Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study.

BACKGROUND: The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy. METHODS: A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics. RESULTS: One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission. CONCLUSIONS: The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.

Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome.

OBJECTIVE: Cerebral hyperperfusion syndrome is a preventable cause of stroke after carotid endarterectomy (CEA). It manifests as headache, seizures, hemiparesis or coma due to raised intracranial pressure or intracerebral haemorrhage (ICH). There is currently no consensus on whether to control blood pressure, blood pressure thresholds associated with cerebral hyperperfusion syndrome, choice of anti-hypertensive agent(s) or duration of treatment. METHOD: A systematic review of the PubMed database (1963-2010) was performed using appropriate search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: A total of 36 studies were identified as fitting a priori inclusion criteria. Following CEA, the incidence of severe hypertension was 19%, that of cerebral hyperperfusion 1% and ICH 0.5%. The postoperative mean systolic blood pressure of patients, who went on to develop cerebral hyperperfusion syndrome, was 164 mmHg (95% confidence interval (CI) 150-178 mmHg) and the cumulative incidence of cases rose appreciably above a postoperative systolic blood pressure of 150 mmHg. The mean systolic blood pressure of cerebral hyperperfusion cases was 189 mmHg (95% CI 183-196 mmHg) at presentation. The incidence of cerebral hyperperfusion in the first week was 92% with a median time to presentation of 5 days (interquartile range (IQR) 3-6 days). 36% of patients presented with seizures 31% with hemiparesis and 33% with both. The proportion of patients with severe hypertension was significantly higher in cases than in post-CEA controls (p < 0.0001, Odds ratio 19 (95% CI 9-41)). Three large case-control studies identify postoperative hypertension as a risk factor for ICH. CONCLUSION: There is currently level-3 evidence for the prevention of ICH through control of postoperative blood pressure. From the available data, we suggest a definition for cerebral hyperperfusion syndrome, blood pressure thresholds, duration of monitoring and a postoperative blood pressure control strategy for validation in a prospective study. The implications of this are that one in five patients would need intravenous anti-hypertensives and home blood pressure monitoring for 1 week.

Studies on the efficacy of Toxorhynchites larvae and three larvivorous fish species for the control of Aedes larval populations in water-storage tanks in the Matale district of Sri Lanka.

A study was conducted to compare the feeding efficacy of Toxorhynchites larvae (L3 & L4) and three larvivorous fish species on Aedes larvae. Ground-level cement water-storage tanks (20%–80%) and water-storing barrels (8.33%–54.55%) formed the majority of Aedes-positive outdoor containers. Ae. albopictus, Ae. macdougali and Ae. vittatus were recorded in water-storage tanks, with Ae. macdougali being dominant. In the laboratory, the consumption rate (time to devour 10 Ae. albopictus L3 larvae in a vessel of 78.57 cm2 of surface area) for Toxorhynchites was significantly lower (mean time of 330 minutes) than for any of the tested fish species, Poecilia reticulata (Guppy), Puntius bimaculatus (Ipilli Kadaya) and Rasbora caveri (Dandiya), which needed 16.67, 27.33 and 24 minutes respectively. There were no significant differences (P=0.062) between the consumption rates of the three fish species. A field study was carried out to determine the feeding efficacy of Toxorhynchites larvae, P. reticulata, P. bimaculatus and R. caveri on Aedes larval populations in outdoor cement tanks by noting the percentage reduction of Aedes larvae per 100 cm2 surface area after one week. Toxorhynchites larvae caused a 20%–83.33% reduction with 1–8 larvae per tank. A complete reduction (100%) was achieved with P. bimaculatus and R. caveri with 1–3 fish per tank. P. reticulata showed similar results, but with 90% reduction being achieved once with two fish per tank. There was a higher possibility of losing Tx. larvae than the fish species during the removal of water by the householders. The efficiency of the three fish species for consuming Aedes larvae was greater than that with Tx. larvae. It appears feasible to use Puntius bimaculatus, Rasbora caveri and Poecilia reticulata for controlling Aedes breeding in outdoor cement water-storage tanks in Sri Lanka.

The use of progesterone and other progestational agents to prevent spontaneous preterm labour and preterm birth.

BACKGROUND: Preterm birth is the major cause of perinatal mortality and morbidity in the developed world, making a huge impact on healthcare costs. There is accumulating evidence that the prophylactic use of progestagens is able to reduce significantly the incidence of low birth weight and preterm birth. OBJECTIVES: to emphasise the importance of preterm birth; to review the role of progesterone in inducing myometrial quiescence which prevent preterm labour and preterm birth; to review the published literature and planned future research on the use of progestagens for the prevention of preterm birth. METHODS: A review of the published literature using accepted search engines. RESULTS/CONCLUSIONS: Progestagens have been demonstrated to reduce the incidence of low birth weight and preterm birth. Many questions remain unanswered, particularly the long-term safety concerns and also whether the use of progestagens results in improved neonatal and childhood outcomes.