[Effects of Obstetric Analgesia with Systemic Opioids on the Newborn - A Review]. / Auswirkungen geburtshilflicher Analgesie mit systemischen Opioiden auf das Neugeborene ­ eine Übersichtsarbeit.

INTRODUCTION: Three-quarters of all women receive analgesia during labor. There are regional and systemic analgesia procedures available. In this review, we investigate the impact of obstetric analgesia using systemic opioids on neonatal outcomes. METHODS: We searched the PubMed and Cochrane Library databases using the following search terms: "meptazinol", "meptide", "analgesia", "painkiller", "pain reliever", "obstetrics", "labor", "labour", "delivery", "neonate", "newborn", "child", "baby", "infant", "fetus", "fetal", "opioid" and "opiate" as well as performed an additional MeSH Terms search in PubMed. RESULTS: Of 355 potentially relevant studies, we included 23 studies in this review. The studies varied widely in quality, sample size, and outcome criteria. Neonatal outcome was often only a secondary endpoint. Rarely were significant differences related to neonatal outcome reported between the different systemic opioids or compared with control groups. Twelve studies compared neonatal APGAR scores between treatment groups, with ten (83%) of these studies showing no differences. DISCUSSION/OUTLOOK: In summary, we assess the evidence as limited and ambiguous as to whether systemic obstetric opioid therapy negatively affects the newborn. Studies regarding the long-term outcome of the newborns are lacking. A statement regarding the necessity of postnatal monitoring of newborns after maternal obstetric opioid therapy cannot be concluded. Further studies, ideally with a prospective study design and control group, should be considered.

Chronic type B aortic dissection in a pregnant patient managed by simultaneous thoracic endovascular aortic repair and cesarean section in the hybrid operating room.

We present the case of a 50-year-old gravida with a chronic Stanford type B aortic dissection with false lumen aneurysm and discuss a literature-based treatment strategy. She underwent oocyte donation in the United States and was seen in week 15 of gestation. We chose a strategy of "watchful waiting" at a constant aortic diameter of 52 mm on magnetic resonance imaging. In week 32 + 6 days, cesarean delivery was induced in a hybrid operating room with subsequent thoracic endovascular aortic repair to reduce the risk of early dilation and rupture during the nursing period. One year later, she cared for her healthy baby with stable aortic diameters.

The combination of intrauterine balloon tamponade and the B-Lynch procedure for the treatment of severe postpartum hemorrhage.

OBJECTIVE: To evaluate intrauterine balloon tamponade with or without B-Lynch sutures in avoiding postpartum hysterectomy in cases with severe postpartum hemorrhage. STUDY DESIGN: Retrospective analysis using all women delivering between January 2005 and July 2010 in our center. Prevention of hysterectomy was the main outcome studied. RESULTS: Twenty-four cases of severe postpartum hemorrhage occurred in which medical treatment alone failed. In 20 cases, the Bakri balloon was the first choice to stop hemorrhage. Sixty percent (n = 12) of these were successfully treated with the balloon alone, 30% (n = 6) with the balloon and the B-Lynch suture. Therefore, 90% (n = 18) were successfully treated with the balloon as part of the treatment. The balloon tamponade was not successful in 2 cases. Four cases were treated with emergency hysterectomy a priori. CONCLUSION: The Bakri balloon with or without B-Lynch sutures in a stepwise approach is an effective option for the treatment of severe PPH.

Type A aortic dissection during late pregnancy in a patient with Marfan syndrome.

PURPOSE: To report the management of a 38-yr-old patient with known Marfan syndrome who presented with acute Stanford type A dissection of the aorta in the 34(th) week of pregnancy. CLINICAL FEATURES: A Cesarean delivery was performed under deep general anesthesia with high-dose opioid administration to avoid tachycardia and hypertension during tracheal intubation and obstetric surgery. Delivery took place less than five minutes after induction of anesthesia, and tracheal intubation of the newborn was required due to opioid-induced hypoventilation. Subsequently, aortic arch repair was performed in the mother after connection to extracorporal bypass. Despite extensive replacement of coagulation factors, severe vaginal bleeding persisted after weaning from extracorporal bypass, and the bleeding stopped only after a hysterectomy was performed. Postoperatively, after a short period in the intensive care unit, mother and child were discharged from hospital in excellent condition ten days after surgery. CONCLUSION: Deep general anesthesia for emergency Cesarean delivery while accepting the risk of respiratory depression in the newborn is a viable option for the anesthetic management of life-threatening events such as Stanford type A dissection.

Prospective testing of the Brisbane Postnatal Depression Index.

BACKGROUND: Over 50 percent of women have one or more risk factors for postnatal depression during pregnancy or in the perinatal period, but only 10 to 15 percent become clinically depressed. The objective of this study was to prospectively test the Brisbane Postnatal Depression Index (referred to here as Index), to validate a theoretical index that was developed earlier, and to establish whether the index could be introduced as a clinically useful method to detect women who may be at risk for developing postnatal depression. METHODS: Antenatally, women were asked about social support and about personal and family history of mental illness, including postnatal depression. Responses were scored according to predefined ratings on the Index. In the postnatal wards, 353 women were recruited and their scores for "blues," social support, feelings about the baby, and satisfaction with the birth process were added. Sixteen weeks after hospital discharge, women were asked to complete the Edinburgh Postnatal Depression Scale. The Brisbane Index was validated by the number of women scoring more than 12 on the Edinburgh Postnatal Depression Scale at 16 weeks postpartum who were correctly predicted by a score of more than 6 on the Index. Sensitivity, specificity, positive predictive value, and negative predictive value for the Index, using >6 as a cutoff point, were calculated. "Ease of use" was assessed informally with participants and staff responsible for administration and scoring the instrument. RESULTS: Compared with results from the derivation study, prospective testing of the index showed an improvement in sensitivity from 36.3 to 47.5 percent and a small decrease in specificity, but no improvement on the positive predictive value from 39.8 to 39.6 percent. CONCLUSION: The Brisbane Postnatal Depression Index was validated in a prospective sample, but its sensitivity and specificity require improvement before introduction as a measure of prediction.

Twin-to-twin transfusion syndrome complicated by spontaneous mid-trimester uterine rupture.

Twin-to-twin-transfusion syndrome (TTS) is a serious complication in about 15% of monochorionic twin pregnancies. In severe TTS, the anemic pump twin (donor) develops anhydramnios and the hypervolemic recipient tense polyhydramnios, which often first calls attention to the condition. The most common problems of TTS are fetal complications such as single or double intrauterine demise, spontaneous abortion, prematurity due to uterine distension leading to contractions, preterm rupture of membranes and ultimately neurological impairment. We report a pregnancy with TTS in which rapid development of polyhydramnios led to rupture of a scarred uterus at 19 weeks' gestation. To the best of our knowledge, this is the first report of a potentially lethal maternal complication of TTS.

Abnormal glucose screening test followed by normal glucose tolerance test and pregnancy outcome.

OBJECTIVE: To study the pregnancy outcome of patients with abnormal glucose screening test followed by normal glucose tolerance test. METHODS: In Sultan Qaboos University Hospital, Sultanate of Oman, a study was made to compare the complication of pregnancy, infant weight, placental weight and neonatal morbidity in women with and without abnormal glucose screening test, it was performed between July 1999 and June 2000. Hundred postnatal files form each group was analyzed. The Chi square test, and test for comparison of proportion were the statistical tests used. RESULTS: Although women with abnormal glucose screening test were older, there was no evidence in this study that increasing parity is a risk factor for abnormal glucose screening test. Candidiasis and polyhydramnios was significantly more frequent in the group with abnormal glucose screening test. The women with abnormal glucose screening test were at higher risk for elective cesarean section, whereas the number of emergency cesarean sections and instrumental deliveries was not significantly different. The mean birth weight of infants in the abnormal glucose screening test group was higher and also, macrosomia was significantly more frequent in this group. The mean weight of placenta from women with abnormal glucose screening test was higher than that of placenta from women with normal glucose screening test. CONCLUSION: The results of this study are consistent with the previous reports that minor abnormalities of glucose metabolism without gestational diabetes are a significant risk factor for fetal overgrowth and its attendant problems.