Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients.

STUDY OBJECTIVE: To examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients. DESIGN: Retrospective cohort study. SETTING: Obstetrical unit at a tertiary care referral center. PATIENTS: Parturients receiving labor epidural analgesia with recognized unintentional dural puncture. INTERVENTIONS: Cases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache. MEASUREMENTS: Development of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay. MAIN RESULTS: Of the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ±â€¯1.8 vs. No morphine: 7.3 ±â€¯2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ±â€¯2.9 days vs. 3.0 ±â€¯1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96). CONCLUSION: In cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.

Efficacy of ropivacaine, bupivacaine, and levobupivacaine for labor epidural analgesia.

STUDY OBJECTIVE: To compare analgesic efficacy and intensity of motor block with continuous infusions of ropivacaine, bupivacaine, and levobupivacaine in combination with fentanyl for labor epidural analgesia. DESIGN: Prospective, randomized, double-blinded study. SETTING: Labor and delivery suite at Magee Womens Hospital, Pittsburgh, PA. PATIENTS: 162 ASA physical status I and II, full-term, primiparous women. INTERVENTIONS: All patients received epidural labor analgesia. Epidural medication consisted of an initial bolus of 8 mL local anesthetic with fentanyl (100 microg) followed by an infusion at 12 mL/h of local anesthetic with 2 microg/mL fentanyl. Patients were allocated to one of three groups, as follows: group 1 received bolus and infusion of bupivacaine 0.125%, group 2 received bolus and infusion of levobupivacaine 0.125%, and group 3 received a bolus of ropivacaine 0.2% and infusion of ropivacaine 0.1%. MEASUREMENTS: Maternal vital signs, pain visual analog scale (VAS) score, sensory levels, and motor block (Bromage score) were recorded every hour. Duration of first and second stage of labor and mode of delivery were also recorded. RESULTS: There were no statistically significant differences in pain VAS or Bromage motor scores among the three groups of patients at any of the measured time intervals. The time to achieve T10 sensory level and patient comfort was shorter in the ropivacaine (9.35 +/- 4.96 min) and levobupivacaine (9.56 +/- 4.71 min) groups than the bupivacaine (11.89 +/- 7.76 min) group, although this difference did not reach a statistically significant level (P = 0.06). The second stage was significantly shorter in the bupivacaine group, lasting 81.27 +/- 63.3 min, compared with the ropivacaine group (121.69 +/- 86.5 min) and the levobupivacaine (115.5 +/- 83.6 minutes) group (P = 0.04). CONCLUSION: There are no significant differences in pain VAS and Bromage scores between 0.1% ropivacaine, 0.125% bupivacaine, and 0.1% levobupivacaine given for labor epidural analgesia.

Nitrous oxide anxiolysis for elective cesarean section.

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.

Induction of labor with oxytocin increases cesarean section rate as compared with oxytocin for augmentation of spontaneous labor in nulliparous parturients controlled for lumbar epidural analgesia.

STUDY OBJECTIVES: To study labor outcomes in parturients receiving oxytocin for augmentation or induction of labor, in the presence of labor epidural analgesia. DESIGN: Retrospective study of data from a continuous quality improvement database. SETTING: Tertiary-care hospital with more than 8000 deliveries per annum. MEASUREMENTS AND MAIN RESULTS: Of the 1671 healthy nulliparous women with singleton pregnancies and who requested labor epidural analgesia at our institution, 675 patients received oxytocin during elective induction of labor, whereas 996 patients received oxytocin for augmentation of spontaneous labor. Measured variables were cervical dilatation at time of epidural analgesia request, epidural insertion to 10-cm time, duration of stage 2 of labor, normal spontaneous vaginal delivery rate, cesarean section rate, operative vaginal delivery rate, and baby weight. Women admitted for induction of labor requested epidural analgesia sooner than those who had their labor augmented (p < 0.001). The incidence of cesarean section was higher in the induced group (p = 0.008). CONCLUSION: Patients who have their labor induced request analgesia sooner and are at a higher risk of cesarean section than are patients who go into labor spontaneously. Any study that purports to assess the effects of epidural analgesia in labor should distinguish between induced and augmented/spontaneous labor.

Amniotic fluid embolism with second trimester pregnancy termination: a case report.

PURPOSE: Describe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination. CLINICAL FEATURES: A 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event. CONCLUSIONS: It is now recognized that the pathophysiological features of AFE are similar to a type-1 hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.

Epidural labor analgesia for a patient with disseminated lymphangiomatosis.

IMPLICATIONS: We describe a case of a parturient with disseminated lymphangiomatosis involving the thorax, retroperitoneum, and lumbar vertebrae who received epidural labor analgesia. Clinical presentations vary depending on the organ systems involved, the extent of the disease, and the stage of pregnancy. Anesthetic implications are discussed.

Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy.

IMPLICATIONS: A single shot spinal anesthetic is not practical in a patient with a lumboperitoneal shunt. Neuraxial block and a blood patch (if necessary) may be performed in a patient on enoxaparin therapy if current guidelines for managing patients on anticoagulant therapy are followed.

Does spinal anesthesia cause hearing loss in the obstetric population?

UNLABELLED: Lumbar puncture is believed to cause hypoacousis by causing cerebrospinal fluid leakage in older individuals. We hypothesized that parturients undergoing subarachnoid block (SAB) may experience hearing loss. We evaluated the effects of SAB on hearing in parturients undergoing elective cesarean delivery. We also compared two types of spinal needles: a pencil-point needle (24-gauge Sprotte needle) and a cutting needle (25-gauge Quincke needle). Sixty patients were studied: 20 received lumbar epidural block for labor analgesia (controls), 20 received a SAB with a Sprotte needle, and 20 others received a SAB with a Quincke needle for cesarean delivery. A tone audiometer was used to test for that decibel level at which the patient heard 125-, 250-, 500-, 1000-, 2000-, 4000-, and 8000-Hz frequencies. The hearing test was performed before anesthesia, after delivery, and on the first and second postoperative days. The results were analyzed by using repeated-measures analysis of variance at P < 0.05. No patient from any of the three groups developed a hearing loss either at low or high frequencies. Spinal anesthesia does not lead to significant hearing loss when a pencil- or a cutting-point needle is used in the obstetric population. IMPLICATIONS: Sixty obstetric patients were enrolled in the study to examine the possible effects of spinal anesthesia on their hearing. By using an audiometer, the patient's hearing was evaluated before delivery, after delivery, and for the following 2 days. There was no significant change of hearing in any of the patients.