[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

[Descriptive study of COVID-19 cases in the third Municipality of Bamako, from March 26 to August 27, 2020]. / Etude descriptive des cas de COVID-19 en Commune III de Bamako du 26 Mars au 27 Aout 2020.

INTRODUCTION: A public health emergency of international concern, COVID-19 is an acute respiratory disease responsible in eight months of approximately 843,158 deaths worldwide, including 29,425 deaths in Africa. The objective was to describe the COVID-19 cases in the health district of Commune III of Bamako. METHODS: This was a descriptive cross-sectional study of COVID-19 surveillance data from March 26 to August 27, 2020. Our variables were extracted from the surveillance database and analyzed on Epi-Info 7.2. Frequencies, rates and proportions were calculated. RESULTS: A positivity rate of 14.86% identified 126 confirmed cases out of an 848 notified suspect. The median age of confirmed cases was 34 years with a minimum of 8 months and a maximum of 93 years. The sex ratio was 2.7 males to females. Civil servants accounted for 32.54% of the positive cases. All the health subdistricts have recorded positive cases. The lethality was 7.94% affecting those over 65 years old. Among asymptomatic people 10.75% were confirmed positive for COVID-19. CONCLUSION: Our study suggests that young males were more likely to be infected with COVID-19. We recommend systematic screening of all contacts and involvement of the community in surveillance.

INTRODUCTION: Urgence de santé publique de portée internationale, la COVID-19 est une maladie respiratoire aiguë responsable en huit mois d'environ 843 158 décès dans le monde dont 29 425 décès en Afrique. L'objectif était de décrire les cas de la COVID-19 en Commune III de Bamako. MÉTHODES: Il s'agissait d'une étude transversale descriptive des données de surveillance de la COVID-19 du 26 Mars au 27 Août 2020. Nos variables ont été extraites de la base de données de surveillance et analysées sur Epi-Info 7.2. Les fréquences, taux et proportions ont été calculés. RÉSULTATS: Un taux de positivité de 14,86% a permis d'identifier 126 cas confirmés sur un 848 suspect notifié. L'âge médian des cas confirmés était de 34 ans avec un minimum de 8 mois et un maximum de 93 ans. Le sex-ratio était de 2,7 en faveur des hommes. Les fonctionnaires représentaient 32,54% des positifs. Toutes les aires de santé ont enregistré des cas confirmés. La létalité était de 7,94% affectant les plus de 65 ans. Parmi les personnes asymptomatiques 10,75% ont été confirmés positives à la COVID-19. CONCLUSION: Notre étude suggère que les jeunes de sexe masculin étaient plus susceptibles d'être infectés par la COVID-19. Nous recommandons le dépistage systématique de tous les contacts et une implication de la communauté dans la surveillance.

Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies.

OBJECTIVE: To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. MATERIAL AND METHODS: Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. RESULTS: The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. CONCLUSION: Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.

An observational study of agreement between percentage pain reduction calculated from visual analog or numerical rating scales versus that reported by parturients during labor epidural analgesia.

BACKGROUND: This study aimed to determine the level of agreement between calculated percentage pain reduction, derived from visual analog or numerical rating scales, and patient-reported percentage pain reduction in patients having labor epidural analgesia. METHODS: In a prospective observational study, parturients were asked to rate their pain intensity on a visual analog scale and numerical rating scale, before and 30min after initiation of epidural analgesia. The percentage pain reduction 30min after epidural analgesia was calculated by the formula: 100×(score before epidural analgesia-score 30min after epidural analgesia)/score before epidural analgesia. To evaluate agreement between calculated percentage pain reduction and patient-reported percentage pain reduction, we computed the concordance correlation coefficient and performed Bland-Altman analysis. RESULTS: Ninety-seven women in labor were enrolled in the study, most of whom were nulliparous, with a singleton fetus and in spontaneous labor. The concordance correlation coefficient with patient-reported percentage pain reduction was 0.76 (95% CI 0.6 to 0.8) and 0.77 (95% CI 0.6 to 0.8) for the visual analog and numerical rating scale, respectively. The Bland-Altman mean difference between calculated percentage pain reduction and patient-reported percentage pain reduction for the visual analog and numerical rating scales was -2.0% (limits of agreement at 29.8%) and 0 (limits of agreement at 28.2%), respectively. CONCLUSION: The agreement between calculated percentage pain reduction from a visual analog or numerical rating scale and patient-reported percentage pain reduction in the context of labor epidural analgesia was moderate. The difference could range up to 30%. Patient-reported percentage pain reduction has advantages as a measurement tool for assessing pain management for childbirth but differences compared with other assessment methods should be taken into account.

Hyperthermic intraperitoneal chemotherapy with cisplatin: Amifostine prevents acute severe renal impairment.

UNLABELLED: Surgical cytoreduction combined with intraperitoneal chemo-hyperthermia (HIPEC) has shown to provide survival benefits in the management of some peritoneal carcinomatosis. The cisplatin (CP) used in HIPEC carries a risk of renal impairment (RI). This risk could be reduced by administration of amifostine (A). The aim of our study was to assess the utility of A in preventing RI during IPCH with CP. PATIENTS AND METHODS: Retrospective study including patients who underwent HIPEC between January 2007 and June 2013. The HIPEC involved administration of CP and mitomycin C, between 41 and 43 °C. The peri-anaesthetic management was consistent to use A after 2010. Renal function was assessed from the measured creatinine clearance (CreatCl) and the change between D0 and D4 was compared between patients who received A (group A+) and those who did not (group A-). Severe RI was defined as the development of a CreatCl of <30 ml/min. The statistical analysis used a Student t-test and Fischer's exact test. A p-value of <0.05 was deemed to be statistically significant. RESULTS: Over the studied period, seventy five patients underwent HIPEC and the findings from fifty two patients were analysed: thirty one in group A+ and twenty one in group A-. The change in mean CreatCl from D0 to D4 did not differ between the two groups although between D1 and D4 a significantly higher percentage of severe RI was seen in group A-. CONCLUSIONS: This study has shown A to offer benefit in terms of reducing severe RI when CP is used in HIPEC. These results, however, will need to be confirmed in prospective series on larger numbers of patients.

[Management of placenta previa and accreta]. / Prise en charge des placenta praevia et accreta.

OBJECTIVE: Produce recommendations for the management of placenta previa and placenta accrete. METHODS: A literature search was conducted using Medline and the Cochrane Library over a period from 1950 to 31/12/2013. Recommendations of the latest scientific societies have also been consulted. RESULTS: In cases of placenta previa, if bleeding episode before 34weeks gestation occurs, a short hospitalization and tocolysis may help stop bleeding (grade C). Vaginal delivery is preferable when the distance between the internal cervical os and the placental edge is greater than 20mm. When this distance is less than 20mm, vaginal delivery is possible (professional consensus). Caesarean section is recommended in cases of placenta overlapping the internal os (professional consensus). Antenatal screening placenta accreta could improve care (EL3). Upon discovery of a placenta accreta during childbirth, it is better to avoid a forced removal of the placenta (grade C). Conservative treatment or cesarean hysterectomy are possible (grade C). The management of placental abnormalities should be planned and managed with a multidisciplinary team (professional consensus). The use of blood-saving techniques such as "cell saver" is possible in situations where early intraoperative bleeding would be>1500mL (grade C). There are no studies that have sufficient methodological value to recommend an anesthetic technique [general anaesthesia (GA) or neuraxial anaesthesia] over another in the context of placental abnormalities (grade B). When a major bleeding risk is identified, GA can be chosen in order to avoid emergency conversions in difficult conditions (professional consensus). CONCLUSION: Placental insertion abnormalities require anesthetic and obstetric coordination. Delivery must be planned in a suitable structure.

6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial.

BACKGROUND: Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS: A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS: The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS: Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION: NCT00694343 (http://clinicaltrials.gov).

Knowledge, attitudes and behaviours related to HIV/AIDS among female migrant workers in the restaurant industry in Guangzhou, China.

OBJECTIVE: The goal of the present study was to assess knowledge and attitudes related to HIV/AIDS among the migrant female workers in the restaurant industry in Guangzhou City, China. METHODS: We performed a questionnaire survey using a judgmental sampling method in the health examination clinic of Yuexiu District of Guangzhou during March 2011. A total of 428 participants completed and returned the questionnaires and data were analysed by descriptive statistics, t-test, one way ANOVA, and Wilcoxon test. RESULTS: Of 428 respondents, the average score of HIV/AIDS-related knowledge was 19.6 (full marks, 26). Knowledge on HIV/AIDS among respondents was classified as poor for 8.2%, fair for 42.5%, and good for 49.3%. The average score of AIDS-related attitudes of respondents was 7.2 (full marks, 10). Most of the respondents (88.8%) had relatively positive attitudes toward AIDS. Unmarried status, ages less than 30 years old and higher levels of education had higher scores of knowledge. Among the respondents who had sex experiences, 57.7% (130/225) reported that they never or only some of the time used condom. The young, unmarried women had significantly higher proportion of condom use than those above 30 years old, and/or married ones. CONCLUSION: Overall, a half of respondents had only moderate and low levels of awareness about HIV/AIDS knowledge, although most of them had tolerant and positive attitudes toward HIV/AIDS. In addition, a relatively lower rate of condom use was reported. The findings indicate that there exists broad space for improvement of knowledge and behaviours toward HIV/AIDS for migrant women in China.

Knowledge, attitudes and behaviours related to HIV/AIDS among female migrant workers in the restaurant industry in Guangzhou, China / Conocimientos, actitudes y comportamientos relacionados con el VIH/SIDA entre las trabajadoras emigrantes en la industria de restaurantes en Guangzhou, China

OBJECTIVE: The goal of the present study was to assess knowledge and attitudes related to HIV/AIDS among the migrant female workers in the restaurant industry in Guangzhou City, China. METHODS: We performed a questionnaire survey using a judgmental sampling method in the health examination clinic of Yuexiu District of Guangzhou during March 2011. A total of 428 participants completed and returned the questionnaires and data were analysed by descriptive statistics, t-test, one way ANOVA, and Wilcoxon test. RESULTS: Of 428 respondents, the average score of HIV/AIDS-related knowledge was 19.6 (full marks, 26). Knowledge on HIV/AIDS among respondents was classified as poor for 8.2%, fair for 42.5%, and good for 49.3%. The average score of AIDS-related attitudes of respondents was 7.2 (full marks, 10). Most of the respondents (88.8%) had relatively positive attitudes toward AIDS. Unmarried status, ages less than 30 years old and higher levels of education had higher scores of knowledge. Among the respondents who had sex experiences, 57.7% (130/225) reported that they never or only some of the time used condom. The young, unmarried women had significantly higher proportion of condom use than those above 30 years old, and/or married ones. CONCLUSIONS: Overall, a half of respondents had only moderate and low levels of awareness about HIV/AIDS knowledge, although most of them had tolerant and positive attitudes toward HIV/AIDS. In addition, a relatively lower rate of condom use was reported. The findings indicate that there exists broad space for improvement of knowledge and behaviours toward HIV/AIDS for migrant women in China.

OBJETIVO: El objetivo del presente estudio fue evaluar los conocimientos y actitudes relacionadas con el VIH/SIDA entre las trabajadoras emigrantes en la industria de restaurantes en la ciudad de Guangzhou, China. MÉTODOS: Realizamos una encuesta en forma de cuestionario utilizando un método de muestreo a juicio en la clínica de examen de salud del distrito de Yuexiu de Guangzhou en marzo de 2011. Un total de 428 participantes llenaron y entregaron los cuestionarios, y los datos fueron analizados mediante estadísticas descriptivas, prueba t, ANOVA unidireccional, y prueba de Wilcoxon. RESULTADOS: De las 428 encuestadas, la puntuación media de los conocimientos relacionados con el VIH/SIDA fue 19.6 (puntuación máxima, 26). El conocimientos sobre el VIH/SIDA entre las encuestadas fue clasificado de pobre por el 8.2 por ciento, aceptable por el 42.5%, y bueno por el 49.3%. La puntuación promedio de las actitudes relacionadas con el SIDA entre las encuestadas fue 7.2 (puntuación máxima, 10). La mayoría de las encuestadas (88.8%) tenían actitudes relativamente positivas hacia el SIDA. El estado civil de soltero, las edades menores de 30 años, y los niveles de educación más altos, estuvieron asociados con puntuaciones más altas de conocimiento. Entre las encuestadas que tenían experiencias sexuales, el 57.7% (130/225) reportó no haber usado condones nunca, o sólo algunas veces. Las mujeres jóvenes solteras hicieron un uso del condón en proporción significativamente mayor que las mujeres mayores de 30 años, y/o las casadas. CONCLUSIONES: En general, la mitad de las encuestadas tenía sólo niveles de conciencia moderados y bajos en cuanto a conocimientos de VIH/SIDA, aunque la mayoría de ellas tenía actitudes tolerantes y positivas hacia el VIH/SIDA. Además, se reportó una tasa relativamente baja de uso del condón. Los hallazgos indican que existe un amplio espacio para mejorar tanto los conocimientos como las conductas hacia el VIH/SIDA para las mujeres emigrantes en China.

[Amniotic fluid embolism: report of the successful outcome of a case with inaugural cardiac arrest and early DIVC complicated by hemoperitoneum of iatrogen origin and bleeding of an hepatic adenoma]. / Embolie amniotique: à propos de l'issue favorable d'un cas avec arrêt cardiaque inaugural et CIVD précoce compliquée d'un hémopéritoine d'origine iatrogène et d'un saignement sur un adénome hépatique.

Amniotic fluid embolism is a relatively rare clinical entity and with difficult medical recognition. However, it is the second leading cause of maternal mortality. We report here the case of a 32-year-old patient who underwent elective caesarean section complicated by an amniotic fluid embolism with cardiac arrest. The presence of a major disseminated intravascular coagulation favored the occurrence of a retroperitoneal hematoma of iatrogenic origin on attempt of femoral venous catheterization and that of hemoperitoneum on bleeding of an hepatic adenoma. The diagnostic of amniotic fluid embolism was confirmed by the presence of amniotic cells in the bronchoalveolar lavage. The patient survived without sequelae.

[Prophylactic anti-emetic strategy: prevention among obstetrician-gynaecologists anaesthesia]. / Prévention des nausées et vomissements postopératoires : enquête sur les pratiques en chirurgie gynécologique auprès des membres du Club d'anesthésie réanimation en obstétrique.

OBJECTIVES: A prophylactic anti-emetic strategy should depend on the number of nausea and vomiting risk factors. This study was undertaken to evaluate the practices of postoperative nausea and vomiting (PONV) prevention practices among obstetrician-gynaecologists, anaesthetists. STUDY DESIGN: A prospective, self-administered questionnaire survey was emailed to all Club d'Anesthésie Réanimation Obstétricale (Caro) members (French Obstetric and Gynaecology Anaesthetists' Association). METHODS: The questionnaire had closed-ended questions to evaluate each Caro member's prophylactic anti-emetic practices. Questions concerned demographic datas, prophylactic anti-emetic drugs administered to the patients with or without well known risk factors for developing PONV, the existence of protocol to prevent PONV in their own department of anaesthesiology and their awareness of the existence of French Society of Anaesthesia and Intensive Care (Sfar) PONV prevention guidelines 2007. RESULTS: Of 115 questionnaires, 66 respondents (57%) returned the questionnaires. Most of the respondents (74%) worked in a university hospital. Forty-two percent practiced exclusively in obstetric-gynaecology department. Fifty-six percent were anaesthetists for more than 20 years. Eighty-five percent of the physicians were well-informed about the SFAR's PONV prevention guidelines. Thirty seven percent of respondents assessed Apfel score systematically for all their patients. The percentages, which didn't calculate the probability of PONV with Apfel score or calculated only in cases of PONV history or travel sickness were 18% and 45% respectively. In cases of two or more risk factors, 63% used droperidol, dexamethasone and ondansetron in double or triple combinations. CONCLUSIONS: Although most surveyed practitioners were well informed about the new guidelines concerning PONV prevention, 27% not follow these guidelines regarding the administration of anti-emetic drugs. The calculation of Apfel score in the preoperative period must be also strengthened.

[Airway management in obstetrics]. / Gestion des voies aériennes en obstétrique.

OBJECTIVE: Reviewing problems related to the airway management in obstetrics, taking into account the recent evolutions of the anaesthetic practices in obstetrics. DATA SOURCES: A review of the literature in English and French was performed in the Pumed database in April 2010. The first research used the following MeshTerms: "Anesthesia, Obstetrical" [Mesh] AND "Intubation, Intratracheal" [Mesh]. Complementary research used alone or in combination the following keywords: difficult tracheal intubation; failed tracheal intubation; airway; prediction of difficult tracheal intubation; maternal mortality; maternal morbidity; liability; aspiration pneumonia and obstetrical anesthesia. STUDY SELECTION: All the publications were retained excluding the correspondence. DATA EXTRACTION: Data analysis for the airway management in obstetrics, the prediction of difficult intubation, the prevention of pulmonary inhalation of gastric fluid, but also on maternal morbi-mortality in link with general anesthesia in obstetrics. DATA SYNTHESIS: Airway management in obstetrics remains a true challenge for various reasons. The physiological and anatomical modifications related to pregnancy are responsible for a faster hypoxemia, a reduction of the diameter of the pharyngolaryngal tract, as well as an increase of the risk of inhalation of gastric contents after 16 weeks of amenorrhea. The emergency or extreme emergency context and the presence of diseases like obesity or preeclampsia raise the risks of difficulties with airway management. The logical evolution of the practices, with the considerable rise of the regional anesthesia/analgesia limits the training and the maintenance of competences for intratracheal intubation in obstetrics. The training per simulation appears particularly interesting on the subject and this approach needs to be developed. The literature indicates that the incidence of difficult intubation is of one per 30. The impossible intubation is one per 280 in obstetrics, eight times greater than in the general population. No criterion of difficult intubation is sufficiently predictive alone. In obstetrics as in other contexts, the association of several criteria will permit to anticipate a difficult intubation. There is a worsening of the Mallampati during the pregnancy and during labour. To limit the risk of a difficult management of the airway in obstetrics, it will be paramount and capital, in addition to give priority to the regional anaesthesia/analgesia each time possible, to perform a careful and repeated evaluation of the predictive criteria of difficult intubation or ventilation. The inhalation of gastric fluid will systematically be prevented. The adapted material and algorithms for difficult intubation must be available in the labour wards. In case of a difficult intubation during an emergency caesarean section, the SFAR algorithms must be applied. In case of a "cannot intubate can ventilate situation", the possibility of carrying on the Caesarean maintaining the Sellick manoeuvre should be considered. The place of the laryngoscopy assisted by videolaryngoscope in this context clearly remains to be defined. Even if in the literature some cases of successful intubation through these devices suggest an interest, there is a clear deviance between the guidelines and the practices concerning general anaesthesia performed at the end of the labour. Indeed they should be systematically performed with rapid sequence induction and tracheal intubation. A reflexion on this theme is necessary in order to grant the practices to the recommendations.

[Factors justifying the choice of labor epidural analgesia by nulliparous women: experience at a maternity center in Antananarivo, Madagascar]. / Quels facteurs motivent le choix de l'analgésie péridurale par les primipares: experience d'un centre de maternité d'Antananarivo, Madagascar.

Epidural analgesia is the most effective method for pain relief during labor. This 10-year exploratory descriptive study on factors underlying women's decisions to request or refuse labor epidural analgesia (LEA) was carried out at a level III maternity hospital in Antananarivo, Madagascar. All patients underwent a pre-anesthesia check-up (PAC) between 32 and 34 weeks of amenorrhea. During the PAC, a questionnaire was administered to determine socio-economic aspects, level of education, and knowledge about labor pain and LEA. In addition, LEA was proposed and patients were asked to explain their reasons for accepting or refusing the procedure. The purpose of this report was to describe the factors underlying acceptance or refusal of EA by nulliparous women. A total of 41 nulliparous women were included. Fourteen (34.14%) accepted LEA and 27 (63.86%) refused. Mean age was 27 years in the acceptance group and 25 years in the refusal group. No patient had good knowledge about LEA. Nulliparous women that accepted EA had a higher socio-economic level, expected stronger labor pain, were better informed about EA, and expressed greater confidence in medical care. In addition to economic aspects, the main reasons for refusing EA involved fear and family background.

Mallampati class changes during pregnancy, labour, and after delivery: can these be predicted?

BACKGROUND: An increase in Mallampati class is associated with difficult laryngoscopy in obstetrics. The goal of our study was to determine the changes in Mallampati class before, during, and after labour, and to identify predictive factors of the changes. METHODS: Mallampati class was evaluated at four time intervals in 87 pregnant patients: during the 8th month of pregnancy (T(1)), placement of epidural catheter (T(2)), 20 min after delivery (T(3)), and 48 h after delivery (T(4)). Factors such as gestational weight gain, duration of first and second stages of labour, and i.v. fluids administered during labour were evaluated for their predictive value. Mallampati classes 3 and 4 were compared for each time interval. Logistic regression was used to test the association between each factor and Mallampati class evolution. RESULTS: Mallampati class did not change for 37% of patients. The proportion of patients falling into Mallampati classes 3 and 4 at the various times of assessment were: T(1), 10.3%; T(2), 36.8%; T(3), 51.7%; and T(4), 20.7%. The differences in percentages were all significant (P<0.01). None of the evaluated factors was predictive. CONCLUSIONS: The incidence of Mallampati classes 3 and 4 increases during labour compared with the pre-labour period, and these changes are not fully reversed by 48 h after delivery. This work confirms the absolute necessity of examining the airway before anaesthetic management in obstetric patients.