A prospective observational study of the change in regional cerebral oxygen saturation during cesarean delivery in women receiving phenylephrine prophylaxis for spinal hypotension.

BACKGROUND: Spinal hypotension causes decreased regional cerebral oxygen saturation (ScO2) in women undergoing cesarean delivery. In this study we aimed to measure the change in ScO2 using near infrared spectroscopy in women receiving a prophylactic phenylephrine infusion during cesarean delivery under spinal anesthesia. METHODS: This was a prospective, observational cohort study. Fifty-three women had ScO2 measurements at the following time points: preoperatively, in the supine position with 30° of left lateral tilt; one and five minutes after spinal anesthesia; at the time of skin incision; immediately after delivery; one minute after commencing the oxytocin infusion; at completion of surgery, and one hour after surgery. Spinal anesthesia and a prophylactic phenylephrine infusion were administered according to a standard treatment protocol. Statistical analysis used the Wilcoxon Signed Rank test with Bonferroni's correction for multiple comparisons. RESULTS: Blood pressure was maintained within 20% of baseline throughout surgery. The baseline mean (range) ScO2 was 61.5% (54.0-66.3%). It decreased significantly at all subsequent measurement points. The maximum decrease was five minutes after spinal anesthesia. Thirty-four (64.2%) of the parturients exhibited ScO2 values <20% of baseline, or a decrease to below an absolute value of 50%. There was no significant correlation between systolic blood pressure and mean ScO2. CONCLUSION: Spinal anesthesia with phenylephrine infusion during cesarean delivery is associated with a significant decrease in ScO2 levels, maximal five minutes later. Further studies are required to establish the clinical significance of this finding.

Preoperative sleep quality predicts postoperative pain after planned caesarean delivery.

BACKGROUND: Severe post-caesarean pain remains an important issue associated with persistent pain and postpartum depression. Women's sleep quality prior to caesarean delivery and its influence on postoperative pain and analgesic intake have not been evaluated yet. METHODS: Women undergoing caesarean delivery with spinal anaesthesia (bupivacaine 12 mg, fentanyl 20 µg, morphine 100 µg) were evaluated preoperatively for sleep quality using the Pittsburgh Sleep Quality Index (PSQI) questionnaire (PSQI 0-5 indicating good sleep quality, PSQI 6-21 poor sleep quality). Peak and average postoperative pain scores at rest, movement and uterine cramping were evaluated during 24 h using a verbal numerical pain score (VNPS; 0 indicating no pain and 100 indicating worst pain imaginable), and analgesic intake was recorded. Primary outcome was peak pain upon movement during the first 24 h. RESULTS: Seventy-eight of 245 women reported good sleep quality (31.2%; average PSQI 3.5 ± 1.2) and 167 poor sleep quality (68.2%; average PSQI 16.0 ± 3.4; p < 0.001). Women with poor sleep quality had significantly higher peak pain scores upon movement (46.7 ± 28.8 vs. 36.2 ± 25.6, respectively; p = 0.006). With multivariable logistic regression analysis, poor sleep quality significantly increased the risk for severe peak pain upon movement (VNPS ≥70; OR 2.64; 95% CI 1.2-6.0; p = 0.02). DISCUSSION: A significant proportion of women scheduled for caesarean delivery were identified preoperatively as having poor sleep quality, which was associated with more severe pain and increased analgesic intake after delivery. The PSQI score may therefore be a useful tool to predict increased risk for acute post-caesarean pain and higher analgesic requirements, and help tailor anaesthetic management. SIGNIFICANCE: Multiple studies have evaluated predictors for severe acute pain after caesarean delivery that may be performed in a clinical setting, however, sleep quality prior to delivery has not been included in predictive models for post-caesarean pain. The PSQI questionnaire, a simple test to administer preoperatively, identified that up to 70% of women report poor sleep quality before delivery, and poor sleep quality was associated with increased post-caesarean pain scores and analgesic intake, indicating that PSQI could help identify preoperatively women at risk for severe pain after caesarean delivery.

Severe pain during local infiltration for spinal anaesthesia predicts post-caesarean pain.

BACKGROUND: Quantitative sensory testing (QST) measures response to painful stimuli and has been used to predict post-caesarean pain. Pain reported upon intravenous cannulation was shown to predict epidural analgesic use and pain intensity during labour. We hypothesized that pain intensity reported by women upon local anaesthesia injection (ILA) for spinal anaesthesia may predict acute pain after caesarean delivery (CD). METHODS: In a prospective observational trial, 229 women undergoing elective CD under spinal anaesthesia were enrolled. Using standardized script before ILA, women received ILA (lidocaine 1% 2.5 mL via 25 G needle), and provided an ILA score after the injection [verbal numeric pain scale (VNPS); 0-100]. Demographic data, average, peak pain (at rest, with movement and uterine cramping) and analgesic requests were recorded for the first 24 h. RESULTS: Fourteen percent of women experienced severe pain (VNPS ≥70) upon ILA. Good correlation was noted between ILA and pain scores at rest and upon mobilization during the 24 h following surgery (average resting pain r = 0.529, p < 0.001, average pain at mobilization r = 0.483, p < 0.0001). Severe acute postoperative pain (VNPS ≥70) was predicted by severe ILA pain with a sensitivity of 91.6% and specificity of 93.3%. CONCLUSION: This is the first study evaluating a clinical measure to predict post-caesarean pain. Our main findings were that 14% of women experience severe pain upon ILA, which was associated with increased pain during the first 24 h.

The radiologic findings in synovial chondromatosis (chondrometaplasia) of the temporomandibular joint.

Synovial chondromatosis or chondrometaplasia is a rare disease in which foci of cartilage may develop in the synovial membrane, usually of the large diarthroidal joints. However, the temporomandibular joint may be affected, with less than 15 such cases documented. It is the purpose of this presentation to define the radiologic findings in synovial chondromatosis of the temporomandibular joint, not previously recorded, which allow for definitive diagnosis. These radiologic findings are: 1) widening of the joint space; 2) limitation of motion; 3) irregularity of joint surfaces; 4) presence of calcified loos bodies (cartilage); and 5) sclerosis of the glenoid fossa and mandibular condyle.