Obstetric emergencies

For more than 60 years the Confidential Enquiries into Maternal Deaths triennial reports have helped build a picture of maternity care within the UK, highlighting not only our successes but failures in caring for women within the puerperal period. Despite most obstetric emergencies being well described and having clear management strategies and guidance, there continues to be substandard management with poor outcomes recorded and this has been highlighted within the latest triennium report. This article describes some common obstetric emergencies with which the anaesthetist will become involved. It emphasizes management related to some deficiencies identified in the Centre for Maternal and Child Enquiries report as well as highlighting a multidisciplinary approach throughout. Good communication between team members is paramount in all aspects of medical care, but this approach should be fostered routinely to ensure that rapid and appropriate decisions are made in a safe and timely manner.     

腮腺肿瘤术中冰冻切片检查的临床分析

目的探讨腮腺肿瘤术中冰冻切片检查的临床效果。方法选取我院2012年1月~2014年3月72例腮腺肿瘤手术治疗患者,手术过程中实施冰冻切片检查,分析其临床效果。结果 快速冰冻检查恶性肿瘤敏感度为87.9%,特异性96.4%。结论 快速冰冻切片在腮腺手术中能够快速准确的诊断良、恶性肿瘤,且可对临床判定腮腺恶性肿瘤恶性程度予以一定参考。     

雷莫司琼预防急诊剖宫产术中恶心呕吐的临床效果

选择急诊剖宫产手术患者206例,随机分成2组:雷莫司琼组(钳夹脐带后静脉给予雷莫司琼0.3 mg,103例),对照组(钳夹脐带后静脉给予等容量生理盐水,103例),分别观察并记录剖宫产娩出胎儿后恶心、呕吐的发生率,术中追加呕吐药的几率,低血压发生率,疼痛评分及其他不良反应发生率.雷莫司琼组患者恶心、呕吐发生率为10.7％(11例),对照组患者发生率为28.2％(29例),差异有统计学意义(P＜0.01),两组术中低血压比较差异无统计学意义(P＞0.05).雷莫司琼能降低急诊剖宫产术中患者恶心呕吐发生率.     

Analgesic effects of intrathecal tramadol in patients undergoing caesarean section: a randomised,double-blind study

BackgroundIntrathecal tramadol combined with local anaesthetics has been used for postoperative analgesia following lower abdominal and perineal surgery. The present study evaluated the effect of intrathecal tramadol on spinal block characteristics and neonatal outcome after elective caesarean section.MethodsEighty full-term parturients scheduled for elective caesarean section were randomly divided into two groups. In the fentanyl group, patients received intrathecal 0.5% bupivacaine 10 mg with fentanyl 10 μg; in the tramadol group, patients were given the same dose of bupivacaine with tramadol 10 mg. Sensory and motor block characteristics, duration of postoperative analgesia, maternal side effects, and neonatal outcome were compared.ResultsOne patient in the tramadol group and two patients in the fentanyl group were excluded from data analysis. Median [interquartile range] duration of postoperative analgesia in the tramadol and the fentanyl groups was 300 [240–360] min and 260 [233–300] min respectively (P = 0.02). The incidence of shivering was lower in patients who received tramadol (5%) than those who had fentanyl (32%) (P = 0.003). Apgar scores, umbilical cord acid–base measurement and neurologic and adaptive capacity scores were comparable between the two groups.ConclusionCompared to intrathecal fentanyl 10 μg, tramadol 10 mg, as an adjunct to bupivacaine for subarachnoid block for caesarean section, showed a longer duration of analgesia with a reduced incidence of shivering.     

How to value patient values: Cesarean sections for the periviable fetus,and home births

Respect for patient autonomy involves providing sufficient information to patients to allow them to make informed decisions, and then honoring their requests unless they are unethical or futile. At times, the factors that patients consider may not be purely biologic ones but rather will include “spiritual” factors (a sense of control in a home birth). When patients balance biologic risks against spiritual gain, physicians may not be comfortable giving deference to patients' choice. In order to explicate this issue we explore two clinical scenarios: home birth, and cesarean section for a periviable fetus; and we consider futility and limits on affirmative autonomy. We argue that bodily integrity must remain inviolate. However, conversations regarding a patient's affirmative rights invoke the moral agency of both patient and provider. Those conversations must include considerations of patient values as well as medical facts. Physicians' values are also part of counseling, but they are appropriately considered only when they are medical values (beneficence, truth telling), not personal beliefs (e.g., children with impairments should have, or not have, a ‘do not resuscitate’ order). Physicians have the right to refuse to participate if they think that the biologic risk overwhelms a potential value-based benefit, but they should be loath to do so if the balance is anywhere close to equipoise, and the patient's values are deeply held.     

Population attributable fractions for three perinatal risk factors for autism spectrum disorders, 2002 and 2008 autism and developmental disabilities monitoring network

PurposeNumerous studies establish associations between adverse perinatal outcomes/complications and autism spectrum disorder (ASD). There has been little assessment of population attributable fractions (PAFs).MethodsWe estimated average ASD PAFs for preterm birth (PTB), small for gestational age (SGA), and Cesarean delivery (CD) in a U.S. population. Average PAF methodology accounts for risk factor co-occurrence. ASD cases were singleton non-Hispanic white, non-Hispanic black, and Hispanic children born in 1994 (n = 703) or 2000 (n = 1339) who resided in 48 U.S. counties included within eight Autism and Developmental Disabilities Monitoring Network sites. Cases were matched on birth year, sex, and maternal county of residence, race-ethnicity, age, and education to 20 controls from U.S. natality files.ResultsFor the 1994 cohort, average PAFs were 4.2%, 0.9%, and 7.9% for PTB, SGA, and CD, respectively. The summary PAF was 13.0% (1.7%–19.5%). For the 2000 cohort, average PAFs were 2.0%, 3.1%, and 6.7% for PTB, SGA, and CD, respectively, with a summary PAF of 11.8% (7.5%–15.9%).ConclusionsThree perinatal risk factors notably contribute to ASD risk in a U.S. population. Because each factor represents multiple etiologic pathways, PAF estimates are best interpreted as the proportion of ASD attributable to having a suboptimal perinatal environment resulting in PTB, SGA, and/or CD.     

中医护理干预促进剖宫产术后肛门排气的效果分析

目的分析中医护理干预促进剖宫产术后肛门排气的效果。方法以2016年12月20日~2017年8月12日作为研究阶段,共纳入研究对象1000例,均为接受剖宫产术患者,采用随机数字表法分为对照组(n=500)和治疗组(n=500),对照组采用常规护理模式,治疗组采用中医护理干预,比较两组护理效果。结果治疗组腹胀发生2例(0.40%),对照组腹胀25例(5.00%),差异有统计学意义(P0.05)。两组首次肛门排气时间、首次排便时间、肠鸣音恢复时间比较差异具有统计学意义(P0.05)。两组护理前SAS、SDS评分差异不显著(P0.05),经过护理后,对照组SAS(48.61±3.78)分、SDS(46.55±3.05)分与治疗组SAS(34.64±4.31)分、SDS(30.56±2.48)分比较差异有统计学意义(P0.05)。治疗组护理满意率99.20%高于对照组84.40%,差异有统计学意义(P0.05)。结论针对接受剖宫产术的产妇采用中医护理干预可有效降低腹胀的发生,实现术后肛门排气时间的提前,有效改善产妇焦虑、抑郁情绪状态,提高护理满意度,值得临床推广与应用。     

A “good practice” approach to the quality and consistency of morphological examination of the internal head structures of the term rabbit fetus

Variation in the interpretation of the regulatory guidelines has resulted in a diversity of techniques employed to examine the internal structures of the foetal rabbit head.Examination of the foetal rabbit brain, using a single transverse section as the sole technique, is considered not to be sufficiently thorough to be regarded as an adequate examination method. It is not compliant with published EPA and OECD guidelines covering required examination of the internal head structures, nor is it considered to conform to the spirit of the safety assessment required by the ICH guideline.Fixation of approximately half of the heads in each litter to allow the examination of multiple transverse sections enables the major structures within the head to be assessed effectively. This method is compliant with current guidelines, represents “good practice” and should be consistently adopted for the examination of the internal head structures of the term rabbit foetus.