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.

Perceived effects and recovery in Oklahoma City firefighters.

This survey of 325 Oklahoma City Firefighters examined their perceptions of the effect of the bombing, their recovery and their sources of support. Other variables that were considered in this analysis included age, usefulness of the Critical Incidence Stress Management (CISM) procedures, and attitude, an aggregate variable that accounted for job satisfaction. Of particular importance in this analysis was the finding that support from "faith" was a primary predictor of positive outcome and positive attitude over the one-year period. However, the effect of the variable differed for older and younger firefighters. That is, there was a greater proportion of younger firefighters among those reporting greater support from faith. These data suggest that, at least in this geographic area, chaplains, and other spiritual leaders may play a particularly important role in the aftermath of such a disaster.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT): a multicenter pilot trial/survey.

BACKGROUND: Whether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted. METHODS: A written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate. RESULTS: Seven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not. CONCLUSIONS: No agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

Epidural analgesia during labor.

Epidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturients given intrapartum epidural analgesia is reported to be over 50 percent at many institutions in the United States. The procedure has few contraindications, the primary ones being patient refusal, maternal hemorrhage and coagulopathy. Induction of epidural analgesia in early labor remains controversial. However, many physicians induce analgesia as soon as the diagnosis of active labor has been established and the patient has requested pain relief. The most common complications occurring with epidural analgesia are maternal hypotension and postdural puncture headache. Retrospective studies have demonstrated an association between epidural analgesia and increases in duration of labor, instrumental vaginal delivery and cesarean section for labor. However, several recent prospective studies have concluded that epidural analgesia does not adversely affect the progress of labor or increase the rate of cesarean section. These remain controversial issues among practicing physicians.

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.

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.

Postpartum tubal ligation after pregnancy complicated by preeclampsia or gestational hypertension.

OBJECTIVE: To determine the anesthetic and surgical morbidity associated with postpartum tubal ligation after pregnancy complicated by pregnancy-induced hypertension. METHODS: Preoperative hemodynamic measurements, laboratory results, choice of anesthetic technique, intraoperative hemodynamic changes, and postoperative morbidity were compared in 53 women with pregnancy-induced hypertension (hypertensive group) and 53 controls who underwent postpartum tubal ligation between October 1992 and November 1995. We used a retrospective case-control design. RESULTS: Preoperative mean blood pressure (BP) measurements ( +/- standard deviation) were greater in hypertensive women than in controls (158 +/- 22/91 +/- 12 versus 126 +/- 13/71 +/- 10 mmHg; P < .001). Among women given spinal anesthetics for tubal ligation, the minimum intraoperative systolic BP was significantly lower in controls than in hypertensive women (P < .05). However, the maximum percentage decrease in systolic BP was greater in hypertensive women than in controls (33 +/- 14 versus 22 +/- 10%; P < .05). Only one patient in each group developed intraoperative hypertension. The percentage of patients discharged later than the first postoperative day was greater in hypertensive women than in controls (23 versus 8%; P < .05). CONCLUSION: The lack of profound hemodynamic responses during spinal or general anesthesia for postpartum tubal ligation supports the continued use of this procedure in selected women with pregnancy-induced hypertension.

Tubal versus uterine transfer of cryopreserved embryos: a prospective randomized trial.

OBJECTIVE: To compare pregnancy rates after fallopian tubal and uterine transfer of cryopreserved embryos. DESIGN: Prospective randomized trial with assignment to treatment groups by a random number table. SETTING: University of Iowa Hospitals and Clinics, a tertiary care academic institution. PATIENTS: Forty patients with patent fallopian tubes and at least three cryopreserved embryos. INTERVENTIONS: Cryopreserved embryos were thawed and transferred to the fallopian tube by laparoscopy or to the uterus by a transcervical catheter. MAIN OUTCOME MEASURES: Clinical and ongoing pregnancy rates. RESULTS: Tubal transfer of cryopreserved embryos resulted in statistically higher clinical (68% versus 24%) and ongoing pregnancy rates (58% versus 19%) when compared with uterine transfer. CONCLUSIONS: Tubal transfer of cryopreserved embryos is highly effective and offers an improved pregnancy rate when compared with uterine transfer of embryos. This method of transfer should be considered in patients with patent fallopian tubes and at least three cryopreserved embryos.

An evaluation of the effect of anesthetic technique on reproductive success after laparoscopic pronuclear stage transfer. Propofol/nitrous oxide versus isoflurane/nitrous oxide.

BACKGROUND: Laparoscopic pronuclear stage transfer (PROST) is the preferred method of embryo transfer after in vitro fertilization in many infertility programs. There are scant data to recommend the use or avoidance of any particular anesthetic agent for use in women undergoing this procedure. The authors hypothesized that propofol would be an ideal anesthetic for laparoscopic PROST because of its characteristic favorable recovery profile that includes minimal sedation and a low incidence of postoperative nausea and vomiting. The purpose of the study was to compare propofol and isoflurance with respect to postanesthetic recovery and pregnancy outcomes after laparoscopic PROST. METHODS: One hundred twelve women scheduled for laparoscopic PROST were randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance of anesthesia. RESULTS: Visual analog scale scores for sedation were lower in the propofol group than in the isoflurance group at all measurements between 30 min and 3 h after surgery. More women experienced emesis and were given an antiemetic during recovery in the isoflurance group than in the propofol group. However, the percentage of pregnancies with evidence of fetal cardiac activity was 54% in the isoflurane group compared with only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy rate was greater in the isoflurane group than in the propofol group (54% vs. 29%, P = 0.014). CONCLUSIONS: Propofol/nitrous oxide anesthesia was associated with lower clinical and ongoing pregnancy rates compared with isoflurane/nitrous oxide anesthesia.

Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin?

BACKGROUND: Some studies suggest that epidural analgesia prolongs labor and increases the incidence of cesarean section, especially if it is administered before 5 cm cervical dilation. The purpose of the current study was to determine whether early administration of epidural analgesia affects obstetric outcome in nulliparous women who are receiving intravenous oxytocin. METHODS: Informed consent was obtained from healthy nulliparous women with a singleton fetus in a vertex presentation, who requested epidural analgesia while receiving intravenous oxytocin at at least 36 weeks' gestation. Each patient was randomized to receive either early or late epidural analgesia. Randomization occurred only after the following conditions were met: (1) the patient requested pain relief at that moment, (2) a lumbar epidural catheter had been placed, and (3) the cervix was at least 3 but less than 5 cm dilated. Patients in the early group immediately received epidural bupivacaine analgesia. Patients in the late group received 10 mg nalbuphine intravenously. Late-group patients did not receive epidural analgesia until they achieved a cervical dilation of at least 5 cm or until at least 1 h had elapsed after a second dose of nalbuphine. RESULTS: Early administration of epidural analgesia did not prolong the interval between randomization and the diagnosis of complete cervical dilation, and it did not increase the incidence of malposition of the vertex at delivery. Also, early administration of epidural analgesia did not result in an increased incidence of cesarean section or instrumental vaginal delivery. Thirteen (18%) of 74 women in the early group and 14 (19%) of 75 women in the late group underwent cesarean section (relative risk for the early group 0.94; 95% confidence interval 0.48-1.84). Patients in the early group had lower pain scores between 30 and 120 min after randomization, and were more likely to experience transient hypotension. Infants in the late group had lower umbilical arterial and venous blood pH and higher umbilical arterial and venous blood carbon dioxide tension measurements at delivery. CONCLUSIONS: Early administration of epidural analgesia did not prolong labor or increase the incidence of operative delivery, when compared with intravenous nalbuphine followed by late administration of epidural analgesia, in nulliparous women who were receiving intravenous oxytocin.

Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor?

BACKGROUND: Some studies suggest that epidural analgesia prolongs labor and increases the incidence of cesarean section, especially if it is administered before 5 cm cervical dilation. The purpose of the current study was to determine whether early administration of epidural analgesia affects obstetric outcome in nulliparous women who are in spontaneous labor. METHODS: Informed consent was obtained from 344 healthy nulliparous women with a singleton fetus in a vertex presentation, who requested epidural analgesia during spontaneous labor at at least 36 weeks' gestation. Each patient was randomized to receive either early or late epidural analgesia. Randomization occurred only after the following conditions were met: (1) the patient requested pain relief at that moment, (2) a lumbar epidural catheter had been placed, and (3) the cervix was at least 3 cm but less than 5 cm dilated. Patients in the early group immediately received epidural bupivacaine analgesia. Patients in the late group received 10 mg nalbuphine intravenously. Late-group patients did not receive epidural analgesia until they achieved a cervical dilation of at least 5 cm or until at least 1 h had elapsed after a second dose of nalbuphine. Ten of the 344 patients were excluded because of a protocol violation or voluntary withdrawal from the study. RESULTS: Early administration of epidural analgesia did not increase the incidence of oxytocin augmentation, prolong the interval between randomization and the diagnosis of complete cervical dilation, or increase the incidence of malposition of the vertex at delivery. Also, early administration of epidural analgesia did not result in an increased incidence of cesarean section or instrumental vaginal delivery. Seventeen (10%) of 172 women in the early group and 13 (8%) of 162 women in the late group underwent cesarean section (relative risk for the early group 1.22; 95% confidence interval 0.62-2.40). Patients in the early group had lower pain scores between 30 and 150 min after randomization. Infants in the late group had lower umbilical arterial and venous blood pH and higher umbilical venous blood carbon dioxide tension measurements at delivery. CONCLUSIONS: Early administration of epidural analgesia did not prolong labor, increase the incidence of oxytocin augmentation, or increase the incidence of operative delivery, when compared with intravenous nalbuphine followed by late administration of epidural analgesia, in nulliparous women who were in spontaneous labor at term.

Ephedrine remains the vasopressor of choice for treatment of hypotension during ritodrine infusion and epidural anesthesia.

BACKGROUND: Historically, ephedrine has been the vasopressor of choice for treatment of most cases of hypotension in obstetric patients. However, the choice of vasopressor in the parturient receiving a beta-adrenergic agent for tocolysis has not been evaluated extensively. The current study evaluated whether ephedrine or phenylephrine better restores uterine blood flow and fetal oxygenation during ritodrine infusion and epidural anesthesia-induced hypotension in gravid ewes. METHODS: Fourteen chronically instrumented gravid ewes between 0.8 and 0.9 timed gestational age were used. On separate days, each animal underwent the experimental protocol with one of three agents: ephedrine, phenylephrine, and normal saline-control. The experimental protocol was as follows: (1) at time zero, intravenous infusion of ritodrine was begun; (2) at 120 min, 2% lidocaine was given epidurally to achieve a sensory level of at least T6; and (3) at 135 min, an intravenous bolus of either ephedrine, phenylephrine, or normal saline-control was given, followed by a continuous intravenous infusion of the same agent for 30 min. In the ephedrine and phenylephrine experiments, the rate of infusion was adjusted to maintain maternal mean arterial pressure close to baseline. RESULTS: Ritodrine infusion alone significantly increased maternal heart rate and cardiac output in all three groups. Epidural anesthesia during ritodrine infusion significantly decreased maternal mean arterial pressure, heart rate, cardiac output, uterine blood flow, and fetal arterial oxygen tension for each of the three groups. Both ephedrine and phenylephrine restored maternal mean arterial pressure to baseline, as designed. Ephedrine significantly increased uterine blood flow and fetal arterial oxygen tension when compared with normal saline--control, but phenylephrine did not. Phenylephrine significantly increased uterine vascular resistance when compared with normal saline--control, but ephedrine did not. CONCLUSIONS: Although ephedrine and phenylephrine provided similar restoration of maternal mean arterial pressure, ephedrine was superior to phenylephrine in restoring uterine blood flow during ritodrine infusion and epidural anesthesia-induced hypotension in gravid ewes. Also, ephedrine, but not phenylephrine, significantly improved fetal oxygenation, when compared to normal saline--control.

The effects of epidural anesthesia on uterine vascular resistance, plasma arginine vasopressin concentrations, and plasma renin activity during hemorrhage in gravid ewes.

In an earlier study, epidural anesthesia increased uterine vascular resistance and fetal acidosis during hemorrhage in gravid ewes. But, it is unclear whether epidural anesthesia modifies the uterine vascular resistance response during hemorrhage, independent of changes in arterial blood pressure. The purpose of this study was to determine the effects of epidural anesthesia on: 1) the mean arterial pressure/uterine vascular resistance relationship; and 2) arginine vasopressin concentrations and plasma renin activity during hemorrhage in gravid ewes. Twenty-four experiments were performed in 12 chronically instrumented animals between 0.8 and 0.9 of timed gestation. The experimental sequence included: 1) T = 0 min: epidural administration of 0.5% bupivacaine (epidural group) or normal saline (control group); 2) T = 30 min: maternal hemorrhage 0.5 mL.kg-1 x min-1 until maternal mean arterial pressure was 60% of baseline measurements (time H); 3) T = H to H + 60 min: adjust hemorrhage to maintain maternal mean arterial pressure at 60% of baseline. At 30 min, epidural bupivacaine resulted in a median sensory level of T-8 in the epidural group. At that time, uterine vascular resistance was similar in both groups despite lower (P = 0.0001) mean arterial pressure in the epidural group. Between H and H + 60 min, uterine vascular resistance was lower (P = 0.045) in the epidural group than in the control group. Also, fetal PCO2 was lower (P = 0.020) in the epidural group than in the control group, but fetal pH and PO2 did not differ significantly between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural anesthesia for postpartum tubal ligation using epidural catheters placed during labor.

STUDY OBJECTIVES: To evaluate the success of epidural anesthesia for postpartum tubal ligation using epidural catheters placed during labor and to determine whether patient characteristics, timing of surgery, or technical factors (e.g., length of epidural catheter inserted into the epidural space) influenced the success of subsequent epidural anesthesia. DESIGN: Retrospective study. SETTING: University hospital labor and delivery suite. PATIENTS: 90 consecutive women scheduled for postpartum tubal ligation using epidural catheters placed during labor. INTERVENTIONS: Epidural catheters were reinjected with 1.5% to 2% lidocaine with epinephrine 5 micrograms/ml or 2% to 3% 2-chloroprocaine immediately before surgery. MEASUREMENTS AND MAIN RESULTS: 74% of the women received satisfactory intraoperative anesthesia using in situ epidural catheters. Reinjecting the catheter within 4 hours of delivery was associated with a greater frequency of successful epidural anesthesia for tubal ligation (95% vs. 67%; p = 0.029). There was no significant difference between the two groups in the length of catheter inserted into the epidural space. CONCLUSIONS: Although other factors may influence the timing of postpartum tubal ligation after delivery, the success of epidural anesthesia for tubal ligation using in situ epidural catheters is greater if surgery is performed shortly after delivery.

Which vasopressor should be used to treat hypotension during magnesium sulfate infusion and epidural anesthesia?

Ephedrine restores and/or protects uterine blood flow and fetal well-being in laboratory animals. In contrast, alpha 1-adrenergic agonists worsen uterine blood flow and fetal condition. We previously demonstrated that magnesium sulfate (MgSO4) attenuates the detrimental effects of phenylephrine on uterine vascular resistance in gravid ewes. Therefore, we performed this study to determine whether ephedrine or phenylephrine better restores and protects uterine blood flow and fetal oxygenation during epidural anesthesia-induced hypotension in hypermagnesemic gravid ewes. Twelve chronically instrumented gravid ewes were each used for three experiments: 1) ephedrine, 2) phenylephrine, and 3) normal saline (NS)-control. For each experiment the protocol was as follows: 1) at time zero, intravenous infusion of MgSO4 was begun; 2) at 150 min a thoracic level of epidural anesthesia was achieved with 2% lidocaine; and 3) at 165 min, an intravenous infusion of ephedrine, phenylephrine, or NS was begun and continued through 195 min. Epidural anesthesia uniformly decreased maternal mean arterial blood pressure (MAP), heart rate, cardiac output, uterine blood flow, and fetal PO2 in each of the three groups. Both ephedrine and phenylephrine restored maternal MAP to baseline, as expected from the experimental design. Ephedrine significantly increased cardiac output and uterine blood flow when compared with NS-control, but phenylephrine did not. Phenylephrine significantly increased uterine vascular resistance when compared with NS-control, but ephedrine did not. As a result, fetal pH and PO2 were significantly greater during ephedrine infusion than during infusion of NS-control. Fetal pH was stable during ephedrine infusion, but it continued to decrease during phenylephrine infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural anesthesia worsens uterine blood flow and fetal oxygenation during hemorrhage in gravid ewes.

Recent studies suggest that epidural anesthesia initiated before hemorrhage may improve survival and acid-base status in laboratory animals. However, studies of hemorrhagic shock in nonpregnant animals may not be applicable to less severe hemorrhage in pregnant animals. The purpose of this study was to determine whether epidural anesthesia alters maternal and fetal hemodynamic and acid-base responses to hemorrhage in gravid ewes. Twenty-four experiments were performed in twelve chronically instrumented animals between 0.8 and 0.9 of timed gestation. The experimental sequence included: 1) T = 0 min: normal saline 500 ml intravenously; 2) T = 15 min: epidural administration of 0.5% bupivacaine (epidural group) or normal saline (control group); 3) T = 30 min: epidural administration of additional 0.5% bupivacaine (epidural group only) if the sensory level of anesthesia was below T10; 4) T = 45 min: maternal hemorrhage 20 ml/kg over 55 min; and 5) T = 110 min: transfusion of collected maternal blood over 55 min. At 45 min (i.e., 30 min after the epidural injection of bupivacaine), epidural bupivacaine resulted in a median sensory level of T9 in the epidural group. At that time, maternal mean arterial pressure was less (P less than 0.05) in the epidural group than in the control group (14 +/- 2% below baseline versus 4 +/- 1% above baseline, respectively). Maternal mean arterial pressure, heart rate, cardiac output, and uterine blood flow, and fetal PO2 and pH all were significantly less during hemorrhage (P less than 0.05) in the epidural group than in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Does epidural fentanyl decrease the efficacy of epidural morphine after cesarean delivery?

Earlier studies have suggested that epidural fentanyl improves intraoperative analgesia during cesarean section, but others have suggested that it worsens postoperative analgesia from epidural morphine. The purpose of this study was to determine whether epidural fentanyl given before epidural morphine improves the quality of intraoperative epidural anesthesia without worsening postoperative analgesia provided by epidural morphine. Sixty patients having epidural anesthesia for cesarean delivery were studied. Epidural anesthesia was established using 2% lidocaine with epinephrine 5 micrograms/mL. After delivery, either fentanyl 100 micrograms/10 mL or normal saline-control 10 mL was injected through the epidural catheter in a randomized, double-blind manner. All patients received 3.5 mg of morphine epidurally after uterine repair. After administration of the epidural study drug, there were no significant differences in the pain responses during surgery between the two groups. Patients in the fentanyl group experienced significantly less nausea and vomiting between delivery and the end of surgery than did patients in the normal saline-control group (P = 0.013). Postoperatively, visual analogue scale scores for pain, pruritus, nausea, and sedation were similar at 1, 2, 4, and 8 h in the two groups. We conclude that fentanyl 100 micrograms administered epidurally during cesarean delivery did not improve intraoperative analgesia, but significantly reduced intraoperative nausea and vomiting without diminishing the efficacy of postoperative analgesia provided by epidural morphine.

Does calcium chloride help restore maternal blood pressure and uterine blood flow during hemorrhagic hypotension in hypermagnesemic gravid ewes?

Magnesium sulfate worsens maternal hypotension and fetal oxygenation during hemorrhage in gravid ewes. The purpose of this study was to determine whether calcium chloride administration is a useful adjunct to blood transfusion during hemorrhagic hypotension in hypermagnesemic gravid ewes. Sixteen experiments were performed in eight chronically instrumented animals between 0.8 and 0.9 of timed gestation. The experimental sequence included (a) T = 0: magnesium sulfate 4 g IV; (b) T = 5: infusion of magnesium sulfate 4 g/h IV; (c) T = 90: maternal hemorrhage 20 mL/kg over 55 min; (d) T = 147: calcium chloride 10 mg/kg or normal saline (NS-control) 0.1 mL/kg IV; (e) T = 160: transfusion of collected maternal blood over 55 min. Magnesium sulfate alone slightly decreased maternal mean arterial pressure (P = 0.002) and increased uterine blood flow (P = 0.0001) in both groups before hemorrhage. During hemorrhage, maternal mean arterial pressure, cardiac output, and uterine blood flow, and fetal PO2 and pH all decreased sharply (P = 0.0001). Cardiac output increased (P = 0.0005) modestly just after the intravenous bolus of calcium chloride. Maternal mean arterial pressure was significantly higher (P = 0.03) during transfusion in the calcium chloride group than in the NS-control group, but only after mean arterial pressure was near baseline measurements. Maternal uterine blood flow and fetal PO2 and pH responses over time were similar in the two groups. We conclude that intravenous administration of calcium chloride (10 mg/kg) transiently increased cardiac output during hemorrhagic hypotension and slightly increased mean arterial pressure during transfusion in hypermagnesemic gravid ewes.(ABSTRACT TRUNCATED AT 250 WORDS)