Background: Several randomised controlled trials show that maintenance of labour epidural analgesia with programmed intermittent epidural bolus reduces the maternal motor block compared with maintenance with a continuous infusion. However, these trials were usually restricted to healthy nulliparous parturients. To assess the generalisability of these randomised controlled trials to 'real-world' conditions, we compared maternal motor function (modified Bromage score) over time between healthy nulliparous and parous women using routinely collected quality-control data. Methods: After ethical approval, all parturients receiving programmed intermittent epidural bolus labour analgesia between June 2013 and October 2014 were included in this prospective cohort study. Bupivacaine 0.1% with fentanyl 2 mg ml À1 was used allowing for patient-controlled bolus every 20 min. The maternal motor function (primary outcome) was regularly assessed from insertion of the epidural catheter until delivery. Results: Of the 839 parturients included, 553 (66%) were nulliparous and 286 (34%) were parous. The parous women had a shorter median duration of epidural analgesia (3 h 59 min vs 5 h 45 min) and a higher incidence of spontaneous delivery (66% vs 37%). The probability of being in a certain Bromage category at birth was similar in nulliparous and parous women in a general additive model adjusting for duration of epidural analgesia, number of rescue top-ups, and number of catheter manipulations (cumulative odds ratio: 1.18; 95% confidence interval: 0.98e1.41). Parous women required a higher time-weighted number and volume of rescue top-ups. Conclusions: The results of the randomised controlled trials on a reduced motor block with programmed intermittent epidural bolus seem generalisable to parturients typically not included in these trials.
(Br J Anaesth. 2019;123:e434–e441)
Neuraxial analgesia is the most widely used labor pain relief method, and patient-controlled epidural analgesia (PCEA) used in combination with a low-dose continuous epidural infusion has been shown to boost patient satisfaction while also increasing the volume of local anesthetics that are used. Researchers who have conducted randomized controlled trials (RCTs) have shown that substituting a programmed intermittent epidural bolus (PIEB) in place of PCEA can decrease local anesthetic consumption, but it is unclear if the maternal motor block in this method has a negative effect on labor progression. Because RCTs are almost always conducted on healthy nulliparous women, their results cannot easily be applied to the variety of patients seen in daily clinical practices. Gabriel and colleagues conducted their study on epidural labor analgesia data in order to compare the maternal motor function of RCT-eligible nulliparous women to parous women who are usually considered RCT-ineligible.
A woman in her early 30s in the 11 2/7 week of pregnancy was admitted with severe abdominal pain and emesis. One year prior, the patient had undergone hysteroscopic adhesiolysis to treat Asherman syndrome resulting from a prior pregnancy. Examination of the patient revealed a haemoperitoneum and an intact intrauterine pregnancy. Laparoscopic adhesiolysis and haemostasis was performed and the patient was transferred to the intensive care unit. Subsequent examination due to persistent abdominal pain revealed an occult iatrogenic perforation of the uterus and placenta percreta with spontaneous uterine rupture. Although treatment for placenta percreta has generally been hysterectomy, in this case, the rupture and perforation sites were resected, representing successful fertility preserving management for this oft-overlooked pregnancy complication.
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