No abstract

Introduction: Women with placenta previa are at high risk from morbidity and mortality from major obstetric haemorrhage. Over the recent years, intraoperative cell salvage has been increasingly recommended in obstetrics. We reviewed the anaesthetic management of caesarean section for placenta previa in our maternity unit. Additionally, we wished to identify risk factors for major blood loss in this group where setting up a cell saver in anticipation would be cost effective. Methods: We did a retrospective study from September 2002 to August 2005, only including those patients with placenta previa who required a caesarean delivery. Patients were identified from the theatre record books. Details collected were: Maternal age, parity, weeks of gestation, urgency of caesarean section, type of anaesthetic, grade of anaesthetist, grade of placenta previa, previous caesarean delivery, estimated blood loss, blood transfusion in the intraoperative and immediate post-operative period, pre and postoperative haemoglobin. Results: Of the 15,033 deliveries,there were 70 patients with placenta previa one patient with placenta accreta. Nearly half of the patients had an emergency caesarean section 34/70 (48.6%) and the rest had an elective caesarean section 36/70 (51.4%). The senior most anaesthetist present was a consultant in 42/70 (60%) patients and either a trainee or staff grade anaesthetist in 28/70 (40% patients). History of at least one previous caesarean section was present in 24 /70 (34%) patients. Regional anaesthesia (RA) was given to 47 /70 (67%) patients and general anaesthesia (GA) was given to 23/70 (33%) patients. Blood transfusion rate was 10% (7/70 patients). Patients who had a GA not only had a higher mean intraoperative blood loss compared to those who had a RA.(GA 1147 mls Vs RA 773 mls) but also were almost 3 times more likely to be transfused than those patients who had RA. (GA 4/23 (17.3%) transfused compared to RA 3/47 (6.3%) patients).Two patients with multiple previous caesarean sections had massive blood loss and needed emergency caesarean hysterectomies. Out of the 8 patients who had a blood loss of more than 1000mls, 5 patients (62%) had a grade 4 placenta previa. Conclusion: Our study reaffirms that regional anaesthesia is a safe anaesthetic technique for caesarean delivery for majority of placenta previa. Our regional anaesthesia rate(67%) was comparable with previous studies(1,2).Patients given GA tended to bleed more and required frequent transfusions. We found an association between multiplicity of previous caesarean sections, having a higher grade of placenta previa, receiving a GA and tendency for major blood loss, these patients may be candidates for intraoperative cell salvage. Further studies are needed in this high risk group to prove the strength of their association.

A ppendicitis is the most common surgical problem in pregnancy (occurs in 1/1500 pregnancies) and requires emergent abdominal surgery. Complications can include peritonitis, sepsis, and abscess formation, particularly for appendiceal rupture. The physiologic changes of pregnancy can make the diagnosis of appendicitis difficult. If the appendicitis is uncomplicated, prompt surgery can avoid the complications of perforation. If the appendix has ruptured, increases in maternal and fetal morbidity and mortality occur, and the method of optimal treatment is unclear. This report presents data on 2 patients with ruptured appendicitis treated without surgery but with antibiotics, bowel rest, and intravenous fluids.The first patient, at 32 4/7 weeks of gestation, reported 1 week of intermittent diarrhea and abdominal cramping. The right lower quadrant examination showed tenderness with rebound and her WBC was 22 Â 10 9 /L. Magnetic resonance imaging (MRI) confirmed the diagnosis of ruptured appendix with a phlegmon measuring 7 cm. She was treated with intravenous ampicillin, gentamicin, and clindamycin. Her WBC count peaked at 33 Â 10 9 /L with 9% bands. She remained clinically stable despite the development of peritoneal inflammation and ileus. Although premature uterine contractions developed, tocolysis and steroids were not administered. Over 2 to 3 days, the patient's clinical status and laboratory studies improved, with resolution of her ileus and uterine contractions. Fetal heart rate tracings were reassuring. A repeat MRI on day 5 revealed no change in the phlegmon size. On day 11, she was discharged home with a normal WBC count. At 38 5/7 weeks of gestation, she had an uncomplicated vaginal delivery of a 3544 g girl with Apgar scores of 8 and 9. The postpartum course was uncomplicated, and 2 months after delivery the patient had an interval laparoscopic appendectomy. Pathologic examination showed xanthogranulomatous appendicitis with partial obstruction of the appendiceal lumen.The second patient presented at 26 6/7 weeks of gestation with an 8-day history of right upper and lower quadrant pain. Her WBC count was 19 Â 10 9 /L. Pelvic ultrasound showed a noncompressible appendix with a phlegmon measuring 1.4 cm. MRI confirmed the presence of a ruptured appendix. Medical management was provided with ampicillin, gentamicin, and clindamycin, bowel rest, and intravenous fluids. She became afebrile and the WBC count returned to normal. She was discharged to home on day 9. At 32 weeks of gestation, her right lower quadrant pain recurred and another MRI showed no change in the appendix or phlegmon. Medical management remained the same. Despite the onset of preterm labor at 33 6/7 weeks, steroids and tocolytic drugs were not administered. She had a cesarean delivery by low transverse uterine incision for breech presentation at that time. A male neonate with Apgar scores of 8 and 9 and weight of 2005 g was delivered. The appendix was removed during the cesarean surgery. The postoperative course was uneventful, and the newbo...