Maternal Hemodynamics Research Articles

Maternal cardiac function in women at high risk for pre-eclampsia treated with 150mg aspirin or placebo: an observational study.

To compare maternal haemodynamics in women at low and high risk for preterm pre-eclampsia (PE), and between those at high risk who are randomised to aspirin or placebo. Prospective, longitudinal observational study. Maternity units in six UK hospitals. Women participating in the Aspirin for Prevention of Preterm Pre-eclampsia (ASPRE) trial. The population comprised three groups of women: low risk for preterm PE (n=1362), high risk for preterm PE treated with aspirin (n=208) and high risk for preterm PE on placebo (n=220). Women had four visits during pregnancy: 11-14, 19-24, 30-34, and 35-37weeks' gestation. Blood pressure was measured with a device validated for pregnancy, and PE and maternal haemodynamics were assessed with a bioreactance monitor at each visit. A multilevel linear mixed-effects analysis was performed to examine longitudinal changes of maternal haemodynamic variables, controlling for demographic characteristics, past medical history and medication use. Longitudinal changes of cardiac output (CO), mean arterial pressure (MAP), and peripheral vascular resistance (PVR). The low-risk group demonstrated the expected changes with an increase in CO and reduction in MAP and PVR, with a quadratic change across gestation. In contrast, the high-risk groups had a declining CO, and higher MAP and PVR during pregnancy. The administration of aspirin did not appear to affect maternal haemodynamics. Women screened as high risk for preterm PE have a pathological cardiac adaptation to pregnancy and the prophylactic use of aspirin (150mg oral daily from the first trimester) in this group may not alter this haemodynamic profile. In women at high risk of pre-eclampsia, prophylactic use of aspirin may not alter the impaired maternal cardiac adaptation.

Comparison between the Effects of Thiopental Sodium and Propofol on Maternal Hemodynamics during Cesarean Section Under General Anesthesia and Apgar score of the newborns

Abstract Background Cesarean delivery is one of the most current surgeries in women and one of the most significant challenges of anesthesiologists in this kind of surgery is the fetuses' exposure to anesthetic drugs. Regional anesthesia is generally preferred during cesarean section, but general anesthesia may be the only option under certain circumstances such as patient preference, back deformities. The most common drugs which are used in cesarean section to induce general anesthesia are thiopental sodium and propofol. Aim compare the effect of sodium thiopental induction versus propofol induction on hemodynamics of mothers undergoing elective cesarean section under general anesthesia and their effect on Apgar score of their newborns. Materials and Methods A total 260 healthy patients were included in an open randomized study, among whom 130 patients received Thiopentone and 130 received Propofol. These patients were premedicated with granisetron and ranitidine, after induction dose the maintenance was similar for both groups. APGAR scoring and umbilical cord venous gas analysis were among the parameters used for determining the general well-being of newborns. There were no significant difference between the two groups regarding Apgar scoring in 1st, 2nd and 5th minutes. Umbilical cord blood gas values were similar . There was no metabolic acidosis in newborns of mothers receiving thiopental or propofol as anesthetic agents during cesarean section. Results Group (T) received general anesthesia with thiopental at a dose of ( 4-6 mg/kg) while patients in group (P) received general anesthesia with propofol at a dose of (2mg/kg). As regards hemodynamic changes, there were no significant difference in maternal heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure during their measurement throughout the procedure-preoperatively, after delivery of the baby,15 minutes after delivery, after extubation and in recovery room- but after intubation, there were significantly lower in propofol group which suppressed hemodynamic response to intubation . Conclusion Thiopental and propofol can be safely used in cesarean sections, but the use of propofol is more advantageous than thiopental because it provides adequate anesthetic suppression of pressor response of intubation without any depressive effect on newborns.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Acute cardiovascular changes in women undergoing in vitro fertilisation (IVF), a systematic review and meta-analysis

ObjectivesOvarian stimulation during fertility treatment leads to profound maternal physiological changes. Women undergoing in vitro fertilisation (IVF) may be at an increased risk of future cardiovascular morbidity, though little is known about the effects on maternal cardiovascular function. We aim to systematically review whether IVF treatment is associated with changes in maternal haemodynamic parameters, and the effects of different protocols. Study DesignA systematic review and meta-analysis of English language studies identified on Medline and EMBASE database, between 1978, to 2019. Search terms: IVF, maternal haemodynamics, and cardiovascular. Studies reporting on ovulation induction, intrauterine insemination, and oocyte donation were excluded. Methodological quality was assessed by using the adapted Critical Appraisal Skills Programme (CASP) checklist. A meta-analysis was conducted for blood pressure and heart rate on patients undergoing the long GnRH agonist protocol according to Cochrane guidelines. We considered four time points in the IVF cycle, in chronological order: pre-treatment, pituitary down regulation, peak oestradiol and the luteal phase. ResultsNine suitable studies were identified; four fulfilled the criteria for meta-analysis. Two studies measuring heart rate found a significant increase in heart rate from pituitary down-regulation to peak estradiol levels, which was supported by the meta-analysis (3.78 ± 2.18 (p= < 0.0001)). Three studies reported a significant decrease in blood pressure from baseline, with those suitable for meta-analysis showing a significant decrease in mean arterial pressure (-2.08 ± 1.79 (p= < 0.0001)). Cardiac functional changes were reported for all studies and the changes depended on the type of protocol used. ConclusionsIn Vitro Fertilisation leads to acute changes in maternal haemodynamics at different time points of the stimulation protocol. We found an increase in heart rate from pituitary down-regulation to peak estradiol levels and a significant decrease in blood pressure from baseline or pituitary down-regulation to the luteal phase. Cardiac functional changes were reported for all studies on the agonist protocol, but no significant changes were found using the antagonist protocol. It remains unclear as to whether these acute changes were associated with pregnancy complications or chronic cardiovascular sequelae.

Effect of sildenafil on maternal hemodynamics in pregnancies complicated by severe early-onset fetal growth restriction: planned subgroup analysis from a multicenter randomized placebo-controlled double-blind trial.

Fetal growth restriction (FGR) is associated with maternal cardiovascular changes. Sildenafil, a phosphodiesterase type-5 inhibitor, potentiates the actions of nitric oxide, and it has been suggested that it alters maternal hemodynamics, potentially improving placental perfusion. Recently, the Dutch STRIDER trial was stopped prematurely owing to excess neonatal mortality secondary to pulmonary hypertension. The main aim of this study was to investigate the effect of sildenafil on maternal hemodynamics in pregnancies with severe early-onset FGR. This was a cardiovascular substudy within a UK multicenter, placebo-controlled trial, in which 135 women with a singleton pregnancy and severe early-onset FGR (defined as a combination of estimated fetal weight or abdominal circumference below the 10th centile and absent/reversed end-diastolic flow in the umbilical artery on Doppler velocimetry, diagnosed between 22 + 0 and 29 + 6 weeks' gestation) were assigned randomly to receive either 25 mg sildenafil three times daily or placebo until 32 + 0 weeks' gestation or delivery. Maternal blood pressure (BP), heart rate (HR), augmentation index, pulse wave velocity (PWV), cardiac output, stroke volume (SV) and total peripheral resistance were recorded before randomization, 1-2 h and 48-72 h post-randomization, and 24-48 h postnatally. For continuous data, analysis was performed using repeated measures ANOVA methods including terms for timepoint, treatment allocation and their interaction. Included were 134 women assigned randomly to sildenafil (n = 69) or placebo (n = 65) who had maternal BP and HR recorded at baseline. At 1-2 h post-randomization, compared with baseline values, sildenafil increased maternal HR by 4bpm more than did placebo (mean difference, 5.00 bpm (95% CI, 1.00-12.00 bpm) vs 1.25 bpm (95% CI, -5.38 to 7.88 bpm); P = 0.004) and reduced systolic BP by 1 mmHg more (mean difference, -4.13 mmHg (95% CI, -9.94 to 1.44 mmHg) vs -2.75 mmHg (95% CI, -7.50 to 5.25 mmHg); P = 0.048). Even after adjusting for maternal mean arterial pressure, sildenafil reduced aortic PWV by 0.60 m/s more than did placebo (mean difference, -0.90 m/s (95% CI, -1.31 to -0.51 m/s) vs -0.26 m/s (95% CI, -0.75 to 0.59 m/s); P = 0.001). Sildenafil was associated with a non-significantly greater decrease in SV index after 1-2 h post-randomization than was placebo (mean difference, -5.50 mL/m2 (95% CI, -11.00 to -0.50 mL/m2 ) vs 0.00 mL/m2 (95% CI, -5.00 to 4.00 mL/m2 ); P = 0.056). Sildenafil in a dose of 25 mg three times daily increases HR, reduces BP and reduces arterial stiffness in pregnancies complicated by severe early-onset FGR. These changes are short term, modest and consistent with the anticipated vasodilatory effect. They have no short- or long-term clinical impact on the mother. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fetal cardiovascular response to acute hypoxia during maternal anesthesia.

Preclinical imaging studies of fetal hemodynamics require anesthesia to immobilize the animal. This may induce cardiovascular depression and confound measures under investigation. We compared the impact of four anesthetic regimes upon maternal and fetal blood gas and hemodynamics during baseline periods of normoxia, and in response to an acute hypoxic challenge in pregnant sheep. Merino ewes were surgically prepared with maternal and fetal vascular catheters and a fetal femoral artery flow probe at 105–109 days gestation. At 110–120 days gestation, ewes were anesthetized with either isoflurane (1.6%), isoflurane (0.8%) plus ketamine (3.6 mg·kg−1·h−1), ketamine (12.6 mg·kg−1·h−1) plus midazolam (0.78 mg·kg−1·h−1), propofol (30 mg·kg−1·h−1), or remained conscious. Following 60 min of baseline recording, nitrogen was administered directly into the maternal trachea to displace oxygen and induce maternal and thus fetal hypoxemia. During normoxia, maternal PaO2 was ~30 mmHg lower in anesthetized ewes compared to conscious controls, regardless of the type of anesthesia (p < .001). There was no effect of anesthesia on fetal mean arterial blood pressure (MAP; p > .05), but heart rate was 32 ± 8 bpm lower in fetuses from ewes administered isoflurane (p = .044). During maternal hypoxia, fetal MAP increased, and peripheral blood flow decreased in all fetuses except those administered propofol (p < .05). Unexpectedly, hypoxemia also induced fetal tachycardia regardless of the anesthetic regime (p < .05). These results indicate that despite maternal anesthesia, the fetus can mount a cardiovascular response to acute hypoxia by increasing blood pressure and reducing peripheral blood flow, although the heart rate response may differ from when no anesthesia is present.

Alterations of Non Invasive Maternal Hemodynamics in Weeks 10 To 14 of Gestation Associated with Preeclampsia and Adverse Perinatal Results

Alterations of Non Invasive Maternal Hemodynamics in Weeks 10 To 14 of Gestation Associated with Preeclampsia and Adverse Perinatal Results

Placental function and fetal weight are associated with maternal hemodynamic indices in uncomplicated pregnancies at 35–37 weeks of gestation

Over the years, there has been an increasing interest in the assessment of maternal hemodynamic responses during pregnancy. With the use of both noninvasive devices and/or maternal echocardiography, it has been shown that mothers who have pregnancy complications have altered hemodynamics compared with those who have uncomplicated pregnancies. It also has been suggested that preexisting maternal cardiac changes might drive the development of complications in pregnancy that are associated with impaired placentation. To understand, however, this potential link in complicated pregnancies, it is important to clarify whether placental function is associated with maternal cardiac functional indices in normal pregnancies. To determine whether placental function, perfusion, and fetal weight are associated with maternal cardiac hemodynamic responses at 35-36 weeks of gestation in normal pregnancies. Prospective screening of women attending Kings' College Hospital for routine hospital visit at 35-37 weeks' gestation. We recorded maternal characteristics and measured mean arterial pressure, uterine artery pulsatility index, sonographic estimated fetal weight, and serum placental growth factor and soluble fms-like tyrosine kinase 1. We also performed maternal echocardiogram to assess cardiac output and peripheral vascular resistance as well as indices of diastolic and systolic function, including global longitudinal systolic function and left ventricular mass indexed to body surface area. We studied 1386 women. Maternal characteristics were associated with both maternal hemodynamics and functional and structural indices. Uterine artery pulsatility index was associated with left ventricular mass (P=.03) and global longitudinal systolic function (P=.017). There were significant nonlinear associations between placental growth factor and cardiac output and peripheral vascular resistance (P<.001 for both) and between soluble fms-like tyrosine kinase 1 and peripheral vascular resistance (P=.018). Estimated fetal weight was associated with maternal cardiac output (mean increase=0.186, 95% confidence interval, 0.133-0.238, P<.001) and peripheral vascular resistance (mean decrease=-0.164, 95% confidence interval, -0.217 to -0.111, P<.001). No association was noted between placental and fetal parameters and maternal cardiac functional and structural indices. In multivariable analysis, placental growth factor remained strongly associated with maternal cardiac output and peripheral vascular resistance (P=.002 for both) over and above maternal characteristics and estimated fetal weight. Estimated fetal weight was associated with left ventricular mass (0.102, 95% confidence interval, 0.044-0.162, P=.001). The results of this study suggest a strong link between maternal hemodynamic responses and fetoplacental needs across the whole spectrum in normal pregnancies. These findings would also indicate that to diagnose maternal cardiac dysfunction in pregnancies complicated by impaired placentation a more extensive echocardiographic assessment might be needed rather than relying on hemodynamics which are strongly associated with fetoplacental indices.

Clinical comparison of prophylactic phenylephrine infusion vs. bolus regimens on maternal hemodynamics and neonatal outcomes during cesarean section

Background and Objective: Phenylephrine bolus or infusion is used to maintain arterial blood pressure during the subarachnoid block (SAB) for cesarean section. The objective was to assess the clinical efficacy of prophylactic phenylephrine infusion or bolus doses for maternal hemodynamics maintenance and its effect on fetal outcomes. Materials and Methods: Sixty parturients were randomized to receive either a continuous prophylactic IV infusion of phenylephrine (n = 30, group A) at a dose of 0.50 μg.kg−1.min−1 or phenylephrine (n = 30, Group B) 50 μg bolus dose after the systolic blood pressure (SBP) fell by 20% from the baseline. The changes in hemodynamics, ill effects, neonatal APGAR scores, and fetal acidosis were recorded at different time intervals. Results: SBP was significantly higher over time in group A. Group A showed a significant fall in heart rate from baseline after giving SAB and remained significantly low throughout the intraoperative period (P 20% from the baseline; however, hypotension was observed in 21 patients in group B (P 20% of baseline value, were noted in 3 out of 30 patients in the Group A. There was also a statistically nonsignificant trend toward a less frequent incidence of nausea and vomiting in the group A (P

Caval Aortic Index: A Novel Tool for Fluid Assessment in Obstetric Emergencies.

Background:Uncorrected maternal hypotension occurring during obstetric emergencies may result in maternal and fetal morbidity. Fluid status of the pregnant mother is a major variable which affects the maternal hemodynamics during patient management, and there is no objective assessment tool for the same. A relatively new sonographic parameter, the inferior vena cava aorta (IVC/Ao) diameter index or caval aortic index, showed promise in this regard, and its application was studied in obstetric patients.Methodology:A prospective analytical study was conducted involving 50 pregnant and 50 nonpregnant women of reproductive age group. Using both subxiphoid and transhepatic views, their normal fasting caval aortic indices were determined from the ratio of mean IVC diameter to the mean aortic diameter. Descriptive and inferential statistical analyses were carried out accordingly.Results:Normal IVC/Ao diameter index for nonpregnant healthy women of reproductive age was 1.11 ± 0.29 in the subxiphoid view and 1.21 ± 0.33 in the transhepatic view. The difference between the two views was not statistically significant. IVC/Ao diameter index for a normal term pregnant woman was 1.03 ± 0.26, and term pregnancy does not significantly cause variation in the index.Conclusions:Caval aortic index is a useful noninvasive tool to assess volume status and guide fluid management in pregnant women presenting to the emergency department, and the transhepatic view is comparable to the traditional subxiphoid view for the measurement of the same.

271: Continuous maternal hemodynamics monitoring at delivery using a novel, noninvasive, wireless, PPG-based sensor

Existing means of hemodynamic monitoring are invasive, expensive, complex to use and associated with complications. In this study, we utilized an innovative, noninvasive, reflective photoplethysmography based device (Biobeat Technologies Ltd.) that enables maternal hemodynamics continuous monitoring to assess cardiovascular changes during labor and delivery. The Biobeat Monitoring Platform includes a wearable watch, placed on parturient wrist, that automatically samples cardiac output (CO), cardiac index (CI), blood pressure (BP), stroke volume (SV), systemic vascular resistance (SVR), heart rate (HR) and more every 5 seconds and uploads all data to a smartphone-based app and to the cloud, where it can be monitored and analyzed remotely. Eight unselected term parturients (age 29.2±8, years; 4 nullipara; BMI 28.4±5.9 Kg/m2) were recruited after initial calibration to maternal weight and height. Overall, over 150,000 measurements were retrieved. Data was normalized to visual presentation using Excel Data Analysis and regression tool. Average measurements were compared 30 minutes before rupture of membranes (first stage of labor), 30 minutes before delivery (second stage of labor) and 30 minutes after delivery. Cardiac output increases with labor reaching a peak of 8 L/min with delivery, after which, it rapidly declines (5.4 vs. 6.1 vs. 5.8, L/min, p< 0.001). This is mainly due to marked changes in HR up to 110 bpm (78 vs. 90 vs. 86, bpm, p< 0.0001) and a slight change in SV (69.3 vs. 67.6 vs. 68.5, ml/beat, p=0.006)(Figure 1). Mean BP remains relatively stable throughout delivery with a slight increase at delivery, reflecting the increase in CO and decrease in SVR with delivery (Figure 2). This study serves as a proof of concept for application of noninvasive maternal hemodynamic monitoring throughout labor and delivery for research and clinical use. Further studies will implement technology to assess maternal hemodynamics and cardiovascular adaptation during labor and delivery in women with cardiovascular risk factors and pregnancy complications. View Large Image Figure ViewerDownload Hi-res image Download (PPT)

762: Epidural effect on maternal hemodynamics using a novel, wireless, PPG-based sensor for continuous non-invasive monitoring

762: Epidural effect on maternal hemodynamics using a novel, wireless, PPG-based sensor for continuous non-invasive monitoring

1105: Safety and feasibility of humidified-warmed PACI (partial-amniotic-carbon-dioxide-insufflation) for fetoscopic spina bifida repair

Fetoscopic spina bifida (SB) repair under humidified-warmed Partial-Amniotic-Carbon-dioxide-Insufflation (hw-PACI) is being clinically implemented without preclinical validation, yet with promising preliminary results. We experimentally assessed the safety and feasibility of hw-PACI for fetoscopic anatomical SB repair. We used a standardized skin-defect fetal lamb model (100days). We first performed a 7-8cm-hysterotomy, inserted 2 microcatheters in the fetal carotid artery and under the skin nearby a 4x2cm lumbar skin marking and closed the uterus. Animals were assigned to either veterinary or clinical general anesthesia (GA). Through an exteriorized uterus, we performed a simulated 3-port fetoscopic anatomical watertight-layered repair of the defect under hw-PACI. Primary outcomes were persistent normal pH (pH≥7.23) (safety) and postoperative watertightness of the skin closure in ≥70% of cases (feasibility). Secondary outcomes were fetal and maternal acid-base status, hemodynamics, fetal survival, operation times. Twelve fetuses (one per ewe) were operated by 2 surgeons (pneumo-amnion 5±1mmHg) and survived, 7 in the veterinary and 5 in the clinical GA groups. Compared to baseline, hw-PACI under veterinary GA induced acidosis from 60min onwards (lower pH, 7.00) and hypercapnia from 30min (higher pCO2, 112mmHg); both resolved 30min after stopping PACI at the end of the procedure (Fig.1). In contrast, acidosis and hypercapnia were transient (< 60min) under clinical GA, occurring only at 60min (lower pH, 7.18) and at 60 and 180min (higher pCO2, 90mmHg) respectively (Fig.2). Fetal pO2, base excess, lactate and heart rate as well as maternal hemodynamics and acid-base status remained normal (Fig.1&2). In both grousps respectively, 5/7 (71%) and 4/5 (80%) closures were watertight. Operation times were long and comparable (insufflation: 202±37min vs. 196±25min; fetal repair: 141±34min vs. 145±33min). Following an adequate clinical anesthetic protocol, hw-PACI for fetoscopic SB repair is safe and allows for watertight layered SB closures.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Central hemodynamics are associated with fetal outcomes in pregnancies of advanced maternal age.

Age is a known risk factor for both maternal cardiovascular disease and adverse outcomes in pregnancy. We aimed to characterize the hemodynamic profiles in pregnancies of advanced maternal age (AMA) and correlate these with fetal outcomes. This was a prospective observational study of pregnancies undergoing antenatal testing. Maternal hemodynamics were measured non-invasively using an imaging probe at the descending aorta and the Uscom BP+arm cuff utilizing pulse pressure wave analysis. The Wilcoxon rank-sum test, Fisher's exact test, and Spearman rank correlation test were used for statistical analysis in R. Hemodynamic measurements, neonatal birthweight. Twenty-one AMA and twenty-four control patients were enrolled. Mean age±SD was 39±3.22 in the AMA cohort and 28±4.32 in the control cohort (p<0.001). AMA patients were evaluated at a later gestational age (36 4/7 weeks) compared to control (34 1/7 weeks, p=0.02). Between groups, there was no difference in BMI, race, hypertensive disease, diabetes, asthma, drug use, or indication for antenatal testing. 38% (AMA) and 37% (control) had hypertensive disorders of pregnancy. In AMA patients but not control patients, cardiac output (r=0.52, p=0.01), systemic vascular resistance (r=-0.53, p=0.01), and systemic vascular resistance index (r=-0.62, p=0.002) were significantly correlated with neonatal birthweight percentile. Hemodynamic alterations consistent with a low output, high resistance cardiovascular circuit were associated with lower birthweight in AMA, but not in control pregnancies.

The Effect of Epidural Neostigmine Combined with Levobupivacaine on Neuraxial Analgesia during Labor

Abstract Background: Neuraxial analgesia is the gold standard for conducting painless labor either by epidural route or combined spinal epidural. Aim of Study: This study is to evaluate the effect of adding neostigmine to levobupivacaine for epidural labor analgesia on mother and neonate. Patient and Methods: After approval from local ethical committee and obtaining written informed consent this pro-spective randomized double-blind study was conducted on 60 laboring mothers, aged between 21 to 38 years, ASA I & II, single pregnancy, gestational age >!37 weeks in active cervical dilatation (!95cm) subjected to normal labor by epidural analgesia. Parturient were randomly divided into two groups: Group L (n=30): Received 15ml of 0.125% levobupivacaine. Group N (n=30): Received 15ml of 0.125% levobupivacaine + 6mic/kg neostigmine. Onset of sensory block, duration of analgesia, maternal hemodynamics, motor block and total dose of levobupivacaine were recorded. Maternal outcome in the form of (duration of labor, mode of delivery), Apgar score at (1 and 5min) and side effects were also recorded. Results: There was faster onset of sensory block and prolonged duration of analgesia with neostigmine group compared with other group. No significant difference between both groups as regard hemodynamics. No motor blockade in both groups. There was significant reduction in the total dose of levobupivacaine with neostigmine group. There was shorter duration of labor with neostigmine group. No significant difference as regard mode of delivery, Apgar score and com-plications between the two groups. Conclusion: Neostigmine can be utilized as a safe adjuvant with levobupivacaine to provide a better quality of analgesia and reduce dose of local anesthetic during management of labor pain. Also it's safe for both mother and fetus.

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

BackgroundBreakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain. MethodsTerm parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 μg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6–10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 μg or fentanyl 100 μg. The primary outcome was ‘success’ of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment. ResultsThere was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine. ConclusionEpidural clonidine 100 μg was not superior to fentanyl 100 μg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

Maternal and Neonatal Effect of Fentanyl as a Premedication before Induction of General Anesthesia in Cesarean Surgery: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background:Although, some clinical trials investigated the maternal and neonatal effect of fentanyl as a premedication before induction of general anesthesia in cesarean section, to the best of our knowledge, there is no systematic review to summarize these results.Objectives:The present systematic review and meta-analysis evaluated the maternal and neonatal effect of intravenous fentanyl as a premedication before induction of general anesthesia in cesarean section.Methods:The databases of Pubmed, Embase, Scopus and Cochrane library were searched till July 2017 to identify randomized clinical trials which evaluated the effects of intravenous fentanyl as a premedication before induction of general anesthesia compared with placebo on neonate first and fifth minute Apgar score and maternal heart rate and mean arterial pressure (MAP) in cesarean section. Standard Mean difference (SMD) was calculated and I-square statistic test was used for heterogeneity analysis.Results:The present systematic review and meta-analysis consisted of three clinical trials including 180 women in labor. Considering the results of meta-analysis, there is no significant differences between fentanyl and placebo in the case of Apgar score at 1 minute; however, the Apgar score of 5 minutes was significantly lower in fentanyl group compared with placebo (SMD -0.68, 95%CI: - 0.98, -0.38, p&lt;0.001). In the term of maternal hemodynamics, the heart rate (SMD -0.43, 95%CI: - 0.72, -0.13, p=0.004) and MAP (SMD -0.78, 95% CI: -1.09, -0.48, p&lt;0.001) in fentanyl group were significantly lower compared with placebo group.Conclusion:The present meta-analysis showed that using intravenous fentanyl as a premedication before induction of general anesthesia had adverse effects on neonate Apgar score. However, it had positive effects on preventing adverse consequences of intubation on maternal hemodynamics.

Association between thyroid-stimulating hormone and maternal hemodynamics in hypertensive disorders of pregnancy: an observational study

BackgroundHypertensive disorders of pregnancy (HDP) are characterized by hemodynamic disturbances. Altered thyroid function is a risk factor for poor outcomes of pregnancy. However, the associations between thyroid function biomarkers and maternal hemodynamics during pregnancy in HDP remain unclear.MethodsFrom January 2016 to January 2018, pregnant women diagnosed with HDP admitted to the Nanjing Maternity and Child Health Care Hospital were prospectively enrolled in the third trimester. Normally distributed variables were expressed as mean ± standard deviation and skewed variables were expressed as median (25th percentile, 75th percentile). Correlations between thyroid-stimulating hormone (TSH) or free thyroxine (FT4) and maternal hemodynamic parameters were assessed by Pearson’s correlation coefficient and 95% confidence interval (95%CI). Bonferroni’s correction for multiple correlations was performed. Logistic regression models with odd ratio (OR) and 95%CI were applied to confirm the associations.ResultsA total of 163 third-trimester pregnant women with HDP with a mean gestational age of 35.62 ± 2.83 weeks were recruited. The infant birth weight of patients with elevated TSH levels was lower than that of patients with normal TSH levels (2635 ± 867 g vs. 3037 ± 673 g, p = 0.002). Reduced cardiac output (CO) was defined as CO < 3.5 L/min. The infant birth weight of patients with reduced CO was lower than that of patients with normal CO (2250 ± 510 g vs. 2890 ± 774 g, p = 0.002). TSH levels were significantly and negatively correlated with CO (r = − 0.260, 95%CI: − 0.392- -0.103, p < 0.001). FT4 levels were not significantly correlated with any of the maternal hemodynamic parameters (all p > 0.05). TSH level (OR = 1.371, 95%CI: 1.086–1.733, p = 0.008) was confirmed associated with reduced CO in the logistic regression analysis.ConclusionsElevated TSH levels are associated with reduced CO in HDP during the third trimester.

Comparison of Mean Onset of Motor and Sensory Block of Isobaric Ropivacaine and Hyperbaric Bupivacaine for Elective Caesarean Sections at Tertiary Care Hospital, Karachi.

Objective: To compare the mean onset time of motor and sensory block of Isobaric Ropivacaine and Hyperbaric Bupivacaine for elective caesarean sections at Tertiary Care Hospital, Karachi.&#x0D; Methods: A double blinded Randomized control trial study carried out over the period of six months, from August 2016 to January 2017 using non probability consecutive sampling technique. A total of 128 pregnant women planned for LSCS under spinal anesthesia were enrolled in this study. Patients were randomly divided into two groups (Group B and Group R) receiving equipotent doses of spinal anaesthetic drugs. In group B, spinal anaesthesia were given to 64 patients with intrathecal injection of 3ml of 0.5% (5mg/ml) Hyperbaric Bupivacaine and in group R, 64 patients received spinal anaesthesia using 3ml of 0.5% (5mg/ml) Isobaric Ropivacaine. Motor block was evaluated by using Modified Bromage scale score and a score of &gt;2 is consider as optimal motor nerve block. Sensory block was evaluated by using 25G needle pinprick method along the mid clavicular line bilaterally and sensory block (loss of sensation to pain) at T6 level is consider as optimal sensory nerve block. At 10 minutes, Final outcome for each group B and R will be labelled in term of mean time of achievement of motor and sensory block and two dermatomal sensory segment regression.&#x0D; Results: Out of 128 patients, 64 patients receiving spinal anaesthesia using Hyperbaric Bupivacaine the mean duration to achieve sensory nerve block at T6 Level is found to be faster as compare to Isobaric Ropivacaine while the mean onset time of motor nerve block was also considerably significant in between the two groups (p=0.049).The Regression time of maximum sensory block from two dermatomal skin level is also found to be earlier in Isobaric Ropivacaine as compare to patients receiving spinal anaesthesia with Hyperbaric Bupivacaine (130.34 ± 15.26 vs 146.41 ± 12.81; p-value=0.0005). These regional anaesthetic properties of Isobaric Ropivacaine makes it a safer regional anaesthetic agent as Hyperbaric Bupivacaine.&#x0D; Conclusion: Spinal anaesthesia using intrathecal Ropivacaine for elective caesarean sections is an effective and optimal drug of choice. Two Dermatomal Sensory Regression was also found to be earlier in Isobaric Ropivacaine thus ropivacaine provides surgically effective anaesthesia of shorter duration and early sensory onset without compromising neonatal outcome and maternal hemodynamics.&#x0D;

Friendly help for clinical use of maternal hemodynamics

Objectives Maternal hemodynamics plays a major role during pregnancy and its evaluation is fundamental to understand obstetric conditions. The modern opinion about maternal hemodynamics assessment is to shift focus from single hemodynamic parameters to the whole hemodynamic profile. Our aim is to create a simple, intuitive, and easily understandable graphing technique to evaluate the main hemodynamic parameters. Methods We enrolled 531 pregnant women without maternal or fetal disease. One hundred and forty five in the first trimester of pregnancy, 258 in the second one and 128 in the third one. We performed hemodynamic assessment with ultrasonic cardiac output monitor method. We selected the six main parameters: cardiac output, systemic vascular resistance, heart rate, potential-to-kinetic energy ratio, inotropy index, and stroke volume variation. We chose the radar chart to display the multivariate data of the hemodynamic measurement of the patient in evaluation. Results We have obtained mean and deviation standard values for the six main hemodynamic parameters in every trimester. They deeply change during the pregnancy, so it is correct to compare a new hemodynamic measurement with the mean values for the specific trimester in order to evaluate any possible alterations. In fact, once a new hemodynamic assessment is performed, we calculate the Z-score in order to fix the positions of the six measured parameters in their specific axis of radar chart. Conclusions At the end of a hemodynamic exam, the physician can input the data in the program obtaining a graphic representation. Using this technique, which simultaneously evaluates six hemodynamic parameters, it is possible to easily understand the patient’s hemodynamic status. By converting the parameters values in Z-score, it is easier to understand when hemodynamics is altered, even if the physician does not have any experience in maternal hemodynamics.