Effect of pain and analgesia on compensatory reserve.

BACKGROUND: The measurement of the body's capacity to compensate for reduced blood volume can be assessed with a compensatory reserve measurement (CRM). The CRM, which is calculated from changes in features of the arterial waveform, represents the integration of compensatory mechanisms during states of low tissue perfusion and oxygenation, such as hemorrhage. This study was designed to test the hypothesis that pain which activates compensatory mechanisms and analgesia that result in reduced blood pressure are associated with lower compensatory reserve. This study evaluated CRM in obstetric patients during labor as pain intensity increased from no pain to severe pain and compared CRM before and after epidural anesthesia. METHODS: CRM was calculated from a finger pulse oximeter placed on the patient's index finger and connected to the DataOx monitor in healthy pregnant women (n = 20) before and during the active labor phase of childbirth. RESULTS: As pain intensity, based on an 11-point scale (0, no pain; 10, worst pain), increased from 0 to 8.4 ± 0.9 (mean ± SD), CRM was not affected (81 ± 10% to 82 ± 13%). Before analgesia, CRM was 84 ± 10%. CRM at 10 minutes, 20 minutes, 30 minutes, 40 minutes, 50 minutes, and 60 minutes after analgesia was 82 ± 11%, 83 ± 14%, 83 ± 15%, 86 ± 12%, 89 ± 9%, and 87 ± 10%, respectively. There was a transient 2% reduction followed by a 5% increase in CRM from before to after epidural anesthesia (p = 0.048). Pain scores before and after analgesia were 7 ± 2 and 1 ± 1, respectively (p < 0.001). CONCLUSION: These results indicate that pain and analgesia contribute minimally, but independently to the reduction in compensatory reserve associated with trauma and hemorrhage. As such, our findings suggest that analgesia can be safely administered on the battlefield while maintaining the maximal capacity of mechanisms to compensate for blood loss. LEVEL OF EVIDENCE: Diagnostic study, level II.

Percutaneous Drainage of a Rapidly Enlarging Simple Ovarian Cyst in the Third Trimester.

BACKGROUND: Persistent adnexal masses increase the risk of pregnancy complications including cyst rupture, ovarian torsion, and labor obstruction. Treatment options include observation, surgical excision, and early first or second trimester drainage. Our case represents the most advanced gestational age for intervention with percutaneous drainage. CASE: A 32-year old G3P1102 at 29.2 weeks gestation presented with left lower quadrant pressure, right abdominal fullness, and left uterine displacement. She had a right, simple-appearing ovarian cyst, which had increased in size from previous ultrasounds to 12.8 × 13.4 × 15.7 cm. Ultrasound-guided percutaneous drainage with pigtail catheter placement removed 1.2 L serous green fluid. Fluid culture was negative and cytology showed no evidence of malignancy. The pigtail catheter was removed at 31.2 weeks because of pain at the surgical site and significant cyst regression. The cyst resolved and she delivered via uncomplicated vaginal delivery at term. CONCLUSION: A few case reports describe first and second trimester percutaneous or transvaginal drainage of symptomatic ovarian cysts as a less invasive approach than surgical excision. However, our case suggests drainage of a simple-appearing cyst as an alternative treatment option in the third trimester when the risk of preterm labor and fetal complications with surgical intervention is at its highest.

Cervicothoracic intradural spinal lipoma without dyraphism diagnosed postpartum.

BACKGROUND: Intradural spinal lipoma without evidence of dysraphism is a rare occurrence comprising approximately 1% of all spinal tumors. CASE: An 18-year-old female who, following her primary cesarean section, began developing progressively worsening lower extremity weakness, paresthesias, spasticity, and hyperreflexia. Magnetic resonance imaging diagnosed a cervicothoracic intradural spinal lipoma. She underwent an osteoplastic laminotomy with subtotal resection of intradural lipoma with an excellent prognosis. CONCLUSION: This case highlights the need for broad differential diagnoses if symptoms do not correlate with the typical postpartum recovery. Our patient's case is the first to describe symptoms developing postpartum with excellent prognosis because of rapid evaluation and diagnosis.

Digoxin immune fab treatment for severe preeclampsia.

We evaluated the efficacy, safety, and biological mechanisms of digoxin immune Fab (DIF) treatment of severe preeclampsia. Fifty-one severe preeclamptic patients were randomized in double-blind fashion to DIF ( N = 24) or placebo ( N = 27) for 48 hours. Primary outcomes were change in creatinine clearance (CrCl) at 24 to 48 hours and antihypertensive drug use. Serum sodium pump inhibition, a sequela of endogenous digitalis-like factors (EDLF), was also assessed. CrCl in DIF subjects was essentially unchanged from baseline versus a decrease with placebo (-3 +/- 10 and -34 +/- 10 mL/min, respectively, P = 0.02). Antihypertensive use was similar between treatments (46 and 52%, respectively, P = 0.7). Serum sodium pump inhibition was decreased with DIF compared with placebo at 24 hours after treatment initiation (least squares mean difference, 19 percentage points, P = 0.03). DIF appeared to be well tolerated. These results suggest DIF prevents a decline in renal function in severe preeclampsia by neutralizing EDLF. Sodium pump inhibition was significantly improved. Further research is warranted.

Vitamin B-6 content of breast milk and neonatal behavioral functioning.

OBJECTIVE: To determine if vitamin B-6 intakes of mothers influence the B-6 vitamer content of transition milk and if correlations exist between the vitamin B-6 content of the milk and the infants' neurobehavioral functioning. DESIGN: Transition milk samples were collected from mothers 8 to 11 days after delivery for B-6 vitamer analysis. Neurobehavioral functioning of the neonates was determined at that time. A 24-hour recall was used in estimating vitamin B-6 intakes of the mothers. SUBJECTS: A convenience sample of low-income, lactating women (n = 25) who had normal pregnancies. MAIN OUTCOME MEASURES: B-6 vitamers were measured in the mothers' transition milk samples. Neurobehavioral functioning was assessed using the Brazelton Neonatal Behavioral Assessment Scale (NBAS), and the Center for Epidemiologic Studies Depression Scale was used to evaluate maternal depression. STATISTICAL ANALYSES PERFORMED: Pearson correlation coefficients were used to assess if statistically significant relationships existed between variables. The Mann-Whitney test was used to determine if median group values were significantly different. RESULTS: The major B-6 vitamer in transition milk was pyridoxal. Mothers with vitamin B-6 intake greater than the median value had a significantly higher median pyridoxal level in their breast milk than did the mothers with intakes below the median value. All except one mother had a dietary vitamin B-6 intake that exceeded the Recommended Dietary Allowance. Infant scores on habituation (r = .94, P < .05) and autonomic stability (r = .34, P < .05) subscales of the NBAS were positively correlated with milk pyridoxal values. APPLICATIONS/CONCLUSIONS: Vitamin B-6 is important for normal behavioral functioning of infants. The mothers' vitamin B-6 intake affects vitamin B-6 levels of breast milk and the need for consuming recommended levels of vitamin B-6 should be emphasized to all pregnant and lactating mothers.

Prolonged-interval delivery between the first and second twin. A case report.

BACKGROUND: Prolonged-interval delivery between twins can improve neonatal outcome and, under careful monitoring, poses minimal maternal risk. CASE: A 27-year-old, nulliparous woman conceived after in vitro fertilization and was found to have diamniotic-dichorionic twins. At 17 weeks she presented with premature preterm rupture of the membranes of twin A. She was offered delivery or expectant management. She chose expectant management and was discharged. At 18 weeks she delivered twin A and decided to expectantly manage the second twin. Amniocentesis was performed to evaluate for intraamniotic infections. There was no evidence of them, and a McDonald cerclage was placed. At 32 weeks, spontaneous rupture of the membranes occurred for twin B. The patient delivered vaginally a male infant (2,070 g) who did not need mechanical ventilation and was discharged from neonatal intensive care on the 7th day of life, with no complications. CONCLUSION: Expectant management of a second twin after delivery of the first in selected patients can improve neonatal outcome.