Multidisciplinary management of idiopathic intracranial hypertension in pregnancy: case series and narrative review

Abstract Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by raised intracranial pressure of unknown etiology with normal cerebrospinal fluid (CSF) composition and no brain lesions. It occurs in pregnant patients at approximately the same frequency as in general population, but obstetric and anesthetic management of the pregnancy and labor remains controversial. In this article we provide a multidisciplinary review of the main aspects of IIH in pregnancy including treatment options, mode of delivery and anesthetic techniques. Additionally, we report three cases of pregnant women diagnosed with IIH between 2012 and 2019 in our institution.

Multidisciplinary management of idiopathic intracranial hypertension in pregnancy: case series and narrative review.

Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by raised intracranial pressure of unknown etiology with normal cerebrospinal fluid (CSF) composition and no brain lesions. It occurs in pregnant patients at approximately the same frequency as in general population, but obstetric and anesthetic management of the pregnancy and labor remains controversial. In this article we provide a multidisciplinary review of the main aspects of IIH in pregnancy including treatment options, mode of delivery and anesthetic techniques. Additionally, we report three cases of pregnant women diagnosed with IIH between 2012 and 2019 in our institution.

Epidural analgesia in the obese obstetric patient: a retrospective and comparative study with non-obese patients at a tertiary hospital.

BACKGROUND AND OBJECTIVES: Obesity is becoming a frequent condition among obstetric patients. A high body mass index (BMI) has been closely related to a higher difficulty to perform the neuraxial technique and to the failure of epidural analgesia. Our study is aimed at analyzing obese obstetric patients who received neuraxial analgesia for labor at a tertiary hospital and assessing aspects related to the technique and its success. METHODS: Retrospective observational descriptive study during one year. Women with a BMI higher than 30 were identified, and variables related to the difficulty and complications of performing the technique, and to analgesia failure rate were assessed. RESULTS AND CONCLUSIONS: Out of 3653 patients, 27.4% had their BMI ≥ 30 kg.m-². Neuraxial techniques are difficult to be performed in obese obstetric patients, as showed by the number of puncture attempts (≥ 3 in 9.1% obese versus 5.3% in non-obese being p < 0.001), but the incidence of complications, as hematic puncture (6.6%) and accidental dural puncture (0.7%) seems to be similar in both obese and non-obese patients. The incidence of cesarean section in obese patients was 23.4% (p <  0.001). Thus, an early performance of epidural analgesia turns out to be essential to control labor pain and to avoid a general anesthesia in such high-risk patients.

Neuraxial labor analgesia: a literature review / Analgesia de parto no neuroeixo: uma revisão da literatura

Abstract The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

Resumo O uso de técnicas de analgesia para o trabalho de parto tem se tornado cada vez mais frequente. As técnicas neuroaxiais são as mais comumente usadas e de maior eficácia. A dor do trabalho de parto traz uma série de consequências fisiológicas que podem ser negativas para a mãe e para o feto, e por isso deve ser tratada. Esta revisão de literatura foi feita na base de dados PubMed, de julho a novembro de 2016, e foram incluídos artigos em inglês ou portuguê publicados entre 2011 e 2016, ou mais antigos que fossem relevantes ao tema. As técnicas foram divididas nos tópicos: indução (peridural, raquiperidural combinada, raquianestesia contínua e peridural com punção dural) e manutenção da analgesia (infusão peridural contínua, analgesia peridural controlada pela paciente e bolus peridural intermitente). A analgesia peridural não altera a incidência de cesarianas nem o prognóstico fetal, e o desejo materno é indicação suficiente para seu início. A técnica combinada apresenta como vantagem um início mais rápido da analgesia, entretanto as pacientes estão sujeitas a maior incidência de prurido decorrente da administração intratecal de opioides. A analgesia controlada pela paciente parece ser uma excelente técnica, diminui o consumo de anestésicos locais e o número de intervenções do anestesiologista e aumenta a satisfação materna.

[Neuraxial labor analgesia: a literature review]. / Analgesia de parto no neuroeixo: uma revisão da literatura.

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural-spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient-controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient-controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.

Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block / Bloqueio combinado raquiperidural para analgesia de parto. Estudo comparativo com bloqueio peridural contínuo

Abstract Introduction: Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia. Methods: Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 cm, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1st and 2nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded. Results: At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5 ± 1.5 min) when compared to GII (11.6 ± 4.6 min) p = 0.01; pain scores in the first and second stages of delivery were lower in GI (0.9 ± 0.3 and 1.8 ± 0.7, respectively) when compared to GII (1.9 ± 0.6 and 2.2 ± 0.5, respectively), with p = 0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p = 0.045) and more frequent use of instrumental (p = 0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p = 0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p = 0.02). Conclusion: The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Resumo Introdução: O bloqueio peridural lombar constitui técnica eficaz e rotineiramente empregada para alívio da dor do parto e o bloqueio combinado raquiperidural tem como benefícios o emprego de doses menores de anestésicos locais e rápido início de analgesia. O objetivo do estudo foi avaliar comparativamente a eficácia e a segurança de duas técnicas anestésicas: bloqueio combinado raquiperidural e peridural contínua em grávidas submetidas à analgesia de parto. Método: Oitenta gestantes, ASA 2 e 3, apresentação cefálica e dilatação cervical entre cinco e seis centímetros, submetidas à analgesia de parto, distribuídas em dois grupos de acordo com a técnica anestésica: técnica combinada raquiperidural (GI) e peridural contínua (GII). Avaliaram-se: intensidade de dor antes do bloqueio; tempo para completa analgesia; grau do bloqueio motor; tempo para dilatação cervical total; duração do 2° estágio do trabalho de parto; intensidade de dor durante o 1° e o 2° estágio do trabalho de parto; tipo de parto; uso de ocitocina durante trabalho de parto; parâmetros cardiocirculatórios, respiratórios e eventos adversos maternos; repercussões neonatais. Resultados: No momento da anestesia a intensidade de dor era semelhante em ambos os grupos. O alívio da dor foi mais rápido no GI (4,5 ± 1,5 min) quando comparado com o GII (11,6 ± 4,6 min) p = 0,01; os escores de dor no primeiro e segundo estágios de parto foram menores no GI (0,9 ± 0,3) e (1,8 ± 0,7) quando comparados com o GII (1,9 ± 0,6) e (2,2 ± 0,5) com p = 0,01 somente no primeiro estágio de trabalho de parto; houve necessidade de complementação com anestésicos locais no GII; partos espontâneos mais frequentes em GI (80% das pacientes) do que em GII (50%) p = 0,045 e instrumentais mais frequentes (p = 0,03) em GII (12 pacientes) quando comparadas com o GI (quatro pacientes); a frequência de partos cesáreos foi significativamente maior (p = 0,02) no Grupo II do que no Grupo I, quatro casos no GI e oito no GII; ausência de alterações cardiocirculatórias e respiratórias maternas e repercussões neonatais; prurido mais frequente no GI (10 pacientes) e (0 paciente no GII) p = 0,02. Conclusão: O bloqueio combinado mostrou-se eficaz com melhor qualidade de analgesia e maior conforto às gestantes, constitui boa opção para a prática de analgesia obstétrica.

[Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block]. / Bloqueio combinado raquiperidural para analgesia de parto. Estudo comparativo com bloqueio peridural contínuo.

INTRODUCTION: Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia. METHODS: Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 centimeters, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1st and 2nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded. RESULTS: At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5±1.5min) when compared to GII (11.6±4.6min) p=0.01; pain scores in the first and second stages of delivery were lower in GI (0.9±0.3 and 1.8±0.7, respectively) when compared to GII (1.9±0.6 and 2.2±0.5, respectively), with p=0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p=0.045) and more frequent use of instrumental (p=0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p=0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p=0.02). CONCLUSION: The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Descripción de la Cronología del Dolor de las Contracciones Uterinas para Analgesia del Trabajo de Parto, una tarea pendiente / Description of the chronology of the pain of uterine contractions for analgesia of labor, a pending task

Propósito: Describir la periodicidad del momento de máxima intensidad del dolor de las contracciones uterinas (CUs) durante el trabajo de parto (TDP) para eventualmente permitir el desarrollo de nuevos modelos de administración de analgesia endovenosa. Material y método: Embarazadas de término en TDP, reclutadas desde marzo 2014 por 18 meses, de manera no probabilística consecutiva. Se obtuvo el momento de máximo dolor por autoreporte de las pacientes con cronómetros, previa capacitación. Análisis: Regresión para medidas repetidas de efectos mixtos a los 3-5, 6-7 y 8-10cm de dilatación. La variable respuesta es el intervalo de tiempo desde el momento de máximo dolor de la CU basal al de la contracción siguiente. Resultados: En 64 pacientes, se obtuvo 5 intervalos de tiempo. Para la dilatación de 3-5cm una mediana=140.92 segundos y los coeficientes de regresión (CR) en 4 intervalos de tiempo con respecto al basal de 4.2, 15.9, -2.7 y -5.8 segundos. Para 67cm una mediana=131.16 seg y CR 13.4, 11.3, 2 y -10 seg. Para 8-10cm una mediana=129.3 seg y CR -6.7, 0.49, -2.5 y -7.7 seg. No hubo diferencias significativas entre los coeficientes de regresión. Conclusiones: Con los datos obtenidos podemos señalar que no hubo diferencias estadísticas significativas entre los intervalos de tiempo de los momentos de máximo dolor durante el TDP en fase activa. Esta información es relevante para apoyar el desarrollo de un modelo predictivo del dolor.

Aim: To describe the timing of the moment of maximum intensity of uterine contraction (UC) pain in labor to possibly enable the development of new models for administering endovenous analgesia. Materials and Methods: Full-term pregnant women in labor, recruited from March 2014 for 18 months, using consecutive nonprobability sampling. The moment of maximum pain was ascertained as self-reported by patients previously trained with chronometers. Analysis: Regression for repeated measurements from mixed results at 3-5, 6-7 and 8-10cm of dilation. The response variable was the time interval from the moment of maximum pain of the baseline UC to the following contraction. Results: In 64 patients, 5 time intervals were obtained. For the dilation of 3-5cm, a median=140.92 seconds and regression coefficients (RC) in 4 time intervals relative to the baseline of 4.2, 15.9, -2.7 and -5.8 seconds. For 6-7cm, a median =131.16 sec and RC 13.4, 11.3, 2 and -10 sec. For 8-10cm, a median =129.3 sec and RC -6.7, 0.49, -2.5 and -7.7 sec. There were no significant differences among the regression coefficients. Conclusions: With the data collected we can report that there were no statistically significant differences between the time intervals of the moments of maximum pain during active labor. This information is relevant to support the development of a predictive model for this pain.

Resultados maternos y perinatales de la analgesia del parto

Objetivos: Determinar los resultados maternos y perinatales de la analgesia de parto. Diseño: Estudio observacional, descriptivo, de casos y controles. Institución: Servicio de Ginecología y Obstetricia, Hospital Docente Madre Niño San Bartolomé, Lima, Perú. Participantes: Gestantes en trabajo de parto. Métodos: Se revisó los datos de 400 gestantes (grupo I=controles; grupo II=casos), atendidas en el periodo septiembre a diciembre de 2013. Principales medidas de resultados: Resultados maternos y perinatales. Resultados: La media de edad en el grupo de casos fue 24,2+/-3,5 años, el peso fue 72,3+/-3,7 kg y la edad gestacional 38,6+/-1,2 semanas. A los 30 minutos, el nivel de dolor descendió significativamente (p < 0,01) en el grupo de los casos, manteniéndose este descenso hasta el final de la dilatación. La dilatación completa para el grupo control se alcanzó a los 233 ± 28,7 minutos y a los 200,9 ± 29,5 minutos para el grupo de los casos, con una diferencia menor estadísticamente significativa. La duración del expulsivo para el grupo control fue 23,3 ± 5,3 minutos comparado con los casos de 27,5 ± 3,7, con una diferencia mayor estadísticamente significativa para el último grupo. Conclusiones: La analgesia de parto con bupivacaína-fentanil resultó un método eficaz para el alivio del dolor del parto cuando fue administrada en trabajo de parto bien establecido (dilatación 4 cm), acortando la duración de manera significativa y no interfiriendo con el reflejo de pujar. Aunque la duración del expulsivo fue significativamente mayor, no tuvo implicancia con la obtención de recién nacidos en buenas condiciones ni aumentó de manera significativa los partos instrumentados y las cesáreas.

Objectives: To determine maternal and perinatal outcomes of intrapartum analgesia. Design: Observational, descriptive, case-control study. Setting: Obstetrics and Gynecology Department, Hospital Docente Madre Niño San Bartolomé, Lima, Peru. Participants: Women in labor. Methods: Four hundred medical charts from pregnant women in labor (Group 1= controls; Group 11= cases) attended between September and December 2013 were reviewed. Main outcome measures: Maternal and perinatal outcomes. Results: Mean age of control group was 24.2 +/-3.5 years. Mean weight was 72.3 +/- 3.7 kg, and mean gestational age 38.6 +/- 1.2 weeks. Pain decreased with significance 30 minutes following analgesia (p < 0.01) in the cases group and lasted until the end of dilatation. Mean complete dilatation time for the control group was 233 +/- 28.7 minutes and 200.9 +/- 29.5 for the cases group with statistical significant minar difference. Length of the expulsive period for the control group was 23.3 +/- 5.3 compared to the cases group time of 27.5 +/- 3.6, with statistical significant majar dif­ ference for the last group. Conclusions: Bupivacaine-Fentanil intrapartum analgesia was an effective method for pain relief during delivery when appropriately administered (dilatation 4 cm or over), shortening duration significantly and not interfering with the pushing reflex. The second stage was longer but did not have implications on neonates or increased operative vaginal delivery or cesarean section rateo

A case of trigeminal hypersensitivity after administration of intrathecal sufentanil and bupivacaine for labor analgesia.

Rostral spread of intrathecal drugs and sensitization of supraspinal sites may provoke several adverse effects. This case describes a patient with right hemifacial paresthesia, trismus and dysphasia on the trigeminal nerve distribution after intrathecal sufentanil administration. Primigravida, 34 years, 39 weeks of pregnancy, with hypothyroidism and pregnancy induced hypertension. Allergic to latex. In the use of puran T4, 50 µg /day. When the patient presented cervical dilatation of 4 cm, she requested analgesia. She was placed in the sitting position and a spinal puncture was performed with a 27G needle pencil point in L4/L5 (1.5 mg of bupivacaine plus 7.5 µg of sufentanil). Next, was performed an epidural puncture in the same space. It was injected bupivacaine 0.065%, 10 ml, to facilitate the passage of the catheter. After 5 min lying down in the lateral upright position, she complained of perioral and right hemifacial paresthesia, mainly maxillary and periorbital, as well as trismus and difficulty to speak. The symptoms lasted for 30 min and resolved spontaneously. After 1 h, patient requested supplementary analgesia (12 ml of bupivacaine 0.125%) and a healthy baby girl was born. Temporary mental alterations have been described with the use of fentanyl and sufentanil in combined epidural-spinal analgesia, such as aphasia, difficulty of swallowing, mental confusion and even unconsciousness. In this patient, facial areas with paresthesia indicated by patient appear in clear association with the ophthalmic and maxillary branches of the trigeminal nerve and the occurrence of trismus and dysphagia are in association with the mandibular motor branch. The exact mechanism of rostral spread is not known, but it is speculated that after spinal drug administration, a subsequent epidural dose may reduce the intratecal space and propel the drug into the supraspinal sites.

Satisfacción y calidad en analgesia del parto / Satisfaction and quality in delivery analgesics

Introducción: La satisfacción de la paciente en analgesia del parto es uno de los objetivos más importantes que perseguimos y es también una medida de resultado y calidad. Los factores asociados a la satisfacción materna resultan aún desconocidos. Objetivos: Nuestro objetivo es medir la satisfacción de las pacientes asociada a la analgesia del parto y analizar las características demográficas de nuestra población obstétrica. Métodos: Realizamos un estudio descriptivo prospectivo a las parturientas, mediante una encuesta a cada paciente. La satisfacción materna fue medida en forma cualitativa y el dolor mediante la escala visual análoga, al inicio y luego de la analgesia para medir la eficacia de la misma. Resultados: Se recogieron un total de 151 encuestas. De estas 151 pacientes, un altísimo porcentaje estuvieron satisfechas y calmadas, 98.01% recomendarían la técnica y 93.37% volverían a solicitarla en un futuro parto. Conclusiones: La satisfacción materna está fuertemente determinada por la efectividad de la técnica (alivio del dolor), no dependiendo solo de éste sino también de otros factores como son el apoyo percibido durante el trabajo de parto y experiencias previas

Satisfacción y calidad en analgesia del parto / Satisfaction and quality in delivery analgesics

La satisfacción de la paciente en analgesia del parto es uno de los objetivos más importantes que perseguimos y es también una medida de resultado y calidad. Los factores asociados a la satisfacción materna resultan aún desconocidos. Objetivos: Nuestro objetivo es medir la satisfacción de las pacientes asociada a la analgesia del parto y analizar las características demográficas de nuestra población obstétrica. Métodos: Realizamos un estudio descriptivo prospectivo a las parturientas, mediante una encuesta a cada paciente. La satisfacción materna fue medida en forma cualitativa y el dolor mediante la escala visual análoga, al inicio y luego de la analgesia para medir la eficacia de la misma. Resultados: Se recogieron un total de 151 encuestas. De estas 151 pacientes, un altísimo porcentaje estuvieron satisfechas y calmadas, 98.01% recomendarían la técnica y 93.37% volverían a solicitarla en un futuro parto. Conclusiones: La satisfacción materna está fuertemente determinada por la efectividad de la técnica (alivio del dolor), no dependiendo solo de éste sino también de otros factores como son el apoyo percibido durante el trabajo de parto y experiencias previas...