International Journal of Obstetric Anesthesia - Articles in Press

Continuous wound infusion with ropivacaine fails to provide adequate analgesia after caesarean section - Corrected Proof

2012-02-20

Abstract: Background: Continuous wound infusion with local anaesthetic has been used in post-caesarean pain management with conflicting results. We carried out a study comparing three groups: continuous ropivacaine wound infusion, intrathecal morphine with saline wound infusion and saline wound infusion only.Methods: Sixty-six women undergoing elective caesarean section under combined spinal-epidural anaesthesia were randomly allocated to receive intrathecal morphine with saline wound infusion or 48h continuous wound infusion with either ropivacaine or saline. All parturients received oral ketoprofen and intravenous oxycodone patient-controlled analgesia. Consumption of oxycodone, visual analogue scale pain scores (0–10cm), patient satisfaction, side effects and recovery parameters were recorded for 48h in a double-blind manner.Results: Continuous wound infusion with ropivacaine failed to reduce oxycodone consumption or pain scores compared with saline control. In the first 24h intrathecal morphine reduced mean oxycodone consumption compared to the ropivacaine wound infusion group (26mg vs. 48mg, P=0.007) and saline wound infusion group (26mg vs. 45mg, P=0.021). The first 24-h mean pain score was also lower in the intrathecal morphine group vs. the saline wound infusion group (1.3 vs. 2.2, P=0.021). Pain scores were not significantly different between intrathecal morphine and ropivacaine wound infusion groups. Pruritus was more common with intrathecal morphine.Conclusion: Compared to saline control, continuous wound infusion with ropivacaine failed to reduce the use of intravenous oxycodone patient-controlled analgesia or pain scores. Intrathecal morphine decreased oxycodone consumption by 46% in the first 24h after surgery when compared to continuous ropivacaine wound infusion.

Pharmacokinetics of a loading dose of intravenous paracetamol post caesarean delivery - Corrected Proof

2012-02-17

Abstract: Background: The postpartum period affects drug disposition, but data of intravenous paracetamol loading dose pharmacokinetics immediately following caesarean delivery have not yet been reported.Methods: Immediately following caesarean delivery, women received a 2-g loading dose of intravenous paracetamol. Plasma samples were collected at 1, 2, 4 and 6h. Individual pharmacokinetics were calculated assuming a linear one-compartment model with instantaneous input and first-order output. Data were reported using median and range.Results: Twenty-eight patients undergoing caesarean delivery were recruited (age 31.5 [20–42] years, weight 79 [57–110] kg, body surface area 1.9 [1.5–2.4]m2). Median paracetamol plasma concentrations after 1, 2, 4 and 6h were 22.5, 15.25, 7.9, and 3.9mg/L respectively. Paracetamol clearance was 20.3 (11.8–62.8) L/h or 10.9 (7–23.8)L/hm2, distribution volume 58.3 (42.9–156) L or 0.72 (0.52–1.56) L/kg.Conclusion: Pharmacokinetics of intravenous paracetamol have been estimated following caesarean delivery. Although limited to a loading dose shortly after surgery, the results are clinically relevant since this is the first description in this patient population. These data provide evidence on which to base further integrated pharmacokinetic/pharmacodynamic studies in peripartum analgesia.

Anesthetic management of a spontaneous spinal-epidural hematoma during pregnancy - Corrected Proof

Y.Y. Jo, D. Lee, Y.J. Chang, H.J. Kwak — 2012-02-17

Abstract: Spontaneous spinal-epidural hematoma is uncommon and rare during pregnancy. We were presented with a 31-year-old patient who developed back pain with lower extremity paralysis at 36weeks of gestation. A magnetic resonance imaging scan demonstrated an acute spinal-epidural hematoma and therefore, an emergency cesarean delivery was performed followed by hemilaminectomy with hematoma removal. Anesthesia was initiated with a volatile-based technique which, following delivery of the baby, was changed to target-controlled infusions of propofol and remifentanil. Postoperatively, dopamine was infused to maintain the blood pressure within the high-normal range to optimize spinal cord perfusion. Successful anesthetic and postoperative management is described together with a review of the literature.

Two doses of spinal bupivacaine for caesarean delivery in severe preeclampsia: a pilot study - Corrected Proof

K. Jain, J.K. Makkar, S. Yadanappudi, I. Anbarasan, S. Gander — 2012-02-17

Spinal anaesthesia-induced hypotension may decrease uteroplacental perfusion in severely preeclamptic women undergoing caesarean delivery. In this pilot study, we aimed to determine whether a reduction in the dose of spinal bupivacaine decreased the incidence of hypotension and the requirement for vasopressors in this group of women.

The 2011 FAER-SOAP Gertie Marx lecture Reflections on studies of epidural analgesia and obstetric outcome - Corrected Proof

D.H. Chestnut — 2012-02-16

It was a privilege for me to know Dr. Gertie Marx. Time does not allow me to give adequate tribute to her contributions to the practice of obstetric anesthesia. In 2000 Dr. Marx received the first Distinguished Service Award from the Society for Obstetric Anesthesia and Perinatology (SOAP). As President of SOAP that year, it was my privilege to present the award to Dr. Marx. At the meeting banquet, four of us – Callie Hoyt, Medge Owen, Dick Wissler, and I – sang a song – barbershop quartet style – to Dr. Marx. The words were written by Dick Wissler and were quite clever. As I recall the singing was not stellar, but I think that Dr. Marx enjoyed it, and it was a lot of fun.

Acute intrathecal haematoma following neuraxial anaesthesia: diagnostic delay after apparently normal radiological imaging - Corrected Proof

M.A. Walters, M. Van de Velde, G. Wilms — 2012-02-16

Abstract: We describe a case of intrathecal haematoma following combined spinal-epidural anaesthesia for caesarean section. The parturient was previously well with no risk factors for haematoma development. Surgical intervention was delayed, resulting in permanent neurological injury. Incorrect interpretation of clinical findings and magnetic resonance imaging contributed to the delay in definitive treatment. We discuss the difficulties in diagnosis, image interpretation and the need for a specialist opinion when abnormal neurological symptoms persist despite apparently normal imaging.

Magnetic resonance imaging of sciatic nerve compression injury after epidural blockade - Corrected Proof

D.M. Mumby, E.L. Hartsilver — 2012-02-15

A fit 32-year-old nulliparous woman presented at term in spontaneous labour requesting epidural analgesia. In the sitting position, an epidural catheter was inserted at L2–3 at the first attempt, without paraesthesia. A loading dose of bupivacaine 15mg and fentanyl 30μg achieved effective analgesia with a block height to ice of T10 bilaterally. An infusion of 0.1% bupivacaine plus fentanyl 2μg/mL was started at 10mL/h. The infusion continued to provide excellent analgesia for the next 8h, at which time the woman gave birth to a healthy infant by normal vaginal delivery. After delivery of the placenta the epidural infusion was stopped and the epidural catheter removed.

Measurement of intra-abdominal pressure in term pregnancy: a pilot study - Corrected Proof

R. Chun, L. Baghirzada, C. Tiruta, A.W. Kirkpatrick — 2012-02-13

Abstract: Background: This study was conducted to assess the feasibility of measuring intra-abdominal pressure in term parturients under spinal anesthesia.Methods: Intra-abdominal pressure was measured in 20 term parturients after spinal anesthesia for elective caesarean section. Pressure was measured in the supine and 10° left lateral tilt positions with a constant reference point throughout.Results: Intra-abdominal pressure measurement was feasible and safe to perform. Pressure was significantly lower in the left lateral tilt position than supine (10.9mmHg±4.67 vs. 8.9mmHg±4.87, P=0.0004). The range of intra-abdominal pressure in pregnancy was wide, from 2 to 20mmHg, with >25% of patients resting with pressures above 12mmHg in both positions.Conclusions: Under spinal anesthesia, intra-abdominal pressure in >25% of healthy term parturients was > 12mmHg, which has conventionally been defined as intra-abdominal hypertension. The intra-abdominal pressure in term pregnancy should be performed in the left lateral tilt position to avoid falsely elevated pressure measurements.

A combined spinal-epidural technique for labor analgesia and symptomatic relief in two parturients with idiopathic intracranial hypertension - Corrected Proof

R.C. Month, S.J. Vaida — 2012-02-13

Abstract: Idiopathic intracranial hypertension is a condition consisting of increased intracranial pressure of unknown etiology, predominantly affecting obese women of childbearing age. Symptomatic relief can be provided by lumbar puncture and withdrawal of cerebrospinal fluid, and the technique has been described in laboring women using an intrathecal catheter. We present two patients who achieved both labor analgesia and symptomatic relief via a combined spinal–epidural technique with small volume cerebrospinal fluid withdrawal. Both women complained of headache of at least a 5 on a 10-point pain scale at the time of labor induction. Between 5 and 6mL of cerebrospinal fluid were withdrawn at the time of combined spinal-epidural insertion and pain relief was successfully achieved with patient-controlled epidural anesthesia. One patient proceeded to cesarean delivery for fetal indications under epidural anesthesia. Both women described significant improvement in headache symptoms that persisted until discharge from hospital, and neither developed new neurologic symptoms. A combined spinal–epidural technique with a small volume of cerebrospinal fluid withdrawal may provide labor analgesia and symptomatic relief in the parturient with idiopathic intracranial hypertension.

Haemodynamics in obese pregnant women - Corrected Proof

A.T. Dennis, J.M. Castro, M. Ong, C. Carr — 2012-02-13

Abstract: Background: Obesity in pregnant women is a serious health issue. Invasive monitoring devices are rarely used in pregnancy due to their risks; however, assessment of cardiac function is often required in these women. Transthoracic echocardiography offers advantages but may be technically difficult to perform. Our aim was to determine the feasibility of transthoracic echocardiography and to quantify left ventricular function and structure using transthoracic echocardiography in obese pregnant women.Method: Fifteen obese but otherwise healthy pregnant women (body mass index >30kg/m2), were compared with 40 healthy non-obese pregnant women. Echocardiography was performed according to American Society of Echocardiography recommendations.Results: Test completion with key haemodynamic data were obtained in 100% of women. Mean (standard deviation) gestation was similar between groups (36±5weeks). Compared with non-obese pregnant women, Gestational age (mean ± SD) mean arterial pressure (88±6 vs. 81±8mmHg, P=0.003), increased left ventricular mass (162.8±35.4 vs. 130.8±21.0g, P=0.008) but similar cardiac output (4417±890 vs. 4109±595mL/min, P=0.230) and diastolic changes (mitral valve E/se′ > 8 in 33% vs. 15% of patients, P=0.26). Septal tissue Doppler indices in obese pregnant women were s′ 9.1±1.9cm/s, e′ 11.6±2.6cm/s, a′ 8.1±2.7cm/s. Tei index was reduced in both groups (0.49±0.12 vs. 0.42±0.09, P=0.05).Conclusions: Transthoracic echocardiography was used to delineate haemodynamics in obese pregnant women. Mean arterial blood pressure and left ventricular mass were increased in obese pregnant woman. The incidence of diastolic impairment and reduced myocardial performance were similar between groups.

Subdural hematoma after an epidural blood patch - Corrected Proof

L.A. Verduzco, S.W. Atlas, E.T. Riley — 2012-02-10

Abstract: We report the case of a 37-year-old postpartum patient who developed a contained subacute spinal subdural hematoma causing mass effect on the cauda equina and severe spinal stenosis after undergoing an epidural blood patch for postdural puncture headache. Recovery occurred following administration of oral steroids.

Tramadol in pregnancy and lactation - Corrected Proof

M. Bloor, M.J. Paech, R. Kaye — 2012-02-10

Abstract: Tramadol produces analgesic effects through both non-opioid and weak opioid activity and is commonly used to treat mild to moderate pain. It has been in use for over 30years and has a well-established safety profile in the general population. Since tramadol is not licensed for use in pregnancy and lactation, there is limited clinical research on its use in this patient population. A systematic review was undertaken of articles published in English before June 2011, searching Pubmed, Medline, CINAHL, Embase and Cochrane databases using the terms ‘tramadol and pregnancy’, ‘tramadol and breastfeeding’, ‘tramadol and lactation’, and ‘tramadol and neonate’.

Combined spinal-epidural anesthesia for cesarean delivery in a patient with capillary pontine telangiectasia - Corrected Proof

R. Month, S. Vaida, A. Budde — 2012-02-10

Capillary pontine telangiectasia (CPT) are vascular malformations in which thin-walled, dilated capillary spaces are interspersed in normal parenchymal tissue. The condition has an incidence of 0.1% in the general population. The majority are found incidentally since they tend to grow slowly, but they may rarely present with mild symptoms including headache, vertigo, or facial weakness. Hemorrhage from CPT is rare.

Anesthetic management of a pregnant patient with multiple pterygium syndrome (Escobar type) - Corrected Proof

W.D. Stoll, L. Hebbar, L.S. Marica — 2012-02-10

Multiple pterygium syndrome is a rare disorder with several subtypes. Its features include pterygia (excessive webbing), arthrogryposis (congenital contractures), ankyloglossia (adhesions of the tongue to the palate), syngnathia (congenital bands of tissue between the maxilla and mandible), cleft palate, micrognathia, scoliosis, short stature, craniofacial dysmorphism, arachnodactyly and congenital respiratory distress. The Escobar subtype includes webbing of the neck that increases with age, lumbar lordosis and webbing of the elbows and knees that develops before adolescence.

Transversus abdominis plane catheters for post-cesarean delivery analgesia: a series of five cases - Corrected Proof

L. Bollag, P. Richebe, C. Ortner, R. Landau — 2011-12-07

Abstract: We present five cases of women who received ultrasound-guided transversus abdominis plane catheters for post-cesarean delivery analgesia. Pain relief was maintained with repeated boluses of local anesthetic combined with oral acetaminophen and ibuprofen unless contraindicated. We conclude that repeated dosing through transversus abdominis plane catheters may be offered to women as an alternative or adjuvant to intrathecal morphine. Larger studies to evaluate the safety and further refinements of this novel procedure are warranted.

Failed epidural top-up for cesarean delivery for failure to progress in labor: the plan is to do a single-shot spinal - Corrected Proof

B. Carvalho — 2011-11-23

As a consequence of increasing use of epidurals for labor analgesia, the majority of women in the United States presenting for cesarean delivery during labor will have an epidural in situ. Most clinicians in this setting elect to use the existing epidural to provide cesarean delivery anesthesia. A failed epidural top-up for cesarean delivery in labor is a potentially serious clinical problem that has gained increasing attention recently. The Royal College of Anaesthetists developed guidelines for acceptable rates for failed neuraxial anesthesia for cesarean delivery. The guidelines state that the conversion rate from regional to general anesthesia should be <1% for elective and <3% for non-elective cesarean delivery.

WITHDRAWN: Remifentanil patient-controlled intravenous analgesia for twin pregnancy - Corrected Proof

P. Gowreesunker, F. Roelants — 2010-08-12

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.