Epoprostenol treatment for idiopathic pulmonary arterial hypertension in pregnancy.

Idiopathic pulmonary arterial hypertension is a rare condition associated with significant maternal mortality. We report the management of a 37-year-old multigravida with severe disease using epoprostenol, a multidisciplinary approach, and a planned delivery. Although the patient survived the pregnancy, her pulmonary function significantly worsened. Epoprostenol, a pulmonary vasodilator, should be considered when indicated during pregnancy. Neither fetal nor neonatal harm was identified.

Antiemetics for obstetric and gynecological procedures.

Nausea and vomiting is a troublesome side-effect that occurs more frequently during obstetric and gynecological procedures than during most other surgical procedures. Recent research has focused on the efficacy and safety of new antiemetic medications, primarily 5-hydroxytryptamine subtype 3 receptor antagonists, as well as clinical comparisons of these new drugs with older, established antiemetics. In the current healthcare environment, the cost-effectiveness of available antiemetic therapies has also become increasingly important, and this has been addressed in some of the recent literature.

Maternal and neonatal fentanyl and bupivacaine concentrations after epidural infusion during labor.

Labor analgesia using continuous epidural infusions of low-dose bupivacaine and fentanyl may be maintained for many hours. We examined the potential for drug accumulation in both mother and neonate after these long-term infusions. Pregnant women receiving a 10-mL/h continuous infusion of labor analgesia with 0.125% bupivacaine and 2 micrograms/mL of fentanyl were evaluated. Maternal venous and umbilical venous drug concentrations were measured at delivery. Umbilical artery blood gases were obtained. Scanlon neurobehavioral testing was performed on all infants. Length of infusion times varied from 1 to 15 h. Maternal and neonatal drug concentrations remained relatively constant throughout the infusion period. All umbilical blood gas values and neurobehavioral scores were within normal limits. In conclusion, even when maintained for many hours, continuous infusion labor analgesia does not appear to result in significant fetal drug accumulation. No adverse neonatal effects were seen.

Epidural analgesia in a preeclamptic parturient after normalization of a prolonged bleeding time with DDAVP.

BACKGROUND AND OBJECTIVES: Despite several advantages to the use of epidural analgesia for the management of labor pain in preeclamptic parturients, this procedure is withheld from many such patients owing to associated thrombocytopenia and platelet dysfunction. METHODS: A preeclamptic parturient with mild thrombocytopenia and platelet dysfunction manifested by a prolonged bleeding time received intravenous DDAVP (0.3 microgram/kg) in an attempt to correct her coagulation abnormality. RESULTS: The patient's bleeding time was normalized with DDAVP administration, allowing her to receive epidural analgesia. CONCLUSIONS: Preeclampsia-induced platelet dysfunction might be corrected with DDAVP: A controlled study is required before its routine use can be advocated.

Measurements of protein binding of lidocaine throughout pregnancy.

Pregnancy-related anatomic and physiologic changes result in altered pharmacologic and toxicologic responses to local anesthetics. Reductions in serum protein binding have been implicated in enhanced toxic effects. Previous studies have demonstrated these reductions in protein binding only in the term parturient. The present study defines the pattern of protein binding changes of lidocaine throughout gestation. Venous samples were obtained from pregnant patients of varying gestational age, as well as from nonpregnant control patients. The percent free drug at a fixed concentration (2 micrograms/mL) was determined for each sample using an ultrafiltration technique. The free concentration of lidocaine increased significantly throughout gestation, reflecting a corresponding decrease in protein binding. However, these changes were small compared to those in the nonparturient, which suggests that toxicity to lidocaine should not vary during pregnancy.

Anesthesia for in vitro fertilization: a comparison of 1.5% and 5% spinal lidocaine for ultrasonically guided oocyte retrieval.

In many institutions, spinal anesthesia is used for surgery involving ultrasonically guided transvaginal oocyte retrieval. Because this relatively short procedure is performed on an outpatient basis, the optimal spinal technique would allow good surgical anesthesia with a short recovery time. The relative regression of equal doses of different concentrations of hyperbaric spinal lidocaine is presented. We compared 1.5% and 5% hyperbaric lidocaine (7.5% dextrose) as spinal drugs for use in this procedure. Fifty-six patients were randomized to receive 60 mg of hyperbaric solutions of either 1.5% or 5% lidocaine in combination with 10 micrograms of spinally administered fentanyl. Visual analog scale pain scores were zero throughout the procedures for all patients. There were no significant differences between the groups with regard to sensory level, maximum motor block, intravenous sedation requirements, time to two-segment regression, and time to full sensory recovery. The group receiving 1.5% lidocaine had significantly shorter times to ambulation (141 +/- 21 min vs 162 +/- 29 min; P < 0.05), voiding (147 +/- 21 min vs 174 +/- 28 min; P < 0.05), full motor recovery (86 +/- 21 min vs 111 +/- 22 min; P < 0.0001), and discharge (170 +/- 38 min vs 201 +/- 41 min; P < 0.05). The use of 1.5% hyperbaric lidocaine for transvaginal oocyte retrieval provides a significantly shorter recovery time when compared to 5% hyperbaric lidocaine and is a good choice for spinal anesthesia for this procedure.

Comparison of metabolic control among diabetic subjects at two clinics.

A cross-sectional study was conducted to investigate whether glucose control in 20 non-insulin-dependent diabetic subjects seen at a remote rural clinic was comparable to control achieved in 66 diabetic subjects seen at the regional hospital clinic. Sampling was done to assure that study subjects were representative of all care-seeking, diagnosed diabetics in a well-defined Navajo community. The two groups of patients were comparable in terms of age, sex, and duration of diabetes from time of diagnosis. Compliance with care, hospitalization rates, and complication rates were similar in each group. Results showed no significant differences in glycemic control between the rural clinic (mean fasting plasma glucose = 177, mean random plasma glucose = 227) and the regional hospital clinic (mean fasting plasma glucose = 187, mean random plasma glucose = 249). The percentages of diabetics under "acceptable" control by American Diabetes Association guidelines was 40 percent at the rural clinic and 29 percent at the hospital clinic (P greater than .05). The authors conclude that adequacy of glycemic control in diabetics is not compromised by providing care at a remote rural clinic.

Metabolic control in non-insulin-dependent diabetes mellitus: factors associated with patient outcomes.

We conducted a cross-sectional study to assess the association of various demographic and medical-care variables with metabolic outcomes in non-insulin-dependent diabetic subjects. The study population was representative of the diagnosed care-seeking diabetic population of a defined geographic community on the Navajo reservation in Arizona. The dependent variable metabolic control was measured as the mean of all random plasma glucose values obtained only at scheduled diabetes clinic visits over 2 yr. Multivariate analysis of the data showed that better metabolic control was most strongly associated with compliance with scheduled appointments. Mode of treatment was also associated with metabolic control. Other variables tested, including source of care, age, sex, duration of diabetes, presence of complications, and weight change, were not associated with metabolic control. The strongest analysis of covariance model with demographic and medical-care variables accounted for 39% of the variance in metabolic control. The analysis suggests that other variables, possibly including several psychosocial variables, need to be assessed for their contribution to metabolic control.