Alison J. Macarthur

Identification of the lumbar interspinous spaces: palpation versus ultrasound.

BACKGROUND:Palpation has been shown to be inaccurate at identifying lumbar interspinous spaces. Our goal in this study was to compare ultrasound imaging of the region to palpation. METHODS:Using ultrasound in the postpartum period, we estimated the interspinous level used for obstetric neuraxial anesthesia in 121 women and compared this estimation with the level estimated by palpation and documented in the chart by the anesthesiologist. RESULTS:In 67 of 121 (55%) patients, the vertebral level of the puncture mark documented by the treating anesthesiologist was in agreement with vertebral level as assessed using ultrasound, and in 39 (32%) women, the skin puncture level was estimated by ultrasound to be at least one interspace higher. The unweighted kappa was 0.08 (95% confidence interval: 0.02, 0.14). CONCLUSIONS:There was poor agreement between palpation and ultrasound estimation of the specific lumbar interspace, and when there was disagreement, the ultrasound estimate was more often higher than the palpitation estimate.

Epidural anaesthesia and low back pain after delivery: a prospective cohort study.

Abstract Objective: To determine whether epidural anaesthesia during labour and delivery is a risk factor for postpartum back pain. Design: Prospective cohort study with follow up at one day, seven days, and six weeks after delivery. Setting: Teaching hospital in Montreal. Subjects: 329 women who delivered a live infant(s) during the study period. Exclusion criteria were back pain before pregnancy and delivery by elective caesarean section. Intervention: Epidural anaesthesia during labour and delivery. Main outcome measures and results: The primary outcome variable was development of postpartum low back pain. Back pain was quantified with self reports (yes/no), a pain score (numeric rating scale), and degree of interference with daily activities. Of the 329 women, 164 received epidural anaesthesia during labour and 165 did not. The incidence of low back pain in epidural v non-epidural group was 53% v 43% on day one; 21% v 23% on day seven; and 14% v 7% at six weeks. The relative risk for low back pain (epidural v non-epidural) adjusted for parity, delivery, ethnicity, and weight was 1.76 (95% confidence interval 1.06 to 2.92) on day one; 1.00 (0.54 to 1.86) on day seven; and 2.22 (0.89 to 5.53) at six weeks. There were no differences between the two groups in pain scores or the frequency of interference with daily activities. Similar results were obtained in the subgroup of women with low back pain of new onset--that is, those women with no back pain during their pregnancy. Conclusions: Postpartum low back pain was common but decreased considerably over the short term. The association between epidural anaesthesia and postpartum low back pain was inconsistent over time with a significantly increased risk of low back pain (epidural v non-epidural) noted only on the first day after delivery.

The incidence and etiology of postpartum headaches: a prospective cohort study

Objectif Determiner ľincidence, la cause, les caracteristiques et les facteurs de risque de toutes les cephalees de la premiere semaine du postpartum.PurposeWe sought to determine the incidence, etiology, characteristics and risk factors for all headaches in the first week postpartum.MethodsThis was a prospective cohort study of 985 women delivering over a three-month period in a single tertiary-care institution. These women underwent a structured interview and follow-up to collect demographic data and to assess for the presence and characteristics of postpartum headache (PPHa) or neck/shoulder pain. All headaches were diagnosed using an algorithm based on the diagnostic criteria of the International Headache Society. Multivariate analysis was used to examine possible risk factors.ResultsThree hundred eighty-one of the 985 study participants (39%) reported headaches or neck/shoulder pain during the study period. The median time to onset of the PPHa was two days (0, 6; 1st and 3rd quartiles) and duration was four hours (2, 24; 1st and 3rd quartiles). Primary headaches accounted for < 75% of PPHa. Only a small number of headaches (4%) were incapacitating. Postdural puncture headache accounted for 4.7% of all PPHa. Significant risk factors for the development of PPHa were: known inadvertent dural puncture [odds ratio (OR)adj = 6.36; 95% confidence interval (CI) 1.29, 31.24]; previous headache history (1-12/yr- ORadj = 1.57; 95% CI 1.01, 2.44; < 12/yr- ORadj = 2.25; 95% CI 1.63, 3.11); multiparity (ORadj = 1.37; 95% CI 1.03, 1.82) and increasing age (ORadj = 1.03/yr; 95% CI 1.00, 1.06).ConclusionsPostpartum headaches are common, often first noted after discharge from hospital. The majority are related to primary headache disorders. Increased awareness of this epidemiological relationship and improved diagnosis of primary headache conditions may lead to improved headache-specific therapy and avoidance of unnecessary investigations or readmission to hospital.RésuméObjectifDéterminer ľincidence, la cause, les caractéristiques et les facteurs de risque de toutes les céphalées de la première semaine du postpartum.MéthodeĽétude a porté sur 985 femmes qui ont accouché au cours ďune période de trois mois dans un hôpital de soins tertiaires. Une entrevue structurée a été suivie ďun examen de contrôle pour recueillir les données démographiques et évaluer la présence et les caractéristiques des céphalées du postpartum (CPP) ou des douleurs au cou ou aux épaules. Un algorithme fondé sur les critères de diagnostic de ľInternational Headache Society a servi à identifier toutes les céphalées. La recherche de facteurs de risque possibles a été faite grâce à une analyse multivariée.RésultatsSur les 985 participantes, 381 (39 %) ont eu des céphalées ou des douleurs au cou ou aux épaules. Le délai moyen ďapparition des CPP a été de deux jours (0, 6 ; 1er et 3e quartiles) et la durée de quatre heures (2, 24 ; 1er et 3e quartiles). Les céphalées primaires comptaient pour < 75 % des CPP. Peu de céphalées (4 %) ont été incapacitantes. Les céphalées post ponction durale comptaient pour 4,7 % des CPP. Les facteurs de risque significatifs de développement des CPP ont été : une ponction de la dure-mère involontaire connue [risque relatif (RR)aju = 6,36 ; intervalle de confiance de 95 % (IC) 1,29, 31,24] ; des antécédents de céphalées (1-12/an- RRaju = 1,57 ; IC de 95 % 1,01, 2,44 ; < 12/an- RRaju = 2,25 ; IC de 95 % 1,63, 3,11) ; la multiparité (RRaju =1,37 ; IC de 95 % 1,03, 1,82) et ľâge croissant (RRaju = 1,03/an ; IC de 95 % 1,00, 1,06).ConclusionLes céphalées du postpartum sont fréquentes, souvent notées après le départ de ľhôpital. Elles sont en majorité primaires. Une meilleure connaissance de cette relation épidémiologique et du diagnostic des céphalées primaires peut améliorer le traitement de céphalées spécifiques et permet ďéviter des examens inutiles ou la réadmission à ľhôpital.

Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study.

The association between epidural anesthesia during labor and subsequent postpartum low back pain remains unclear.The objective of this follow-up cohort study was to determine whether epidural anesthesia was associated with chronic back pain 1 yr after delivery. We contacted 329 women by telephone and asked them to complete a standardized questionnaire 1 yr (+/- 1 mo) after delivery. One hundred sixty-four women had received epidural analgesia for labor and delivery, and 165 had not. Subjects were asked to quantify their back pain (yes/no, numeric rating score, and interference with daily activities). Differences between the two groups were tested by using the chi squared test and the Mann-Whitney U-test, and logistic regression was used to control for confounding variables. The response rate was 244 of 329 (74%). Responders and nonresponders were similar in their demographic and clinical characteristics. There was no difference in the prevalence of back pain between women who had received epidural anesthesia (12 of 121, 10%) and those who had not (17 of 123, 14%). The adjusted relative risk of low back pain at 1 yr (epidural versus nonepidural) was 0.63 (95% confidence interval 0.25, 1.56). There were also no differences between the two groups on numeric rating scores or level of interference with activities. This prospective follow-up study demonstrated no association between epidural anesthesia for labor and delivery and chronic back pain 1 yr after delivery. Implications: We evaluated the presence of low back pain 1 yr after delivery in two groups of women-those who chose epidural analgesia for labor and those who did not. There was no increased risk of back pain in women who had used epidural analgesia. This finding is consistent with those of other North American studies. (Anesth Analg 1997;85:1066-70)

Ľincidence et la cause des céphalées du postpartum : une étude prospective

Objectif Determiner ľincidence, la cause, les caracteristiques et les facteurs de risque de toutes les cephalees de la premiere semaine du postpartum.PurposeWe sought to determine the incidence, etiology, characteristics and risk factors for all headaches in the first week postpartum.MethodsThis was a prospective cohort study of 985 women delivering over a three-month period in a single tertiary-care institution. These women underwent a structured interview and follow-up to collect demographic data and to assess for the presence and characteristics of postpartum headache (PPHa) or neck/shoulder pain. All headaches were diagnosed using an algorithm based on the diagnostic criteria of the International Headache Society. Multivariate analysis was used to examine possible risk factors.ResultsThree hundred eighty-one of the 985 study participants (39%) reported headaches or neck/shoulder pain during the study period. The median time to onset of the PPHa was two days (0, 6; 1st and 3rd quartiles) and duration was four hours (2, 24; 1st and 3rd quartiles). Primary headaches accounted for < 75% of PPHa. Only a small number of headaches (4%) were incapacitating. Postdural puncture headache accounted for 4.7% of all PPHa. Significant risk factors for the development of PPHa were: known inadvertent dural puncture [odds ratio (OR)adj = 6.36; 95% confidence interval (CI) 1.29, 31.24]; previous headache history (1-12/yr- ORadj = 1.57; 95% CI 1.01, 2.44; < 12/yr- ORadj = 2.25; 95% CI 1.63, 3.11); multiparity (ORadj = 1.37; 95% CI 1.03, 1.82) and increasing age (ORadj = 1.03/yr; 95% CI 1.00, 1.06).ConclusionsPostpartum headaches are common, often first noted after discharge from hospital. The majority are related to primary headache disorders. Increased awareness of this epidemiological relationship and improved diagnosis of primary headache conditions may lead to improved headache-specific therapy and avoidance of unnecessary investigations or readmission to hospital.RésuméObjectifDéterminer ľincidence, la cause, les caractéristiques et les facteurs de risque de toutes les céphalées de la première semaine du postpartum.MéthodeĽétude a porté sur 985 femmes qui ont accouché au cours ďune période de trois mois dans un hôpital de soins tertiaires. Une entrevue structurée a été suivie ďun examen de contrôle pour recueillir les données démographiques et évaluer la présence et les caractéristiques des céphalées du postpartum (CPP) ou des douleurs au cou ou aux épaules. Un algorithme fondé sur les critères de diagnostic de ľInternational Headache Society a servi à identifier toutes les céphalées. La recherche de facteurs de risque possibles a été faite grâce à une analyse multivariée.RésultatsSur les 985 participantes, 381 (39 %) ont eu des céphalées ou des douleurs au cou ou aux épaules. Le délai moyen ďapparition des CPP a été de deux jours (0, 6 ; 1er et 3e quartiles) et la durée de quatre heures (2, 24 ; 1er et 3e quartiles). Les céphalées primaires comptaient pour < 75 % des CPP. Peu de céphalées (4 %) ont été incapacitantes. Les céphalées post ponction durale comptaient pour 4,7 % des CPP. Les facteurs de risque significatifs de développement des CPP ont été : une ponction de la dure-mère involontaire connue [risque relatif (RR)aju = 6,36 ; intervalle de confiance de 95 % (IC) 1,29, 31,24] ; des antécédents de céphalées (1-12/an- RRaju = 1,57 ; IC de 95 % 1,01, 2,44 ; < 12/an- RRaju = 2,25 ; IC de 95 % 1,63, 3,11) ; la multiparité (RRaju =1,37 ; IC de 95 % 1,03, 1,82) et ľâge croissant (RRaju = 1,03/an ; IC de 95 % 1,00, 1,06).ConclusionLes céphalées du postpartum sont fréquentes, souvent notées après le départ de ľhôpital. Elles sont en majorité primaires. Une meilleure connaissance de cette relation épidémiologique et du diagnostic des céphalées primaires peut améliorer le traitement de céphalées spécifiques et permet ďéviter des examens inutiles ou la réadmission à ľhôpital.

A randomized, double-blind, placebo-controlled trial of epidural morphine analgesia after vaginal delivery

BACKGROUND: Pain after vaginal delivery can interfere with the activities of daily living. We hypothesized that epidural medication administered after delivery would be of benefit for acute postpartum pain management. The objective of this study was to assess whether epidural morphine after vaginal delivery would reduce the analgesic requirements for perineal pain. METHODS: This randomized, double-blind, placebo-controlled trial included 228 parturients who received epidural morphine, 2.5 mg, or epidural saline within 1 h of delivery. The primary outcome was the proportion of women who received additional analgesics in the first 24 h postpartum. We also evaluated the time to first request for analgesia, pain and satisfaction scores, and the incidence of side effects due to epidural morphine. RESULTS: The majority of the 228 women participating in the study were Caucasian, primiparous patients >30 yr old. The proportion of women requiring additional analgesics was less among those who received epidural morphine (8 of 113; 7%) compared with saline (37 of 115; 32%), regardless of the degree of perineal trauma (RR = 0.22, 95% CI: 0.12–0.41). The relative risk reduction in receiving additional analgesics for primiparous patients receiving epidural morphine compared with saline was 0.25 (95% confidence interval [CI]: 0.13–0.49) and for multiparous women was 0.12 (95% CI: 0.02–0.63). The time to first request for analgesics was later for those who received morphine (mean 22.9 h, 95% CI: 22.2–23.7) compared with saline (mean 18.9 h, 95% CI: 17.4–20.4) (P < 0.0001). The side-effect incidence (pruritus, nausea and vomiting, and sedation) was not different between the 2 groups. CONCLUSION: There was a 78% reduction in analgesic requirements in women given epidural morphine after vaginal delivery compared with placebo for both primiparous and multiparous patients. Women who receive epidural labor analgesia for vaginal deliveries and stay in the hospital for 24 h after delivery may benefit from postpartum administration of epidural morphine.

Multidisciplinary perinatal management of the compromised airway on placental support: lessons learned

The aims of this study were to review fetal and maternal outcomes after management of the compromised perinatal airway via operation on placental support or ex utero intrapartum treatment and to discuss implications for future management of these complex and rare cases.

Review of a high-risk obstetric anesthesia antepartum consult clinic

To the Editor, The co-management of high-risk pregnancies for women with significant medical comorbidities is becoming an increasingly prominent responsibility for anesthesiologists. The most recent report by the Centre for Maternal and Child Enquiries suggests that there is a lack of appropriate referral for high-risk patients and that many of the women who died from preexisting medical conditions did not receive pre-counselling or did not see the referred specialist in time. Nonetheless, there is a paucity of literature on this subject, which is not surprising given the low incidence of high-risk antenatal anesthetic clinics. A survey of practice in the United Kingdom revealed that a dedicated clinic for pre-assessment of highrisk obstetric cases existed in only 30% of obstetric units. Only one review detailing an obstetrical anesthesia assessment clinic has been published to date. A voluntary high-risk obstetrical anesthesia patient registry exists in the United Kingdom with publications focused on subspecialty cases, but denominator data are unavailable to estimate incidences of various high-risk disorders. Consequently, we undertook a retrospective chart review to determine the incidence of antepartum high-risk obstetrical anesthesia consultations at our institution and to describe the nature of the medical conditions most commonly referred to the clinic. The study received hospital Research Ethics Board approval. All high-risk antenatal anesthesia consultations were identified during three representative years (2001, 2006, and 2011). Data collected included the primary indication for consultation, secondary diagnoses, maternal age, gestational age at clinic visit, and parity. The proportion of women with high-risk deliveries to receive an anesthesia antenatal consultation was estimated by examining the total number of high-risk deliveries in randomly selected months. During the examined years, 1,357 women attended the high-risk obstetrical anesthesia clinic, representing 7.0% of overall deliveries (95% confidence interval [CI]: 6.6 to 7.3). Mean (SD) maternal age was 32.9 (5.1) yr. Fifty-two percent of the women were nulliparous and the average (SD) gestational age at time of consultation was 34.3 (3.3) weeks. The three most common diagnoses for maternal referral across the three years were cardiac (19.7%; 95% CI: 17.6 to 21.9), musculoskeletal (15.5%; 95% CI: 13.6 to 17.5), and hematologic (13.5%; 95% CI: 11.6 to 15.3) (Table). Congenital cardiac disease (corrected or uncorrected cyanotic congenital heart disease, septal defects, coarctation of the aorta, other complex congenital cardiac disease with or without repair) represented 25-27% of cardiac patients and 5-7% of all consults seen at the clinic. Uncorrected scoliosis represented 47% of musculoskeletal patients seen in the clinic. Previous thromboembolic disease and/or known hypercoagulable state were the primary reasons (53%) in the hematological category, followed closely by thrombocytopenia (47%). Consultations due to obesity (body mass index [30 kg m) increased from 1% of all consults in 2001 to 12% in 2011 (P \ 0.001). The proportion of women with more than one major medical disorder increased from 74 (18%) patients in 2001 to 173 (41%) patients in 2006 and 276 (53%) patients in 2011 (P \ 0.001). It was estimated that only 24.7% of eligible women for antepartum high-risk obstetrical anesthesia consultation F. Bharwani, MD (&) A. Macarthur, MD Department of Anesthesia, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada e-mail: fayazbharwani@gmail.com

Best evidence in anesthetic practice prognosis: the Apgar score predicts 28-day neonatal mortality

Structured abstractQuestionIn infants born before term (26–36 weeks of gestation) and infants born at term (≥37 weeks of gestation), does the Apgar score, at five minutes of age, predict 28-day neonatal death?DesignProspective cohort.SettingAcademic hospital with a level III neonatal intensive care unit.Patients151,891 live-born singleton infants, with gestational age ≥26 weeks, who were delivered between January 1988 and December 1998. Infants with missing umbilical blood gas results (n=6264) were excluded.Assessment of prognostic factorsThe cohort was divided by general anesthesia and five-minute Apgar score. Umbilical blood pH were also recorded. Gestational age was based on the estimate used for clinical care. Apgar score was measured by nursing staff or third-year pediatric house staff. Obstetrical data sheets and hospital records were used to extract neonatal data.Main outcomesNeonatal death during the first 28 days after birth.Main resultsPreterm infants had higher neonatal death rates than term infants (Table I). Apgar scores of 0–3 and 4–6 are associated with increased risk of death compared to Apgar scores of 7–10 (Table I). Severity of metabolic academia did not appreciably modify the relative risk of death associated with Apgar scores ≤3; however, infants with Apgar scores ≤3 and umbilical blood pH ≤7.0 were at significant risk for death (preterm, relative risk (RR) 102, 95% confidence interval (CI) 65–160; term, RR 3204, 95% CI 1864–5508).Conclusion28-day neonatal mortality was associated with lower five-minute Apgar scores in infants born at ≥26 weeks of gestation.FundingNot described.