made. Eventually the needle was withdrawn, but the dis-tal 5 cm were missing. A plain X-ray revealed the man-gled needle fragment, off centre at the intended level(Fig. 1). Successful spinal anaesthesia was then per-formed by an experienced obstetric anaesthetist andcaesarean section was performed uneventfully.

The patient was informed of the broken needle after theoperation had been completed. Neurological examinationrevealed no untoward findings. She was reviewed by theduty spinal surgeon that evening, and a decision was madeto remove the needle fragment on an elective surgical listthe following week, by which time the initial discomfortof the first operation would have subsided. After 4 days,the patient was transferred to the spinal surgery unit for re-moval of needle under general anaesthesia. Intra-opera-tive findings confirmed that the deep fascia was intact.The broken needle was removed and the wound wasclosed in layers. The patient was discharged home the fol-lowing day. She was reviewed after four weeks when thewound had healed well. She had no residual symptoms.

The use of caesarean delivery in the developed worldhas risen steadily in the recent years, reaching 21% inthe UK in 2002,1 and 26% in this maternity unit in2003. Most of the growth in operative delivery has beenaccompanied by an increasing use of spinal anaesthesia,which became popular when fine-gauge atraumaticneedles became widely available.

All forms of anaesthesia are associated with morbid-ity. In a study involving 300 000 women over five years,the overall incidence of serious complications was1/4000. Most frequent was accidental dural puncture;other complications included convulsions, meningitis,epidural abscess and spinal cord infarction.3 Complica-tions may be related to the needle or catheter or to thedrug. Needle size and shape may influence the incidenceof paraesthesia, post dural puncture headache and othercomplications. It is suggested that the use of 27-gaugeneedles reduces the post dural puncture headache ratebut not the incidence of transient paraesthesiae.4 Partur-ients may wish to be informed of all possible complica-

tions associated with epidural analgesia, but most do notwant to know the incidence.5

There is no information in the literature about a pos-sible risk of breaking the needle during the performanceof regional anaesthesia. Fracture of a 27-gauge spinalneedle has occurred twice in more than 20 years in thismaternity unit, giving an incidence of approximately1:5000 spinal anaesthetics. Surgery was successful onboth occasions and there were no sequelae.

M. A. Abou-Shameh, MRCSEdClinical Fellow Trauma and Orthopaedics

E-mail: mshameh@yahoo.co.ukG. Lyons, MD FRCA

Consultant AnaesthetistA. Roa FRCS (Orth)

Consultant Spinal SurgeonS. Mushtaque MRCS

Clinical Fellow Trauma and OrthopaedicsSt James’s University Hospital, Leeds, UK

REFERENCES

1. Jenkins J G, Khan M M. Anaesthesia for caesarean section: a surveyin a UK region from 1992-2002. Anaesthesia 2003; 58: 1114–1115.

2. Khor L H, Jeskins G, Cooper G M. National obstetric anaestheticpractice in the UK 1997/1998. Anaesthesia 2000; 55: 1168–1172.

3. Palot M, Visseanex H, Botmans C, Pire J C. Epidemiology ofcomplications of obstetric epidural analgesia. Cah Anesthesiol1994; 42: 229–233.

4. Landau R, Ciliberto C F, Goodman S R, Kim-Lo S H, Smiley R M.Complications with 25-gauge and 27-gauge Whitacre needlesduring combined spinal-epidural analgesia in labor. Int J ObstetAnesth 2001; 10: 168–171.

5. Jackson A, Henry R, Avery N, Vandenkerkhof E, Milne B.Informed consent for labour epidurals: what labouring women wantto know. Can J Anaesth 2000; 47: 1068–1073.

doi:10.1016/j.ijoa.2005.12.001

UK obstetric recovery practice

I read with interest the recent survey of UK obstetricrecovery practice.1 The authors are to be commendedfor highlighting the deficiencies in practice in compari-son with published guidelines. However, I must disputetheir conclusion that only 1.5% of units have at leasttwo staff members present when there is a single patientin recovery. The form used to conduct the survey, whichwas reproduced in the appendix, does not provide anopportunity for respondents to record how many staffmembers are present in such circumstances. My ownpersonal experience is that in this small area at least,practice is not as poor as the authors� conclusionssuggest.

Bernard NormanMagill Department of Anaesthetics

Chelsea and Westminster Hospital, London, UKE-mail: b.norman@lineone.net

Fig. 1 Plain X-ray showing the presence of needle fragment in thepatient�s back.

Correspondence 179

REFERENCE

1. Walker E, Moore P. Obstetric recovery practice: a survey of UKobstetric anaesthetists. Int J Obstet Anesth 2005; 14: 193–199.

doi:10.1016/j.ijoa.2005.10.008

Isolated tinnitus following placement of anintrathecal catheter for accidental dural puncture

The use of an intrathecal catheter following inadvertentdural puncture has dramatically increased in the last fewyears.1 The results of a recent survey of UK practicesuggest that the most common reasons for this changein practice are to avoid another dural puncture and toallow immediate analgesia for labour. Over half therespondents believed that there was a reduction in inci-dence and/or severity of post dural puncture headache(PDPH).1 The available evidence for the role of an intra-thecal catheter in reducing PDPH is conflicting andthere are no comparative data on less common manifes-tations of cerebrospinal fluid (CSF) leak such as visualor auditory symptoms. Thus, I would like to report acase of isolated tinnitus associated with the use of anintrathecal catheter for accidental dural puncture in la-bour analgesia.

A 28-year-old, ASA I, primiparous woman with anuncomplicated pregnancy presented in labour. Duringattempted epidural insertion of a 16-gauge Tuohy nee-dle, there was an accidental dural puncture. An intrathe-cal catheter was placed and used effectively for labouranalgesia and vaginal delivery. As was the practice inthis maternity unit, the catheter was left in situ for24 h post partum with the aim of reducing the possibilityof PDPH. After removal of the catheter, there was noheadache but the patient developed bilateral postural tin-nitus, which was initially treated with increased oralfluid intake. The symptoms worsened over the next24 h and an epidural blood patch was performed onthe third day with complete relief of symptoms by thenext day.

Auditory symptoms are infrequently reported alongwith headache following dural puncture.2,3 The mecha-nism is related to intracranial hypotension caused byCSF loss that leads to a pressure imbalance and tractionon the vestibulocochlear nerve. The nerve is vulnerableas it crosses the posterior cranial fossa and enters the tightinternal acoustic meatus, and when affected can lead totinnitus and sometimes deafness.2–4 The incidence andtime course of tinnitus are not clearly related to PDPHseverity, though the principles of treatment are the samefor both.2–4 There are reports in the literature of delayedpresentation of post dural puncture auditory symptomsand a similar idiopathic picture called spontaneous intra-cranial hypotension attributed to CSF leakage from spinalmeningeal defects, both of which have been successfullytreated with epidural blood patch.4 To my knowledge

there are no other reports of isolated post dural puncturetinnitus associated with the use of an intrathecal catheter.

Radha RaviManchester, UK

E-mail: radhasravi@yahoo.co.uk

REFERENCES

1. Baraz R, Collis R E. The management of accidental dural punctureduring labour epidural analgesia: a survey of UK practice.Anaesthesia 2005; 60: 673–679.

2. Loo C C, Dahlgren G, Irestedt L. Neurological complications inobstetric regional anaesthesia. Int J Obstet Anesth 2000; 9: 99–124.

3. Wong A Y C, Irwin M G. Postdural puncture tinnitus. Br J Anaesth2003; 91: 762–763.

4. Narchi P, Veyrac P, Viale M. Long-term postdural punctureauditory symptoms: effective relief after epidural blood patch.Anesth Analg 1996; 82: 1303.

doi:10.1016/j.ijoa.2005.10.013

Prostaglandin F2a: French guidelines for uterineatony management

I thank Dr Shannon for his interest in our article.1 Thisgives us the opportunity to add some more informationon the use of i.v. prostaglandin F2a. Whereas post-par-tum hemorrhage (PPH) is a leading cause of maternalmortality in France,2 87% of deaths after PPH have beenjudged avoidable by an expert committee on maternalmortality during a study period from 1997 to 1999.2

The leading cause of PPH was uterine atony. Delayedtreatment with oxytocic drugs such as prostaglandinshas been noted by experts to be a contributing factorin maternal mortality.2

Sulprostone is a synthetic prostaglandin E2, derivedfrom dinoprostone with potent uterotonic action. Frenchguidelines for treatment of PPH recommend starting sul-prostone infusion without further delay if the first treat-ment (oxytocin, manual removal of the placenta,uterine, vaginal and cervical examinations) has beenunsuccessful in the first 30 min after delivery.3 InFrance, the use of sulprostone has been officially autho-rized to be given for this indication according to a stricti.v. infusion regime since 1986. Dosage is 500 lg in 50mL normal saline. The initial dose is 1.7 lg/min (10mL/h) and can be increased if necessary in steps of1.7 lg/min every 15 min not exceeding 8.5 lg/min(50 mL/h). The success of this treatment depends onits being started as soon as the initial treatment ofPPH fails.

The contraindications to this treatment include pros-taglandin allergy, hypertension, asthma, coronary arterydisease, cardiac failure, glaucoma, epilepsy, deep ve-nous thromboembolism and uncontrolled diabetes. Inthe presence of one of these contraindications, if post-partum haemorrhage is life-threatening, the benefit-risk

180 International Journal of Obstetric Anesthesia