Chronobiology of labour pain perception: an observational study.

BACKGROUND: Circadian variation may affect many biological and pharmacological phenomena. METHODS: To assess circadian variations in labour pain perception, 222 consecutive nulliparous women with uncomplicated pregnancy, spontaneous labour, cervical dilatation (3-5 cm), ruptured membranes and normal fetal heart rate tracings were studied. Visual analogue pain scores (VAPS) were analysed and divided into four periods: night (1:01 a.m. to 7:00 a.m.), morning (7:01 a.m. to 1:00 p.m.), afternoon (1:01 p.m. to 7:00 p.m.) and evening (7:01 p.m. to 1:00 a.m.). VAPS were also compared between daytime (morning+afternoon) and nocturnal (evening+night) periods. RESULTS: Daytime mean VAPS were lower than nocturnal scores [75.6 (15.1) vs 85.7 (14.1), P<0.0001]. VAPS were lower in the morning than in the afternoon, evening and night periods (anova, P<0.0001). CONCLUSION: Labour pain perception appears to be chronobiological, and this might be taken into account when enrolling parturients in studies designed to assess or treat labour pain.

[Dural puncture in obstetric analgesia. Epidemiologic features and therapeutic management]. / Brèche durale en analgésie obstétricale. Aspects épidémiologiques et prise en charge thérapeutique.

OBJECTIVE: To assess the time of occurrence, circumstances and presenting symptoms of unintentional dural puncture (UDP), the location and intensity of postdural puncture headaches (PDPH), and the efficacy of their treatment by epidural blood-patch (EBP). STUDY DESIGN: Cohort study. PATIENTS: Cases of UDP recorded over a 4-year period in an obstetric anaesthesia unit. METHODS: The following variables were studied: maternal age, weight and height, hour of occurrence and number of puncture attempts, existence of reflux of cerebrospinal fluid (CSF) through the needle, experience of the practitioners, subsequent modalities of obstetrical analgesia, frequency of occurrence, clinical characteristics and therapeutic management of PDPH. In case of EBP, the amount of blood and the efficacy of the procedure were also recorded. RESULTS: Twenty-one patients presented with UDP (0.66%). No reflux of CSF was identified in nine cases. Most UDP occurred at the first or second attempt, usually when performed by a practitioner poorly trained in epidural analgesia in obstetrics. The risk of UDP was higher during night-time work (risk ratio: 3.0; 95% confidence interval: 1.1-8.0; p = 0.04). Subsequent analgesia was provided via the epidural route in 19 cases, subarachnoidal route in one, and intravenous route in one case. PDPH did not develop in two patients. Three patients were given prophylactic EPB, and 16 received curative EBP. A second EBP was required 24 h later in seven patients. One patient developed meralgia paresthetica following EBP. CONCLUSION: In parturients, UDP usually results in PDPH. A rapid and effective treatment is required, mainly EBP. Another EBP is eventually necessary in some patients.

Increased risk of unintentional dural puncture in night-time obstetric epidural anesthesia.

PURPOSE: To evaluate the experience of the operator and the time of epidural anesthesia as factors contributing to unintentional dural puncture (UDP). METHODS: In a prospective analysis of recorded cases of UDP the following variables were recorded: maternal height, weight, and weight gain, type of personnel providing epidural analgesia, number of attempts, and hour of the epidural procedure. Work time was divided into day-time (8 AM to 7 PM) and night-time (7 PM to 8 AM), according to the change of coverage of the delivery suite. Night-time was divided into first (7 PM to midnight) and second parts (midnight to 8 AM). Relative risk was used to compare the incidence of UDP among different work-times. RESULTS: A total of 1489 consecutive epidural procedures were considered. The incidence of dural puncture was 0.8% (12 cases). The relative risk was higher for night-time than day-time (risk ratio 6.33; 95% confidence interval, 1.39 to 28.80; P = 0.006). Seven cases were caused by three operators with poor expertise, and five by two skilled obstetric anesthesiologists. CONCLUSION: Operator experience and hour of procedure appear to be two important risk factors of UDP The increased risk of UDP in night-work could result from human factors such as fatigue, sleep deprivation or interruption.

Intravenous nicardipine for severe hypertension in pre-eclampsia--effects of an acute treatment on mother and foetus.

OBJECTIVES: To assess the efficacy in lowering blood pressure, and the safety for mother and foetus of an acute nicardipine therapy in severe pre-eclampsia. DESIGN: Prospective clinical study. SETTING: One university hospital obstetric unit. PATIENTS: Twenty consecutive adult pre-eclamptic patients with severe hypertension. INTERVENTION: Nicardipine, 1 microgram/kg per min, was given intravenously to lower the mean arterial pressure (MAP) by at least 15%. Then, the dosage was reduced by 1/3, and the final dosage was determined to maintain MAP at 20-30% below the initial value, by increasing or decreasing the infusion rate by 0.5 mg/h. MEASUREMENTS AND RESULTS: Maternal MAP and heart rate (HR) were assessed every 5 min for 1 h. Foetal HR (FHR) was recorded throughout the study period and assessed for Fischer score. Gestational age, Apgar scores, birth weight, capillary filling time and the duration of stay in the paediatric intensive care unit (ICU) were used to evaluate the short-term perinatal outcome. A 15-30% decrease in MAP occurred within 15-20 min in all patients. An increase in HR was noted, and two patients had severe tachycardia. Maternal side effects included flushing, headache, nausea and dizziness. FHR showed a transient decrease in acceleration episodes and occurrence of decelerations. No nicardipine-related foetal distress occurred. Four infants born during the study period did well at birth and had a good outcome. CONCLUSIONS: Acute nicardipine therapy can induce severe maternal tachycardia. No severe foetal or neonatal adverse effects occurred. This dose scheme requires comparison with alternative therapeutic options.

[Pressure-controlled mechanical ventilation: a simplified titration method of the extrinsic positive expiratory pressure]. / Ventilation mécanique en pression contrôlée: une méthode simplifiée de titration de la pression expiratoire positive extrinsèque.

OBJECTIVES: Extrinsic positive end-expiratory pressure (PEEPe) may improve gas distribution within the lungs, induce alveolar recruitment or, conversely, produce pulmonary overdistension, and modify the respiratory impedance. Under pressure-controlled mechanical ventilation (PCV) this phenomenon modifies the minute ventilation and the dynamic compliance of the respiratory system (Crs,dyn). This study was aimed to assess the incidence of a significant gain in Crs,dyn under the effect of PEEPe during PCV. STUDY DESIGN: Prospective, open, descriptive, case series study. PATIENTS: Surgical intensive care unit patients, under sedation, neuromuscular blockade and PCV because of severe hypoxaemia (ARDS or acute lung injury). METHODS: Four incremental levels of PEEPe (4 to 16 cmH2O) of 30 minute duration were applied. Crs,dyn, and PaO2/FIO2 were recorded at the end of each level of PEEPe. The resulting gain in Crs,dyn was calculated and considered as significant if it was greater than the upper limit of confidence (at 99.8%) of the statistical distribution of all the recorded gains. RESULTS: Thirty patients were included, median and extreme values (within brackets) of PaO2/FIO2 of 117 [53-230] and Crs,dyn without PEEPe of 29 [14.3-46.8] mL.cmH2O-1. Among the 120 recorded gains, a gain in Crs,dyn was found significant at least once in 15 tests of PEEPe out of 30. Within the two groups of patients, the increase in PaO2/FIO2 with incremental PEEPe was similar. The levels of PEEPe producing the greatest increase in Crs,dyn were not correlated with the increase in PaO2/FIO2. CONCLUSION: In 50% of the studied patients a significant gain in Crs,dyn was found, allowing a less traumatic PCV. These results suggest the clinical usefulness of this method of titration of PEEPe, which requires neither specific devices nor a disconnection of the patient.

Severe preeclampsia superimposed on polyarteritis nodosa.

A patient with a history of drug abuse and histologically diagnosed hepatitis B-related polyarteritis nodosa was admitted for severe hypertension. After a cesarean section because of worsening of her clinical status with severe proteinuria and edema, she improved dramatically. No sign of acute polyarteritis nodosa occurred.

[Severe preeclampsia. Principal management modalities before patient transfer]. / Pré-éclampsie sévère. Principales modalités de la prise en charge avant transfert.

Preeclampsia is relatively frequent during pregnancy. The occurrence of complications implies referral to a specialized center for optimal care of both mother and fetus. The transfer of these patients is very critical with risk of worsening the mother's status. Management before referral aims to stabilize material clinical status, requiring precise clinical assessment, treatment of severe hypertension or pulmonary edema, and prevention or treatment of eclampsia. The management of oliguria and the tracheal intubation are associated with specific problems. Fetal wellbeing is assessed before and during emergency treatments of maternal disorders.

[Optimal use of peripheral nerve blocks]. / Optimisation des blocs périphériques.

The advantages of regional over general anaesthesia have led to an increased use of peripheral nerve blocks. Among the few risks of regional anaesthesia are those of overdosage, systemic and neural toxicity. Techniques have been proposed to improve the success of peripheral nerve blocks and to avoid nerve damage or systemic toxicity. Nerve stimulator, anatomic landmarks, needles and anaesthetic solutions are discussed.

[Postdural puncture headache]. / Les céphalées après ponction dure-mérienne.

PDPH are not the privilege of spinal anaesthesia, as they can occur in various circumstances including epidural anesthesia, surgical wound of the dura, spinal tap and/or myclography. Diagnosis PDPH can be discussed with four etiologies: cortical vein thrombosis, meningitis, intracranial haematomas (intracerebral, subdural) or migraine. PDPH result from the leakage of CSF via the dural hole, responsible of hypotension of CSF in the subarachnoid compartment. Several etiologies and predisposing factors are discussed. The incidence of PDPH varies with age, maximum from 15 to 50 years-old, the decreasing to reach a very low incidence over 65 PDPH seems to occur more frequently in women, especially during pregnancy. The diameter of the spinal needle is the main factor of PDPH. Using small diameters (25 G and less) allows to reduce the percentage of PDPH, as well as using specially designed needles with a "pinpoint bevel" (Sprîtte, Whitacre). When PDPH occur, no specific treatment is required before the fifth day, as they spontaneously resolve in 80% of the patients, without any intervention. After then, epidural blood patch allows 90% success rate. Other therapeutic proposals are discussed. Finally, prevention of PDPH appears to be the keypoint, paying particular attention to the choice of the needle and of the spinal puncture technique.

Teaching employees breast self examination. Factors that may influence practice.

Breast self examination is a widely known technique used for detection of breast lumps. Many women do not practice monthly breast self examination, although it has been proven that with early detection the prognosis of breast cancer can be improved greatly. When tend to be taught, or learn about, breast self examination at an early age. The educational techniques used during the instruction can influence the practice of BSE later on. Health professionals can make a difference in the practice of BSE by communicating the value of this detection technique. BSE is a viable breast cancer detection technique that employees can be taught easily in employee wellness programs by health professionals.