General anaesthesia using remifentanil for caesarean section in parturients with critical aortic stenosis: a series of four cases.

Although heart disease is now the joint leading cause of maternal mortality in the UK, critical aortic stenosis is rarely encountered in parturients. Caesarean section is advisable in these patients to minimise the haemodynamic stress of labour and delivery. The use of an opioid-based general anaesthetic technique also helps to maintain cardiovascular stability. During a two-year period, four women with critical aortic stenosis requiring caesarean section presented to our institution. In all women, a rapid sequence induction of anaesthesia was performed using etomidate 0.1 to 0.2 mg.kg(-1), suxamethonium 1.5 mg.kg(-1) and remifentanil 2 to 4 micrograms.kg(-1). Anaesthesia was then maintained with isoflurane, nitrous oxide and a remifentanil infusion at 0.05 to 0.15 micrograms.kg(-1)min(-1). There was good haemodynamic stability throughout, except for a short period in one patient who became hypotensive after a significant post-partum haemorrhage secondary to uterine atony. All parturients were successfully extubated at the end of surgery and made excellent postoperative recoveries. Neonates were born in good condition with Apgar scores of 10, 9, 6 and 5 at 1 min and 10, 10, 10 and 10 at 5 min. We suggest that remifentanil is an ideal agent for parturients with severe aortic stenosis requiring general anaesthesia for caesarean section. Remifentanil provides cardiovascular stability in conjunction with rapid emergence from anaesthesia in the parturient and minimal side effects in the neonate.

Intubation with propofol: evaluation of pre-treatment with alfentanil or lignocaine.

The effect of lignocaine or alfentanil pre-treatment on conditions at orotracheal intubation following induction with propofol, but without the use of muscle relaxants, were compared in a prospective, controlled, double-blind study. Forty five healthy patients undergoing elective surgery were randomly allocated to receive either 0.9% saline (control), alfentanil 20 micrograms/kg-1, or lignocaine 1.5 mg kg-1 prior to induction with propofol 2.5 mg kg-1. Ease of intubation was scored on a four point scale from 'excellent' = 1 to 'not possible' = 4. Alfentanil pre-treatment allowed intubation in 93% of patients compared to 60% in each of the groups pre-treated with lignocaine or saline. Intubation scores of 1 or 2 were obtained in 14 out of 15 patients (93%) in the alfentanil group and this was significantly better than the lignocaine group (33%) or control group (20%). No difference was detected between the scores of the latter two groups.

Ibuprofen versus acetaminophen with codeine for the relief of perineal pain after childbirth: a randomized controlled trial.

BACKGROUND: Pain from episiotomy or tearing of perineal tissues during childbirth is often poorly treated and may be severe. This randomized double-blind controlled trial was performed to compare the effectiveness, side effects and cost of, and patient preference for, 2 analgesics for the management of postpartum perineal pain. METHODS: A total of 237 women who gave birth vaginally with episiotomy or a third- or fourth-degree tear between August 1995 and November 1996 at a tertiary-level teaching and referral centre for obstetric care in Vancouver were randomly assigned to receive either ibuprofen (400 mg) (n = 127) or acetaminophen (600 mg) with codeine (60 mg) and caffeine (15 mg) (Tylenol No. 3) (n = 110), both given orally every 4 hours as necessary. Pain ratings were recorded before the first dose and at 1, 2, 3, 4, 12 and 24 hours after the first dose on a 10-cm visual analogue scale. Side effects and overall opinion were assessed at 24 hours. RESULTS: Ibuprofen and acetaminophen with codeine had similar analgesic properties in the first 24 hours post partum (mean pain rating 3.4 and 3.3, mean number of doses in 24 hours 3.4 and 3.3, and proportion of treatment failures 13.8% [16/116] and 16.0% [16/100] respectively). Significantly fewer subjects in the ibuprofen group than in the acetaminophen with codeine group experienced side effects (52.4% v. 71.7%) (p = 0.006). There were no significant differences in overall patient satisfaction between the 2 groups. The major determinant of pain intensity was forceps-assisted delivery. Overall, 78% of the treatment failures were in women with forceps-assisted deliveries. INTERPRETATION: Since the 2 analgesics were rated similarly, ibuprofen may be the preferred choice because it is less expensive and requires less nursing time to dispense. Further studies need to address improved analgesia for women with forceps-assisted deliveries.

The use of acute hemodilution in parturients undergoing cesarean section.

OBJECTIVE: Concern over transmissible disease has increased interest in methods of minimizing homologous blood transfusion during elective surgery. One method is acute hemodilution, a technique previously unreported in parturients. This study was designed to determine its feasibility and safety in women at risk of hemorrhage during cesarean section. STUDY DESIGN: This technique was performed on 38 parturients. Collected blood was retransfused at the end of surgery or earlier, if required. Hemoglobin was measured before hemodilution, after hemodilution, before transfusion, after transfusion, and 24 hours postoperatively. Neonatal assessment included umbilical blood gases and Apgar scores. RESULTS: All patients were hemodynamically stable and no fetal heart rate abnormalities were observed during the procedure. One patient received homologous blood and 14 received previously donated autologous blood. Umbilical blood gases were normal and 5-minute Apgar scores were > or = 7. CONCLUSION: This study suggests that acute hemodilution is well tolerated in parturients undergoing cesarean section. This may limit exposure to homologous blood transfusion.

Anaesthesia in a parturient with Noonan's syndrome.

PURPOSE: To report the management of labour analgesia and subsequent anaesthesia for postpartum bleeding in a 19-yr-old parturient with Noonan's syndrome. CLINICAL FEATURES: The patient presented in active labour at 36-wk gestation. She was known to have Noonan's syndrome and had been assessed regularly throughout pregnancy. Features of the syndrome exhibited by the patient included typical facies, chest skeletal abnormalities, pulmonary valve dysplasia, mental retardation and lymphoedema. In addition, she had Factor XI deficiency (0.46 mg.L-1) and thrombocytopenia (92 x 10(9).L-1), previously unreported in a parturient with this syndrome. Although epidural analgesia may have been considered the labour analgesic technique of choice, the risk of epidural haematoma caused by her bleeding diathesis made this unacceptable. This risk was balanced against the possibility of a potentially difficult intubation due to facial abnormalities, should emergency operative delivery become necessary. Labour analgesia was provided with intravenous patient controlled opioid analgesia (fentanyl 25 micrograms bolus, five minute lockout) despite her mental retardation. Dilatation and curettage required general anaesthesia after intubation with awake direct laryngoscopy using cautious sedation. CONCLUSION: Noonan's syndrome is characterised by multi-system involvement, requiring thorough preoperative assessment of cardiovascular, skeletal, haematological and central nervous systems. Clotting and platelet defects considerably restrict the possible analgesic and anaesthetic options for labouring patients with this syndrome.