International Journal of Obstetric Anesthesia

Editorial Board

2010-07-01

Oxytocin protocols during cesarean delivery: time to acknowledge the risk/benefit ratio?

Lawrence C. Tsen, Mrinalini Balki — 2010-06-07

A hormone discovered and synthesized over 50years ago, oxytocin is currently used in the majority of births in developed countries and a growing number of births in the developing world. Commonly employed to induce or augment the process of labor to effect vaginal delivery, oxytocin is also used as the first line drug to restore uterine tone and minimize postpartum blood loss following cesarean delivery. The purpose of this editorial, which is echoed in the review article by Dyer and colleagues in this issue of IJOA, is to illuminate the risks associated with large intravenous (i.v.) bolus doses of oxytocin administered during cesarean delivery and to advocate an evidenced-based, infusion approach to dosing.

Observational study of the effect of μ-opioid receptor genetic polymorphism on intrathecal opioid labor analgesia and post-cesarean delivery analgesia

C.A. Wong, R.J. McCarthy, J. Blouin, R. Landau — 2010-02-22

Abstract: Background: The purpose of this two-part prospective observational and blinded trial was to determine whether the single nucleotide polymorphism of the μ-opioid receptor gene (OPRM1:c.304A>G) modifies (1) the duration of intrathecal fentanyl labor analgesia and (2) supplemental analgesic requirements after intrathecal morphine analgesia following cesarean delivery.Methods: Labor analgesia was initiated with intrathecal fentanyl 25 μg. Patients undergoing primary cesarean delivery under spinal anesthesia received intrathecal morphine 150 μg. The primary outcome variables were duration of intrathecal fentanyl analgesia in the labor study and the requirement for supplemental systemic analgesia in the cesarean study. Outcomes were compared between 304A homozygotes (group A) and 304A>G heterozygotes and 304G homozygotes (group G).Results: The labor study included 190 participants and the post-cesarean study included 103 participants; 24% subjects carried the 304A>G allele. The median (95% CI) duration of intrathecal fentanyl analgesia was 70 min (62, 78) in group A and 63 min (50, 76) in group G (P = 0.54). There was no difference in the amount of supplemental oral morphine equivalents required to treat breakthrough pain within 72 h after intrathecal morphine between groups A and G (median [IQR] 68 mg (37, 97) and 75 mg (37, 90) respectively, P = 0.99) or in the duration of intrathecal morphine analgesia (P = 0.84). The incidence of pruritus was greater in group A.Conclusions: Using the two outcome parameters duration of analgesia and treatment for breakthrough pain, we did not find a simple association between intrathecal opioid analgesia and OPRM1 304A/G polymorphism.

The influence of ATP-binding cassette sub-family B member -1 (ABCB1) genetic polymorphisms on acute and chronic pain after intrathecal morphine for caesarean section: a prospective cohort study

A.T. Sia, B.L. Sng, E.C. Lim, H. Law, E.C. Tan — 2010-06-04

Abstract: Background: Polymorphisms of the ATP-binding cassette sub-family B member -1 (ABCB1) gene that codes for P-glycoprotein could influence the efflux of morphine from the central nervous system affecting its analgesic action. We investigated the effect of ABCB1 gene polymorphisms on analgesia and the development of persistent pain in post caesarean patients.Methods: Women of Chinese descent who received spinal anaesthesia with intrathecal morphine for elective caesarean section were recruited. They were given intravenous morphine via a patient-controlled analgesia pump for postoperative analgesia. Blood samples were collected and analysed for the presence of C1236T, G2677T/A and C3435T single nucleotide polymorphisms of the ABCB1 gene. We primarily investigated the association between ABCB1 polymorphisms and the effect of morphine. In a postpartum phone survey of the subjects six months after surgery, the occurrence of persistent abdominal wound scar pain was established.Results: We found no significant statistical difference in total morphine consumption, pain scores and side effects among the various genotypes. For C3435T polymorphism, there was a trend towards the association of the T allele and persistent pain for three months after surgery but this did not reach statistical significance (P=0.07). The TT genotype had the longest mean survival time of wound pain in comparison with CT and CC genotypes (P=0.004 and P=0.014, respectively).Conclusion: Polymorphisms of ABCB1 were not associated with differences in morphine use in the first 24h after surgery. Women with the T allele of C3435T polymorphism showed a trend towards a higher risk of developing persistent postoperative pain.

Sensory testing of spinal anaesthesia for caesarean section: differential block and variability

M. Kocarev, E. Watkins, H. McLure, M. Columb, G. Lyons — 2010-06-04

Abstract: Background: The aim of this study was to determine if sensory block following spinal anaesthesia, measured with a range of devices, corresponded to the hierarchy of nerve fibre size in the area of differential block, and to compare the distribution and variability of recorded measurements.Methods: Women with singleton pregnancies >36weeks of gestation undergoing elective caesarean section under combined spinal–epidural anaesthesia were recruited. An identical spinal anaesthetic was given to all. A single researcher with no clinical role assessed block height at 20min from the time of spinal injection. Six tests were used in random order to measure four sensory modalities: ethyl chloride (cold), calibrated Neuropen (sharp), standardized monofilament 10g (pressure), Neurotip stroking (light touch), monofilament stroking (light touch), cotton wool (light touch). The cost of each method of testing was noted.Results: The median differences between the four modalities were significant (Friedman test, P<0.0001), but paired tests failed to find significant differences between Neuropen (sharp) and monofilament (pressure), monofilament (pressure) and Neurotip (light touch), and between tests for light touch. The tests for light touch had the least dermatomal spread and produced a unimodal distribution. The coefficient of variation was highest with ethyl chloride (24.1%) and the lowest with cotton wool (10.4%).Conclusions: Sensory fibre hierarchy could be identified. Tests for light touch showed the least variability. More expensive tests do not appear to have any advantage over the least expensive test, cotton wool.

Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery

E. Goldszmidt, A. Macarthur, C. Silversides, J. Colman, M. Sermer, S. Siu — 2010-03-02

Abstract: Background: The cardiovascular changes of pregnancy may place additional stress upon women with pre-existing heart disease, increasing peripartum morbidity and mortality. The purpose of this descriptive study was to report the anesthetic management of a large cohort of pregnant women with heart disease.Methods: The medical records of 522 consecutive parturients (657 pregnancies) with heart disease who delivered at Toronto General Hospital or Mount Sinai Hospital in Toronto, Ontario, Canada between 1986 and 2004 were reviewed. Obstetric, medical and anesthetic management data were collected and the women were stratified by New York Heart Association (NYHA) functional status at delivery. The main outcome of interest was the method of analgesia or anesthesia administered during labor and delivery. Univariate and multivariate analysis was performed to identify risk factors associated with the administration of general anesthesia.Results: Of 657 pregnant women, 602 were NYHA 1/2 and 55 were NYHA 3/4 at time of delivery. Epidural analgesia was administered to 84% of NYH 1/2 women and 83% of NYH 3/4. The cesarean section rates were 29% and 31% respectively. The rate of general anesthesia for the entire cohort was 9%. Factors associated with the use of general anesthesia for operative delivery included cesarean delivery (adjusted O.R. 74; 95% CI 9.5, 573), delivering at Toronto General Hospital site (adjusted O.R. 5.5; 95% CI 2.3, 13.3), presence of complex congenital heart lesion (adjusted O.R. 2.3; 95% CI 1.0, 5.4) and each week of premature delivery (adjusted O.R. 1.3; 95% CI 1.1, 1.5). Three percent suffered intrapartum cardiac complications; there was one death.Conclusions: Pregnant women with heart disease managed within an organized program may undergo labor and delivery with acceptable rates of complications. Cesarean section, epidural analgesia/anesthesia and general anesthesia rates are similar to those in the general obstetric population.

Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study

P.M. Wieczorek, S. Guest, M. Balki, V. Shah, J.C.A. Carvalho — 2010-06-04

Abstract: Background: Epidural labor analgesia inclusive of high-dose fentanyl has been thought to affect breastfeeding in multiparous patients. In our experience, this effect is not as significant as quoted in the literature. This study was designed to evaluate breastfeeding success in women receiving epidural analgesia with fentanyl-containing solutions at our institution.Methods: Term multiparous women who received epidural analgesia for labor, had previously breastfed, and who intended to breastfeed, were recruited. Baseline demographics, as well as detailed epidural, obstetric and neonatal data, were collected. Epidural analgesia was achieved with a mixture of bupivacaine and fentanyl. Subjects were telephoned both 1 and 6weeks after delivery, and a breastfeeding questionnaire was completed. Our primary outcome was breastfeeding cessation at 6weeks.Results: One hundred and five women were recruited, with 18 exclusions. The median cumulative epidural fentanyl dose was 151.4μg (30–570μg). No neonates developed complications attributable to labor analgesia. Four women stopped breastfeeding because of issues related to the baby (4.6%); only one of them received a fentanyl dose >150μg. The breastfeeding success rate was therefore >95%. The women had a median maternity leave of 12months, and 69% received post-partum lactation support.Conclusions: The incidence of successful breastfeeding in multiparous women who undergo vaginal delivery with epidural analgesia inclusive of fentanyl is much greater at our institution than previously reported in the literature. This may be due to favorable conditions such as time off work and post-natal support.

A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom

V.J. Webster, R. Stewart, P. Stewart — 2010-06-04

Abstract: Background: Massive haemorrhage remains a leading cause of maternal death worldwide. Interventional radiology can be used to prevent or treat life-threatening haemorrhage, but evidence for its efficacy is limited to case series predominantly from large tertiary centres. The current availability of interventional radiology for management of obstetric haemorrhage in the UK is unknown.Methods: A postal questionnaire on the use of interventional radiology was sent to the lead clinician for obstetric anaesthesia in 226 UK maternity units.Results: The response rate was 72%; 74 respondents (46%) had considered and 51 (31%) used interventional radiology for control of obstetric haemorrhage. Its use was primarily confined to large tertiary obstetric units and limited by availability of equipment and staff.Conclusions: Interventional radiology to assist in the management of obstetric haemorrhage is not uniformly available in the UK and experience remains limited. Access to this resource is subject to striking local variability and influenced by the size and nature of the hospital supporting the delivery unit.

An observational study of skin conductance monitoring as a means of predicting hypotension from spinal anaesthesia for caesarean delivery

T. Ledowski, M.J. Paech, R. Browning, J. Preuss, S.A. Schug — 2010-06-04

Abstract: Background: Hypotension after spinal anaesthesia is a common and important complication at caesarean delivery. Skin conductance monitoring has been shown to predict post-spinal hypotension in elderly patients and may be a rapid, non-invasive means of predicting risk in the obstetric population.Methods: Women having elective caesarean delivery were included in this observational pilot trial. Baseline data were obtained for blood pressure, heart rate and skin conductance variables before administration of spinal anaesthesia and at 1-min intervals for 20min thereafter. Correlations between baseline data and minimum post-spinal blood pressure were calculated, and the predictive value of baseline variables was estimated by use of receiver operator characteristics.Results: Forty women completed the study. Spinal anaesthesia was followed in most cases by a significant reduction from baseline in systolic blood pressure [0–9% n=2 (5%), 10–20% n=21 (52.5%), 20–30% n=12 (30%), >30% n=5 (12.5%)]. Minimum systolic blood pressure was >100mmHg in 25 (62%), 80–100mmHg in 12 (30%) and <80mmHg in 3 (7.5%) patients. Fasting times, spinal block distribution, baseline heart rate, blood pressure or baseline skin conductance did not predict post-spinal hypotension or neonatal outcome.Conclusion: In contrast to a previous report in elderly patients, we were unable to demonstrate a significant relationship between baseline sympathetic tone, measured by skin conductance, and hypotension following spinal anaesthesia in women undergoing elective caesarean delivery.

Pulmonary effects of bupivacaine, ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: A randomised controlled study

P. Lirk, N. Kleber, G. Mitterschiffthaler, C. Keller, A. Benzer, G. Putz — 2010-06-04

Abstract: Background: Spinal anaesthesia is the method of choice for elective caesarean delivery, but has been reported to worsen dynamic pulmonary function when using bupivacaine. Similar investigations are lacking for ropivacaine and levobupivacaine. We have therefore compared the pulmonary effects of intrathecal bupivacaine, ropivacaine and levobupivacaine used for caesarean delivery.Methods: Forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow rate were measured in 48 parturients before and after onset of spinal anaesthesia using either 0.5% bupivacaine 10mg, 1% ropivacaine 20mg, or 0.5% levobupivacaine 10mg. Apgar scores and umbilical arterial pH were recorded.Results: The final level of sensory blockade was not different between groups. Forced vital capacity was significantly decreased with bupivacaine (3.6±0.5L to 3.5±0.4L, P<0.05) and ropivacaine (3.2±0.4L to 3.1±0.5L, P<0.05), but not with levobupivacaine (3.6±0.5L to 3.4±0.6L). Forced expiratory volume during the first second was not decreased in any group. Peak expiratory flow rate was significantly decreased with ropivacaine (5.5±1.5L/s to 5.0±1.1L/s, P<0.05) and levobupivacaine (from 6.0±1.1L/s to 5.2±0.9L/s, P<0.01). Neonatal vital parameters did not differ between the three groups.Conclusions: Decreases in maternal pulmonary function tests were similar following spinal anaesthesia with bupivacaine, ropivacaine, or levobupivacaine for caesarean delivery. The clinical maternal and neonatal effects of these alterations appeared negligible.

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study

2010-06-04

Abstract: Background: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia.Methods: In this double-blind randomized prospective study, infiltration with 15mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded.Results: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0h with 1% lidocaine, and 16.6h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8±11.6, lidocaine 12.4±9.7; and saline 16.2±11.5, P=0.08).Conclusion: For the first 24h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.

A functional understanding of moderate to complex congenital heart disease and the impact of pregnancy. Part I: The transposition complexes

D.P. Dob, M.A. Naguib, M.A. Gatzoulis — 2010-06-04

Before the introduction of successful open heart surgery in the early 1950s, patients with moderate to complex congenital heart disease had a short life expectancy with a poor quality of life. The first Fallot’s tetralogy repair, followed by the Mustard and Senning procedures for transposition of the great arteries in the 1960s, gave a whole generation of babies with congenital heart disease the chance to grow to adulthood. It is estimated that 85% of children with congenital heart disease (CHD) now survive into adulthood, a figure that includes patients with single ventricle physiology undergoing the Fontan operation. As a result, a growing number of women with CHD now wish to undergo possibly the greatest cardiovascular challenge of a woman’s life: pregnancy and childbirth. Unfortunately, this is not without risk. As more women with CHD become pregnant, a better understanding of moderate to complex heart disease, different surgical repair procedures, residual anomalies and the influence of pregnancy on all of the above is paramount.

A functional understanding of moderate to complex congenital heart disease and the impact of pregnancy. Part II: Tetralogy of Fallot, Eisenmenger’s syndrome and the Fontan operation

M.A. Naguib, D.P. Dob, M.A. Gatzoulis — 2010-06-04

Since the introduction of cardiopulmonary bypass procedures, the survival of babies with moderate to complex congenital heart disease (CHD) has become the norm. More than 85% survive to adulthood. As a result a new cohort of women wishes to risk the cardiovascular challenges of pregnancy and childbirth.

The use of uterotonic drugs during caesarean section

R.A. Dyer, D. van Dyk, A. Dresner — 2010-06-07

Abstract: The administration of oxytocic drugs during caesarean section is an important intervention to prevent uterine atony or treat established postpartum haemorrhage. Considerable past and current research has shown that these agents have a narrow therapeutic range. A detailed knowledge by anaesthetists of optimal doses and side effects is therefore required. Oxytocin remains the first line agent. In view of receptor desensitisation, second line agents may be required, namely ergot alkaloids and prostaglandins. This review examines the adverse haemodynamic and side effects, and methods for their limitation. An approach to dosing and choices of agent for the limitation of postpartum haemorrhage is suggested.

Ultrasound in obstetric anaesthesia: a review of current applications

P. Ecimovic, J.P.R. Loughrey — 2010-06-04

Abstract: Ultrasound equipment is increasingly used by non-radiologists to perform interventional techniques and for diagnostic evaluation. Equipment is becoming more portable and durable, with easier user-interface and software enhancement to improve image quality. While obstetric utilisation of ultrasound for fetal assessment has developed over more than 40years, the same technology has not found a widespread role in obstetric anaesthesia. Within the broader specialty of anaesthesia; vascular access, cardiac imaging and regional anaesthesia are the areas in which ultrasound is becoming increasingly established. In addition to ultrasound for neuraxial blocks, these other clinical applications may be of value in obstetric anaesthesia practice.

Maternal death due to extended spectrum β-lactamase-producing E. coli: A warning for the future?

B.A. Loughnan, M. Grover, P.B. Nielsen — 2010-06-04

Abstract: We describe a maternal death due to necrotising fasciitis caused by an extended spectrum β-lactamase-producing Escherichia coli resistant to routinely used antimicrobial agents. Necrotising fasciitis is a rare complication of septicaemia with a high mortality. Signs of infection were insidious and masked by the use of routine analgesic agents and concurrent preeclampsia. The incidence of infection with extended spectrum β-lactamase-producing organisms is increasing both in the United Kingdom and globally and will need to be considered in the obstetric setting. The use of the current Modified Early Warning Scores was of limited help in this case. Where there is no response to routine antibiotics within 12h, microbiological review is indicated.

Side effects of spiramycin masquerading as local anesthetic toxicity during labor epidural analgesia

B. Julliac, H. Théophile, M. Begorre, B. Richez, F. Haramburu — 2010-06-04

Abstract: Significant fetal bradycardia occurred when a parturient receiving labor epidural analgesia experienced generalized numbness and tingling, a metallic taste and hot flushes. An emergent cesarean delivery under general anesthesia was performed with favorable outcomes for the mother and baby. The most likely source of the maternal symptoms was spiramycin, which was being administered for treatment of toxoplasmosis.

Reversal of prolonged rocuronium neuromuscular blockade with sugammadex in an obstetric patient with transverse myelitis

G. Weekes, N. Hayes, M. Bowen — 2010-06-04

Abstract: A 38-year-old wheelchair-bound primigravida with transverse myelitis presented at 38weeks of gestation for elective caesarean section. Transverse myelitis, which is characterised by bilateral inflammation of the spinal cord and myelin destruction, is associated with myopathy, autonomic dysreflexia and pulmonary aspiration. Regional anaesthesia was contraindicated in this case as the patient had undergone two previous lumbar spinal fusion procedures. Rocuronium 1.2mg/kg was used to facilitate rapid intubating conditions. The caesarean section proceeded uneventfully, but even after administration of neostigmine the patient exhibited prolonged neuromuscular blockade. After 3h and 15min sugammadex was obtained to reverse neuromuscular blockade; the drug was not stocked in our hospital. Sugammadex 4mg/kg resulted in complete reversal of blockade after 2min. We believe that myopathy associated with transverse myelitis led to the prolonged duration of action of rocuronium. Sugammadex is a relatively new drug with few reported side effects. In this case it was used to reverse neuromuscular blockade and prevented prolonged postoperative ventilatory support.

Anaesthetic management of a pregnant patient with multiple myeloma

D.M. Dabrowska, C. Gore, S. Griffiths, M. Mudzingwa, S. Varaday — 2010-06-07

Abstract: We describe a 42-year-old multiparous woman who was admitted to our hospital in the 28th week of her twin pregnancy because of anaemia and proteinuria. She was subsequently diagnosed with multiple myeloma. An uncomplicated elective caesarean section was performed at 35 weeks under combined spinal–epidural anaesthesia with a good outcome for mother and both babies. After two weeks, however, the mother developed cardiac failure due to peripartum cardiomyopathy. To our knowledge, there have been no more then twenty reports of multiple myeloma in pregnant patients, of which only five have been diagnosed during pregnancy. This is the first case report describing anaesthetic implications and management of a parturient with multiple myeloma.

Management of a parturient with high-grade osteosarcoma of the proximal femur: a multidisciplinary approach

A.A. Quaye, K.A. Raskin, J.L. Ecker, L.R. Leffert — 2010-06-07

Abstract: Osteosarcoma is the most common primary malignant bone tumor, yet it is exceedingly rare in pregnancy. We present a case of a 33-year-old multiparous woman diagnosed with high-grade osteosarcoma during the third trimester of pregnancy. A plan was formulated to perform cesarean delivery at 33 weeks of gestation under spinal anesthesia, and, in subsequent surgery, radical femoral neck resection with limb salvage and adjuvant chemotherapy. The outcome was a healthy newborn baby boy and a disease-free mother. This case highlights the benefits of multidisciplinary planning: balancing the needs of the developing fetus with those of the mother, mitigating the risk of pathologic fracture and ensuring timely oncologic therapy.

For induction of spinal anaesthesia is sitting really the same as the lateral position?

I.F. Russell — 2010-06-04

The ongoing debate as to the best position for the induction of spinal anaesthesia for caesarean section and how the block should be tested remains unresolved, in part due to the large cohorts of patients required to show statistically significant differences in failure rates. Thus the paper by Sng and colleagues, which suggested no difference in failure rates between the sitting or lateral positions (P=0.4), is welcomed. However, I am not convinced that their data support this. In their analysis only partial block failures (i.e. those needing supplementary intraoperative analgesia) were included. There were four other patients, all sitting inductions, who received general anaesthesia before surgery commenced for an inadequate block level. It is not clear why these women were excluded from the analysis but their inclusion would have resulted in a significant difference between sitting and lateral ‘failures’ (P=0.04). Unfortunately there are insufficient details to give a clear understanding of how the block levels were assessed. They state that loss of cold sensation was used to determine the height of sensory block at the start of surgery and inadequate sensory block was defined as an upper level lower than T5. Was this a complete loss of cold sensation, or a change in the appreciation of the cold sensation? However assessed, it would be of interest to know the level of cold block in the 37 women who required intra-operative supplements. If the level was T5 or above, then it would suggest that loss of cold sensation is not an appropriate testing method to differentiate between blocks that will or will not be adequate for caesarean section.

In reply

B.L. Sng, Y. Lim, A.T.H. Sia — 2010-06-04

We thank Dr Russell for his interest in our report. A ‘total’ failed block requiring conversion to general anaesthesia before skin incision is an event whose clinical significance is distinct from a ‘partial’ failure, where supplemental analgesics are given in the intra-operative period.

Can oxygenation or ventilation realistically be achieved via percutaneous cricothyrotomy?

V. Kushakovskyy, O. Kushakovska — 2010-06-04

We read with great interest the recent paper by Bullough and Carraretto on the availability of obstetric airway equipment in the UK. Although the manuscript was based on data collected in 2003, the authors indicated that percutaneous cricothyrotomy sets were available in 96% of the units. While this is reassuring, we are anxious to know what kind of oxygenation equipment is immediately available to achieve oxygenation or provide ventilation through this route (e.g. Sanders injector). It is not clear from the manuscript whether the survey addressed this question nor if individuals are adequately prepared to provide such assistance. Clarification from authors would be extremely welcomed.

In reply

A.S. Bullough, M. Carraretto — 2010-06-02

We thank Drs. Kushakovsky and Kushakovska for their comments on our UK national obstetric intubation equipment survey. Our questionnaire addressed the availability of percutaneous cricothyrotomy sets and associated equipment. Due to the variation in commercially available needles, cannulae and surgical cricothyrotomy kits and training in the use of these devices, we did not ask the respondents to specify the equipment or the training provided. Each kit has advantages and limitations, with success dependent on the operator skill, experience and situational awareness.

A 10 year retrospective audit of monitoring following intrathecal and epidural opioids

E. O’Shea, R. Jee, M. Wee — 2010-06-04

In 1994 central neuraxial diamorphine was introduced to Poole Maternity Unit. In response to safety concerns, and following discussion with the Maternity Clinical Management Group, detailed postoperative observations were recorded on women undergoing caesarean section who received neuraxial opioids. Data collected included time of administration and maternal respiratory rate, pain and sedation scores which were recorded every 30min for 2h, then hourly for 10h. Sedation was scored from 0 to 3 [0=alert or normal sleep (easily roused); 1=mildly sedated (occasionally drowsy but easily roused); 2=moderately sedated (frequently drowsy but easily roused); and 3=severely sedated (somnolent and difficult to rouse)].

Subclinical factor X deficiency may increase hemorrhage in women undergoing cesarean section

C. Bachlechner, C. Pechlaner, G. Putz, G. Mitterschiffthaler, H. Herff, P. Paal — 2010-06-04

A 32-year-old patient with a mild deficiency of coagulation factor X (FX) was scheduled for cesarean section in her 37th week of pregnancy. Her two earlier cesarean sections were complicated by severe diffuse postoperative hemorrhage requiring treatment in the intensive care unit and transfusion of 12 units of packed red blood cells and fresh frozen plasma. After the second cesarean section, FX deficiency was diagnosed and confirmed with repeatedly low FX measurements (range 0.44–0.62U/mL; normal value >0.70U/mL). Prior to her third cesarean section, low hemoglobin and FX levels were observed (), however, all other coagulation tests and factors V, VII, VIII, IX, XI, XIII were within normal range. Preoperatively, we administered 2.0IU of prothrombin complex concentrate (Beriplex®, CSL Behring, Marburg, Germany). Spinal anesthesia and cesarean section were uneventful, with no postoperative hemorrhage observed.

Subcutaneous fluid collection following single-shot spinal anaesthesia for caesarean section

J.N. Darvall, H. Kocent — 2010-06-04

A 27-year-old female presented six days after an elective caesarean section with complaints of a severe postural headache. Her past medical history was unremarkable, with two previous uncomplicated caesarean sections with epidural and spinal techniques, respectively. Her most recent caesarean section was performed under a spinal anaesthetic at L3–4 with 0.5% hyperbaric bupivacaine 2.2mL and 15μg fentanyl injected through a 25-gauge pencil-point needle on the second pass. This was preceded by skin infiltration with 1% lignocaine 5mL. The patient was discharged uneventfully without headache three days after delivery.

Severe hemorrhage in a first-trimester cesarean scar pregnancy during dilation and curettage

K. Kim, A. Pietrzak, S. Gonzalez, K. Podgony — 2010-06-04

Embryo implantation in a cesarean scar is a rare event and a risk factor for placenta previa or accreta. Despite an increasing number of reports of scar pregnancy in the obstetric literature, limited anesthetic guidance is available. A previously healthy 31-year-old woman (G5P4) presented for dilation and curettage (D&C) at 16weeks of gestation, five weeks after embryonic demise. Her obstetric history included one cesarean and three vaginal deliveries. Ultrasound examinations at 8 and 9weeks showed a lower uterine segment gestational sac consistent with a scar pregnancy, which was reconfirmed at 11weeks, when embryonic demise was also diagnosed. She elected to have observant management and was seen at 16weeks following a week of light vaginal bleeding. Ultrasound examination showed a persistent gestational sac without fetal cardiac activity and an ultrasound-guided D&C was advised. Information regarding the scar pregnancy was not disclosed to the anesthesia team.

Stability and sterility of succinylcholine chloride

D. Boulay, D. Antier, M. Laffon — 2010-06-04

Anaesthesiologists often prepare syringes of induction agents in advance to save time before emergent caesarean delivery. These syringes are stored in the obstetric operating setting at room temperature (22±1°C) or in a refrigerator (+2 to +4°C). In France, two succinylcholine chloride solutions, 10mg/mL (10mL) and 50mg/mL (2mL), are available. Whereas the more dilute succinylcholine 10mg/mL solution has been observed to remain sterile and potent when drawn up into a syringe for up to 8days at room temperature, there are no such data regarding succinylcholine 50mg/mL when diluted (10mg/mL) with sterile saline. The clinical storage of diluted succinylcholine in syringes is limited to a 24h period, which is in keeping with recommendations for parenteral preparations without preservatives [United States Pharmacopeia, 2008 Guidebook to Pharmaceutical Compounding – Sterile Preparations]. However, the daily renewal of diluted drug syringes increases cost, waste and ties up manpower.

Epidural catheter markings and the morbidly obese

S.P. Singh, S. Sagadai — 2010-06-07

The number of morbidly obese parturients is on the rise and it is a global phenomenon. Risks related to obesity in pregnancy have been well documented. We would like to share our experience of managing a morbidly obese woman.

Forthcoming meetings

2010-07-01