Cardiopulmonary morbidity as a complication of severe preeclampsia HELLP syndrome.

OBJECTIVE: To profile the types and frequencies of cardiopulmonary morbidity encountered in patients with severe preeclampsia with or without hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). STUDY DESIGN: We initiated a retrospective study of 979 patients with severe preeclampsia with and without HELLP syndrome. Types of cardiopulmonary morbidity were analyzed among the three classes of HELLP syndrome and severe preeclampsia without HELLP syndrome. RESULTS: Cardiopulmonary morbidity occurred in 7.6% of study patients. As a group, patients with cardiopulmonary complications were more likely to have cesareans (11% vs 6%, p = 0.019) earlier in gestation (1366 +/- 700 gm birth weight versus 1734 +/- 892 gm birth weight, p = 0.021), with higher peak postpartum blood pressures (< 0.001) and with more abnormal laboratory values indicative of multisystem disease, compared with patients without this complication. Patients with cardiopulmonary complications required almost twice as long to achieve diuresis as comparison patients (22 +/- 23 hours versus 12 +/- 11 hours, p < 0.001). CONCLUSION: The probability of cardiopulmonary complications increases significantly when patients develop class 1 HELLP syndrome. Of all cardiopulmonary complications, acute lung injury/acute respiratory distress syndrome is most specific to class 1 HELLP syndrome. Transient renal dysfunction is closely related to cardiopulmonary morbidity.

Spinal anesthesia for postpartum tubal ligation after pregnancy complicated by preeclampsia or gestational hypertension.

BACKGROUND AND OBJECTIVES: The American College of Obstetricians & Gynecologists has opposed postpartum tubal ligation (PPTL) in patients whose pregnancies have been complicated by a medical condition, including hypertension. A prospective study was conducted to assess the appropriateness of spinal anesthesia for PPTL in patients with hypertensive disorders of pregnancy. METHODS: After institutional review board approval and written informed consent, women scheduled for PPTL were enrolled. The hypertensive group (n = 25) consisted of women whose pregnancies were complicated by gestational hypertension, preeclampsia, or chronic hypertension with superimposed preeclampsia. For each hypertensive patient, a matched control was designated by selecting the next consenting normotensive patient scheduled for PPTL. After an intravenous bolus of lactated ringers solution 500 mL, spinal anesthesia was induced with hyperbaric lidocaine. Hemodynamic measurements were recorded every 2 minutes for 20 minutes after spinal injection. Ephedrine IV was administered for systolic blood pressure < or =90 mm Hg. RESULTS: The mean preoperative mean blood pressure (MAP) was 107+/-17 mm Hg in the hypertensive group and 85+/-11 mm Hg in the controls, P<.0001. The hypertensive group sustained a more profound percentage decrease in MAP than did their control counterparts during spinal anesthesia (29%+/-12% v. 15%+/-8%, P<.0001). However, the lowest intraoperative MAP was similar in both groups. Thirty-five percent of hypertensive patients and 24% of the controls received ephedrine IV. CONCLUSIONS: PPTL during spinal anesthesia in patients whose pregnancies have been complicated by hypertension had results comparable with patients with uncomplicated pregnancies; however, further studies are needed to ascertain its safety.

Prophylactic angiotensin II infusion during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Angiotensin II may prove useful in treating regional anesthesia-induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery. METHODS: Fifty-four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 microg/ml) or ephedrine (5 mg/ml) was initiated at 10 ng x kg(-1) x min(-1) and 50 microg x kg(-1) x min(-1), respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90-100% of baseline. RESULTS: Cumulative vasopressor doses (mean+/-SD) through 10, 20, and 30 min were 150+/-100, 310+/-180, and 500+/-320 ng/kg in the angiotensin group and 480+/-210, 660+/-390, and 790+/-640 microg/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group. CONCLUSIONS: Angiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

A randomized trial of epidural anesthesia to improve external cephalic version success.

OBJECTIVE: This study was designed to determine whether epidural anesthesia would improve external cephalic version success in a safe and effective manner. STUDY DESIGN: All women > 37 weeks' gestation with breech presentation scheduled for external cephalic version at the medical center from Dec. 1, 1993, to July 31, 1996, were randomized to receive an epidural or no epidural anesthesia. Under ultrasonographic guidance up to three version attempts were performed. RESULTS: Sixty-nine women were randomized to receive epidural (n = 35) versus no epidural (n = 34) anesthesia for external cephalic version. There were no statistically significant differences in maternal age, parity, maternal weight, gestational age, estimated fetal weight, or station of the presenting part. The success rate was better for the epidural group (relative risk 2.12, 95% confidence interval 1.24 to 3.62). Neither anterior placentation or oligohydramnios affected the success rate. CONCLUSION: Epidural anesthesia increases success of external cephalic version without any apparent detrimental effect on the maternal-fetal unit.

Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia.

OBJECTIVE: Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women. STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted. RESULTS: One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first (p = 0.54) or second (p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently (p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration. CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.

Laparoscopic surgery during pregnancy.

BACKGROUND: Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS: We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these women's charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS: Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS: Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

Acute tocolysis for suspected intrapartum fetal distress: maternal effects of terbutaline versus magnesium sulfate.

This study was undertaken to determine the maternal hemodynamic impact of terbutaline versus magnesium sulfate in the acute treatment of fetal distress prior to cesarean delivery. Forty-six women were prospectively randomized to receive 0.25 mg subcutaneous terbutaline or 4.0 g intravenous magnesium sulfate for in utero fetal resuscitation before cesarean delivery. There were no significant differences between groups in baseline mean arterial pressure, arterial pressure before and after induction of anesthesia, maternal heart rate, maternal oxygen saturation, estimated blood loss, and pre- and postoperative hematocrits. Magnesium sulfate-treated women received significantly more intraoperative intravenous fluids (2365 +/- 877 ml) than the terbutaline group (1624 +/- 564 ml; P < 0.001). However, mean urine output was significantly greater in the terbutaline group (88 +/- 42 ml/h) than in those treated with magnesium sulfate (61 +/- 26 ml/h; P < 0.03). Terbutaline, the superior agent for acute tocolysis, is not associated with an increase in maternal cardiovascular side effects during anesthesia.

Reduction of pain and nausea after laparoscopic sterilization with bupivacaine, metoclopramide, scopolamine, ketorolac, and gastric suctioning.

OBJECTIVE: To determine whether postoperative pain and nausea after laparoscopic sterilization can be reduced with a combination of bupivacaine, metoclopramide, scopolamine, ketorolac, and gastric suctioning. METHODS: Women undergoing outpatient laparoscopic sterilization were randomized to protocol management or nontreatment groups. Each patient received standard general endotracheal anesthesia. Protocol subjects received intramuscular ketorolac 60 mg and scopolamine 0.25 mg, intravenous metoclopramide 10 mg, and gastric suctioning; bupivacaine (2.5 mg/mL) with epinephrine (5 micrograms/mL) was injected at trocar sites and dripped onto the fallopian tubes. The nontreatment group served as controls. Visual analogue scales were used to evaluate pain and nausea (measured in millimeters). Demographic characteristics, postoperative requirements for analgesics and antiemetics, time to discharge, and unscheduled admission were also evaluated. RESULTS: During a 7-month period, 71 women were enrolled. Protocol subjects (N = 35) reported pain severity of 27.9 +/- 19.1 mm (mean +/- standard deviation), whereas controls (N = 36) reported 59.3 +/- 23.3 mm (P < .001). Fourteen protocol patients requested additional pain medication, compared with 29 controls (P < .001). Protocol patients indicated a nausea severity of 9.9 +/- 18.7 mm, whereas the controls reported 38.8 +/- 35.5 mm (P < .001). Only one protocol patient required nausea medication, compared with nine controls (P < .02). Severity of pain correlated with severity of nausea (r = 0.38166, P < .001). Protocol patients were discharged from the outpatient surgery unit in 148.6 +/- 45.0 minutes, compared with 176.4 +/- 58.5 minutes for controls (P < .03). CONCLUSION: This regimen reduced the severity of pain and nausea after outpatient laparoscopic sterilization. The need for additional analgesics and antiemetics was also reduced. Protocol patients were discharged earlier than controls. These benefits seem to accrue without significant risk. We believe that this regimen may also be useful in other ambulatory laparoscopic procedures.

Management of anesthetic complications and emergencies in the obstetric patient.

The importance of cooperation and understanding between the obstetrician and anesthesiologist in the management of obstetric emergencies cannot be overemphasized. Indications for cesarean section and choice of anesthetic are significant considerations. Algorithms for the management of special treatment problems such as malignant hyperthermia, postdural headache, and epidural abscess and hematoma are presented. Posting of protocols for the management of particular crises in both delivery and postanesthesia care units is strongly recommended.

Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without HELLP syndrome.

OBJECTIVE: To explore the efficacy of plasmapheresis/plasma exchange as the primary therapy to arrest and reverse the progression of severe preeclampsia with or without HELLP syndrome in order to postpone delivery and improve perinatal outcome in very preterm pregnancies. STUDY DESIGN: In this case series of patients managed over a 4-year period from 1984 to 1987, seven gravidas with severe preterm preeclampsia underwent 1-2 plasmaphereses/plasma exchange procedures using the IBM 2997 Cell Separator with continuous electronic fetal heart rate monitoring (n = 7 patients) and central cardiovascular monitoring (n = 3 patients). RESULTS: The seven patients (one with HELLP syndrome, six without HELLP) presented between 24 and 30 weeks gestation and, despite plasmapheresis/plasma exchange, the severity of each study subject's preeclampsia persisted without clinically significant improvement. Maternal-fetal deterioration required cesarean delivery in all cases within 48 (in four patients within < 36) hours of therapy. No clinically significant adverse effect of plasma exchange therapy was recorded during cardiovascular and laboratory monitoring; two fetuses developed repetitive late decelerations during exchange despite adequate maternal fluid preload. The only patient with HELLP syndrome developed eclampsia as her third plasma exchange within 25 hours was being initiated. Significant problems with fluid retention and displacement (variable amounts of pulmonary edema, pleural effusions, large volume ascites) were encountered in all patients. Four neonates died (24-27 weeks/438-820 g) and three survived intact (740, 950, and 1,280 g). One mother (case 5) developed end-stage renal disease 21 months postpartum. CONCLUSIONS: The application of plasmapheresis/plasma exchange therapy as described in order to prolong very preterm pregnancies in the undelivered patient with severe preeclampsia/eclampsia with or without HELLP syndrome did not produced encouraging results. Patients in general were exposed to additional medical and surgical risk without a corresponding improvement in perinatal outcome.

Plasma exchange for preeclampsia: III. Immediate peripartal utilization for selected patients with HELLP syndrome.

OBJECTIVE: To explore the potential efficacy of plasma exchange as an ancillary interventive therapeutic tool immediately before or after delivery in the patient with severe preeclampsia/eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. STUDY DESIGN: Two gravidas with complicated severe preeclampsia/eclampsia/HELLP syndrome were treated emergently in the immediate peripartal period with single-volume plasma exchange and fresh frozen plasma fluid replacement using the IBM 2997 Cell Separator. RESULTS: Despite multiple platelet unit infusions, one primigravida in active labor at 5 cm cervical dilation and 39 weeks' gestation remained at a platelet count of 14,000/microL and began to ooze from her guns. A second primigravida remained obtunded, oliguric, and thrombocytopenic with epistaxis and hematuria following cesarean delivery and platelet transfusions. A single expedited 3-liter plasma exchange procedure reversed the rapidly deteriorating clinical situation for each patient and accelerated recovery from HELLP syndrome. Both patients and progeny suffered no permanent sequelae. CONCLUSION: Based on our experience, we believe that the therapeutic modality of plasma exchange with fresh frozen plasma can be employed effectively for the pregnant patient with severe atypical HELLP syndrome that progressively worsens during labor or the early puerperium despite the use of conventional transfusion therapy.

Bromocriptine inhibition of anesthesia-induced hyperprolactinemia: effect on serum and follicular fluid hormones, oocyte fertilization, and embryo cleavage rates during in vitro fertilization.

Thirty-two patients undergoing in vitro fertilization (IVF) were given bromocriptine either 1 or 12 hours before anesthesia or received no drug to determine what effect suppression of transient, anesthesia-induced hyperprolactinemia would have on peripheral and follicular fluid hormones, fertilization and cleavage rates, and pregnancy. Thirty minutes after anesthesia, there was a 120-ng/mL rise in serum prolactin (PRL) in control patients versus an insignificant change in women given bromocriptine. Levels of PRL in follicular fluid were significantly less, and estradiol (E2) levels were higher (P less than 0.05) in all bromocriptine-treated patients compared with controls, whereas follicular fluid levels of progesterone (P), inhibin activity, and midluteal serum P were unaffected. Although fertilization and pregnancy rates were similar, a greater proportion of fertilized oocytes from bromocriptine-treated patients advanced to cleaving embryos compared with controls (95% versus 63%, respectively; P less than 0.001). We conclude that bromocriptine, given before anesthesia, can suppress transient, anesthesia-induced hyperprolactinemia and dramatically alter follicular fluid concentrations of PRL and E2. Although these changes in hormonal milieu affected neither oocyte fertilization nor pregnancy rate in our IVF patients, they seemed to have a positive influence on embryonic development after IVF.

Intradiploic leptomeningeal cyst of the frontal bone occurring as a complication of head injury in an adult.

Intradiploic cysts are rare complications of skull fractures. Only five cases of cranial intradiploic cyst can be found in the literature, all affecting the occipital bone. In all, the primary injury occurred in childhood and the cyst presented many years later. The case described here is of a frontal intradiploic leptomeningeal cyst developing in an adult as a sequel to a skull injury 12 months earlier. Intradiploic cysts occurring after fractures in adulthood do not appear to have been described previously.

MRI diagnosis of vertebral arteriovenous malformations in neurofibromatosis.

We describe two patients with neurofibromatosis, each of whom was found to have an arteriovenous malformation (AVM), an uncommon manifestation of the disease, presenting as an extradural space-occupying lesion in the cervical spine. In one patient the finding of an unsuspected AVM at operation led to massive blood loss; in the other magnetic resonance imaging (MRI) of the neck allowed the diagnosis to be made and the hazard of an operation to be avoided. Solid tumours that may occur in the disease of neurofibromatosis are known to cause neurological deficits as the result of space occupation. We wish to draw attention to another pathological entity which may cause neurological deficits: that of AVMs. We also propose that in the investigation of such a patient MRI be borne in mind as a non-invasive radiological tool, particularly as, hopefully, its cost reduces and its availability becomes more widespread.

Fentanyl does not inhibit fertilization or early development of sea urchin eggs.

Sea urchin (Lytechinus variegatus) eggs have been used to study the effects of fentanyl on in vitro fertilization and early development as a model of human in vitro fertilization. Fentanyl did not affect fertilization or subsequent cell division when present in concentrations calculated to approximate or exceed those to which human ora would be exposed during clinical anesthesia. Lytechinus eggs exposed to fentanyl, then washed in fentanyl-free sea water before fertilization were also not affected and divided normally. The results suggest potential clinical utility of fentanyl during the harvesting of human ova for subsequent in vitro fertilization.

Pheochromocytoma in pregnancy: diagnosis and collaborative management.

Antenatal diagnosis and appropriate management of pheochromocytoma complicating pregnancy offers a reduction in mortality for both mother and fetus. We have presented the successful management of such a case, emphasizing the close collaboration between obstetricians, pediatricians, anesthesiologists, surgeons, and internists that is mandatory for a successful outcome.

Modular approach to CPR training.

Basic and advanced cardiopulmonary resuscitation training is worthwhile yet time consuming. Anesthesiologists should be among the most qualified leaders in CPR teaching programs. Using a modular self-teaching presentation for basic and advanced cardiac life support courses, minimal instructor time is required to accomplish proficiency in both didactic and mannequin performance for participants. This method can be adapted to various educational levels and time constraints without compromising quality of teaching.

Laryngeal papillomatosis: anesthetic management.

We reviewed the anesthetic management of all children admitted with laryngeal papillomatosis during a six-year period. This included 147 endoscopies on 16 patients, most referred with advanced disease after initial care in other hospitals. Onset of the disease before age 2 was associated with the most severe upper airway involvement. Eight patients required tracheostomy at some time during treatment, and management of the shared airway during surgical manipulation was particularly difficult in these children. Inhalational induction with halothane was used rountinely, with surprisingly few instances of laryngospasm or upper airway obstruction. Topical lidocaine spray and orotracheal intubation were preferred; insufflation technics were frequently abandoned when attempted. Extubation under deep anesthesia after clearing the glottis of secretions was usually followed by smooth emergence and minimal airway difficulties. There was only one instance of postoperative stridor suggesting croup. A standard anesthetic approach can be recommended, on the basis of the experience in this series, but possible variations in technic are also discussed for particular clinical applications.

Accidental subdural analgesia: A case report, possible clinical implications and relevance to "massive extradurals".

A continuous obstetric epidural is described, in which an abnormally extensive block and hypotension resulted. The catheter was subsequently shown to enter the subdural space. As this case resembles a "massive epidural", it is suggested that subdural injection may explain the phenomenon.