Obstetric Anaesthetists' Association

s President: Dr T. Bryson (liverpool). Treasurer: Dr John Anderton (Manchester). Secretary: Dr Trevor Thomas (Bristol Maternity Cimetidine; its use as an oral cmtacid in obstetrics Hospital. Southwell Street, Bristol BS2 8EG). J.R. Johnston, J.W. Dundee, J. Moore & W. Minute Secretary: J. Thorburn (Glasgow). McCaughy (Bevast) Patients undergoing elective Caesarean section were given cimetidine 400 mg orally, 9G150 minutes preoperatively, and a pre-induction dose of I 5 ml of 0.3 M sodium citrate. Seventy-two patients have been Joint meeting of the Obstetric Anaesthetists’ Association and ‘Iub d’Anasthesia Reanimation en ObSteehique The Autumn Meeting of the Obstetric Anaesthetists’ studied; the intragastric pH was consistantly above Association wasajoint venture with Club d’Anasthesia 3.75. Reanimation en Obstetrique of France. It was held in Nearly 6000 patient have received cimetidine the Centre Hospitalier Universitaire, Pitie-Salpetriere, routinely during labour, 400 mg is given when labour Pans, on 18 September 1981. starts, followed by 200 mg 2-hourly until delivery. News and notices 491 earlier in pregnancy and before any of the stigmata are present. Other target systems affected are kidney, with characteristic glomerular endotheliosis, and the coagulation system. Should an anaesthetic be required, 15 ml of sodium citrate is given within 10 minutes of induction; of the 135 women studied using this regimen, only five had an intragastric pH of less than 2.5. Two of these were anaesthetised before the cimetidine would be active, and the remaining three had blood levels below the therapeutic level; large gastric residues, indicating poor drug absorption, were measured in those patients. Analysis of the blood cimetidine levels indicates a general absence of accumulation of the drug, although several women exhibited high blood levels. Placental transfer is moderate, the feto maternal ratio being 0.45-0.65, once steady-state has been established. No detrimental effects on the mother or neonate were observed. Diagnosis and treatment of gastric aspiration G. Duval & J.H. Gaudy (Paris) Note. This paper did not confine itself to obstetric anaesthesia, and the frequency of the event was not stated. The diagnosis of the aspiration pneumonia is made by the history of vomiting followed by the onset of respiratory signs which cannot be explained by any other cause. This diagnosis is confirmed by examination, the presence of pneumonia, hypoxia and the findings of fibroscopy. Experience has shown that there are two different types of disorder, in which the treatment and the prognosis are different. The first condition is localised, and does not present with severe septic shock. Treatment is by antibiotic therapy, using anti-anaerobe drugs (penicillin G and metronidazole) and continuous positive airway pressure (CPAP). The second type is more serious; there is widespread pneumonia and the problem is the major infection and resulting hypoxia. Treatment with broad spectrum antibiotics is required, the choice being made by identification of the organisms and their sensitivity. Intubation and intermittent positive pressure ventilation with CPAP is also required. The pathology of pre-eclampsia C.R.W. Redman (Oxford) Pre-eclampsia is defined as a triad of signs and symptoms affecting 1 to 5% of the obstetric population. The basic lesion is in the spinal arteries; these exhibit characteristic changes, similar, but not identical to, the morphology of renal allograft rejection, in that there is little inflammation. These changes result in placental infarcts, and all fetal consequences arise from this, as the changes are irreversible; only the secondary features can be studied, but there is evidence that the disorder exists before there is evidence of the primary uterine pathology affecting target systems with the development of hypertension as patients who will develop preeclampsia show an abnormal angiotensin response The preparation before delivery of patients with preeclampsia J. Selwyn Crawford (Birmingham) The features of pre-eclampsia are hypertension, hypovolaemia (often overlooked), a tendency to develop a coagulopathy and convulsions. Renal and hepatic function are rarely impaired sufficiently to affect drug metabolism, but the severity of the proteinuria is an index of the extent of the hypovolaemia. Patients with mild pre-eclampsia require little additional care unless there is evidence of fetal distress. Epidural analgesia is an advantage; this reduces maternal acidosis and the contribution pain makes to the hypertension, but it should be preceded with an intravenous infusion of one litre of crystalloid to correct the hypovolaemia. If a Caesarean section is required, either general anaesthesia (GA) or epidural may be used, but the patient should be pre-loaded with 1 litre of crystalloid for GA, and 2 litres for epidural. Severe pre-eclampsia is usually treated with hydrallazine and diazepam by pump infusion in the United Kingdom. Epidural analgesia is an advantage, but a coagulopathy must be excluded, and the hypovolaemia corrected before the block is started. At least 2 litres of crystalloid, or incremental aliquots of plasma protein solution should be infused, but care should be taken to avoid over transfusion and the resultant pulmonary oedema. Unacceptable reduction of the arterial blood pressure should be avoided, and the rate of infusion of the antihypertensive drug should be reduced before each epidural increment. Ergometrine should be avoided, the bearing down reflex obtunded, and gentle forcep delivery undertaken. Urgent delivery should be undertaken by GA. The same precautions apply. A coagulation screen should be obtained and the patient adequately pre-loaded. Controlled ventilation should be maintained for 6 to 12 hours to reduce the risk of an eclamptic fit and to protect the airway. A gastric tube should be passed as a routine and magnesium trisilicate administered every 2 hours. Preliminary results of haemodynamic studies in patients with severe hypertension A.M. Baglin, T. Gallais, R. Maneglia, J.P. Oliver0 de Rubiana, 0. Gateau, D. Pathier & M.T. Cousin (Paris and Ivry sur Siene) Preliminary results of investigation (balloon flotation catheterisation) and treatment (antihypertensive agents) in six patients were reported: three of the patients received epidural analgesia. Treatment resulted 498 News and notices in a reduction of the left ventricular stroke work and total peripheral resistance, with little change in the cardiac index. Epidural analgesia resulted in a modest decrease in the peripheral resistance; in one patient the cardiac index was significantly reduced, this was attributed to caval occlusion. The cardiovascular state remained stable during and after delivery but one patient exhibited a rise from 9 to 22 mmHg in pulmonary wedge pressure. This was a result of too rapid infusion of intravenous fluids; 8 hours after delivery and cessation of treatment, the haemodynamic status had returned to control levels. Anaesthetic problems in pre-eclumpsiu J. Thorburn (Glasgow) A review of the anaesthetic problems relating to a total population of 10200 deliveries was presented; hypertensive disease complicated 8.6% of all deliveries. Epidural analgesia was confirmed as the single most effective and popular therapeutic measure; in selected groups of this population, the obstetric intervention rate increases dramatically, with Caesarean section rates of over 40%. The anaesthetic problems are related to the wellknown hazards associated with the techniques used in obstetric anaesthesia and analgesia, and are . not specifically related to the underlying disease. There is however, a small group with eclampsia and/or a sustained diastolic pressure of 120 mmHg or greater, occurring with a frequency of 2.1 per 1000 deliveries in which the anaesthetic problems relate to the underlying pathophysiologic features. Disease of this severity is invariably associated with a severe consumptive coagulopathy, and 50% of the patients exhibited acute incipient renal failure. Epidural analgesia is absolutely contra-indicated in disease of this severity. Intra-operative control of the blood pressure M. Palot (Rheims) The objectives of treatment are to stabilise the maternal blood pressure, to select and modify, if necessary, a general anaesthetic technique with minimal fetal sideeffects, and to monitor the haemodynamic status of the patient. Hydrallazine is the agent of choice for hypotensive therapy, as it is a vasodilator of short duration of action and is simple to control when used intravenously. Severe hypertension is associated with. an increase in the arterial and pulmonary artery pressures at intubation and extubation, and the hypotensive agent should be administered continuously to minimise these effects. General agreement exists regarding the choice of general anaesthetic techniquethiopentone, suxamethonium, oxygen and nitrous oxide and halothane or enflurane, but this was modified in the present study by using pancuronium for intubation; using this technique and continuous infusion of hydrallazine, the pulse, central venous pressure and arterial blood pressure were relatively stable. If both the arterial and central vein pressures are elevated, it is recommended that the patients be monitored by insertion of a balloon flotation catheter. Post-operative problems J.J. Rouby (Paris) Sixteen obstetric patients have required admission to the intensive care unit (ITU) during the last 4 years. The obstetric population differed significantly from that of the general ITU in that the patients were younger, the average duration of stay was shorter (9 days), and mortality (one patient died), was much lower than the average of 40%. Six patients were admitted with eclampsia, and nine with severe hypertension, eight patients had delivered prior to admission to the unit. One patient, admitted with the diagnosis of pulmonary embo