Oscar Sadan

Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine

The ideal technique for identifying the epidural space remains unclear. Five-hundred-forty-seven women in labor who requested epidural analgesia were randomly allocated to three groups according to the technique by which the epidural space was identified: 1) loss-of-resistance with air (air; n = 180), 2) loss-of-resistance with lidocaine (lidocaine; n = 185), and 3) loss-of-resistance with both air and lidocaine (air-plus-lidocaine; n = 182). We assessed ease of epidural catheter insertion, characteristics of the blockade, quality of analgesia, and complications. The inability to thread the epidural catheter occurred in 16% of the air, 4% of the lidocaine, and 3% of the air-plus-lidocaine patients (P < 0.001). More patients from the air group had unblocked segments (6.6% versus 3.2% and 2.2%, respectively; P < 0.02). The incidence of accidental dural puncture was greater in the air group (1.7% versus 0% in the other two groups; P < 0.02). Pain scores, time to onset of analgesia, upper sensory level, motor blockade, and the incidence of hypotension, transient neurological deficits, postpartum urinary retention, and postdural puncture headache were comparable. Identification of the epidural space with air was more difficult and caused more dural punctures than with lidocaine or air plus lidocaine. Additionally, sequential use of air and lidocaine had no advantage over lidocaine alone.

Role of Sonography in the Diagnosis of Retained Products of Conception

Objective. To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. Methods. This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty‐one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. Results. Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false‐positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false‐positive rates were 28.9% and 51.5%, respectively. Conclusions. Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false‐positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

A new approach to office hysteroscopy compared with traditional hysteroscopy: a randomized controlled trial.

OBJECTIVE: To compare a “no touch” approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%. METHODS: A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy. RESULTS: The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8±2.7 versus 5.34±3.23, P=.01; VAS2: 3.02±2.50 versus 4.57±3.30, P=.008). Patient satisfaction rate was similar in both groups. CONCLUSION: Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410 LEVEL OF EVIDENCE: II-1

Favorable outcome following emergency second trimester cerclage

Background: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. Methods A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16–27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. Results Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3 ± 6.5 vs 9.3 ± 4.8 weeks, p = 0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6 ± 4.6 vs 29.5 ± 3.2 weeks, p = 0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p = 0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p = 0.2). Conclusions Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.

Personality, fear of childbirth and cesarean delivery on demand

Objectives. To investigate both the psychological traits and the demographic factors associated with cesarean section on maternal demand. Design. Cross‐sectional questionnaire study. Setting. Delivery ward, Edith Wolfson Medical Center, Holon, Israel. Sample. Fifty‐nine healthy primigravida with a singleton pregnancy were recruited during 2009, of whom 28 requested and were delivered by cesarean section without obstetrical indication, whereas 31 opted for spontaneous vaginal delivery. Methods. All questionnaires were administered to the two groups at term. Various psychological (fear of childbirth questionnaire, Millon Clinical Multiaxial Inventory III, Anxiety Sensitivity Index, State‐Trait Anxiety Index and social support scale) as well as demographic variables were measured before labor and compared. A priori power calculation yielded a power of 95%. Main Outcome Measures. Fear of childbirth, various personality disorders and psychiatric clinical syndromes (29 Millon Clinical Multiaxial Inventory III scales), Anxiety Sensitivity, State Anxiety Index, social support and demographic variables. Results. Differences in age and method of conceiving (p<0.001) were found between the groups. The study group reported a higher level of fear of childbirth (p<0.001), but no differences were found in all other personality characteristics measured (29 Millon Clinical Multiaxial Inventory III scales, State‐Trait Anxiety, Anxiety Sensitivity and social support scale). The origin of the difference regarding the fear of childbirth was located to two specific questions: ‘Have you always been afraid of giving birth?’ and ‘Have you sometimes thought of the delivery as something unnatural?’ Conclusions. The only psychological variable associated with the choice for cesarean section on maternal request was the fear of childbirth.

Different degrees of fetal oxidative stress in elective and emergent cesarean section.

Background: Several studies have addressed the influence of labor and mode of delivery on oxidative stress. Still it is unclear whether oxidative stress is related to delivery itself or whether it reflects a pre-existing fetal oxidative status. Objective: To investigate whether the degree of fetal oxidative stress is different between distressed fetuses that were delivered by emergent cesarean section and non-distressed fetuses that were delivered by elective cesarean section. Methods: The protocol of this prospective study was approved by the Institutional Review Board Committee. Amniotic fluid and umbilical artery blood were prospectively collected from 21 parturients who were delivered by an emergent cesarean section for non-reassuring fetal heart rate pattern and from 21 parturients who were delivered by an elective cesarean section in a tertiary care center. Oxidative stress was evaluated in amniotic fluid, umbilical cord plasma and erythrocytes by determining malondialdehyde concentration and glutathione peroxidase (GPX) activity. Results: Malondialdehyde concentration was higher in amniotic fluid (mean ± SEM) (2.2 ± 0.7 nmol/l vs. 0.6 ± 0.02 nmol/l, p < 0.05), in umbilical cord plasma (1.2 ± 0.2 nmol/l vs. 0.7 ± 0.3 nmol/l, p < 0.05) and in umbilical cord erythrocytes (159.6 ± 48.6 nmol/g Hb vs. 85.8 ± 5.2 nmol/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean. GPX activity was enhanced in amniotic fluid (12.4 ± 2.2 U/l vs. 5.1 ± 0.6 U/l, p < 0.05) and GPX activity/hemoglobin ratio was higher in cord blood (22.0 ± 0.8 U/g Hb vs. 18.7 ± 0.9 U/g Hb, p < 0.05) in women delivering by emergent cesarean compared to those delivering by elective cesarean. Conclusion: Distressed fetuses delivered by emergency cesarean exhibited increased malondialdehyde concentrations, an indicative parameter for oxidative damage, and enhanced GPX activity an antioxidant enzyme, in amniotic fluid and umbilical cord blood compared to non-distressed fetuses delivered by elective cesarean section. This is probably an indication of higher fetal oxidative stress.

Laparoscopic Surgery for Extrauterine Pregnancy in Hemodynamically Unstable Patients

STUDY OBJECTIVE To assess the feasibility and safety of laparoscopic surgery in treatment of ectopic pregnancy in hemodynamically unstable women. DESIGN Three-year observational study (Canadian Task Force classification II-2). SETTING Tertiary university hospital. PATIENTS One hundred one women with ectopic pregnancy who underwent laparoscopic surgery, 18 with substantial intraabdominal bleeding and with clinical signs and symptoms of hemodynamic instability. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS Compared with stable patients, hemodynamically unstable women had significantly more free blood in the abdomen (1244 +/- 590 vs 173 +/- 301 ml, p <0.0001), had significantly lower hemoglobin levels (7.8 +/- 1.4 vs 11.9 +/-1.4 g%, p <0.0001), and required significantly more frequent blood transfusions (83% vs 3.6%, p <0.0001). Similarly, their hemodynamic values such as pulse rate and blood pressures were worse. Among these women, 15 (83%) had a tubal pregnancy, 2 had an interstitial pregnancy, and 1 had a tubal abortion. Those with tubal pregnancy who were hemodynamically unstable underwent salpingectomy. Only one required conversion to laparotomy. No major intraoperative or postoperative complications occurred, and all women made a full and uneventful recovery. CONCLUSION Improved anesthesia and cardiovascular monitoring, together with advanced laparoscopic surgical skills and experience, justifies operative laparoscopy for surgical treatment of ectopic pregnancy even in women with hemodynamic instability.

The effects of remifentanil or acetaminophen with epidural ropivacaine on body temperature during labor

PurposeEpidural analgesia is associated with hyperthermia during labor and presumably causes it, although no convincing mechanism has been postulated. It seems likely that fever associated with pyrogenic factors related to labor is suppressed by opioids, whereas it is expressed normally in patients given epidural analgesia. We examined this hypothesis and the possible etiology of temperature elevation in labor.MethodsIn this prospective, randomized, controlled study, we assessed 201 parturients during spontaneous labor. Analgesia was randomly provided with one of four treatment groups: (1) epidural ropivacaine alone, (2) IV remifentanil alone, (3) epidural ropivacaine plus IV remifentanil, and (4) epidural ropivacaine plus IV acetaminophen. At randomization, patients were normothermic. Intrapartum hyperthermia (≥38°C) was correlated to the analgesic technique.ResultsThe maximum increase in oral temperature was greatest in the ropivacaine group (0.7 ± 0.6°C) and least in the remifentanil group (0.3 ± 0.4°C; P = 0.013). The percentage of patients who became hyperthermic (≥38°C) during the first 6 h of labor was greatest in the ropivacaine group (14%) and least in the remifentanil-alone group (2%), but the difference was not statistically significant. The maximum forearm-finger gradients were lower (less vasoconstriction) in the remifentanil group when compared to the gradients in patients with epidural analgesia (1.4 ± 1.8 vs 3.0 ± 1.7, respectively; P < 0.001).ConclusionOur results are consistent with the theory that low-dose opioids inhibit fever in patients not given epidural analgesia. However, in view of the negative results, the hypothesis of epidural-induced hyperthermia may be questionable.

Positive serology for Helicobacter pylori and vomiting in the pregnancy

Introduction.Recently, several investigators have suggested that H. pylori may be a contributory factor in hyperemesis gravidarum. The purpose of this study was to evaluate whether seropositivity for IgG antibodies to H. pylori may also be related to nausea, vomiting, heartburn and epigastric pain in pregnancy.Materials and methods.One hundred and eighty-five women, at term pregnancy, were included in the study. All women completed a questionnaire regarding information on the number of pregnancies and deliveries, weight gain, smoking and gastrointestinal complaints before and during pregnancy. The presence of H. pylori infection was determined by serology.Results.The overall prevalence rate of H. pylori seropositivity was 45.9%. Women positive for H. pylori IgG were older (28.7±4.5 vs. 27.0±4.5, p=0.02), had more prior pregnancies (3.2±2.1 vs. 2.6±1.6, p=0.02) and deliveries (2.6±1.6 vs. 2.0±1.1, p=0.006) and reported vomiting in the first trimester more frequently than H. pylori negative patients (81.2% vs. 65%, p=0.004). On the other hand vomiting in the second trimester was reported more frequently among smokers during pregnancy compared to non-smokers.Conclusions.H. pylori seropositivity is significantly associated with emesis gravidarum but not with gastro-intestinal symptoms later in pregnancy. First trimester vomiting more than doubles the likelihood that the gravida is H. pylori IgG positive.

The role of tamoxifen in the treatment of symptomatic uterine leiomyomata — a pilot study

OBJECTIVES To determine the efficacy of tamoxifen in patients with leiomyomata complaining of abdominal pains and vaginal bleeding. STUDY DESIGN Prospective, randomized, double blind study. A total of 10 patients received for 6 months 20 mg tamoxifen daily, and 10 women received placebo. All patients underwent serial pelvic and ultrasound exams and endometrial sampling was performed prior to initiation of treatment. After 5 years, the patients were interviewed again. RESULTS Uterine size was not affected by the use of tamoxifen. Patients reported a blood loss decrease of 40--50% at the end of the study (P=0.0001). In the control group a slight increase in blood loss was reported. Hemoglobin levels remained unchanged in both groups. In the study group patients reported after 4 months of treatment a substantial decrease in the intensity of pain (P=0.018). Seven patients in the study group and one patient in the control group developed ovarian cysts. CONCLUSIONS Treatment with tamoxifen added only marginal benefit while causing unacceptable side effects. Tamoxifen does not seem to be a useful adjunct in the treatment of symptomatic uterine leiomyomata and its use for this indication should be discouraged.