Seizures in the peripartum period: Epidemiology, diagnosis and management.

The occurrence of seizures in the peripartum period is a rare but particularly challenging situation. Seizures in the peripartum period could result from three categories of conditions: first and most frequent is the exacerbation of a known pre-existing seizure disorder, mainly epilepsy. A therapeutic evaluation is needed; second is the new onset of seizures due to a non-pregnancy-related problem. An accurate diagnosis and a specific treatment are required; third is range of pregnancy-related conditions. The present review focuses on this third category, with a special attention to disorders occurring in the peripartum period. It is structured in two sections. The first section is a focus on eclampsia since, based on ICU admission data, it appears to be the leading cause of pregnancy-related seizures. Its epidemiology, pathophysiology, clinical diagnosis, neuro-imaging features and recommended management are reviewed. The efficacy and safety of the recommended regimens of MgSO4 therapy are discussed, as well as controversies on the alteration of these regimens and the use of MgSO4 in women with mild preeclampsia. In the second section, the other causes of pregnancy-related new onset seizures are summarized. These include posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, thrombotic thrombocytopenic purpura, amniotic fluid embolism, and air embolism. Noteworthy is the fact that most of these pregnancy-related seizure conditions overlap with each other, mainly in terms of clinical presentations and neuro-imaging. Therefore, the diagnosis and the treatment options should be considered on a multidisciplinary basis.

[Lipid emulsions for the treatment of systemic local anesthetic toxicity: Efficacy and limits]. / Les émulsions lipidiques dans le traitement de la toxicité systémique des anesthésiques locaux : efficacité et limites.

Local anaesthetic toxicity always results from rapid and important increase in their plasma concentrations. Clinically, neurologic and cardiovascular symptoms may occur, especially life-threatening cardiac arrhythmias and cardiac depression. Resuscitating patients from cardiac toxicity was known as difficult, until the introduction of lipid emulsion therapy. From experimental data, at least two mechanisms of action can be proposed, a sink-effect and an improvement of cardiomyocyte metabolism. The present article is a mini-review of the current use of lipid emulsions for the treatment of local anaesthetic cardiac toxicity. The mechanisms of cardiac toxicity and those of lipid emulsion therapy are summarized, and the clinical experience of this therapy and its limits are presented.

[Anesthesia and preeclampsia]. / Anesthésie et prééclampsie.

An assessment of the patient must take place as early as possible in view of anaesthesia. It is recommended to perform a clotting screen as close as possible to the performing of an epidural anaesthesia. The use of aspirin, if indicated for the prevention of PE, does not as such, constitute a contraindication to performing an epidural anaesthesia if: With regards to the minimum platelet count, the recommended cut-off value for the performing of an epidural and spinal anaesthesia are 75 & 50 x 10(9)/l respectively, only if all of the following conditions are met: It is recommended to quickly set up an epidural anaesthesia because this will improve the blood pressure as well as the utero-placenteric haemodynamics and also because this will facilitate the management in case of a caesarean section. Whereas methylergometrine (Methergin) is contraindicated in the preeclamptic patient, it is possible to use oxytocin (Syntocinion) during and after labour. Before performing a spinal anaesthesia, it is recommended to restrain the administration of crystalloids to a maximum of 1000 ml. Also the i.v. antihypertensive treatment should be reduced or interrupted until complete establishment of the anaesthetic. In case a general anaesthesia is to be performed, an assessment of the criteria for difficult intubation should be performed immediately prior to the induction. The technique employed should be a rapid sequence induction with intubation, while preventing a surge in blood pressure induced by the tracheal intubation. Difficulties to extubate should systematically be anticipated. It is possible to perform a loco-regional anaesthesia following an eclamptic crisis if the following conditions are met: In case of overlapping seizures and/or impaired consciousness, a general anaesthesia is recommended.

Chronobiology of labour pain perception: an observational study.

BACKGROUND: Circadian variation may affect many biological and pharmacological phenomena. METHODS: To assess circadian variations in labour pain perception, 222 consecutive nulliparous women with uncomplicated pregnancy, spontaneous labour, cervical dilatation (3-5 cm), ruptured membranes and normal fetal heart rate tracings were studied. Visual analogue pain scores (VAPS) were analysed and divided into four periods: night (1:01 a.m. to 7:00 a.m.), morning (7:01 a.m. to 1:00 p.m.), afternoon (1:01 p.m. to 7:00 p.m.) and evening (7:01 p.m. to 1:00 a.m.). VAPS were also compared between daytime (morning+afternoon) and nocturnal (evening+night) periods. RESULTS: Daytime mean VAPS were lower than nocturnal scores [75.6 (15.1) vs 85.7 (14.1), P<0.0001]. VAPS were lower in the morning than in the afternoon, evening and night periods (anova, P<0.0001). CONCLUSION: Labour pain perception appears to be chronobiological, and this might be taken into account when enrolling parturients in studies designed to assess or treat labour pain.