Pre-SOAP 2005 Newsletter

37th Annual MeetingMay 4-7, 2005

Registration is still available throughApril 4, 2005 at www.soap.org.

JW Marriott Desert Springs Resort & SpaPalm Desert, California

JW Marriott DesertSprings Resort & Spa

Scientific ProgramWednesday, May 4, 20051:00 - 5:00 pm Workshop on Neonatal Resuscitation

Program (By Ticket Only - Limited Registration) Gurinder M. S. Vasdev, MD;Edwin H. Rho, MD; et al.

6:00 - 8:00 pm SOAP Opening Reception

Thursday, May 5, 20057:00 - 7:45 am Breakfast with Exhibitors; Posters7:45 - 8:00 am Opening Remarks and Welcome

M. Joanne Douglas, MD, FRCP;William R. Camann, MD;Mark I. Zakowski, MD

8:00 - 9:30 am Gertie Marx Symposium (6)Moderator: G. M. Bassell, MDJudges: Yaakov Beilin, MD;M. Joanne Douglas, MD, FRCP;Alan C. Santos, MD, MPH;Richard N. Wissler, MD, PhD

9:30 - 9:45 am Distinguished Service AwardAwarded to Frederick P. Zuspan, MDPresenter: M. Joanne Douglas, MD, FRCP

9:45 - 10:15 am Coffee with Exhibitors; Posters10:15 - 11:30 am Oral Presentations (4)

Moderator: Pamela Flood, MD11:30 - 12:30 pm Fred Hehre Lecture: Pain and Delivery –

Why, What, and WhenIntroduction: M. Joanne Douglas, MD, FRCPJames C. Eisenach, MD

12:30 - 1:30 pm Lunch with Exhibitors; Posters1:30 - 2:30 pm What’s New in Obstetrics?

Introduction: William R. Camann, MDErrol R. Norwitz, MD, PhD

2:30 - 3:30 pm Zuspan Award Symposium (4)Moderator: John Thomas, MDJudges: Joy L. Hawkins, MD; Ruth Landau, MD;Raymond Powrie, MD, FRCP(C), FACP;Gurinder M. S. Vasdev, MD

3:30 - 4:00 pm Coffee Break with Exhibitors; Posters4:00 - 6:00 pm SOAP Business Meeting – Awards

PresentationsModerator: M. Joanne Douglas, MD, FRCP

Friday, May 6, 20056:00 - 7:00 am Fun Run/Walk7:00 - 8:00 am Breakfast with Exhibitors; Posters8:00 - 9:00 am Oral Presentations (4)

Moderator: Felicity Plaat, MD9:00 - 10:00 am What’s New in Obstetric Medicine?

Introduction: William R. Camann, MDRaymond Powrie, MD, FRCP(C), FACP

Friday, May 6, 2005 (continued)10:00 - 10:30 am Coffee with Exhibitors; Posters10:30 - 11:30 am Poster Review #1

Moderator:Alison J. MacArthur, MD, MSc, FRCPC

11:30 - 1:00 pm Panel Discussion: International Aspects ofObstetric AnesthesiaModerator: William R. Camann, MDPanelists: Yasodananda Kumar Areti, MD;Jose Carvalho, MD, PhD, FRCPC;Medge D. Owen, MD; Giridhara Rao, MD

1:00 pm SOAP Golf and Tennis Activities

Saturday, May 7, 20057:00 - 8:00 am Breakfast with the Experts

Moderator:Donald H. Penning, MD, MSc, FRCPCExperts: Jose Carvalho, MD, PhD, FRCPC;Roshan Fernando, FRCA;Miriam Harnett, MB, FFARCSI;David L. Hepner, MD; Ruth Landau, MD;Kenneth E. Nelson, MD;Moeen K. Panni, MD, PhD;May Pian-Smith, MD, MS; John Sullivan, MD;Lawrence C. Tsen, MD; Bernard Wittels, MD;David J. Wlody, MD

8:15 - 9:15 am Gerard W. Ostheimer Lecture: What’s Newin OB Anesthesia? Introduction: Lawrence C. Tsen, MDBrenda A. Bucklin, MD

9:15 - 9:45 am Coffee Break; Posters9:45 - 10:45 am Poster Review #2

Moderator: Linda S. Polley, MD10:45 - 11:45 am PRO/CON Debate: Is Cell Salvage a Safe

Technique for the Obstetric Patient?Moderator: Bhavani S. Kodali, MDPro: Jonathan H. Waters, MDCon: Paula J. Santrach, MD

11:45 - 1:00 pm Lunch (On Your Own)1:00 - 2:00 pm Poster Case Reports: You did What? The

Best Case Reports of the Year!Moderator: Scott Segal, MD

2:00 - 3:30 pm Best Paper Presentations (6)Moderator: Geraldine O’Sullivan, MD, FRCAJudges: David C. Campbell, MD, MSc, FRCPC;Robert S. McKay, MD;Peter H. Pan, MD; Cynthia A. Wong, MD;Mark I. Zakowski, MD

3:30 - 3:45 pm Break3:45 - 5:00 pm Research Hour

Robert D’Angelo, MD; Steven Shafer, MD;Richard M. Smiley, MD, PhD

5:00 pm Meeting Adjourned6:00 - 11:00 pm SOAP Banquet

Society for Obstetric Anesthesia and Perinatology

www.soap.org

NewsletterNewsletter

Spring 22005

President’s Message

I trust with the bizarre winter weather allof us have been having [lots of snowand cold in the East (love the way theysay it comes down from "Canada") andtorrential rains in the Northwest ("thepineapple express" from Hawaii)] all ofyou are dreaming about the SOAPAnnual Meeting in Palm Desert wheresnow and rain are uncommon, if notrare events. Mark Zakowski and BillCamann have put together a terrificprogram in a terrific place so we arecounting on all of you to attend.

In this, my last Newsletter article asPresident, I would like to challenge youto consider ways in which you can helpSOAP grow. The MembershipCommittee (now chaired by SecondVice-President, Gary Vasdev) has severalnew ideas but you may want to speak tothose in your department who are notyet members and encourage them tojoin. In particular, growth is bestachieved when the seeds are sown early,so encourage your younger members(and especially fellows!) to considerjoining SOAP. For me, SOAP is a specialorganization where I can learn about the

advances in our subspecialty and can engage indebate about the best management of a specificproblem. This type of dialogue and interactionis invaluable in the practice of obstetricanesthesia. Also, consider how you can becomeinvolved in SOAP. The Board of Directorsrepresents you - at least that is our intent. Speakto one of us at the Annual Meeting or e-mail uswith your suggestions for changes to SOAP thatmay include suggestions for speakers for theannual meeting and/or content for the annualmeeting. For example, special competitions(Gertie Marx, Fred Zuspan, Best Paper of themeeting) and the special talks (e.g. What's New)are important aspects of the meeting and withthe present three day meeting it is impossible toincorporate more panel discussions or debates.Do you have a suggestion as to the format? Is itworking for you? Now is the time to considerthis before the planning committee for the 2006meeting meets in Palm Desert. Be involved!This is your Society!

Lastly, I want to thank all of you for yoursupport during my term as President. I want tothank the Board of Directors who willinglyundertook any task presented to them and havestraightened this Canadian out, when necessary.Bill Camann, in particular, has been a superbsounding board for me and will make anexcellent president. I know that you willsupport him as you have me as he assumes thereins of power in Palm Desert.

Welcome to Palm Desert . . . . . . .page 4

Treasurer’s Report . . . . . . . . . . . .page 4

Pro/Con . . . . . . . . . . . . . . . . . . . .page 5

Bylaw Changes . . . . . . . . . . . . . . .page 7

Research Committee . . . . . . . . . .page 8

Management of Accidental Dural Puncture . . . . . . . . . . . . . . .page 9

37th Annual Meeting Abstracts .page 11

INSIDE

M. Joanne Douglas, MD, FRCP

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Welcome to Palm Desert, CA

The upcoming SOAP 2005 annual meeting will be the best ever!

Beautifully situated among the hills and desert of Palm Desert(adjacent to Palm Springs), California, the wondrous Marriott Hoteloffers pools, a lake, golf courses, running courses, multiple restaurantsand shops as well as a world-class spa. Nearby attractions include theAerial Tramway to the top of the mountain with hiking in the nationalforest, a local Indian Casino, hiking in Indian Canyons, the LivingDesert Zoo and Gardens (great for kids), outlet malls, and upscaleshopping galore! For those of you who are interested in some specialentertainment on Thursday night you can sign up for the world famousPalm Springs Follies.

The program starts at 1:00 Wednesday, May 4th with our early-birdNeonatal resuscitation Program (limited registration). Our SOAPopening reception will be held at The Pointe, a fabulous outdoorpeninsula with the best view. We have an outstanding faculty therebybringing the best to the West. Dr. Frederick Zuspan will receive theDistinguished Service Award. Dr. James Eisenach will present the FredHehre Lecture, "Pain and Delivery - Why, What, and When." Dr. ErrolNorwitz will inform us with "What's New in Obstetrics?"

Friday, May 6th starts off with the Fun Run. Our colleague fromNASOM (North American Society of Obstetric Medicine), Dr.Raymond Powrie, presents "What's New in Obstetric Medicine?" Anew topic for SOAP, Dr. Bill Camann is moderating a panel discussion,"International Aspects of Obstetric Anesthesia." The SOAP Golf andTennis Activities are scheduled right after lunch. The afternoon andevening are free to do as you please and take advantage of what thedesert has to offer.

Saturday, May 7th begins with Breakfast With The Experts. Dr. BrendaBucklin is presenting the Ostheimer Lecture, "What's New in OBAnesthesia?" We have a Pro/Con debate, "Is Cell Salvage a SafeTechnique for the Obstetric Patient?" with Dr. Jonathan Waters PROand Dr. Paula Santrach CON. The SOAP banquet is in the evening -another wonderful affair, not to be missed! We have a specialmagician/comedian entertainer from the Magic Castle in Los Angelesand a band. Sign up today - space is limited!!!

I would like to thank Drs. Bill Camann and Joanne Douglas as well asthe IARS team (Pam Happ, Carol Wisniewski, and Jackie Dzurilla) andof course my assistant, Susie Sussman, for their help in making SOAP2005 a big success!!!

Mark Zakowski, MDMeeting Host, SOAP 2005

Treasurer’s Report

Treasurer's Report on the Financial ImpactCreated by a Change in Management Firms

As I promised in the Fall Newsletter, I would like to report briefly onthe impact that the change in management, from Ruggles to IARS, hashad on our bottom line. By now, most of you are aware that thechangeover occurred, with very few glitches, in November 2003. Manyof you attended the very successful 2004 annual meeting with IARS incharge. The staff came in six months before the meeting and made thetransition seem almost seamless. However, as the treasurer I watchedfor an expected positive impact on our bottom line, and I have notbeen disappointed.

When the requests for proposals were sent out to the competingmanagement firms, two line item accounts most concerned the Boardat the time. Those two items were the overall management fee and thecost of the website. Under the previous contract the management feewas a monthly base plus a percentage of the revenue from the annualmeeting. As a result, the total paid for financial year (FY) 2003 was$81,073. Our current contract with IARS pays a base fee whichincludes the management of the annual meeting. That base iscurrently set at $48,000 per annum, a savings of $33,073 over theprevious contract.

As for the website charges, those evolved over time to a base monthlyfee to cover so many hours of work. If more hours were spent thanpredetermined, the Society was charged an extra "per hour" rate.Alarmingly, the baseline hours were always being exceeded resulting in

our website charges increasing dramatically. For FY 2003, we werecharged $13,743, and that followed multiple renegotiations to decreasethe fee. Under our current contract with IARS, we were charged$3,503 for FY 2004 and most of the website expenses are nowincluded in the management fee. Extra is charged for redesign andother major projects but, even so, contractual fees will never allow theexpense of the website to grow like that again.

Less obviously, but with no less of an impact, were the charges leviedfor many items that are now fully or partially covered in the IARS basefee, such as phone use, postage, and site inspection. Additionally, theSociety was forced to absorb a business expense incurred due to a lackof oversight by Ruggles. Even with that factored in, the Society spent$21,390 less for this fiscal year as compared to the previous year. Thebottom line in all this is that SOAP's transition to IARS managementhas saved $54,463 in operating expenses!

Not included in the above is the impact that changing to IARS has hadon the annual meeting budget. Not everything with the transition hada positive effect on our bottom line but in taxes and hotel room creditsalone we saved over $10,000, and our total expenses were more than$73,000 under the budget set by the previous management.

This newsletter should reach you just before the May annual meeting.There, I will present a full report during the business meeting and willthen submit it for publication in the Fall Newsletter. Of course, givenwhat I have just written and added to it the generosity of Dr. Marx toSOAP, this is one report I will very much enjoy giving!

McCallum R. Hoyt, MD, MBATreasurer, SOAP

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Pro/ConShould anesthesiologists bill for epidural blood patchperformed after accidental dural puncture?

McCallum R. Hoyt, MD, MBAChair, Economic and Government Affairs Committee, SOAP

Medical Director, Perioperative ServicesCentral Maine Medical Center

Lewiston, ME

PRO

To bill or not to bill: that is the question: Whether 'tis nobler in themind to suffer the financial losses for one's misfortune, or to sendcharges for cures to patients' troubles, and by such action validate all?1

Conversations with SOAP members have led me to believe that inmany anesthesiology departments in the US there is an unwrittenpolicy that epidural blood patches (EBP) performed as a result of ourhaving punctured the dura shall not result in a charge to the patient.I can only ask "Why not?" Certainly with the significant incidence ofepidural "wet taps" and resulting symptoms, all who administer suchblocks warn their patients of the potential for this complication.Regardless of our precautionary information, we perform neuraxialblockade because our patients accept the risks. Then why don't wewant to charge for our time and resources when they ask us toperform an EBP to reverse the effects of the complication? Certainlyour time and skills have value to the patient since she is asking for ourassistance despite our informing her that the symptoms caused by awet tap are time-limited. The response to that point is generally,"Well, the patient is certainly not going to let the one who did the wettap perform her patch!", and that is generally a true statement. Shemay well consent only on the proviso that another anesthesiologistperform the procedure under the false sense that her risk is nowreduced. We all know that our performance of an EBP puts her onceagain at risk for another wet tap, of which I can only assume she wasinformed, yet she once again accepts the risk if she requests our help.So why aren't you charging?

Even before the report on medical mistakes from the NationalAcademy of Sciences' Institute of Medicine was released, it was easyto find articles in the medical literature reporting on adverse events,patient outcomes and costs. Our heightened awareness that theseevents result in untold millions in health-care costs led manyinstitutions to develop a quality improvement process to examinecausation. Over time it became apparent that many of the errorswere the result of an internal systems failure. This prompted changesin policy and the development of algorithms to direct patientmanagement.2-4 However, even in the most systems-savvy programs,there is now evidence that complication rates reach a threshold thatstays constant over time and which is probably due to a humanfactor.5 In other words, once all systematic and technical issues areaddressed what is left are the training and expertise of the physician.Certainly epidural punctures fall under this category. Although thereis a wide range of puncture rates reported in the literature and despite

technological re-designs, as long as there is a needle being pushed upagainst a dura, punctures will happen.

We have all seen or been involved in the management of patients whosuffered a complication and are now on our surgery schedule. Arecent example of mine was that of an elderly man who came to theOR for a cystoscopy and fulguration. He had suffered a traumaticfoley insertion at the hands of an aggressive resident and had beenbleeding for the past couple days. To be sure, I charged the patientfor my skill and time and the hospital did the same for the resourcesI used to provide anesthetic services to this patient. His course wasunfortunate but he had consented to the foley insertion. Never wasit suggested that the use of services and resources to address theconsequences of that complication should obligate any professionalor the hospital to provide free care for the remainder of his stay.

A variation on this theme is that of the patient who finds his/her wayto your institution to correct a complication suffered at another site.Under this scenario, and the thinking of "We weren't responsible,"there is no hesitancy to charge for resources and services used. Thisthought process also holds when we are asked to perform an EBP ona patient who suffers from a post-procedural headache following amyelogram or diagnostic spinal tap. "And that's the point. I didn'tcause the problem!" is the usual rebuttal statement made along withvarious hand signals as I am reminded that in this case the dural tapoccurred during that anesthesiologist's placement and so it followsthat he/she should not charge for the patch. Let's look at that in an-other light. There is inherent risk involved in any procedure. The factthat the risk assumed becomes a reality does not mean that somethingwas performed incorrectly or that there was an error in judgment. Weall know that even in the best of hands dural taps occur, and whenthey do, the occurrence does not imply incompetence on anyone'spart. Yet to not charge for the procedure requested may suggest justthe opposite to the patient. People expect to be charged for servicesrendered, so to not charge might suggest that something was doneincorrectly.

The next question asked usually falls along the lines of "But aren't Imore at risk for a lawsuit if I charge?" The ASA closed claimsdatabase does indeed show that lawsuits for headaches in the obstetricpopulation comprise 18% of the total. Besides the headaches, painduring anesthesia, back pain and emotional distress total a full 33% ofall obstetric claims; items that total only 6% in the non-obstetricdatabase. What all this means is that the obstetric population is moreprone to sue for what are categorized as "minor" injuries.6 But closerexamination of the statements accompanying these files shows thatpatients with these types of claims felt ignored, mistreated, orbelieved they were not getting their needs met, and that suggests thereal motivation for the suit.7 Nowhere is the suggestion made thatcharging for appropriate management to address a complicationprecipitated the lawsuit.

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Continued on page 6

PRO

Continued from page 5

If after all this, you are not swayed by my arguments, then let meleave you with one more thought. If you are going to insist on notcharging for your services, then make it the labor epidural you don'tcharge for since that is where the complication occurred. But by allmeans, charge for the patch you administered to relieve hersymptoms!

ReferencesWith apologies to W. Shakespeare. From Hamlet 3:1.Bates DW, Spell N, Cullen DJ, et al. The Costs of Adverse DrugEvents in Hospitalized Patients. JAMA. 1997;277:307-311.Morris JA, Carrillo Y, Jenkins JM, et al. Surgical Adverse Events,Risk Management, and Malpractice Outcome: Morbidity andMortality Review is not Enough. Ann of Surg. 2003;237:844-852.Feldman SE and Roblin DW. Medical Accidents in Hospital Care:Applications of Failure Analysis to Hospital Quality Appraisal. JQual Improvement. 1997;23:567-580.Hoyt DB, Coimbra R, Potenza B, et al. A Twelve-Year Analysisof Disease and Provider complications on an Organized Level ITrauma Service: As Good As It Gets? J Trauma. 2003;54:26-37.Ross BK. ASA Closed Claims in Obstetrics: Lessons Learned.Anesthesiology Clin N Am. 2003;21:183-197.Meyers AR. "Lumping It": The Hidden Denominator of theMedical Malpractice Crisis. Am J Public Health. 1987;77:1544-1548.

Bernard Wittels MD, PhDAssociate Professor

Director of Obstetric AnesthesiaDepartment of Anesthesia and Critical Care

University of ChicagoChicago, IL

CON

Anesthesiologists should perform epidural bloodpatches free of charge to parturients who havepostdural puncture headaches.

The clinical presentation of postdural puncture headache (PDPH) inthe puerperium is usually one of profound and incapacitatingsymptoms that an epidural blood patch can relieve instantly andusually permanently. The procedure is performed by ananesthesiologist, typically more than 24 hours after the dural puncture.Because some anesthesiologists perform the procedure at a separatetime from labor and delivery, they feel obliged to submit a bill for thisadditional service. I disagree and discuss my reasoning below.

First and foremost, patient safety is the primary concern. Initial andrecurrent PDPH left untreated over many weeks, can lead to subduralhematoma, altered levels of consciousness, coma, and death. Goodpatient rapport and proper communication can help ensure thatpatients seek treatment expeditiously, whereas additional costs and fees

may dissuade some patients from seeking further care, predisposingthem to develop more serious complications.

Second, unhappy, dissatisfied, and litigious patients have wonsettlements against anesthesiologists for developing PDPH. What canbe done to reduce the risk of litigation? Fully informed consent forthe initial epidural anesthetic for labor and delivery should includediscussing the risks of PDPH, its treatment, and related costs, if any.The same intrinsic patient characteristics (morbid obesity, non-palpable posterior spinous processes, and poor patient cooperation)that may have contributed to the initial dural puncture may still bepresent at the time of epidural blood patch, so the risk of performinga second accidental dural puncture also exists. To the disgruntledparturient who undergoes these procedures, even the simplest misstep(including receiving a bill for an epidural blood patch that isunexpected, unwanted, and unpayable) can trigger a quick phone callto an attorney, and a chronic headache for the anesthesiologist.

Third, federal government regulations currently utilize CPT codes thattend to bundle under one code all related obstetric anesthesia careduring labor and delivery; unplanned cesarean delivery and cesareanhysterectomy can be billed using second codes. Although one mayunearth a distinct CPT code for an epidural injection, federal agenciesmay view the addition as double-billing for a procedure that should beincluded in the initial, total OB anesthesia care CPT code. The federalgovernment considers double-billing fraudulent, a felony punishableby both fines and imprisonment. Is that potential additionalreimbursement from an epidural blood patch bill really worth the risk?I think not.

Fourth, consider competing business models in two hospitals: hospitalA performs epidural blood patches at no cost to those parturients whorequire them; hospital B charges an additional fee for all epidural bloodpatches. In the long term, hospital A will attract more parturients, fillmore beds, and be more financially sound, while hospital B will accruemore lawsuits, pay more legal settlements and attorney fees, and suffera declining patient census. One can only imagine what might happenif an administrator in hospital B makes demands of the labor anddelivery unit to generate more fees.

Finally, the ethical practice of medicine demands that care be providedwithout regard for the patient's ability to pay. In this way, every patientreceives fair, unbiased medical attention with the highest regard for thesafest and most effective medical, surgical and nursing treatments. Itis the responsibility of society (in the form of government agencies)to provide the financial support to patients in lower socioeconomicstrata, and (in the form of hospital organizations) to provide financialsupport to the doctors and nurses who care for these patients.

References:Cranial Subdural Haematoma after Spinal Anesthesia. Acharya R,Chhabra SS, Ratra M, and Sehgal AD; Br J Anaesth 86(6):893-5,2001.Subdural Hematoma Following Lumbar Puncture, Gaucher DJ Jr,Perez JA Jr, Arch Int Med 162(16):1904-5, 2002.Ethics: An Essential Dimension of Clinical Obstetric Anesthesia.Chervenak FA, McCullough LB, and Birnbach DL, Anesth Analg96:1480-5, 2003.

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Pro/ConKlaus Kjaer, MD

Assistant Professor of AnesthesiologyCo-Director, Obstetric Anesthesia

New York Presbyterian Weill Cornell Medical CenterNew York, NY

Ancillary Charges Associated With Epidural BloodPatch

When a post-partum patient requires an epidural blood patch for post-dural puncture headache, some anesthesiologists choose not to bill thepatient for the blood patch. However, the patient may still receive a billfor a series of other charges from the facility where the procedure isperformed. For inpatients, these may include:

-- A charge for readmission from the post-partum floor to the laborand delivery recovery room, which is where this procedure is oftenperformed. Readmission allows the patient to have a nursingassessment, including a set of vital signs, upon arrival. It also allowsthe patient to have continued nursing care while waiting for, orrecovering from, the blood patch. Nursing care may be required foranything from monitoring of vital signs (if the patient was sedated forthe blood patch) to assistance with pumping breast milk (whichsometimes just can't wait!).

-- An IV charge, if one is restarted.

For outpatients, an additional charge may include:

-- Registration for an outpatient admission to the labor and deliveryarea, so that documentation of the patient's evaluation and treatmentcan be generated and added to the patient's medical record. This isimportant for medicolegal reasons and quality assurance purposes.Moreover, in hospitals with electronic patient record systems, it istypically not possible to write notes and orders unless the patient isofficially admitted.

The sum of these ancillary charges will vary among facilities. Inaddition, coverage will vary from one third-party payer to the next.The bottom line is that most providers caring for a post-partum patientreceiving an epidural blood patch simply do not know what the cost tothe patient will be. The patient, of course, eventually finds out.

If you choose not to bill your post-partum patients for epidural bloodpatches, it makes sense to negotiate with your hospital to waive theancillary charges as well.

7

Proposed Bylaw Changes

New Text:4. INDEMNIFICATION OF DIRECTORS, OFFICERS, EMPLOYEESAND AGENTS

4.1 The Board shall indemnify its officers, directors, employees and agents tothe extent permitted by the General Corporation Law of the State ofCalifornia.

Existing Text: 5. MEMBERS OF THE BOARD OF DIRECTORS

5.5.1 Meeting Hosts: Serve on Board of Directors for a total of two years, theterm to end at the close of the Annual Business Meeting the year of theirMeeting.

Revised Text: 6. MEMBERS OF THE BOARD OF DIRECTORS

6.5.1 Meeting Hosts: Serve on Board of Directors for a total of three years,the term to end one year after the close of the Annual Business Meeting theyear of their Meeting.

Existing Text: 9. STANDING COMMITTEES This SOCIETY deems thefollowing committees essential to its mission.

9.6.1 GOVERNMENT AFFAIRS COMMITTEE Chair: appointed to a three year term, beginning in 1996, by President withapproval of the Board of Directors. Members: as appointed

9.6.2 Duties: to foster communication among this SOCIETY and others ofsimilar or related activities and goals.Revised Text: 10. STANDING COMMITTEES This SOCIETY deems thefollowing committees essential to its mission.

10.6.1 ECONOMIC AND GOVERNMENT AFFAIRS COMMITTEEChair: appointed to a three year term, beginning in 1996, by President withapproval of the Board of Directors. Members: as appointed

10.6.2 Duties: To monitor and communicate legislative and regulatory issuesand to review and communicate economic issues as they pertain to themembership of this SOCIETY and the practice of obstetric anesthesia.

New Text:10.9.1 INTERNATIONAL OUTREACH COMMITTEE

Chair: appointed to a three year term, beginning in 2005, by President withapproval of the Board of Directors. Members: as appointed

10.9.2 Duties: to promote obstetrical anesthesia education to less developednations through logistical support, to provide advice to the BOD regardingpossible financial support for these endeavors.

13. These Bylaws were revised in January 2005. If approved andaccepted at the Annual Business Meeting of the SOCIETY FOROBSTETRIC ANESTHESIA AND PERINATOLOGY on May 5,2005 they will take effect, replacing all previous Bylaws, on May 5,2005.

Proposed bylaw changes to be voted on at the annual businessmeeting on, Thursday, May 5.

The Research Committee of SOAP presents this column in an effortto assist members in conducting and evaluating research, stimulatingideas and conversations, and expanding the scope of obstetricanesthesia. If you have ideas, suggestions, or questions for futuretopics, please write, phone, fax, or E-mail me:

Philip Hess, MD Coordinator, SOAP Research Column Dept. of AnesthesiologyBeth Israel Deaconess Medical Center330 Brookline Ave. East Campus/St-308Boston, MA 02215Phone: (617) 667-3112 or Fax: (617) 667-7849 E-mail: phess@bidmc.harvard.edu

Pharmacogenetics Applied to Obstetric Anesthesia:Myth or Reality?

Over this last decade, there has been an explosion of scientificpublications in the field of pharmacogenetics, the study of thevariability in drug response due to genetic variability, and more recentlyin pharmacogenomics, which incorporates recently acquiredsophisticated genomic tests and a genome wide approach to define theinherited nature of drug response.1 Does all this tremendous worktranslate into anything tangible and applicable for OBanesthesiologists?

Undoubtedly, the knowledge and technology acquired during thesepast years through the Human Genome Project should contribute toprevent genetically determined diseases, and promote "targetedpersonalized medicine." The ultimate goal of pharmacogeneticsresearch is to help doctors tailor doses of medicines to a person'sunique genetic make-up (http://www.PharmGKb.org, thePharmacogenetics Research Network). This paradigm shift shouldmake medicines safer and more effective for everyone.

Clinically relevant polymorphismsFor anesthesiologists, numerous drugs used in our daily practice maydisplay important inter-individual variability in their effects due togenetic polymorphisms. Single nucleotide polymorphisms (SNP's) arenaturally occurring variants in the structure of genes that may have asignificant influence on therapeutically important drugs. Furthermore,marked ethnic differences in frequency of numerous genetic variantsmay in part explain interethnic differences in drug responses anddisease severities. An exhaustive catalogue of all alterations in efficacyand toxicity profiles is beyond the scope of this column, but thefollowing examples may serve to illustrate the impact ofpharmacogenetics on OB clinical anesthesia and pain therapies.

Adrenergic receptorsAs part of the autonomic nervous system, adrenergic receptorsparticipate in regulation of numerous features paramount for theanesthesiologist, such as heart rate, blood pressure and vascularreactivity, bronchial tone, uterine tone, and nociception, among others.

The ß1 adrenergic receptor (ß1-AR)The ß1-AR mediates chronotropic and inotropic responses tocatecholamines. The Arg389 variant of a common polymorphism,

Arg389Gly, has been shown in vitro to have a greater response toagonist stimulation. Reduced sensitivity of individuals with the Gly389allele to atenolol was determined in clinical trials.2 Furthermore, theGly389 allele was found to be more frequent in populations of Africandescent (42%) compared with white subjects (28%) and maycontribute to the known decreased sensitivity to ß-blockade reportedin black subjects.

The ß2 adrenergic receptor (ß2-AR)The ß2-AR is expressed at the surface of numerous cells, such assmooth muscles cells (bronchial, uterine, vascular, etc.) with arelaxation of cells in response to endogenous catecholamines andsynthetic ß2-agonists. Several SNP's have been identified on ß2-AR,with three SNP's (Arg16Gly, Gln27Glu, Thr164Ile) specificallyassociated with interesting phenotypes.3 It has been determined in vitrothat the Gly variant increases receptor down-regulation, while thepresence of the mutant Glu27 appears to decrease receptor down-regulation, hence preventing tachyphylaxis.4 Consistent with this,asthmatic subjects homozygous for Arg16 have been found to have anenhanced response to ß2-agonist bronchodilators.5

The Arg16 genotype might have a protective effect in women at riskfor preterm delivery.6 Furthermore, it is most likely that the responseto ß2-agonist therapy for tocolysis is influenced by the genetic profileof women presenting with preterm labor. It remains to be determinedwhether ß2-AR genotype influences the severity of the disease (i.e.,that Arg16 homozygote women present with a milder disease thanwomen with other genotypes) or directly affects the response totherapy.

Opioids Inter-individual variability in pain perception and sensitivity toanalgesic therapy has been long noted. Although opioids are amongthe most widely used drugs for the management of acute and chronicpain, they display large interindividual variability in efficacy, sideeffects, and tolerance profiles.

µ-opioid receptor (m-OR)The µ-opioid receptor (µ-OR), encoded by genetic locus OPRM1, hasbeen the focus of numerous genetic studies because this receptor is theprimary site of action for many endogenous opioid peptides andopioid analgesics. In vitro, the A118G polymorphism appears toincrease the binding affinity and potency of ß-endorphin.7 Therefore,individuals carrying the variant receptor gene may show differences insome of the functions mediated by ß-endorphin action at the alteredµ-OR.

Ethnic variability has been shown to be important, with 22% ofsubjects carrying at least one G118 allele regardless of gender amongwhite subjects. In Asians, the frequency of the G118 variant is muchhigher, ranging between 35 and to 47%.8 Interestingly, in an African-American population, the variant was found to be much rarer than inall other ethnic groups.9 A relatively high frequency of the A118Gvariant was shown to occur in a diverse obstetric population from twodifferent institutions (in USA and Europe).10 The fact that a geneticvariant of the µ-OR associated with an increased response to

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Pharmacogenetics applied to Obstetric Anesthesia:Myth or Reality?

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ß-endorphin was present in more than 30% of an obstetric populationmight have clinical implications. Further studies to elucidate the impactof this genetic variant on labor pain and neuraxial opioid requirementsfor labor analgesia are ongoing.

Future applicationsTo date, the choice of one medication over another does not take intoaccount inter-individual genetic variability. It might well be that certaindrugs have the potential for serious side effects or are ineffective in acertain subset of the population. With the advances in technology, it islikely that each genetic subset of the population will be treated with aspecifically tailored drug to obtain the sought therapeutic effect.

In conclusion, while it is probably too premature to expect immediateimplications on the daily practice of anesthesiologists, it is most likelythat advances in the field of genomics will identify with greatercertainty which polymorphisms definitely impact on drug responses.

References(1) Nature 2004; 429: 464-8. (2) Clin Pharmacol Ther 2003; 73: 366-71.(3) N Engl J Med 2002; 346: 536-8. (4) Biochemistry 1994; 33: 9414-9.(5) Clin Pharmacol Ther 1999; 65: 519-25. (6) Am J Obstet Gynecol2002; 187: 1294-8. (7) Proc Natl Acad Sci U S A 1998; 95: 9608-13. (8)Neuroreport 2003; 14: 569-72. (9) Psychiatr Genet 2003; 13: 169-73.(10) Anesthesiology 2004; 100: 1030-3.

Ruth Landau, MDChef de Clinique ScientifiqueService d'AnesthesiologieHôpitaux Universitaires de GenèveGeneva, Switzerlandruth.landau@hcuge.ch

Visiting Assistant ProfessorObstetric AnesthesiaColumbia University Medical CenterNew York, New Yorkrl262@columbia.edu

Review

Management of Accidental Dural Puncture and Subsequent Headache

Stephanie Goodman, MDDepartment of Anesthesia

Columbia Presbyterian Medical CenterNew York, NY

While the overall incidence of postdural puncture headache (PDPH)remains between 1 and 5% after neuraxial anesthesia1, the incidenceapproaches 80% when accidental dural puncture occurs with anepidural needle2. If a laboring woman experiences accidental duralpuncture with an epidural needle, many anesthesiologists advocategiving a small spinal dose of medication (for example 2.5mgbupivacaine with 20mcg fentanyl) through the epidural needle toachieve immediate comfort in the face of a complication. Some ofthis dose will escape with the outflow of cerebrospinal fluid throughthe dural puncture and thus be ineffective; however, enough of themedication should enter the subarachnoid space to at least provideinitial analgesia.

At the time of dural puncture, there are then two options for providingcontinuing analgesia. The first and probably most common approachis to remove the epidural needle and replace it at a different interspace.One risk of this approach is causing a second dural puncture. Also, itmay be technically difficult, which may have been a contributing factorfor the initial dural puncture. With this strategy, all subsequent dosingmust be done carefully since the spread of drug may be increased dueto intrathecal passage through the dural tear.3 One major advantage ofreplacing the epidural catheter is that it can be used postpartum foradministration of a prophylactic epidural blood patch (EBP).Advocates of this approach believe that the prophylactic EBP isefficacious and spares the patient from experiencing a headache andthe need to undergo a second procedure.4 A recent study by Scavone,et al showed that prophylactic EBP did not decrease the incidence ofPDPH or the need for therapeutic EBP, but it did decrease theduration and severity of symptoms.5

Some anesthesiologists still replace an epidural catheter after accidentaldural puncture but do not feel that prophylactic EBP is indicated.They argue that prophylactic patches unnecessarily treat approximately20% of women who will not develop PDPH, and that this exposesthose patients to the risks of EBP, namely backache, radicular pain andinfection.6 Controversy remains regarding both the volume of bloodneeded for effective EBP and the timing of therapeutic EBP inrelation to dural puncture, but discussion of these topics is beyond thescope of this review.7 There are successful reports of the use ofepidural saline and dextran8 for prophylaxis and epidural dextran,colloid9, and fibrin glue10 for PDPH treatment, but the standardtreatment remains autologous blood11.

A second strategy at the time of accidental dural puncture is to placethe catheter through the needle into the intrathecal space. The biggestdisadvantage of this approach is the risk of inadvertentlyadministering an epidural dose intrathecally. Advantages of a spinal

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Management of Accidental Dural Puncture and Subsequent Headache

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catheter include the provision of rapid and predictable analgesia andanesthesia without risk of patchy blocks from an epidural evidence orlocal anesthetic toxicity from larger epidural doses.12 There is someevidence that administering intrathecal normal saline after anaccidental dural puncture has occurred may decrease the incidence ofPDPH and the need for EBP.13 There is also evidence that leaving anintrathecal catheter in place for 24 hours may reduce the incidence ofPDPH. Ayad, et al, found that only 6% of patients with intrathecalcatheters for 24 hours had PDPH compared to 91% who hadreplacement of the epidural catheter14.

When patients refuse EBP or if the procedure is contraindicated bycoagulopathy or sepsis, medications may play a role in the treatment ofPDPH. Caffeine, a cerebral vasoconstrictor, has been used to treatPDPH with some success.15 Sumatriptan, typically used for thetreatment of migraine, has been reported to decrease PDPHsymptoms as well.16 And while there are case reports ofadrenocorticotrophic hormone and its synthetic analogues beingefficacious in the treatment of PDPH17, a recent randomized trial didnot confirm its usefulness18.

ReferencesLambert DH, Hurley RJ, Hertwig L, Datta S: Role of needle gaugeand tip configuration in the production of lumbar punctureheadache. Reg Anesth 1997; 22: 66-72Stride PC, Cooper GM: Dural taps revisited. A 20-year survey fromBirmingham Maternity Hospital. Anaesthesia 1993; 48: 247-55Swenson JD, Wisniewski M, McJames S, Ashburn MA, Pace NL:The effect of prior dural puncture on cisternal cerebrospinal fluidmorphine concentrations in sheep after administration of lumbarepidural morphine. Anesth Analg 1996; 83: 523-5Trivedi NS, Eddi D, Shevde K: Headache prevention followingaccidental dural puncture in obstetric patients. J Clin Anesth 1993;5: 42-5Scavone BM, Wong CA, Sullivan JT, Yaghmour E, Sherwani SS,McCarthy RJ: Efficacy of a prophylactic epidural blood patch inpreventing post dural puncture headache in parturients afterinadvertent dural puncture. Anesthesiology 2004; 101: 1422-7Abouleish E, Vega S, Blendinger I, Tio TO: Long-term follow-upof epidural blood patch. Anesth Analg 1975; 54: 459-63Banks S, Paech M, Gurrin L: An audit of epidural blood patch afteraccidental dural puncture with a Tuohy needle in obstetric patients.Int J Obstet Anesth 2001; 10: 172-6Salvador L, Carrero E, Castillo J, Villalonga A, Nalda MA:Prevention of post dural puncture headache with epidural-administered dextran 40. Reg Anesth 1992; 17: 357-8Chiron B, Laffon M, Ferrandiere M, Pittet JF: Postdural punctureheadache in a parturient with sickle cell disease: use of an epiduralcolloid patch. Can J Anaesth 2003; 50: 812-4Crul BJ, Gerritse BM, van Dongen RT, Schoonderwaldt HC:Epidural fibrin glue injection stops persistent postdural punctureheadache. Anesthesiology 1999; 91: 576-7

Safa-Tisseront V, Thormann F, Malassine P, Henry M, Riou B,Coriat P, Seebacher J: Effectiveness of epidural blood patch in themanagement of post-dural puncture headache. Anesthesiology2001; 95: 334-9Rutter SV, Shields F, Broadbent CR, Popat M, Russell R:Management of accidental dural puncture in labour withintrathecal catheters: an analysis of 10 years' experience. Int JObstet Anesth 2001; 10: 177-81Charsley MM, Abram SE: The injection of intrathecal normalsaline reduces the severity of postdural puncture headache. RegAnesth Pain Med 2001; 26: 301-5Ayad S, Demian Y, Narouze SN, Tetzlaff JE: Subarachnoidcatheter placement after wet tap for analgesia in labor: influenceon the risk of headache in obstetric patients. Reg Anesth Pain Med2003; 28: 512-5Camann WR, Murray RS, Mushlin PS, Lambert DH: Effects oforal caffeine on postdural puncture headache. A double-blind,placebo-controlled trial. Anesth Analg 1990; 70: 181-4Carp H, Singh PJ, Vadhera R, Jayaram A: Effects of the serotonin-receptor agonist sumatriptan on postdural puncture headache:report of six cases. Anesth Analg 1994; 79: 180-2Carter BL, Pasupuleti R: Use of intravenous cosyntropin in thetreatment of postdural puncture headache. Anesthesiology 2000;92: 272-4Rucklidge MW, Yentis SM, Paech MJ: Synacthen Depot for thetreatment of postdural puncture headache. Anaesthesia 2004; 59:1.

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Offered to SOAP Members in good standing.Mailing list for research use only.The research survey must be IRB approved at the primaryinvestigator's institution.The survey and IRB approval letter must be submitted to theSOAP Headquarters.The survey will then be reviewed by the SOAP ResearchCommittee.A fee of $100 will be charged for this one-time distribution/useof pre-printed mailing labels. Requests for mailing labels forfollow-up surveys will be handled on a case-by-case basis. (Note:No email addresses will be provided.)

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SOAP A1THE EFFECT OF SERIAL IN-VITROHEMODILUTION WITH MATERNAL CSFON TEG BLOOD COAGULATIONPARAMETERS - IMPLICATIONS FOREPIDURAL BLOOD PATCH

SOAP A2EXPRESSION OF CALCITONIN GENE-RELATED PEPTIDE (CGRP) ANDSOMATOSTATIN (SST) IN NEURONSINNERVATING THE UTERINE CERVIX

SOAP A3PREVENTION OF HYPOTENSIONFOLLOWING SPINAL ANESTHESIA FORCESAREAN SECTION USINGNONINVASIVE TRANSTHORACICELECTRICAL IMPEDANCECARDIOGRAPHY

SOAP A4PROSTAGLANDIN E2 RECEPTORSREGULATE ENDOTHELIAL NITRICOXIDE SYNTHASE EXPRESSION:CLINICAL IMPLICATION INMODULATION OF UTERINE TONE FORHUMAN PREGNANCY

SOAP A5MATERNAL CARDIAC OUTPUT CHANGESOCCURRING WITH PHENYLEPHRINEAND EPHEDRINE INFUSIONS AFTERSPINAL ANESTHESIA FOR ELECTIVECESAREAN SECTION

SOAP A6COMPARISON OF VISUAL ANALOG PAINSCALE (VAPS) AND VERBAL NUMERICRATING SCALE (VNRS) FOR PAINASSESSMENT DURING LABORANALGESIA

SOAP A7OXYTOCIN REQUIREMENTS ATCESAREAN SECTION FOR FAILURE TOPROGRESS IN LABOR: A DOSE-FINDINGSTUDY

SOAP A8IS OBSTETRIC OUTCOME RELATED TOEPIDURAL ANALGESIA LOCALANESTHETIC CONCENTRATION?

SOAP A9EPIDURAL TOP-UP IN THE COMBINEDSPINAL EPIDURAL ANALGESIA HASTIME-LIMITED DIRECT SPINAL EFFECT

SOAP A10PREDICTORS OF PAIN AND ANALGESICUSE AFTER CESAREAN SECTION

SOAP A11THE EFFECT OF MATERNAL POSITIONON UMBILICAL DOPPLER VELOCIMETRYIN NORMAL TERM PREGNANCY

SOAP A12THE INFLUENCE OF MORBID OBESITYON THE INCIDENCE OF CESAREANDELIVERY

SOAP A13COMPLICATIONS OF EXTERIORIZEDVERSUS IN SITU UTERINE REPAIR ATCESAREAN SECTION UNDER SPINALANESTHESIA

SOAP A14IS THE INDIGENT POPULATION MOREAT RISK FOR EPIDURAL FEVER?

SOAP A15A COMPARATIVE STUDY OF LOW DOSESOF ISOBARIC OR HYPERBARICBUPIVACAINE FOR CSE ANESTHESIAFOR ELECTIVE CESAREAN SECTION

SOAP A16TIMED INTERMITTENT EPIDURALBOLUS COMPARED TO CONTINUOUSEPIDURAL INFUSION FOR THEMAINTENANCE OF LABOR ANALGESIA

SOAP A17VALDECOXIB FOR POSTOPERATIVEPAIN MANAGEMENT AFTER CESAREANSECTION: A RANDOMIZED, DOUBLE-BLINDED, PLACEBO-CONTROLLEDSTUDY

SOAP A18RISK TO DEVELOP CHRONIC PAINAFTER ELECTIVE CESAREAN DELIVERYIN YOUNG HEALTHY PARTURIENTS

SOAP A25A NOVEL, IN VITRO MODEL OFTOCOLYTIC DESENSITIZATION

SOAP A26ASP298 POLYMORPHISM OFENDOTHELIAL NITRIC OXIDESYNTHASE DOES NOT AFFECTRESPONSE TO TREATMENT OFHYPOTENSION DURING SPINALANESTHESIA FOR CESAREAN SECTION

SOAP A27MYOMETRIAL RELAXATION: THESODIUM CALCIUM EXCHANGERFUNCTION IN HUMAN MYOMETRIALMYOCYTES

SOAP A28EPIDURAL MORPHINE FOR POST-VAGINAL DELIVERY PERINEAL PAIN: ARANDOMIZED DOUBLE-BLIND TRIAL

SOAP A29MECONIUM ACCELERATES THEPROCOAGULOPATHIC EFFECTS OFAMNIOTIC FLUID

SOAP A30DOES INTERMITTENT EPIDURAL LABORANALGESIA PREVENT MATERNALINTRAPARTUM FEVER?

SOAP A31ASSESSING ADEQUACY OF DEPTH OFGENERAL ANESTHESIA USING THEPATIENT STATE INDEX (PSI) DURINGCESAREAN SECTION

SOAP A32REDUCING SUPERFICIAL BLEEDINGAND PAIN DURING EPIDURALCATHETER INSERTION

SOAP A33OBESE PARTURIENTS HAVE LOWEREPIDURAL LOCAL ANALGESICREQUIREMENTS

SOAP A34FOUR YEAR'S EXPERIENCE OFPERIPARTUM HYSTERECTOMIES AND90% AVERAGE C-SECTION RATE

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SOAP 2005 AbstractsGertie Marx Symposium

Thursday, May, 5, 8:00-9:30 amSOAP A1-A6

Oral Presentation #1Thursday, May 5, 10:15-11:30 am

SOAP A7-A10

Zuspan Award SymposiumThursday, May 5, 2:30-3:30 pm

SOAP A11-A14

Oral Presentation #2 Friday, May 6, 8:00-9:00 am

SOAP A15-A18

Poster Review #1Friday, May 6, 10:30-11:30 am

SOAP A25-60

SOAP A35CONVERSION OF EPIDURAL LABOURANALGESIA TO EPIDURAL SURGICALANESTHESIA FOR INTRAPARTUMCESAREAN DELIVERY

SOAP A36THE PROBABILITY OFSUPPLEMENTATION FOR PAIN DURINGLABOR EPIDURAL ANALGESIA:IMPLICATION FOR THE ETIOLOGY OFPAIN

SOAP A37THE RELATIONSHIP BETWEEN THEDEPTH FROM THE SKIN TO THEEPIDURAL SPACE AND BODY MASSINDEX IN PARTURIENTS

SOAP A38REVIEW OF TRAUMA IN PREGNANCY:THE CONSEQUENCES OF RISKBEHAVIORS

SOAP A39EFFICACY OF THE ADDITION OFINTRATHECAL FENTANYL TO SPINALANESTHESIA FOR UTERINEEXTERIORIZATION DURING ELECTIVECESAREAN DELIVERY

SOAP A40EPIDURAL ANALGESIA HAS AFAVORABLE EFFECT ON FUNIC BASEEXCESS COMPARED TO NO ANALGESIADURING LABOR

SOAP A41CURRENT STATE OF ACADEMIC OBANESTHESIA: WHAT EXPERIENCES AREANESTHESIOLOGY TRAINEESRECEIVING?

SOAP A42ETHNICITY CONTRIBUTES TODIFFERENCES IN PAIN PERCEPTIONDURING LABOR

SOAP A43EFFECTIVENESS OF LOCAL ANESTHETICTECHNIQUES IN IMPROVING POSTCESAREAN SECTION ANALGESIA - AQUALITATIVE SYSTEMATIC REVIEW

SOAP A44EFFECTS OF SUPPLEMENTAL OXYGENADMINISTRATION ON THE INCIDENCEOF NAUSEA/VOMITING DURINGREGIONAL ANESTHESIA FOR CESAREANDELIVERY

SOAP A45DOES FORCED AIR-WARMING REDUCEHYPOTHERMIA AND SHIVERING FORPATIENTS UNDERGOING CESAREANSECTION WITH SPINAL ANESTHESIA?

SOAP A46A SURVEY OF LABOR PATIENT-CONTROLLED EPIDURAL ANESTHESIAPRACTICE IN CALIFORNIAN HOSPITALS

SOAP A47RESUSCITATION OF PARTURIENTS: ACRITICAL KNOWLEDGE SURVEY AMONGPHYSICIANS

SOAP A48EVALUATION OF THE PLATELETFUNCTION ANALYZER (PFA-100®) VS.THE THROMBOELASTOGRAM (TEG) INTHE PARTURIENT

SOAP A49ADMISSION PATTERN AND OUTCOME OFPARTURIENTS TO INTENSIVE CARE

SOAP A50FETAL AND MATERNAL EFFECTS OFBOLUS OF PHENYLEPHRINE ORMETARAMINOL DURING SPINALANESTHESIA FOR CESAREAN DELIVERY

SOAP A51RISK FACTORS FOR TRANSFUSION INOBSTETRIC PATIENTS

SOAP A52THE EFFECT OF EPIDURAL ANESTHESIAWITH AND WITHOUT FENTANYL ONINFANT BREAST FEEDING: APROSPECTIVE, RANDOMIZED, DOUBLE-BLIND STUDY

SOAP A53THE EFFECT OF ADDING EPINEPHRINETO AN ULTRA-LOW DOSE EPIDURALSOLUTION AFTER COMBINED SPINALEPIDURAL ANALGESIA

SOAP A54PHARMACOKINETIC SIMULATION OFREMIFENTANIL FOR LABOR ANALGESIA

SOAP A55A COMPARISON OF ANALGESICREQUIREMENTS AND POSTOPERATIVERECOVERY: ELECTIVE VS. UNPLANNEDCESAREAN DELIVERY

SOAP A56CONTINUOUS SPINAL ANAESTHESIA INHIGH RISK PARTURIENTS UNDERGOINGELECTIVE CESARIAN SECTION: ANOBSERVATIONAL STUDY

SOAP A57A SYSTEMATIC REVIEW OF PREGNANCYOUTCOMES FOLLOWING BARIATRICSURGERY FOR MORBID OBESITY

SOAP A58A SURVEY OF SUBARACHNOID ANDINTRAVENOUS TEST-DOSE PRACTICES INEPIDURAL AND COMBINED SPINALEPIDURAL OBSTETRIC ANESTHESIA

SOAP A59TRAUMA IN PREGNANCY: DO LOCALFEATURES MAKE A DIFFERENCE?

SOAP A60MATERNAL AND FETALHAEMODYNAMICS DURING SPINALANAESTHESIA FOR CAESAREANSECTION USING PROPHYLACTICPHENYLEPHRINE

SOAP A61EFFECT OF 2-CHLOROPROCAINE ONBLOOD COAGULATION IN PREGNANCY

SOAP A62DOES PREMATURE RUPTURE OFMEMBRANES INCREASE THE NEED FORCESAREAN DELIVERY IN WOMEN WITHPRETERM RUPTURE OF MEMBRANESBETWEEN 24 AND 34 WEEKSGESTATION?

SOAP A63ASSESSING COMPETENCE IN NEURAXIALANESTHESIA PROCEDURES : ANAPPLICATION OF THE CUSUM METHOD

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Poster Review #1Friday, May 6, 10:30-11:30 am

SOAP A25-A60continued

Poster Review #2Saturday, May 7, 9:45 - 10:45 am

SOAP A61-A96

SOAP A64PREVENTION OF HYPOTENSIONFOLLOWING CSE ANESTHESIA FOR CSECTION: A COMPARATIVE STUDY OFSMALL DOSES OF HYPERBARIC ORISOBARIC BUPIVACAINE

SOAP A65MENISCUS CHANGE IN THE EPIDURALCATHETER AS A TEST CONFIRMINGCORRECT PLACEMENT

SOAP A66EXIT TO ECMO FOR A FETUS WITHPERICARDIAL TERATOMA AND SEVEREHYDROPS

SOAP A67COMBINED SPINAL AND EPIDURALANESTHESIA - INCIDENCE OF "DY-TAP"26-G GERTIE MARX NEEDLE

SOAP A68TRANSCUTANEOUS ACUPOINTELECTRICAL STIMULATION USING THERELIEFBAND® FOR THE PREVENTIONOF INTRAOPERATIVE ANDPOSTOPERATIVE NAUSEA ANDVOMITING IN WOMEN UNDERGOINGCESAREAN SECTION UNDER SPINALANESTHESIA

SOAP A69A RANDOMIZED CONTROLLED DOUBLE-BLIND TRIAL OF THE EFFICACY OFSUFENTANIL ADDITION TOROPIVACAINE EPIDURAL ANESTHESIAFOR CESAREAN SECTION

SOAP A70CHRONOBIOLOGY OF MOTOR BLOCKDURING LABOR

SOAP A71OPEN LABEL COMPARISON OF EPIDURALNEOSTIGMINE IN PARTURIENTSUNDERGOING ELECTIVE CESAREANSECTION

SOAP A72MASSIVE OBSTETRIC HAEMORRHAGE: ASURVEY OF OBSTETRIC UNITS IN THE UK

SOAP A73A COMPARISON OF TWO SITTINGPOSITIONS FOR PLACEMENT OF CSEANESTHESIA FOR CESAREAN DELIVERY

SOAP A74PRELIMINARY DEVELOPMENT OF THECHILDBIRTH PAIN BELIEFS SCALE

SOAP A75LOCAL ANESTHETICS AND OBSTETRICOUTCOME: BUPIVACAINE VS.ROPIVACAINE VS. BUPIVACAINE. APROSPECTIVE RANDOMIZED DOUBLEBLIND STUDY

SOAP A76EVALUATION OF A NEW LOSS OFRESISTANCE SYRINGE FOR EPIDURALPLACEMENT

SOAP A77DOES PREGNANCY LOWER GENERALANESTHETIC REQUIREMENTS?

SOAP A78THE EFFECTS OF MATERNAL OBESITYON THE SUCCESS OF EXTERNALCEPHALIC VERSION

SOAP A79ADDITION OF LIPOPHILIC OPIOIDS TOBUPIVICAINE-MORPHINE MIXTURE FORCESAREAN SECTION REDUCESINTRAOPERATIVE AND EARLYPOSTOPERATIVE PAIN

SOAP A80INITIATING AN OBSTETRIC ANESTHESIACOLLABORATION TO REDUCEMATERNAL AND NEONATAL MORTALITYAND MORBIDITY IN GHANA

SOAP A81A COMPARISON OF EPIDURALROPIVACAINE WITH LIDOCAINE FORCESAREAN SECTION (C/S)

SOAP A82IMPACT ON OBSTETRIC OUTCOMEOF THE INTRODUCTION OFPATIENT-CONTROLLED EPIDURALANALGESIA WITH BACKGROUNDINFUSION COMPARED WITHCONTINUOUS EPIDURAL INFUSIONTECHNIQUE

SOAP A83INADEQUATE EPIDURAL STUDY

SOAP A84TEACHING NEW ROBOTS OLDTRICKS FOR EPIDURAL PLACEMENTUSING A VIRTUAL REALITYSIMULATOR

SOAP A85WHAT IS THE APPROPRIATE BASALRATE FOR EXTREME LIGHT PCEAINFUSIONS FOR LABOR ANALGESIA?

SOAP A86THE EFFECT OF COMBINED SPINALEPIDURAL LABOR ANALGESIA ONFETAL OXYGEN SATURATION

SOAP A87HYPNOSIS FOR CHILDBIRTH: APATIENT SATISFACTIONQUESTIONNAIRE

SOAP A88EPIDURAL LEVOBUPIVACAINE FOREMERGENCY CESAREAN SECTION

SOAP A89OBSTETRIC HEMORRHAGE ANDMATERNAL MORTALITY:IMPROVEMENT IN OUTCOMETHROUGH SYSTEMATIC CHANGE

SOAP A90EPHEDRINE AND PHENYLEPHRINEIN SPINAL INDUCED HYPOTENSION :MYTH AND REALITY

SOAP A91INFLUENCES ON ANALGESICCHOICES FOR LABOR ANALGESIAAMONG FIRST TIME MOTHERS

SOAP A92POST DURAL PUNCTURE HEADACHE:EXPERIENCE FROM A WESTAFRICAN OBSTETRIC UNIT

SOAP A93COMBINED-SPINAL-EPIDURAL (CSE)ANESTHESIA FOR CESAREANSECTION: ARROW VERSUS B BRAUNEPIDURAL CATHETER

SOAP A94KYBELE: OBSTETRIC ANESTHESIAOUTREACH TO TURKEY 2004

SOAP A95CHANGE IN CERVICAL LENGTHWITH CERCLAGE PLACEMENT

SOAP A96DO IT YOURSELF - EPIDURAL MODEL

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Poster Review #2Saturday, May 7, 9:45 - 10:45 am

SOAP A61-A96continued

SOAP A97CASE REPORT: EPIDURALHEMATOMA AFTER CATHETERREMOVAL IN A PARTURIENTWITHOUT IDENTIFIABLE RISKFACTORS

SOAP A98EFFICACY OF FACTOR VIIADMINISTRATION IN PARTURIENTWITH FACTOR VII DEFICIENCY

SOAP A99MANAGEMENT OF A PARTURIENT INLABOR WITH AN INTRATHORACICTUMOR

SOAP A100AWAKE CRANIOTOMY FOLLOWED BYCESAREAN DELIVERY FOR A CASE OFRECURRENT BREAST CANCER WITHBRAIN METASTASIS DURING 27TH WEEKGESTATION

SOAP A101SUCCESSFUL LABOR EPIDURALANALGESIA IN A PATIENT WITHSPINOCEREBELLAR ATAXIA

SOAP A102POSTURAL HEADACHE AFTER CSE: WHATELSE COULD IT BE?

SOAP A103ANESTHETIC MANAGEMENT OF TWOMALIGNANT HYPERTHERMIASUSCEPTIBLE PARTURIENTS REQUIRINGCESAREAN SECTION ON THE SAME DAY

SOAP A104PANCREATITIS AS A RARECOMPLICATION OF PRE-ECLAMPSIA

SOAP A105ANESTHESIA FOR CESAREAN SECTIONIN A PATIENT WITH DYSTONIA ANDIMPLANTED DEEP BRAIN STEMELECTRODE

SOAP A106ANESTHETIC MANAGEMENT OF APARTURIENT WITH POSTERIOR FOSSATUMOR FOR CESAREAN SECTION

SOAP A107ANESTHETIC MANAGEMENT OF A T4-T5PARAPLEGIC PARTURIENT WITH MASSMOTOR REFLEX INTERFERING WITHRESPIRATORY FUNCTION ANDAUTONOMIC HYPERREFLEXIA

SOAP A108ANESTHETIC MANAGEMENT OF A 19YEAR OLD PARTURIENT WITH MAPLESYRUP URINE DISEASE

SOAP A109COMBINED SPINAL EPIDURAL FORCAESAREAN SECTION IN A PATIENTWITH LONG QT SYNDROME AND ANAUTOMATIC IMPLANTABLE CARDIACDEFIBRILLATOR

SOAP A110ANESTHETIC MANAGEMENT FORCESAREAN SECTION IN A PARTURIENTWITH MYOTONIA CONGENITA

SOAP A111TARGET CONTROLLED INFUSION OFPROPOFOL PLUS REMIFENTANIL FORHELLP PATIENTS: ANOTHER TOOL FORTHEIR MANAGEMENT

SOAP A112 CEREBRAL HEMORRHAGE AND DEATHIN AN ECLAMPTIC PARTURIENT

SOAP A113ARRHYTHMOGENIC RIGHTVENTRICULAR DYSPLASIA IN LABOUR:IMPLICATIONS FOR ANAESTHESIA

SOAP A114DIABETES INSIPIDUS AFTERPOSTPARTUM EMERGENTHYSTERECTOMY

SOAP A115ANESTHETIC MANAGEMENT OF APARTURIENT WITH STICKLERSYNDROME AFTER TWO PRIOR FETALDEATHS

SOAP A116PHAEOCHROMOCYTOMA IN TWINPREGNANCY

SOAP A117ANESTHETIC MANAGEMENT DURINGLABOR AND DELIVERY OF PARTURIENTSWITH FACTOR XI DEFICIENCY: A REPORTOF FOUR CASES

SOAP A118RIGHT VENTRICULAR TACHYCARDIA INTHE PARTURIENT: THREE CASES!

SOAP A119PNEUMOCEPHALUS COMPLICATINGLABOUR EPIDURAL ANALGESIA: SHOULDWE REALLY STILL BE USING AIR?

SOAP A120CONTINUOUS HEMODYNAMICMONITORING WITH LIDCOTM IN APARTURIENT WITH CONGENITAL HEARTDISEASE AND IDIOPATHIC RESTRICTIVECARDIOMYOPATHY UNDERGOINGCESARIAN DELIVERY

SOAP A121MATERNAL SPINA BIFIDA: NOT ACONTRAINDICATION TO VAGINALDELIVERY

SOAP A122A PARTURIENT WITHNEUROFIBROMATOSIS TYPE 2:ANESTHETIC AND OBSTETRICCONSIDERATIONS FOR DELIVERY

SOAP A123ANESTHETIC MANAGEMENT OF APREGNANT PATIENT WITH ANINCARCERATED, CONGENITAL,DIAPHRAGMATIC HERNIA

SOAP A124MOYAMOYA DISEASE IN A PARTURIENTUNDERGOING URGENT CESAREANSECTION

SOAP A125ANESTHETIC MANAGEMENT OF ACESAREAN SECTION IN A PARTURIENTWITH FAMILIAL MEDITERRANEANFEVER (FMF)

SOAP A126SUCCESSFUL MANAGEMENT OF A 30YEAR OLD PARTURIENT WITH AMNIOTICFLUID EMBOLUS AND ELEVATED SERUMTRYPTASE

SOAP A127BLURRED VISION AS A RESULT OF APOSITIVE EPIDURAL TEST DOSE

SOAP A128SUPRAVENTRICULAR TACHYCARDIA(SVT) COMPLICATING EMERGENCY C-SECTION

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Poster Case ReportsSaturday, May 7, 1:00 - 2:00 pm

SOAP A97-A151

SOAP A129LABOR ANALGESIA IN A PARTURIENTWITH MARFAN SYNDROME,COMPLICATED BY LUMBOSACRAL DURALECTASIA: A CASE REPORT

SOAP A130HEMIPLEGIA FOLLOWING CESAREANDELIVERY

SOAP A131ANESTHESIA AND CARDIOPULMONARYBYPASS FOR A PREGNANT PATIENT WITHMULTIPLE SCLEROSIS

SOAP A132FETAL KARYOTYPING FROM VAGINALPOOL FLUID IN A PREGNANCYCOMPLICATED BY SPONTANEOUSMEMBRANE RUPTURE

SOAP A133ANESTHETIC CONSIDERATIONS FORCESAREAN SECTION IN A PATIENT WITHSPONDYLOEPIPHYSEAL DYSPLASIACONGENITA: A CASE REPORT

SOAP A134HYPERTROPHIC CARDIOMYOPATHYCOMPLICATED BY PREGNANCY

SOAP A135NEURAXIAL LABOR ANALGESIA IN AMORBIDLY-OBESE PARTURIENT WITHEBSTEIN'S ANOMALY, WPW-SYNDROMEAND COPD

SOAP A136INADVERTENT EPIDURALADMINISTRATION OF MAGNESIUMSULFATE TO A PARTURIENT - 2 CASEREPORTS

SOAP A137NITROGLYCERIN FOR UTERINEINVERSION IN ABSENCE OF PLACENTALFRAGMENTS

SOAP A138METASTATIC NON-SMALL CELL LUNGCANCER IN PREGNANCY: A CASEREPORT

SOAP A139SACRAL CYST AND CHOICE OFANESTHESIA TECHNIQUE FORCESAREAN SECTION

SOAP A140A CASE REPORT: ANESTHETICMANAGEMENT OF A PARTURIENT WITHEISENMENGER'S SYNDROME

SOAP A141HOW DURABLE ARE THESE EPIDURALNEEDLES?

SOAP A142TWO EPIDURAL TECHNIQUE FOR APARTURIENT WITH PANCREATITIS

SOAP A143PERIPARTUM CARDIOMYOPATHY: ACOMMON CAUSE OF LATE MATERNALMORTALITY IN NORTH CAROLINA

SOAP A144PERIPARTUM MANAGEMENT OFFULMINANT COLITIS

SOAP A145VENTILATORY SUPPORT USING BIPAPDURING NEURAXIAL BLOCKADE INPATIENTS WITH SEVERE RESPIRATORYCOMPROMISE

SOAP A146ANESTHETIC MANAGEMENT OFELECTIVE CARDIOVERSION FOR APARTURIENT WITH ATRIALFIBBRILLATION

SOAP A147SEVERE CERVICAL RADICULAR PAINWITH LUMBAR EPIDURAL BOLUSINJECTION

SOAP A148MASSIVE INTRAOPERATIVEHEMORRHAGE DURING A D&CPROCEDURE

SOAP A149DIAGNOSTIC LUMBAR PUNCTURE IN THEPARTURIENT WITH HISTORY OFPREVIOUS POST-LUMBAR PUNCTUREHEADACHE

SOAP A150AMPHETAMINE USE IN THE PARTURIENT

SOAP A151RAPID ONSET OF PERIPARTUM DILATEDCARDIOMYOPATHY DURING ANELECTIVE REPEAT CESARIAN SECTION

SOAP A19BETA-2 ADRENOCEPTOR GENOTYPEAFFECTS TREATMENT RESPONSE TOHYPOTENSION AFTER SPINALANESTHESIA FOR CESAREAN SECTION

SOAP A20FOCAL ADHESION SIGNALINGCONTRIBUTES TO ERK ACTIVATION INMYOMETRIUM DURING LATEPREGNANCY

SOAP A21MATERNAL GENERAL ANESTHESIA (GA)PRODUCES GESTATIONAL-AGEDEPENDENT CHANGES IN FETALCEREBRAL OXYGENATION

SOAP A22RELIABILITY AND VALIDITY OF ASCORING SYSTEM USED TO MEASURERESIDENT PERFORMANCE DURING ANOBSTETRIC ANESTHETIC SCENARIO ONA HUMAN PATIENT SIMULATOR

SOAP A23POLYMORPHISM OF µ-OPIOID RECEPTOR(A118G) AFFECTS INTRATHECALFENTANYL ED50 FOR LABOR ANALGESIA

SOAP A24EFFICIENCY AND ACCURACY OF UP-DOWN VS. RANDOM ALLOCATION TODETERMINE ANALGESIC POTENCY ANDDOSE RESPONSE

15

Poster Case ReportsSaturday, May 7, 1:00-2:00 pm

SOAP A97-A151continued

Best Paper PresentationsSaturday, May 7, 2:00-3:30 pm

SOAP A19-A24

Society for Obstetric Anesthesia and Perinatology2004-2005 Board of Directors

PresidentM. Joanne Douglas, MD, FRCPVancouver, British ColumbiaCanada

TreasurerMcCallum R. Hoyt, MD, MBAGreene, ME

Meeting HHost 22005Mark I. Zakowski, MDLos Angeles, CA

President-EElectWilliam R. Camann, MDBoston, MA

SecretaryLawrence C. Tsen, MDBoston, MA

Meeting CCo-HHosts 22006David J. Birnbach, MD & Jose Carvalho, MDMiami, FL Toronto, ON,

Canada

First VVice PPresidentEditorDavid J. Wlody, MDNew York, NY

Immediate PPast PPresidentRichard N. Wissler, MD, PhDRochester, NY

Director aat LLargeDivina J. Santos, MDBriarcliff Manor, NY

Second VVice PPresidentGurinder M. S. Vasdev, MDRochester, MN

Chair, AASA CCommittee oon Obstetric AAnesthesiaDavid J. Birnbach, MDMiami, FL

Representative: AASA HHouse oof DDelegatesAndrew P. Harris, MD, MHSBaltimore, MD

ASA AAlternate DDelegateJoy L. Hawkins, MDDenver, CO

2 Summit Park Drive, Suite 140Cleveland, Ohio 44131