R.C. Wilson

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

BACKGROUND Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy. METHODS We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre. RESULTS Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%). CONCLUSION In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.

Regional blockade for delivery in women with scoliosis or previous spinal surgery

We conducted a prospective observational study between 1992 and 2001 identifying obstetric patients with untreated or surgically corrected scoliosis or lumbar-sacral fusion surgery. The regional techniques for labour and delivery that were offered were epidural analgesia, combined spinal epidural anaesthesia (CSE), single shot spinal or continuous spinal anaesthesia (CSA) depending on the degree of scoliosis, previous surgery, cardio-respiratory compromise and planned mode of delivery. Forty women were included in the study, one woman with two separate deliveries, giving 41 cases for analysis. Twenty-four women presented in labour: 11 required no regional technique, seven received effective epidural analgesia and six received CSA. Seventeen women presented for elective caesarean delivery: two received a CSE technique, two received single shot spinal and 13 had CSA. From a total of 19 CSA techniques attempted sixteen catheters were successfully inserted and produced good analgesia or anaesthesia for vaginal or operative delivery in 12 women (63%). There was one case of post dural puncture headache following a CSA for labour and delivery. We discuss the choices available for regional anaesthetic techniques in scoliotic women and the relative merits of each.

Double-space combined spinal-epidural technique for elective caesarean section: a review of 10 years' experience in a UK teaching maternity unit

BACKGROUND In obstetric practice use of a regional technique with a low failure rate minimises the need to convert to general anaesthesia (GA). Previous studies have suggested that combined spinal-epidural anaesthesia (CSE) has a lower GA conversion rate than spinal or epidural anaesthesia alone. In addition, a double-space CSE may be associated with fewer failures than the needle-through-needle technique. However, whether this has an effect on GA conversion rate is unknown. We aimed to review our practice of the double-space CSE technique for elective caesarean section. METHODS Data from 3519 elective caesarean sections performed between 1999 and 2008 using the double-space CSE technique were collected retrospectively from the electronic database, original case records and annual reviews collated by the Department of Obstetric Anaesthesia, St Jamess University Hospital, Leeds. Complications such as conversion to GA, accidental dural puncture (ADP), post-dural-puncture headache (PDPH) and blood patching were specifically reviewed. RESULTS The GA conversion rate in our unit was 0.23% (1:440). The ADP rate was 0.7% (1:141) with a 52% incidence of severe PDPH. The overall need for blood patching was 0.4% (1:251). One in five epidurals was supplemented during caesarean section. CONCLUSION Compared to previously published work using spinal or needle-through-needle CSE anaesthesia we have found a lower GA conversion rate in our unit using the double-space CSE technique for elective caesarean section.