The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique.

OBJECTIVE: To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery. TECHNIQUE: Local anaesthetic (20 ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall. STUDY DESIGN: We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n=51) or the surgical rectus sheath block (n=47) for post-operative pain relief. MAIN OUTCOME MEASURES: (1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay. RESULTS: The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0-1) vs. 2 (1-3), p<0.001], required less morphine post-operatively [12 mg (9-26) vs. 36 mg (30-48), p<0.001], had their PCAs discontinued earlier [24h (18-34) vs. 37 h (28-48), p<0.001] and went home earlier [4 days (3-4) vs. 5 days post-op (4-8), p<0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound. CONCLUSIONS: The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further.

Twin trisomies-Edward and Patau syndromes.

OBJECTIVE: To report the rare occurrence of dichorionic diamniotic twins with dissimilar aneuploidies. DESIGN: Case report. SETTING: District general hospital. PATIENT(S): A 36-year-old woman conceived by in vitro fertilization. Dichorionic diamniotic twins were found to have elevated nuchal translucencies and cystic hygromas. Intrauterine deaths occurred at 13 and 17 weeks gestation. INTERVENTION(S): Medical termination of pregnancy. MAIN OUTCOME MEASURE(S): Karyotypes. RESULT(S): Cytogenetic studies confirmed Edward's and Patau's syndromes. CONCLUSION(S): The aetiology is unknown but maternal age and in vitro fertilization may be linked since the incidence of aneuploidy rises with maternal age and the incidence of twins' increases with assisted reproductive techniques. This case highlights the need for obstetricians to have good communication and counselling skills.

Obstetric care of Jehovah's Witnesses: a 14-year observational study.

Over a 14-year period, the obstetric outcome of Jehovah's Witnesses in an inner city hospital was reviewed and the effect of refusal of blood on morbidity and mortality evaluated. Ninety women had 116 deliveries and of these, 24% were delivered by caesarean section, 10% had instrumental deliveries and 66% were normal vaginal deliveries. Postpartum haemorrhage of >1,000 mls occurred in 6% and postpartum anaemia was the commonest complication. The mean postdelivery haemoglobin (11.10 +/- 1.15 g/dl) was not significantly less from the mean predelivery haemoglobin level (11.81 +/- 1.62 g/dl) (P > 0.05, paired t test). The single maternal death occurred after caesarean hysterectomy, which when extrapolated, resulted in a 65-fold increased risk of maternal death compared to the national rate. The optimum management of pregnant women who decline transfusion is discussed.

Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population.

The aim of this study was to determine the demographics, indication and complications of emergency postpartum hysterectomy in a multiethnic high-risk obstetric population and to assess if there is a change in trend between 1983 and 2003. Eighteen women underwent postpartum hysterectomies in the 20 year period (prevalence 0.028%) and there were two maternal deaths. Overall, 77% of the postpartum hysterectomies were performed for intractable haemorrhage following caesarean section (CS). There is a statistically significant threefold increase (Mann-Whitney test, p=0.007) in the prevalence of emergency postpartum hysterectomies between 1994 and 2003 as compared to the previous 10 years between 1983 and 1993 despite the introduction of new pharmacological agents and conservative surgical techniques. Subtotal abdominal hysterectomy appears to be the procedure of choice in the more recent 10 years (60% of cases between 1994 and 2003 compared to 25% of cases between 1983 and 1993). Previous Caesarean section, advancing maternal age, abnormal placentation (including placenta praevia) appear to be risk factors for postpartum hysterectomy. Women of black African origin appear to be more at risk for hysterectomy compared to women of other ethinicity.