conclusions: Serious epidural catheter-related infection in obstetric patients is rare, but our incidence of serious deep tissue infection was at the upper extreme of figures quoted in other studies.

Retrospective study of association between choice of vasopressor given during spinal anaesthesia for high-risk caesarean delivery and fetal pH

D.W. Cooper, S. Sharma, P. Orakkan, S. Gurung — 2009-11-30

Abstract: Background: Phenylephrine given during spinal anaesthesia for low-risk caesarean section is associated with higher fetal pH than ephedrine. However, there is little evidence on the effects of ephedrine and phenylephrine in complicated pregnancies. The aim of this study was to compare umbilical artery pH with phenylephrine and ephedrine given during spinal anaesthesia where caesarean section was performed because of an increased risk of fetal compromise.Methods: We reviewed the case notes of all women at our hospital from 2000-2003 who had undergone high-risk caesarean section under spinal anaesthesia, where umbilical artery and venous pH had been recorded at delivery. Umbilical artery pH was compared by choice of vasopressor and multiple regression analysis was used to investigate the effects of other possible confounding variables.Results: One hundred and fifteen patients received no vasopressor, 122 ephedrine (group E) and 148 phenylephrine (group P). The median umbilical artery pH was 7.26 (IQR 7.21–7.30) for the no-vasopressor group, 7.27 (7.22–7.30) for group E and 7.28 (7.22–7.32) for group P (P=0.21). Using multiple regression analysis, the only variable associated with altered umbilical artery pH was a non-reassuring fetal heart trace.Conclusions: Umbilical artery pH was similar whether ephedrine or phenylephrine was used to maintain maternal arterial pressure, which contrasts with studies of low-risk caesarean section.

Phosphorylation of spinal signaling-regulated kinases by acute uterine cervical distension in rats

L.Z. Wang, X. Liu, W.X. Wu, R.K. Chai, X.Y. Chang — 2009-11-30

Abstract: Background: Spinal extracellular signaling-regulated kinase 1 and 2 (ERK 1/2) have been found to contribute to nociceptive processing, but the role of spinal ERK 1/2 in visceral pain related to the uterine cervix, the source of pain during the first stage of labor, is unknown. The aim of this study was to investigate ERK activation (phosphorylation) in spinal dorsal horn neurons after acute uterine cervical distension.Methods: Under intraperitoneal anesthesia using chloral hydrate 300mg/kg, female Sprague-Dawley rats were exposed to a 10-s uterine cervical distension of 25, 50, 75, and 100g or no distension (sham). The electromyographic response in the rectus abdominis muscle and mean arterial blood pressure and heart rate changes to uterine cervical distension were determined. The numbers of phosphorylated-ERK 1/2- immunoreactive (pERK 1/2-IR) dorsal horn neurons in cervical (C5-8), thoracic (T5-8), thoracolumbar (T12-L2) and lumbosacral (L6-S1) segments were counted using immunohistochemistry.Results: Compared with the non-distended sham rats, uterine cervical distension resulted in a stimulus-dependent increase in electromyographic activity and the number of pERK-IR neurons that selectively located to the thoracolumbar segment, mostly in the deep dorsal and the central canal regions. The time course study demonstrated that spinal ERK activation peaked at 60min with a slow decline for 120min after uterine cervical distension stimulation.Conclusion: This study suggests that activation of spinal ERK might be involved in acute visceral pain arising from the uterine cervix.

Reduction of severity of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine: a randomised comparison of prophylactic granisetron and ondansetron

T. Tan, R. Ojo, S. Immani, P. Choroszczak, M. Carey — 2009-11-30

Abstract: Background: The incidence of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine may be 60-100%, and is a common cause of maternal dissatisfaction. Ondansetron has been shown to reduce pruritus but the effect is short-lived. The objective of this randomized double-blind trial was to evaluate the anti-pruritic efficacy of granisetron compared with ondansetron.Methods: Eighty ASA I or II women undergoing elective caesarean section received spinal anaesthesia with 0.5% hyperbaric bupivacaine10mg, fentanyl 25μg and preservative-free morphine 150μg. After delivery of the baby and clamping of the umbilical cord, they were randomised to receive granisetron 3mg i.v. (group G) or ondansetron 8mg i.v. (group O).Results: The two groups were similar for age, gestational age, height and weight. According to visual analogue pruritus scores, patients in group G experienced less pruritus at 8h (P=0.003) and 24h (P=0.01). Fewer patients in group G (n=8) than group O (n=18) required rescue anti-pruritic medication (P=0.03). Satisfaction scores were also higher in group G than in group O (P=0.03). There was no difference in overall incidence of pruritus, nausea and vomiting, and visual analogue pain scores between the two groups.Conclusions: Administration of granisetron 3mg i.v. reduces the severity of pruritus and the use of rescue anti-pruritic medication, and improves satisfaction but does not reduce the overall incidence of pruritus in women who have received subarachnoid morphine 150μg compared to ondansetron 8mg i.v.

A double blind comparison of the variability of block levels assessed using a hand help Neurotip™ or a Neuropen® at elective caesarean section under spinal anaesthesia

A.T. Shirgaonkar, M. Purva, I.F. Russell — 2009-11-30

Abstract: Background: We previously noted that when two experienced anaesthetists assessed the level of spinal block to touch at caesarean section, one with a hand held device (Neurotip™), and the other with a very similar spring loaded device (Neuropen®), the median difference between the assessed levels of block was zero but there were some wide individual paired differences between the anaesthetists. We theorised that differences in the applied pressure of the stimulus may have contributed to this variation. We wished to investigate whether compared to the Neurotip™, the Neuropen® would reduce the variability of assessed block levels between anaesthetists of varying experience.Methods: The levels of block to touch and sharp pinprick were assessed by paired anaesthetists using both the Neurotip™ and Neuropen®. The anaesthetists were blind to each other’s assessments. To ensure comparability of dermatome identification, the patient’s torso was marked before surgery.Results: In 44 cases, managed by 35 different pairs of anaesthetists, there was no statistically significant difference in the variability of differences in assessed levels of block between anaesthetists (P=0.23) whether the Neurotip™ or Neuropen® or touch or sharp pinprick were used. The median dermatomal difference [upper quartile, lower quartile] was 0 [1, -1] for both instruments with both touch and sharp pinprick.Conclusion: Compared to the Neurotip™, the Neuropen® did not result in a reduction of the variability in the differences in spinal block levels when assessed by 35 different pairs of anaesthetists.

Estimation of blood haemoglobin concentration using the HemoCue® during caesarean section: the effect of sampling site

N.A. Richards, H. Boyce, S.M. Yentis — 2009-11-30

Abstract: Background: Haemoglobin concentration measured using the HemoCue® is accurate for capillary and venous/arterial blood, provided the recommended sampling method is strictly observed. Analysis of blood, particularly of capillary samples, using the HemoCue® is useful during caesarean section. The toe might be preferred to the thumb since it is numb during neuraxial anaesthesia, but whether sampling at either site is accurate in this situation, given the cardiovascular effects of anaesthesia and pregnancy, is not known. We aimed to compare haemoglobin values measured in venous and capillary samples (toe and thumb) during caesarean section under neuraxial anaesthesia.Method: Fifty healthy women having caesarean section under spinal or combined spinal-epidural anaesthesia were included. At the end of surgery, the great toe and thumb (non-i.v. fluid side) were lanced as recommended for a HemoCue® reading. A venous blood sample (non-i.v. fluid side) was also taken and sent for formal laboratory measurement and tested with the HemoCue®. Bland-Altman analysis was applied to the haemoglobin values.Results: Bias (mean difference) and precision ± 2 SD were respectively 0.2 ±1.6 for laboratory vs. toe, 0.1 ±1.8 for laboratory vs. thumb, and 0.2 ±1.6 laboratory vs. venous.Conclusion: Our results suggest that in terms of accuracy, the two sites are equally suitable for use during caesarean section under neuraxial anaesthesia.

Effect of propofol on human fetal placental circulation

R. Soares de Moura, G.A.M. Silva, T. Tano, A.C. Resende — 2009-11-30

Abstract: Background: Propofol is an alternative to thiopental for induction of general anaesthesia for cesarean section. It crosses the placenta and induces vasodilatation of isolated vessels and may therefore alter fetal placental vascular resistance. The direct effect of propofol on the fetal placental circulation was studied in vitro. The actions of propofol on vasoconstrictive effects induced by angiotensin II (Ang II), bradykinin (BK), prostaglandin F2α (PGF2α) and potassium chloride (KCl) were evaluated.Methods: Full-term healthy human placentas (n=48) were perfused with modified Tyrode’s solution using a pulsatile pump. Placental perfusion pressure was measured in response to injection of Ang II, BK, KCl and PGF2α before and after perfusion with propofol (1.7×10−5 and 5.6×10−5 M).Results: BK, Ang II, KCl and PGF2α induced a dose-dependent increase in placental perfusion pressure. Propofol induced a concentration-dependent decrease in placental perfusion pressure, but this was not observed with the propofol solvent (Intralipid). Propofol, but not Intralipid, reduced the vasoconstrictor effects of BK, KCl and PGF2α, while the effect of Ang II was not changed. The effect of KCl was abolished in placentas perfused with Ca2+-free solution, while the effect of Ang II was not altered.Conclusions: Propofol induced vasodilatation and inhibited the vasoconstrictive effects of BK and PGF2α, in the human placenta. These findings suggest that propofol may not reduce fetal placental blood flow. Since propofol reduced the vasoconstricting effect of KCl but not that of AngII, we propose that the vasodilatory effect of propofol in the human placenta involves inhibition of Ca2+ channels.

Prospective case control comparison of fetal intrapartum oxygen saturations during epidural analgesia

E. Caliskan, D. Ozdamar, E. Doger, Y. Cakiroglu, A. Kus, A. Corakci — 2009-11-30

Abstract: Background: The purpose of this study was to compare fetal oxygen saturation by fetal pulse oximetry in parturients with and without epidural labor analgesia in a prospective case control study.Methods: Fetal oxygen saturation values were compared in term pregnant women who received epidural analgesia (epidural group) with those in women who did not (control group). Mode of delivery, Apgar score, fetal oxygen saturation, cord blood gas analysis and fetal outcomes were also compared.Results: A total of 150 pregnant women (75 in each group) gave written consent and were enrolled. The average fetal oxygen saturation during the first stage of labor (active phase) was 45.6 ± 8.1% for the epidural group and 45.9 ± 7.4% for the control group (NS); saturations for the second stage of labor were 44.9 ± 8.8% and 45.3 ± 6.7%, respectively (NS). In the epidural group, the duration of the first stage of labor was significantly longer (565 ± 217 min) than the control group (434 ± 222 min; P= 0.001). Cesarean delivery rates, neonatal cord blood gas analysis, Apgar scores, and neonatal outcomes were similar in the two groups.Conclusions: Fetal oxygen saturation values are similar in the first and second stage of labor in the presence or absence of epidural labor analgesia.

Anticoagulation with argatroban in a parturient with heparin-induced thrombocytopenia

A. Ekbatani, L.R. Asaro, A.M. Malinow — 2009-07-22

Abstract: Unfractionated heparin and low-molecular-weight heparin are currently the anticoagulants of choice for the prevention of recurrent thromboembolic disease during pregnancy. However, heparin-induced thrombocytopenia contraindicates the use of unfractionated heparin and low-molecular-weight heparin. We describe a patient who was admitted to our hospital with deep vein thrombosis at 18weeks of gestation and who developed heparin-induced thrombocytopenia during her antenatal care. Therapeutic anticoagulation was initially achieved with argatroban, then changed to fondaparinux. During early labor, fondaparinux was discontinued and intravenous argatroban was substituted. Argatroban was discontinued during transition to active labor. After return of a normal partial thromboplastin time, combined spinal-epidural analgesia was induced for routine completion of labor and vaginal delivery. We discuss the decisions made in the maintenance of this patient’s anticoagulation during the peripartum period as well as timing of her neuraxial labor analgesia.

Spinal subarachnoid hematoma following spinal anesthesia in a patient with HELLP syndrome

2009-11-30

Abstract: A case of subarachnoid hematoma following spinal anesthesia for cesarean section in a patient with HELLP syndrome is reported. A 39-year-old woman underwent cesarean section under spinal anesthesia for worsening preeclampsia with HELLP syndrome. Despite full recovery from the spinal anesthetic, on the second postoperative day she felt numbness on the posterior aspect of her right leg, noticed she was insensitive to bladder fullness and had mild flaccid paraparesis. Magnetic resonance imaging revealed a spinal subarachnoid hematoma with cauda equina compression. With conservative management she made an almost complete recovery within three months. Serial magnetic resonance imaging showed spontaneous regression of the hematoma. The risk of spinal subarachnoid hematoma following obstetric regional anesthesia is exceedingly small even in a patient with coagulopathy and, to our knowledge, this is only the second reported case following obstetric regional anesthesia. Anesthesia for HELLP syndrome in patients with an adequate platelet count but without disseminated intravascular coagulation is controversial. It is therefore important for clinicians to recognize the symptoms and signs of spinal subarachnoid hematoma to avoid delay in treatment that might result in severe neurological deficit.

Asymptomatic spinal cord neoplasm detected during induction of spinal anesthesia

P.A. Armstrong, L.S. Polley — 2009-08-25

Abstract: We report a case of an asymptomatic spinal cord neoplasm detected during the placement of a 25-gauge Whitacre spinal needle for spinal anesthesia before elective cesarean delivery. Subarachnoid blood was repeatedly aspirated during otherwise uncomplicated induction of spinal anesthesia. Magnetic resonance imaging revealed a spinal cord ependymoma in the lumbar spine. Asymptomatic spinal cord neoplasms and ependymomas are reviewed. Central nervous system pathology should be considered in the presence of persistent subarachnoid blood.

Paradoxical amniotic fluid embolism presenting before caesarean section in a woman with an atrial septal defect

V. Kumar, M. Khatwani, S. Aneja, K.K. Kapur — 2009-08-25

Abstract: We present a case of presumed amniotic fluid embolism in a 33-year-old parturient at 30 weeks of gestation, which occurred just before she was due to receive spinal anaesthesia for urgent caesarean section. While sitting, the woman suddenly lost consciousness, started having convulsions and finally suffered cardiorespiratory collapse. She was resuscitated and a live baby was delivered by emergency caesarean section. An echocardiogram performed postoperatively showed a large atrial septal defect and severe right ventricular dysfunction with moderate pulmonary hypertension. Paradoxical amniotic fluid embolism was diagnosed. After extubation she was aphasic and had a right hemiparesis. She made a good recovery and was discharged from hospital 24 days later, at which time she had a slight weakness on her right side. Three months later she had a normal gait with no obvious neurological deficit.

Anaesthetic management of an obstetric patient with idiopathic acute transverse myelitis

P. Walsh, C. Grange, N. Beale — 2009-11-30

Abstract: Idiopathic acute transverse myelitis is a rare focal inflammatory disorder of the spinal cord causing motor, sensory and autonomic dysfunction. We report the successful use of general anaesthesia for caesarean section in a patient with this disease. Potential anaesthetic concerns include autonomic dysreflexia and hyperkalaemia following the use of suxamethonium. Further complicating issues with this patient included psychotic depression and new-onset neuropathic pain on a background of chronic pain symptoms.

Intrauterine death following green tree viper bite presenting as antepartum hemorrhage

H.P. Pant, R. Poudel, V. Dsovza — 2009-11-30

Abstract: Few reports exist on venomous snake bites during pregnancy. Envenomation during pregnancy can result in fetal and maternal death. A woman at 33 weeks of gestation presented with green tree viper envenomation and vaginal bleeding. Investigation revealed a grossly deranged coagulation profile, severe anemia and a dead fetus. After correction of the coagulation profile, induction of labor was followed by vaginal delivery. Postpartum care was uneventful, and the patient was discharged five days post partum. Green tree viper bite may cause fetal demise before the onset of maternal symptoms.

Anesthetic management for resection of cor triatriatum during the second trimester of pregnancy

W. Bai, S. Kaushal, S. Malviya, K. Griffith, R.G. Ohye — 2009-11-30

Abstract: Hemodynamic changes during pregnancy can result in cardiovascular decompensation in women with pre-existing cardiac diseases. Despite optimized medical treatment, some patients with severe structural cardiac abnormalities may need surgical intervention during pregnancy. We describe a woman who presented at 20 weeks of gestation with acute heart failure due to cor triatriatum, a rare form of congenital heart disease. This condition is characterized by a perforated fibromuscular membrane dividing the left atrium into two chambers. The clinical presentation varies from asymptomatic to acute heart failure depending on the size of the fenestrations in the membrane and the presence of associated cardiac malformations. In our patient, two severely restrictive orifices in a membrane within the left atrium, moderate to severe pulmonary hypertension and good biventricular function were demonstrated by transthoracic echocardiography. Without surgical resection, the increased blood volume and cardiac output associated with pregnancy could have resulted in cardiovascular decompensation. She underwent urgent corrective open heart surgery with cardiopulmonary bypass. Perioperative anesthetic management included prevention of tachycardia, atrial dysrhythmias and pulmonary hypertension, close monitoring for and prompt treatment of maternal hypotension, maintaining euvolemia and good cardiac contractility and avoiding hemodilution and hypothermia. These approaches, together with minimizing bypass time, resulted in successful maternal and fetal outcome.

Anesthetic management of a patient with cleidocranial dysplasia undergoing various obstetric procedures

A. Ioscovich, D. Barth, A. Samueloff, S. Grisaru-Granovsky, S. Halpern — 2009-11-30

Abstract: Patients with cleidocranial dysplasia, a rare autosomal dominant genetic syndrome, possess abnormal anatomical features of the head, mouth, neck and spinal column. These features may result in perioperative problems such as difficult airway and complicated regional anesthesia. We report the anesthetic management of a young woman with cleidocranial dysplasia undergoing four caesarean sections, one vaginal delivery and a dilatation and curettage, employing different modes of anesthesia. Anesthetic management in this disorder presents challenges for both general and neuraxial anesthesia.

Intrathecal anesthesia for cesarean delivery via a subarachnoid drain in a woman with benign intracranial hypertension

J. Heckathorn, J.P. Cata, S. Barsoum — 2009-11-30

Abstract: A 26-year-old primiparous patient with intractable benign intracranial hypertension treated by cerebrospinal fluid drainage through an indwelling spinal catheter was expecting twins. At 30 weeks she presented for emergent cesarean delivery secondary to a non-reassuring fetal condition. In consultation with the neurosurgical team, spinal anesthesia for the cesarean delivery was induced successfully through the spinal catheter. Cesarean delivery proceeded uneventfully with a favorable neonatal outcome.

Unintentional subdural catheter placement during labor analgesia shows typical radiological pattern but atypical response to the Tsui test

A.R. Moore, N. Siddiqui, E.E. Kassel, J.C.A. Carvalho — 2009-11-30

Abstract: Subdural injection may be associated with abnormally extensive or limited spread of local anesthetics during neuraxial anesthesia. This complication is difficult to diagnose clinically. Radiological imaging is the gold standard for confirming the location of subdural catheter, but electrical stimulation of the catheter has also been described as a useful diagnostic tool. We present the case of an obstetric patient with unintentional subdural catheter placement that presented as a failed epidural block associated with severe upper back and scapular pain on catheter injection. Electrical stimulation of the catheter did not elicit muscle contractions until a current of 4 mAmp was attained, which is the response pattern of epidural placement. Subdural location of the catheter was subsequently confirmed by contrast radiography. This case adds to the evidence that subdural catheters are difficult to identify clinically, and that electrical stimulation may not differentiate them from epidural catheters.

Caesarean section in a parturient with a spinal cord stimulator

D. Sommerfield, P. Hu, D. O’Keeffe, K. McKeatinga — 2009-11-30

Abstract: A 35-year-old G2P1 parturient at 32 weeks of gestation with an implanted spinal cord stimulator was admitted for urgent caesarean section. Spinal anaesthesia was performed below the spinal cord stimulator leads at the L4-5 level, and a healthy female infant was delivered. A basic description of the technology and resulting implications for the parturient are discussed.

Ten years of experience with accidental dural puncture and post-dural-puncture headache in a tertiary obstetric anaesthesia department

R. Hartopp, L. Hamlyn, G. Stocks — 2009-11-30

We read with interest the article by Van de Velde et al. and would like to congratulate them on their work. As the authors point out, opposers of routine combined spinal-epidural (CSE) analgesia for labour argue that deliberate dural puncture leads to a significant increased risk of post-dural-puncture headache (PDPH). After analysing data from over 16 000 CSEs, Van de Velde et al. conclude that CSE does not seem to alter the risk of accidental dural puncture or PDPH compared to previous studies.

Translation and interpretation requirements for maternity services in the UK

Rachel Collis, Mike Wee, Stephen Michael Kinsella — 2009-11-30

Women from ethnic minorities in the UK are known to have a higher risk of dying during pregnancy, and of certain complications such as type-2 diabetes. Communication with women who do not speak English requires specific facilities and materials. The Obstetric Anaesthetists’ Association (OAA) has produced translations of its patient information booklets. We wished to gain information on the languages that should be given priority for further translations, and therefore conducted a postal survey of the 235 UK lead obstetric anaesthetists on the OAA database. We asked respondents to list the five languages most commonly requiring the services of an interpreter in their obstetric population.

Low-dose naloxone infusion for the treatment of intractable nausea and vomiting after intrathecal morphine in a parturient

J.A. Sposito, A.S. Habib — 2009-11-30

Studies investigating the efficacy of naloxone for prophylaxis of nausea and vomiting following neuraxial morphine administration have yielded conflicting results, and no data exist regarding the use of naloxone infusion for the treatment of established postoperative nausea and vomiting (PONV). We present a case of PONV following intrathecal morphine for cesarean delivery, that was resistant to treatment with multiple agents, but responded to a low-dose naloxone i.v. infusion.

Pressure ulcers in parturients

K. Cheesman, S. Makinde, G. Bird — 2009-11-30

While the incidence of pressure ulcers in general hospital patients is well documented at 4-10%, there are only a few published case reports relating to the obstetric population, in whom, anecdotally, the incidence seems to be rising. In 2000 Morrison and Baker reported a local incidence of 0.15%. In our unit in the last year the incidence was 0.2%. Although infrequent, pressure ulcers are not only distressing to the mother, who is unable to sit down and breast feed her newborn, they can also lead to litigation against hospitals on the grounds of poor nursing care.

Ketamine for labour analgesia

A.S. Joselyn, V.T. Cherian, S. Joel — 2009-11-30

Ketamine, in sub-anaesthetic doses, has been shown to provide acceptable intra- and postoperative analgesia. We conducted a preliminary, prospective trial to assess the efficacy and safety of a low-dose ketamine infusion for labour analgesia.

GlideScope® use in the obstetric patient

T.P. Turkstra, P.M. Armstrong, P.M. Jones, T. Quach — 2009-11-30

Parturients present well described, specific problems with airway management. Moreover, it is not uncommon for obstetric suites to be sited away from the main operating rooms (ORs), as in our institution, necessitating a separate difficult airway cart. Because of the potential for airway problems in this remote location, we decided to obtain a GlideScope® videolaryngoscope for use in the obstetric suite. This decision proved to be fortunate, as we recently made urgent use of the GlideScope® in two patients in one day.

Problems with a continuous spinal anaesthesia technique for caesarean section

I.F. Russell — 2009-11-30

Two aspects of the study of continuous spinal anaesthesia (CSA) for caesarean section by Alonso and colleagues deserve comment. Despite excluding technical failures, the authors observed a high failure rate (12/94) when even 15 mg of bupivacaine with fentanyl 20μg did not result in the desired level of block: T4 to cold. Fifteen milligrams of bupivacaine is well above the ED 95 (13.6 mg) for attaining a T5 block to touch with a single-shot spinal. Bearing in mind that a block to cold will be several dermatomes higher than a block to touch, this suggests that, compared to a single-shot spinal, the CSA technique inhibits the spread of spinal anaesthesia. The authors discussed two possible causes for this, catheter position and narrowing of the subarachnoid space due to venous engorgement. The issues related to catheter position are well rehearsed, but the authors did not discuss narrowing of the subarachnoid space. Their proposition that such venous engorgement may have reduced the spread of bupivacaine is not supported by the literature, and indeed is contrary to the view in the cited supporting reference. The generally held view is that venous engorgement within the spinal canal reduces cerebrospinal fluid (CSF) volume and enhances the spread of spinal anaesthesia, although this simple statement requires further exploration.

In reply

E.A. Yanci — 2009-11-30

We would like to thank Dr Russell for his interesting letter about our study. We agree with his comments about the influence of pregnancy and venous engorgement on spinal anesthesia and the effect of positioning during and after local anesthetic administration. The spread of subarachnoid local anesthetics is clearly greater in pregnancy due to these changes. Our hypothesis was that reduced cerebrospinal fluid volume resulting from venous engorgement within the spinal canal might lead to increased difficulty inserting a spinal catheter.

Hysterical conversion mimicking acute paraplegia after spinal anaesthesia

J-C. Sleth — 2009-11-30

Severe neurological deficit following spinal anaesthesia is extremely rare, with a behavioural aetiology most unusual. A fit 37-year-old G3 P2 Caucasian female presented for caesarean section. Her medical history included malaria and a caesarean section under spinal anaesthesia three years previously in our institution. She lived in Africa and worked as a teacher. Preoperative assessment was unremarkable although she confessed that her mood was different during this pregnancy. Coagulation screen was normal and she tested negative for HIV and syphilis. The same anaesthesiologist present at her previous caesarean section performed an uncomplicated spinal anaesthetic consisting of hyperbaric bupivacaine 12.5mg, morphine 150μg and sufentanil 2.5μg injected at the L4-5 interspace using a 25-gauge Whitacre needle. The operation was uneventful with no major haemodynamic change. At the end of surgery the patient was transferred to the post-anaesthesia care unit (PACU) where mobility of her lower limbs was regularly tested. Three hours later the anaesthesiologist was informed that the patient could not move her legs. On examination no voluntary leg movements could be elicited and there was apparently total sensory loss below the waist. Her legs were not hypotonic but held stiffly and could not be bent easily. Anal tone and tendon reflexes were normal and plantar reflexes were flexor. She appeared unconcerned about her symptoms but wanted to know whether anticoagulants were prescribed to prevent thrombophlebitis. As the situation was unchanged two hours later a consultant neurologist was asked to review. He confirmed the diagnosis of hysterical paraplegia. Magnetic resonance imaging (MRI) 9h after the spinal anaesthetic was normal. No bladder dysfunction occurred after catheter removal. On the second postoperative day she started to move her legs; she stood up on day 3 but was unable to walk and described persistent sensory loss of both legs. On day 5 she walked in her room with the help of a frame and was seen taking a shower. Her condition continued gradually to improve. A psychiatrist confirmed the hysterical conversion and started the antipsychotic olanzapine. She was discharged walking unaided on day 12.

Sequential combined spinal-epidural for caesarean delivery in osteogenesis imperfecta

S. Murray, W. Shamsuddin, R. Russell — 2009-11-30

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder with an expression that varies from mild to severe disease affecting bone, sclera and middle ear. A 24-year-old nulliparous woman with type-III OI was transferred to our obstetric unit from another hospital at 22 weeks of gestation. She was referred to our high-risk obstetric anaesthetic clinic and seen at 26 weeks. She had been diagnosed with OI in infancy and suffered multiple bone fractures, with the exception of her skull, mandible and vertebral column, in childhood. She had not sustained fractures in the past seven years. General anaesthesia had previously been administered without complication. Her weight was 25kg and her height 91cm (BMI 30.1kg/m); she was confined to a wheelchair. Cardiovascular examination was normal and her respiratory system was not obviously compromised by pregnancy. The distance from pubis to xiphisternum was 17cm and she had a marked scoliosis (). Her iliac crests, spinous processes and sacrum were all palpable. Airway assessment revealed good mouth opening (Mallampati class 1) and normal dentition. Her haemoglobin was 10.7g/dL, platelet count 257×109/L, platelet function analysis normal, prothrombin time 13.1s and activated partial thromboplastin time 27.5s. Echocardiography was normal.

ACKNOWLEDGEMENTS

2009-11-30

Forthcoming meetings

2010-01-01