A comparison of epidural tramadol and epidural morphine for postoperative analgesia

The present study compared epidural tramadol with epidural morphine for postoperative analgesia in 20 patients undergoing major abdominal surgery. Intraoperatively, the patients were anaesthetized by a balanced technique of general anaesthesia combined with lumbar epidural lidocaine. In ten of the patients 100 mg tramadol diluted in 10 ml normal saline was also injected epidurally, while 4 mg epidural morphine was used in the other ten patients. In all patients, the visual analogue pain score, PaO₂, PaCO₂ and respiratory rate were monitored every hour for the first 24 hr postoperatively. In both the tramadol and morphine groups, the mean hourly pain scores ranged from 0.2 ± 0.6 to 1.4 ± 2.5 throughout the period of observations. However, the mean PaO₂ was decreased postoperatively in the epidural morphine group, while no change was observed in the epidural tramadol group. The maximal decrease of PaO₂ in the epidural morphine group was observed at the tenth hour postoperatively, when it decreased to 72.8 ± 10.3 mm Hg. This was not associated with any increase in PaCO₂ or a decrease of respiratory rate, suggesting that hypoxaemia rather than hypercarbia or decreased respiratory rate may be an earlier indicator of respiratory depression in patients breathing room air without oxygen supplementation. The absence of clinically relevant respiratory depression following epidural tramadol compared with epidural morphine may be attributed to the different mechanisms of their analgesic action. The results suggest that epidural tramadol can be used to provide prolonged postoperative analgesia without serious side effects.     

Urinary bladder perforation: an unusual complication of neonatal nasogastric tube feeding

Nasogastric tube (NGT) feeding is an accepted method of feeding premature infants. This case report records an unusual and previously unreported complication of NGT feeding in a neonate. Received: 15 January 1997 Accepted: 4 April 1997     

Care of the pregnancy complicated by HELLP syndrome

Pregnancies complicated by HELLP syndrome require a well-formulated management plan. The development of this syndrome after 34 weeks' gestation or with documentation of fetal lung maturity is an indication for delivery. Vaginal delivery can be accomplished in most cases; however, if cesarean section is required, the use of general anesthesia, subfascial drains, and preoperative platelet transfusion for platelet counts less than 50,000/mm3 can reduce the incidence of complications. It is advisable that patients with complications of HELLP syndrome such as pulmonary edema, acute renal failure, liver rupture, or extreme prematurity be referred to a tertiary care center where maternal and neonatal intensive care facilities are available.     

Monitored outpatient management of mild gestational hypertension remote from term in teenage pregnancies

OBJECTIVE: Our purpose was to compare maternal and perinatal outcomes of teenage and adult pregnancies with mild gestational hypertension remote from term managed with an outpatient program.STUDY DESIGN: A matched cohort design was used. Maternal and perinatal outcomes of 60 teenage pregnancies with mild gestational hypertension remote from term were compared with 120 adult controls 20 to 42 years old. The groups were matched for race, gestational age, and proteinuria status at enrollment. All were monitored on an outpatient basis with four times daily outomated blood pressure measurement and daily assessment of weight, proteinuria, and fetal movement.RESULTS: The mean gestational age at enrollment was 33.5 ± 2.6 weeks for both groups (range 27 to 36 weeks). Only 60% of teenagers had a high school degree or equivalent compared with 76% of adults (p = 0.024). The teenagers were more likely than the adults to be of single marital status (75% vs 13%, p = 0.015). The mean gestational age at delivery (37.0 ± 2.0 vs 37.0 ± 2.2 weeks), mean pregnancy prolongation (23.5 ± 19.0 vs 24.5 ± 17.4 days), and mean birth weights (2915 ± 669 vs 2879 ± 678 gm) were not statistically different between the teenagers and adults (all p> 0.05). There were no stillbirths, neonatal deaths, or cases of eclampsia in either group.CONCLUSIONS: In spite of a study population characterized by limited education, single marital status, and young age at enrollement, monitored outpatient management of mild gestational hypertension remote from term in teenage pregnancies is associated with maternal and perinatal outcomes similar to those observed in adults.     

Ependymal brain cyst

Ependymal cerebral cysts are rare and almost unknown in infants. We report the case of such a cyst in the right cerebral hemisphere of a four-month-old infant. The tumor was totally removed and the child made a good recovery.     

Plasma volume, umbilical artery Doppler flow, and antepartum fetal heart testing in high-risk pregnancies

The purpose of this clinical study is to investigate the diagnostic value of plasma volume (PV), nonstress test (NST), contraction stress test (CST), and umbilical artery Doppler (UAD) in detecting fetal compromise in 81 patients (83 fetuses) at risk for fetal growth retardation. Neither PV nor UAD studies were used in the clinical management. There were two stillbirths and three neonatal deaths for a perinatal mortality of 6%. Twenty-seven infants (32.5%) were small for gestational age (SGA), seven (8.6%) had cord pH 7.20 or less, and five (6.2%) had 5-minute Apgar scores less than 7. Overall, PV had the highest sensitivity and NST the highest specificity regarding delivery of SGA infants. The positive and negative predictive values for infants with low cord pH and low Apgar scores were similar among the various tests. There were nine fetuses with zero or reverse diastolic flow: seven were SGA (four perinatal deaths) and all of them had both nonreactive NST and positive CST. The other two infants were appropriate for gestational age with all other tests being normal. Antepartum fetal heart rate testing appears to be similar to other tests in predicting poor fetal outcome in high-risk pregnancies.     

Eclampsia

The incidence of eclampsia has decreased over the past two decades. Proper prenatal care with early identification and hospitalization of patients with mild pre-eclampsia is responsible for this reduction. Modifications of current obstetrics teachings designed to heighten awareness of the risk of both midtrimester and late-postpartum eclampsia could further reduce its occurrence. However, there will always be a small number of women in whom eclampsia is not preventable. Eclamptic patients should be counseled regarding the increased risk of pre-eclampsia or eclampsia in their sisters and daughters as well as their increased risk for both recurrence of the disease and perinatal death in subsequent pregnancies.     

An aspirin a day to prevent prematurity.

Intrauterine fetal growth retardation and preeclampsia remain a substantial cause of preterm birth world wide. There is evidence to suggest that a functional imbalance between vascular prostacyclin and platelet-derived thromboxane A2 production plays a central role in the pathogenesis of these disorders. Low-dose aspirin appears to reverse the above functional balance resulting in increased prostacyclin to thromboxane ratio. The efficacy and safety of low-dose aspirin in preventing preeclampsia and fetal growth retardation were tested in several randomized and uncontrolled trials. The data in the literature suggest that low-dose aspirin is effective in reducing preterm birth due to the above complications in selected high-risk pregnant women.     

How small is too small and how early is too early? A survey of American obstetricians specializing in high-risk pregnancies.

Four hundred and five Maternal-Fetal Medicine specialists were surveyed to determine their clinical opinions regarding intrapartum management of the severely preterm fetus requiring delivery. Intrapartum fetal heart rate monitoring was initiated at 23, 24, and 25 weeks' gestation by 10%, 43%, and 66% of respondents, respectively. Cesarean section was not performed at less than 24 weeks' gestation or less than 500 gm fetal weight. Ninety percent of respondents were willing to perform cesarean section for fetal distress or breech presentation at 26 weeks' gestation or 750 gm fetal weight. Delivery management prior to 26 weeks' gestation or for fetuses smaller than 750 gm was variable and appeared to be individualized. Due to inherent uncertainty regarding appropriate management and observed variability of response, we conclude that studies be performed to assess objectively safety and efficacy of cesarean section for fetal indications at less than 26 weeks' gestation or less than 750 gm estimated fetal weight.