Hemoperitoneum in peripartum: A case-series.

Hemorrhages are the first cause of perinatal deaths in French women. Thirteen percent of these deaths are not linked to obstetrical problems but rather to hemoperitoneum. These incidents are under-diagnosed and as a result, treatment is delayed and fetal and maternal mortality increases. We report three cases of patients, all White female in their last trimester of a non-problematic pregnancy presenting with hemoperitoneum and resulting in different outcomes. The analysis of published materials and of our cases leads us to infer that a diagnosis of hemoperitoneum must be considered in pregnant women when abdominal pain, symptoms of shock and a decrease in hemoglobin are associated. An immediate response and intensive care followed by hemostatic surgery give these patients the best chance to survive.

[Antimicrobial prophylaxis for caesarean delivery: changes in practice and administration before incision, feasibility study to paediatricians in Auvergne]. / Antibioprophylaxie pour césarienne: modification des pratiques et administration avant incision, enquête de faisabilité auprès des pédiatres du réseau de santé périnatale d'Auvergne (RSPA).

OBJECTIVE: To describe the knowledge of paediatricians regarding the practice of antimicrobial prophylaxis for caesarean section in reference to the Consensus Conference of the French Society of Anesthesia and Intensive Care (SFAR) and assess the feasibility of a change in attitude (injection of the antibiotic prior to incision) among paediatricians Perinatal Health Network of Auvergne (RSPA) working in maternity. STUDY DESIGN: Cross sectional study by survey. METHODS: First questionnaire was sent to 46 RSPA paediatricians working in maternity. Almost one-third of paediatricians who returned the questionnaire said they were not concerned. A second questionnaire was developed with two paediatricians of the CHU and sent to the same 46 paediatricians. The statistical part involved percentages. RESULTS: Response rates were respectively 61% and 67%. For the first questionnaire, only 25% of the paediatricians knew the antibiotic and the time for injection. For the second questionnaire, 87% were in favour of an administration before incision and 42% thought it will not affect the care of the newborn. For 35% of respondents, it could lead to a change in the duration of antibiotic therapy in cases of perinatal infection and for 13% only a delay in the implementation of antibiotic therapy in children. CONCLUSION: The RSPA paediatricians did not know the practices of antibiotic prophylaxis for caesarean section. However, they did not appear opposed to an administration before cord clamping as it would not delay the implementation of any antibiotics in the newborn.

Influence of opioid choice on mechanical ventilation duration and ICU length of stay.

BACKGROUND: The aim of this study was to assess the impact on mechanical ventilation and ICU outcomes of substituting remifentanil for sufentanil, in an analgesia-based sedation protocol. A database of data prospectively collected was retrospectively analyzed. The study was carried out in a 16-bed tertiary-care ICU. METHODS: The study included 1544 mechanically ventilated patients admitted from January 2001 to December 2006. Patients were compared between two consecutive phases. Analgesia-based sedation guidelines were the same, except for the opiate used. The patient-to-nurse ratio (2.5) and ventilator weaning practices remained unchanged. 794 patients were included during the sufentanil phase, and 750 during the remifentanil phase. Remifentanil was associated with significantly less time spent on mechanical ventilation (10 days[3-21] vs. 14 days[3-27], P<0.01) and in the ICU (16 days[3-22] vs. 19 days[4-26], P<0.01). The difference was significant for patients ventilated no longer than four days (P=0.0035) but not for patients ventilated more than four days (P=0.058). Sedation target on the Ramsay scale was reached more often with remifentanil. The use and amount of hypnotic agents in addition to the opiate were significantly lower with remifentanil. The cost of analgesia-based sedation was similar in the sufentanil and the remifentanil group. CONCLUSION: Our study suggests that using a short-acting opiate with short context-sensitive half-life in an analgesia-based sedation protocol may significantly decrease the duration of mechanical ventilation and the ICU length of stay even though not significantly in long term sedation, while improving the achievement of sedation goals despite a lower requirement for adjunctive hypnotic agents, with no additional costs.

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.

[Ogilvie's syndrome after cesarean section: a case report]. / Syndrome d'Ogilvie post-césarienne : à propos d'une observation.

We report a case of acute postcesarean colonic pseudo-obstruction (Ogilvie's syndrome). We report the treatment algorithm we followed. Recording to this algorithm may improve the treatment of this pathology and perhaps avoid surgical treatment in emergency.

[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.

Perispinal analgesia for labour followed by patient-controlled infusion with bupivacaine and sufentanil: combined spinal-epidural vs. epidural analgesia alone.

BACKGROUND AND OBJECTIVE: Combined spinal-epidural is an alternative technique to epidural analgesia for labour, but its benefits are not clearly identified. METHODS: A prospective, blinded, randomized study was undertaken involving 113 women attending a university hospital obstetric department. Analgesia was initiated with intrathecal bupivacaine 0.25% 1 mL + sufentanil 5 microg in the combined spinal-epidural group (n = 54), and with bupivacaine 0.125% + epinephrine 2.5 microg mL(-1) + sufentanil 7.5 microg in the epidural group (n = 59). In both cases this was followed by patient-controlled epidural analgesia with bupivacaine 0.125% (+ sufentanil 0.25 microg mL(-1)). Duration of labour, quality of analgesia and side-effects were compared between groups. RESULTS: In the combined spinal-epidural group, the onset of analgesia was faster (5 vs. 15 min, P < 0.001), the consumption of bupivacaine was lower (7.5 vs. 11.3 mg h(-1), P = 0.003) and there was less unilateral analgesia (14.8% vs. 40.7%, P = 0.002) than in the epidural group. The characteristics of labour were similar in both groups. However, in the combined spinal-epidural group, there was a higher incidence of posterior presentation (25.9% vs. 10%, P = 0.03), pruritus (P < 0.001), hypotension (P = 0.002), somnolence (P = 0.01), nausea (P = 0.02) and one case of meningitis. CONCLUSIONS: The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.

Only centromeres can supply the partition system required for ARS function in the yeast Yarrowia lipolytica.

Autonomously replicating sequences (ARSs) in the yeast Yarrowia lipolytica require two components: an origin of replication (ORI) and centromere (CEN) DNA, both of which are necessary for extrachromosomal maintenance. To investigate this cooperation in more detail, we performed a screen for genomic sequences able to confer high frequency of transformation to a plasmid-borne ORI. Our results confirm a cooperation between ORI and CEN sequences to form an ARS, since all sequences identified in this screen displayed features of centromeric DNA and included the previously characterized CEN1-1, CEN3-1 and CEN5-1 fragments. Two new centromeric DNAs were identified as they are unique, map to different chromosomes (II and IV) and induce chromosome breakage after genomic integration. A third sequence, which is adjacent to, but distinct from the previously characterized CEN1-1 region was isolated from chromosome I. Although these CEN sequences do not share significant sequence similarities, they display a complex pattern of short repeats, including conserved blocks of 9 to 14 bp and regions of dyad symmetry. Consistent with their A+T-richness and strong negative roll angle, Y. lipolytica CEN-derived sequences, but not ORIs, were capable of binding isolated Drosophila nuclear scaffolds. However, a Drosophila scaffold attachment region that functions as an ARS in other yeasts was unable to confer autonomous replication to an ORI-containing plasmid. Deletion analysis of CEN1-1 showed that the sequences responsible for the induction of chromosome breakage could be eliminated without compromising extrachromosomal maintenance. We propose that, while Y. lipolytica CEN DNA is essential for plasmid maintenance, this function can be supplied by several sub-fragments which, together, form the active chromosomal centromere. This complex organization of Y. lipolytica centromeres is reminiscent of the regional structures described in the yeast Schizosaccharomyces pombe or in multicellular eukaryotes.

Short DNA fragments without sequence similarity are initiation sites for replication in the chromosome of the yeast Yarrowia lipolytica.

We have previously shown that both a centromere (CEN) and a replication origin are necessary for plasmid maintenance in the yeast Yarrowia lipolytica (). Because of this requirement, only a small number of centromere-proximal replication origins have been isolated from Yarrowia. We used a CEN-based plasmid to obtain noncentromeric origins, and several new fragments, some unique and some repetitive sequences, were isolated. Some of them were analyzed by two-dimensional gel electrophoresis and correspond to actual sites of initiation (ORI) on the chromosome. We observed that a 125-bp fragment is sufficient for a functional ORI on plasmid, and that chromosomal origins moved to ectopic sites on the chromosome continue to act as initiation sites. These Yarrowia origins share an 8-bp motif, which is not essential for origin function on plasmids. The Yarrowia origins do not display any obvious common structural features, like bent DNA or DNA unwinding elements, generally present at or near eukaryotic replication origins. Y. lipolytica origins thus share features of those in the unicellular Saccharomyces cerevisiae and in multicellular eukaryotes: they are discrete and short genetic elements without sequence similarity.

An origin of replication and a centromere are both needed to establish a replicative plasmid in the yeast Yarrowia lipolytica.

Two DNA fragments displaying ARS activity on plasmids in the yeast Yarrowia lipolytica have previously been cloned and shown to harbor centromeric sequences (P. Fournier, A. Abbas, M. Chasles, B. Kudla, D. M. Ogrydziak, D. Yaver, J.-W. Xuan, A. Peito, A.-M. Ribet, C. Feynerol, F. He, and C. Gaillardin, Proc. Natl. Acad. Sci. USA 90:4912-4916, 1993; and P. Fournier, L. Guyaneux, M. Chasles, and C. Gaillardin, Yeast 7:25-36, 1991). We have used the integration properties of centromeric sequences to show that all Y. lipolytica ARS elements so far isolated are composed of both a replication origin and a centromere. The sequence and the distance between the origin and centromere do not seem to play a critical role, and many origins can function in association with one given centromere. A centromeric plasmid can therefore be used to clone putative chromosomal origins coming from several genomic locations, which confer the replicative property on the plasmid. The DNA sequences responsible for initiation in plasmids are short (several hundred base pairs) stretches which map close to or at replication initiation sites in the chromosome. Their chromosomal deletion abolishes initiation, but changing their chromosomal environment does not.