6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial.

BACKGROUND: Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS: A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS: The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS: Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION: NCT00694343 (http://clinicaltrials.gov).

Epidural injection of hydroxyethyl starch in the management of postdural puncture headache.

Epidural blood patch is the standard treatment for postdural puncture headache when symptomatic therapy is ineffective. We report the cases of two patients who received an epidural injection of hydroxyethyl starch when an epidural blood patch was contraindicated; one due to Streptococcus agalactiae bacteraemia and one due to acute leukaemia. Relief of headache was achieved in both patients with no adverse effects. The use of an epidural hydroxyethyl starch injection may be a suitable alternative for treatment of postdural puncture headache if epidural blood patch is contraindicated.

Addition of clonidine to a continuous patient-controlled epidural infusion of low-concentration levobupivacaine plus sufentanil in primiparous women during labour.

We studied the potentiation of analgesia for labour by the addition of clonidine to epidural low-concentration levobupivacaine with sufentanil in a randomised, double-blinded study. We enrolled primiparous women who were in spontaneous labour. The study solutions, made of 100 ml levobupivacaine 0.0625% plus sufentanil 0.45 µg.ml(-1) and either 150 µg clonidine or no clonidine, were used for induction of analgesia, and for its maintenance with self-administered boluses and a continuous background infusion. The need for additional epidural boluses during labour was lower and analgesia and maternal satisfaction were better in the clonidine (n = 57) than in the control group (n = 58). Blood pressure was lower and the rate of instrumental delivery higher in the clonidine group. Clonidine (1.36 µg.ml(-1)) added to the epidural solution of low-concentration levobupivacaine improves the quality of analgesia. The relevance of the haemodynamic effects should be explored in larger validation studies.

[Post-partum haemorrhage in delivery room: anaesthetists' practioner in Auvergne]. / Hémorragie du post-partum en salle de naissance : pratique déclarée des anesthésistes en région Auvergne.

OBJECTIVE: To assess the management of post-partum haemorrhage (PPH) in delivery rooms by the anaesthetists of the Auvergne region. STUDY DESIGN: Cross sectional study. METHODS: An anonymous postal survey was sent to all the anaesthetists working in a public or private hospital with a maternity unit. RESULTS: The response rate was about 70 %. Eight percent of the respondents never practiced in obstetrics; others all declared to have managed PPH at least once. Only 66 % declared to know the right definition of PPH, 98 % declared to have guidelines in the delivery room, 87 % to use graduate blood receipt pockets, 85 % to work under midwives-directed delivery at expulsion, 88 % to have a HemoCue™ system. More than 80 % declared to use first oxytocin and to switch for prostaglandins in case of failure, to put two venous catheters and a urinary catheter, to administer broad-spectrum prophylactic antibiotic and to draw a blood sample for early biology. Packed red cells, platelets and fresh frozen plasma were accessible in less than 30 minutes for 98 %. Transfusion guidelines were applied. Only 27 % could have arterial radiologic embolisation on site. The knowledge about PPH and its consensual care tended to be poorer in practitioners from the university hospital, and younger under 40 also. CONCLUSION: This survey, with a good response rate, showed a practice generally fitting to the guidelines, although with some failures depending on the practioner's age and type of hospital.

Continuous patient-controlled epidural infusion of levobupivacaine plus sufentanil in labouring primiparous women: effects of concentration.

The effects of two different concentrations of epidural levobupivacaine were compared when used to provide analgesia for labour. Primiparous women in spontaneous uncomplicated labour were enrolled in a prospective, randomised and partially double-blinded study. The study solutions were either 0.568 mg x ml(-1) levobupivacaine (low concentration group) or 1.136 mg x ml(-1) levobupivacaine (high concentration group), with sufentanil 0.45 microg x ml(-1) added to both solutions. Epidural analgesia was initiated with 20 ml of the study solution, followed by a standardised algorithm of top-up bolus injections. Epidural analgesia was then continued by self-administered boluses of 5-ml plus a continuous infusion of 5 ml x h(-1). Analgesia was found to be more efficacious in the high-concentration group. The dose of levobupivacaine administered was higher and sometimes overstepping recommended limits in the high concentration group, but with no observed increase in side-effects. The choice between these two concentrations may still be made according to the patient's and the practitioner's preferences. The effects of an intermediate concentration should be studied in the future.

[Laparoscopy during pregnancy: experience of the French university hospital of Clermont-Ferrand]. / Coelioscopie en cours de grossesse: expérience du centre hospitalier universitaire (CHU) de Clermont-Ferrand.

OBJECTIVE: To describe perioperative management and perinatal outcome for patients undergoing laparoscopy during pregnancy. PATIENTS AND METHODS: We conducted a retrospective study of all cases of laparoscopy during pregnancy performed in our university hospital over a period of six years (from February 2000 to February 2006). RESULTS: We observed 34 cases managed from five to 30 weeks of gestation (11 cases of adnexal torsion, ten adnexal masses, eight appendicitis, one cholecystitis, one sigmoid volvulus, one pelvic peritonitis, two heterotopic pregnancies). Open laparoscopy was used in 12 cases. Conversion was required in two cases mainly due to adherences (one borderline lesion at 16 weeks and one tubal cyst torsion at 24 weeks). No maternal complication was observed. One miscarriage occurred at Day 1 (peritonitis, five weeks of gestation) and one patient opted for abortion. No threatened preterm labour occurred after the perioperative course and no neonate required admission in neonatology unit. DISCUSSION AND CONCLUSION: This study illustrates safety and efficacy of laparoscopy in management of surgical diseases in the gravid patient. Emergent indications are the most common, highlighting the need for all physicians to know specific recommendations related to laparoscopy during pregnancy.

[Epidural analgesia in obstetrics: anaesthesiologists practice in Auvergne]. / Analgésie péridurale obstétricale: pratique declarée des anesthésistes réanimateurs en région Auvergne.

OBJECTIVE: To evaluate the practice of labour epidural analgesia in Auvergne. STUDY DESIGN: Cross-sectional study by a mail survey. METHODS: An anonymous postal questionnaire was sent to all anaesthetists working in public or private hospital having a maternity unit. RESULTS: The response rate was 82%. Eighty-eight percent of the respondents practise epidural analgesia in obstetrics (EAO) for labour pain relief, but 49% of them did so only on call. Fifty percent of the respondents ask for platelets and fibrinogen beforehand and 41% accept a one month validity for these tests. One third uses a full aseptic method (surgical hand washing, cap and face mask, sterile gloves and gown, double disinfection of patient's back). Nearly all respondents practice skin anaesthesia, 67% use saline solution for identification of the epidural space, 58% insert the catheter 4cm into the epidural space and 25% use a lidocaine-epinephrine epidural test dose. The analgesic solution is mostly based on ropivacaine (83%) associated with sufentanil (96%); patient controlled epidural analgesia rate is used by 58% of anaesthetists whereas 37% of them never use epidural clonidine and 52% never practice combined spinal epidural (CSE) analgesia during labour. CONCLUSION: EAO is mainly practiced on call. There are too many laboratory tests ordered before EAO. Technique used to insert epidural catheter is partly uniform and ropivacaine with sufentanil is the analgesic solution most often used. CSE for labour analgesia is still not often used.

[Autoimmune hepatitis and pregnancy: about a patient's three consecutive pregnancies]. / Hépatite auto-immune et grossesse: à propos de trois grossesses consécutives chez une patiente.

Spontaneous evolution of autoimmune hepatitis during pregnancy is not well known, nor are its consequences on pregnancy evolution. Immunosuppressive treatment during pregnancy is sometimes necessary but the long- and short-term consequences are unrecognized. We relate a patient's disease with autoimmune hepatitis and cirrhosis and three consecutive pregnancies with different obstetrical and medical complications.

Takotsubo syndrome during induction of general anaesthesia.

A 77-year-old female was admitted in our hospital for uterine prolapse surgery. She developed ventricular tachycardia during induction of general anaesthesia and after initial symptomatic measures, she was transferred to the coronary care unit. Heart failure persisted and electrocardiographic changes mimicking acute myocardial infarction appeared. Coronary angiography was normal and left ventriculography revealed akinesis of the apical region of the left ventricle and apical ballooning during systole, with relative sparing of the base of the heart. Complete recovery of left ventricular function occurred 8 days after the initial onset of symptoms. A diagnosis of Takotsubo syndrome was made on the basis of consistent clinical and laboratory findings, typical echocardiography and angiography findings, and reversible course. This case emphasises the importance of being aware of uncommon causes of cardiac dysfunction in stressful situations, especially during induction of general anaesthesia.

[Perineal regional anaesthesia: indications in gynaecologic and proctologic surgery and in obstetric]. / Techniques d'anesthésie locorégionale du périnée: indications en gynécologie, en proctologie et en obstétrique.

Perineal and proctologic surgery is well known as very painful. The apparition of new specific needles, long acting and less toxic local anaesthetics and neurostimulation allowed reconsidering some old forgotten techniques. Those blocks appear really useful to optimize multimodal postoperative analgesia and postoperative rehabilitation. After anatomic review, authors describe perineal regional anaesthesia and discuss about main indications and advantages, in the eyes of their experience and bibliographic review.

[Fertiloscopy: Clermont-Ferrand's experiment]. / Fertiloscopie: l'expérience clermontoise.

OBJECTIVE: Evaluation of fertiloscopy's place in the management of female infertility. PATIENTS AND METHODS: Retrospective study including 229 women presenting primary or secondary infertility without pathology raising of an evident surgical sanction and benefitting from a fertiloscopy. Perioperative data analysis (context of the infertility, operating technique, complications). RESULTS: Two hundred and three fertiloscopic procedures succeeded (88.6%), revealing lesions in 58 cases (28.6%) requiring a laparoscopy. These are represented by adherences (21 cases), endometriosis (17 cases), an abnormality of the tubal permeability (10 cases), complete or partial failure to visualize the adnexae (6 cases) and ovarian cysts visualization (4 cases). Five complications (2.5%) without major consequence will be deplored: two rectal injuries, two hemorrhagic complications and a postoperative salpingitis. Most of procedures (97.5%) have been performed in an ambulatory setting except when a geographic remoteness did not allow it (5 patients). DISCUSSION AND CONCLUSION: Fertiloscopy is a safe and reliable procedure. It can be substituted to laparoscopy in the routine assessment of infertile women management in case of not obvious surgical indication.

[Pelvic pain by acute symphysis pubis separation after vaginal delivery]. / Douleur pelvienne par disjonction pubienne après accouchement par voie basse.

Pelvic pain during pregnancy and postpartum period is common. Pubic separation is a physiologic phenomenon caused by pregnancy and delivery. It's an aetiology of pregnancy and postpartum pain requiring a specialized management in case of severe pain. We report the case of a 34-year-old multiparous woman suffering from severe pubic symphysis pain after twin delivery by vaginal approach, with extraction support, under epidural analgesia. Pubic symphysis separation was diagnosed according both to the clinical symptoms and to the radiology. A local anesthetic infiltration was performed twice to substantially relieve the patient.

[Laparoscopic management of ovarian cysts during pregnancy]. / Traitement coelioscopique des kystes de l'ovaire au cours de la grossesse.

OBJECTIVE: To evaluate the results of laparoscopic surgery in the management of ovarian cysts in pregnant patients. PATIENTS AND METHODS: Retrospective study including 26 pregnant patients who underwent the laparoscopic management of ovarian cysts. The indications for surgery were persistent adnexal mass, abnormal ovarian cysts revealed by ultrasound examination, suspicion of cyst complications. The technique used, the immediate postoperative results and obstetrical outcomes were studied. RESULTS: Twelve patients were operated during the first trimester of pregnancy, 13 in the second, and one in the third trimester. A 12 mmHg CO2 pneumoperitoneum was created, using a Veress needle in 22 cases, and an open technique in 4 cases. Trocar sites were decided according to the uterine size and to the cyst situation. A cystectomy was performed in 11 cases, an adnexectomy in 7 cases, an oophorectomy in one case, a cyst aspiration with a biopsy of the cyst wall in 6 cases and an ovarian torsion removal in one case. A conversion to laparotomy was necessary in 3 cases. There were no immediate postoperative complications and obstetrical outcomes were good in all cases. DISCUSSION AND CONCLUSION: In pregnant patients, laparoscopic management of adnexal masses appears to be safe for both mother and child.

[Pregnant woman anaesthetic management in gynaecologic laparoscopic surgery at the maternity hospital of Clermont-Ferrand]. / Prise en charge anesthésique de la femme enceinte pour coeliochirurgie gynécologique non obstétricale à la maternité de Clermont-Ferrand.

OBJECTIVE: To evaluate the anaesthetic management intended for pregnant women in the field of non obstetric and gynaecologic laparoscopic surgery. STUDY DESIGN: Retrospective and monocentric investigation. PATIENTS AND METHODS: Analysis of the anaesthetic and obstetric files from 27 pregnant women operated on in the establishment, between January 2001 and July 2004. RESULTS: 27 female patients involved in the study. The mean pregnancy term was 15 weeks when laparoscopic surgery was performed, though a single patient was at 30 weeks. The average duration of the surgery was 61 minutes, of which 28 minutes were dedicated to pneumoperitoneum. Twenty-four patients underwent general anaesthesia, the three others underwent locoregional anaesthesia. During the perioperative period no surgical, anaesthetic or obstetric complications were observed. CONCLUSION: Laparoscopic surgery during pregnancy requires double skilled management, both in anaesthesiology and obstetrics. On haemodynamics and breathing, pneumoperitoneum does not induce any additional effects when compared to operations without pregnancy. Except with delivery cases, anaesthetic support in laparoscopic surgery intended for pregnant women eventually does not generate any specific problems, but requires the same rigorous management as the one usually following surgery for pregnant patients.

[About three consecutive pregnancies in a patient suffering from liver cirrhosis]. / A propos de trois grossesses consécutives chez une patiente cirrhotique.

We report the case of a patient suffering from an immune liver cirrhosis with chronic liver insufficiency and a portal hypertension, presenting with three consecutive pregnancies. During the first pregnancy, stillbirth occurred at 34 weeks gestation (WG) with a justified vaginal delivery. There was no liver deterioration during the second pregnancy until 36 WG when fetal distress occurred, requiring a caesarean section under general anaesthesia. During the third pregnancy, fetal distress and maternal hepatic failure occurred at 35 WG, requiring an emergency caesarean section complicated with post partum haemorrhage and an episode of encephalopathy.

[Prolonged motor blockade after combined epidural and general anaesthesia for oncologic gynaecological surgery]. / Bloc moteur prolongé après anesthésie péridurale combinée à l'anesthésie générale pour chirurgie gynécologique carcinologique.

The case described is a patient submitted to an oncologic gynaecological surgery under combined epidural and general anaesthesia. The anaesthesia involved complications, a prolonged motor blockade for up to 9 h whereas recommended doses had been respected. A few later after a magnetic resonance imaging that did not showed any extradural haematoma, full recovery occurred. The combined epidural and general anaesthesia was approved as an interesting technique for both per and postoperative analgesia, but also for postoperative rehabilitation. Nevertheless, for older patients, inhalational anaesthetics and opioids have to be decreased during the intervention, moreover local anaesthetics doses for epidural anaesthesia have to be reduced too, in order to control motor blockade duration.