Feyce Peralta

The Relationship of Body Mass Index with the Incidence of Postdural Puncture Headache in Parturients.

BACKGROUND:Unintentional dural puncture is a known risk after epidural or combined spinal–epidural procedures, occurring in approximately 1% of labor epidural catheters placed in parturients with normal body habitus but may be as high as 4% in morbidly obese parturients. Anecdotal experience and limited publications suggest that an inverse relationship between body mass index (BMI) and postdural puncture headache (PDPH) may exist. We hypothesized that parturients with increased BMI have a lower incidence of PDPH than those with a lower BMI after unintentional dural puncture. METHODS:After IRB approval, we performed a retrospective cohort study by medical record review. Case logs from our institution were searched for patients with documented unintentional dural puncture during attempted neuraxial analgesia between January 1, 2004, and December 13, 2013. The primary outcome was the incidence of PDPH. The association between BMI and PDPH was assessed using binary logistic regression, and the Wilcoxon-Mann-Whitney odds and confidence intervals (CIs) for a random pair of BMI values from a PDPH subject compared with a non-PDPH subject were calculated from the area under the receiver operator characteristics curve. Classification tree analysis was used to determine the BMI cutoff value for the risk of developing a PDPH. The presence or absence of second-stage labor pushing and placement of an intrathecal catheter after unintentional dural puncture were compared in parturients with and without PDPH using the Fisher exact test. BMI groups were dichotomized at the cutoff value (low and high BMI groups). We compared the incidence of a PDPH between high and low BMI groups using the Fisher exact test after controlling for pushing during labor and placement of an intrathecal catheter at the time of unintentional dural puncture. Secondary analysis evaluated the highest reported numeric rating of pain scores for headache and the need for an epidural blood patch between BMI groups. RESULTS:Unintentional dural puncture was identified in 518 (0.53%) patients (95% CI, 0.48%–0.58%). The overall incidence of PDPH after unintentional dural puncture was 51% (95% CI, 46%–55%). The Wilcoxon-Mann-Whitney odds for a random pair of BMI values from a PDPH subject compared with a non-PDPH subject was 0.74 (95% CI, 0.60–0.90, P = 0.001). The odds ratio for developing a PDPH in women who pushed during delivery was 2.4 (95% CI, 1.2–3.9, P = 0.001) compared with women who did not push. Classification tree analysis identified a BMI cutoff value of 31.5 kg/m2 for prediction of a PDPH. The incidence of PDPH in parturients with a BMI ≥31.5 kg/m2 (39%) was lower than in parturients with a BMI <31.5 kg/m2 (56%; difference −17%; 95% CI, −7% to −26%, P = 0.0004). The odds ratio for a PDPH in the high BMI compared with the low BMI group was 0.36 (95% CI, 0.14–0.92, P = 0.04) in parturients who pushed during labor and 0.62 (95% CI, 0.41–0.97, P = 0. 04) in parturients who did not push. After the unintentional dural puncture, 112 (22%) parturients had an intrathecal catheter placed. The incidence of PDPH in parturients with an intrathecal catheter was 59% (95% CI, 49%–68%) compared with 48% (95% CI, 43%–54%) in women with an epidural catheter (P = 0.06). Median (interquartile range) headache severity (0–10 verbal rating scale) was 8 (6–9) and did not differ between parturients in the high versus low BMI groups (P = 0.61). The rate of epidural blood patch administration for PDPH treatment was similar in BMI groups (difference −12%; 95% CI, 4 to −27, P = 0.13). CONCLUSIONS:The findings are consistent with previous reports of decreased PDPH incidence after unintentional dural puncture in parturients with an increased BMI, even after controlling for pushing during labor. Severity of headache and need for epidural blood patch treatment were similar in low and high BMI groups.

Interventional radiology in the pregnant patient for obstetric and nonobstetric indications: organizational, anesthetic, and procedural issues.

Purpose of review As indications for interventional radiology procedures during pregnancy continue to expand, anesthesiologists must be aware of the indications for specific procedures as well as provide the safest possible anesthetic care to both the mother and the fetus in nontraditional environments. Recent findings Among the different imaging modalities employed for interventional procedures, ultrasonography and MRI without gadolinium-based contrast are preferred because they are free of ionizing radiation. Providers continue to report cases in which interventional techniques are used in a well tolerated and effective manner. The current literature emphasizes radiation-sparing maneuvers to minimize maternal and fetal ionizing radiation exposure. Maternal physiologic changes should be considered when planning anesthetic management for interventional radiology procedures. Because most of these procedures are performed outside the operating rooms or labor and delivery suites, the anesthesiologists should familiarize themselves with the environment prior to providing anesthesia. Summary The risk to the fetus of the imaging procedure must be weighed against the benefit to the mother of early and accurate diagnosis and treatment of the underlying pathology. As the organizational aspects of providing care become more complex, simulation, guidelines, and protocols may become important to the safe care of these patients.

Neuraxial labor analgesia is not an independent predictor of perineal lacerations after vaginal delivery of patients with intrauterine fetal demise

INTRODUCTION The role of neuraxial labor analgesia in perineal trauma following live births is controversial, and no studies have assessed the association in women delivering an intrauterine fetal demise. We evaluated the relationship between neuraxial labor analgesia and perineal laceration in these patients. METHODS This was a retrospective case-control study of women with a diagnosis of fetal death after 20weeks of gestation, a vaginal delivery, and an Apgar score of 0 at delivery, during the period from January 2007 through December 2015. The presence of a perineal laceration and its severity, graded from grade I to IV based on the 2014 American College of Obstetricians and Gynecologists guidelines, was recorded. RESULTS A total of 329/422 (78%) patients received neuraxial, and 93/422 (22%) non-neuraxial, labor analgesia. A perineal laceration occurred in 23% in the neuraxial versus 10% in the non-neuraxial analgesia group, a difference of 13% (95% CI of difference 4% to 20%, P=0.005). After adjusting for confounder bias, greater birthweight (OR 4.22, 95% CI 3.00 to 5.92, P<0.001) and lower parity (OR 0.44, 95% CI 0.24 to 0.82, P=0.009), but not neuraxial analgesia (OR 1.29, 95% CI 0.47 to 3.57, P=0.61) were independent predictors of perineal laceration. The maintenance concentration of bupivacaine did not affect the rate of perineal injury. CONCLUSIONS Neuraxial labor analgesia does not appear to be an independent risk for a perineal laceration in patients with intrauterine fetal demise. Our data suggests that the use of neuraxial analgesia should not raise concern about increased rates of perineal injury.

Any news on the postdural puncture headache front

Unintentional dural puncture followed by postdural puncture headache is a well-known complication following neuraxial labor analgesia. Risk factors for the development of postdural puncture headache may be related to the patients history and characteristics, the neuraxial technique, and obstetrical events. The diagnosis of postdural puncture headache is usually made depending on the clinical presentation (orthostatic headache after a neuraxial procedure). Occasionally, neuroimaging and neurological consultation are warranted. Complications following postdural puncture headache may include transient or permanent hypoacusis, cranial nerve palsies, subdural hematoma, and chronic headache. Evidence is limited regarding the safety and effectiveness of different interventions aimed to prevent or treat postdural puncture headache.

Optimal Characteristics of an Obstetric Anesthesia Paper vs. Electronic Hand-Off Tool

Optimal Characteristics of an Obstetric Anesthesia Paper vs. Electronic Hand-Off Tool Approximately 61% of vaginal deliveries utilize neuraxial (epidural or spinal) analgesia for labor pain relief. Hand-offs are commonplace in obstetric anesthesia practice. Unfortunately, communication failures are consistently cited as the leading root cause of sentinel events. The purpose of this qualitative study was to explore optimal obstetric anesthesia hand-off characteristics and to evaluate the perceived effectiveness of a paper compared with an electronic hand-off template using face-to-face interviews with anesthesia team members.