Clinical Service Line 09 - Maternity, Gynaecology & Fertility, Delivery Suite, Sexual Health

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    Central neuraxial blockade in an obstetric patient with subacute combined degeneration of the spinal cord
    (2023-05) House, K
    Introduction: Subacute combined degeneration of the spinal cord (SACD) is an acquired, reversable neurological condition with sensory, motor, psychological and haematological manifestations. Pathologically it is characterised by demyelination in the dorsal and lateral columns of the spinal cord which can be seen on MRI and is a result of vitamin B12 deficiency [1]. B12 is absorbed in the distal ileum with the aid of intrinsic factor and involved in the metabolic pathways responsible for maintaining myelin. The main causes are poor nutrition or absorption and drugs such as antacids and nitrous oxide. Case Report: A 28-year-old woman presented to the high-risk obstetric anaesthetic clinic in September 2022 with a history of SACD secondary to recreational nitrous oxide use. She was planning for a normal vaginal delivery. Her medical history was elicited. She had developed paraesthesia and weakness in her hands and feet in October 2021 which spread proximally and left her almost paralysed. She was found to have normal electromyography but low B12 levels, and a diagnosis of SACD was confirmed in December 2021. She was treated with vitamin B12 supplementation over several months and in June 2022 her B12 levels were in the normal range and MRI spine had no pathology evident. Her neurological symptoms improved over this time period to the point where, in clinic, she only had a remaining patch of numbness over her right thigh. After a review of the literature, which produced minimal evidence regarding safety of central neuraxial anaesthesia in this patient group (obstetric or otherwise), the risks and benefits of regional anaesthesia were discussed and agreed to be appropriate if required. The patient was admitted to the delivery suite several weeks later in spontaneous labour. She received a combined spinal epidural for labour, which was subsequently used for an emergency caesarean section. The patient was reviewed prior to discharge and appeared well with no deterioration in neurological function. She was then followed up over the next three months, in which time there was no development of neurological deficit. Discussion(s): There is no literature currently available that can guide decision making in this group of patients with regards to central neuraxial blockade. We hope that this case gives some evidence to its safety, although the question remains whether it would be appropriate in a patient that remained untreated and symptomatic at the time of delivery.
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    Three-Dimensional Volume Rendering of Pelvic Floor Anatomy with Focus on Fibroids in Relation to the Lower Urogenital Tract Based on Cross-Sectional MRI Images
    (2023) Fan, Ka Siu; Durnea, Constantin; Nygaard, Christiana Campani; Khalil, Miriam; Doumouchtsis, Stergios K.
    We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management.