Patient-controlled epidural analgesia: the role of epidural fentanyl in peripartum urinary retention.

BACKGROUND: Urinary bladder function is impaired during labor and delivery, predisposing to urinary retention. The effect of low-dose epidural opioid on bladder function remains unclear. We tested the hypothesis that adding low-dose fentanyl to epidural ropivacaine for patient-controlled labor analgesia does not promote urinary retention. METHODS: Laboring women who requested patient-controlled epidural analgesia were randomly assigned in a double blind study to 0.2% ropivacaine (R-group, n=100) or 0.2% ropivacaine with fentanyl 2 microg/mL (RF-group, n=98). Urinary bladder distension was assessed clinically every hour. The post-void residual urine volume was measured by ultrasonography. Urine volume exceeding 100 mL was drained by catheterization. Bladder volume of > or =300 mL, as determined by catheterization was considered as evidence of urinary retention. RESULTS: Thirty percent of the patients in each group developed urinary retention during labor. There was no statistically significant difference between the groups. There was an excellent correlation between bladder volume as estimated by ultrasonography and that by catheterization: catheterization volume=0.93 x ultrasound volume + 25; r(2)=0.83. The bias (mean error) was -1+/-99 mL and the precision (average absolute error) between the ultrasound estimate and actual bladder volume determined by catheterization was 58+/-79 mL. CONCLUSION: Addition of fentanyl to patient-controlled epidural analgesia did not increase the risk of urinary retention. Ultrasound measurements were effective and reliable in assessing urinary bladder volumes during labor.

A novel use of spironolactone: treatment of hirsutism.

An excess of androgens is the recognized cause of hirsutism in women. In this study, the antiandrogenic properties of spironolactone were tested clinically in 30 hirsute women. The drug was administered from the 4th to the 22nd day of each menstrual cycle. The moderate side effects in no case forced interruption of the treatment. Hair growth diminished substantially in 23 of the patients, the effect becoming evident 3-5 months after the commencement of treatment. Serum testosterone concentrations decreased in all patients, and estradiol increased in 25 women. Our data suggest that the antiandrogenic properties of spironolactone render it a suitable agent in the treatment of hirsutism.

Experimental allergic encephalomyelitis: passive transfer of resistance during lactation.

Pregnant rats challenged with encephalitogenic antigen in complete Freund's adjuvant (CFA) during pregnancy, transferred a resistance to induction of experimental allergic encephalomyelitis (EAE) in encephalitogenic challenged offspring. The resistance to induction of EAE was transferred during the whole lactation period, until weaning, and not during pregnancy. Through the milk, anti-myelin basic protein antibodies were transferred to the newborn animals. The degree of protection against EAE decayed with age and was not influenced by EAE occurrence in the mothers. In addition, the course of EAE in the rats was not affected by pregnancy. We believe that such transfer of resistance and antibodies may serve as a model for the study of milk-transmitted maternal immunocompetent factors, as well as a model for the mechanisms involved in the resistance of EAE.

Pulmonary complications following endotracheal intubation for anesthesia in breech extraction.

A 28-year-old, healthy pregnant patient developed bilateral pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum following endotracheal intubation and manual ventilation during general anesthesia for breech extraction. It is likely that positive-pressure ventilation was the cause for this very rare combination of complications. Early recognition and treatment may prevent such a catastrophe.

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results.

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).

Induction of ovulation with spironolactone (Aldactone) in anovulatory oligomenorrheic and hyperandrogenic women.

Thirteen anovulatory oligomenorrheic, hyperandrogenic, and normoprolactinemic women were treated with spironolactone (aldactone) throughout six consecutive menstrual cycles in a dosage of 100 to 150 mg/day. During this treatment a significant decrease in serum luteinizing hormone (LH), testosterone, prolactin, and 17-ketosteroid values were observed that were accompanied by ovulation in 11 women (85%), according to basal body temperature (BBT) and progesterone values. In addition, improvement of hirsutism was observed in 9 (70%) and restoration of regular cycles in 11 (85%) of the patients. The side effects observed were mild and did not lead to interruption of the treatment. Our data suggest that the antiandrogenic properties of spironolactone render it a suitable agent in the treatment of anovulatory, oligomenorrheic, and hyperandrogenic women.

Induction of ovulation with combined human gonadotropins and dexamethasone in women with polycystic ovarian disease.

A combined treatment of human menopausal gonadotropin (hMG), human chorionic gonadotropin (hCG), and dexamethasone was administered to 27 infertile patients with polycystic ovarian disease who failed to conceive with clomiphene citrate and hMG-hCG alone. Twenty-two (81%) of the patients ovulated according to basal body temperature and progesterone values, and 20 (74%) conceived during one to four treatment cycles. Fifteen (74%) pregnancies terminated in live full-term deliveries (14 singletons and 1 set of twins), and 5 (25%) have terminated in first-trimester abortions. Only one of the treatment cycles was complicated by moderate ovarian hyperstimulation. The average hMG dose required for the induction of ovulation was significantly reduced from 25 ampules with hMG-hCG alone to 18 ampules under the combined treatment (P less than 0.01). The combination of hMG-hCG and dexamethasone is an additional, safe, and effective nonsurgical treatment for women with polycystic ovarian disease who have failed to respond to an hMG-hCG regimen alone.

Difficult airway in obstetric anesthesia: a review.

UNLABELLED: Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases. LEARNING OBJECTIVES: After completion of this article, the reader will be able to break down the complex issues in managing the difficult airway in the obstetric patient, outline the reasons for difficult intubations in pregnancy, and describe the evaluation used to predict a difficult intubation.

A new animal model for action myoclonus.

Morphine was injected into a catheter implanted chronically into the intrathecal space of rats. Three to eight minutes after drug administration, 80% of the rats developed arrhythmic stimulus-sensitive jerks that lasted up to 1 hr. The morphine-induced myoclonic activity was markedly reduced by naloxone. Methadone, pethidine, and etorphine failed to produce the syndrome. In spinally transected rats, morphine injected below the level of transection did not produce the syndrome. No significant changes in PaCO2 and PaO2 were produced by morphine before and throughout the period of myoclonic activity. Neither did induced hypoxia augment the effect of morphine. However, irreversible hypoxic-ischemic cell changes were noticed in some brain regions. The phenomenon described here resembles the human syndrome of action myoclonus and may serve as an animal model for studying the mechanism of that neurological disorder.

Induction of ovulation by combined clomiphene citrate and dexamethasone treatment in clomiphene citrate nonresponders.

Fifteen anovulatory, oligomenorrheic, hyperandrogenic and normoprolactinemic women who failed to respond to prolonged clomiphene citrate (CC) treatment, were subsequently treated with CC and small doses of dexamethasone (Dex). Twelve (80%) of the patients ovulated according to BBT and progesterone values, and 7 (49%) conceived during 3--6 treatment cycles. Five of these pregnancies terminated in live, single, full term deliveries, one set of twins and one first trimester abortion. It is concluded that a regimen of combined CC and a small dose of Dex may be offered to CC nonresponders as an effective alternative to Menotropins--HCG treatment.

High incidence of preeclamptic toxemia in patients with polycystic ovarian disease.

The incidence of preeclamptic toxemia (PET) was investigated in 72 anovulatory, oligomenorrheic and previously nulliparous women who conceived after an induction of ovulation. One-thousand consecutive spontaneous pregnancies and 1,000 pregnancies of primiparae were used as control groups. The anovulatory group consisted of 33 consecutive well-documented cases of polycystic ovarian disease (PCO) and 39 anovulatory patients in whom PCO was excluded (A-NPCO). The results indicate that pregnancies after induction of ovulation are accompanied with a higher incidence of PET. The rate of this disorder was significantly higher in PCO groups than in A-NPCO women (28.5 vs. 4%), when calculated per number of all pregnancies. The difference between the incidence of PET in PCO, A-NPCO, control primiparae and normal control patients was even more pronounced when calculated on the basis of the number of patients (54.5, 12.5, 11 and 2.5%, respectively). Overproduction of steroid hormones, especially androgens, was suggested as the main factor for the appearance of PET in PCO patients.

Postoperative analgesia by percutaneous electrical stimulation in gynecology and obstetrics.

Percutaneous electrical stimulation (PES) for relief of acute postoperative pain was applied in 10 patients after cesarean section and in 20 women who had undergone various gynecological operations. Thirty other women, subjected to identical surgical interventions, served as controls. In the latter group, the electrodes were attached to a nonfunctioning apparatus. In all patients, including the controls, the two electrodes were introduced intradermally, one on each side of the incision. Implantation was carried out at the end of the surgical procedure while the patient was still anesthetized, and stimulation was commenced immediately. The electrical stimulation was applied continuously for 1 to 3 postoperative days. The generation of pulses was perceived by the patients as a tingling sensation. Complete pain relief was obtained in 40% of the patients treated with PES, whilst in 27% the pain was markedly diminished. Postoperative analgesic medication in this group was reduced by 50-80% as compared to the analgesic requirements in the control group. Other beneficial effects observed in the treated patients included early ambulation, early peristalsis, postpartum uterine contractions and absence of respiratory complications.

Congenital afibrinogenemia and recurrent early abortion: a case report.

The role of the fibrinogen molecule in the maintenance of normal pregnancy is not yet well understood; however, several cases have been previously reported in which failure to complete normal pregnancy was associated with either hypofibrinogenemia, dysfibrinogenemia, or deficiency in factor XIII (fibrin-stabilizing factor) which is important for the crosslinking of the fibrin. A case of congenital afibrinogenemia is described. The patient, a 22-yr-old woman, who suffered from a moderate hemorrhagic tendency associated with very low (less than 10 mg/dl) plasma fibrinogen levels, had three consecutive spontaneous abortions. In view of the previous cases reported, the question is raised whether patients with low or abnormal fibrinogen should be treated with plasma transfusions in order to maintain a normal pregnancy.

Biliary disease in young women and its association with pregnancy or oral contraceptives.

In view of the reported association between the use of oral contraceptives and gallbladder disease, 686 consecutive cholecystectomies for cholecystitis and cholelithiasis performed between 1967 and 1976 in our hospital were analyzed. Fifteen patients (2.18 per cent) were under 21 years of age and 78 (11.3 per cent) between 22 and 28 years of age. All the patients in the former group and 22% in the latter were females. There was a history of recent pregnancy and/or oral contraceptive use in a substantial number of patients. The increased incidence of gallbladder disease during the previous five years, 1972-1976, as compared to 1967-1971 in females between the ages of 22 to 28, from 8% to 17.6% may be attributed to the increased use of oral contraceptives (from 32% to 42%). The occurrence of previous pregnancies was nearly the same in both groups (84% and 83% respectively). The frequency of gallbladder disease was significantly higher in patients who had used oral contraceptives for six to twelve months as compared with women who had used them for longer or shorter periods.

[The use of IUD as an etiological factor of acute pelvic inflammatory disease].

PIP: The authors review the body of literature dealing with the association between the use of IUDs and the development of acute PID (Pelvic Inflammatory Disease); the sources, dating from 1930 to 1976, include published articles from several nations as well as proceedings of international conferences. Limitations of studies done to date include: 1) the imprecise diagnostic criteria of PID; 2) an undue emphasis on hospitalized patients; 3) missed cases in which an IUD is removed shortly before the onset of PID; 4) absence of appropriate control groups and; 5) the use of sample sizes which are too small. These methodological deficiencies make it difficult to assess the true incidence of PID which occurs in association with the use of IUDs; nevertheless, researchers agree that an increased risk does exist. In addition, IUD users have an increased risk of pain and bleeding; future sterility; and ectopic pregnancy. In consideration of these risks, especially that of subsequent sterility, the authors recommend that IUDs not be used in nulliparae. They recommend that IUDs only be inserted in the absence of any genital infection; in parts of the world where gonorrhea is prevalent, antibiotics should be administered prophylactically before insertion of the device.^ieng

[The management of HIV patients during surgery and in the delivery ward: anesthetic considerations].

To date a total of more than 50 million individuals worldwide have been infected with HIV and more than 20 million have died from the disease. Two thirds of the known carriers of HIV 36 million worldwide, live in Africa. In Israel, as of December 31, 2000, there are a total of 2,843 reported carriers and 165 persons alive with AIDS. On the basis of future projections of increasing incidence of HIV/AIDS in obstetric patients undergoing anesthesia and surgery, obstetricians and anesthesiologists should be aware of the disease and its impact on anesthetic techniques and possible interactions between anesthetic drugs and HIV therapeutic agents. Surgical staff members should be knowledgeable and updated concerning safety precautions during surgical and anesthetic procedures.

Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy.

BACKGROUND: The postoperative analgesic effects of rectal indomethacin and tramadol were compared in patients undergoing elective termination of first trimester pregnancy and diagnostic dilatation and curettage. METHODS: Eighty-one American Society of Anesthesiologists class I and II women undergoing first trimester termination of pregnancy or diagnostic dilation and curettage were randomly allocated to receive rectal suppositories of either tramadol 100 mg (n=41) or indomethacin 100 mg (n=40) 90 min before induction of anesthesia. Pain scores and side effects were evaluated until discharge. Intraoperative anesthetic and postoperative analgesic consumption was also recorded. Intravenous metamizole 1 g was employed for postoperative rescue analgesia. RESULTS: When compared to the indomethacin group, the tramadol group required less intraoperative propofol [136 mg ±28 vs. 160 mg ±35 (P=0.001)], less rescue analgesia [2.4% vs. 22% (P=0.005)] and lower visual analogue pain scores [2.4 ±8 vs. 23 ±22 (P=0.005)]. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSION: When compared to indomethacin 100 mg, preoperative administration of tramadol 100 mg provides superior postoperative analgesia with minimal adverse effects.

Obstetric anesthesia units in Israel: a national questionnaire-based survey.

BACKGROUND: This survey was performed to assess the organization and practice of obstetric anesthesia units in Israel. METHODS: A written questionnaire was mailed at the end of December 2005 to all Israeli anesthesia departments providing labor and delivery services in 2005 (n=25). RESULTS: A response rate of 100% accounted for 125,340 deliveries. All labor and delivery suites had on-site anesthesia department services. Data are presented as mean (range) or frequency. Eleven hospitals performed 2500-4999 deliveries/year, 6 hospitals 5000-7499 deliveries/year, and 4 hospitals 7500-9999 deliveries/year. The overall cesarean delivery rate was 20% (0-27). Anesthesia for cesarean delivery (elective and emergency combined) was provided by: general anesthesia 15% (0.5-50), epidural 14.5% (0-99.5), spinal 68% (0-98), or combined spinal-epidural technique 0% (0-30). There was an operating room within or immediately adjacent to the labor ward in 16/25 units, including 10/11 units with >5000 deliveries/year. Labor analgesia was provided by epidural techniques in 50% (4-93) and nitrous oxide in 0.5% (0-90) of deliveries. A total of 11 units had 24h dedicated anesthesiologist coverage, including all units >7500 deliveries but only 3/8 (38%) with 5000-7500 deliveries. Two of the 4 units with >7500 deliveries had no faculty member with formal training in obstetric anesthesia. Written protocols were available for labor analgesia (17/25), post-partum hemorrhage (12/25), aspiration prophylaxis (15/25) and maternal resuscitation (8/25). CONCLUSION: In this national appraisal of Israeli obstetric anesthesia services, a notable lack of written protocols, wide variations in staffing, and few specifically trained obstetric anesthesia personnel were observed.