Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management.

PURPOSE: Unintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years. METHODS: Clinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis. RESULTS: Between January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06). CONCLUSIONS: Rates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.

Time profile of appearance and disappearance of circulating placenta-derived mRNA in maternal plasma.

BACKGROUND: Fetal RNA of placental origin has been detected in the plasma of pregnant women, but the timing of the first appearance and the detailed kinetics of postdelivery clearance of such circulating RNA have not been studied. METHODS: To address the timing of the first appearance of circulating placental RNA, we collected serial maternal blood samples from 47 women who had conceived by assisted reproductive procedures. To address the postdelivery clearance kinetics, we collected serial postdelivery blood samples from 6 pregnant women who had delivered by cesarean section. Placenta-derived transcripts were sought by real-time quantitative reverse transcription-PCR. RESULTS: The earliest gestational age at which human placental lactogen and human chorionic gonadotropin beta-subunit mRNAs were detectable in a proportion of the pregnant women was the 4th week of gestation. The postdelivery study indicated that the median apparent half-life for the clearance of human placental lactogen mRNA was 14 min. CONCLUSIONS: Placenta-derived mRNA can be found in maternal plasma from very early on in gestation, suggesting a possible role for early noninvasive prenatal diagnosis or monitoring. The rapid kinetics of circulating placental mRNA suggest that its plasma concentrations may be used to monitor recent physiologic or pathologic events.