A.J. Macarthur’s research while affiliated with Mount Sinai Hospital, Toronto and other places

Background Cardiac disease is the leading cause of maternal death. Non-fatal ischemic events may go unnoted during the time of delivery. The aim of this study was to assess the incidence of subclinical myocardial ischemia amongst parturients, as evidenced by a raised troponin assay in the postpartum period. Methods We undertook a prospective observational pilot study in a tertiary obstetric hospital with over 7000 deliveries a year. Targeted sampling was used to enter subjects in pre-defined high- or low-risk groups for myocardial strain, according to their clinical history and a brief questionnaire. Troponin T levels of 140 women were assessed between 8 and 24 h postpartum. Results Ninety-one women considered to be at high risk and 49 at low risk women for myocardial strain were enrolled. The overall mean (± SD) serum troponin T level at 24 h postpartum was 8.7 ± 19.7 ng/L (normal range <14 ng/L). The incidence of a positive troponin result was 4.3% (95% CI 1.6, 9.1). Four patients (8.2%) of the low-risk group and two (2.2%) in the high-risk group had elevated troponin T assays. Conclusion This study found that 4% of women had elevated postpartum troponin assays, within levels in the range suggestive of myocardial damage. However, we were unable to ascertain how to identify this group of women prospectively. At this time, we recommend a low threshold for investigation should be maintained.

Background: Quality of life assessments are increasingly recognised in healthcare. The aim of this study was to evaluate psychometric characteristics of Nottingham Health Profile in the postpartum period. Methods: A random sample of 133 English speaking women completed the scale in hospital between 24 and 48h of delivery and again at 7days postpartum. Descriptive analysis was used to evaluate psychometric parameters of the questionnaire. Results: The questionnaire indicated that in the acute setting, physical ability, energy level and pain were most affected. At follow-up, women described greatest difficulties with energy level and pain domains. The scores for physical ability, pain, sleep and energy level improved compared to baseline (P<0.05). Women who had caesarean delivery had lower scores for physical ability, pain and energy level domains at 1-2week follow-up compared to the vaginal delivery group (P<0.05). Conclusions: The scale was found to be suitable for evaluation of quality of life in a population of postpartum women. However a more culturally and geographically diverse population is needed to test reliability and validity of the instrument.

A safe and effective intrathecal dose of bupivacaine alone for cesarean delivery has not yet been established. This study tested the hypothesis that an intrathecal dose of hyperbaric bupivacaine 15 mg would produce equivalent spinal anesthesia for cesarean delivery as the combination of hyperbaric bupivacaine 12 mg and fentanyl 15 μg. This was a single center, double-blind, randomized clinical trial of equivalence. One hundred and thirty-eight healthy parturients scheduled for elective cesarean delivery were randomized to receive either intrathecal hyperbaric bupivacaine 15 mg (Group B) or hyperbaric bupivacaine 12 mg with fentanyl 15 μg (Group BF). Parturients where asked to describe their degree of sensation during surgery using a four-point scale 20 min after spinal injection. Secondary outcomes included the incidence of maternal side effects, maternal hemodynamics and the need for supplemental analgesia. There was no difference in the quality of anesthesia between the two groups. Sixty-eight of 69 and 69/69 patients in Group B and Group BF, respectively had anesthesia classified as successful (RR=1.01; 95% CI 0.85, 1.22). The only two secondary outcomes that were different between the groups were the largest change in mean arterial pressure (decrease of 40 mmHg and 34 mmHg for Group B and Group BF, respectively; P=0.004) and the incidence of nausea (59% and 35% for Group B and Group BF, respectively; P=0.006). There was no difference in the degree of sensation at 20 min between Group B and Group BF. The only significant differences between the two techniques were a higher incidence of nausea and decrease in maternal blood pressure in Group B.

When diagnosed antenatally placenta accreta has often been managed by cesarean hysterectomy, but recently techniques involving uterine preservation have been developed. Uterine artery embolization has become an adjuvant treatment, although the potential for obstetric hemorrhage still exists. A multidisciplinary approach has permitted the development of anesthetic strategies for these patients. A retrospective case note review of patients with placenta accreta between 2000 and 2008 at our institution was conducted. Anesthetic technique, estimated blood loss, requirement for blood products and disposition of patients postoperatively were recorded. A total of 23 cases were identified. In six, epidural anesthesia with progression to general anesthesia was planned. In 17 cases, neuraxial anesthesia was planned and in five of these (29%) excessive blood loss necessitated conversion to general anesthesia. Nine patients (39%) had intraoperative blood loss estimated at > 2L, and six required intraoperative blood transfusion. Eleven patients (48%) required hysterectomy, seven of which were performed on the day of delivery. In this case series, the expectation of major blood loss at cesarean delivery in the presence of placenta accreta and attempts at uterine conservation surgery initially prompted a conservative approach using general anesthesia. Greater experience has permitted modification of this approach and neuraxial anesthesia is now employed more frequently. When managed appropriately, most patients are able to tolerate both prolonged surgery and significant blood loss under epidural anesthesia.

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