Terrance W. Breen

Epidural anesthesia for labor in an ambulatory patient.

The effectiveness of two epidural analgesic regimens on the ability to ambulate was compared in women in labor by a prospective, randomized, double-blind design. One group of patients received epidural fentanyl, a 75-micrograms bolus and an infusion of fentanyl 2.5 micrograms/mL at 15 mL/h (FENT, n = 53). A second group received ultra low-dose bupivacaine (0.04%), epinephrine (1.7 micrograms/mL), and fentanyl (1.7 micrograms/mL) (BEF, n = 77), a 15-mL bolus followed by an infusion at 15 mL/h. Adequate analgesia was rapidly obtained in 90.6% of patients in the FENT group and 92.2% of patients in the BEF group (P = 0.89). Seventy percent of patients in the FENT group ambulated versus 68% in the other group. The BEF mixture provided analgesia of longer duration (287 +/- 171 min versus 156 +/- 72 min, P = 0.0001). The number of patients delivering during administration of only their study drug (without needing higher doses of local anesthetics) was 52% for BEF and 21% for FENT (P = 0.0005). Hip flexion weakness precluding ambulation occurred in 17% (P = 0.002) of BEF patients and orthostatic hypotension in 9% (P = 0.08). Neither problem occurred in FENT patients. Neonatal outcome was similar in both groups. Approximately 70% of women receiving epidural analgesia with fentanyl or ultra low-dose bupivacaine, epinephrine, and fentanyl may ambulate safely during labor.

Factors Associated with Back Pain after Childbirth

BackgroundBack pain after childbirth is a frequent complaint. The purpose of this study was to determine the incidence of back pain 1–2 months post partum and to identify the factors, including epidural anesthesia for labor and delivery, that may predispose to it. MethodsWomen delivering a viable singleton infant were interviewed 12–48 h after delivery for a history of back pain that occurred before, during, or both before and during the recent pregnancy and for details of their delivery experience. Two months later, the women interviewed were sent a follow-up questionnaire regarding the occurrence of back pain 1–2 months post partum. ResultsFollow-up data were available for 1,042 (88%) of the 1,185 women originally interviewed. The Incidence of post partum back pain in women who received epidural anesthesia was equivalent to those who did not (44% vs. 45%). Through stepwise multiple logistic regression, post partum back pain was found to be associated with a history of back pain, younger age, and greater weight. However, new-onset post partum back pain was found to be associated with greater weight and shorter stature. No statistically significant association was found between post partum back pain and epidural anesthesia, number of attempts at epidural placement, duration of second stage of labor, mode of delivery, or birth weight. ConclusionsThe overall incidence of back pain 1–2 months post partum in this population was 44%. Predisposing factors were a history of back pain, younger age, and greater weight. Predisposing factors for new-onset post partum back pain were greater weight and shorter stature. Epidural anesthesia for labor and delivery did not appear to be associated with back pain 1–2 months post partum.

A Multicenter Randomized Controlled Trial Comparing Patient-Controlled Epidural with Intravenous Analgesia for Pain Relief in Labor

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 &mgr;g/mL (n = 124). There was no difference in the incidence of cesarean delivery—10.2% (12 of 118) versus 9.7% (12 of 124)—or instrumental vaginal delivery—21.2% (25 of 118) versus 29% (36 of 124)—between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

A Multicenter, Randomized, Controlled Trial Comparing Bupivacaine with Ropivacaine for Labor Analgesia

Background A meta-analysis of studies comparing high doses of bupivacaine with ropivacaine for labor pain found a higher incidence of forceps deliveries, motor block, and poorer neonatal outcome with bupivacaine. The purpose of this study was to determine if there is a difference in these outcomes when a low concentration of patient-controlled epidural bupivacaine combined with fentanyl is compared with ropivacaine combined with fentanyl. Methods This was a multicenter, randomized, controlled trial, including term, nulliparous women undergoing induction of labor. For the initiation of analgesia, patients were randomized to receive either 15 ml bupivacaine, 0.1%, or 15 ml ropivacaine, 0.1%, each with 5 &mgr;g/ml fentanyl. Analgesia was maintained with patient-controlled analgesia with either local anesthetic, 0.08%, with 2 &mgr;g/ml fentanyl. The primary outcome was the incidence of operative delivery. We also examined other obstetric, neonatal, and analgesic outcomes. Results There was no difference in the incidence of operative delivery between the two groups (148 of 276 bupivacaine recipients vs. 135 of 279 ropivacaine recipients;P = 0.25) or any obstetric or neonatal outcome. The incidence of motor block was significantly increased in the bupivacaine group compared with the ropivacaine group at 6 h (47 of 93 vs. 29 of 93, respectively;P = 0.006) and 10 h (29 of 47 vs. 16 of 41, respectively;P = 0.03) after injection. Satisfaction with mobility was higher with ropivacaine than with bupivacaine (mean ± SD: 76 ± 23 vs. 72 ± 23, respectively;P = 0.013). Satisfaction for analgesia at delivery was higher for bupivacaine than for ropivacaine (mean ± SD: 71 ± 25 vs. 66 ± 26, respectively;P = 0.037). Conclusions There was no difference in the incidence of operative delivery or neonatal outcome among nulliparous patients who received low concentrations of bupivacaine or ropivacaine for labor analgesia.

Adding fentanyl 0.0002% to epidural bupivacaine 0.125% does not delay gastric emptying in laboring parturients.

Previous studies have shown that bolus doses of fentanyl (50 and 100 micro gram) with epidural bupivacaine delay gastric emptying by up to 45 min.We studied the effect of the addition of small-dose fentanyl to epidural bupivacaine infusions on gastric emptying during labor. The acetaminophen absorption technique was used to infer gastric emptying. Twenty-eight patients in established labor consented to participate in the study. They were randomized to receive either 1) 10 mL bupivacaine 0.125% followed by an infusion of 0.125% bupivacaine at 10 mL/h or 2) 10 mL bupivacaine 0.125% with 50 micro gram fentanyl followed by an infusion of 0.125% bupivacaine and 0.0002% fentanyl at 10 mL/h. Two hours after initiation of epidural analgesia, each patient ingested 20 mg/kg acetaminophen in a suspension of 150 mL water. Venous blood samples were drawn for a baseline and then every 15 min for 2 1/2 h. There were no significant demographic differences between the groups. There were no differences detected between groups in the peak plasma concentrations of acetaminophen, the time to achieve the peak plasma concentrations, or the area under the curve at 45 and 90 min. Our results indicate that epidural infusions for labor analgesia using 0.125% bupivacaine and 0.0002% fentanyl do not delay gastric emptying compared to infusions of bupivacaine 0.125% alone. (Anesth Analg 1996;82:612-6)

Intrathecal morphine for analgesia after postpartum bilateral tubal ligation

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 &mgr;g intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 &mgr;g of fentanyl, and either 50 &mgr;g of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P = 0.003) and pain was less intense at rest (P = 0.008) and on movement (P < 0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P = 0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P = 0.006), pain on movement was significantly less at 4 h (P = 0.002) and 12 h (P = 0.0004), and pruritus was significantly more frequent at 12 h (P = 0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P = 0.006) and the time to first request of analgesia was significantly longer (P = 0.006) in the morphine group. We conclude that the addition of 50 &mgr;g of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

Prevalence of coagulation abnormalities associated with intrauterine fetal death

PurposeThe purpose of this study was to determine factors associated with abnormal coagulation in the setting of intrauterine fetal death (IUFD).MethodsWe reviewed the charts of 238 patients diagnosed with IUFD over ten years. Data included demographics, coexisting obstetric disease and coagulation studies. A coagulation score was assigned based on the platelet count, prothrombin time, activated partial thromboplastin time and plasma fibrinogen concentration. Approximately 90% of the study population had coagulation scores <4. A score of > 4 was considered abnormal.ResultsComplete coagulation analysis was available in 183/238 patients (77%) within 24 hr of delivery. One hundred and sixty-four of these (89.6%) had a coagulation score <4 and 19 had a score > 4 (10.4%). No relationship between the coagulation score and age, parity, gestational age at delivery, and number of days the dead fetus remained in utero was found. A coagulation score > 4 was associated with the presence of a pregnancy-related disease (P < 0.05), notably abruption (P < 0.001) and uterine perforation (P < 0.05). Four patients without co-existing disease (3.2%), had a coagulation score ≥4.ConclusionIn most pregnancies complicated by fetal demise, the fetus and placenta are delivered within one week of fetal demise. The previously reported severe coagulation disturbances are largely eliminated by early delivery. Our study shows that coagulation abnormalities occur in some patients with uncomplicated IUFDs (3.2%) and that this number rises in the presence of abruption or uterine perforation.RésuméObjectifCette étude visait à déterminer les facteurs associés à une coagulation anormale dans un contexte de mortalité foetale in utero (MFIU).MéthodesLes auteurs ont relevé les dossiers de 238 patientes porteuses d’un diagnostic de MFIU sur une période de dix ans. Les données incluaient la démographie, les affections obstétricales associées et le bilan hémostatique. Un score de coagulabilité a été assigné d’après le décompte plaquettaire, le temps de prothrombine, le temps de thromboplastine partielle activé et la concentration plasmatique du fibrinogène. Environ 90% de la population étudiée avait un score de coagulabilité <4. Un score ≥4 était considéré comme anormal.RésultatsUn bilan hémostatique était disponible chez 183/238 patientes (77%) à 24 h de l’accouchement. De ces patientes, 164 (89,6%) avaient un score de coagulabilité <4, et 19 avaient un score ≥4 (10,4%). On n’a pas trouvé de rapport entre le score de coagulabilité et l’âge, la parité, l’âge gestationel à l’accouchement et la durée de présence du foetus mort in utero. Un score de coagulabilité ≥ 4 était associé à une maladie de la grossesse (P < 0,05), notamment à un décollement placentaire (P < 0,001) ou à perforation utérine (P < 0,05). Quatre patientes sans maladies obstétricales associées (3,2%) avaient un score de coagulabilité ≥4.ConclusionLa plupart des grossesses compliquées par une mort foetale expulsent le foetus et le placenta dans le semaine qui suit ta mort du foetus. Les dérangements graves de la coagulation rapportés antérieurement sont en grande partie éliminés par un accouchement précoce. Notre étude montre que les anomalies de la coagulation surviennent chez certaines patientes avec une MFIU (3,2%) et que ce nombre augmente en présence d’un décollement placentaire ou d’une perforation utérine.

Epidural fentanyl and caesarean section: when should fentanyl be given?

Epidural fentanyl is often added to epidural local anaesthetic agents to improve the quality of anaesthesia obtained during Caesarean section. Fentanyl may be given either before or after delivery of the infant. When given before delivery, fentanyl has not been reported to cause neonatal depression, although this remains a concern. A prospective, randomized, double-blind study was undertaken to determine if fentanyl was more effective if given before or after delivery of the baby in 64 women undergoing Caesarean section under lidocaine epidural anaesthesia. Maternal outcome was determined by time to achieve T4 neural blockade, the dose of lidocaine necessary to achieve this block and intraoperative scores for pain, nausea, vomiting, shivering, and sedation. Neonates were assessed by umbilical arterial blood pH and Apgar scores. No differences were detected in either group with respect to maternal or neonatal outcome. We recommend using only epidural local anaesthetic agents before delivery, and giving epidural fentanyl following delivery of the infant.RésuméLe fentanyl est souvent ajouté aux agents anesthésiques locaux administrés par voie épidurale afin d’améliorer la qualité de l’anesthésie au cours d’une césarienne. Le fentanyl peut être administré avant ou après la naissance. Une étude prospective, à double insu, avec distribution aléatoire, a été faite chez 64 parturientes qui ont accouché par césarienne sous anesthésie épidurale. Le but était de déterminer si le fentanyl était plus efficace lorsque donné avant la naissance. Les paramètres évalués chez la mère étaient le temps requis pour atteindre un bloc sensitif au niveau de T4, la dose de lidocaine nécessaire pour atteindre ce niveau d’anesthésie, la douleur peropératoire, le degré de sédation, ainsi que l’incidence de frissons, nausées et vomissements. L’Apgar et le pH du sang artériel ombilical ont été évalués chez les nouveaunés. Aucune différence significative n’a été trouvee entre les groupes pour chacun des paramétres évalués chez les méres et les nouveaunés. Nous recommandons d’administrer seulement l’agent anesthésique local par voie épidurale avant l’accouchement et de donner le fentanyl après la naissance.

The changing role of magnesium sulphate therapy.

Magnesium sulphate is not an effective tocolytic. Magnesium sulphate therapy was also linked to preterm neonatal deaths in one study, which was stopped before completion. Other studies suggest a possible neuroprotective effect of magnesium. Both of these issues require further study. Magnesium sulphate is clearly the drug of choice to prevent recurrent eclampsia and to treat severe pre-eclampsia.

Natural History of Postpartum Back Pain and Its Relationship with Epidural Anesthesia

Natural History of Postpartum Back Pain and Its Relationship with Epidural Anesthesia P. Groves;T. Breen;B. Ransil;N. Oriol; Anesthesiology