[Anesthesia for cesarean section in a Marfan patient with complicated aortic dissection]. / Anesthésie pour césarienne chez une patiente présentant une dissection aortique compliquée.

We report the anaesthetic management of a 32-year-old pregnant women with aortic dissection and Marfan syndrome for caesarean section. The patient has presented at 31 weeks gestation of a first pregnancy an aortic dissection that required an emergency aortic replacement. Three years later, she presented at 31 weeks gestation with aortic dissection, mitral valve dysfunction and acute pulmonary oedema. She was treated in intensive care unit with deslanoside, diuretic and twice a day echographic examination. Delivery was planned by caesarean section after haemodynamic stabilisation on the sixth day. Combined spinal and epidural anaesthesia was performed after monitoring. The initial intrathecal injection of bupivacaine, morphine and fentanyl provided rapid onset of analgesia. Epidural anaesthesia was used with diluted lidocaine and fentanyl boluses. With appropriate preoperative care and monitoring, uneventful combined spinal and epidural anaesthesia for Caesarean section was achieved in a patient with Marfan syndrome in the presence of aortic dissection complicated by mitral valve dysfunction and acute pulmonary oedema.

[Maternal emergencies requiring controlled ventilation: epidemiology and prognosis]. / Urgences maternelles nécessitant une ventilation assistée: étude épidémiologique et pronostique.

OBJECTIVE: Evaluation of severe maternal morbidity in peripartum period leading to controlled ventilation in the obstetrical intensive care unit. STUDY DESIGN: A retrospective study was carried out during a period of three years, from March 1998 to March 2001, in the obstetrical intensive care unit (ICU) of Farhat Hached hospital, Sousse (Tunisia). PATIENTS AND METHODS: Twenty obstetric patients requiring controlled ventilation were admitted in the ICU. Obstetric data included maternal age, gestational age, parity, diagnosis of the disease requiring controlled ventilation and maternal outcome. RESULTS: A total of 24812 deliveries occurred during the study period at Farhat Hached maternal center. Twenty patients (0.08 percent) required controlled ventilation for a mean duration of 38 hours (range: five hours- 21 days). The mean age was 30 +3 years. Eight patients were primigravida. The mean gestational age was 33 +2 weeks. Seventeen patients (85 percent) underwent cesarean section. The mean duration in the ICU was six days (range: 5 hours - 34 days). There were six maternal deaths (30 percent). Maternal mortality was attributed to neurologic 40 percent, hemodynamic 30 percent or respiratory 30 percent failure which complicated eclampsia, hemorrhagic shock, pulmonary edema or sepsis. CONCLUSION: There were 0.08 percent of obstetric patients requiring controlled ventilation. The serious maternal morbidity and the high mortality require better care of obstetric patients.

Acute appendicitis during pregnancy.

Acute appendicitis is the most common surgical emergency occurring during pregnancy. To determine possible methods for improving diagnostic and management accuracy, a retrospective review was conducted of 23 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 2 patients, the second trimester in 6 patients and the third trimester in 15 patients. Eighteen patients (78.26%) had pathologically proven acute appendicitis. Perforation occurred in 2 patients. Postoperative fetal complications included one intrauterine death (4.3%) and three premature births. There was no maternal deaths and morbidity was limited to atelectasis and wound infection in 4 patients. Gestational physiologic changes make difficult the diagnosis of acute appendicitis. Prompt surgical intervention prevent maternal complications and foetal loss.

[Maternal and perinatal morbidity and mortality associated with hellp syndrome] . / Morbidité et mortalité materno-foetales associées au Hellp syndrome.

OBJECTIVES: Our purpose was to describe the effects of serious obstetric complications on maternal and perinatal outcome in pregnancies complicated by Hellp syndrome. STUDY DESIGN: Retrospective study. PATIENTS: Sixteen patients managed from January 1994 through December 1998 in whom pregnancy was complicated by Hellp Syndrome. RESULTS: The incidence of Hellp syndrome among women with severe preeclampsia and/or eclampsia (164 cases) was 9.7%. Fourteen cases occurred before and two after delivery. In nine cases, Hellp occurred before 32 weeks of gestation and later in two other cases. Mean gestational age at delivery was 32.4 weeks. Serious maternal morbidity included acute renal failure (five cases), disseminated intravascular coagulation (two cases), pulmonary oedema (one case), severe ascites (five cases), pleural effusion (three cases), adult respiratory distress syndrome (one case). Abruptio placenta, acute renal failure and disseminated intravascular coagulation were always associated. Ten patients required transfusions with blood products. Caesarean delivery was performed in 15 cases. General anaesthesia was used in all patients. There was one maternal death from multiple organ failure. Perinatal outcome was poor. Six perinatal deaths were related to abruptio placenta, intrauterine asphyxia and extreme prematurity. CONCLUSION: The high maternal and perinatal mortality and morbidity reported with the presence of Hellp syndrome requires maternal-fetal follow-up in a tertiary centre where intensive maternal and neonatal care are available.

[Peripartum cardiomyopathy. Clinical case series]. / Cardiomyopathie du péripartum. Série de cas cliniques.

We report a retrospective analysis of four cases of peripartum cardiomyopathy admitted, within a 10-year period, to the maternity hospital of Sousse. The age of the patients was over 30 years, two had gemellary pregnancies and two suffered toxaemia. Congestive cardiac failure, mainly of the left ventricle, with acute pulmonary oedema, was the main symptom. Chest X-ray showed a cardiothoracic index above 0.58 and echocardiography a left ventricular telediastolic diameter above 5.7 cm and a shortening ratio of 25% or less. Endomyocardial biopsy for ascertaining the diagnosis was not available. Treatment included bed rest, water and salt restriction, digitalis, a diuretic and an anticoagulant in case antepartum cardiomyopathy, a converting enzyme inhibitor and a diuretic in case of postpartum cardiomyopathy. Three patients recovered totally and in one echocardiography showed a persisting impaired left ventricular function. Five neonates had a favourable outcome and one foetus died in utero. Main problems raised by peripartum cardiomyopathy are discussed.