A comparison of paracervical block with single-shot spinal for labour analgesia in multiparous women: a randomised controlled trial.

BACKGROUND: Epidural and spinal analgesia may be contraindicated or unavailable in labour. This randomised controlled study examined the suitability of paracervical block as an alternative method of labour analgesia. METHODS: Multiparous women in labour were randomised to receive either paracervical block or single-shot spinal analgesia. Pain was quantified using a numerical rating scale. Subsequent analgesia, progress of labour, and mode of delivery were noted. Fetal heart rate patterns were reviewed. Apgar scores and umbilical artery pH measurements were collected. Parturients' satisfaction and willingness to have the same method of labour analgesia again were recorded. RESULTS: 122 parturients were randomised with data available on 104. Median pain scores decreased significantly in both groups; this was greater with single-shot spinal analgesia (difference between means 2.7; 95% CI 1.9-3.5; P(g)<0.001). Parturients receiving paracervical block received subsequent analgesia more often (23/56 vs. 3/48, P<0.001). Progress of labour, instrumental delivery rates, detected abnormal decelerations in cardiotocography and neonatal outcome were similar between groups. Shivering (P<0.04) and pruritus (P<0.001) were more common with single-shot spinal analgesia. Parturients in the paracervical block group were less satisfied (median 7.0, IQR 3.0-8.0 vs. median 9.0, IQR 8.0-10.0; P<0.001) and less willing (28/55 vs. 39/48, P=0.002) to have the same labour analgesia again. CONCLUSIONS: Paracervical block was less effective than single-shot spinal analgesia. Both methods were associated with a low incidence of fetal bradycardia but maternal side effects were more common with single-shot spinal analgesia.

Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study.

BACKGROUND: This study evaluated efficacy, safety and patient satisfaction with incisional analgesia with a subfascial catheter compared to epidural analgesia for pain relief following caesarean section. METHODS: Forty patients were randomised after elective caesarean section to receive either intermittent 10-mL boluses of 0.125% levobupivacaine into the epidural space and physiologic saline into the surgical wound or intermittent 10-mL boluses of 0.25% levobupivacaine into the wound and epidural saline with a repeated 10-dose regimen. Analgesic efficacy was evaluated by numerical pain scores (0-10, 0=no pain, 10=worst pain) and based on the consumption of supplemental opioid. Side effects, patient satisfaction and plasma concentrations of levobupivacaine were recorded. RESULTS: In the epidural group average pain scores were lower (1.8 vs. 3, P=0.006) and the consumption of local anaesthetic (29 mL vs. 38 mL, P=0.01) was smaller during the first four postoperative hours, after which both groups had pain scores of 3 or less at rest. All parturients were able to walk after the 24-h study period. The total consumption of rescue opioid oxycodone (32 vs. 37 mg, P=0.6) during the whole 72-h study period was low in both study groups. Side effects were mild and rare. Satisfaction scores were equally high in the two groups. Peak plasma concentrations of levobupivacaine were below the toxic range. CONCLUSION: Incisional local analgesia via a subfascial catheter provided satisfactory pain relief with patient satisfaction comparable to that seen with epidural analgesia. This technique may be a good alternative to the more invasive epidural technique following caesarean section as a component of multimodal pain management.

Serum lipids and lipoproteins in postmenopausal women receiving transdermal oestrogen in combination with a levonorgestrel-releasing intrauterine device.

OBJECTIVES: To compare the effects of a non-oral combination of a transdermal oestradiol patch (50 micrograms daily) and an intrauterine device (IUD) releasing 20 micrograms of levonorgestrel daily on the serum pattern of lipids and lipoproteins with an established oral regimen of a daily dose of 2 mg of estradiol and 1 mg of noretisterone acetate. METHODS: An open, randomized study comprised of 40 healthy, early postmenopausal women. RESULTS: During 1 year the concentration of total cholesterol decreased 5.0% in the LNg-IUD group and 10.6% in the oral therapy group; HDL cholesterol decreased 10.9% and 12.8%, respectively, and HDL2 cholesterol decreased 18.1% and 26.9%, respectively. LDL cholesterol values did not change in the LNg-IUD group, whereas a 10.3% decrease was observed in the oral therapy group. Triglyceride values did not change in either group. There were no significant differences in the serum lipoprotein changes between the groups during the treatment. CONCLUSIONS: The use of a non-oral regimen of hormone replacement therapy has been advocated to minimize the effect of steroids on the liver. Its effects on the serum pattern of lipids and lipoproteins, however, did not differ significantly from those induced by a continuous oral treatment regimen.

Transdermal estrogen with a levonorgestrel-releasing intrauterine device for climacteric complaints: clinical and endometrial responses.

OBJECTIVE: Our purpose was to study the effects of intrauterine release of a daily dose of 20 micrograms levonorgestrel by an intrauterine device on climacteric symptoms, bleeding pattern, and endometrial histologic features in postmenopausal women receiving transdermal estrogen replacement therapy. STUDY DESIGN: Forty parous postmenopausal women were randomly allocated into two groups for 1 year: 20 women receiving a continuous transdermal daily dose of 50 micrograms of estradiol had a levonorgestrel-releasing intrauterine contraceptive device inserted, and the control group of 20 women received a continuous oral dose of 2 mg of estradiol valerate and 1 mg of norethisterone acetate daily. The climacteric symptoms, bleeding patterns, endometrial thickness, and endometrial changes in biopsy samples were analyzed. Serum levels of estradiol in both groups and levonorgestrel levels in the intrauterine device group were also determined. RESULTS: Both treatment regimens effectively relieved climacteric symptoms. Spotting was more common in the intrauterine contraceptive device group than in the oral therapy group for the first 3 months. After that, the proportion of women without any bleeding was similar in both groups. Two patients in each group dropped out because of bleeding. CONCLUSION: These preliminary findings suggest that the levonorgestrel-releasing intrauterine contraceptive device is a useful alternative mode of progestin administration for certain selected women receiving estrogen replacement therapy.

PIP: The purpose was to study the effects of intrauterine release of a daily dose of 20 mcg levonorgestrel by an IUD on climacteric symptoms, bleeding pattern, and endometrial histologic features in postmenopausal women receiving transdermal estrogen replacement therapy. 40 parous postmenopausal women were randomly allocated into 2 groups for 1 year. They were required to be parous, to have an intact uterus, and to have had amenorrhea for at least 6 months but less than 5 years. 20 women received a combination of 50 mcg of estradiol per 24 hours delivered transdermally from a patch, and received estrogen pretreatment for 1 month to make insertion of a levonorgestrel-releasing IUD (Levonova), which was installed a month later, easier. This combination was continued for 1 year. The control group of 20 women received an established form of continuous oral estrogen and progestin with a daily dose of 2 mg of estradiol, and 1 mg of norethindrone acetate also administered for 1 year. Checkup visits were scheduled at 3, 6, and 12 months. The climacteric symptoms, bleeding patterns, endometrial thickness, and endometrial changes in biopsy samples were analyzed. The increase in estradiol concentration was similar in both groups, and the mean concentrations of levonorgestrel in the IUD group were 216 +or- 25 pg/ml at 3 months, 209 +or- 11 pg/ml at 6 months, and 212 + 10.5 pg/ml at 12 months. Both treatment regimens effectively relieved climacteric symptoms. The IUD group experienced more days of bleeding, primarily spotting, during the first 3 months than did the oral therapy group but the differences between the groups had disappeared by 6 months. Both treatments resulted in an atrophic endometrium developing from a proliferative one. Two patients in each group dropped out because of bleeding. The levonorgestrel-releasing IUD is a useful alternative mode of progestin administration for certain selected women receiving estrogen replacement therapy.