Transversus abdominis plane block with liposomal bupivacaine for pain control after cesarean delivery: a retrospective chart review.

BACKGROUND: Adverse effects of opioid analgesics and potential for chronic use are limitations in the cesarean setting. Regional anesthesia using transversus abdominis plane (TAP) block post-cesarean delivery may improve analgesia and reduce opioid consumption. Effectiveness of TAP block using liposomal bupivacaine (LB) to reduce post-cesarean pain is unknown. METHODS: We performed a single-center retrospective chart review of patients aged ≥18 years who underwent cesarean delivery with a multimodal pain management protocol with or without TAP block with LB 266 mg. Assessments included postsurgical opioid consumption; area under the curve (AUC) of numeric rating scale pain scores from 0 to 3 days; proportion of opioid-free patients; discharge- and post-anesthesia care unit (PACU)-ready time; times to ambulation, solid food, and bowel movement; hospital length of stay (LOS); and adverse events (AEs). Data were analyzed in the total population and in first- and repeat-cesarean subgroups using Wilcoxon, chi-squared, and Student's t-tests. RESULTS: Of 201 patients, 101 were treated with LB TAP block (LB-TAPB) and 100 without LB-TAPB. Treatment with LB-TAPB vs without LB-TAPB significantly reduced mean post-surgical opioid consumption (total, 47%; first-cesarean, 54%; repeat-cesarean, 42%; P<0.001 each) and mean AUC of pain scores (total, 46%; first-cesarean, 57%; repeat-cesarean, 40%; P<0.001 each). Patients treated with LB-TAPB had significantly shorter mean discharge-ready times (2.9 vs 3.6 days; P=0.006), PACU-ready times (138 vs 163 minutes; P=0.028), and LOS (2.9 vs 3.9 days; P<0.001). LB-TAPB significantly decreased mean times to ambulation and solid food by 39% and 31% (P<0.01 each), respectively, and numerically reduced mean time to bowel movement (26%; P=0.05). Fewer patients treated with LB-TAPB vs without LB-TAPB reported an AE (34% vs 50%; P=0.026). CONCLUSION: These results suggest multimodal pain management incorporating TAP block with LB 266 mg is an effective approach to reducing opioid requirements and improving analgesia post-cesarean delivery.

Ultrasonographic surveillance in red blood cell alloimmunization.

OBJECTIVE: This study was undertaken to audit ultrasonographic measurements of fetal liver length and middle cerebral artery peak velocity in cases of red blood cell alloimmunization between 1986 and 1999. STUDY DESIGN: A total of 200 fetuses at risk for anemia because of red blood cell alloimmunization underwent ultrasonographic measurement of the length of the right lobe of the liver, 45 underwent Doppler recording of middle cerebral artery peak velocity, and 119 underwent fetal blood sampling. RESULTS: The overall survival was 188 of 200 (94%). Among 69 fetuses found to have anemia, liver length values in 64 (93%) were at the 95th percentile or greater, and the other 5 were in the upper part of the normal range. The middle cerebral artery peak velocity was > or =95th percentile in 15 of the 19 cases of anemia in which this value was measured (79%). Among those measured within 1 week of birth, all liver lengths were at least in the upper part of the normal range, with most >95th percentile, including 1 case with a cord blood hemoglobin concentration <90 g/L. CONCLUSIONS: All fetuses with anemia identified at fetal blood sampling had enlarged livers with 93% at > or =95th percentile. The peak velocity in the middle cerebral artery was abnormal in most fetuses with anemia.

Improved patient acceptability with a transdermal drug-in-adhesive oestradiol patch.

The aim of this trial was to assess the relative patient acceptability of two transdermal oestradiol patches used in treatment of oestrogen deficiency in postmenopausal women. Thirty-five hysterectomised postmenopausal women with no previous experience of transdermal oestradiol delivery systems received treatment with either once-weekly drug-in-adhesive (DIA) patches or twice-weekly reservoir patches for 4 weeks, and were then switched to the alternative treatment for a further 4 weeks. At the end of the study, the patients completed a questionnaire to assess their relative preference for a number of characteristics of the 2 transdermal systems and, where possible, their preference for transdermal compared with oral hormone replacement therapy. Thirty-one patients completed the study; four withdrew during treatment with the reservoir patch. The DIA patch was preferred for being 'easiest to remember to apply' by 80% of patients (p < 0.01), 'easiest to open' and 'easiest to apply' by 68% (p = 0.025), and as having 'best cosmetic appearance' by 65% (p = 0.05) and 'best overall skin adhesion' by 61% (p < 0.01). While 10% of patients rated the reservoir patch as 'least irritating to the skin' (p = 0.03), only one patient found this patch 'most comfortable to wear' (p < 0.01). The DIA patch was selected by 87% of patients as their preferred treatment overall (p = 0.001). Ninety-one per cent of 22 responding patients were at least as confident of treatment with transdermal patches as with oral hormone replacement therapy (p = 0.006) and 74 % of 27 responders preferred transdermal to oral treatment (p = 0.004). The DIA patch appears to be more acceptable to patients than the reservoir patch as a transdermal oestradiol delivery system for the treatment of postmenopausal oestrogen deficiency. Characteristics of the DIA patch which may account for improved patient acceptance include ease of remembering once-weekly patch application, improved cosmetic appearance and comfort, and better adhesion.

D-D dimers: a poor correlate of PPIH and subsequent outcomes.

OBJECTIVES: To ascertain the normal range of D-D dimer levels in pregnancy in our population, and whether dimer levels are of value as a correlate of proteinuric pregnancy-induced hypertension (PPIH) or a predictor of adverse outcome. METHODS: Dimer levels were measured in 44 women diagnosed with PPIH after 32 weeks' gestation and 55 controls recruited before 24 weeks' gestation. RESULTS: Mean dimer levels in the second and third trimester of normal pregnancy were 45 ng/ml (+/- 1 S.D., 15-134) and 85 ng/ml (+/- 1 S.D., 40-180), respectively (P < 0.001). Mean dimer level in PPIH was 148 ng/ml (+/- 1 S.D., 76-292), differing significantly from normal pregnancy by ELISA but not by latex particle assay. No correlation was found between dimer levels and adverse outcome, nor between dimer levels and any one particular adverse outcome. CONCLUSION: These results suggest that dimer levels are not a useful correlate of PPIH, nor do they have a useful predictive value for adverse outcome in PPIH.

Risk factors for wound infection following caesarean section.

A prospective study was performed between April 1, 1991 and April 30, 1992 to determine factors involved in the development of post-Caesarean section wound infection. During this period there were 4,857 deliveries, 428 by Caesarean section (8.8%). Complete data were available on 328 (76.6%) patients. Wound infection occurred in 25.3% of women and was confirmed by positive bacteriology in 77.1%; 36% of wound infections were diagnosed following the patients' discharge from hospital. A negative correlation was found between maternal age and development of wound infection up to age 40 (p = 0.03). Maternal weight was a highly significant indicator of subsequent wound infection development (p = 0.0001), the relationship between increasing maternal weight and infection appearing linear. Antibiotic prophylaxis was found to be the most significant protective factor (p = 0.0007) in the reduction of postoperative wound infection. This relationship was independent of maternal weight.

Racial variation in serum uric acid concentration in pregnancy: a comparison between European, New Zealand Maori and Polynesian women.

A prospective study was undertaken to measure serum uric acid levels in normal pregnant women of different races, to ascertain if there was any significant interracial variation. A total of 48 women were studied of which 13 were European, 11 New Zealand Maori, 22 Pacific Islanders and 2 Indian. In the second trimester, European, Maori and Cook Island women had similar uric acid levels and other Polynesian groups showed significantly higher levels. In the third trimester, both Maori and Cook Island women showed a marked rise so that their levels came to equal those of other Polynesian groups, all 3 having significantly higher levels than European women. The importance of these observations relates to the use of uric acid levels in the management of patients with gestational proteinuric hypertension. It is possible that in these cases unusually high results may alarm the clinician into hasty intervention.