C. Davitian

Intérêt de l’instillation pariétale unique de ropivacaïne dans la prévention des douleurs après césarienne

OBJECTIVE To assess the efficiency of single-shot ropivacaine wound infiltration during cesarean section for postoperative pain relief, using a prospective, randomized, double-blinded study. PATIENTS AND METHODS One hundred consecutive patients with planned cesarean section were enrolled between September 2007 and May 2008 and randomized into two groups: single-shot wound infiltration of 20mL of ropivacaine 7.5mg/mL (Group R; n=56) or single-shot wound infiltration of 20mL of saline solution (group T; n=44). The primary goal of this study was the double-blinded evaluation of the postoperative pain after coughing and leg raise using the 100-mm visual analog scales (VAS) during the first 48 postoperative hours after cesarean delivery. The secondary goals were the occurrence of nausea and vomiting and the morphine consumption. RESULTS Numerical pain rating scale for pain evaluation was significantly lower (P<0.05) in the ropivacaine group than in the control group at M0, M20, M40, M60, H2 and H4. But, at H8, H12 and H24, no significant difference for VAS was noted between the two groups. The occurrence of nausea and vomiting and the total morphine consumption were not significantly different between the two groups during the first 48 postoperative hours. DISCUSSION AND CONCLUSION Single-shot ropivacaine wound infiltration during planned cesarean section is a simple and safe procedure that provides effective reduction of post-partum pain within the first 4hours.

Estimation clinique du poids fœtal et hauteur utérine dans le dépistage de l’hypotrophie fœtale à terme

OBJECTIVES To evaluate the estimation of fetal weight by external abdominal measurements, alone or associated with fundal height measurement and/or ultrasonographic exams near 32 weeks, to detect intra-uterine growth retardation (IUGR) near term. PATIENTS AND METHODS A retrospective cohort study included all women who delivered a small-for-gestational-age infant less than 37 weeks gestation during 2008-2009. We analyzed the sensitivity of estimation of fetal weight by external abdominal measurements and the others different routine exams during third trimester, and compared them to detect IUGR near term. RESULTS The estimation of fetal weight by external abdominal measurements was used in 263 pregnant patients. External abdominal measurements and fundal height measurement were not statistically different and were better tests than ultrasonographic exams at 32 weeks to detect IUGR near term (sensitivity: 41.4%, 42.2% and 22.8%, respectively; P<0.05). External abdominal measurements associated with regular ultrasonographic examination at 32 weeks of gestation significantly increased the sensitivity to detect IUGR near term (42.9% vs. 22.8%; P<0.05). But, the association of external abdominal measurements and fundal height measurement did not increase the rate of detection (47.9% vs. 42.2%; P=0.22). DISCUSSION AND CONCLUSION The present findings confirm that the use of the estimation of fetal weight by external abdominal measurements to detect intra-uterine growth retardation is effective. Measures to improve the learning of this technique and its reproducibility are recommended.

Control del embarazo normal

El control prenatal del embarazo normal forma parte de un protocolo de acompanamiento que garantiza la deteccion sistematica y la prevencion de las complicaciones maternas o fetales. El elemento mas importante de la prevencion es la informacion a las embarazadas, sobre todo la relativa a algunas enfermedades infecciosas, y al consumo de toxicos (alcohol, tabaco y otras sustancias). La continuidad en la asistencia es fundamental para la seguridad y el bienestar tanto de la madre como del nino. La organizacion de la asistencia perinatal cuenta con medicos intra y extrahospitalarios, con ginecologos-obstetras y con matronas. Estan previstas siete consultas prenatales, detecciones sistematicas sanguineas y tres ecografias. La consulta del primer trimestre es determinante, ya que detecta los embarazos con un riesgo especial y permite facilitar a la embarazada un seguimiento mas adecuado. Gracias al seguimiento mensual, se pueden detectar enfermedades o riesgos potenciales. Las sesiones de preparacion y las consultas del final del embarazo permiten preparar el parto y el posparto. Las consultas no programadas, o urgentes, son parte integrante del seguimiento de un embarazo.

Fisiología del inicio espontáneo del trabajo de parto

El proceso fisiologico del parto es complejo. Intervienen en el tres actores en constante interaccion: la madre, el nino y la placenta. Actualmente, su comprension esta limitada en el plano metodologico tanto por los limites justificados de la investigacion en la mujer embarazada como por la inadecuacion de los estudios realizados en los modelos animales. Parece estar basado en mecanismos endocrinologicos, como el balance progesterona/estrogenos, la hormona liberadora de corticotropina, e inmunologicos, como el NF-κB y la familia de los receptores tipo Toll. Existen numerosas moleculas efectoras, desde las prostaglandinas hasta las proteinas de membrana acopladas a proteinas G con el fin de conectar la senal en las celulas. El conjunto de estas acciones actua, entre otras formas, por contiguidad entre los diferentes microentornos que son el miometrio, el cuello uterino, las membranas fetales y la placenta. Parece ser que diferentes elementos exogenos, infecciosos pero tambien ambientales, pueden interferir con estos mecanismos y provocar el inicio del trabajo del parto. Es indispensable conocer mejor estos mecanismos para prevenir partos prematuros o para manejar mejor el parto.