A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia.

BACKGROUND: We designed this prospective, double-blind, randomized study to examine whether a dural puncture without intrathecal drug administration immediately before epidural drug administration would improve labor analgesia when compared to a traditional epidural technique without prior dural puncture. METHODS: Eighty nulliparous parturients with cervical dilation less than 5 cm were randomly assigned to receive a standardized epidural technique, with or without a single dural puncture with a 25-gauge (G) Whitacre spinal needle. After successful placement of the needle(s) and the epidural catheter, 12 mL of bupivacaine 2.5 mg/mL was administered through the epidural catheter and a patient-controlled epidural infusion of bupivacaine 1.25 mg/mL + fentanyl 2 mug/mL was initiated. The presence of sacral analgesia (S1) and pain scores were compared between groups. RESULTS: In demographically similar groups, parturients with prior dural puncture had more frequent blockade of the S1 dermatome (absolute risk difference [95% confidence interval] 22% [6-39]), more frequent visual analog scale scores <10/100 at 20 min (absolute risk difference 20% [1-38]), and reduced one-sided analgesia (absolute risk difference [95% CI] 17% [2-330]). The highest median sensory level (T10) was no different between groups. CONCLUSIONS: Dural puncture with a 25-G spinal needle immediately before the initiation of epidural analgesia improves the sacral spread, onset, and bilateral pain relief produced by analgesic concentrations of bupivacaine with fentanyl in laboring nulliparous patients.

Transdermal scopolamine for prevention of intrathecal morphine-induced nausea and vomiting after cesarean delivery.

BACKGROUND: Intrathecal morphine for cesarean delivery provides excellent postoperative analgesia but is associated with significant nausea and vomiting. METHODS: We compared the antiemetic efficacy of transdermal scopolamine, IV ondansetron, and placebo during the first 24 h postoperatively. Two-hundred forty women undergoing cesarean delivery under spinal anesthesia were randomly allocated, in a double-blind study design, to receive transdermal scopolamine 1.5 mg, ondansetron 4 mg, or placebo at the time of cord clamping. RESULTS: Our study showed that the overall rates for all emesis were 59.3% in the placebo group and were reduced to 40% in the scopolamine group and 41.8% in the ondansetron group. The greatest reduction in emesis in the scopolamine group when compared with placebo was in the 6-24 h time period. CONCLUSION: Scopolamine is an effective medication for prophylactic use in parturients receiving intrathecal morphine while undergoing cesarean delivery. Its use, however, was associated with a higher incidence of side effects such as dry mouth and blurry vision.

Cesarean delivery in the interventional radiology suite: a novel approach to obstetric hemostasis.

BACKGROUND: The adjunctive use of interventional radiology procedures to minimize and control bleeding at the time of cesarean delivery has become increasingly common. These procedures require modern imaging equipment and supplies not available in traditional operating rooms. METHODS: We describe three women who strongly desired continued reproductive function in clinical circumstances where postpartum hemorrhage and hysterectomy were likely. RESULTS: Cesarean delivery was performed in the interventional radiology suite after selective uterine artery balloon placement and/or embolotherapy, which successfully minimized blood loss during delivery. CONCLUSION: We propose that this novel surgical location is feasible, and may offer advantages in select patients.

Laparoscopic surgery during pregnancy.

PURPOSE OF REVIEW: In the past decade, laparoscopic procedures have become increasingly popular owing to decreased morbidity and convalescence compared with open procedures. The purpose of this review is to evaluate recent literature on laparoscopic surgery in pregnancy and make recommendations for anesthesia based on understanding of physiology of carbon dioxide pneumoperitoneum. RECENT FINDINGS: Increasing numbers of successful cases of laparoscopic surgery are being reported. For reasons unknown, the results obtained in sheep studies do not match the observations in humans. Maternal respiratory acidosis, a common finding in sheep studies during CO2 pneumoperitoneum has not been observed in pregnant women undergoing laparoscopic surgery. A recent finding of persisting fetal sheep hypoxia beyond the duration of CO2 pneumoperitoneum calls for further investigation to determine if this finding is limited to sheep akin to sheep maternal respiratory acidosis. SUMMARY: Present evidence suggests laparoscopic surgery in pregnancy is a safe option. Left uterine displacement, maintaining end-tidal carbon dioxide between 32-34 mmHg and maternal blood pressures within 20% of baseline, and limiting abdominal insufflation pressure of carbon dioxide to 12-15 mmHg are essential hallmarks of anesthesia procedure. Although no apparent long time consequences have been reported, further studies are necessary to confirm the validity of sheep fetal hypoxia studies.

Laryngeal nerve monitoring during thyroid surgery in pregnancy.

A 32-week parturient required partial thyroidectomy for suspicious carcinoma. The surgeon requested laryngeal nerve monitoring to decrease the chances of laryngeal nerve injury during surgery. After rapid-sequence induction of general anesthesia and intubation, a size 3 laryngeal mask airway was inserted posterior to the endotracheal tube and the cuff inflated with 15 mL of air. A fiberoptic bronchoscope inserted through the laryngeal mask airway provided an unhindered view of vocal cords for laryngeal nerve identification and testing during surgery. This combined technique also offered the advantages of a secured airway, as well as positive pressure ventilation in the parturient during thyroid surgery.