[Von Hippel-Lindau disease and obstetric anaesthesia: 3 cases report]. / Maladie de von Hippel-Lindau et anesthésie obstétricale: à propos de 3 cas.

Von Hippel-Lindau (VHL) disease is a rare autosomal dominant genetic disorder with retinal and nervous system haemangioblastomas, phaeochromocytomia, kidney, pancreas and endolymphatic tumors. The management of childbirth, including epidural anaesthesia is controversial. The possible presence of vascular malformations (retinal and central nervous system and spinal haemangioblastomas) increases the risk of disrupting central nervous system haemangioblastoma during delivery and when epidural anaesthesia is initiated. We report 3 cases of patient with VHL disease with successful epidural anaesthesia 2 for delivery and 1 for Caesarean section.

[Single ventricle and obstetric anaesthesia: two cases report]. / Ventricule unique et anesthésie obstétricale: à propos de deux cas.

Single ventricle is a relatively rare abnormality found only in 0.5-1.5% of patients with congenital heart disease. Pregnancy results in an increased maternal morbidity and mortality in patients with right to left shunting, especially in cases associated with pulmonary hypertension and polycythemia and decreased arterial oxygen saturation. Most complications arise from decreases in systemic vascular resistance, causing an increase in right to left shunting and further hypoxemia and acidosis. For this reason, the major regional anaesthetic techniques are often avoided in these patients. The authors reported two successful management of regional anaesthesia for both caesarean and vaginal delivery.

Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during cesarean section.

UNLABELLED: Seventy-eight pregnant women at term, scheduled for elective cesarean section, were enrolled in this multicenter trial to compare the analgesic efficacy and side effect profile of a spinal block with hyperbaric bupivacaine alone (Group B) or combined with 75 microg of clonidine (Group BC) or with clonidine 75 microg and fentanyl 12.5 microg (Group BCF). Intraoperatively, clonidine increased the spread of the sensory block and decreased pain (pain scores 23+/-7 mm vs 17+/-6 and 2+/-1 mm for Group B versus Groups BC and BCF; P < 0.05) and analgesic supplementation. This improved analgesia was best with the clonidine-fentanyl combination (Group BC versus Group BCF; P < 0.05). Postoperative analgesia was prolonged only in Group BCF (215+/-79 min vs 137+/-35 and 183+/-80 min for Group BCF versus Groups B and BC; P < 0.05). Blood pressure and heart rate changes were not significantly different among groups, whereas sedation and pruritus were significantly more frequent in Group BCF. Nausea and vomiting were decreased in Groups BC and BCF. Apgar scores and umbilical artery blood pH were not different among groups. We conclude that adding a small dose of intrathecal clonidine to bupivacaine increases the quality of intraoperative analgesia and decreases pain during cesarean section. Combining clonidine with fentanyl further improved analgesia. IMPLICATIONS: In this study, we demonstrate improved intraoperative spinal analgesia by adding 75 microg of clonidine to bupivacaine; side effects were not increased. The combination of clonidine and fentanyl further improved analgesia but moderately increased sedation and pruritus.

Continuous extradural infusion of ropivacaine 2 mg ml-1 for pain relief during labour.

We have assessed the dose-response relationship of a solution of ropivacaine 2 mg ml-1, given as a continuous extradural infusion to women in labour. A total of 133 parturients were allocated randomly to one of four groups to receive a fixed rate ropivacaine infusion of 4, 6, 8 or 10 ml h-1 with additional bolus doses as necessary. Contraction pain, quality of analgesia, sensory block, motor block and neonatal Apgar scores were assessed. There were no significant differences between groups in terms of analgesia or motor block, although significantly more bolus doses were required by the group receiving 4 ml h-1 (P < 0.05 compared with the other groups), and a significantly higher total dose of ropivacaine was administered to the 10-ml h-1 group compared with the 6-ml h-1 group (P = 0.044). There were no significant differences between groups in terms of obstetric or neonatal outcome. We conclude that ropivacaine 2 mg ml-1 was effective and well tolerated when given as a continuous extradural infusion at 6-8 ml h-1 and may be used as the sole analgesic during labour.

[Epidural anesthesia for labor]. / L'anesthésie péridurale pour le travail.

Since the last decade, lumbar epidural analgesia has gained widespread use in obstetrics. Approximately 80% of parturients receive epidural analgesia for labour and vaginal delivery as well as caesarean section in most centres. There is little doubt that the most successful application of epidural analgesia during labour, considered by more than 75% of primiparas as extremely painful. The quality of analgesia is far superior to that which can be achieved by either parenteral or inhalation approaches and, unlike these methods, the mother remains alert. Epidural analgesia also prevents, or greatly diminishes, most of the physiological and chemical responses to labour pain that can be considered as stress responses, similar to those that have been described during surgery. There are considerable benefits, therefore, to both mother and child. Thus, epidural analgesia usually can be extended to relieve both uterine pain and pain related to distension of the lower birth canal, as well as providing analgesia for forceps delivery or caesarean section. Epidural analgesia allows the mother to be awake, minimizes or completely avoids the problems of maternal aspiration and avoids neonatal drug depression from general anaesthetics. If the most popular indication for epidural analgesia is the provision of pain relief, there are certain complications of pregnancy in which epidural analgesia appears to be indicated on therapeutic grounds such as pregnancy-induced hypertension, breech delivery, multiple pregnancy, incoordinate uterine action and fetal and/or maternal medical complications.

[Opiates for epidural analgesia: for or against?]. / Opiacés pour l'analgésie péridurale: pour ou contre?

Epidural opiate administration is routinely used by many anaesthesiologists involved in obstetric anaesthesia. Epidural injection of a local anaesthetic combined with an opioid generates a more rapid onset of more profound analgesia with little motor blockade. Thus pain relief lasts longer than after either drug alone. A combination of dilute concentrations of bupivacaine and opioids lowers the risk of systemic local anaesthetic toxicity significantly. Fentanyl was the first opioid widely used as an adjunct to local anaesthetics for labour analgesia. An initial dose of fentanyl 50 micrograms combined with 0.25% or 0.125% bupivacaine can produce good initial analgesia for most laboring parturients. A continuous infusion of 0.125% or 0.0625% bupivacaine with 1 microgram.ml-1 fentanyl at 10-12 ml.h-1 will maintain good pain relief throughout parturition. No adverse effects on either the mother or the neonate have been attributed to this technique. Recently, sufentanil was introduced in obstetric analgesia. Sufentanil appears to induce a faster onset of more profound, long lasting analgesia with extremely low concentrations of bupivacaine than that with fentanyl. The reduction of the total amount of bupivacaine is correlated with a significant decrease in motor blockade and instrumental deliveries. There were no adverse maternal or fetal effects and umbilical cord levels were too low to be detected.

[Alkalization of bupivacaine in the combination fentanyl-bupivacaine in epidural obstetrical analgesia]. / Alcalinisation de la bupivacaïne dans l'association fentanyl-bupivacaïne pour l'analgésie péridurale obstétricale.

A randomized double blind study was carried out to determine whether alkalization of a 0.25% bupivacaine solution in a fentanyl-bupivacaine mixture hastened the onset, and increased the duration and quality, of extradural analgesia during labour. The study included 120 women with uncomplicated full-term gestation. Prior to the extradural injection, 0.1 ml of either 8.4% sodium bicarbonate or normal saline was randomly added to 20 ml of 0.25% bupivacaine. The patients were given 75 micrograms fentanyl with 12 ml of either alkalized or unaltered bupivacaine. Data for analysis were obtained in 106 parturients (bicarbonate group n = 54; control group n = 52). The pH of alkalized and unaltered bupivacaine were 7.07 +/- 0.01 and 5.56 +/- 0.01 respectively. There were no statistically significant differences between the bicarbonate and control groups with regard to the speed of onset of analgesia (7.08 +/- 0.7 min vs. 6.78 +/- 0.6 min), its duration (123.6 +/- 10.7 min vs. 113 +/- 6.6 min), and the number of cases of inadequate pain relief (6 and 3 respectively). The rate of maternal adverse effects, and neonatal status, were similar in both groups. It can be concluded that alkalizing a 0.25% bupivacaine solution in a fentanyl-bupivacaine mixture for epidural analgesia in labour has no clinical value.

Intravenous propofol during cesarean section: placental transfer, concentrations in breast milk, and neonatal effects. A preliminary study.

Placental transfer and neonatal effects of propofol were investigated in 21 women undergoing elective cesarean section under general anesthesia. This study was conducted in two separate phases according to the use of propofol. In both phases, anesthesia was induced with an iv bolus of 2.5 mg/kg of propofol. In phase 1 (n = 10), anesthesia was maintained with 50% nitrous oxide in oxygen and halothane. In phase 2 (n = 11), a continuous infusion of propofol at a rate of 5 mg.kg-1.h-1 was started after the induction dose. Maternal venous and umbilical cord arterial and venous samples were obtained at delivery. The propofol concentration in whole blood was measured with a high performance liquid chromatography method. Where possible, breast milk/colostrum was expressed for both phases postoperatively and a sample of blood was collected during phase 2 from neonates via a heel prick 2 h after birth. Propofol crossed the placenta, as demonstrated by concentrations found in umbilical venous blood in phase 1 (0.13-0.75 micrograms/ml) and in phase 2 (0.78-1.37 micrograms/ml). At delivery, the ratio of the drug concentration in umbilical venous blood to that in maternal blood was 0.70 +/- 0.06 for phase 1 and 0.76 +/- 0.10 for phase 2. The ratio of propofol concentration in the umbilical artery to that in the umbilical vein was 1.09 +/- 0.04 for phase 1 and 0.70 +/- 0.05 for phase 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of diluting fentanyl on epidural bupivacaine during labor analgesia.

In a randomized prospective study carried out on 60 laboring primiparous parturients, fentanyl 80 micrograms, either in 2 ml or in 8 ml, was added to 12 ml of 0.25% bupivacaine administered epidurally for pain relief. The aims of this protocol were to evaluate the effect of varying the volume of fentanyl added to epidural bupivacaine on the quality and duration of labor analgesia. There was no significant difference in either the duration or quality of analgesia between the two groups. The incidence of pruritus was higher in the fentanyl-diluted group (43% versus 23%). No clinical advantage was found in this study, therefore, when fentanyl 80 micrograms was added to 0.25% bupivacaine.

[Neonatal effects of propofol administered to the mother in anesthesia in cesarean section]. / Effets néonatals du propofol administré à la mère pour l'anesthésie de la césarienne.

Propofol, 2-6 diisopropylphenol ("Diprivan", ICI) has been shown to be safe and effective for induction and maintenance of anesthesia when injected intravenously. Its pharmacological profile suggests that it may prove to be a useful agent in obstetric anesthetic practice. But, obstetrics is a specialized field in which the acute effects of the anesthetic agent on the fetus must be considered. This open non comparative study was therefore designed to investigate the neonatal assessments when propofol was used either for induction of anesthesia or for induction and maintenance of anesthesia during elective cesarean section. This study was conducted in two separate phases according to the use of propofol. In both phases, anesthesia was induced with an intravenous bolus of 2.5 mg.kg-1 of propofol. In phase 1 (n = 10), anesthesia was maintained with 50% nitrous oxide in oxygen and halothane. In phase 2 (n = 11), a continuous infusion of propofol at a rate of 5 mg.kg-1.h-1 was started after the induction dose. At time of delivery, blood samples were taken from maternal artery, umbilical vein and artery for acid-base and blood gas status. The condition of the infant was evaluated using Apgar score at 1, 5 and 10 min, time to sustained spontaneous respiration and the Neurologic and Adaptative Capacity Score was assessed at 30 min, 2 hours and 24 hours after birth. Maternal and neonatal blood gas tensions and acid-base status at delivery were within the normal clinical limits in both phases and compared favorably with results published by others workers using established methods of anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Controlled trial of extradural bupivacaine with fentanyl, morphine or placebo for pain relief in labour.

In a prospective, randomized double-blind study carried out on 255 parturients, fentanyl 80 micrograms (n = 81), morphine 4 mg (n = 83) or placebo (n = 85) was added to 0.25% bupivacaine administered extradurally for pain relief during labour. Fentanyl increased the mean duration of bupivacaine analgesia by 30% and did not reduce the rate of inadequate pain relief. Morphine did not increase the mean duration of bupivacaine analgesia significantly, but increased the rate of inadequate pain relief. It was concluded that morphine 4 mg added to extradural 0.25% bupivacaine was of no value.

[A combination of sufentanil and 0.25% bupivacaine administered epidurally for obstetrical analgesia. Comparison with fentanyl and placebo]. / Association sufentanil-bupivacaïne à 0.25% par voie péridurale pour l'analgésie obstétricale. Comparaison avec le fentanyl et un placebo.

The study reported was designed to determine whether 15 micrograms sufentanil would provide analgesia comparable in duration and quality with that given by 75 micrograms fentanyl, when associated with plain 0.25% bupivacaine for extradural analgesia for labour. Patients (n = 124) in labour and at full term were randomly divided into 3 groups. Group 1 (n = 41) were given 12 ml of 0.25% plain bupivacaine with saline, group 2 (n = 41) 12 ml of 0.25% plain bupivacaine with 75 micrograms fentanyl and group 3 (n = 42) 12 ml of 0.25% plain bupivacaine with 15 micrograms sufentanil. 11 cases were excluded from the study (8 Caesarean sections, 3 technical failures). The duration of analgesia obtained with the two opioids was similar (group 2: 126.7 +/- 6.5 min, p less than 0.01; group 3: 114.9 +/- 5.8 min, p less than 0.01; group 1: 93.6 +/- 5.4 min) as well as the quality of pain relief. There were no differences between the three groups with regard to Apgar scores. The only side-effect seen with sufentanil and fentanyl was pruritus (group 2: 21.9%, p less than 0.05; group 3: 21.4%, p less than 0.05; group 1: 2.4%). These results showed that 15 micrograms sufentanil could replace 75 micrograms fentanyl for extradural pain relief of labour with plain 0.25% bupivacaine. However, the use of opioids with local anaesthetics would seem to be of interest only if labour is likely to be prolonged.