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Objective  We study whether using an intra-aortic balloon (IAB) during cesarean hysterectomy decreases delivery morbidity in patients with suspected morbidly adherent placentation. Study Design  This is a retrospective cohort study of deliveries complicated by suspected abnormal placentation between 2009 and 2016 comparing maternal and neonatal outcomes with an IAB placed prior to cesarean hysterectomy versus no IAB. The primary outcome included quantified blood loss (QBL). Results  Thirty-five cases were reviewed, 16 with IAB and 19 without IAB. No difference was seen in median QBL between the two groups (1,351 vs. 1,397 mL; p  = 0.90). There were no significant differences in overall surgical complications (19% IAB, 21% no IAB; p  = 0.86), bladder complications (12 vs. 21%; p  = 0.66), intensive care unit admissions (12 vs. 26%; p  = 0.41), surgical duration (2.9 vs. 2.8 hour; p  = 0.83), or blood transfusions (median 2 vs. 2; p  = 0.27) between the two groups. There was one groin hematoma at the balloon site that was managed conservatively. There were no complications involving thrombosis or limb ischemia in the IAB group. Conclusion  While we did not detect statistically significant differences, larger studies may be warranted given the potential for extreme morbidity in these cases. This study highlights the potential use of an IAB in the management of these cases.

Purpose Neuraxial hydromorphone has been reported to provide rapid onset of labour analgesia, effective segmental pain relief, and a longer duration of action than commonly used lipophilic opioids. This study was conducted to test the hypothesis that intrathecal hydromorphone reduces the dose requirement for intrathecal bupivacaine to induce rapid analgesia for women in the first stage of labour. Methods In this double-blind randomized controlled sequential allocation trial, 88 labouring parturients received combined spinal-epidural analgesia at 2-6 cm cervical dilation. Participants received intrathecal bupivacaine alone or bupivacaine plus hydromorphone 100 lg with the bupivacaine dose determined using updown sequential allocation. An effective dose was defined as a visual analogue pain score of B10 mm (on a 100-mm pain scale) reported within 20 min of injection. The median effective doses were calculated using the formula of Dixon and Massey and verified using isotonic regression. Results A decrease was observed in the median local analgesic doses (effective dose [ED50]) estimated according to the formulas of Dixon and Massey, with a between-group difference of -0.45 mg. The precision of the estimate was wide-ranging (95% confidence interval -1.23 to 0.33), so no definitive conclusion can be drawn. Conclusion Further research is needed to determine whether or not intrathecal hydromorphone 100 lg changes the dose of intrathecal bupivacaine required to induce labour analgesia within 20 min. Trial registration The trial was conducted in 2007 prior to widespread acceptance of the standard for clinical trial registration. RésuméObjectif Il a été décrit que l'hydromorphone administrée par voie neuraxiale favorisait l'installation rapide de

Labor analgesia researchers have pursued better and safer ways to provide pain relief in labor. Although some pharmacologic investigations have focused on alternative mechanisms to target and medications to employ, a large part of the recent obstetric anesthesiology literature has contributed toward the safety and efficacy of techniques dependent on traditional therapeutics, specifically local anesthetics given through a neuraxial anesthetic technique. Investigators have worked to demonstrate and remove doubts that neuraxial anesthesia can be a safe method of labor analgesia. Pharmacodynamic studies during the last 3 decades have revealed ways to achieve adequate analgesia with minimal doses and correspondingly minimal risks. Dose-sparing opiate adjuncts to local anesthetics are now commonplace. To avoid excessive dosages, clinical up-down sequential allocation experiments identified the minimum amounts of local analgesia needed. Modifications to the administration of drug allowed total doses to be further reduced. This historical overview highlights some of these important advances in the present and recent past of neuraxial labor analgesia, and it traces how desired outcomes are being achieved with less and less total drug.

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METHODS: MAPs were compared between women with and without hypertensive disorders in labor pre and post butorphanol administration between January 2010 and December 2012. Independent t test assessed for differences between MAP in women with HTN disorders and those who did not. RESULTS: 154 women were included with 77 in each group. The women in the hypertensive group were significantly delivered at a younger gestational age (P,.003) and found to have a larger BMI (P,.0015). There was no statistical difference in race, parity, or mode of delivery between the two groups. Women in the hypertensive group had significantly elevated blood pressures as compared to the normotensive group at all study intervals (P,.001). The blood pressure decreased at the 1 hour mark after administration in the hypertensive group (P5.02) but there was no statistically significant difference between the pre and post administration MAPs at any of the other time intervals studied in either group. CONCLUSION: There is no increase in mean arterial blood pressure after butorphanol administration in laboring pregnant women. Butorphanol is a safe analgesic choice for women with and without hypertensive disorders.

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