International Journal of Obstetric Anesthesia

Editorial Board

2012-01-01

Iatrogenic headaches: giving everyone a sore head

M.J. Paech — 2012-01-01

A Greek proverb says “When you go to bed with a clear head, you will not get up with a headache”. Not so for postdural puncture headache (PDPH): a consequence of a spinal, and a complication of an epidural, familiar to all obstetric anaesthetists. It frequently causes significant distress, especially since post-delivery it may restrict or even totally prevent a mother dealing with the challenging functional demands of a newborn child, sometimes while she is recovering from major surgery. Postdural puncture headache is induced by cerebrospinal fluid (CSF) loss and the consequences of low intracranial pressure and cerebral vasodilation when in the non-recumbent position. If it follows use of a small-gauge spinal needle, the intensity is usually mild to moderate and symptoms can often be managed expectantly, on the basis that spontaneous resolution usually occurs within a few days to a week. In contrast, PDPH following use of a large-gauge cutting-edge spinal needle or an epidural needle is most frequently of moderate to severe intensity and most patients are still suffering after one week. Up to 15% of these headaches persist for weeks or even years.

Obtaining informed consent for clinical trials – Seldom easy, often difficult, and sometimes impossible

G.M. Joynt — 2012-01-01

“If one looks out for faults it is only as a means of recognizing goodness”Confucius, Analects 4.8Following the infamous human experimentation abuses exposed at the Nuremberg trials, the later controversial exposure of the conduct of the Tuskegee study, and others since, there have been consistent efforts made by the medical community and regulatory bodies to ensure that all medical research is conducted in an ethical manner. Careful examination of the ethical principles of medical practice, and the medical profession’s relationship with society have informed decisions on how medical research should be practiced. One of the main objectives of this process has been to reassure individuals within society that they will not be unwittingly exposed to research that may potentially harm them. The Declaration of Helsiniki, first promulgated in 1964 clearly outlined a set of principles governing research practice that have stood the test of time, although some amendments over the past 45 years have been made to allow the Declaration to address evolving societal needs. Some countries, including the European Union and the United Kingdom, have also developed regulatory requirements governing aspects of medical research. Central to the Declaration of Helsinki and these regulations is the need for informed consent from all participants taking part in clinical trials. This ensures that the requirement for doctors to respect patient autonomy, a key moral principle informing the ethical practice of medicine, is respected. Thus in the conduct of clinical trials, autonomy is embodied in the general requirement that informed consent from an individual is necessary before participation is allowed.

A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour

I.F. Russell — 2011-12-09

Abstract: Background: After accidental dural puncture in labour it is suggested that inserting an intrathecal catheter and converting to spinal analgesia reduces postdural puncture headache and epidural blood patch rates. This treatment has never been tested in a controlled manner.Methods: Thirty-four hospitals were randomised to one of two protocols for managing accidental dural puncture during attempted labour epidural analgesia: repeating the epidural procedure or converting to spinal analgesia by inserting the epidural catheter intrathecally. Hospitals changed protocols at six-month intervals for two years.Results: One hundred and fifteen women were recruited but 18 were excluded from initial analysis because of practical complications which had the potential to affect the incidence of headache and blood patch rates. Of the remaining 97 women, 47 were assigned to the repeat epidural group and 50 to the spinal analgesia group. Conversion to spinal analgesia did not reduce the incidence of postdural puncture headache (spinal 72% vs. epidural 62%, P=0.2) or blood patch (spinal 50% vs. epidural 55%, P=0.6). Binary logistic analysis revealed the relative risk of headache increased with 16-gauge vs. 18-gauge epidural needles (RR=2.21, 95% CI 1.4–2.6, P=0.005); anaesthetist inexperience (RR=1.02 per year difference in experience, 95% CI 1.001–1.05, P=0.043), and spontaneous vaginal compared to caesarean delivery (RR=1.58, 95% CI 1.14–1.79, P=0.02). These same factors also increased the risk of a blood patch: 16-gauge vs. 18-gauge needles (RR=2.92, 95% CI 1.37–3.87, P=0.01), anaesthetist inexperience (RR=1.06 per year difference in experience, 95% CI 1.02–1.09, P=0.006), spontaneous vaginal versus caesarean delivery (RR=2.22, 95% CI 1.47–2.63, P=0.002). When all patients were included for analysis of complications, there was a significantly greater requirement for two or more additional attempts to establish neuraxial analgesia associated with repeating the epidural (41% vs. 12%, P=0.0004) and a 9% risk of second dural puncture.Conclusions: Converting to spinal analgesia after accidental dural puncture did not reduce the incidence of headache or blood patch, but was associated with easier establishment of neuraxial analgesia for labour. The most significant factor increasing headache and blood patch rates was the use of a 16-gauge compared to an 18-gauge epidural needle.

Study of equivalence: spinal bupivacaine 15mg versus bupivacaine 12mg with fentanyl 15μg for cesarean delivery

R.A. Meyer, A.J. Macarthur, K. Downey — 2011-11-28

Abstract: Background: A safe and effective intrathecal dose of bupivacaine alone for cesarean delivery has not yet been established. This study tested the hypothesis that an intrathecal dose of hyperbaric bupivacaine 15mg would produce equivalent spinal anesthesia for cesarean delivery as the combination of hyperbaric bupivacaine 12mg and fentanyl 15μg.Methods: This was a single center, double-blind, randomized clinical trial of equivalence. One hundred and thirty-eight healthy parturients scheduled for elective cesarean delivery were randomized to receive either intrathecal hyperbaric bupivacaine 15mg (Group B) or hyperbaric bupivacaine 12mg with fentanyl 15μg (Group BF). Parturients where asked to describe their degree of sensation during surgery using a four-point scale 20min after spinal injection. Secondary outcomes included the incidence of maternal side effects, maternal hemodynamics and the need for supplemental analgesia.Results: There was no difference in the quality of anesthesia between the two groups. Sixty-eight of 69 and 69/69 patients in Group B and Group BF, respectively had anesthesia classified as successful (RR=1.01; 95% CI 0.85, 1.22). The only two secondary outcomes that were different between the groups were the largest change in mean arterial pressure (decrease of 40mmHg and 34mmHg for Group B and Group BF, respectively; P=0.004) and the incidence of nausea (59% and 35% for Group B and Group BF, respectively; P=0.006).Conclusion: There was no difference in the degree of sensation at 20min between Group B and Group BF. The only significant differences between the two techniques were a higher incidence of nausea and decrease in maternal blood pressure in Group B.

Reduction in spinal-induced hypotension with ondansetron in parturients undergoing caesarean section: A double-blind randomised, placebo-controlled study

T. Sahoo, C. SenDasgupta, A. Goswami, A. Hazra — 2011-11-21

Abstract: Background: Subarachnoid block is the preferred method of anaesthesia for caesarean section, but is associated with hypotension and bradycardia, which may be deleterious to both parturient and baby. Animal studies suggest that in the presence of decreased blood volume, 5-HT may be an important factor inducing the Bezold Jarisch reflex via 5-HT3 receptors located in intracardiac vagal nerve endings. In this study, we evaluated the effect of ondansetron, as a 5-HT3 receptor antagonist, on the haemodynamic response following subarachnoid block in parturients undergoing elective caesarean section.Methods: Fifty-two parturients scheduled for elective caesarean section were randomly allocated into two groups. Before induction of spinal anaesthesia Group O (n=26) received intravenous ondansetron 4mg; Group S (n=26) received normal saline. Blood pressure, heart rate and vasopressor requirements were assessed.Results: Decreases in mean arterial pressure were significantly lower in Group O than Group S from 14min until 35min. Patients in Group O required significantly less vasopressor (P=0.009) and had significantly lower incidences of nausea and vomiting (P=0.049).Conclusion: Ondansetron 4mg, given intravenously 5min before subarachnoid block reduced hypotension and vasopressor use in parturients undergoing elective caesarean section.

Intrathecal fentanyl added to bupivacaine and morphine for cesarean delivery may induce a subtle acute opioid tolerance

B. Carvalho, D.R. Drover, Y. Ginosar, S.E. Cohen, E.T. Riley — 2011-11-21

Abstract: Background: Previous studies have demonstrated that the addition of intrathecal fentanyl to a spinal anesthetic for cesarean delivery improves intraoperative analgesia. However, intrathecal fentanyl may induce acute tolerance to opioids. The objective of this study was to investigate whether the addition of intrathecal fentanyl to spinal anesthesia with intrathecal morphine increases postoperative analgesic requirements and pain scores.Methods: In this randomized, double-blinded study, 40 women having elective cesarean delivery were enrolled. Patients received spinal anesthesia with hyperbaric bupivacaine 12mg, morphine 200μg, and fentanyl 0, 5, 10 or 25μg. Each patient received intravenous patient-controlled analgesia morphine for 24h postoperatively. Outcome measures included postoperative morphine usage and pain scores, as well as intraoperative pain, nausea, hypotension and vasopressor use.Results: Total morphine use over the 24-h post-spinal study period was similar among the study groups (P=0.129). Postoperative pain scores were higher in patients receiving fentanyl 5, 10 and 25μg compared to fentanyl 0μg control group (P=0.003).Conclusions: The study results suggest that intrathecal fentanyl may induce acute tolerance to intrathecal morphine. However, because there was no difference in postoperative analgesia requirement and the difference in pain scores was small, the clinical significance of this finding is uncertain.

Assessment of salivary amylase as a stress biomarker in pregnant patients

2011-11-28

Abstract: Background: Chronic stress during pregnancy has been associated with worsened maternal and fetal outcomes. Acute stress immediately before spinal anaesthesia for caesarean section may contribute to hypotension. Therefore objective measures of acute stress may help identify women at risk of adverse outcomes. Salivary alpha-amylase is a stress biomarker that has so far been poorly investigated during pregnancy. The reference change value is the difference between two sequential results that must be exceeded for a change to be considered clinically relevant. Our first aim was to determine if salivary alpha-amylase increased in pregnant patients when subjected to the stress of transfer to the operating room. Our second aim was to determine if changes in salivary alpha-amylase were likely to be clinically significant by measuring reference change value in healthy volunteers.Methods: In 15 pregnant patients undergoing planned caesarean section under spinal anaesthesia, salivary alpha-amylase, systolic blood pressure, heart rate, and immediate anxiety were measured on the morning of surgery on the ward and again in the operating room. The reference change value was calculated from 18 healthy volunteers.Results: A median 220% increase in salivary alpha-amylase activity (P=0.0015) and a 17% increase in systolic blood pressure (P=0.0006) were observed between the ward and operating room. No changes of immediate anxiety or heart rate were observed. Reference change value was ±76% in volunteers and 13 of the 15 pregnant patients had a salivary alpha-amylase increase greater than the reference change value.Conclusion: When pregnant women are taken to the operating room, a clinically and statistically significant increase in salivary alpha-amylase was observed. Further studies are required to define its clinical usefulness.

Effect of μ-opioid receptor A118G polymorphism on the ED50 of epidural sufentanil for labor analgesia

M. Camorcia, G. Capogna, S. Stirparo, C. Berritta, J.L. Blouin, R. Landau — 2011-12-07

Abstract: Background: A common polymorphism of the μ-opioid receptor gene (OPRM1, p.118A/G), which has been shown to effect the response to neuraxial opioids, occurs in 30% of Caucasian women. This double-blind up-down sequential allocation study was designed to examine the effect of p.118A/G on the ED50 of epidural sufentanil for labor analgesia.Methods: Nulliparous women were recruited at 35weeks of gestation (n=77) and genotyped for p.118A/G. Those subsequently requesting epidural labor analgesia were enrolled. Each woman received epidural sufentanil diluted with 0.9% saline to a volume of 5mL. The initial sufentanil dose was 21μg, with subsequent doses determined by the response of the previous patient (testing interval 1μg). Efficacy was accepted if the visual analogue score decreased to <10mm on a 100-mm scale within 30min of drug administration.Results: Twenty patients were excluded, leaving 57 women from whom data were analyzed: 33 in Group A (wild-type A118 homozygotes) and 24 in Group G (heterozygotes and homozygotes G118). The ED50 for epidural sufentanil was 25.2μg in Group A (95% CI 23.2–26.4) and 20.2μg in Group G (95% CI 14.2–23.6) (P=0.03). The potency ratio for epidural sufentanil in Group G compared to Group A was 1.25 (95% CI 1.00–1.64).Conclusion: Women carrying the variant allele of p.118A/G of OPRM1 (G118) had a lower ED50 for epidural sufentanil given for early labor analgesia than women homozygous for the wild-type allele.

Onset of labor epidural analgesia with ropivacaine and a varying dose of fentanyl: a randomized controlled trial

E.C. Bang, H.S. Lee, Y.I. Kang, K.S. Cho, S.Y. Kim, H. Park — 2011-12-07

Abstract: Background: This study was conducted to investigate the onset of labor epidural analgesia using 0.17% ropivacaine with a varying dose of fentanyl. We hypothesized that the onset of analgesia would be shortened in proportion to an increase in fentanyl dose.Methods: Women requesting labor epidural analgesia were enrolled in this randomized controlled clinical trial. Each woman was randomly assigned to receive fentanyl 0, 50, 75, or 100μg with 0.17% ropivacaine 12mL. The onset and duration of analgesia, the incidence of side effects and patient satisfaction were measured.Results: Data from 102 women were analyzed. The onset of analgesia (mean±SD) was shortened with an increasing dose of fentanyl (14.3±5.4, 14.2±6.5, 12.1±5.1, and 8.7±3.8min with fentanyl 0, 50, 75, or 100μg, respectively, P=0.001). The duration of analgesia was prolonged with an increasing dose of fentanyl (87.4±20.8, 112.3±19.5, 140.8±18.8, and 143.6±18.6min with fentanyl 0, 50, 75, or 100μg, respectively, P<0.001). The incidence of pruritus increased with an increasing dose of fentanyl (P=0.027) but there were no differences for other maternal side effects. There was a significant difference in satisfaction score among groups (P=0.009).Conclusion: The addition of increasing doses of fentanyl to 0.17% ropivacaine contributed to shortened onset as well as prolonged duration of labor epidural analgesia and improved patient satisfaction.

Maternal sepsis during pregnancy or the postpartum period requiring intensive care admission

2011-12-08

Abstract: Background: Previous studies on severe maternal sepsis during pregnancy or the postpartum period are rare and have focused on septic abortion. Voluntary abortion was legalized in France in 1975. This study was conducted to reassess the characteristics of maternal sepsis that have been managed in a French intensive care unit.Methods: A retrospective study of 66 women admitted to an intensive care unit for sepsis from 1977–2008 was performed. Data on sources of infection, microbial agents and maternal and fetal outcomes were collected. Data from 1977–1992 and 1993–2008 were compared.Results: Over time, the rate of intensive care admission for maternal sepsis did not change (0.75 episodes per 1000 deliveries in 1977–1992 versus 0.72/1000 in 1993–2008, P=1.0). The percentage of septic abortions decreased from 14% to 0%, whereas that of antepartum infections increased from 50% to 79% (P<0.01). The percentage of non-bacterial infections increased from 0% to 19% (P=0.04), and the percentage of pelvic infections had a tendency to decrease from 54% to 27% (P=0.06). Pelvic infections were due to enterobacteriaceae (50%), gram-positive cocci (45%), and/or anaerobes (23%). Maternal and fetal mortality rates were 6% and 33%, respectively.Conclusions: Over time, our intensive care unit has seen fewer cases of septic abortion. However, maternal sepsis remained a cause of intensive care admission and both maternal and fetal death. The percentages of antepartum and non-bacterial infections have increased over time. A prospective multicentre study is required to confirm these results and to investigate questions such as the effect of maternal sepsis on long-term fetal outcome.

Sepsis in obstetrics and the role of the anaesthetist

D.N. Lucas, P.N. Robinson, M.R. Nel — 2011-12-14

Abstract: Sepsis in pregnancy and the puerperium remains a significant cause of maternal mortality and morbidity worldwide. Major morbidity arising as a result of obstetric sepsis includes fetal demise, organ failure, chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. Early recognition and timely response are key to ensuring good outcome. This review examines the clinical problem of sepsis in obstetrics and the role of the anaesthetist in the management of this condition.

What’s new in obstetric anesthesia: the 2011 Gerard W. Ostheimer lecture

P. Toledo — 2012-01-01

Abstract: The Gerard W. Ostheimer lecture is delivered at the Society for Obstetric Anesthesia and Perinatology Annual Meeting. The lecture provides a comprehensive review of the previous year’s literature in obstetric anesthesia, obstetrics, perinatology, and health services research relevant for obstetric anesthesiologists. This article covers several of the major themes that emerged from the 2010 literature.

Type A aortic dissection in pregnancy

C. Johnston, F. Schroeder, S.N. Fletcher, C. Bigham, R. Wendler — 2011-12-06

Abstract: Type A aortic dissection is a life-threatening event to both mother and baby, and accounted for 14% of maternal cardiac deaths in the 2006–2008 UK Confidential Enquiries into Maternal Deaths. Difficulty exists in the diagnosis of this rare but potentially curable condition, the mortality of which increases with delay in diagnosis. We present a case of acute type A aortic dissection in a previously well multiparous woman, treated successfully by aortic root repair immediately following caesarean section. The acute presentation of aortic dissection and diagnostic clues that may have expedited the diagnosis are discussed. A brief literature review is presented of the perioperative management of patients undergoing cardiothoracic surgery post-caesarean section and the modifications to standard techniques that are required.

Transfusion practice in major obstetric haemorrhage: lessons from trauma

I. Saule, N. Hawkins — 2011-11-28

Abstract: The management of massive haemorrhage with blood products is changing as evidence arrives from civilian and military trauma. Rapid early replacement of coagulation factors and platelets is now becoming central to improving outcome, usually given in higher ratios with respect to red cell units than previously recommended and using empiric transfusion based on clinical rather than laboratory parameters. The management of three cases of major obstetric haemorrhage based on these principles is presented. Packed red blood cells, fresh frozen plasma, platelets and cryoprecipitate were transfused in the ratios 5:2:2:1, 4.5:1:1:1 and 4.5:2:1:1. Each patient had acceptable full blood count and coagulation results after surgery and all made an uneventful recovery. These outcomes support the opinion that major obstetric haemorrhage can be managed in a similar fashion to blood loss in trauma. Recommendations from the Association of Anaesthetists of Great Britain and Ireland, and the UK National Patient Safety Agency should be considered during major obstetric haemorrhage.

Anesthetic management of vaginal delivery in a parturient with hemochromatosis induced end-organ failure

A.L. Hoefnagel, R. Wissler — 2011-11-21

Abstract: The vast majority of females affected by hemochromatosis are asymptomatic during childbearing years. We were able to provide effective obstetric anesthesia care to a 35-year-old woman with severe hemochromatosis. She had systolic heart failure with a left ventricular ejection fraction of 15%, severe pulmonary hypertension, mitral insufficiency, a history of ventricular tachycardia, cirrhosis, obstructive sleep apnea, gestational diabetes, and severe scoliosis. A multidisciplinary approach was used to stabilize her heart failure and prepare her for childbirth. An arterial line and epidural analgesic were placed before induction of labor. Vaginal delivery was accomplished with passive decent of the fetus and forceps assistance. We discuss hemochromatosis and its implications for the parturient.

Multidisciplinary management of an obstetric patient with glycogen storage disease type 3

S.D. Bolton, V.A. Clark, J.E. Norman — 2011-12-05

Abstract: A 22-year-old primiparous woman with known glycogen storage disease type 3a presented to our hospital during her 12th week of pregnancy. Glycogen storage disease type 3 is a rare inherited disorder resulting from a deficiency of the glycogen debranching enzyme, causing the accumulation of abnormal short-chain glycogen in liver, blood cells, myocardium and striated muscle. Symptoms improve after puberty but the increased metabolism of pregnancy predisposes to hypoglycaemia, ketosis and lactic acidosis. Cardiomyopathy, distal weakness and peripheral neuropathy may present after the third decade. The patient was managed antenatally with regular cornflour feeds and was scheduled for elective caesarean delivery. She presented in early labour at 38weeks and delivered a healthy neonate by urgent caesarean delivery under spinal anaesthesia. Intravenous dextrose infusion and regular blood glucose monitoring were used during the perinatal period to prevent hypoglycaemia. An arterial line was inserted in the operating room for frequent blood sampling and to avoid muscle cramps which could be induced by the intermittent inflation of the automated blood pressure cuff. Obstetric, anaesthetic and neonatal outcomes were uneventful.

Peripartum management of two parturients with ornithine transcarbamylase deficiency

U. Ituk, O.C. Constantinescu, T.K. Allen, M.J. Small, A.S. Habib — 2011-12-06

Abstract: Ornithine transcarbamylase deficiency is a rare X-linked disorder in which female carriers are usually heterozygous for the ornithine transcarbamylase deficiency gene. In pregnancy it has been associated with altered mental status, seizures, coma and death, especially in the postpartum period. We report the management of labor and delivery in two parturients with known ornithine transcarbamylase deficiency. Both patients were maintained on arginine, citrulline and sodium phenylacetate therapy with restricted protein intake during pregnancy. Neuraxial techniques were used for pain relief in labor and anesthesia for operative delivery. A dextrose infusion provided caloric intake during labor and perioperatively.

Perioperative management of a parturient with hyponatraemia due to carbamazepine therapy

C. Staikou, A. Mani, G. Petropoulos — 2011-12-07

Abstract: We describe the perioperative management of an epileptic parturient who developed hyponatraemia due to carbamazepine therapy. Caesarean delivery was performed under combined spinal-epidural anaesthesia with a good outcome for both mother and neonate. The diagnostic and therapeutic approach, anaesthetic implications and maternal and neonatal risks for a patient with hyponatraemia complicating carbamazepine therapy are discussed.

Atosiban and non-cardiogenic pulmonary oedema

G.A. Wright, D.M. Levy — 2011-08-16

We were interested in the report from Fernández, Domínguez and Delgado which described non-cardiogenic pulmonary oedema secondary to atosiban and steroids. We are, however, perplexed by the assertion that atosiban has an antidiuretic action. If that were the case, surely it would reduce the likelihood of congestive heart failure and hypertension, rather than increase the risk? Moreover, this point is not actually explored in the associated reference. Lastly, the authors stated that the woman had a Glasgow Coma Scale score of 12/15 in the operating room, ‘although she remained cooperative.’ From which of the three categories of ‘eyes’, ‘verbal’ and ‘motor’ was a 3-point deficit calculated?

In Reply

A.B. Fernández, A. Sancho De Avila, D. Domínguez, L.M. Delgado — 2011-12-05

We thank Drs. Wright and Levy for their interest in our report. We agree that the explanation about the effects of atosiban was not completely clear in the reference provided. However, we disagree that the antidiuretic effect of atosiban reduces the risk of congestive heart failure, and in fact consider that the opposite is true. We would like to qualify our original statement; “because of its structure, atosiban has affinity for vasopressin receptors and inhibition of anti-diuretic effects may cause congestive heart failure and hypertension.” A possible explanation for this was given by Donders et al. who suggested that when the oxytocin receptor is activated, the subsequent intracellular cascade can lead to activation of an inhibitory protein, which is antagonistic and inhibits the anti-diuretic effect, or to activation of a Gi protein with stimulatory effect. This leads to an initiation of a selective intracellular cascade, which is the main mechanism involved in tumour-cell proliferation. As Donders et al. highlight, this paradoxical agonistic mechanism on the oxytocin receptor could be also implicated in the pathogenesis of non-cardiogenic pulmonary oedema, leading to the down regulation of the signal transduction of the V1 vascular vasopressin receptor and causing congestive heart disease and hypertension. Although more studies and investigations are needed, there could be a physiological explanation for how atosiban, acting as a vasopressin inhibitor, can lead to pulmonary oedema.

A national survey of UK obstetric units: The challenges of isolation

S.J. Marstin, E.M. Read, T.D. Madamombe, H.A. Swales — 2011-12-09

The 2000–2002 Confidential Enquiry into Maternal and Child Health report stated “isolated obstetric units present major difficulties in terms of immediate availability of additional skilled anaesthetic back-up and assistance from other specialties, including critical care.” In October 2009 we conducted a survey of UK obstetric units, approved by the Obstetric Anaesthetists’ Association (OAA), to quantify the number of isolated obstetric units and the challenges they face. We defined a split-site maternity unit as one that was not within the main hospital building that houses the adult intensive care unit.

Increased anaesthetic workload associated with increased maternal age

L. Peltola, J. Mayer, J. Cook, R. Bedson, L. Arrandale — 2011-11-21

The latest Centre for Maternal and Child Enquiries (CMACE) report highlighted concerns with the ability of labour ward staff to cope with emergency admissions when staffing is at maximum capacity. We performed a retrospective study which strongly supports existing evidence that the increasing age of pregnant women is stretching maternity services yet further.

New techniques and technologies for obstetric anaesthesia

M.J. Paech, S.G. Hillyard — 2011-12-02

A number of new techniques and technologies have been introduced to obstetric anaesthesia practice during the past decade. These include remifentanil patient-controlled intravenous analgesia (PCIA) for labour pain, transversus abdominis plane (TAP) blocks for post-caesarean analgesia, neuraxial ultrasound imaging for epidural insertion, brain function monitoring for depth of anaesthesia and limited transthoracic echocardiography (TTE) or minimally invasive cardiac output monitoring (COM) to assess and monitor cardiac function. One author (M.P.) conducted a pilot survey during sabbatical leave in 2010 while attending four tertiary referral obstetric units in four different countries: KK Women’s Hospital (Singapore), Chelsea and Westminster Hospital (London, UK), Stanford Medical Center (Palo Alto, USA) and King Edward Memorial Hospital for Women (Perth, Australia). Ninety questionnaires were distributed to obstetric anaesthetists, requesting information about their experience with, and attitudes toward, the above techniques and technologies, as applied to pregnant women.

Erratum to “In reply: The use of thromboelastography for the peripartum management of a patient with storage pool disorder” [Int J Obstet Anesth 20 (2011) 361]

G. Rajpal, J.M. Pomerantz, J.H. Waters, M.C. Vallejo — 2011-11-21

Dr. Rajpal’s name is listed incorrectly, and therefore the authorship list should read as above.

Acknowledgements

2011-11-28