Fracture of an epidural catheter inserted for labour analgesia.

A primiparous 28-year-old woman undergoing augmentation of labour requested epidural analgesia. During the apparently uneventful insertion, the catheter snapped and a fragment was retained in her back. The management options for labour analgesia, the optimal methods of locating the retained fragment and the indications for surgical removal are discussed.

Complete failure of spinal anaesthesia in obstetrics.

Intrathecal anaesthesia, either as a single shot-spinal or as part of a combined spinal-epidural technique, is now widely accepted as the management of choice for caesarean section. It generally produces rapid and predictable anaesthesia, yet occasionally fails for no apparent reason. Four case reports of seemingly inexplicable complete failure of intrathecal anaesthesia are presented, together with a literature review of other cases and possible causes of the failure, which include anatomical abnormality, drug failure and management failure.

Anaesthesia for emergency caesarean section, 2000-2004, at the Royal Women's Hospital, Melbourne.

The provision of anaesthesia for emergency caesarean section is a major part of the workload of obstetric anaesthetists and the urgency often dictates the mode of anaesthesia that can be provided. We have audited the provision of anaesthesia for 'immediate' caesarean sections over a four-year period following the introduction of a 'Code Green' system to coordinate a rapid response to an obstetric decision to proceed with an 'immediate' caesarean section. The records of all patients for whom a Code Green was called between July 2000 and June 2004 were studied. The reasons for the call, interval timings (for example decision-to-delivery interval) and type of anaesthesia used were collected. There were 444 Code Green procedures, of which 47 were excluded due to incomplete data. The most common indication was fetal distress' and the three most common types of anaesthesia used were general (n = 206), Epidural top-up (n = 106) and spinal (n = 65). Mean decision-to-delivery intervals (+/- SD) for all caesarean sections were 17 (+/- 6) minutes with general anaesthesia, 19 (+/- 9) minutes with epidural and 26 (+/- 9) minutes with spinal anaesthesia. Forty-five percent of calls were made between the hours of 0700 and 1700 h. General anaesthesia was most used between the hours of 0700 and 1700 h. A swift response to the call for an immediate caesarean section can be achieved when suitable facilities and procedures are in place. Administering an epidural bolus into an already established epidural catheter that is working effectively can allow a decision-to-delivery interval almost as short as general anaesthesia.

Recombinant factor VIIa in massive postpartum haemorrhage.

Massive postpartum haemorrhage is a major cause of maternal and fetal morbidity and mortality. Management mainstays include transfusion therapy, uterotonic agents and surgery. The "off label" use of recombinant activated factor VII appears to have an evolving role in the management of massive postpartum haemorrhage refractory to conventional treatments. The current literature is reviewed.

Incidence of epidural blood patch following obstetric regional analgesia in private Australian anaesthetic practice.

BACKGROUND: Collection of audit data about epidural blood patches has traditionally relied on voluntary reporting, which is notoriously incomplete. The records of Medicare-funded Australian private obstetric practice, which represents 30% of all deliveries, allow a novel method of central data collection and retrieval. METHOD: Data relating to all deliveries, epidurals and blood patches in private practice in Australia over a two-year period were retrieved from the Health Insurance Commission. RESULTS: The overall rate of epidural analgesia in labour was estimated at 30% and the proportion of epidurals that progressed to blood patching was 0.35%. The rate of epidural blood patching varied between states from 0.18% to 0.56%. CONCLUSION: Despite certain limitations of our data interpretation, we regard this technique as a useful audit tool capable of generating accurate and robust audit data that might otherwise be unobtainable.

Seizures and the pituitary gland during pregnancy.

We present the anaesthetic management of a woman who, at 10 days post partum, suffered a series of convulsions in the context of two episodes of post partum haemorrhage. The probable aetiology of the convulsions is discussed.

Arterial aneurysms of the lienorenal axis during pregnancy.

Rupture of an aneurysm of the renal or splenic arteries remains a rare but catastrophic complication of pregnancy with a generally dismal prognosis for both mother and fetus. Improvements in abdominal imaging for incidental conditions are unlikely to lead to earlier diagnosis of such abnormalities antenatally, hence cardiovascular collapse during pregnancy is likely to continue to be their usual presentation. Two cases are described, both of splenic artery rupture. The literature of these rare events is reviewed.

Stability of Mycoplasma pneumoniae cytadherence-accessory protein HMW1 correlates with its association with the triton shell.

Mycoplasma pneumoniae adsorbs to host respiratory epithelium primarily by its attachment organelle, the proper function of which depends upon mycoplasma adhesin and cytoskeletal proteins. Among the latter are the cytadherence-associated proteins HMW1 and HMW2, whose specific roles in this process are unknown. In the M. pneumoniae cytadherence mutant I-2, loss of HMW2 results in accelerated turnover of HMW1 and other cytadherence-accessory proteins, probably by proteolysis. However, both the mechanism of degradation and the means by which these proteins are rendered susceptible to it are not understood. In this study, we addressed whether HMW1 degradation is a function of its presence among specific subcellular fractions and established that HMW1 is a peripheral membrane protein that is antibody accessible on the outer surfaces of both wild-type and mutant I-2 M. pneumoniae but to a considerably lesser extent in the mutant. Quantitation of HMW1 in Triton X-100-fractionated extracts from cells pulse-labeled with [(35)S]methionine indicated that HMW1 is synthesized in a Triton X-100-soluble form that exists in equilibrium with an insoluble (cytoskeletal) form. Pulse-chase analysis demonstrated that over time, HMW1 becomes stabilized in the cytoskeletal fraction and associated with the cell surface in wild-type M. pneumoniae. The less efficient transition to the cytoskeleton and mycoplasma cell surface in mutant I-2 leads to accelerated degradation of HMW1. These data suggest a role for HMW2 in promoting export of HMW1 to the cell surface, where it is stable and fully functional.

Spinal anaesthesia and dysfibrinogenaemia.

We report the case of a 34-year-old woman who presented to the delivery unit at 36 weeks' gestation with spontaneous rupture of membranes. She had a triplet pregnancy following in vitro fertilisation. An elective caesarean section was performed under spinal anaesthesia 4h after admission. The patient had a massive postpartum haemorrhage in the recovery area at which time she mentioned that she was known to have 'low fibrinogen'. Further investigation showed that she suffered from dysfibrinogenaemia, as did several members of her family. We can find no reported cases of the use of central neural blockade in a patient with untreated dysfibrinogenaemia. Central neural blockade is often considered contraindicated in patients with disorders of fibrinogen; there were fortunately no neurological sequelae following spinal anaesthesia in this patient.

Transcriptional analysis of the hmw gene cluster of Mycoplasma pneumoniae.

Mycoplasma pneumoniae adherence to host cells is a multifactorial process that requires the cytadhesin P1 and additional accessory proteins. The hmw gene cluster consists of the genes p30, hmw3, and hmw1, the products of which are known to be essential for cytadherence, the rpsD gene, and six open reading frames of unknown function. Putative transcriptional terminators flank this locus, raising the possibility that these genes are expressed as a single transcriptional unit. However, S1 nuclease protection and primer extension experiments identified probable transcriptional start sites upstream of the p32, p21, p50, and rpsD genes. Each was preceded at the appropriate spacing by the -10-like sequence TTAAAATT, but the -35 regions were not conserved. Analysis of the M. pneumoniae genome sequence indicated that this promoter-like sequence is found upstream of only a limited number of open reading frames, including the genes for P65 and P200, which are structurally related to HMW1 and HMW3. Promoter deletion studies demonstrated that the promoter-like region upstream of p21 was necessary for the expression of p30 and an hmw3-cat fusion in M. pneumoniae, while deletion of the promoter-like region upstream of p32 had no apparent effect. Analysis by reverse transcription-PCR confirmed transcriptional linkage of all the open reading frames in the hmw gene cluster. Taken together, these findings suggest that the genes of this locus constitute an operon expressed from overlapping transcripts.

Lymphocytic hypophysitis complicated by post-partum haemorrhage.

We report the anaesthetic management of a primiparous patient presenting in late pregnancy with rapidly progressive bitemporal hemianopia due to a pituitary mass caused by autoimmune hypophysitis. Caesarean section was complicated by post-partum haemorrhage. Anaesthesia is discussed together with a review of the literature on lymphocytic hypophysitis.

Loss of HMW1 and HMW3 in noncytadhering mutants of Mycoplasma pneumoniae occurs post-translationally.

The genomic sequence of Mycoplasma pneumoniae establish this cell-wall-less prokaryote as among the smallest known microorganisms capable of self-replication. However, this genomic simplicity and corresponding biosynthetic austerity are sharply contrasted by the complex terminal structure found in this species. This tip structure (attachment organelle) directs colonization of the human respiratory mucosa, leading to bronchitis and atypical pneumonia. Furthermore, formation of a second tip structure appears to precede cell division, implying temporal regulation. However, the organization, regulation, and assembly of the attachment organelle in M. pneumoniae are poorly understood, and no counterparts have been identified among the walled bacteria. M. pneumoniae possesses a cytoskeleton-like structure required to localize adhesin proteins to the attachment organelle. The cytadherence-associated proteins HMW1, HMW2, and HMW3 are components of the mycoplasma cytoskeleton, with HMW1 localizing strictly along the filamentous extensions from the cell body and HMW3 being a key structural element of the terminal organelle. Disruptions in hmw2 result in the loss of HMW1 and HMW3. However, the hmw1 and hmw3 genes were transcribed and translated at wild-type levels in hmw2 mutants. HMW1 and HMW3 were relatively stable in the wild-type background over 8 h but disappeared in the mutants over this time period. Evaluation of recombinant HMW1 levels in mycoplasma mutants suggested a requirement for the C-terminal domain of HMW1 for turnover. Finally, an apparent defect in the processing of the precursor for the adhesin protein P1 was noted in the HMW- mutants.

Epidural bupivacaine/fentanyl infusions vs. intermittent top-ups: a retrospective study of the effects on mode of delivery in primiparous women.

This study was designed to determine whether the introduction of epidural infusions containing fentanyl and bupivacaine has affected the mode of delivery in primiparous women attending our maternity department. We reviewed retrospectively the computerized records of 4362 consecutive primiparous women in labour. All the women were admitted with the expectation of a vaginal delivery. The results were analysed using logistic regression analysis adjusted for age, weight, gestation, cervical dilatation at epidural insertion, use of oxytocin, the year of entry into the study and the type of epidural block received. In women receiving an epidural block at 3-6 cm cervical dilatation (n = 1534), those who received an infusion were significantly less likely to have an emergency Caesarean section than those having intermittent 'topups' (P = 0.0019). In the same subgroup of women, the Caesarean section rate specifically for failure to progress followed the same trend, but just failed to reach statistical significance (P = 0.058). This provides evidence to support the theory that epidural infusions containing a low dose bupivacaine/fentanyl combination may reduce the risk of Caesarean section in primiparous women.

The anaesthetic management of intracranial haemorrhage from arteriovenous malformations during pregnancy: three cases.

We report three cases of intracranial haemorrhage from arteriovenous malformations during pregnancy. The anaesthetic management of the pregnant patient undergoing a major neurosurgical procedure and the anaesthetic management of caesarean section in a patient at risk of recurrent intracranial haemorrhage are discussed.

Low dose bupivacaine/fentanyl epidural infusions in labour and mode of delivery.

The aim of this study was to determine the effect on the instrumental delivery rate of two different concentrations of bupivacaine combined with fentanyl in epidural infusions during labour. Only primiparous women in whom a spontaneous vaginal delivery was anticipated, were included in the study. Those women receiving a higher concentration of bupivacaine and therefore a greater amount of local anaesthetic agent during labour were significantly more likely to have an instrumental delivery with Kielland's rotational forceps (p < 0.01). Those women receiving a lower concentration and smaller amount of bupivacaine were significantly more likely to have an instrumental delivery with Neville-Barnes forceps (p < 0.05). This provides evidence to support the theory that epidural analgesia may contribute to inadequate rotation of the presenting fetal part due to weakened pelvic floor muscles and that this is more likely to occur when higher concentrations of bupivacaine are used and a greater degree of motor block occurs.