The Effect of Prolonged Face Mask Ventilation on Gastric Insufflation: A Prospective Observational Study.

BACKGROUND: Pulmonary aspiration is a potentially lethal perioperative complication that can be precipitated by gastric insufflation. Face mask ventilation (FMV), a ubiquitous anesthetic procedure, can cause gastric insufflation. FMV with an inspiratory pressure of 15 cm H2O provides the best balance between adequate pulmonary ventilation and a low probability of gastric insufflation. There is no data about the effects of FMV > 120 seconds. OBJECTIVES: To investigate the effect of prolonged FMV on gastric insufflation. METHODS: We conducted a prospective observational study at a tertiary medical center with female patients who underwent oocyte retrieval surgery under general anesthesia FMV. Pre- and postoperative gastric ultrasound examinations measured the gastric antral cross-sectional area to detect gastric insufflation. Pressure-controlled FMV with an inspiratory pressure of 15 cm H2O was continued from the anesthesia induction until the end of the surgery. RESULTS: The study comprised 49 patients. Baseline preoperative gastric ultrasound demonstrated optimal and good image quality. All supine measurements were feasible. The median duration of FMV was 13 minutes (interquartile range 9-18). In the postoperative period, gastric insufflation was detected in only 2 of 49 patients (4.1%). There was no association between the duration of FMV and delta gastric antral cross-sectional area (ß -0.01; 95% confidence interval -0.04 to 0.01, P = 0.31). CONCLUSIONS: Pressure-controlled FMV with an inspiratory pressure of 15 cm H2O carries a low incidence of gastric insufflations, not only as a bridge to a definitive airway but as an alternative ventilation method for relatively short procedures in selective populations.

Incidence of conversion to general anaesthesia and need for intravenous supplementation in parturients undergoing caesarean section under spinal anaesthesia: A retrospective observational study.

BACKGROUND: Conversion from spinal anaesthesia to general anaesthesia (GA) was shown to be associated with more complications. It has been postulated that spinal injection of a low dose of local anaesthetic is a risk factor. We aimed to discover the rate of conversion from spinal anaesthesia to GA in women who received at least 10 mg heavy bupivacaine and opioids and assess its risk factors. METHODS: All women that underwent spinal anaesthesia for caesarean section from 1 January 2017 to 31 December 2020 were included in this analysis. Spinal anaesthesia was performed according to department protocol using heavy bupivacaine 0.5% 10-13 mg, fentanyl 20 µg, and morphine 0.1 mg. We examined rate of conversion from spinal anaesthesia to GA and rate of need for analgesia/sedation. RESULTS: There were 1.7% of women that required conversion to GA. Bupivacaine dose (OR 0.54 [95% CI 0.38 to 0.75], p < 0.001), surgery time (OR 1.03 [95% CI 1.02 to 1.04], p < 0.001), emergency caesarean section (OR 1.06 [95% CI 1.16 to 3.76], p = 0.015), and postpartum haemorrhage (OR 5.96 [95% CI 1.09 to 25.18], p = 0.025) were independent predictors of need for conversion to GA. Of the women who had CS under spinal anaesthesia, 4.1% of parturients required intraoperative analgesics/sedatives and 9.1% required anxiolysis. CONCLUSIONS: A small proportion of women required conversion to GA. This conversion occurred especially with emergency caesarean section and when low spinal bupivacaine doses were used.

Flouroscopic versus conventional epidural blood patch in obstetrics: A retrospective cohort study.

BACKGROUND: Epidural blood patch is a common effective treatment for postdural puncture headache after accidental dural puncture during labor and may be done in conventional or fluoroscopy-guided methods. The aim of this study was to compare intensity of headache at the time of discharge from the hospital and to compare blood volumes injected in conventional epidural blood patches versus fluoroscopic-guided blood patches and evaluate the side effects of both method of treatment. METHODS: Between the years 2010 and 2020, 84 patients who were diagnosed with postdural puncture headache received either a conventional epidural blood patch or a fluoroscopic-guided blood patch. Blood volumes were compared and evaluation of side effects was made based on data collected during and after the procedure. RESULTS: Eighty-four patients were included in this study. Fifty-two women in the conventional epidural blood patch group and 32 in the fluoroscopic-guided blood patch group. Women in the conventional epidural blood patch group received statistically significantly higher doses of blood than women in the fluoroscopic-guided blood patch group: conventional method 29 ml IQR [23-36] versus fluoroscopic method 16 ml, IQR [12-18], p < .001 with no difference in headache pain intensity at hospital release. There was no difference between groups in hospital length of stay, or persistent PDPH. There was also no difference chronic headache or backache between the two groups. CONCLUSIONS: Women who received fluoroscopic epidural blood patch required a much lower volume of blood injected while there was no difference between groups in headache pain intensity at discharge.

The relationship between resited epidural catheters after secondary epidural catheter failure and vaginal delivery: A retrospective case-control study.

BACKGROUND: There are cases where epidural analgesia is initially effective but subsequently fails and needs to be resited. We evaluated the rate of normal vaginal delivery and operative delivery among parturients who had resited epidurals compared to parturients with epidurals that were not resited. METHODS: A retrospective electronic medical review of parturients with a singleton gestation attempting normal vaginal delivery under epidural analgesia between the years 2012-2016 was conducted. Resited epidurals were defined as epidurals that were considered effective but subsequently removed and reinserted. For each resited epidural, two previous and two consecutive deliveries of parturients with normally functioning epidural catheter inserted by the same anesthesiologist were matched controls (non-resited epidurals). RESULTS: There were 35,984 attempted vaginal deliveries with 118 resited epidurals and 472 non-resited epidurals. When adjusted for nulliparity, oxytocin administration, sex and weight of the baby, and maternal BMI, labor epidural catheter replacement was not associated with need for instrumental or caesarean delivery, (OR 1.5, 95% CI 0.91-2.49, P = .11). CONCLUSIONS: Need for labor epidural catheter replacement does not appear to be associated with need for operative delivery based on this single-centre cohort analysis.

Long-term psychological and physical outcomes of women after postdural puncture headache: A retrospective, cohort study.

BACKGROUND: Postdural puncture headache after accidental dural puncture during labour may lead to chronic sequalae. OBJECTIVES: We aimed to measure the incidence of postpartum depression, posttraumatic stress disorder, chronic headache, backache and breastfeeding rates after a postdural puncture headache. DESIGN: A retrospective, case-matched cohort study. SETTING: A review of documented cases of dural puncture and matched case controls occurring at Rabin Medical Center and Shamir Medical Center from 01 January 2012 to 30 September 2018. PATIENTS: The study cohort consisted of women with a documented postdural puncture headache and the controls were women with uneventful labour epidurals in the same 24-h period. Women were interviewed by telephone. PRIMARY OUTCOMES MEASURE: The primary outcome measure was the incidence of postpartum depression after a postdural puncture headache. RESULTS: Women with postdural puncture headache (n = 132) and controls (n = 276) had similar demographic data. The incidence of postpartum depression was 67/128 (52.3%) versus 31/276 (11.2%) for controls, P < 0.0001, 95% confidence intervals of the difference 31.5 to 50.2. Posttraumatic stress disorder was more frequent among women with postdural puncture headache, 17/132 (12.8%) versus controls 1/276 (0.4%), P < 0.0001, 95% confidence intervals of the difference 7.6 to 19.5. Women with postdural puncture headache breastfed less, 74/126 (54.5%) versus controls 212/276 (76.8%), P < 0.0001, 95% confidence intervals of the difference 33.1 to 55.2. Current headache and backache were significantly more frequent among women with postdural puncture headache [current headache 42/129 (32.6%) versus controls 42/276 (15.2%) P < 0.00001, 95% confidence intervals 0.085 to 0.266; current backache 58/129 (43.9%) versus controls 58/275 (21%) P < 0.0001, 95% confidence intervals 14.1 to 33.5]. CONCLUSION: We report an increased incidence of postpartum depression, posttraumatic stress disorder, chronic headache and backache and decreased breastfeeding following a postdural puncture headache. Our findings emphasise the need for postpartum follow-up for women with postdural puncture headache. TRIAL REGISTRY NUMBER: Clinical trial registry number: NCT03550586.

Epidural/spinal anesthesia during delivery in women with factor XI deficiency, a single center experience.

INTRODUCTION: The safety of neuro-axial anaesthesia (epidural/spinal) at labour of women with partial factor XI (FXI) deficiency is uncertain. Although FXI deficiency is frequent in Ashkenazi Jews, it is not routinely measured before labour. Our institute serves a large Ashkenazi population. We assumed that 10% of them have undiagnosed FXI deficiency. AIM: Assess the incidence, bleeding tendency and coagulation status among Jewish Ashkenazi women with FXI deficiency that underwent neuro-axial anaesthesia at delivery. METHODS: Jewish Ashkenazi women who underwent neuro-axial anaesthesia at labour completed the SSC ISTH bleeding assessment tool (BAT) and had blood drawn for coagulation tests, FXI and thrombin generation after labour. Estimation for 10 years was calculated from the 1-year sample. RESULTS: We recruited 261 women during 12 months. Among them, 39 (15%) had FXI deficiency (<70%) with median FXI levels of 63% (range: 33%-70%). Around 50% of them underwent amniocentesis in the current pregnancy and prior neuro-axial anaesthesia with no bleeding complications. BAT score and thrombin generation did not differ between women regardless of FXI status. aPTT was longer in women with partial FXI deficiency (median - 28.6 sec vs 26.3 sec, P < .001, Table 2), although within the normal range in all women. No bleeding complications after neuro-axial anaesthesia at delivery were reported in our centre in the last decade though, and according to our estimation, at least 2150 women had partial FXI deficiency. CONCLUSIONS: A significant number of Jewish Ashkenazi women with undiagnosed partial FXI deficiency undergo neuro-axial anaesthesia at labour without bleeding complications.

[MALIGNANT HYPERTHERMIA].

INTRODUCTION: In this article we describe the treatment of a patient who developed suspicious symptoms of malignant hyperthermia syndrome during anesthesia for elective cerebral catheterization. We also described an up-to-date review of malignant hyperthermia, diagnosis and treatment. Details regarding the case: this is a case of a 57 year old male patient who was admitted for an elective catheterization under general anesthesia. Four hours following anesthesia induction, the patient presented with the following symptoms: a gradual increase in end tidal carbon dioxide measurements, an elevated core temperature, tachycardia, decreased oxygen saturation and excessive sweating. Arterial blood gases indicated respiratory acidosis. With a clinical diagnosis of malignant hyperthermia, the catheterization procedure was stopped. The patient was disconnected from the anesthesia machine and was ventilated with a clean ventilator with 100% oxygen. Additionally, active patient cooling was initiated along with supportive pharmacologic treatment. The patient was then moved, anesthetized and ventilated into the post anaesthesia care unit. Following a clinical and laboratory improvement the patient was extubated.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort.

BACKGROUND: The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding. METHODS: In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks. RESULTS: The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001). CONCLUSIONS: In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

No longer rare diseases and obstetric anesthesia.

PURPOSE OF REVIEW: With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist. RECENT FINDINGS: With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances. SUMMARY: Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Risk Factors for Unintended Dural Puncture in Obstetric Patients: A Retrospective Cohort Study.

BACKGROUND: Unintended dural puncture (UDP) is one of the main risks of epidural analgesia, with a reported incidence of approximately 1.5% among the obstetric population. UDP is associated with maternal adverse outcomes, with the most frequent adverse outcome being postdural puncture headache (PDPH). Our retrospective cohort study objective was to identify demographic and obstetric risk factors that increase the risk of unintentional dural puncture as well as describing the obstetric outcome once a dural puncture has occurred. METHODS: We retrospectively reviewed all cases of UDPs during attempted vaginal delivery between the years 2004 and 2013 in a single Israeli hospital. Each UDP case was matched with the 2 parturients who received epidural analgesia before and 2 parturients after performed by the same anesthesiologist (control group). Demographic, anesthetic, and obstetric variables were compared between the UDP and control groups. RESULTS: Out of 46,668 epidural procedures, 177 cases of UDPs were documented (0.4%). One hundred seven women (60.5%) developed PDPH, and 38 (35.5%) required an epidural blood patch. In multivariate logistic regression, the degree of cervical dilation in centimeters at the time of epidural insertion was associated with an increased rate of UDP (P < .001). Multiparity was associated with PDPH after UDP (P = .004). Women with UDP had longer length of hospital stay than those without UDP (P < .001). CONCLUSIONS: UDP, an uncommon complication, is associated with obstetric factors. Nevertheless, it does not seem to be associated with adverse obstetric outcomes except for prolonged duration of hospital stay.

Peripartum anesthetic management of patients with Factor XI deficiency.

INTRODUCTION: Factor XI deficiency is predominantly found in the Ashkenazi Jewish population with a prevalence of 9%, but also seen in other ethnicities. Little information is available on obstetric anesthesia management in women with Factor XI deficiency. Therefore, we undertook a study to evaluate obstetric, anesthetic and perinatal outcomes in parturients with Factor XI deficiency. METHODS: A retrospective study was conducted with chart reviews from 1996 to 2011 resulted in 74 women with Factor XI level deficiency. We compared anesthetic and obstetric management in parturients with low (≤30%) level of Factor XI to those with higher levels. RESULTS: Ninety-one pregnancy outcomes were reviewed in these 74 women with Factor XI deficiency. Forty-three women had levels ≤30% in 46 labors while 31 women had levels >30% in 45 labors. Women with low levels of Factor XI were significantly more likely to receive FFP and less likely to receive neuroaxial anesthesia. There were no anesthetic complications and no difference in mode of delivery or neonatal outcomes. DISCUSSION: This study is the first step in building a national database for anesthetic cases and outcomes of parturients with Factor XI deficiency. Further efforts must be made to provide safe analgesia for these women.

National survey of postoperative pain control after cesarean delivery.

BACKGROUND: Postoperative pain is a common problem after cesarean deliveries. OBJECTIVES: To characterize common obstetric anesthesia practices after cesarean deliveries in Israel in order to standardize postoperative pain relief protocols. METHODS: A questionnaire was completed during an interview with every obstetric anesthesia unit in all 25 delivery wards in Israel. Data were gathered on intraoperative anesthesia and analgesia protocols as well as postoperative pain relief protocols. A sub-analysis compared units whose director completed a formal obstetric anesthesia training program with those whose directors did not. RESULTS: Neuraxial morphine was used routinely in 12% of hospitals. No unit providing intrathecal morphine complied with American Society of Anesthesiologists guidelines for respiratory monitoring after use of neuraxial opioids. Additionally, non-steroidal anti-inflammatory drugs (NSAIDs) .were used routinely in only half the wards, while patient-controlled analgesia was used infrequently. Postoperative verbal analog scores were not recorded routinely in 71% of units on postoperative day 1. The unit director's training significantly influenced the unit protocols. CONCLUSIONS: Intrathecal morphine, the gold standard of care in cesarean deliveries, is rarely used, mainly due to shortage of staff and lack of formal obstetric anesthesia training. In addition, NSAIDs are also underused. There is a need for more formal training for obstetric anesthesiologists in Israel.

The effect of preoperative anxiety and ovarian stimulation on gastric antrum size: a prospective observational study.

Pulmonary aspiration is a potentially lethal perioperative complication related to gastric size and contents. Several perioperative factors are believed to increase gastric size, while others are less studied. This prospective observational study aimed to investigate the effect of preoperative anxiety and hormone-induced ovarian stimulation on gastric size examined by gastric ultrasound. We recruited 49 female patients undergoing hormone-induced ovarian stimulation and oocyte retrieval for in vitro fertilization at Rabin Medical Centre, Petah Tikva, Israel. Preoperatively, women ranked their anxiety level using a verbal numeric anxiety score (VNS). In addition, we recorded the extent of ovarian stimulation and measured the antral cross-sectional area (CSA) using gastric ultrasound. There was no substantial correlation between preoperative VNS anxiety and antral CSA (p = .697). Moreover, the number of follicles, blood estradiol, and progesterone levels did not correlate with antral CSA (p = .590, p = .104, and p = .511, respectively). In conclusion, neither preoperative anxiety nor extensive ovarian stimulation affects gastric size in fasting healthy patients. However, further studies are warranted in this area to define these findings better. Trial registration: Clinicaltrials.gov, identifier: NCT04833530.

Partner's presence during initiation of epidural labor analgesia does not decrease maternal stress: a prospective randomized controlled trial.

BACKGROUND: Epidural analgesia reduces pain and anxiety during childbirth. In this randomized controlled trial, we sought to determine whether partner presence during the initiation of epidural analgesia reduces stress of both the mother and her partner and their perception of maternal pain. METHODS: Healthy, nulliparous women who were accompanied by their partners and requested neuraxial analgesia were enrolled into the study. The study took place in the Labor and Delivery Unit of a large tertiary hospital in Israel. Upon request for epidural analgesia, both partners were assessed for baseline anxiety (numerical rating scale, 0 to 10), systolic blood pressure, heart rate, estimated contraction pain of parturient (verbal rating scale for pain, 0 to 10), and salivary amylase. After measurements, couples were randomized into 1 of 2 groups: "partner in" and "partner out." Immediately after epidural catheter insertion, anxiety, arterial blood pressure, heart rate, and salivary amylase were measured again in both partners. Both partners were asked to complete the State Anxiety Inventory questionnaire measuring current anxiety. The parturient was asked to rate the pain of epidural catheter insertion. The primary outcome measurement was parturient and partner anxiety as assessed by the numerical rating scale. RESULTS: Eighty-four couples were randomized (partner in 41, partner out 42, protocol violation 1). At baseline there was no difference in self-reported anxiety of parturients between the partner-in and partner-out groups (median interquartile range 7.5 [6.0 to 9.0] versus 7.0 [3.5 to 8.5]; P = 0.26, difference in medians = -1.0; 95% confidence interval [CI] of difference -2.0 to 1.0). After epidural catheter insertion, parturients in the partner-in group had a higher level of anxiety than those in the partner-out group (8.0 [7.0 to 10.0] versus 7.0 [5.0 to 9.0]; P = 0.03, difference in medians -1.0; 95% CI of difference -2.0 to 0.0). Pain scores during epidural catheter placement were higher in partner-in than in partner-out groups (7.0 [4.0 to 8.0] versus 4.0 [3.0 to 6.0]; P = 0.004, difference in medians = -2.0; 95% CI of difference -3.0 to -1.0). CONCLUSION: Partner presence during epidural catheter insertion for labor analgesia did not decrease anxiety levels. To the contrary, anxiety and pain of epidural catheter placement were greater if the partner remained in the room.

Intraoperative pain during caesarean delivery: Incidence, risk factors and physician perception.

BACKGROUND: Intraoperative pain is a possible complication of neuraxial anaesthesia for caesarean delivery. There is little information available about its incidence, risk factors and physician perception. METHODS: Parturients undergoing spinal anaesthesia for elective caesarean delivery were enrolled. Before surgery, parturients were asked about preoperative anxiety on a verbal numerical scale (VNS), anticipated analgesic requirement, postoperative pain levels, Spielberger STATE-TRAIT inventory index, Pain Catastrophizing Scale. After surgery, parturients were asked to answer questions (intraoperative VNS pain). The anaesthesiologist and obstetrician were asked to fill out a questionnaire asking about perceived intraoperative pain. Influence of preoperative anxiety on intraoperative pain (yes/no) was assessed using logistic regression. Mc Fadden's R2 was calculated. The agreement in physician perception of intraoperative pain with reported pain by the parturient was examined by calculating Cohen's kappa and 95% Confidence Intervals (CI). RESULTS: We included 193 parturients in our analysis. Incidence of intraoperative pain was 11.9%. Median intraoperative VNS pain of parturients with pain was 4.0 (1st quartile 4.0; 3rd quartile 9.0). Preoperative anxiety was not a good predictor of intraoperative pain (p-value of ß-coefficient = 0.43, Mc Fadden's R2  = 0.01). Including further preoperative variables did not result in a good prediction model. Cohen's kappa between reported pain by parturient and by the obstetrician was 0.21 (95% CI: 0.01, 0.41) and by the anaesthesiologist was 0.3 (95% CI: 0.12, 0.48). CONCLUSIONS: We found a substantial incidence (11.9%) of intraoperative pain during caesarean delivery. Preoperative anxiety did not predict intraoperative pain. Physicians did not accurately identify parturients' intraoperative pain. SIGNIFICANCE: Intraoperative pain occurred in 11.9% and severe intraoperative pain occurred in 1.11% of parturients undergoing elective caesarean delivery under spinal anaesthesia. We did not find any preoperative variables that could reliably predict intraoperative pain. Obstetricians and anaesthesiologists underestimated the incidence of intraoperative pain in our cohort and thus, more attention must be put to parturients' pain.

Attitudes to anesthesiology residency among medical students in the American and the Israel programs at Sackler Faculty of Medicine, Tel Aviv University.

BACKGROUND: There is a growing shortage of anesthesiologists practicing in Israel. This shortage is in contrast with the United States where anesthesiology has become a very desired specialty. OBJECTIVES: To discover what factors attract Israeli students to choose a residency and how students view the option of choosing anesthesiology. METHODS: We sent questionnaires to students in the Israeli and American programs at Tel Aviv University's Sackler Faculty of Medicine asking about factors that influenced their choice of residency and the advantages and disadvantages of a residency in anesthesiology. Although the students were studying at the same medical school and hospitals, students in the Israeli program were planning to enroll in Israeli residency programs while students in the American program planned to apply for residency in the United States. RESULTS: A significantly larger proportion of American students (12.9%) were interested in an anesthesiology residency when compared with the Israeli students (0%) (P = 0.034). American students considered salary and working conditions to be advantages of the anesthesiology residency while Israeli students considered Israeli working conditions and salaries to be a disadvantage. CONCLUSIONS: Whereas there is considerable interest among American students at Sackler Medical School in an anesthesiology residency, there is little interest among Israeli students.

Labor neuraxial analgesia and breastfeeding: An updated systematic review.

INTRODUCTION: There have been numerous reports studying the effect of neuraxial analgesia on breastfeeding success, but the results are inconsistent. METHODS: We performed a literature search in various databases for studies comparing neuraxial analgesia to non-neuraxial or no analgesia. Outcomes were the percentage of women breastfeeding fully or mixed with formula. Where possible, nulliparous parturients were analyzed separately. We conducted an analysis excluding studies of serious and critical risk of bias. Odds ratios and 95% confidence intervals were calculated. RESULTS: We included 15 studies (13 observational studies, 1 secondary analysis of a randomized controlled trial, 1 case-control study) with 16,112 participants. Overall, there were 6 studies that found no difference between groups, 6 studies that showed a significantly lower incidence of breastfeeding in the neuraxial group and 3 studies finding mixed results (at some time-points statistically significant and at some time-point statistically non-significant results). In nulliparous only studies, 2 found no difference between study groups, 1 found a lower breastfeeding rate in the neuraxial group and 3 studies showed mixed results. Excluding studies with a serious and critical risk of bias, 1 study found no difference between study groups, 3 studies found a decrease of breastfeeding rates in the neuraxial group, and 1 study showed mixed results. DISCUSSION: In our review we found a high disparity in results. One reason is probably the high potential of confounding (immediate skin to skin placement, maternity leave etc.). Education programs and breastfeeding support are likely more important in determining long term breastfeeding success.

Maternal age and cardiovascular and metabolic disease outcomes: a retrospective cohort study using data from population-based electronic medical records.

Objective: To evaluate whether a woman's age at first birth is associated with cardiovascular risk and metabolic health outcomes (cardiometabolic outcomes) by age 45.Methods: This is a retrospective, population-based cohort study that uses electronic health record data from the largest health fund in Israel. Women aged 34-39 at baseline (2004-2006) free of chronic diseases were identified as nulliparous at baseline and were followed up to 10 years (through 2016). The cohort was divided into three groups based on their age at first birth: younger parturients (ages 35-39), older parturients (ages 40-44), and never had children. The percentage of adverse pregnancy events and cardiometabolic outcomes at age 45 were compared across these three groups as well as to women in the general population. Cardiovascular risk and metabolic health outcomes were defined as: Type 2 diabetes, obesity, hypertension, cardiovascular disease, and Framingham risk score.Methods and results: Out of a group of 126,121 women aged 34-39 at baseline, 9979 were nulliparous and free of comorbidities. Over the course of the follow-up, there were 952 younger parturients and 673 older parturients who had their first birth, and 8354 women who remained persistent nulliparous. While older parturients had more adverse pregnancy events, there was no difference in rates of cardiometabolic outcomes between the two parturient groups, and they both had lower rates than the persistent nulliparous and the general population.Conclusions: Parturients free of major chronic diseases who give birth at a later age do not have increased cardiometabolic outcomes in midlife as compared to a general population of women in a large retrospective cohort. Our results may support clinicians when counseling healthy women who are seeking advice regarding delaying their first pregnancy without a tradeoff on health outcomes.

Transdermal nitroglycerin as an adjuvant to patient-controlled morphine analgesia after total knee arthroplasty.

BACKGROUND: Nitroglycerin (NTG) has been shown to be a useful adjunct for pain treatment without increasing adverse side effects. The effects of NTG on postoperative morphine consumption after knee replacement were evaluated. METHODS: After undergoing total knee replacement, patients receiving patient-controlled morphine analgesia were randomly assigned to receive either an NTG or a placebo patch. The blinded investigator assessed each patient using a visual analogue scale at rest and while moving, as well as the patient's morphine requirements, sedation score, sleep quality, nausea and vomiting, vital signs and postoperative bleeding. RESULTS: Two of the patients in the NTG group suffered postoperative myocardial infarctions after removal of the patch. Because of these two serious adverse effects, the study was stopped prematurely. In the subset of patients studied, NTG conferred no advantage over placebo in pain control (visual analogue scale at rest or during movement) and in satisfaction scores. CONCLUSIONS: The use of NTG patches conferred no advantage over the use of placebo in patients receiving patient-controlled morphine analgesia after total knee replacement. Two myocardial infarcts occurred in this group. Therefore, the safety of postoperative NTG patch use for pain control must be questioned.