During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.
Anesthesia, Conduction ; Blood Coagulation Factors ; Blood Transfusion ; Drug Therapy ; Erythrocytes ; Factor VII ; Factor VIII ; Factor X ; Female ; Fibrinogen ; Fibrinolysis ; Hematoma ; Hemorrhage ; Hemostasis ; Humans ; Mortality ; Partial Thromboplastin Time ; Plasma ; Platelet Count ; Postpartum Hemorrhage ; Postpartum Period ; Pregnancy ; Pregnant Women ; Protein S ; Prothrombin Time ; Thrombelastography ; Tranexamic Acid

BACKGROUND: This prospective randomized double-blinded study was designed to compare the efficacy of a combination of high dose metoclopramide and dexamethasone with that of haloperidol, midazolam and dexamethasone, for the prevention of postoperative nausea and vomiting (PONV) in patients scheduled for laparoscopic gynecologic surgery who are receiving fentanyl intravenous-patient controlled analgesia. METHODS: The subjects were randomly allocated to either group M (20 mg metoclopramide and 10 mg dexamethasone was administered at induction, n = 35) or group H (1 mg haloperidol, 3 mg midazolam and 10 mg dexamethasone were administered at induction, n = 35). The incidence of PONV and the severity (measured by numeric rating scale) of the patients' nausea and pain were evaluated at 6 hours, 24 hours, and 48 hours, postoperatively. RESULTS: The overall incidence of the PONV was not significantly different between the two groups during the 48 hours period (group M: 21% vs. group H: 12%). The severity of the nausea and pain were similar between the two groups. CONCLUSIONS: The prophylactic use of a combination of 1 mg haloperidol, 3 mg midazolam and 10 mg dexamethasone is as effective and inexpensive as 20 mg metoclopramide and 10 mg dexamethasone to prevent PONV.
Analgesia ; Dexamethasone* ; Female ; Fentanyl ; Gynecologic Surgical Procedures* ; Haloperidol* ; Humans ; Incidence ; Metoclopramide* ; Midazolam* ; Nausea ; Postoperative Nausea and Vomiting* ; Prospective Studies

We report on failed spinal anesthesia (SA) after free flow of cerebrospinal fluid (CSF) and successful SA after no free flow of CSF in SA for laboring parturients undergoing emergency cesarean section (CS). We introduced a 25-gauge Sprotte type spinal needle for anesthesia for case 1 and confirmed backflow and aspiration of CSF. We injected 10 mg bupivacaine plus 15 µg fentanyl. However, sensory and motor block were not observed. During SA for case 2, a convincing dural “pop” was felt but without flow of CSF. Injection of 10 mg bupivacaine and 15 µg fentanyl produced successful sensory and motor block suitable for CS. The failure or success of SA in these intrapartum CS cases ran contrary to our expectations and could be related to the use of pencil-point needle and movement of the dura mater during labor.
Anesthesia ; Anesthesia, Spinal* ; Bupivacaine ; Cerebrospinal Fluid* ; Cesarean Section* ; Dura Mater ; Emergencies ; Female ; Fentanyl ; Needles ; Pregnancy

BACKGROUND: The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS. METHODS: Both groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups. RESULTS: The failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups. CONCLUSIONS: SA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.
Analgesia* ; Anesthesia* ; Anesthesia, Epidural ; Anesthesia, General ; Anesthesia, Spinal* ; Bupivacaine ; Cesarean Section* ; Epinephrine ; Female ; Fentanyl ; Hypotension ; Incidence ; Labor Pain ; Lidocaine ; Nausea ; Pregnancy ; Prospective Studies* ; Shivering ; Vomiting

A 39-year-old woman with an intrauterine pregnancy and small-for-gestational-age fetus was admitted at 34 + 1 weeks for management of pregnancy-induced hypertension. On the 13th day of admission, the patient was found in the ward toilet with a cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated immediately and cardiac monitoring revealed asystole. Manual uterine displacement was performed for CPR to be effective. A return of spontaneous circulation was observed, but repeated cardiac arrest occurred subsequently. Twenty-one minutes after starting CPR, a peri-mortem cesarean section was started, and delivery occurred 1 minute later. After delivery of the fetus, the patients' blood pressure stabilized, but there was no spontaneous respiration. Emergency brain CT revealed a large subarachnoid hemorrhage. Neonatal brain ultrasound showed hypoxic-ischemic encephalopathy. The patient was transferred to another hospital for neurosurgical intervention, where she expired on the third day after cardiac arrest.
Adult ; Blood Pressure ; Brain ; Cardiopulmonary Resuscitation ; Cesarean Section ; Emergencies ; Female ; Fetus ; Heart Arrest* ; Humans ; Hypertension, Pregnancy-Induced* ; Hypoxia-Ischemia, Brain ; Pregnancy ; Pregnant Women* ; Respiration ; Subarachnoid Hemorrhage ; Ultrasonography

BACKGROUND: Postoperative nausea and vomiting (PONV) is a major concern during the post-surgical period. 5-hydroxy-tryptamine (5-HT3) receptor antagonists may be useful for the prevention of PONV. The recently developed 5-HT3 receptor antagonists, ramosetron and palonosetron, have a greater receptor affinity and a longer elimination half-life. This study was designed to assess the efficacy of palonosetron and ramosetron for prevention of PONV in patients receiving intravenous patient-controlled analgesia (IV-PCA) with opioids after gynecological oncology surgery. METHODS: In this prospective trial, 290 female patients scheduled for elective gynecologic oncology surgery with IV-PCA with opioids were randomized to receive either 0.3 mg ramosetron or 0.075 mg palonosetron intravenously. The occurrence of nausea and vomiting and the use of rescue antiemetics were recorded immediately after the end of surgery, and 0-3 h, 3-24 h, and 24-48 h postoperatively. RESULTS: The total incidence of PONV was similar between the two groups 0-48 h after surgery, but the incidence of nausea was significantly lower in the ramosetron group 24-48 h postoperatively (11.5% vs. 22.0%, P = 0.036). The incidence of vomiting and the use of rescue antiemetics were not significantly different between the two groups during any of the time intervals. Pain intensity scores and total fentanyl consumption were significantly lower in the ramosetron group 24-48 h postoperatively compared to the palonosetron group (P = 0.021, P = 0.041, respectively). CONCLUSIONS: The prophylactic effects of ramosetron and palonosetron on PONV incidence in the postoperative 48 h were similar in patients undergoing gynecologic oncology surgery and those receiving opioid-based IV-PCA.
Analgesia, Patient-Controlled ; Analgesics, Opioid ; Antiemetics ; Female ; Fentanyl ; Half-Life ; Humans ; Incidence ; Nausea ; Postoperative Nausea and Vomiting* ; Prospective Studies ; Receptors, Serotonin, 5-HT3 ; Vomiting

BACKGROUND: Patients anesthetized by extension of epidural analgesia during labor frequently experience intraoperative visceral pain during cesarean section. Visceral pain is known to be related to anxiety. We evaluated pain and preoperative anxiety using the numeric rating scale (NRS-11), and examined the relationship of anxiety with failure of extension of epidural analgesia due to intraoperative pain. METHODS: Patients received continuous epidural infusion at a rate of 10 ml/h for labor pain. Two percent lidocaine mixed with 100 microg fentanyl, 1:200,000 epinephrine, and 2 mEq bicarbonate was injected through the epidural catheter for cesarean section. Failure of epidural anesthesia was defined as the need for conversion to general anesthesia or supplementation with opioids, sedatives, or inhalants after epidural anesthesia for cesarean section. We investigated the relationship of preoperative factors including preoperative anxiety with failure of epidural anesthesia. RESULTS: Heavier weight of parturients, more cervical dilatation at the time of epidural analgesia administration, higher pain NRS score after epidural analgesia, higher pain NRS score before epidural analgesia for cesarean section, and lower rate of iv pethidine due to shivering were associated with a higher failure rate of epidural anesthesia. The failure rate of epidural anesthesia was comparable between the high anxiety group (NRS > 4) and the low anxiety group (NRS < or = 4). CONCLUSIONS: Preoperative anxiety evaluated by NRS may not be associated with failure of extension of epidural analgesia due to visceral pain during intrapartum cesarean section.
Analgesia, Epidural* ; Analgesics, Opioid ; Anesthesia, Epidural ; Anesthesia, General ; Anxiety* ; Catheters ; Cesarean Section* ; Epinephrine ; Female ; Fentanyl ; Humans ; Hypnotics and Sedatives ; Labor Pain ; Labor Stage, First ; Lidocaine ; Meperidine ; Pregnancy ; Shivering ; Visceral Pain

BACKGROUND: Spinal anesthesia (SA) after epidural labor analgesia (ELA) can have advantages over augmentation of ELA due to its rapid onset and high-quality analgesia. However, unexpected side effects and diverse failure rates have been reported in women that received SA after ELA. We prospectively compared the effectiveness and side effects of SA after ELA versus SA only for intrapartum cesarean section. METHODS: The ELA/SA group received continuous epidural infusion at a rate of 10 ml/h for labor pain. In both groups, spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 microg of fentanyl using a pencil point needle. The rate of conversion to general anesthesia, the need for intraoperative analgesic supplements, and the incidence of high spinal block and hypotension were investigated. RESULTS: The rate of conversion to general anesthesia was higher in the ELA/SA group compared with the SA group (15.2 vs. 2.7%). Eighty percent of the conversion cases in the ELA/SA group were converted due to lack of sensory block. The need for intraoperative analgesic supplements and the rates of high spinal block and hypotension were comparable in the two groups. CONCLUSIONS: SA after ELA is associated with a high rate of conversion to general anesthesia during intrapartum cesarean section.
Analgesia* ; Analgesia, Epidural ; Anesthesia, General ; Anesthesia, Spinal* ; Bupivacaine ; Cesarean Section* ; Female ; Fentanyl ; Humans ; Hypotension ; Incidence ; Labor Pain ; Needles ; Pregnancy ; Prospective Studies

Plasmacytoma in patients with multiple myeloma usually develops in the advanced stage of the disease. We report herein an atypical case of extramedullary relapse of multiple myeloma that presented as mechanical obstruction of the small bowel in a patient who had achieved complete remission after chemotherapy. A 75-year-old man was diagnosed with multiple myeloma 25 months previously and treated with a bortezomib-containing chemotherapy regimen. He presented for evaluation of abdominal pain. A circumferential mass resulting in mechanical ileus was observed by abdominal computed tomography. Biopsy after surgical resection confirmed the diagnosis of plasmacytoma. The patient was subsequently treated with thalidomide-containing chemotherapy, but he died of disease progression after 6 months. We suggest careful observation of unusual relapses of multiple myeloma in patients who have achieved complete remission after antimyeloma therapy.
Abdominal Pain ; Aged ; Biopsy ; Diagnosis ; Disease Progression ; Drug Therapy ; Humans ; Ileus ; Intestinal Obstruction ; Multiple Myeloma* ; Plasmacytoma ; Recurrence*

BACKGROUND: Ephedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthesia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section. METHODS: In obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combination of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (2011-2012, two years). RESULTS: There were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal seizure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002). CONCLUSIONS: Conversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a significant decrease in the incidence of 1 min Apgar < 7.
Anesthesia, Obstetrical ; Anesthesia, Spinal* ; Apgar Score ; Cesarean Section* ; Continuous Positive Airway Pressure ; Ephedrine* ; Female ; Hemorrhage ; Humans ; Hydrogen-Ion Concentration ; Hypoxia-Ischemia, Brain ; Incidence ; Infant ; Infant Mortality ; Infant, Newborn ; Intermittent Positive-Pressure Ventilation ; Leukomalacia, Periventricular ; Phenylephrine* ; Pregnancy ; Retrospective Studies ; Seizures ; Umbilical Cord