Persistent pain after caesarean section and its association with maternal anxiety and socioeconomic background

BackgroundPain, both from the surgical site, and from other sources such as musculoskeletal backache, can persist after caesarean section. In this study of a predominantly socially deprived population we have sought to prospectively examine the association between antenatal maternal anxiety and socioeconomic background and the development of persistent pain of all sources after caesarean section.MethodsDemographic details and an anxiety questionnaire were completed by 205 women before elective caesarean section. On the first postoperative day, pain scores were recorded, and at four months patients were asked to complete a Brief Pain Inventory and an Edinburgh Postnatal Depression Score.ResultsOf 205 parturients recruited, 186 records were complete at the hospital admission phase and 98 (52.7%) were complete at the four-month follow-up phase. At recruitment, 15.1% reported pain. At four months 41.8% (95% CI 32.1 to 51.6%) reported pain, of whom pain was a new finding in 35.7% (95% CI 26.2 to 45.2%). Antenatal anxiety was not a significant predictor of severity of new pain at four months (P=0.44 for state anxiety, P=0.52 for trait anxiety). However, four-month pain severity did correlate with social deprivation (P=0.011), postnatal depression (P <0.001) and pain at 24 h (P=0.018).ConclusionPersistent pain from a variety of sources after caesarean section is common. Our findings do not support the use of antenatal anxiety scoring to predict persistent pain in this setting, but suggest that persistent pain is influenced by acute pain, postnatal depression and socioeconomic deprivation.     

The influence of ATP-binding cassette sub-family B member -1 (ABCB1) genetic polymorphisms on acute and chronic pain after intrathecal morphine for caesarean section: a prospective cohort study

BackgroundPolymorphisms of the ATP-binding cassette sub-family B member -1 (ABCB1) gene that codes for P-glycoprotein could influence the efflux of morphine from the central nervous system affecting its analgesic action. We investigated the effect of ABCB1 gene polymorphisms on analgesia and the development of persistent pain in post caesarean patients.MethodsWomen of Chinese descent who received spinal anaesthesia with intrathecal morphine for elective caesarean section were recruited. They were given intravenous morphine via a patient-controlled analgesia pump for postoperative analgesia. Blood samples were collected and analysed for the presence of C1236T, G2677T/A and C3435T single nucleotide polymorphisms of the ABCB1 gene. We primarily investigated the association between ABCB1 polymorphisms and the effect of morphine. In a postpartum phone survey of the subjects six months after surgery, the occurrence of persistent abdominal wound scar pain was established.ResultsWe found no significant statistical difference in total morphine consumption, pain scores and side effects among the various genotypes. For C3435T polymorphism, there was a trend towards the association of the T allele and persistent pain for three months after surgery but this did not reach statistical significance (P = 0.07). The TT genotype had the longest mean survival time of wound pain in comparison with CT and CC genotypes (P = 0.004 and P = 0.014, respectively).ConclusionPolymorphisms of ABCB1 were not associated with differences in morphine use in the first 24 h after surgery. Women with the T allele of C3435T polymorphism showed a trend towards a higher risk of developing persistent postoperative pain.     

Antenatal fibrinogen concentrations and postpartum haemorrhage

BackgroundIt is unclear whether antenatal fibrinogen concentrations are associated with postpartum haemorrhage.MethodsThis retrospective study included 871 women with a singleton pregnancy but no known risk factors for postpartum haemorrhage, in whom fibrinogen concentration was measured within the 21 days before delivery. Correlation between antenatal fibrinogen concentrations and estimated blood loss was analysed. We tested the hypothesis that the risk of postpartum haemorrhage was higher in women with antenatal fibrinogen concentrations of <3.3 g/L. Postpartum haemorrhage was defined as an estimated blood loss ⩾700 mL following vaginal delivery and ⩾1000 mL following caesarean delivery.ResultsIn women delivering vaginally (n = 337), estimated blood loss tended to increase with decreasing antenatal fibrinogen concentration (R = −0.107, P = 0.05), median fibrinogen concentration was significantly lower in 69 women with postpartum haemorrhage than in 268 women without postpartum haemorrhage (3.93 vs. 4.18 g/L, P = 0.025), and postpartum haemorrhage occurred significantly more often in women with fibrinogen concentrations <3.3 g/L than in those with concentrations ⩾3.3 g/L (38% [11/29] vs. 19% [58/308], P = 0.018). In women undergoing caesarean delivery (n = 534), median fibrinogen concentration did not differ between those who experienced postpartum haemorrhage (n = 128) and those who did not (n = 406) (4.18 g/L vs. 4.07 g/L, P = 0.43). Antenatal fibrinogen concentrations of <3.3 g/L were not associated with higher rates of postpartum haemorrhage (26% [11/43] vs. 24% [117/491], P = 0.80).ConclusionsAntenatal fibrinogen concentration <3.3 g/L may be a risk factor for postpartum haemorrhage among women following vaginal delivery.     

Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital

BackgroundAt our institution, the emergency obstetric ‘code green’ activates the system for immediate birth, usually by caesarean section. This study aimed to determine the incidence of immediate birth, indications, modes of anaesthesia, and short-term neonatal and maternal outcomes.MethodA review was performed for all women at the Royal Women’s Hospital, Parkville, Australia who underwent immediate birth over a two-year period: January 1, 2013 to December 31, 2014.ResultsWithin the study period 14,115 women gave birth, of which 387 women underwent an immediate birth, the majority (83%) by caesarean section. The commonest indication for immediate birth was prolonged fetal bradycardia (53%), however cord prolapse (4%) produced the most rapid decision-to-delivery interval, with a median [IQR] time of 14 [13–16] min versus 18 [14–23] min for all immediate births (P < 0.01). Epidural top-up was the most common anaesthesia method. Conversion to general anaesthesia following inadequate neuraxial anaesthesia occurred in 6.2% of women. Among 103 general anaesthetics, there was one failed intubation (successful ventilation) and one dental injury. Nine women (2.3%) were admitted to the high dependency or intensive care units, and there were no maternal deaths. Babies born by caesarean section with a decision-to-delivery interval of less than 30 min were more likely to have longer times to establish respiration (22.6% vs 16.7%, P < 0.001).ConclusionRequest for immediate delivery is a common obstetric emergency. Epidural top-up has become the most common anaesthetic technique. Rapid delivery times can be achieved with an integrated emergency response system.     

Bupivacaine-soaked absorbable gelatin sponges in caesarean section wounds: effect on postoperative pain,analgesic requirement and haemodynamic profile

BackgroundPain is a common distressing adverse effect in the early postoperative period following caesarean section. The aim of this study was to investigate the effect on postoperative pain, analgesic requirement and haemodynamic profile of placing a suprafacial bupivacaine-soaked absorbable gelatin sponge in the caesarean section wound.MethodsA total of 164 healthy patients scheduled to undergo general anaesthesia for elective caesarean section were randomised to a study group (n=81) or a control group (n=83). In the study group, a bupivacaine-soaked absorbable gelatin sponge was placed subcutaneously in the caesarean section wound. Intramuscular diclofenac 75 mg was given to all patients at 8-h intervals during the first 24 h. Postoperatively, visual analogue scale pain scores, requirement for pethidine and diclofenac and changes in blood pressure and heart rate were compared between groups.ResultsPain scores were lower in the study group compared to the control group at all assessments (P <0.001). During the first eight hours after surgery, fewer patients in the study group required rescue pethidine compared with the control group (4 vs. 33, P <0.001). In the study group, total opioid and diclofenac consumption was lower (P <0.001), and blood pressure and heart rate were lower (P <0.001) compared to the control group.ConclusionSuprafascial wound placement of a bupivacaine-soaked absorbable gelatin sponge improved postoperative analgesia and decreased opioid consumption following caesarean section.     

Reduction of severity of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine: a randomised comparison of prophylactic granisetron and ondansetron

BackgroundThe incidence of pruritus after elective caesarean section under spinal anaesthesia with subarachnoid morphine may be 60-100%, and is a common cause of maternal dissatisfaction. Ondansetron has been shown to reduce pruritus but the effect is short-lived. The objective of this randomized double-blind trial was to evaluate the anti-pruritic efficacy of granisetron compared with ondansetron.MethodsEighty ASA I or II women undergoing elective caesarean section received spinal anaesthesia with 0.5% hyperbaric bupivacaine10 mg, fentanyl 25 μg and preservative-free morphine 150 μg. After delivery of the baby and clamping of the umbilical cord, they were randomised to receive granisetron 3 mg i.v. (group G) or ondansetron 8 mg i.v. (group O).ResultsThe two groups were similar for age, gestational age, height and weight. According to visual analogue pruritus scores, patients in group G experienced less pruritus at 8 h (P = 0.003) and 24 h (P = 0.01). Fewer patients in group G (n = 8) than group O (n = 18) required rescue anti-pruritic medication (P = 0.03). Satisfaction scores were also higher in group G than in group O (P = 0.03). There was no difference in overall incidence of pruritus, nausea and vomiting, and visual analogue pain scores between the two groups.ConclusionsAdministration of granisetron 3 mg i.v. reduces the severity of pruritus and the use of rescue anti-pruritic medication, and improves satisfaction but does not reduce the overall incidence of pruritus in women who have received subarachnoid morphine 150 μg compared to ondansetron 8 mg i.v.     

The effects of a resistive warming mattress during caesarean section: a randomised,controlled trial

BackgroundThe adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section.MethodsA total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0°C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded.ResultsThe incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P = 0.043); mean temperatures differed between the two groups, 36.5°C and 36.3°C, respectively (P = 0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at −1.1 ± 0.9 g/dL versus −1.6 ± 0.9 g/dL in the control group (P = 0.007). There was no difference in shivering (P = 0.798).ConclusionsA resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.     

An observational study of skin conductance monitoring as a means of predicting hypotension from spinal anaesthesia for caesarean delivery

BackgroundHypotension after spinal anaesthesia is a common and important complication at caesarean delivery. Skin conductance monitoring has been shown to predict post-spinal hypotension in elderly patients and may be a rapid, non-invasive means of predicting risk in the obstetric population.MethodsWomen having elective caesarean delivery were included in this observational pilot trial. Baseline data were obtained for blood pressure, heart rate and skin conductance variables before administration of spinal anaesthesia and at 1-min intervals for 20 min thereafter. Correlations between baseline data and minimum post-spinal blood pressure were calculated, and the predictive value of baseline variables was estimated by use of receiver operator characteristics.ResultsForty women completed the study. Spinal anaesthesia was followed in most cases by a significant reduction from baseline in systolic blood pressure [0–9% n = 2 (5%), 10–20% n = 21 (52.5%), 20–30% n = 12 (30%), >30% n = 5 (12.5%)]. Minimum systolic blood pressure was >100 mmHg in 25 (62%), 80–100 mmHg in 12 (30%) and <80 mmHg in 3 (7.5%) patients. Fasting times, spinal block distribution, baseline heart rate, blood pressure or baseline skin conductance did not predict post-spinal hypotension or neonatal outcome.ConclusionIn contrast to a previous report in elderly patients, we were unable to demonstrate a significant relationship between baseline sympathetic tone, measured by skin conductance, and hypotension following spinal anaesthesia in women undergoing elective caesarean delivery.     

The effect of intravenous ondansetron on maternal haemodynamics during elective caesarean delivery under spinal anaesthesia: a double-blind,randomised, placebo-controlled trial

BackgroundSpinal anaesthesia for caesarean delivery is frequently associated with adverse effects such as maternal hypotension and bradycardia. Prophylactic administration of ondansetron has been reported to provide a protective effect. We studied the effect of different doses of ondansetron in obstetric patients.MethodsThis prospective double-blind, randomised, placebo-controlled study included 128 healthy pregnant women scheduled for elective caesarean delivery under spinal anaesthesia. Women were randomly allocated into four groups (n = 32) to receive either placebo or ondansetron 2, 4 or 8 mg intravenously before induction of spinal anaesthesia. Demographic, obstetric, intraoperative timing and anaesthetic variables were assessed at 16 time points. Anaesthetic variables assessed included blood pressure, heart rate, oxygen saturation, nausea, vomiting, electrocardiographic changes, skin flushing, discomfort or pruritus and vasopressor requirements.ResultsThere were no differences in the number of patients with hypotension in the placebo (43.8%) and ondansetron 2 mg (53.1%), 4 mg (56.3%) and 8 mg (53.1%) groups (P = 0.77), nor the percentage of time points with systolic hypotension (7.3% in the placebo group and 11.1%, 15.7% and 12.6% in the ondansetron 2, 4 and 8 mg groups, respectively, P = 0.32). There were no differences between groups in ephedrine (P = 0.11) or phenylephrine (P = 0.89) requirements and the number of patients with adverse effects.ConclusionsIn our study, prophylactic ondansetron had little effect on the incidence of hypotension in healthy parturients undergoing spinal anaesthesia with bupivacaine and fentanyl for elective caesarean delivery.     

Pharmacokinetics of intravenous ketorolac following caesarean delivery

BackgroundDrug disposition is altered by pregnancy and the peripartum period but data on intravenous ketorolac pharmacokinetics following caesarean delivery have not been previously reported.MethodsAt the end of caesarean delivery, women received an intravenous bolus of ketorolac tromethamine 30 mg (immediate postpartum, Group IP). Plasma samples were collected at 1, 2, 4, 6 and 8 h. A similar pharmacokinetic study was repeated in a subgroup of these women 4–5 months after delivery (late postpartum, Group LP) and in a group of unrelated, healthy non-pregnant female volunteers (controls, Group C). A non-compartmental linear disposition model was applied to analyse individual ketorolac time–concentration profiles. Results at delivery were compared with controls using unpaired or paired statistics as appropriate. Covariates of pharmacokinetic estimates at delivery were examined.ResultsThirty-nine women were studied at caesarean delivery, of whom eight were re-evaluated 4–5 months later. In addition, eight volunteers were studied. Clearance in Group IP was higher compared to Groups LP and C (2.11 vs. 1.43 and 1.07 L/h·m² respectively, P < 0.05). Volume of distribution was also increased in Group IP compared to Groups LP and C (0.24 vs. 0.16 and 0.17 L/kg respectively, P < 0.05). No significant covariates of pharmacokinetic estimates, including gestational age, preterm vs. term, twin vs. singleton and maternal co-morbidity, were seen in Group IP.ConclusionsKetorolac clearance and distribution volume are significantly increased following caesarean delivery. These data provide pharmacokinetic estimates on which to base studies on post caesarean analgesia.     

Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study

IntroductionWe hypothesised that preoperative administration of a single-dose of pregabalin would be associated with lower morphine consumption after uncomplicated caesarean delivery.MethodsAfter Institutional Ethics Committee approval, 135 parturients scheduled for elective caesarean delivery under spinal anaesthesia were randomly allocated to receive either placebo, or oral pregabalin 150 mg or 300 mg, one hour before induction of anaesthesia. Maternal cumulative morphine requirement at 24 h, pain scores, sedation scores, nausea and vomiting, pruritus, pregabalin-related adverse effects, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status were recorded.ResultsCompared with placebo or pregabalin 150 mg, the use of a preoperative dose of pregabalin 300 mg resulted in significantly lower cumulative morphine consumption at 24 h (mean dose: placebo 12.9 mg [95% CI 11.6 to 14.2]; pregabalin 150 mg 11.9 mg; [95% CI 10.7 to 13.1]; pregabalin 300 mg 6 mg [95% CI 5.4 to 7.3]; P<0.001). Pregabalin 300 mg resulted in lower pain scores at 4 h and 6 h after delivery (P<0.001), and fewer instances of nausea, vomiting and pruritus (P<0.009). Dizziness and abnormal vision were observed most frequently in the pregabalin 300 mg group (P<0.05 and P<0.009, respectively). The three groups were similar in terms of maternal sedation, Apgar scores, Neurologic and Adaptive Capacity scores and umbilical cord acid-base status. Three babies in the pregabalin 300 mg group (6.7%) experienced short-term poor latching-on for breastfeeding.ConclusionIn our study, preoperative administration of pregabalin 300 mg reduced postoperative morphine consumption and early postoperative pain in parturients undergoing elective caesarean delivery, although maternal side effects were more common.     

Effects of a head elevated ramped position during elective caesarean delivery after combined spinal-epidural anaesthesia

BackgroundElevating the torso in a Head Elevated Ramped Position during caesarean delivery benefits the mother by improving comfort and ventilation while reducing reflux symptoms and providing a better airway position. We hypothesised that using an elevation pillow for an elective caesarean delivery under combined spinal-epidural anaesthesia would not significantly increase the time to achieve a T4 block.MethodsFollowing ethical approval and informed consent, 60 women undergoing elective caesarean delivery under combined spinal-epidural anaesthesia were randomised to one of three groups: Control – horizontal with a small pillow under the head; Head Elevated Ramped Position – torso on an elevation pillow; and Head Elevated Ramped Position with initial position horizontal. Data collected were time to T4, block height at 30 and 120 min, adequate block at 12 min, need for epidural supplementation, maternal comfort and airway position assessment.ResultsTime to T4 among the three groups was not significantly different (P = 0.14). However, there was a significant difference in achievement of block height of T4 at 12 min and greater need for epidural supplementation in the intervention groups compared to the control group (P = 0.021). Non-inferiority analyses of time to T4 of both head elevated ramped positions were inconclusive about inferiority relative to the control. Head Elevated Ramped Position was significantly more comfortable than control (P = 0.007). Using the level of the external auditory meatus to the sternal notch as an indicator for ease of laryngoscopy, Head Elevated Ramped Position provided a significantly better position than control (P < 0.001).ConclusionElevating the parturient undergoing elective caesarean delivery into the Head Elevated Ramped Position immediately or once the block had been established did not appear to significantly alter time to an adequate block height of T4; however, the need for epidural supplementation was greater in the intervention groups. Cautious use of this novel position change can provide a more comfortable experience and provide a better airway position should conversion to general anaesthesia be required.     

The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal–epidural anaesthesia: a prospective double blind randomised study

BackgroundCombined spinal–epidural anaesthesia is commonly used for elective caesarean section. Intrathecal injection produces rapid onset with minimal doses of local anaesthetic and epidural administration can be used to prolong the block. Our study examined the effects of adding magnesium sulphate to epidural bupivacaine and fentanyl in patients undergoing elective caesarean section using combined spinal–epidural anaesthesia.MethodsWomen ASA physical status I or II at term were recruited. All received 2 mL intrathecal 0.5% hyperbaric bupivacaine, 10 mL epidural 0.25% plain bupivacaine with fentanyl 100 μg, and were randomly allocated to receive either 10 mL of epidural 0.9% sodium chloride or 10 mL epidural 5% magnesium sulphate. The quality of surgical anaesthesia, incidence of hypotension, Apgar scores, intraoperative pain assessment, onset of postoperative pain, sedation scores and side effects were recorded in the postoperative period.ResultsNinety women were recruited. There was no difference in the time taken for the block to reach T4 sensory level, time to reach the highest level of sensory block, time interval between first neuraxial injection and onset of surgery between the groups. Women who received magnesium had greater motor block and muscle relaxation (P < 0.05). Apgar scores were 7 or more in almost all neonates in both groups. There was no significant difference in the incidence of hypotension, nausea and vomiting and duration of motor blockade between the groups. Women who received magnesium showed less shivering and later onset of post operative pain (P < 0.05).ConclusionThe addition of magnesium to epidural bupivacaine and fentanyl in women undergoing elective caesarean section with combined spinal–epidural anaesthesia improved intraoperative conditions and the quality of postoperative analgesia.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

Remifentanil versus placebo for analgesia during external cephalic version: a randomised clinical trial

BackgroundBreech presentation occurs in up to 3% of pregnancies at term and may be an indication for caesarean delivery. External cephalic version can be effective in repositioning the fetus in a cephalic presentation, but may be painful for the mother. Our aim was to assess the efficacy of remifentanil versus placebo for pain relief during external cephalic version.MethodsA randomized, double-blind, controlled trial that included women at 36–41 weeks of gestation with non-cephalic presentations was performed. Women were randomized to receive either a remifentanil infusion at 0.1 μg/kg/min and demand boluses of 0.1 μg/kg, or saline placebo. The primary outcome was the numerical rating pain score (0–10) after external cephalic version.ResultsSixty women were recruited, 29 in the control group and 31 in the remifentanil group. There were significant differences in pain scores at the end of the procedure (control 6.5 ± 2.4 vs. remifentanil 4.7 ± 2.5, P = 0.005) but not 10 min later (P = 0.054). The overall success rate for external cephalic version was 49% with no significant differences between groups (remifentanil group 54.8% vs. control group 41.3%, P = 0.358). In the remifentanil group, there was one case of nausea and vomiting, one of drowsiness and three cases of fetal bradycardia. In the control group, there were three cases of nausea and vomiting, one of dizziness and nine cases of fetal bradycardia.ConclusionIntravenous remifentanil with bolus doses on demand during external cephalic version achieved a reduction in pain and increased maternal satisfaction. There were no additional adverse effects, and no difference in the success rate of external cephalic version or the incidence of fetal bradycardia.     

The effect of antenatal anaesthetic consultation on maternal decision-making,anxiety level and risk perception in obese pregnant women

BackgroundObese parturients are recognised as high risk and an antenatal anaesthetic consultation is recommended. The potential positive and negative effects of this consultation have not been investigated. This prospective observational study aimed to determine if antenatal anaesthetic consultation affects decisional conflict, anxiety scores or risk perception in obese women planning vaginal delivery.MethodsEligible women had a body mass index of ⩾35 kg/m², planning a vaginal delivery, aged ⩾18 years and able to complete a questionnaire presented in English. Before their anaesthetic consultation, women completed a written decisional conflict questionnaire, the Six-Point Short Form of the Speilberger State-Trait Anxiety Inventory and two questions regarding risk perception. All questions were repeated by telephone consultation two weeks later. Independent samples t-tests were used to detect differences between pre and post-test scores.ResultsOf 114 women recruited, 89 completed the protocol and were analysed. Women had a mean ± SD age of 29.4 ± 5.2 years and body mass index of 43.6 ± 5.6 kg/m². Decisional conflict scores were significantly lower after the consultation (30.04 vs. 16.54, P < 0.001). Anxiety scores were lower (9.41 vs. 8.49, P = 0.002) but this was not clinically significant. Only 19.1% of women felt their health was at risk in pregnancy; this did not change after the consultation. Thirteen women changed their preference toward epidural analgesia (P = 0.01).DiscussionOur results support the current practice of referral of obese parturients for anaesthetic consultation, but demonstrate that most women remain unaware of the risks of obesity in pregnancy despite anaesthetic consultation.     

Efficacité et sécurité de l’acide tranexamique en prévention et/ou en traitement de l’hémorragie du post-partum : une revue systématique de la littérature avec méta-analyse

Objective(s)Assess the efficacy and safety of tranexamic acid administration for the prevention and/or the treatment of postpartum haemorrhage.Study designSystematic review with meta-analysis.Material and methodsSystematic review of the literature with the aim of identifying prospective, randomised, controlled trials that assessed the effect of tranexamic acid on peripartum blood loss and transfusion requirement in three clinical contexts: (i) prevention of post-partum haemorrhage in case of elective caesarean section, (ii) prevention of post-partum haemorrhage in case of vaginal delivery, (iii) treatment of post-partum haemorrhage.ResultsProphylactic administration of tranexamic acid reduced blood loss (mean difference for intraoperative blood loss: −177.9 mL, IC 95%: −189.51 to −166.35, total blood loss: −183.94, IC 95%: −198.29 to −169.60), and the incidence of severe post-partum haemorrhage (OR: 0.49, IC 95%: 0.33 to 0.74). None of the published trials assessed the effect of tranexamic acid on blood products administration or transfusion requirement. Only one study assessed and reported the efficacy of tranexamic acid when administered as a treatment for postpartum haemorrhage. A significant reduction in blood loss was reported within 30 minutes after randomisation (P = 0.03) and confirmed after 6 hours (median: 170 mL (58–323) vs 221 mL (110–543), P = 0.04). None of the included studies adequately studied the incidence of side effects after tranexamic acid administration.ConclusionAlthough tranexamic acid administration seemed to significantly reduce blood loss and the incidence of severe post-partum haemorrhage, further prospective trials are needed to confirm the efficacy and safety of tranexamic administration in the treatment of postpartum haemorrhage. Those studies should assess the pharmacokinetic profile and the safety of this drug in pregnant women.     

To estimate the minimum effective dose of oxytocin required to produce adequate uterine tone in women undergoing elective caesarean delivery

To estimate the minimum effective dose of oxytocin required to produce adequate uterine tone in women undergoing elective caesarean delivery under spinal anaesthesia.BackgroundPatients undergoing caesarean delivery are at increased risk of obstetric haemorrhage. Uterine atony has been shown to be most common aetiology (30%) for PPH in patients undergoing caesarean delivery. Use of uterotonic agents decreases the incidence of PPH by approximately 40% when compared with placebo. Oxytocin is the most frequently used uterotonic agent because of less side-effects compared with all other available agents. We did the study to find out the minimal dose of oxytocin required to produce adequate uterine tone (UT) in primigravida women undergoing elective caesarean delivery.MethodsThis randomized double blind study was conducted in ninety full term primigravidas undergoing elective caesarean delivery under spinal anaesthesia. All patients received intravenous bolus of either 0.5, 1, or 2 unit oxytocin followed by infusion of 10 unit/h. UT was assessed by a blinded obstetrician as either adequate or inadequate, and using a five point scale, where 1 = atonic, 2 = partial but inadequate contraction, 3 = adequate contraction, 4 = well contracted and 5 = very well contracted at 2, 3, 6, and 9 min after oxytocin administration. Minimum effective doses of oxytocin were analysed. Oxytocin related side-effects (including hypotension) were recorded.ResultsThere were no significant differences in the prevalence of adequate UT among the study groups at 2 min (86%, 90% and 93% for, 0.5, 1 and 2 unit oxytocin, respectively). The prevalence of nausea and vomiting was significantly higher after 2 unit oxytocin vs 0.5 unit at 1 min (13% vs 3%).ConclusionSmall bolus dosages of oxytocin (0.5–2 unit) result in adequate uterine tone in primigravida women undergoing elective caesarean delivery with minimal effects on haemodynamic parameters and less incidence of nausea and vomiting.