Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy.

BACKGROUND: The postoperative analgesic effects of rectal indomethacin and tramadol were compared in patients undergoing elective termination of first trimester pregnancy and diagnostic dilatation and curettage. METHODS: Eighty-one American Society of Anesthesiologists class I and II women undergoing first trimester termination of pregnancy or diagnostic dilation and curettage were randomly allocated to receive rectal suppositories of either tramadol 100 mg (n=41) or indomethacin 100 mg (n=40) 90 min before induction of anesthesia. Pain scores and side effects were evaluated until discharge. Intraoperative anesthetic and postoperative analgesic consumption was also recorded. Intravenous metamizole 1 g was employed for postoperative rescue analgesia. RESULTS: When compared to the indomethacin group, the tramadol group required less intraoperative propofol [136 mg ±28 vs. 160 mg ±35 (P=0.001)], less rescue analgesia [2.4% vs. 22% (P=0.005)] and lower visual analogue pain scores [2.4 ±8 vs. 23 ±22 (P=0.005)]. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSION: When compared to indomethacin 100 mg, preoperative administration of tramadol 100 mg provides superior postoperative analgesia with minimal adverse effects.

Obstetric anesthesia units in Israel: a national questionnaire-based survey.

BACKGROUND: This survey was performed to assess the organization and practice of obstetric anesthesia units in Israel. METHODS: A written questionnaire was mailed at the end of December 2005 to all Israeli anesthesia departments providing labor and delivery services in 2005 (n=25). RESULTS: A response rate of 100% accounted for 125,340 deliveries. All labor and delivery suites had on-site anesthesia department services. Data are presented as mean (range) or frequency. Eleven hospitals performed 2500-4999 deliveries/year, 6 hospitals 5000-7499 deliveries/year, and 4 hospitals 7500-9999 deliveries/year. The overall cesarean delivery rate was 20% (0-27). Anesthesia for cesarean delivery (elective and emergency combined) was provided by: general anesthesia 15% (0.5-50), epidural 14.5% (0-99.5), spinal 68% (0-98), or combined spinal-epidural technique 0% (0-30). There was an operating room within or immediately adjacent to the labor ward in 16/25 units, including 10/11 units with >5000 deliveries/year. Labor analgesia was provided by epidural techniques in 50% (4-93) and nitrous oxide in 0.5% (0-90) of deliveries. A total of 11 units had 24h dedicated anesthesiologist coverage, including all units >7500 deliveries but only 3/8 (38%) with 5000-7500 deliveries. Two of the 4 units with >7500 deliveries had no faculty member with formal training in obstetric anesthesia. Written protocols were available for labor analgesia (17/25), post-partum hemorrhage (12/25), aspiration prophylaxis (15/25) and maternal resuscitation (8/25). CONCLUSION: In this national appraisal of Israeli obstetric anesthesia services, a notable lack of written protocols, wide variations in staffing, and few specifically trained obstetric anesthesia personnel were observed.

Patient-controlled epidural analgesia: the role of epidural fentanyl in peripartum urinary retention.

BACKGROUND: Urinary bladder function is impaired during labor and delivery, predisposing to urinary retention. The effect of low-dose epidural opioid on bladder function remains unclear. We tested the hypothesis that adding low-dose fentanyl to epidural ropivacaine for patient-controlled labor analgesia does not promote urinary retention. METHODS: Laboring women who requested patient-controlled epidural analgesia were randomly assigned in a double blind study to 0.2% ropivacaine (R-group, n=100) or 0.2% ropivacaine with fentanyl 2 microg/mL (RF-group, n=98). Urinary bladder distension was assessed clinically every hour. The post-void residual urine volume was measured by ultrasonography. Urine volume exceeding 100 mL was drained by catheterization. Bladder volume of > or =300 mL, as determined by catheterization was considered as evidence of urinary retention. RESULTS: Thirty percent of the patients in each group developed urinary retention during labor. There was no statistically significant difference between the groups. There was an excellent correlation between bladder volume as estimated by ultrasonography and that by catheterization: catheterization volume=0.93 x ultrasound volume + 25; r(2)=0.83. The bias (mean error) was -1+/-99 mL and the precision (average absolute error) between the ultrasound estimate and actual bladder volume determined by catheterization was 58+/-79 mL. CONCLUSION: Addition of fentanyl to patient-controlled epidural analgesia did not increase the risk of urinary retention. Ultrasound measurements were effective and reliable in assessing urinary bladder volumes during labor.

[The management of HIV patients during surgery and in the delivery ward: anesthetic considerations].

To date a total of more than 50 million individuals worldwide have been infected with HIV and more than 20 million have died from the disease. Two thirds of the known carriers of HIV 36 million worldwide, live in Africa. In Israel, as of December 31, 2000, there are a total of 2,843 reported carriers and 165 persons alive with AIDS. On the basis of future projections of increasing incidence of HIV/AIDS in obstetric patients undergoing anesthesia and surgery, obstetricians and anesthesiologists should be aware of the disease and its impact on anesthetic techniques and possible interactions between anesthetic drugs and HIV therapeutic agents. Surgical staff members should be knowledgeable and updated concerning safety precautions during surgical and anesthetic procedures.

Difficult airway in obstetric anesthesia: a review.

UNLABELLED: Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases. LEARNING OBJECTIVES: After completion of this article, the reader will be able to break down the complex issues in managing the difficult airway in the obstetric patient, outline the reasons for difficult intubations in pregnancy, and describe the evaluation used to predict a difficult intubation.

Oligohydramnios: maternal complications and fetal outcome in 145 cases.

One hundred and forty-five cases of oligohydramnios in the second and third trimester were diagnosed by ultrasonography out of 25,000 obstetrics patients (0.58%). In this group, pregnancy complications included hypertension (22.1%) and bleeding in the second trimester (4.1%). We found a high incidence of meconium-stained amniotic fluid (29.1%), fetal distress (7.9%) and premature placental separation (4.2%). IUGR occurred in 24.5% of cases. Asphyxia during labor occurred in 11.5% and different other perinatal problems in 23.5%. Cesarean section was performed in 35.2% of these pregnancies. Seventeen percent of the cases presented as breech. Intrauterine fetal death occurred in 5.5% of these pregnancies. The gross perinatal mortality was 16% and the corrected perinatal mortality was 10.7%. The overall rate of fetal malformations was 11% and that of lethal malformations 4.8%. The skeletal (7.6%) and urinary system (4.1%) were the predominant systems affected. Oligohydramnios is associated with a higher rate of pregnancy complications and increased fetal morbidity and mortality, and thus termination should be considered when pulmonary maturity is present or in cases of fetal distress.

Effect of experimental autoimmune encephalomyelitis on pregnancy: studies in rabbits and rats.

The influence of experimental autoimmune encephalomyelitis (EAE) on the course and outcome of pregnancy, and the effect of pregnancy on EAE development, was investigated in rabbits and rats. Animals were immunized with encephalitogenic antigen in complete Freund's adjuvant (CFA) either before or during pregnancy. Abortion or fetal resorption was observed in most of the rabbits immunized before or during pregnancy, but not in pregnant rabbits injected with CFA or saline alone. Fetal loss was higher in those rabbits that developed clinical EAE. In rats, fetal loss occurred only when immunization was carried out during the first half of pregnancy. The appearance of EAE in pregnant rabbits, but not in rats, was delayed until after abortion or termination of pregnancy. The incidence of EAE in rabbits was lower, with milder severity and longer duration. Serum antibody levels to myelin basic protein, the autoantigen of EAE, was lower in pregnant rabbits, but not in rats, as compared to non pregnant animals. These results indicate that in species where pregnancy has a suppressive influence on the development of experimental autoimmune demyelinating disease, immunization with the neuroantigen induces a high rate of fetal loss.

Experimental allergic encephalomyelitis: passive transfer of resistance during lactation.

Pregnant rats challenged with encephalitogenic antigen in complete Freund's adjuvant (CFA) during pregnancy, transferred a resistance to induction of experimental allergic encephalomyelitis (EAE) in encephalitogenic challenged offspring. The resistance to induction of EAE was transferred during the whole lactation period, until weaning, and not during pregnancy. Through the milk, anti-myelin basic protein antibodies were transferred to the newborn animals. The degree of protection against EAE decayed with age and was not influenced by EAE occurrence in the mothers. In addition, the course of EAE in the rats was not affected by pregnancy. We believe that such transfer of resistance and antibodies may serve as a model for the study of milk-transmitted maternal immunocompetent factors, as well as a model for the mechanisms involved in the resistance of EAE.

Severe peripheral arteriospasm following oxytocin administration.

A parturient patient with imminent gangrene of the extremity caused by oxytocin-induced arteriospasm is described. The appliance of conventional measures such as anticoagulation and vasodilatation produced an immediate and sustained reversal of the arteriospasm together with dramatic relief of symptoms and signs.

The action of intrathecal morphine and methadone on the lower urinary tract in the dog.

The effects of intrathecally administered morphine and methadone on lower urinary tract dynamics were investigated by cystometrograms and urethral pressure profiles in 16 anesthetized dogs. The examinations were performed before and 30, 60 and 90 minutes following intrathecal injection of 0.03 mg./kg. morphine or methadone. Intrathecal normal saline was used for control studies. Significant relaxation of the detrusor was noted after intrathecal morphine as expressed by a decrease in mean intravesical pressure (p less than 0.05) and by a rise in the calculated detrusor compliance. These effects were reversed by intravenously injected naloxone. As opposed to morphine, methadone caused an increase in detrusor tone. No appreciable effects were observed on the urethra after intrathecal morphine or methadone. Neither intravenous injection of the opiates nor intrathecal administration of saline caused alterations in bladder tone. The result may imply a spinal, albeit opposing, effect of the two opiates on bladder dynamics.

A new animal model for action myoclonus.

Morphine was injected into a catheter implanted chronically into the intrathecal space of rats. Three to eight minutes after drug administration, 80% of the rats developed arrhythmic stimulus-sensitive jerks that lasted up to 1 hr. The morphine-induced myoclonic activity was markedly reduced by naloxone. Methadone, pethidine, and etorphine failed to produce the syndrome. In spinally transected rats, morphine injected below the level of transection did not produce the syndrome. No significant changes in PaCO2 and PaO2 were produced by morphine before and throughout the period of myoclonic activity. Neither did induced hypoxia augment the effect of morphine. However, irreversible hypoxic-ischemic cell changes were noticed in some brain regions. The phenomenon described here resembles the human syndrome of action myoclonus and may serve as an animal model for studying the mechanism of that neurological disorder.

Treatment of experimental allergic encephalomyelitis in rabbits with alpha-fetoprotein.

We studied the ability of alpha-fetoprotein (AFP) to suppress experimental allergic encephalomyelitis (EAE) in rabbits. Animals were treated with daily injections of 50 micrograms of AFP following the onset of neurological signs. Clinical status, anti-myelin basic protein (MBP) antibody titers, and histopathological changes in the CNS were determined. Treatment with AFP significantly improved the clinical scores of the affected rabbits and inhibited the binding of anti-MBP antibodies to MBP in vitro. However, there was no significant difference in the titers of anti-MBP antibody, and no amelioration of histopathological changes between treated and control animals. We conclude that AFP is effective in improving the clinical status of animals with EAE, even after the appearance of clinical signs.

Congenital afibrinogenemia and recurrent early abortion: a case report.

The role of the fibrinogen molecule in the maintenance of normal pregnancy is not yet well understood; however, several cases have been previously reported in which failure to complete normal pregnancy was associated with either hypofibrinogenemia, dysfibrinogenemia, or deficiency in factor XIII (fibrin-stabilizing factor) which is important for the crosslinking of the fibrin. A case of congenital afibrinogenemia is described. The patient, a 22-yr-old woman, who suffered from a moderate hemorrhagic tendency associated with very low (less than 10 mg/dl) plasma fibrinogen levels, had three consecutive spontaneous abortions. In view of the previous cases reported, the question is raised whether patients with low or abnormal fibrinogen should be treated with plasma transfusions in order to maintain a normal pregnancy.

Recurrent molar pregnancies associated with clomiphene citrate and human gonadotropins.

A 34-year-old patient, gravida 7, para 0, with three consecutive spontaneous abortions followed by four recurrent molar pregnancies is described. The patient conceived only with clomiphene citrate or human gonadotropin treatment. The occurrence of molar pregnancies succeeded spontaneous abortions with one remaining pregnancy progressing to gestational trophoblastic disease. The role of clomiphene citrate and human gonadotropins in the pathogenesis of this disease is discussed.

Nonimmunologic hydrops fetalis: a review of 11 cases.

Eleven cases of nonimmunologic hydrops fetalis occurring during a six year period were reviewed. The etiology of hydrops fetalis was established only in four cases. It included one case of endocardial fibrosis, two cases of non-immunologic hemolysis and one case of tachycardia. The pregnancies were complicated by polyhydramnios in 9 cases, preterm delivery in 10 cases, twins in 3 cases and pre-eclampsia in one case. Four of 11 fetuses died in utero, on one of them, intrauterine blood transfusion and administration of digoxin and furosemide was carried out. Five fetuses died neonatally and two survived. In one of the later cases, intravenous administration of digoxin with quinidine to the mother was without effect, nor did such treatment cause any effect on the neonate after delivery. Electric cardioversion supplemented with digoxin slowed the neonatal cardiac rhythm to normal range with later successful outcome. Earlier diagnosis by ultrasonography especially in cases of hydramnios and appropriate treatment are likely to improve this outcome.

Pulmonary complications following endotracheal intubation for anesthesia in breech extraction.

A 28-year-old, healthy pregnant patient developed bilateral pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum following endotracheal intubation and manual ventilation during general anesthesia for breech extraction. It is likely that positive-pressure ventilation was the cause for this very rare combination of complications. Early recognition and treatment may prevent such a catastrophe.