Junichi Hasegawa

Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome

PurposeWe aimed to clarify whether the short-term adverse neonatal outcomes associated with epidural analgesia are due to the epidural analgesia itself or to the instrumental delivery.MethodsA retrospective case–control study was conducted to evaluate the relationship between epidural analgesia, labor length, and perinatal outcomes. A total of 350 pregnant women at term who delivered under epidural analgesia (cases) were compared with 1400 patients without epidural analgesia (controls).ResultsVacuum extraction (6.5 vs. 2.9xa0%) and cesarean section (19.9 vs. 11.1xa0%) were more frequently performed in the cases than controls (pxa0<xa00.001). Using a Kaplan–Meier algorithm, it was determined that the mean lengths of the 1st and 2nd stages of labor and the overall durations of labor and delivery were significantly longer in cases compared with controls. A Cox regression analysis showed that the longer labor remained even after adjustment for parity. The neonatal variables stratified by mode of delivery were not different in cases and controls, except for a slightly lower umbilical arterial pH in spontaneous delivery for the cases group. However, the Apgar scores and umbilical arterial pH were significantly lower in the neonates delivered by vacuum extraction compared with those in the neonates delivered by spontaneous delivery or cesarean section, regardless of whether epidural analgesia was performed. A multivariable analysis showed that vacuum extraction much more consistently affected the arterial pH than the analgesia itself (the β coefficients were −0.036 for epidural analgesia vs. −0.050 for vacuum extraction).ConclusionEpidural analgesia was associated with slowly progressing labor, thus resulting in an increased rate of instrumental delivery. This instrumental delivery appears to adversely affect the neonatal outcomes more strongly than the analgesia itself.

Analysis of the ultrasonographic findings predictive of vasa previa

To clarify the ultrasonographic findings indicative of prenatal vasa previa.

Location of the placenta or the umbilical cord insertion site in the lowest uterine segment is associated with low maternal blood pressure

Please cite this paper as: Hasegawa J, Sekizawa A, Farina A, Nakamura M, Matsuoka R, Ichizuka K, Okai T. Location of the placenta or the umbilical cord insertion site in the lowest uterine segment is associated with low maternal blood pressure. BJOG 2011;118:1464–1469.

The association between preeclampsia and placental disruption induced by chorionic villous sampling.

The objectives of this study were (1) to evaluate if the elevation of maternal serum α‐feto protein (MSAFP) and pregnancy‐associated placental protein‐A (PAPP‐A) in the maternal blood after chorionic villous sampling (CVS) is associated with a higher preeclampsia (PE) rate and (2) to verify the clinical utility of the analytes elevation for predicting PE.

Umbilical cord insertion into the lower segment of the uterus at 11 to 13 weeks' gestation is associated with maternal serum PAPP-A

To evaluate whether the location of the placental cord insertion (CI) at 11 to 13 weeks gestation affects the maternal serum pregnancy‐associated plasma protein‐A (PAPP‐A).

Author's response to the letter by Basaran et al.

This letter by Basaran comments on our article about serum pregnancy associated plasma protein A (PAPPA) and serum alpha-fetoprotein (AFP) before and after chorionic villus sampling (CVS). The title of Basaran’s letter is misleading, as our paper does not affirm any reliable association between serum markers and preeclampsia (PE) but, instead, a rise in serum levels before and after CVS as a possible correlation with the degree of villus disruption. Of course, as villus disruption has been associated with PE, a correlation between the degree of marker aberration and PE might be possible, but that is not to say it is clearly demonstrated. Basaran’s letter contains several criticisms, basically addressing the results and the statistical method. However, the second part does not at all relate to our paper as it reports some analyses advanced by other studies about the risk of PE and CVS. I, thus, fail to grasp the real purpose of this letter, which seems no more than a cursory reanalysis of other studies. However, I am more than happy to clarify the items that regard our paper. One point of confusion may be that Basaran did not read the conclusion or the aim of our paper carefully. He focused on the following items:

Prostaglandin E1 increased cardiac contractility in cardiac arrest during open-heart surgery

In recent years, weaning from the cardiopulmonary bypass in open heart surgery has been made easy by the development of myocardial protection, and postoperative cardiac failure has decreased as well, However, weaning from the cardiopulmonary bypass has continued to be difficult in patients with decreased cardiac function or myocardial damage before surgery;!. Prostaglandin E l (PGE l ) has a number of potent biological actions including direct relaxing effects on vascular smooth musclesa5 • PGE1 is applied in the neonate to maintain the patency of the ductus arteriosus, and also beneficial effect of PGE1 has been reported in patients with congestive heart failure, However, the exact mechanism of the latter effect remains unknown as the potent vasodilating property. PGE1 would likely change the cardiac loading conditions and mask an eventual positive inotropic effect.

Changes in hemodynamics of anaphylactic reaction induced by transfused blood during operation

Many kinds of drug, such as anesthetics, muscle relaxants, blood products and others, are reported to be causes to anaphylaxis or anaphylactoid reaction during induction of anesthesia and operationl 5 . Incompatible transfusion obviously cause hemolytic adverse reaction, and in a patient with antiHLA antibody, transfusion of whole blood and packed cell blood including leukocytes also induce a severe allergic reaction. However, in the patient without anti-erythrocyte or anti-HLA antibody, transfusion during operation is reported to cause cardiac arrest and severe hypotension with generalized urticarlal:. We experienced hypotension with generalized urticaria in prone position during a vertebral operation, the cause of which is likely to be transfusion. We report changes in hemodynamics from 1 hour to 20 hr after an aggregated anaphylactic reaction induced transfusion.

Isosorbide dinitrate attenuated coronary artery spasm during general anesthesia for non-cardiac surgery

Isosorbide dinitrate (ISDN) is effective for congestive heart failure and unstable angina 3 • ISDN is also used during coronary ar-teriography for the resolution of coronary artery spasm through a general inhibition of smooth muscle contraction. There have been several case reports on coronary artery spasm during general anesthesia successfully treated with intravenous administrations of nitroglycerin alone, or a combination of nitroglycerin and a calcium entry blocking drug<, However, the effect of ISDN on coronary artery spasm during general anesthesia has not been reported. This is a report of the occurrence of coronary artery spasm, suggested by marked ST-segment elevation and wide QRS complexes on electrocardiogram (ECG) during general anesthesia for non-cardiac surgery, which was dramatically attenuated by ISDN administration.

Relationship between minor side-effects and maneuvers in stellate ganglion block.

Stellate ganglion block (SGB) has been known to associate with some side-effects. Major side-effects caused by intravascular or subarachnoid injection of local anesthetics, puncture of the pleura and so forth have been noted and discussed previouslyl-3. However, such major side-effects occur rarely in the daily practice of pain clinic. On the other hand, the minor side-effects, such as hoarseness, dysphagia feeling, and brachial sensory loss, occur frequently and trouble patients in SGB therapy. Such minor side-effects can be approximateley attributed to two causes. The first cause is the factor concerning to the maneuvers of the block, including the point of injection and the amount of the local anesthetic used in the block. The second is the one concerning to the individual differences in the anatomical structure of the neck. We studied to correlate an occurrence of minor side-effects with a point of injection, an amount of the local anes-