Kan Amano

Perinatal outcome and management of single fetal death in twin pregnancy : A case series and review

Abstract Objective: To determine neonatal outcome of single fetal death in twin pregnancy. Methods: Retrospective study was performed on 30 cases of single fetal death in twin pregnancy during the period from August 1971 to December 1997 at Kitasato university hospital. Results: The incidence of single fetal death in twin pregnancy was 6.2％ among total number of 481 twins. Prognosis of surviving infants was satisfactory except in one case, with malformation in 10 cases of dichorionic twins (total 242 sets). In contrast, neonatal death occurred in 6 cases of 20 monochorionic twins (total 239 sets), 4 of which were among 7 cases of twin-to-twin transfusion syndrome (TTTS). Cerebral palsy occurred in 2 infants of monochorionic twins. One case was diagnosed as periventricular leukomalacia (PVL) within one week after birth, and this was the case of delivery 1 day after one twin fetal death. Conclusion: Single fetal death itself occurs more often in monochorionic twins. There seems to be a benign outcome for the surviving dichorionic twins. On the other hand, there may be a grave outcome, though infrequent, for monochorionic twins when concomitant TTTS has existed. It is very important to identify the chorionicity by ultrasound examination in early pregnancy.

Elective Induction of Labor at 39 Weeks of Gestation: A Prospective Randomized Trial

Objective: To clarify the safety of elective induction of labor at 39 weeks of gestation.

Prenatal diagnosis and treatment strategy for congenital mesoblastic nephroma

By means of the recent sophisticated technology regarding prenatal diagnosis, congenital mesoblastic nephroma (CMN) has become detectable before birth, or at a younger age than previously. Recently we treated an infant with a huge CMN in whom fetal asphyxia and tumor rupture occurred during the perinatal observation period after prenatal detection. Emergency surgery was required, and the postoperative course was complicated. The treatment strategy of the perinatal care team should focus on (1) reliable maternal transportation (2) continuous monitoring of fetal condition including cardiovascular status, (3) control of polyhydramnios to avoid premature labor, and (4) elective surgery at a stable or stabilized condition. Emergency surgery should be performed when circulatory disturbance, respiratory distress, and/or impending rupture are suspected.

A double-blind randomized controlled trial of patient- controlled epidural analgesia with or without a background infusion following initial spinal analgesia for labor pain

BACKGROUND Patient-controlled epidural analgesia (PCEA) combined with spinal analgesia is an option for pain relief in labor. However, the effect of a CBI on the analgesic requirements of laboring women is still debated. This double-blind study investigated the effect of CBI with PCEA following spinal analgesia on the local anesthetic requirements of parturients during labor. METHODS Sixty-six nulliparous women were randomly assigned to a standard PCEA protocol (5-mL demand bolus, 10-min lockout) with or without a CBI of 6 mL/h. The epidural solution consisted of 0.1% ropivacaine with fentanyl 2 microg/mL. Labor analgesia was initiated in both groups with intrathecal bupivacaine 2.5 mg plus fentanyl 25 microg. The number of demands per hour and the hourly dose of ropivacaine were calculated for both groups. RESULTS The median [range] number of analgesic boluses per hour in the PCEA group that were demanded: 2.4 [0.8-12.2] and delivered: 1.6 [0.8-2.6], were significantly greater than those in the PCEA+CBI group: 0.7 [0.4-4.2] and 0.6 [0.2-1.3] (P 0.05). However, the hourly ropivacaine dose in the PCEA group (7.9 [3.9-13.2] mg/h) was not significantly different from that in the PCEA+CBI group (8.4 [6.0-12.5] mg/h). CONCLUSION In laboring nulliparous patients provided initial labor analgesia with spinal anesthesia, the use of a continuous background infusion decreases PCEA demand dosing, but not the total hourly amount of ropivacaine and fentanyl used.

Patient-controlled epidural analgesia during labor using ropivacaine and fentanyl provides better maternal satisfaction with less local anesthetic requirement.

PurposeTo test the hypothesis that patient-controlled epidural analgesia (PCEA) using ropivacaine and fentanyl provides better maternal satisfaction and less anesthetic requirement than conventional continuous epidural infusion (CEI) during labor, we studied 58 uncomplicated parturients (singleton, vertex presentation).MethodsAfter establishing effective epidural analgesia with 11 ml of 0.2% ropivacaine, all parturients were randomly divided into one of two groups: the PCEA group (n = 29) or the CEI group (n = 29). In the PCEA group, the pump was initiated to deliver a basal infusion at 6 ml·h−1 and a demand dose of 5 ml; the lockout interval was 10 min, and there was a 31 ml·h−1 limit. The drugs used were 0.1% ropivacaine + fentanyl 2 µg·ml−1. In the CEI group, epidural analgesia was maintained with the same solution as the PCEA group at a constant rate of 10 ml·h−1. If parturients requested additional analgesia in the CEI group, we added 8 ml of epidural 0.2% ropivacaine without fentanyl.ResultsParturients’ demographic data, such as duration of labor, mode of delivery, Apgar score, and umbilical arterial pH did not differ between the two groups. However, the hourly requirement of ropivacaine was significantly less in the PCEA group than in the CEI group (9.3 ± 2.5 vs. 17.6 ± 7.6 mg·h−1; P < 0.05). Parturients’ satisfaction assessed by the Visual Analogue Scale tended to be higher in the PCEA group than in the CEI group. Side effects such as nausea, hypotension, and itching were similar for the two groups.ConclusionWe found that PCEA was an effective means of providing optimal analgesia, with better satisfaction during labor and less local anesthetic requirement.

Prophylactic epidural naloxone reduces the incidence and severity of neuraxial fentanyl-induced pruritus during labour analgesia in primiparous parturients.

1 ( 3%) 0 ( 0%) Hypotension (%) 4 (11%) 1 ( 3%) Nausea (%) 4 (11%) 3 ( 9%) Itching (%) * 25 (71%) 9 (26%) VAIS ** 20 (0, 72) 0 (0, 40) Fetal deceleration (n) 11 (31 %) 6 (18 %)

Significance of fetal fibronectin and cytokine measurement in the cervicovaginal secretions of women at term in predicting term labor and post-term pregnancy

OBJECTIVE To determine whether fetal fibronectin (FFN) or cytokine concentrations in cervicovaginal secretions can be used to predict term labor and post-term pregnancy. STUDY DESIGN FFN and cytokines were assayed in cervicovaginal mucus from 122 pregnant women at 29-35 weeks and weekly from week 36 to parturition. RESULTS FFN concentrations were elevated from about 3 weeks before parturition; a correlation was found between FFN levels and sampling-to-delivery intervals. Parturition was best predicted within 7 days of sampling when the FFN value was >or=50ng/ml between 36 and 41 gestational weeks. Interleukin-1beta (IL-1beta) concentrations were elevated from 3 to 4 weeks before parturition; a correlation was found between IL-1beta levels and sampling-to-delivery intervals. Parturition was best predicted within 7 days of sampling, with an IL-1beta cut-off value of >or=100pg/ml. CONCLUSION Term labor and post-term pregnancy can be predicted within 7 days of sampling, using FFN and IL-1beta concentrations in cervicovaginal secretions of pregnant women.

Effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long-term neonatal neurologic prognosis

To examine the effect of the interval between onset of sustained fetal bradycardia and cesarean delivery on long‐term neonatal neurologic prognosis.

Effect of epidural epinephrine infusion with bupivacaine on labor pain and mother-fetus outcome in humans☆

Background and Objectives: Epinephrine is used with local anesthetics to prolong the duration of epidural analgesia and decrease the peak plasma concentrations of local anesthetics. In the practice of obstetric anesthesia, the utero‐placental and fetal effects of epinephrine are controversial issues. We designed a prospective, randomized, and double‐blind study to examine the effects of epinephrine infusion on the quality of analgesia and uterine or umbilical blood flows with Doppler ultrasound, as well as the duration of the first or the second stage of labor, and fetal outcome. Methods: Twenty‐eight parturients received continuous epidural bupivacaine 0.25% (4 mL/h) combined either with epinephrine (20 μg/h) (n = 13) or without epinephrine (n = 15) for analgesia during labor. If patients requested additional analgesia, an additional bolus of 1% or 1.5% lidocaine (6 to 10 mL) was admimistered. Results: The total amount of additional lidocaine was greater in the plain bupivacaine group (130 [0, 280] mg; median [25th, 75th percentile] with P < .05) than in the epinephrine group (0 [0, 60] mg). Epinephrine infusion did not alter the resistance of the uterine and umbilical arteries as measured by resistance index. The duration of the first or second stages of labor did not significantly differ in the 2 groups. Epinephrine infusion did not change the fetal heart rate or the blood gas data in the umbilical artery. Conclusions: A low‐dose epidural infusion of epinephrine decreased anesthetic requirements.

Effect of standard diluted epinephrine infusion on epidural anesthesia in labor.

Background and Objectives Epinephrine is used with local anesthetics to prolong the duration of epidural analgesia and decrease the peak plasma concentrations of local anesthetics. However, the duration of labor may be prolonged because epinephrine reduces uterine activity. We designed a prospective, randomized, and doubleblind study to examine the effects of epinephrine infusion on the quality of analgesia and plasma concentration of local anesthetic, as well as the effect on the uteroplacental circulation, duration of the first or second stage of labor, and fetal outcome. Methods Twenty-four parturients received continuous epidural bupivacaine 0.125% (8 mL/h) combined either with epinephrine (40 μg/h) (n = 12) or without epinephrine (n = 12) for analgesia during labor. If patients requested additional analgesia, a bolus of 1% or 1.5% lidocaine (6 to 10 mL) was given. Results Only the plain bupivacaine group required additional lidocaine. However, epinephrine infusion prolonged the median (range) duration of the second stages of labor: 69 (21 to 231) minutes with epinephrine group versus 31 (8 to 99) minutes without epinephrine group (P < .05), and decreased pH in umbilical artery at the time of delivery. Epinephrine infusion did not change the uterine and umbilical blood flow, which were determined as the resistance indices. Changes in the fetal heart rate and Apgar score were also comparable. Epinephrine significantly reduced the umbilical venous to maternal arterial bupivacaine concentration (P < .05). Conclusions A standard diluted epinephrine infusion (40 μg/h) into epidural space decreased anesthetic requirements. The possibility of the prolonged duration of labor remains a problem.