Miriam J. P. Harnett

Herbal medicine use in parturients

Alternative medicine use has increased dramatically over the last decade. Recently a 22% incidence of herbal medicine use in presurgical patients was reported. Of concern is the potential for these medications to cause adverse drug-herb interactions or other effects such as bleeding complications. We sought to determine the prevalence and pattern of use of herbal remedies in parturients. A one-page questionnaire examining the use of all prescription and nonprescription medications, including herbal remedies, was sent to parturients expected to deliver within 20 wk who had preregistered with the hospital’s admissions office. Sixty-one percent of the parturients responded to the survey, with 7.1% of parturients reporting the use of herbal remedies. Only 14.6% of users considered them to be medications. Parturients in the 41–50 yr age bracket (5.6% of parturients) were the most likely to use herbal remedies (17.1% rate of use in this age group). Many parturients who took herbal remedies (46%) did so on the recommendation of their health care provider.

Airway complications in infants: comparison of laryngeal mask airway and the facemask-oral airway

Purpose: To compare the incidence of airway complications in children less than one year of age whose airways were maintained during anesthesia with either a laryngeal mask airway (LMA) or a facemask and oral airway (FM-OA).Methods: We randomized 49 — ASA class 1&2 — infants to an LMA or FM-OA group. All infants were undergoing minor general, urological or orthopedic procedures. Anesthesia was induced and maintained with halothane in nitrous oxide 50% and oxygen. The airway was removed in both groups when the infant was awake. The occurrence of airway complications (breath-holding, coughing, laryngospasm, secretions, obstruction and oxygen saturation <95%) at induction of anesthesia, intraoperatively and during emergence from anesthesia was recorded.Results: Airway complications occurred perioperatively in 15 of 27 infants in the LMA group and in 5 of 22 infants in the FM-OA group (P :0.02).Conclusion: In infants, the use of the LMA is associated with an increased incidence of airway complications compared with the use of the FM-OA.RésuméObjectif: Comparer l’incidence de complications de la canulation chez des enfants de moins d’un an dont l’accès aux voies aériennes a été maintenu pendant l’anesthésie, soit avec un masque laryngé (ML), soit avec un masque et une canule orale (M-CO).Méthode: Nous avons réparti 49 enfants — ASA I et II — en groupes ML ou M-CO. Tous les enfants devaient subir une intervention mineure, urologique ou orthopédique. L’anesthésie a été induite et maintenue avec de l’halothane dans un mélange à 50% de protoxyde d’azote et d’oxygène. La canule a été retirée chez tous les enfants à leur réveil. On a noté l’occurrence de complications de la canulation (arrêt de la respiration, toux, laryngospasme, sécrétions, obstruction et saturation en oxygène<95%) lors de l’induction de l’naesthésie, pendant l’opération et pendant la récupération de l’anesthésie.Résultats: Les complications peropératoires de la canulation sont survenues chez 15 des 27 enfants du groupe ML et chez 5 des 22 enfants du groupe M-CO (P: 0,02).Conclusion: Chez les enfants, l’usage du ML, comparé à celui d’un masque et d’une canule orale, est associé à une incidence accrue de complications de la canulation.

Transdermal scopolamine for prevention of intrathecal morphine-induced nausea and vomiting after cesarean delivery.

BACKGROUND:Intrathecal morphine for cesarean delivery provides excellent postoperative analgesia but is associated with significant nausea and vomiting. METHODS:We compared the antiemetic efficacy of transdermal scopolamine, IV ondansetron, and placebo during the first 24 h postoperatively. Two-hundred forty women undergoing cesarean delivery under spinal anesthesia were randomly allocated, in a double-blind study design, to receive transdermal scopolamine 1.5 mg, ondansetron 4 mg, or placebo at the time of cord clamping. RESULTS:Our study showed that the overall rates for all emesis were 59.3% in the placebo group and were reduced to 40% in the scopolamine group and 41.8% in the ondansetron group. The greatest reduction in emesis in the scopolamine group when compared with placebo was in the 6–24 h time period. CONCLUSION:Scopolamine is an effective medication for prophylactic use in parturients receiving intrathecal morphine while undergoing cesarean delivery. Its use, however, was associated with a higher incidence of side effects such as dry mouth and blurry vision.

In vitro fertilization-induced alterations in coagulation and fibrinolysis as measured by thromboelastography.

Supraphysiologic increases in estrogen produced by in vitro fertilization (IVF) promote the expression of hemostatic markers. Although quantitative studies of individual markers have been performed during IVF, their results are conflicting and do not reveal the qualitative effect of each marker on the overall coagulation and fibrinolytic processes. Thrombelastograph (TEG) coagulation analysis, by contrast, provides a global measure of coagulation and fibrinolysis and can indicate the relative contributions of clotting factors, fibrinogen, and platelets to each process. We studied the serum estrogen concentrations and TEG variables in 24 women at the beginning and conclusion of an IVF stimulation cycle. Serum estradiol (E(2)) concentrations (mean +/- SD) increased from 26.9 +/- 8.6 to 2098 +/- 913 pg/mL (P < 0.005) at baseline and oocyte retrieval, respectively. The measured TEG indices demonstrated alterations in coagulation rather than fibrinolysis. Although significant changes were noted in both the clot formation time and the coagulation index (P < 0.005), all TEG values remained within the normal range. In addition, an increased role of fibrinogen in promoting clot strength was observed. These findings may assist in the treatment of IVF patients who ultimately develop thromboembolic complications as a result of ovarian hyperstimulation. IMPLICATIONS. The dramatic changes in estrogen produced by in vitro fertilization therapies result in hemostatic marker alterations. Thrombelastograph coagulation analysis, which provides a global assessment of these changes, demonstrated significant alterations in two coagulation indices (clot formation time, coagulation index), although all variables remained within normal limits. The relative importance of fibrinogen versus platelets in determining clot strength was observed. No significant alterations in fibrinolysis were detected.

Effect of amniotic fluid on coagulation and platelet function in pregnancy: an evaluation using thromboelastography*

Amniotic fluid embolism is a rare obstetric complication. The exact pathogenesis of this syndrome remains unknown and significant controversy exists whether coagulopathy should always be present. We used thromboelastography to assess the effect of amniotic fluid on coagulation and platelet function in pregnant women. Different volumes of amniotic fluid (10–60 μl) were added to blood (330 μl) from pregnant women and thromboelastography variables determined. There were three important findings. R time, reflecting time to first clot formation, was significantly decreased with the addition of 10 μl amniotic fluid; platelet function, as determined by Reopro‐TEG technique, was increased with the addition of 30 μl of amniotic fluid; and there was no evidence of fibrinolysis in any samples studied. In conclusion, our study substantiates the hypothesis that coagulation profile changes are invariable accompaniments of amniotic fluid embolism.

The effect of magnesium on coagulation in parturients with preeclampsia

Preeclampsia is associated with complex coagulation abnormalities that include altered platelet function and consumption and activation of the fibrinolytic system. Magnesium sulfate, which is used as a therapeutic modality for the prevention of seizures in preeclamptic parturients, has anticoagulant and antiplatelet effects. We sought to determine the effects of magnesium on various components of the coagulation system in patients with preeclampsia. We assessed the coagulation status of 18 parturients with preeclampsia being treated with magnesium. The assessment was performed with the thromboelastograph test, which provides an overall assessment of blood coagulation via the coagulation index. Thromboelastography was performed before beginning magnesium therapy and 30 min and 2 h after a 6-g bolus of IV magnesium. The R value (time to first clot formation) was found to be significantly slower (P < 0.05) at 30 min after the magnesium bolus. This result suggests increased coagulant factor activity resulting from the magnesium bolus. However, there was no effect of magnesium on the overall coagulation, as evidenced by the lack of change in the coagulation index either at 30 min or at 2 h after the completion of the initial magnesium bolus. Therefore, this therapy should have no effect on the use of neuraxial techniques.

Factor XI deficiency and obstetrical anesthesia.

Factor XI (FXI) deficiency is a rare inherited coagulation disorder associated with prolonged activated partial thromboplastin time. The severity of bleeding often does not correlate with plasma factor levels. We reviewed the medical and anesthetic records of 13 parturients with FXI deficiency that presented for delivery. Nine cases were managed with neuraxial anesthesia. (epidural, seven; spinal, one; combined spinal-epidural, one). Three received general anesthesia for cesarean delivery, and one had an unmedicated vaginal delivery. Baseline factor levels ranged from severe (<15%) to mild (near 50%) deficiency. Fresh frozen plasma was administered to correct activated partial thromboplastin time in most, but not all, cases. Hematology consultation was obtained for all. No hematological or anesthetic complications were noted. FXI deficiency is not an absolute contraindication to neuraxial anesthesia, provided appropriate hematology consultation has been obtained, and factor replacement is provided as guided by clinical and laboratory hemostatic evaluation.

The use of central neuraxial techniques in parturients with factor V leiden mutation.

The factor V Leiden (FVL) mutation is a leading cause of thrombosis, particularly during pregnancy. During pregnancy, women with thrombotic disorders including FVL are often considered candidates for antepartum anticoagulation with low molecular weight heparin. Pregnancy complications related to thrombosis and the unpredictable timing of labor cause unique challenges with regard to the provision of regional anesthesia. A patient with heterozygotic FVL presenting with thrombotic disease and a complicated anticoagulation status lead us to review 16 additional parturients with FVL. This report focuses on the anesthetic implications that arise in parturients with FVL. We recommend that anesthesiologists be made aware of FVL patients before their due date, anticoagulation with low molecular weight heparin should be transitioned to unfractionated heparin before the 38th gestational week, and multidisciplinary collaborative investigation and care should continue for this disorder.

Pregnancy, labour and delivery in a Jehovah’s Witness with esophageal varices and thrombocytopenia

Purpose: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10 – 61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah’s Witness.Clinical features: A 25-yr-old Jehovah’s Witness parturient with portal hypertension and esophageal varices secondary to crytogenic cirrhosis was referred to our obsetrical unit at eight weeks gestation. In addition she was thrombotyopenic with platelet counts ranging from 42,000–67,000·μl−1. Here esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesaren section which could result in massive hemorrhage, to elective induction of labour wiht an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.Conclusion: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.RésuméObjectif: Un nombre croissant de femmes souffrant de cirrhose deviennent enceintes et mènent leur grossesse à terme. Cependant, la taux de mortalité maternelle demeure élevé (10 – 61%). Le présent article décrit la démarche anesthésique adoptée avec une patiente, Témoin de Jéhovah, qui présente des varices oesophagiennes et une thrombocytopénie.Élements cliniques: Une parturiente de 25 ans, Témoin de Jéhovah, présentant une hypertension portale et des varices œsophagiennes secondaires à une cirrhose nodulaire postnécrotique, a été dirigée vers notre unité obstétricale à 8 sem de gestation. Elle avait aussi une thrombocytopénie, la numération plaquettaire étant de 42,000–67,000·μl−1. Trois fois pendant la grossesse, des bandes prophylactiques ont été posées sur les varices œsophagiennes. Un examen d’IRM, fait à 32 sem de gestation, a montré une tête de Méduse et une varice médiane dominante. Pour cette raison, on a remplacé la césarienne prévue, qui aurait pu provoquer une hémorrhagie massive, par une induction du travil et une expulsion assistée. La patiente refusait toute transfusion de produit sanguin, sauf une hémodilution et une autotransfusion immédiates, au besoin, pendant le travail et l’accouchement. Malgré les préparatifs élaborés en prévision d’un accouchement par voie vaginale, la patiente a connu un travail rapide imprévu. La rachianalgésie a été administrée pour faciliter un accouchement assisté en douceur.Conclusion: Le succès de l’accouchement chez les parturientes atteintes de cirrhose repose sur une démarche multidisciplinaire. L’examen périodique et le bandage des varices œsophagiennes sont recommandés pendant la gorssesse. On devrait considérer sérieusement les bénéfices qu’offre l’anesthésie régionale.

Herbal medicinal products during pregnancy: are they safe?

requiring obstetric intervention after delivery of the first twin. Knowing the limitation of the study (retrospective in nature, possibility of other bias and presence of other obstetric interventions that may affect the result) and authors admitting these, an arbitrary time limit of 30 minutes was still suggested. This was not based on any other clinical outcome indicators and we suspected this limit would not be acceptable by most other obstetricians. This time limit will also set a ‘benchmark’ for the maximum time interval for the delivery of the second twin and has significant medicolegal implication. If the second twin is not delivered by 30 minutes, are we going to stop all manoeuvre and proceed straight for an emergency caesarean section? Actually looking at the study itself, there are four problems. Firstly, the incidence of combined vaginal–caesarean birth was 16.9%, which was highest among all the studies. Samra et al. reported an incidence of 4.3% in Birmingham in 1990. Persad et al. reported an increasing incidence of combined vaginal– caesarean birth from 1980 to 1999 (from 2% to 6.2%) in Grace Maternity Hospital, Nova Scotia, Canada. The period of the Leung et al. study was not mentioned in the article so comparison with other studies was not possible but the incidence of combined vaginal–caesarean birth for the second twin was at least two times higher than that of Persad et al.’s study. Secondly, the authors did not try to explain for the significantly higher incidence of combined vaginal–caesarean delivery. It can be related to the ineffective or inadequate use of oxytocin after the delivery of the first twin, the lack of using external cephalic version, internal podalic version and breech extraction and above all the experience of the accoucheur. All these confounding variables or manipulations can directly or indirectly affect the success of the second twin delivery and thus, the delivery time interval, the cord blood result and the baby outcome. The degree of employing the above obstetric interventions was not mentioned in the original paper. Thirdly, the baby outcome was only measured by a single test (i.e. cord blood gas analysis) and there were no clinical parameters for comparison such as low Apgar score, need of intubation, need of neonatal intensive care, etc. What did a low pH at birth mean clinically and was the blood gas repeated 5 to 10 minutes later on those babies found acidotic? Only with these clinical indicators of baby’s outcome can we conclude that the 30-minute limit is biochemically and clinically significant. It is unwise to decide for a major obstetric intervention (i.e. caesarean section) purely on the time limit and ignoring other favourable factors for continuation of vaginal delivery (head descending and normal fetal heart pattern). Fourthly, Leung et al. found a significantly higher incidence of fetal distress if the intertwin delivery interval was more than 30 minutes (73%) but the definition of ‘fetal distress’ was not clearly stated. It can be an abnormal cardiotocographic trace, deceleration, bradycardia or others, bearing in mind the difficulty in interpreting second stage cardiotocograph. Fetal distress was the indication for emergency caesarean section in 70% of their cases, which was significantly higher than other series. In Persad et al.’s series, the indication for emergency caesarean section for the second twin was fetal distress 18%, cord prolapse 18%, malpresentation 40% and failure to descend 22%. Without a clear definition of fetal distress, the conclusions drawn by the authors can be misleading and the intervention proposed for the second twin can be hazardous. We are not objecting to setting an upper limit for the twin-totwin delivery interval as a good clinical practice guideline, but the time limit, if ever set, should not be used as an absolute indication for abdominal delivery. Other confounding factors should also be considered: level of experience of staff present, competence of intrauterine manipulation, progress of labour, fetal heart pattern and wish of patients as well. Persad et al. proposed a more proactive approach including the use of uterine tocolysis as an adjunct to version and extraction of the second twin in transverse lie or breech extraction, which could reduce the need for caesarean delivery. In the same study, a higher incidence of maternal complications (need of general anaesthetic, puerperal infection and longer hospital stay) was noted in women having combined vaginal–caesarean delivery. Delivery of twin pregnancy, especially the second twin, needs special experience and skill of the obstetricians and a clinical protocol should be developed to decide for continuation of vaginal delivery or for emergency caesarean section. The decision sometimes can be difficult but should not be purely based on a time limit.