Best Practice & Research Clinical Obstetrics & Gynaecology RSS feed: Current Issue. In practical paperback format, each 200 page topic-based issue of Best Practice & Research Clinical Obstetrics & Gynaecology will provide a comprehensive review of current clinical practice and thinking within the specialties of obstetrics and gynaecology. All chapters are commissioned and written by an international team of practising clinicians with the Guest Editors for each issue drawn from a pool of renowned experts and opinion leaders. Reference is made to: • the latest original research • Cochrane Reviews • audits and confidential enquiries • national and international conferences • national and international guidelines • personal communications All chapters take the form of practical, evidence-based reviews that seek to address key clinical issues of diagnosis, treatment and patient management. Each issue follows a problem-orientated approach that focuses on the key questions to be addressed, clearly defining what is known and not known. Management will be described in practical terms so that it can be applied to the individual patient. Boxed and bulleted Learning Objectives and Practice Points are features within each chapter and will highlight the core and essential knowledge that will help the physician to provide the best care to their patients. The series' objective is to provide a continuous update for the busy clinician and researcher. 2009 Topics Volume 23 Issues 1-6 1. Menopause and menopause transition M. Lumsden (UK) 2. Contraception and sexual health J. Stephenson and C. Wilkinson (UK) 3. Near miss audit in obstetrics R. Pattinson (South Africa) 4. Acute gynaecology and early pregnancy complications - Volume 1 T. Bourne (UK) and G. Condous (Australia) 5. Acute gynaecology and early pregnancy complications - Volume 2 T. Bourne (UK) and G. Condous (Australia) 6. Intrauterine fetal growth restriction J. and S. Dornan (Ireland) 2010 Topics Volume 24 Issues 1-6 1. Reproduction and cancer J. Tzafettas (Greece) 2. Adolescent and paediatric gynaecology G. Creatsas (Greece) 3. Obstetric analgesia and anaesthesia N. Robinson and P. Howel (UK) 4. Abortion and post-abortion care: Vol. 1 T. Mahmood (UK) 5. Abortion and post-abortion care: Vol. 2 T. Mahmood (UK) 6. Training, education and assessment M. Murphy (UK)http://www.bestpracticeobgyn.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. Best Practice & Research Clinical Obstetrics & Gynaecology1521-6934243June 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.bestpracticeobgyn.com/article/PIIS1521693410000635/abstract?rss=yesAims and Scope/Editorial Board10.1016/S1521-6934(10)00063-5Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Obstetrics & Gynaecology2010-06-01243S1521-6934(10)X0004-9iiiiiihttp://www.bestpracticeobgyn.com/article/PIIS1521693410000027/abstract?rss=yesAll obstetric management is directed towards the ultimate goal of providing high-quality maternal care with the outcome of a live, healthy baby and a well mother. In recent years, maternal care has become more complex, and also more challenging as potentially sicker patients with significant co-morbidities become pregnant.PrefacePaul Howell, Neville Robinson10.1016/j.bpobgyn.2010.01.001Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-01-25Best Practice & Research Clinical Obstetrics & Gynaecology2010-01-25243S1521-6934(10)X0004-9259259http://www.bestpracticeobgyn.com/article/PIIS1521693409001539/abstract?rss=yesThe importance of early identification and management of the high-risk obstetric patient is emphasised in the Confidential Enquiry into Maternal and Child Health (CEMACH) report. High-risk patients who need anaesthetic input include those with airway problems, cardiorespiratory disease and rare genetic conditions, such as malignant hyperthermia and suxamethonium apnoea. Anaesthetic options for labour analgesia as well as anaesthesia for operative delivery will need to be discussed in detail with the patient if a delivery management plan is to be constructed. Input from other medical teams, such as cardiologists or haematologists, are often needed. Ultimately, these measures should reduce maternal morbidity and mortality.The preoperative assessment of obstetric patientsAnelia Hinova, Roshan Fernando10.1016/j.bpobgyn.2009.12.003Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-31Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-31243S1521-6934(10)X0004-9261276http://www.bestpracticeobgyn.com/article/PIIS1521693409001473/abstract?rss=yesGenomic discoveries in the field of perioperative medicine and anaesthesia have generated multiple publications and some hope that pharmacogenetic testing may guide clinicians to provide safe and effective medicine in a ’tailored' manner. Within the field of anaesthesia, many consider that ‘titration of drugs to the desired effect works just fine’ and wonder if pharmacogenomics will ever impact on their daily practice. This review will cite practical examples of relevant candidates genes and common polymorphisms that have shown to alter the response to medication prescribed in the peripartum period by obstetricians and anaesthesiologists.Pharmacogenetic influences in obstetric anaesthesiaRuth Landau10.1016/j.bpobgyn.2009.11.009Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-23Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-23243S1521-6934(10)X0004-9277287http://www.bestpracticeobgyn.com/article/PIIS1521693409001412/abstract?rss=yesMaternal labour pain and stress are associated with progressive fetal metabolic acidosis. Systemic opioid analgesia does little to mitigate this stress, but opioids readily cross the placenta and cause fetal-neonatal depression and impair breast feeding. Pethidine remains the most widely used, but alternatives, with the possible exception of remifentanil, have little more to offer. Inhalational analgesia using Entonox is more effective and, being rapidly exhaled by the newborn, is less likely to produce lasting depression. Neuraxial analgesia has maternal physiological and biochemical effects, some of which are potentially detrimental and some favourable to the fetus. Actual neonatal outcome, however, suggests that benefits outweigh detrimental influences. Meta-analysis demonstrates that Apgar score is better after epidural than systemic opioid analgesia, while neonatal acid-base balance is improved by epidural compared to systemic analgesia and even compared to no analgesia. Successful breast feeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia.The effects of maternal labour analgesia on the fetusFelicity Reynolds10.1016/j.bpobgyn.2009.11.003Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-11-30Best Practice & Research Clinical Obstetrics & Gynaecology2009-11-30243S1521-6934(10)X0004-9289302http://www.bestpracticeobgyn.com/article/PIIS1521693409001497/abstract?rss=yesThe increasing trend of caesarean section in the setting of increasing maternal age, obesity and other concomitant diseases will continue to challenge the obstetric anaesthetist in his/her task of providing regional and general anaesthesia. The challenges of providing anaesthesia for an emergency caesarean section, particularly the risks of general anaesthesia, will be debated. The need for involvement of a multidisciplinary team, good communication and challenges surrounding the provision of anaesthesia to such patients are discussed.The ongoing challenges of regional and general anaesthesia in obstetricsAlex T.H. Sia, Wendy L. Fun, Terry U. Tan10.1016/j.bpobgyn.2009.12.001Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-01-04Best Practice & Research Clinical Obstetrics & Gynaecology2010-01-04243S1521-6934(10)X0004-9303312http://www.bestpracticeobgyn.com/article/PIIS1521693409001515/abstract?rss=yesThe number of women with serious (non-obstetric) systemic diseases achieving pregnancy and requiring obstetric anaesthetic management is increasing. The conditions that are most likely to cause maternal morbidity and mortality are cardiac disease, respiratory disease, neuromuscular disease, haematological disease, connective and metabolic diseases and psychiatric conditions including substance abuse. This article discusses the anaesthetic management of the pregnant mother with such serious systemic diseases.Anaesthesia for the obstetric patient with (non-obstetric) systemic diseasePeter J.W. Reide, Steve M. Yentis10.1016/j.bpobgyn.2009.11.012Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-01-04Best Practice & Research Clinical Obstetrics & Gynaecology2010-01-04243S1521-6934(10)X0004-9313326http://www.bestpracticeobgyn.com/article/PIIS1521693409001424/abstract?rss=yesMagnesium is a critical physiological ion, and magnesium deficiency might contribute to the development of pre-eclampsia, to impaired neonatal development and to metabolic problems extending into adult life. Pharmacologically, magnesium is a calcium antagonist with substantial vasodilator properties but without myocardial depression. Cardiac output usually increases following magnesium administration, compensating for the vasodilatation and minimising hypotension. Neurologically, the inhibition of calcium channels and antagonism of the N-methyl-d-aspartic acid (NMDA) receptor raises the possibility of neuronal protection, and magnesium administration to women with premature labour may decrease the incidence of cerebral palsy. It is the first-line anticonvulsant for the management of pre-eclampsia and eclampsia, and it should be administered to all patients with severe pre-eclampsia or eclampsia. Magnesium is a moderate tocolytic but the evidence for its effectiveness remains disputed. The side effects of magnesium therapy are generally mild but the major hazard of magnesium therapy is neuromuscular weakness.Magnesium in obstetricsM.F.M. James10.1016/j.bpobgyn.2009.11.004Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-07Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-07243S1521-6934(10)X0004-9327337http://www.bestpracticeobgyn.com/article/PIIS1521693409001485/abstract?rss=yesThe coagulation system undergoes significant change during pregnancy. The clinician caring for the parturient must understand these changes, particularly when the parturient has a pre-existing haematological condition. Because many haematological conditions are rare, there often is limited information to guide the obstetric and anaesthetic management of these parturients.Coagulation in pregnancyPatrick Thornton, Joanne Douglas10.1016/j.bpobgyn.2009.11.010Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-28Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-28243S1521-6934(10)X0004-9339352http://www.bestpracticeobgyn.com/article/PIIS1521693409001503/abstract?rss=yesEvery minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric haemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world while resource-rich countries have a rising caesarean section rate with its consequential effect on the incidence of abnormal placentation and its link with peripartum hysterectomy.Management of obstetric haemorrhage involves early recognition, assessment and resuscitation. Various methods are available to try to stop the bleeding – from pharmacological methods to aid uterine contraction (e.g., oxytocinon, ergometrine and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures or arterial ligation). Interventional radiology can be used if placenta accreta is suspected. Cell salvage has been introduced into obstetrics relatively recently in an attempt to reduce allogeneic transfusion.Challenges of major obstetric haemorrhageArlene Wise, Vicki Clark10.1016/j.bpobgyn.2009.11.011Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-01-11Best Practice & Research Clinical Obstetrics & Gynaecology2010-01-11243S1521-6934(10)X0004-9353365http://www.bestpracticeobgyn.com/article/PIIS1521693409001461/abstract?rss=yesSerious and permanent neurologic complications in the obstetric population are rare. Most neurologic complications following childbirth are intrinsic obstetric palsies. The most common intrinsic obstetric palsy is lateral femoral neuropathy. Palsies of the femoral, obturator, sciatic, common peroneal nerves and lumbosacral plexus have also been reported. Meticulous technique during neuraxial anaesthesia will decrease the risk of injury secondary to neuraxial procedures. Direct trauma to the spinal cord and spinal nerves may occur during neuraxial anaesthesia. Sterile technique should be employed during neuraxial procedures and precautions should be taken to ensure that the proper drug/concentration is being injected. Postpartum complaints should be addressed promptly. For infection and space-occupying lesions of the neuraxial canal, prompt diagnosis and treatment are essential to prevent permanent injury or death. Survey studies have demonstrated that women want to be told of the risks of neuraxial procedures, even when the incidence is rare.Nerve injuries after neuraxial anaesthesia and their medicolegal implicationsCynthia A. Wong10.1016/j.bpobgyn.2009.11.008Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-31Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-31243S1521-6934(10)X0004-9367381http://www.bestpracticeobgyn.com/article/PIIS1521693410000441/abstract?rss=yesCardiopulmonary arrest occurs in 1: 30 000 pregnancies. Although rare, optimal outcomes are dependent on the cause of the arrest, the rapid response team’s understanding of the physiological effects of pregnancy on the resuscitative efforts and application of the latest principles of advanced cardiac life support (ACLS). Anaesthesia-related complications, secondary to difficult or failed intubation, and inability to oxygenate and ventilate can result in adverse outcomes for mother and baby. Experience in advanced airway management has been shown to decrease the incidence of brain death and maternal mortality. Awareness of lipid resuscitation of local anaesthetic toxicity is important. The effects of lipid resuscitation and its interference with ACLS medications are also important. Peri-mortem caesarean delivery of the foetus greater than 24 weeks’ gestational age must be considered. Caesarean delivery should be performed no later than 4min after initial maternal cardiac arrest. A foetus delivered within 5min has the best chance of survival. Delivery of the baby helps in the maternal resuscitation efforts and recovery of circulation. Finally, the 2003 International Liaison Committee on Resuscitation (ILCOR) and the 2005 American Heart Association (AHA) advocate the provision of mild therapeutic hypothermia to the survivors of cardiac arrest. This will improve the neurological outcomes by decreasing cerebral oxygen consumption, suppression of the radical reactions and reduction of intracellular acidosis and inhibition of excitatory neurotransmitters.Cardiopulmonary resuscitation and the parturientMaya S. Suresh, Chawla LaToya Mason, Uma Munnur10.1016/j.bpobgyn.2010.01.002Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-04-12Best Practice & Research Clinical Obstetrics & Gynaecology2010-04-12243S1521-6934(10)X0004-9383400http://www.bestpracticeobgyn.com/article/PIIS1521693409001436/abstract?rss=yesClose co-operation between obstetricians and obstetric anaesthesia providers is crucial for the safety and comfort of parturients, particularly in low-resource environments. Maternal and foetal mortality is unacceptably high, and the practice of obstetric anaesthesia has an important influence on outcome. Well-conducted national audits have identified the contributing factors to anaesthesia-related deaths. Spinal anaesthesia for caesarean section is the method of choice in the absence of contraindications, but is associated with significant morbidity and mortality. Minimum requirements for safe practice are adequate skills, anaesthesia monitors, disposables and drugs and relevant management protocols for each level of care. The importance of current outreach initiatives is emphasised, and educational resources and the available financial sources discussed. The difficulties of efficient procurement of equipment and drugs are outlined. Guiding principles for the practice of analgesia for labour, anaesthesia for caesarean section and the management of obstetric emergencies, where the anaesthetist also has a central role, are suggested.Obstetric anaesthesia in low-resource settingsRobert A. Dyer, Anthony R. Reed, Michael F. James10.1016/j.bpobgyn.2009.11.005Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2009-12-07Best Practice & Research Clinical Obstetrics & Gynaecology2009-12-07243S1521-6934(10)X0004-9401412http://www.bestpracticeobgyn.com/article/PIIS1521693409001527/abstract?rss=yesAfter briefly expounding the principles of an audit, this article focusses on the role of obstetric audit and how it can influence, and even shape, obstetric anaesthetic practice. The impact may be on service delivery, anaesthetic practice or the generation of new information. The relevance of maternal mortality reporting and of obstetric haemorrhage audit to anaesthetic practice is used to illustrate these concepts. Further examples include how different types of audit of pregnancy outcome, obstetric practice or areas of cross-interest to both obstetricians and anaesthetists are used by anaesthetists to evaluate health-care delivery, their own practices and to generate new audit and research agendas. Audits drive change and, hopefully, improvements that continue to make pregnancy a safer and more satisfying event for the mother and child.Obstetric audit and its implications for obstetric anaesthesiaMichael Paech, Aneeta Sinha10.1016/j.bpobgyn.2009.12.002Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-01-06Best Practice & Research Clinical Obstetrics & Gynaecology2010-01-06243S1521-6934(10)X0004-9413425http://www.bestpracticeobgyn.com/article/PIIS1521693410000696/abstract?rss=yesIndex10.1016/S1521-6934(10)00069-6Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Obstetrics & Gynaecology2010-06-01243S1521-6934(10)X0004-9I1I1http://www.bestpracticeobgyn.com/article/PIIS152169341000057X/abstract?rss=yes Regarding regional anaesthesia the following is/are true?Obstetric Analgesia and Anaesthesia Multiple Choice Questions for Vol. 24, No. 310.1016/j.bpobgyn.2010.04.006Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-05-10Best Practice & Research Clinical Obstetrics & Gynaecology2010-05-10243S1521-6934(10)X0004-9FrontmatterA1A5http://www.bestpracticeobgyn.com/article/PIIS1521693410000581/abstract?rss=yes1.(a) F(b) T(c) F(d) F(e) F The ASRA (American society of regional anesthesia) suggests that 12hours should have elapsed before an epidural is sited following prophylactic LMWH. 24hours should have elapsed before an epidural is sited after a therapeutic dose of LMWH. There is no evidence that a regional block is contraindicated in HIV patients for this indication alone. Many units use a platelet count between 70 and 80 as a cut off for regional anaesthesia if the patient has no other coagulation problems. This is not really evidence based and a bleeding time in this instance does not help with clinical decision making.Adolescent and Paediatric Gynaecology Answers to Multiple Choice Questions for Vol. 24, No. 210.1016/j.bpobgyn.2010.04.007Best Practice & Research Clinical Obstetrics & Gynaecology 24, 3 (2010)2010-05-10Best Practice & Research Clinical Obstetrics & Gynaecology2010-05-10243S1521-6934(10)X0004-9FrontmatterA7A13