Labor analgesia in preeclampsia:remifentanil patient controlled intravenous analgesia versus epidural analgesia

Epidural analgesia is considered to be the preferred method of labor analgesia in preeclamptic patients. Systemic opioids are another good effective, easy to administer alternative but may cause maternal and fetal respiratory depression. Remifentanil's rapid onset and offset of effects, should make it an ideal drug for the intermittent painful contraction during labor. 30 preeclamptic patients were randomly assigned to one of two equal groups; Epidural Group: received epidural analgesia according to a standardized protocol using bupivacaine plus fentanyl. Remifentanil Group: PCA was set up to deliver remlfentanil 0.5 micro g/kg as a loading bolus infused over 20 seconds, lockout time of 5 minutes, PCA bolus of 0.25 micro g/kg, continuous background infusion of 0.05 micro g/kg/min, and maximum dose is 3 mg in 4 hours. Women were advised to start the PCA bolus when they feel the signs of a coming uterine contraction. All women demonstrated a significant decrease in VAS score in the first hour after administration of analgesia [P<0.05]. Analgesic quality as regard Visual Analog Pain Scores, sedation score, and post-delivery patient satisfaction in both groups, are comparable [P>0.05]. PCA remifentanil infusion until time of delivery produce no observable maternal, fetal or neonatal side effects [P<0.05]. PCA intravenous remifentanil is an effective option for pain relief with minimal maternal and neonatal side effects in labor for preeclamptic patients with contraindications to epidural analgesia or requesting opioid analgesia

Comprehensive assessment of fetal wellbeing in intrauterine growth restriction: biophysical profile and doppler cerebroplacental ratio

The current routine prenatal surveillance tests such as the non-stress test and fetal biophysical profile [BPP] may not be sensitive or specific enough to detect fetuses with an early compromise. Studies suggest that the cerebroplacental ratio [CPR] may be a highly sensitive Doppler index for assessment of wellbeing and prediction of outcome in fetuses with intrauterine growth restriction [IUGR]. To evaluate [1] the screening efficiency of Doppler CPR, compared with BPP, for the prediction of IUGR and the associated perinatal complications; and [2] whether the additional use of CPR improves the prediction of such outcomes over BPP alone. A comparative cross-sectional study. Department of Obstetrics and Gynecology, Kasr El-Aini Hospital, Cairo University. Fifty singleton pregnancies at risk for IUGR. Cases were managed with weekly or twice weekly BPP, and Doppler velocimetry of the umbilical artery [UA] and middle cerebral artery [MCA] was performed when delivery is indicated. The CPR, defined as the MCA-RI divided by the UA-RI, was considered abnormal if <1.0. Adverse perinatal outcome was defined as any combination of IUGR and perinatal complications. The perinatal outcomes were correlated to the results of BPP and CPR, and the accuracy of BPP and CPR in the prediction of adverse outcome was calculated. Sixteen cases [32%] had normal outcome and 34 cases [68%] had adverse outcome. The BPP and CPR were significantly lower in cases with adverse outcome [p=0.002 and 0.001, respectively]. Cases with abnormal BPP and CPR had a very high risk of adverse outcome [27/28; 96%]. The CPR was comparable to BPP; and the correlation of BPP and CPR increased the accuracy of prediction of adverse outcome as shown by sensitivity, specificity, +ve predictive value, -ve predictive value, overall accuracy, likelihood ratio +ve, and likelihood ratio-ve of 79%, 75%, 87%, 63%, 78%, 3.16, and 0.28, respectively, for BPP alone; and 82%, 69%, 85%, 65%, 78%, 2.65, and 0.26, respectively, for CPR alone; compared to 79%, 94%, 96%, 68%, 84%, 13.17, and 0.22, respectively, for both BPP and CPR. The main finding was an increase in the perinatal risk when abnormal BPP and CPR are observed. The additional use of CPR appears to improve risk prediction over BPP alone

Hyperbaric bupivacaine and fentanyl for elective cesarean section: effect of a height and weight adjusting dose

There are large varieties of dosage regimens which are in use for spinal anesthesia for Cesarean section [3]. All aiming for limiting the dose of Bupivacaine to reduce incidence of maternal hypotension and vasopressor requirements, decreasing nausea and vomiting, reducing time to discharge from post anesthesia unit, and improving maternal satisfaction [4]. This study was designed to assess the validity of adjusting the dosage of intrathecal hyperbaric bupivacaine according to the patient's height and weight would provide adequate surgical anesthesia for elective cesarean section while decreasing the incidence of maternal hypotension and the use of vasopressor to treat hypotension and consequently fetal outcome. Patients were randomly assigned to be involved into two groups. Group 1: The fixed dose group, patients received fentanyl 20 microgram [0.4ml] added to hyperbaric bupivacaine 0.5% 2.4ml. Group 2: The adjusting dosage group, patients receive fentanyl 20 microgram [0.4ml] added to a volume of hyperbaric bupivacaine 0.5% that is determined by referencing to the dosage regimen detailed Table. All the cardiovascular data measured plus the incidence of nausea and vomiting were statistically significantly lower in the adjusted group compared to the fixed one [p<0.05]. Time to loss of cold [T4] and to pinprick sensation to T64 on both sides were significantly slower in the adjusted group [p<0.05]. There were no significant differences as regard the visual analogue scale, number of patients needed supplementary analgesia, or the fetal outcome between the two groups at different time intervals [p>0.05]. Adjusting the intrathecal hyperbaric Bupivacaine dose to patient's height and weight combined with 20 microgram Fenatnyl provide adequate anesthesia with less maternal side effects for patients undergoing elective cesarean section

Correlation between MRI, ultrasonography and arthroscopy in diagnosis of internal derangement of the knee

The clinical value ofsonography and MRI of the knee compared to arthroscopy is controversial. The aim of this study was to evaluate the sensitivity of both ultrasonogrophy and magnetic resonance imaging in diagnosis of internal derangement of the knee in comparison to arthroscopic assessment. Fifty-three patients with positive clinical findings by orthopedic surgeon were subjected to MRI, Ultrasono-graphy and subsequently arthroscopy, a conclusion was that MRI was more sensitive than ultrasonography in the diagnosis of pathological knee conditions, but with respectable percentage of fallacies in comparison to arthroscopic assessment

Osteolytic pseudotumor induced by a piece of wood

A case of osteolytic lesion in the right proximal tibia due to an intraosseous wooden foreign body in a 20 years old man is described. Surgical treatment that consisted of removal of foreign body granuloma followed by bone grafting resulted in good clinical and radiological outcome with excellent and painless range of movement of the knee and incorporation of the graft. Areview of the relevant literature showed that our case was unique in some respects, particularly as regards the size and site of the foreign body and the extent of injury. In any case of osteolytic or osteoblastic lesion, the possibility of a pseudotumor should be considered in the differential diagnosis and recent imaging techniques should be used