RESUMO
BACKGROUND: Superior Hypogastric nerve Block (SHNB) has been shown to be an effective pain management technique after Uterine Fibroid Embolization (UFE), reducing the need for opiates and allowing same-day discharge after UFE. In this technical note we discuss relevant anatomy and technical details in performing SHNB. MAIN BODY: The Superior hypogastric plexus (SHP) is the part of the abdominopelvic sympathetic nervous system that provides a targeted intervention to sympathetic-mediated pain pathways of pelvic organs and a target for an anterior approach Superior Hypogastric nerve Block after embolization. Vascular structures are in close relation to the intended site of target of the SHP at the L5 vertebral body include aortic bifurcation and IVC confluence, hence a detailed knowledge of this is essential. A step by step technical approach to SHNB includes patient positioning for the block, image guidance and needle positioning, choice and technique of anesthetic injection. Traversing a large fibroid uterus, inadvertent vascular opacification and Local anesthetic systemic toxicity present challenges to performing the block and are addressed. CONCLUSION: Superior Hypogastric nerve Block (SHNB) can be a useful tool in the Interventional armamentarium to make UFE a better experience for patients with fibroids, allowing for better pain control as well as facilitating same day discharge. Performing SHNB appear to be can be performed with technical ease for an interventional radiologist.
RESUMO
We compared perinatal outcomes in pregnancies in which insulin glargine was used in the management of patients with pregnancies in which standard insulin therapy was used at a single institution. A retrospective analysis of 114 pregnant patients with diabetes (pregestational or gestational) managed at a single center between January 2004 and August 2006 was undertaken. Sixty-five patients managed with insulin glargine were compared with 49 patients managed with neutral protamine Hagedorn (NPH) insulin. Both groups were also treated with short-acting insulin (either regular, lispro, or aspart insulin). Maternal age, parity, prepregnancy weight, body mass index, duration of diabetes, hemoglobin A (1C) (at entry and final recorded) and gestational age at entry were similar for each group (glargine and NPH). Thirty patients had gestational diabetes (18 glargine and 12 NPH); there were no differences in numbers of patients in higher-order White's classification between the two groups. Cesarean section for obstetric reasons included labor abnormalities, malpresentation, fetal distress, and suspected macrosomia. There were no differences in gestational age at delivery, birth weight, preeclampsia, or frequency of cesarean section (total or for obstetric reasons). The frequency of shoulder dystocia was higher in the NPH group. Regarding neonatal outcomes, gestational age at delivery, birth weight, Apgar scores, admission to the neonatal intensive care unit, respiratory distress syndrome, hypoglycemia, and congenital anomalies were similar between the two groups. From this retrospective analysis, no adverse maternal or neonatal effects were seen from maternal administration of insulin glargine. A larger multicenter study is needed to confirm these findings. This preliminary report suggests that use of insulin glargine during pregnancy can be considered if maternal metabolic control is suboptimal using the standard split-mix regimen.
