M. Joanne Douglas

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model

BACKGROUND Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder. METHODS We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting. FINDINGS 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility. INTERPRETATION The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia. FUNDING Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.

Epidural morphine for analgesia after Caesarean section: a report of 4880 patients

This retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following Caesarean section under epidural anaesthesia. The morphine was administered as a single bolus, following delivery, in doses ranging from 2 to 5 mg. The charts of 4880 Caesarean sections, performed on 4500 patients, were reviewed. The duration of analgesia and the occurrence of any symptoms which might be side-effects of the epidural morphine were recorded. The duration of analgesia was 22.9 ±10.1 hr and was not correlated with the dose of epidural morphine. Eleven per cent of the patients required no supplemental analgesia during the first 48 hr. Twelve patients (0.25 per cent) had respiratory rates < 10 breaths per minute, on at least one occasion. No serious sequelae resulted from these periods of bradypnoea. Pruritus occurred in 58 per cent of patients, nausea and vomiting in 39.9 per cent and dizziness in ten per cent. Herpes simplex labialis was recorded in 3.5 per cent of patients. Epidural morphine is thus confirmed as an effective analgesic technique post-Caesarean section with 3 mg being the optimal dose. Even in this young healthy patient population, clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated.RésuméAfin d’en évaluer l’ejficacité et la sûreté en post-op de césarienne sous anesthésie épidurale, nous avons revu au sein de 4500 dossiers, 4880 cas d’analgésie à la morphine par voie épidurale où on avait injecté de 2 à 5 mg de morphine en bolus aprés la naissance. D’abord, la durée de l’analgésie (22,9 ±10,1 hre) semblait indépendante de la dose utilisée et 11 pour cent des patientes n’avaient requis aucun autre analgésique pendant les 48 premiéres heures. Ensuite, de la bradypnée (fréquence respiratoire < 10/min) était survenue chez 12 patientes à au moins une occasion, n’entraînant cependant aucune séquelle; 58 pour cent des patientes s’étaient plaintes de prurit, 39,9 pour cent de nausée ou de vomissement et dix pour cent d’étourdissement. Enfin, on avait observé la présence d’une lésion herpétique labiate dans 3,5 pour cent des cas. Il semble donc que la morphine par voie épidurale constitue un mode d’analgésie efficace aprés une césarienne et qu’une dose de 3 mg soit idéate. Pourtant, même chez ces patientes jeunes et en bonne santé, une dépression respiratoire peut survenir et justifie un monitorage clinique de la respiration.

Venous Thromboembolism and Antithrombotic Therapy in Pregnancy

OBJECTIVE To present an approach, based on current evidence, for the diagnosis, treatment, and thromboprophylaxis of venous thromboembolism in pregnancy and postpartum. EVIDENCE Published literature was retrieved through searches of PubMed, Medline, CINAHL, and The Cochrane Library from November 2011 to July 2013 using appropriate controlled vocabulary (e.g. pregnancy, venous thromboembolism, deep vein thrombosis, pulmonary embolism, pulmonary thrombosis) and key words (e.g., maternal morbidity, pregnancy complications, thromboprophylaxis, antithrombotic therapy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Grey (unpublished) literature was identified through searching the websites of clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).

Spinal subdural haematoma in a parturient after attempted epidural anaesthesia

We report a case of spinal subdural haematoma with neurological deficit in a 36-yr-old woman following Caesarean section for severe preeclampsia and placental abruption. She had been taking chronic trifluoperazine treatment for depression. Her activated partial thromboplastin time (aPTT) was 49 sec (normal = 26–36) but all other tests of coagulation were normal. Epidural anaesthesia was attempted but, despite a negative test dose, injection of local anaesthetic resulted in a generalized seizure and general anaesthesia was induced. Seventy-two hours after delivery, she was found to have bilateral leg weakness, urinary incontinence, absent rectal sphincter tone and asymmetrical leg reflexes. The diagnosis of spinal haematoma was confirmed by magnetic resonance imaging. She underwent emergency laminectomy and made a full neurological recovery.RésuméNous rapportons un cas d’hématome sous-dural rachidien avec déficit neurologique chez une femme de 36 ans, après une césa-rienne pour éclampsie sévère et décollement prématuré d’un placenta normalement inséré. La patiente suivait un traitement de longue durée à la trifluopérazine pour dépression. Son temps de céphaline activé (aPTT) est de 49 sec (N = 26–36) mais tous les autres tests de coagulation sont normaux. Une anesthésie épidurale mise en marche mais, malgré une dose-test négative, l’injection de l’anesthésique local provoque une crise convulsive. Une anesthésie générale est réalisée. Soixante-douze heures après la naissance on constate une faiblesse bilatérale des jambes, une incontinence urinaire, une absence du tonus du sphincter anal et des réflexes asymétriques aux membres inférieurs. Le diagnostic d’hématome sous-dural rachidien est confirmé par le cliché de résonnance magnétique nucléaire. Elle subit une laminectomie en urgence, suivie d’une récupération neurologique complète.

Effect of pH-adjustment of bupivacaine on onset and duration of epidural analgesia in parturients.

Previous studies have reported that elevation of the pH of local anaesthetics is associated with enhanced quality and duration of block. This study investigated the effect, on time to onset and duration of analgesia, of pH adjustment of 0.25 per cent bupivacaine immediately prior to injection into the epidural space in parturients. Addition of 0.1 ml of 8.4 per cent sodium bicarbonate to 20 ml of 0.25 per cent bupivacaine consistently raised the pH of the local anaesthetic from 5.65 to 7.26 (mean values).Thirty parturients received an epidural injection of 8 ml of pH-adjusted 0.25 per cent bupivacaine and a control group of 30 parturients received 8 ml of the standardcommercial preparation of 0.25 per cent bupivacaine. Elevation of the pH of the local anaesthetic significantly increased the speed of onset of analgesia from 6.0 minutes to 3.2 minutes and the duration of analgesia was significantly lengthened from 79.4 minutes to 96.5 minutes. There was no significant influence on time to peak effect, nor on mean maternal plasma levels of bupivacaine.RésuméDes étude préliminaires ont rapporté que l’augmentation du pH des anesthésiques locaux est associée avec une amélioration de la qualité et de la durée du bloc. Cette étude investigue l’effet sur le début d’action et la durée de l’analgésie après ajustement du pH de 0.25 pour cent de bupivacaîne immédiatement avant l’injection dans l’espace épidural chez des femmes à terme. L’addition de 0.1 ml de 8.4 pour cent de bicarbonate de soude à 20 ml de 0.25 pour cent de bupivacaîne augmenta le pH de l’anesthésique local de 5.65 à 7.26 (valeurs moyennes).Trente parturientes ont reçu en injection épidurale 8 ml de bupivacaîne 0.25 pour cent à pH ajusté et un groupe contrôle de 30 parturientes a reçu 8 ml de la solution commerciale standard de préparation de 0.25 pour cent de bupivacaîne. L’augmentation du pH de l’ anesthésique local accéléra significativement le début de l’analgésie de 6.0 minutes à 3.2 minutes ainsi que la durée de l’analgésie qui augmenta significativement de 79.4 minutes à 96.5 minutes. It n’y avail aucune influence significative sur le temps d’effet maximal ni sur le niveau plasmatique moyen maternel de bupivacaîne.

Patient-controlled analgesia following caesarean section under general anaesthesia: a comparison of fentanyl with morphine.

This prospective, randomised, double-blind study compared PCA fentanyl with PCA morphine for post-Caesarean section analgesia. Following a standardised general anaesthetic, 37 women were allocated to receive either fentanyl (n = 18) or morphine (n = 19). The PCA was commenced after the women had been made comfortable in the postanaesthetic recovery room with the appropriate opioid solution (mean dose required = fentanyl 375 μg or morphine 16 mg). Initial PCA settings were bolus 1 ml (fentanyl 25 μg or morphine 1 mg), lockout time ten minutes, and no background infusion. Both analgesic solutions provided effective analgesia for a mean of 37 hr with high levels of patient satisfaction, and there were no differences in VAS scores for pain and patient satisfaction, or for side effects (nausea, itch, and sleepiness) between fentanyl or morphine. However, more patients in the fentanyl group required supplementary boluses or alterations to the PCA settings (13/18 vs 4/19: P = 0.005), and one patient was removed from the study due to inadequate analgesia. We conclude that fentanyl is not recommended for routine PCA use following Caesarean section.RésuméCette étude randomisée et à double aveugle compare la PCA au fentanyl avec la PCA à la morphine pour l’analgésie postcésarienne. Après une anesthésie générate standard, 37 femmes sont réparties pour recevoir soil du fentanyl (n = 18) soil de la morphine (n = 19). La PCA est debutée à la salle de réveil des que les patientes se sentent confortables sous une solution appropriée de morphinique (dose moyenne requise, fentanyl 375 μg ou morphine 16 mg). Le régime initial consiste en un bolus d’un ml (fentanyl 25 μg ou morphine 1 mg), un intervalle de sécurité de dix minutes, sans perfusion continue. Les deux solutions produisent une analgésie satisfaisante pour 37 h en moyenne avec un degré élevé de satisfaction pour la patiente, et on ne note pas de différence entre le fentanyl et la morphine pour l’évaluation de la douleur par EVA, le degré de satisfaction, et pour les effets secondaires (nausée, prurit et somnolence). Cependant, plus de patientes sous fentanyl ont eu besoin de bolus supplémentaires ou des modifications aux réglages de la PCA (13/18 vs 4/19; P = 0,005). Une patiente est exclue de l’étude pour raison d’insuffisance d’analgésie. En conclusion, nous ne recommandons pas la PCA au fentanyl après la césarienne.

Obstetric anesthesia and uncommon disorders

Preface Part I. Cardiovascular and Respiratory Disorders: 1. Structural heart disease in pregnant women Brendan Carvalho and Ethan Jackson 2. Disorders of cardiac conduction Jean E. Swenerton, Ravishankar Agaram and Victor F. Huckell 3. Vascular diseases David R. Gambling 4. Respiratory disorders in pregnancy John Philip and Shiv K. Sharma Part II. Musculo-skeletal Disorders: 5. Myopathies Chantal Crochetiere 6. Parturients of short stature Andrea Fuller, Sheila E. Cohen and Emily F. Ratner 7. Disorders of the vertebral column Edward T. Crosby 8. Miscellaneous skeletal and connective tissue disorders in pregnancy Caroline Grange Part III. Nervous System Disorders: 9. Disorders of the central nervous system in pregnancy J. Martinez-Tica and R. B. Vadhera 10. Spinal cord disorders Roanne Preston 11. Peripheral neuropathy Felicity Reynolds 12. Chronic pain in pregnancy Hector J. Lacassie and Holly A. Muir Part IV. Metabolic Disorders: 13. Disorders of intermediary metabolism Stephen Halpern and Bhadresh Shah 14. Liver and renal disease M. J. Paech and K. Scott 15. Malignant hyperthermia M. Joanne Douglas 16. Rare endocrine disorders J. M. Mhyre and L. S. Polley Part V. Other Disorders: 17. Blood disorders M. Joanne Douglas and Penny Ballem 18. Infectious diseases in pregnancy Robert S. F. McKay and Gabriela Rocha Lauretti 19. Dermatoses Robert S. F. McKay and John Schlicher 20. Psychiatric disorders in pregnancy Timothy J. G. Pavy 21. Malignancy and pregnancy Holly Muir, Michael Smith and David R. Gambling 22. Pregnancy and transplantation Kerri M. Robertson 23. Autoimmune diseases Caroline Grange Index.

Epidural anesthesia in three parturients with lumbar tattoos: a review of possible implications

PurposeTo discuss the possible ramifications of neuraxial analgesia and anesthesia in women with tattoos involving their midline lumbar area.Clinical findingsRecently the authors have received requests for epidural anesthesia in three women with tattoos over the midline of their lumbar spine. In one patient the tattoo covered her entire back. In the other two, it was possible to locate a lumbar interspace that did not have tattoo pigment in the overlying skin. All three women received uneventful epidural analgesia.A Medline and EMBASE search for relevant publications using the keywords: epidural, spinal, tattoos, tattooing, complications did not find any reports of complications from inserting a needle through a tattoo. As none were found, the literature on tattoos and on coring with neuraxial anesthesia was reviewed to see if neuraxial anesthesia might be problematic if the needle passed through the tattoo. Coring is a complication of neuraxial anesthesia that may lead to epidermoid tumours in the subarachnoid space. Theoretically, a pigment-containing tissue core from a tattoo could be deposited into the epidural, subdural or subarachnoid spaces, leading to later neurological complications.ConclusionsThere is no information in the literature about possible risks from inserting needles through tattoos during the performance of neuraxial anesthesia. This report discusses the possible implications.RésuméObjectifExaminer les ramifications possibles de l’analgésie et de l’anesthésie neuraxiales chez des femmes qui ont des tatouages dans la zone lombaire médiane.Éléments cliniquesRécemment, les auteurs ont reçu une demande d’anesthésie épidurale pour trois femmes ayant des tatouages au milieu de la colonne lombaire. Chez l’une des patientes, le tatouage couvrait entièrement le dos. Chez les deux autres, il a été possible de trouver un espace intercostal sans pigment de tatouage sur la peau sus-jacente. Les trois femmes ont reçu une analgésie épidurale sans incident. Lors d’une recherche dans Medline et EMBASE selon les mots clés epidural, spinal, tattoos, tattooing, complications, nous n’avons trouvé aucun article sur des complications causées par l’insertion d’une aiguille au travers d’un tatouage. Nous avons donc passé en revue la documentation sur le tatouage et sur le carottage lié à l’anesthésie neuraxiale pour vérifier si l’anesthésie neuraxiale pouvait être problématique dans le cas d’une aiguille qui perce un tatouage. Le carottage est une complication de l’anesthésie neuraxiale. Il pourrait causer des tumeurs épidermoïdes dans l’espace sous-arachnoïdien. Théoriquement, le carottage de tissu contenant du pigment de tatouage peut être déposé dans les espaces péridural, sous-dural ou sous-arachnoïdien et provoquer des complications neurologiques ultérieures.ConclusionAucun risque possible lié à l’insertion d’aiguilles dans des tatouages pendant la réalisation de l’anesthésie neuraxiale n’a encore été documenté. Le présent article examine les implications possibles.

The use of acute hemodilution in parturients undergoing cesarean section

OBJECTIVE Concern over transmissible disease has increased interest in methods of minimizing homologous blood transfusion during elective surgery. One method is acute hemodilution, a technique previously unreported in parturients. This study was designed to determine its feasibility and safety in women at risk of hemorrhage during cesarean section. STUDY DESIGN This technique was performed on 38 parturients. Collected blood was retransfused at the end of surgery or earlier, if required. Hemoglobin was measured before hemodilution, after hemodilution, before transfusion, after transfusion, and 24 hours postoperatively. Neonatal assessment included umbilical blood gases and Apgar scores. RESULTS All patients were hemodynamically stable and no fetal heart rate abnormalities were observed during the procedure. One patient received homologous blood and 14 received previously donated autologous blood. Umbilical blood gases were normal and 5-minute Apgar scores were > or = 7. CONCLUSION This study suggests that acute hemodilution is well tolerated in parturients undergoing cesarean section. This may limit exposure to homologous blood transfusion.

The active implementation of pregnancy hypertension guidelines in British Columbia.

OBJECTIVE: To reduce maternal and perinatal morbidity and mortality associated with the hypertensive disorders of pregnancy by using an active model of guideline implementation. METHODS: This study used a preintervention and postintervention cohort comparison design. We interrogated the British Columbia Perinatal Database Registry for 6 years of existing prospectively gathered data (fiscal years 2000–2001 to 2005–2006), introduced the hypertensive disorders of pregnancy guidelines, and assessed the incidence of the combined adverse maternal and perinatal outcomes for the next 2 years (fiscal years 2006–2007 and 2007–2008). The combined adverse maternal outcome was maternal death, life-threatening, or life-altering complications. The combined perinatal outcome included the severe complications of prematurity and hypoxic–ischemic encephalopathy. RESULTS: Eighteen thousand seventy-six women were diagnosed with hypertensive disorder of pregnancy in British Columbia from 2000–2001 to 2007–2008. Outcomes were compared preguideline (n=13,150 deliveries) and postguideline (n=4,926 deliveries) implementation. The incidence of the combined adverse maternal outcome decreased from 3.1% to 1.9% (relative risk 0.60, 95% confidence interval 0.48–0.75). There was a concomitant fall in the incidence of the combined adverse perinatal outcome. CONCLUSION: The active introduction of standardized management of women with a hypertensive disorder of pregnancy is associated with reduced maternal and perinatal risk. LEVEL OF EVIDENCE: II