Aim: To evaluate the incidence of occiput posterior position in labour with and without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine.Material and Methods: This study focused on 132 women subdivided in two groups, patients in spontaneous and in labour analgesia, administered by a low dose CSE by sufentanyl and ropivacaine; all women were evaluated by digital examinations and ultrasound till delivery. All data were collected and analyzed by an independent reviewer.Results: In the second stage, 79 were persistent occiput posterior position (POPP) fetuses and 36 were translated from anterior to posterior position (TAPP) fetuses. Specifically, in spontaneous labour on 25 women in anterior position, there were 17 TAPP and in CSE analgesia on 28 women in anterior, there were 19 in TAPP, without significant differences. The number of asynclitisms was higher in the POPP group (84%) respect to the TAPP group (75%), so as the rate of caesarean section (67% versus 52.7%).Conclusions: The labour with low dose of ropivacaine and sufentanyl does not increase the occiput posterior position during fetal descent, leading to a POPP. Finally, since in the occiput anterior presentation labour analgesia significantly lengthens time to delivery, in the occiput posterior position this is significantly increased, with a prolonged second stage of labour and reduced time of descent of fetal head in obstetric pelvis.

BACKGROUND:We carried out this prospective, randomized, double-blind study in order to evaluate whether the intrathecal addition of sufentanil 3.3 mcg affects both the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for a caesarean section and enhances the spinal block characteristics.METHODS:One hundred and eighty women were randomly allocated into four groups: levobupivacaine (Group L), levobupivacaine plus sufentanil (Group L+S), ropivacaine (Group R) and ropivacaine plus sufentanil (Group R+S). Each received 3 ml of the study solution intrathecally as part of a combined spinal/epidural technique. The initial dose was 12 mg for Groups L and L+S, and 15 mg for Groups R and R+S. The test solution was required to achieve a visual analogue pain score (VAPS) of 30 mm or less to be considered effective at skin incision, uterine incision, birth, peritoneal closure and at the conclusion of surgery. Effective or ineffective responses determined a 0.5 mg decrease or increase of the same drug, respectively, for the next patient in the same group, using an up-down sequential allocation.RESULTS:Using the Dixon and Massey formula, the MLAD was 10.65 mg [confidence interval (CI) 95%: 10.14-11.56] in Group L, 4.73 mg (CI 95%: 4.39-5.07) in Group L+S, 14.12 mg (CI 95%: 13.50-14.60) in Group R and 6.44 mg (CI 95%: 5.86-7.02) in Group R+S.CONCLUSIONS:The addition of sufentanil reduced the MLAD of both the local anaesthetics. It did not affect their potency ratio significantly and resulted in enhanced spinal anaesthesia.

Pre-eclampsia (PE) is a clinical pregnancy-related condition, characterised by an elevated blood pressure and proteinuria. The author treated selected cases of PE with long-term epidural analgesia (LTEA), that reduced labour pain and operated directly on the PE aetiopathogenesis, not on the symptoms. A total of 15 women with PE were hospitalised at 35-37 weeks of pregnancy, checked for blood pressure, liver and renal function, platelet count and had an epidural catheter inserted for a continuous administration of an analgesic mixture of Naropin, Sufentanil and Clonidine. The average weeks at delivery were 37 weeks and 1 day; 10 women had a spontaneous delivery and five a caesarean section: the mean birth weight was 2,906g and the Apgar scores at 1min and 5min exceeded 7 in all cases. All the parameters improved after hospital admission and at discharge. All the patients were discharged in good condition and no patients needed supplementary antihypertensive treatment. The LTEA utilisation for 1 week is well tolerated and improves uteroplacental perfusion, but further studies and a larger number of patients are required to evaluate this pharmacological procedure and determine its place in the management of PE.

A case of intra- and retroperitoneal haemorrhage after a splenic vein aneurysm rupture is described. A 27-year-old woman complained of chest pain on her first postpartum day. Symptoms were initially suggestive of pulmonary embolism, but within 3 h she developed severe acute abdominal pain, abdominal distension and haemodynamic instability. Ultrasound demonstrated a non-echogenic mass in the abdomen suggestive of a fluid collection and a computed tomography scan confirmed the presence of a lesion at the pancreatic tail. Urgent laparotomy revealed splenic vein rupture near the pancreatic tail. Partial pancreatectomy and splenectomy were performed. The patient subsequently made an uneventful recovery. Histological examination revealed a splenic vein aneurysm and chronic inflammatory changes in the pancreatic tissue. Rupture of a splenic vein aneurysm is a rare event and the diagnosis may present difficulty because its presentation is similar to several other more common conditions. However, rupture of a splenic vein aneurysm should be suspected in any pregnant woman with unexplained abdominal pain or with clear signs of haemorrhage, as delay in diagnosis can have devastating consequences.

ethods: We randomly scheduled 180 women who were divided nto four groups. Each received 3 ml of study solution through a ombined spinal/epidural technique. The initial dose was 12 mg for he levobupivacaine (Group L) and levobupivacaine plus sufentanil Group L S) groups and 15 mg for the ropivacaine (Group R) and opivacaine plus sufentanil (Group R S) groups. We required the est solution to achieve a visual analogue pain score (VAPS) of 30 m or less to be considered effective, at skin incision, uterine ncision, birth, peritoneal closure, and at the conclusion of surgery. ffective or ineffective responses determined a 0.5 mg decrease or ncrease of the same drug respectively for the next patient in the ame group, using an up-down sequential allocation.

Objective: The pattern of labor progression in contemporary practice differs significantly from the Friedman curve. Induction of labor, oxytocin use, neuroaxial analgesia, and fetal heart rate monitoring are very common in contemporary practice. The aim of our study is to value the effects of analgesia during labor and above neonatal outcome.

ethods: In this prospective randomized double-blinded study, e examined the analgesic efficacy of demand only PCEA and CEA with basal infusion. We recruited 300 nulliparous parturints. Analgesia was initiated with intrathecal ropivacaine 2 mg and entanyl 15 mcg, and maintained with epidural ropivacaine 0.1% ith fentanyl2 mcg /mL. Parturients were randomized to one of 3 roups. Group 0: demand only PCEA, bolus of 5 mL, lockout nterval of 15 min. Group 5: background infusion of 5 mL/h, bolus f 5 mL, lockout interval of 12 min. Group 10: background infusion f 10 mL/h, bolus of 5 mL, lockout interval of 10 min. The maxium dose of all groups was 20 mL/h. The primary outcome was ncidence of breakthrough pain. Secondary outcomes included inrapartum pain scores, neuraxial blockade characteristics, side efects, the total and hourly volume of ropivacaine, neonatal outomes and obstetric outcomes.

ackground and Aims: The technique of epidural volume exension (EVE) involves the injection of saline into the epidural pace soon after the intrathecal injection when a combined spinalpidural anesthesia is performed. The benefit of EVE should be a eduction in local anesthetic request. This study aimed at comparng the median effective dose (ED50) of ropivacaine with and ithout EVE in spontaneous labouring women.

L. BERTINI 1, G. SAVOIA 2, A. DE NICOLA 3, G. IVANI 4, E. GRAVINO 5, A. ALBANI 6, F. ALEMANNO 7 A. BARBATI 8, B. BORGHI 9, F. BORROMETI 10, A. CASATI 11, D. CELLENO 12, A. CIASCHI 1 A. CORCIONE 13, P. DE NEGRI 14, P. DI BENEDETTO 15, M. EVANGELISTA 16, G. FANELLI 11, P. GROSSI 17 M. LORETO 8, E. MARGARIA 18, P. MASTRONARDI 5, C. MATTIA 19, F. NICOSIA 20, M. NOLLI 21 A. RUTILI 22, E. SANTANGELO 23, J. SUCRE 3, V. TAGARIELLO 24, G. VARRASSI 25, F. PAOLETTI 26 R. TUFANO 5

Background and objective: The low cardiovascular and neurological toxicity of levobupivacaine has led to its application as a local anaesthetic in a wide variety of specialist applications including peribulbar block for cataract surgery. The aim of this study was to evaluate the efficacy of levobupivacaine 0.5% and to compare block quality vs. ropivacaine 0.75% in peribulbar anaesthesia. Methods: We examined 208 patients subjected to cataract surgery by phacoemulsification who were randomized into two groups according to the anaesthetic used for peribulbar block, namely levobupivacaine 0.5% or ropivacaine 0.75%, both with the addition of hyaluronidase. Nerve block was carried out by injection of 6 mL of the anaesthetic mixture equally distributed between the inferotemporal and superonasal areas. The success of the block was evaluated by determining the time of motor and sensory onset, akinesia score, times of motor and sensory offset and satisfaction of the patient and surgeon after 24 h. Pre‐block, post‐block and postoperative intraocular pressure as well as the duration of surgical intervention was also determined. Results: With respect to ropivacaine, levobupivacaine showed a significant reduction (P < 0.001) in the average motor and sensory onset. Both the akinesia score (P < 0.01) and mean motor and sensory offset times were also higher (P < 0.001). Neither the average intervention times nor the satisfaction of the patient/surgeon showed any significant differences between the two groups. Conclusions: Levobupivacaine (0.5%) has better anaesthetic properties with respect to 0.75% ropivacaine and is well‐suited for peribulbar block in cataract surgery.

We determined the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for Caesarean section. Ninety women were randomly allocated to two groups and received 3 ml of study solution by a combined spinal/epidural technique. The initial dose was 12 mg for levobupivacaine and 17 mg for ropivacaine groups. To be considered effective, a test solution had to achieve a visual analogue pain score (VAPS) of 30 mm or less at skin incision, uterine incision, birth, peritoneal closure, and at the end of surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the same drug for the next patient in the same group, using up-down sequential allocation. The MLAD of levobupivacaine was 10.58 mg (CI 95%: 10.08-11.09) and the MLAD of ropivacaine 14.22 mg (CI 95%: 13.67-14.77), using the Dixon and Massey formula. The potency ratio between spinal levobupivacaine and spinal ropivacaine was 1.34.

BACKGROUND:This double-blind, randomized study was aimed at detecting the effect of three different volumes of intrathecal levobupivacaine on the minimum local analgesic dose in early labor.METHODS:Ninety-three nulliparous women requesting combined spinal-epidural analgesia, at more than 37 weeks gestation, with spontaneous onset of labor, cervical dilatation from 2 to 5 cm, were enrolled. Parturients received 10 ml (group 10), 5 ml (group 5), or 2.5 ml (group 2.5) of the spinal solution containing plain levobupivacaine diluted with 0.9% wt/vol saline to achieve the desired dose and volume at room temperature. A lumbar epidural catheter was then placed. The initial dose for each group was 2.0 mg, and the following doses were determined by the response of the previous patient using up-down sequential allocation. The authors required the test solution to achieve a visual analog pain score of 10 mm or less to be considered effective. The up-down sequences were analyzed using the Dixon and Massey formula and regression logistic model.RESULTS:The minimum local analgesic dose of spinal levobupivacaine in spontaneously laboring women was 1.35 mg (95% confidence interval, 1.25-1.45 mg) in group 10, 1.63 mg (95% confidence interval, 1.51-1.76 mg) in group 5, and 1.97 mg (95% confidence interval, 1.89-2.05 mg) in group 2.5. A unit change in volume increased the odds of an effective response multiplicatively by a factor of 1.8.CONCLUSIONS:Analgesia can be achieved using lower doses and higher volumes even in subarachnoid space. The important role of the volume should be considered not only in epidural but also in spinal analgesia.