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Summary: Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long‐term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university‐affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter. [ABSTRACT FROM AUTHOR]

Accidental dural puncture during labor analgesia can lead to post-dural puncture headache (PDPH) and other complications. The gold standard treatment for PDPH is an epidural blood patch (EBP), but it is not always successful. A recent study investigated the use of prophylactic intravenous cosyntropin to prevent PDPH and reduce the need for EBP. However, the study found that cosyntropin did not mitigate PDPH or eliminate the need for EBP. Another study showed that inserting an intrathecal catheter and injecting intrathecal saline decreased the severity of PDPH and the need for EBP. The addition of prophylactic cosyntropin did not reduce the occurrence of PDPH but may decrease the need for EBP. Further research is needed to confirm these findings. [Extracted from the article]

The articles discusses the blood pressure, cardiac output and hemodynamics of pregnant women who have cesarean section deliveries (CDs), offering a comparison of women with both twin and single pregnancies. The administration of prophylactic phenylephrine infusion (PPI) and spinal anesthesia to parturients, or pregnant women, is discussed.

Background: Severe post-caesarean pain remains an important issue associated with persistent pain and postpartum depression. Women's sleep quality prior to caesarean delivery and its influence on postoperative pain and analgesic intake have not been evaluated yet.Methods: Women undergoing caesarean delivery with spinal anaesthesia (bupivacaine 12 mg, fentanyl 20 μg, morphine 100 μg) were evaluated preoperatively for sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire (PSQI 0-5 indicating good sleep quality, PSQI 6-21 poor sleep quality). Peak and average postoperative pain scores at rest, movement and uterine cramping were evaluated during 24 h using a verbal numerical pain score (VNPS; 0 indicating no pain and 100 indicating worst pain imaginable), and analgesic intake was recorded. Primary outcome was peak pain upon movement during the first 24 h.Results: Seventy-eight of 245 women reported good sleep quality (31.2%; average PSQI 3.5 ± 1.2) and 167 poor sleep quality (68.2%; average PSQI 16.0 ± 3.4; p < 0.001). Women with poor sleep quality had significantly higher peak pain scores upon movement (46.7 ± 28.8 vs. 36.2 ± 25.6, respectively; p = 0.006). With multivariable logistic regression analysis, poor sleep quality significantly increased the risk for severe peak pain upon movement (VNPS ≥70; OR 2.64; 95% CI 1.2-6.0; p = 0.02).Discussion: A significant proportion of women scheduled for caesarean delivery were identified preoperatively as having poor sleep quality, which was associated with more severe pain and increased analgesic intake after delivery. The PSQI score may therefore be a useful tool to predict increased risk for acute post-caesarean pain and higher analgesic requirements, and help tailor anaesthetic management.Significance: Multiple studies have evaluated predictors for severe acute pain after caesarean delivery that may be performed in a clinical setting, however, sleep quality prior to delivery has not been included in predictive models for post-caesarean pain. The PSQI questionnaire, a simple test to administer preoperatively, identified that up to 70% of women report poor sleep quality before delivery, and poor sleep quality was associated with increased post-caesarean pain scores and analgesic intake, indicating that PSQI could help identify preoperatively women at risk for severe pain after caesarean delivery. [ABSTRACT FROM AUTHOR]

As the number and success of renal transplantation has grown, there has been an increase in the number of renal transplant patients giving birth. To date, there has been no data on obstetric anesthesia management of these patients. The purpose of this study was to build an Israeli national database on parturients after renal transplant. A sixteen-year (calendar years 1996-2011) retrospective study was conducted at three major tertiary centers with a combined current birth rate of approximately 25 000 deliveries annually. We found 83 labors in 64 women. Forty-two percent of this population suffered from hypertension while 12.5% had diabetes. Forty-seven percent of women had a vaginal delivery while 53% of women had a cesarean section. The rate of epidural analgesia for labor was 59%, and rate of regional anesthesia during cesarean section was 75%. There were no anesthetic complications in any cases. Standard ASA monitoring was used in all cases except for one woman with severe hypertension who required an arterial line during her cesarean section. Forty-seven percent of newborn were under 37 weeks with average gestational week 36 ± 3 days and birth weight 2.5 ± 0.7 kg. Average Apgar was 8.4 ± 1.3 at one minute and 9.3 ± 0.7 at five minutes. There was one neonatal death in the CS group due to placental abruption. Patients after renal transplant can safely undergo birth and obstetric analgesia. [ABSTRACT FROM AUTHOR]

Fetal surgery presents distinctive anesthetic challenges due to the need to balance maternal and fetal safety. This retrospective study evaluates the anesthetic management strategies used at a single center for various fetal interventions, including fetoscopic laser photocoagulation, fetal endoluminal tracheal occlusion, bipolar cord coagulation, and fetoscopic spina bifida repair. We reviewed 195 fetal procedures performed between 2019 and 2023 at Rabin Medical Center. Data collected included maternal and fetal characteristics, anesthetic techniques (spinal, combined spinal-epidural, general), intraoperative hypotension, and perioperative complications. We examined the evolution of anesthetic practice, particularly focusing on hemodynamic management and postoperative pain control. Spinal anesthesia was increasingly preferred for shorter procedures such as fetoscopic laser photocoagulation and bipolar cord coagulation, while general anesthesia was used exclusively for spina bifida repair. Intraoperative hypotension was a significant issue, leading to the implementation of prophylactic phenylephrine infusions, which improved blood pressure control. A shift from volatile anesthesia to total intravenous anesthesia in spina bifida repair resulted in fewer complications, including reduced bleeding. Postoperative pain management was optimized with a multimodal approach, improving pain scores. This study underscores the importance of tailoring anesthetic techniques to the specific fetal surgery. Key improvements in hypotension management, adopting total intravenous anesthesia for complex surgeries, and optimized postoperative pain control have contributed to better maternal and fetal outcomes. Ongoing reassessment and adaptation of anesthetic protocols remain critical as fetal surgery evolves., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Intraoperative pain during cesarean delivery with or without conversion to general anesthesia has been shown to negatively impact maternal and perinatal morbidity. Efforts to reduce these adverse events are a recent focus of obstetric anesthesia care. We aimed to assess rates of and risk factors for conversion to general anesthesia and intraoperative pain during intrapartum cesarean delivery with an indwelling epidural catheter in our academic center., Methods: In this retrospective cohort study, all women undergoing cesarean delivery with an indwelling epidural catheter between January 2017 and June 2022 were included. Labor epidural analgesia was provided according to a standardized protocol, and conversion to epidural anesthesia was achieved in the operating room before surgery. We determined the conversion rate to general anesthesia and associated risk factors. Second, we examined the rate of administration of analgesics/sedatives and related risk factors in cesarean cases that were not converted to general anesthesia., Results: Among the 1192 women undergoing intrapartum cesarean delivery with epidural anesthesia, there were 97 cases with conversion to general anesthesia (8.1%), of which 87 (89.7%) were due to a failed epidural. Higher age, higher weight, and higher gestational age were associated with decreased odds of conversion to general anesthesia. Higher gravidity and longer surgical time were associated with increased odds. An emergent indication was not associated with conversion to general anesthesia. Intravenous analgesic/sedative supplementation occurred in 141 cases (12.9%). Higher age was associated with decreased odds of supplementation, and longer surgical time was associated with increased odds., Conclusion: In our tertiary academic center, the rate of intraoperative conversion to general anesthesia and administration of analgesic/sedative medication among women undergoing intrapartum cesarean delivery with epidural anesthesia was relatively high. Emergency cesarean delivery was not associated with either of the above endpoints., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)