Anesthesia in Preeclampsia and Related Researches
Date Issued
2007
Date
2007
Author(s)
Chen, Li-Kuei
DOI
zh-TW
Abstract
The main objective of this thesis is focus on the clinical and basic research of obstetric anesthesia & analgesia. Although the majority of obstetric patients are young and healthy women, risk of obstetric anesthesia is still much higher than the other field of anesthesia, due to the unpredictable physiological change of those pregnant women. According the statistics from 1985 to 1990 in US, every 1,000,000 parturient women happened to produce 1.7mortality, attributed to the risk and complications of obstetric anesthesia, particularly for urgent Caesarean section. In fact, the risk of obstetric anesthesia is almost 2 times higher than anesthesia for general operation. The scope of obstetric anesthesia includes anesthesia for cesarean section, including post operative pain conrol0, the anesthetic management of high risk pregnancy and painless labor during natural spontaneous delivery. Either general or regional anesthesia could be applied for cesarean delivery anesthesia, but for general practice, regional anesthesia should be superior to general, due to the safety consideration for mother and fetus. Clinically under some special conditions or dangerous situations for parturient or fetus (like the spontaneous fetal distress or unexpected massive bleeding of pregnant women in labor), general anesthesia should be conducted immediately, in order to deliver the fetus as soon as possible. Both spinal and epidural anesthesia are categorized as the regional anesthesia. Technically, epidural anesthesia is more difficult, complicated and risky than spinal anesthesia, and epidural anesthesia always needs longer time for the onset of drug effect. Due to the following characteristics: (1) Less influence on the blood pressure of parturient, with less negative impact on the fetus. (2) Anesthetic or analgesic drug for operaton or for painless could be injected through the epidural catheter at any time. (3) More analgesic effect and convenient, epidural analgesia for post operative pain control is better for early ambulation and for wound healing, epidural anesthesia or analgesia for painlees labor and obstetric anesthesia (including post operative pain relief) could be accepted and used widely in clinical practice. Except the different drug or different dose injected through epidural catheter, the thechnique of epidural anesthesia for obstetric anesthesia or painless lobor might be similar. In the first part of this thesis, preeclampsia (one of the common disease of high risk pregnancy) is the target for study. In the second and third part of this thesis, the issues of epidural for obstetric anesthesia or painless lobor could be the focus for research.
Part I
The first part of the study tries to elucidate the pathogenesis of preeclampsia, through the evaluation on the association study between Taiwanese pregnant women with preeclampsia and the genetic polymorphism of endothelial nitric oxide synthase.
Li-Kuei Chen, Chi-Hsiang Huang, Heui-Ming Yeh, Chien-Nan Lee, Ming-Kwang Shyu, Fon-Jou Hsieh, Ling-Ping Lai , Wei-Zen Sun. Polymorphisms in the Endothelial Nitric Oxide Synthase Gene May Be Protective Against Preeclampsia in a Taiwanese Population. Reproductive Sciences 2007; 14: (2): 175-181.
Preeclampsia (PE) is a common disease of human pregnancy with an unidentified genetic component. Past reports have demonstrated that endothelial nitric oxide synthase (eNOS) gene is associated with vascular diseases in western countries population and severe PE in the Japanese population. The association data between PE and eNOS gene is lacking in the Taiwanese population. Therefore, we examined the association between PE and two common polymorphisms of maternal eNOS gene in a Taiwanese population.We included 92 women with PE (systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg, on at least two occasions 6 hours apart, and proteinuria > 0.3 g/L or a dipstick proteinuria reading of 2+) and 256 healthy control pregnant who were genotyped for the Glu298Asp polymorphism in exon7 and the number of 27 base-pair repeats in intron 4 of the eNOS gene. The frequency of the variant T allele was significantly lower in PE group than in control group (9.24% vs 18.16%, p<0.05) and the frequency of eNOS4a (small allele with 4 repeats of 27 bp) was also significantly lower in PE group than in control group (4.9% vs 9.8%, p<0.05). The genotype distribution of Glu298Glu, Glu298Asp and Asp298Asp in eNOS exon 7 revealed statistically significant differences between control and PE groups (71.1% vs 84.8%, 21.5% vs 12.0% and 7.4% vs 3.2% respectively, p<0.05). The genotype distribution of bb type and ab type in eNOS intron 4 was also significantly different between control and PE groups (80.5% vs 90.2% and 19.5% vs 9.8%, p<0.05). This is the first study to evaluate the association between two polymorphisms in maternal eNOS gene with PE simultaneously in a Taiwanese population. Similar to the findings in other western countries population, but in contrast to the result in other Japanese populations, polymorphisms in the eNOS gene may be protective against PE in a Taiwanese population.
Part II
The second part of the study tries to invesigate the effects of continuous epidural local anesthetic (0.075% bupivacaine) on the Doppler velocimetry of uterine arterie at five different periods during painless labor.
Li-Kuei Chen, Chen-Jung Lin, Chi-Hsiang Huang, Mao-Hsien Wang, Pei-Lin Lin, Chien-Nan Lee, Wei-Zen Sun. The Effects of Continuous Epidural Analgesia on Doppler Velocimetry of Uterine Arteries during Different Periods of Labour Analgesia. Br J Anaesth. 2006; 96(2):226-30.
The effects of epidural anaesthesia with 0.25-0.5% bupivacaine on the Doppler velocimetry of umbilical and uterine arteries for caesarean section pregnant women had been reported, but the effects of continuous epidural with lower dose bupivacaine (0.05-0.1%) infusion for labour analgesia on the Doppler velocimetry of uterine arteries have never been reported. In this study, we evaluated the effects of continuous epidural 0.075% bupivacaine on the Doppler velocimetry of uterine arteries. Twenty pregnant women for labour analgesia received continuous epidural 0.075% bupivacaine infusion. We used a 4-MHz continuous-wave Doppler probe (Multigon 500A) with a 200-Hz thump filter to detect uterine blood flow velocity. We recorded the velocimetry data of uterine blood flow (during uterine relaxation and contraction) in five periods: pre-epidural insertion, 1 hr, 2 hr and 4 hr post-epidural infusion and after foetus delivered to evaluate the effects of continuous epidural bupivacaine infusion for labour analgesia on the uterine blood flow. Our data showed that when uterus was under relaxation or contraction condition, the mean velocimetric indices (S/D ratio, PI and RI) of uterine artery were significantly increased post-epidural infusion (1h, 2h and 4 hr) when compared with the pre-epidural level, but almost returned to baseline post-delivery. This study demonstrates that continuous epidural analgesia for labour analgesia with 0.075% bupivacaine increases the resistance of uterine artery and therefore possibly reduces the uterine blood flow. Further studies are required to elucidate whether the decrease of uterine blood flow during epidural labour analgesia with 0.075% bupivacaine will result in a significant clinical impact on the fetus or the mother.
Part III
The third part of the study tries to evaluate the optimal and effective blood volume in conducting epidural blood patch for Taiwanes pregnant women with post-dural puncture headache (PDPH).
Li-Kuei Chen, Wei-Horng Jean, Chi-Hsiang Huang, Cheng-Wei Lu, Chen-Jung Lin, Wei-Zen Sun, Mao-Hsien Wang. The Effective Epidural Blood Patch Volume to Treat Post Dural Puncture Headache for Taiwanese Women. J Formos Med Assoc, 2007; 106(2): 134-140.
Epidural blood patch (EDBP) is the most commonly used method to treat post-dural puncture headache (PDPH). The optimal and effective blood volume for epidural injection is still controversial and under debated. This study is designed to compare the therapeutic efficacy of 7.5 ml blood vs 15 ml blood for EDBP via epidural catheter injection.Thirty-three patients who suffered from severe PDPH due to accidental dural puncture during epidural anesthesia for cesarean section or epidural analgesia for labor pain control were randomly allocated into to two groups. EDBP was conducted and autologous blood 7.5 ml or 15ml was injected via an epidural catheter in semi-sitting position in group I (N=17) and II (N=16). For all patients in both groups, the severity of the PDPH was registered on a four-point scale (no, mild, moderate, severe) and assessed 1 hour, 24 hours and 3 days after EDBP. The rates of different severity of PDPH (no, mild, moderate, severe) before EDBP were 0/17, 0/17, 2/17, 15/17 and 0/16, 0/16, 1/16, 15/16. 1 hour after EDBP in group I and II were 10/17, 6/17, 1/17, 0/17 and 8/16, 6/16, 2/16, 0/16 respectively, without any statistically difference. 24 hour after EDBP in group I and II were 12/17, 4/17, 1/17, 0/17 and 11/16, 4/16, 1/16, 0/16 respectively, without any statistically difference. 3 days after EDBP in group I and II were 15/17, 2/17, 0/17, 0/17 and 13/16, 3/16, 0/16, 0/16 respectively, without any statistically difference. No special side effects or complications happening to any patient in both Groups during or after EDBP injection was noted, except 2 patients (2/17) in Group I complaining nerve root irritating pain during 7.5 ml blood injection for EDBP and 9 patients (9/16) in Group II with the same complaint during blood injection.From the result of this study, we may conclude that half blood volume with 7.5 ml for EDBP could provide almost the same effect to treat PDPH, but reduce the incidence of nerve root irritating pain when compared with larger blood volume
Subjects
子癲前症
基因多形性
血管內皮細胞一氧化氮合成酵素
硬脊膜外減痛分娩
子宮動脈血流量
硬脊膜穿刺引起頭痛
硬脊膜外注射血液補釘法
preeclampsia
genetic polymorphism
endothelial nitric oxide synthase
epidural painless
uterine blood flow
post-dural puncture headache
pidural blood patch
SDGs
Type
text
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