Cytotoxic and ichthyotoxic compounds from marine Opisthobranchia and soft coral

Epidural analgesia in labour using local anaesthetics is very efficient, but the technique has been associated with undesired motor block and an increased use of instrumental deliveries. A new epidural analgesia technique, using a combination of low-dose local anaesthetics and opioids (fentanyl and sufentanil), has recently come into practice. The new epidural technique provides excellent analgesia, minimises motor block, allows the mother to ambulate, and minimises the need for instrumental delivery. Furthermore, it constitutes a good alternative to parenteral pethidine. We are of the opinion that all pregnant women should be given detailed information about both the benefits and the possible side-effects of epidural analgesia in good time before they go into labour. This will allow them to participate more actively in deciding whether or not to use analgesia during labour. Optimal use of epidural analgesia not only depends on the availability of a 24-hour anaesthesia service, but also on adequate knowledge and the cooperation and enthusiasm of all those involved, namely midwives, obstetricians and anaesthesiologists.     

"Gentlemen, this is not a humbug". The 150th anniversary of anesthesia

On 16 October 1996 it was 150 years since William T.G. Morton performed the first successful demonstration of ether anaesthesia in the Massachusetts General Hospital, Boston, USA. Controlling the pain caused by surgery had been a problem for a long time. In fact, many chemical agents with pain relieving properties were recognized before they were used in practice. Morton started systematic studies on the anaesthetic effects of ether and convinced the medical world of the importance of pain free operations through his demonstration of ether inhalation. The news about ether anaesthesia spread around the world very quickly. The first ether anaesthesia administered in Norway took place at Rigshospitalet in Christiania on 4 March 1847. The first death from anaesthesia in Norway occurred in 1852. This article presents some aspects of both the Norwegian and international history of anaesthesia.     

Use of the Vibrio harveyi toxicity test for evaluating mixture interactions of nitrobenzene and dinitrobenzene

Trauma during wartime has been the scourge of the ages. Conventional anesthesia with ether has been available since 1846 when it was demonstrated in Boston by a dentist named William Morton. Subsequently, ether was used during the Mexican-American War in 1847, and chloroform was used during the Crimean War from 1854 to 1856. Nurse anesthetists have made substantial contributions to care of the war-injured by initiating acute airway management and resuscitation efforts and by the administration of anesthesia care for critically injured war casualties undergoing surgical procedures. They have further contributed to goodwill in war-torn areas by providing anesthesia care to many civilian children and adults living in these areas of conflict. The evolution of nurse anesthesia contributions to the treatment of traumatized war casualties is the central focus of this article.     

Obstetric analgesia in Norwegian hospitals]

We report the results of a questionnaire sent to anaesthetists and midwives on the use of obstetric analgesia and anaesthesia in Norwegian hospitals in 1996. 95% of the 49 hospitals involved responded to the questionnaire, representing a total of 56,884 births. The use of epidural analgesia in labour varied from 0 to 25% in the different hospitals with a mean value of 15%. Epidural analgesia was much more widely used in university and regional hospitals than in local hospitals (p < 0.001). Five of the local hospitals did not offer epidural analgesia during labour at all. The combination of low-dose local anaesthetic and an opioid (either sufentanil or fentanyl) had not been introduced in nine of the hospitals (20%). The optimal use of epidural analgesia to relieve labour pain was judged to be more frequent by the anaesthetists than by the midwives (19% versus 11%, p < 0.01). In response to what factors limited the frequency of epidural analgesia, the anaesthetists specified factors related to the attitude of the midwife, and the midwives specified factors related to the anaesthetist. Only five of the hospitals provided written information on the various analgesic methods that could be employed during labour. The majority of midwives considered the analgesic methods employed on their maternity ward to be good or excellent. The frequency of Caesarean section was 12%; spinal anaesthesia was used in 55%, epidural anaesthesia in 17%, and general anaesthesia in 28% of the cases.     

"Ventricularization" of the pulmonary artery pressure curve: a hemodynamic sign of proximal pulmonary embolism

OBJECTIVE: To determine the relative expression of cyclo-oxygenase (COX)-1 and COX-2 in the chorion-decidual part of human fetal membranes following delivery at term and to identify any changes in expression associated with labour. METHODS: Fetal membranes were collected from 12 term pregnancies before labour following elective caesarean section and from 12 spontaneous vaginal deliveries. Expression of COX-1 and COX-2 mRNA was measured using a previously validated quantitative RT-PCR assay. RESULTS: COX-2 expression exceeded that of COX-1 by approximately eight-fold. COX-1 expression did not change but COX-2 expression was found to increase four-fold with labour. CONCLUSIONS: Chorion-decidua has the capacity to contribute to the increase in prostaglandin synthesis within the uterus associated with labour. As in the amnion, it is COX-2 and not COX-1 which is upregulated with labour. COX-2 selective anti-prostaglandins should therefore be as effective as nonselective drugs in inhibition of fetal membrane prostaglandin synthesis.     

Randomised trial of one versus two doses of prostaglandin E2 for induction of labour: 2. Analysis of cost

OBJECTIVE: To compare the impact upon maternity unit resources and finances of two protocols for induction of labour using prostaglandins. DESIGN: A prospective randomised trial comparing a single dose of prostaglandin E2 (2 mg) in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe, followed if necessary by formal induction of labour by amniotomy and oxytocin infusion 14 to 20 hours after the initial prostaglandin E2 dose. Outcome for nulliparae and multiparae were analysed separately, by treatment intention. SETTING: A maternity unit in a district general hospital delivering > 6000 women annually. PARTICIPANTS: Nine hundred and fifty-five women with viable singleton pregnancies and cephalic presentation at term without previous history of caesarean section who were advised to have labour induced with prostaglandins. MAIN OUTCOME MEASURES: Costs incurred in managing all aspects of labour, including time spent on the antenatal ward and, in the delivery unit; costs associated with formal induction, augmentation of labour and epidural analgesia; costs of intrapartum maternal morbidity, mode of delivery and immediate neonatal care. Costs of postpartum hospital stay were estimated from unit statistics. RESULTS: The overall mean cost of induction of labour was Pounds 5.00 and Pounds 7.22 less per woman for nulliparae and multiparae, respectively, if the two dose regimen was used. The main reason for the differences was due to delivery suite costs from the slightly greater rate of assisted deliveries in the single treatment groups. In contrast, costs for neonatal care were marginally lower if only one prostaglandin dose was used. CONCLUSIONS: The increased drug costs providing two prostaglandin E2 doses when required were off-set by reductions in the costs of other intrapartum interventions for both nulliparae and multiparae. The advantages of less time spent on the antenatal ward for multiparae when two prostaglandin E2 doses were used may be eliminated if amniotomy and oxytocin infusion was commenced six hours after the initial prostaglandin dose had been given if labour had not started.     

Mental symptoms in Parkinson''s disease during chronic treatment with levodopa

The influence of epidural block with bupivacaine (Marcaine-adrenalin) on fetal heart rate, uterine activity, and the frequency and intensity of contractions was studied in twenty-five nulliparae at term. Uterine activity was found to decrease during the first 30 minutes following epidural block. In the time interval 30 to 40 minutes after epidural block uterine activity increased again and attained the same level as during the last 10 minutes before analgesia. The frequency of uterine contractions did not decrease after the block. The lower levels of uterine contractility were due only to a lower amplitude of the contractions. The regularizing effect of epidural analgesia on incoordinate uterine action was noted. The recording of fetal heart rate in the time interval studied revealed no pathological findings. Mode of delivery, mean labour duration and Apgar scores after epidural block were comparable with earlier studies of a larger patient population. This study suggest that epidural analgesia does not induce any important changes in fetal heart rate but temporarily decreases uterine activity.     

Intrathecal sufentanil compared with epidural bupivacaine analgesia in labour

Epidural analgesia for pain relief during labour has certain disadvantages including slow onset. However, intrathecal sufentanil provides rapid onset and well-controlled analgesia lasting 1-4 h. The aim of this study was to compare the analgesia and the side effects of intrathecal sufentanil with epidural bupivacaine during labour. In a randomized, double-blind and controlled trial 58 parturient women requesting analgesia during labour were studied. The patients received either intrathecal sufentanil 10 micrograms and epidural saline, or intrathecal saline and epidural bupivacaine 20 mg. Visual analogue scores (VAS) for pain, blood pressure, heart rate, respiratory rate, level of sedation and the incidence of pruritus and nausea were recorded. Pain scores were significantly lower between 5 and 90 min after injection in patients receiving intrathecal sufentanil. Pruritus was significantly more frequent among those receiving intrathecal sufentanil. The rapid onset and effective analgesia of intrathecal sufentanil may in certain situations be advantageous.     

150 years ago physicians and surgeons heeded the call of their country

PURPOSE: To evaluate the efficacy of ropivacaine 0.25% when administered epidurally for relief of labour pain and to compare it with bupivacaine 0.25%. METHODS: In a multicentre investigation, 60 ASA I and II labouring women were randomized in a double-blind fashion to receive either bupivacaine 0.25% or ropivacaine 0.25% administered epidurally by intermittent top-up for labour analgesia. Using a standardized technique, epidural analgesia was initiated after the woman received 10-15 ml-kg.1 crystalloid solution. Maternal blood pressure, heart rate, analgesia sensory level, degree of motor block and visual analogue pain scores were measured by the research nurse prior to, and at regular intervals, following the administration of analgesia. Total dose of local anaesthetic administered, duration of labour, mode of delivery, and maternal and fetal/neonatal side effects were noted. The fetus/neonate was assessed by the research nurse using the fetal heart rate tracing, Apgar scores at delivery and neonatal neurobehavioural assessments at 2 and 24 hr postnatally. Maternal and investigators' satisfaction with the analgesia achieved was assessed after delivery. RESULTS: No differences were found between the two agents in any of the variables studied. CONCLUSION: Ropivacaine 0.25%, when administered epidurally by intermittent top-ups for labour analgesia, was equally efficacious as bupivacaine 0.25%.     

The effect of segmental epidural analgesia on maternal and foetal acid-base balance, lactate, serum potassium and creatine phosphokinase during labour

Maternal and foetal acid-base balance, PaO2, lactate, potassium and creatine phosphokinase (CPK) were studied during the course of 28 induced labours. Every second mother received segmental epidural analgesia during the first stage of labour (epidural group), while the remaining mothers (who were given pethidine for pain relief, if necessary) acted as a control group. In the epidural group the patients had only minimal changes in acid-base balance and lactate concentration during the first stage. During the second stage lactate concentration increased. In the control group, on the other hand, the acid-base balance showed signs of hyperventilation and lactic acid accumulation during the first stage. The potassium changes were quite minimal and were not significantly different between the groups. The CPK level did not change during labour, but 2 and 4 h after delivery it was significantly elevated in both groups. The foetal acid-base balance, potassium, lactate and PaO2 values revealed no differences between the groups at any time. The CPK level in umbilical venous blood was significantly higher in the epidural group.     

Current practices in obstetrical analgesia in German university clinics. Results of a 1996 survey. Part 2

Obviously there is a world-wide trend towards regional analgesia for pain relief during delivery. Data on the current practice in Germany are lacking. METHODS: In 1996 questionnaires on obstetric anaesthesia and analgesia were mailed to all university departments of anaesthesia. RESULTS: All 38 university hospitals with obstetric units replied (100%). Mean annual delivery rate was 1156. Epidural analgesia (EA) (n = 22), intramuscular injection of opioids (n = 18), and non-opioids as a suppository (n = 17) were often used for pain relief during labour. Intravenous injections (n = 12) or pudendus anaesthesia (n = 7) were practised as well. Entonox (N2O/O2), paracervical blocks or transcutaneous electrical stimulation (TENS) was rarely used. EA for relief of labour pain was offered in all university hospitals. Twelve of them had an epidural rate of less than 10%, in nine the rate was 10-19%, in eight hospitals 20-29% and 30% or more in nine. Indication for EA was a demand by the parturient (n = 34), by the obstetrician (n = 26) or the midwife (n = 18), predominantly because of prolonged labour (n = 32) or significant pain (n = 21). Half of the university departments used an epidural combination of local anaesthetics (bupivacaine) and opioids (sufentanil (n = 12) and/or fentanyl (n = 9)). In all but one department the application of an epidural catheter was performed by anaesthesiologists exclusively. In some hospitals obstetricians (n = 10) or midwives (n = 4) were allowed to give epidural top-up injections. Of the 38 university departments 11 had an anaesthesiologists on duty 24 h a day responsible for the obstetric unit exclusively. CONCLUSION: In 1977, 14 of 18 university departments of anaesthesiology offered epidural analgesia for parturients. This option was available in all university departments in 1996. A mean rate of 10-20% epidurals for vaginal delivery is well within the limits reported from other countries, whereas the rate of regional anaesthesia for scheduled caesarean section (40%) still is rather low in Germany, as reported in part 1 of this survey (Anaesthesist 1998;47:59-63).     

Delivery of the overweight woman. Analysis of 115 patients

OBJECTIVE: Our purpose was to assess the effect of weight gain during pregnancy on labor and delivery. Abnormal pregnancies were excluded from the study to avoid interaction with the management of labor. POPULATION AND METHODS: A retrospective monocentric case-control study was carried out. We analysed 115 pregnancies delivered in our institution between June 1994 and November 1994. The course of labor was studied in 2 groups of patients: a group of overweight patients and a control group. RESULTS: In the overweight patients, the frequency of induction of labor (25%) and of obstetrical analgesia (82%) was significantly higher than in the control group (respectively 7% and 64%), as well as the average duration of labour and the average duration of the rupture of the membranes. The rate of cesarean section was higher in the overweight patient group (16.7%) than in the control group (3.7%). The difference was not significant because of the small number of patients. CONCLUSION: These results show a more frequent requirement of induction of labour, analgesia, and cesarean section in overweight patients. This led us to propose a multidisciplinary management of overweight patients to minimize these different obstetrical risks during labor.     

Obstetric analgesia using continuous epidural perfusion of bupivacaine, adrenaline, and fentanyl

OBJECTIVES: To determine the efficacy and complications of continuous epidural perfusion of bupivacaine, adrenaline and fentanyl in the relief of pain during first and second stage labour during vaginal birth. PATIENTS AND METHODS: Between January 1990 and March 1993 we used continuous epidural perfusion for control of pain during labor in 1307 women. The solution administered through an epidural catheter and maintained until expulsion was one 10 ml bolus of bupivacaine 0.25% with adrenaline 1:200,000 and fentanyl 25 micrograms followed by continuous perfusion of bupivacaine 0.0625% with adrenaline 1:200,000 and fentanyl 2 micrograms/ml at an infusion rate of 12 ml/h. When analgesia was insufficient, a bolus of local anesthetic was administered or a pudendal block was carried out. RESULTS: Ninety-two percent of the birthing women reported good analgesic effect during the first stage; for 7% the effect was fair and for 0.55% it was poor. During the second stage 88% reported satisfactory analgesia, and 8% fair or poor. Assessment was not possible for the remaining women, who underwent cesarean sections. Complications were few and easily controllable. CONCLUSIONS: Maintenance of epidural perfusion with 0.0625% bupivacaine with adrenaline 1:200,000 and fentanyl 2 micrograms/ml provides sufficient analgesia during all stages of childbirth.     

Obstetric outcome of teenage pregnancies

A retrospective cohort study was performed in a tertiary centre to determine if teenage nulliparas (aged alpha19 years, study group) had higher incidences of instrumental and Caesarean deliveries compared with nulliparas aged 20-34 years (control group) selected from the first women in the birth registry who delivered after each study case and satisfying the criteria for controls. The hospital records of the study and control cases were retrieved for review. Comparison was made in the maternal demographics, major antenatal complications, outcome of labour, mode of delivery, and perinatal outcome. In the study group, maternal height was similar but the body mass index was lower. Although the mean birthweight was lower and the incidences of preterm labour and small-for-gestational-age infants higher, there were also increased incidences of large-for-gestational-age and macrosomic infants. While there was no difference in the types of labour, there were fewer Caesarean and instrumental deliveries, a finding that persisted even after excluding the preterm deliveries. Lastly, teenage mothers aged <17 years had similar outcomes to those aged 17-19 years. These results indicated that teenage mothers had better obstetric outcomes, despite the higher incidence of preterm labour, and that young adolescents (<17 years) performed as well as their older peers.     

The effects of Entonox and epidural analgesia on arterial oxygen saturation of women in labour

The arterial oxygen saturation of 40 mothers in the first stage of labour was monitored using pulse oximetry. Half the mothers received epidural analgesia and the rest inhaled Entonox for pain relief. Eight mothers in the Entonox group and six in the epidural group had at least one episode of significant hypoxia (saturation < 90%). There was little difference in the number of hypoxic episodes experienced by either group (29 in the Entonox and 21 in the epidural) although their mean duration and severity was greater in the Entonox group. Women in labour who inhale Entonox have an appreciable incidence of arterial desaturation. Epidural analgesia reduces the severity of hypoxic episodes although it does not eliminate them.     

Influence of lumbar peridural anaesthesia on fetal heart rate patterns in the second stage of labour (author's transl)

The influence of lumbar peridural anaesthesia (PA) on fetal heart rate patterns in the second stage of labour was studied in 218 vaginal deliveries without maternal and fetal risk. A CTG-Score as proposed by Hammacher was used to evaluate fetal heart rate patterns. No influence of PA on fetal heart rate in the second stage of labour was found with primiparae, whereas multiparae showed more normal patterns under PA than without PA. All patients were strictly kept in lateral position throughout the first and second stage of labour. The pushing-period in lateral position was limited to 30 minutes (pushing 3-times per 10 minutes).     

Pain and dissociation in the cold pressor test: A study of hypnotic analgesia with "hidden reports" through automatic key pressing and automatic talking.

To test whether pain blocked by hypnotic analgesia may still be perceived at some level, 20 highly hypnotizable undergraduates participated in an experiment involving cold pressor pain in the normal condition and in hypnotically suggested analgesia. 3 reports were obtained reflecting felt pain within the hypnotic analgesia condition: the usual verbal report on a numerical scale, a manual report by "automatic key pressing," and a retrospective verbal report through "automatic talking." 9 Ss who were amnesic for both keypressing and automatic talking reported more pain in the automatic (hidden) reports than in their usual verbal reports. 8 of these 9, following release of amnesia, had a clear perception of 2 levels of awareness of the pain: the usual hypnotic experience of pain attenuated by analgesia suggestions, and a knowledge at another level of a more severe pain. In no case, however, did an S give a retrospective report of normal suffering at this "hidden" level. The hypnotically analgesic S may have reported no pain verbally because he was amnesic for it; when amnesia was removed he recalled the sensory pain, but without a suffering component, because suffering apparently did not occur. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Latex allergy in the operating room: case report and a brief review of the literature

OBJECTIVE: To study whether the use of analgesic treatment in labour is influenced by ethnicity. DESIGN: A cross-sectional study of hospital patients. Setting; the two municipal hospitals, Ullev?l and Aker, in Oslo, Norway. Subjects; a total of 137 obstetrical patients, 67 Pakistani women and 70 Norwegian women. Main outcome measure; use of analgesics in labour. RESULTS: 30% of the Pakistani and 9% of the Norwegian women received no analgesia in labour. Pethidine injection was the preferred analgesic administered to Pakistani women. Women of Pakistani origin received epidural infusion or nitrous oxide and oxygen gas less frequently than Norwegian women. They also received fewer combinations of other analgesic methods. When adjusted for the mothers' age, parity and duration of delivery, Pakistani origin was the only significant predictor for receiving no analgesia in labour. CONCLUSION: Women of Pakistani origin were more than three times as likely not to receive analgesia in labour as Norwegian women. The health services offered to Pakistani women in labour were different from those offered to Norwegian women. These results indicate that women of Pakistani origin may be offered insufficient obstetrical analgesia, or that Norwegian women received unnecessary pain relief in labour.     

Patients' attitudes to induction and labour

An attempt was made to ascertain patients' attitudes towards planned induction and labour. Twenty per cent of patients had not heard of induction before their pregnancy, and those who had had most probably heard about it from relations and friends rather than the media. Most patients had no firm opinions on induction of labour but were usually glad to have their pregnancy ended. Many considered that they had not been given enough information by the medical staff on their induction. The amount of pain experienced by patients at amniotomy was related to the "favourability" of the cervix. Possibly women with a low cervical score should be given more premedication or inhalation analgesia at amniotomy. Most patients found injections of narcotic agents adequate analgesia in labour. Those patients who did not receive adequate analgesia were principally those who had either very short or quite long labours. Patients with long labours may benefit from more liberal use of analgesia, but no satisfactory form of analgesia seems to be available for patients who are likely to deliver within two or three hours of induction.     

The estrous cycle and estrogen modulate stress-induced analgesia.

In this article we investigate the impact of estrous cycle, ovariectomy, and estrogen replacement on both opioid and nonopioid stress-induced analgesia. Stage of estrous strongly influenced analgesia. Diestrus females exhibited the typical male pattern produced by the analgesia inducing procedures used—strong nonopioid analgesia following 10–20 tailshocks, and strong opioid analgesia following 80–200 taskshocks. In these experiments the nonopioid analgesia was slightly attenuated during estrus, but the opioid analgesia was markedly reduced. The role of estrogen in producing these changes was studied with estrogen replacement in ovariectomized subjects. Ovariectomy only slightly altered nonopioid analgesia but eliminated opioid analgesia, which suggests that some estrogen might be necessary to maintain the integrity of the system(s) underlying opioid analgesia. Estrogen administration restored opioid analgesia, but further estrogen suppressed opioid analgesia, duplicating the estrus pattern. It did not suppress nonopioid analgesia. Opioid analgesia was enhanced 102 hr after estrogen replacement, thus duplicating the diestrus pattern. Estrogen thus appears to be responsible for the impact of estrous cycle on opioid but not on nonopioid analgesia. These results suggest that ovarian hormones may modulate the impact of stressors on endogenous pain inhibition and other stress-responsive systems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)