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Background Available literature on pregnant women with severe pulmonary hypertension (PH) relies mainly on anecdotal case reports and two series only. Methods The authors reviewed the charts of all pregnant women with severe PH who were followed up at their institution during the past 10 yr, to assess the multidisciplinary treatment and outcome of these patients. Results Fifteen pregnancies in 14 women with severe PH were managed during this period: There were 4 cases of idiopathic pulmonary arterial hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of mixed connective tissue-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks' gestation. Four patients had vaginal deliveries with regional anesthesia: One died 3 months postpartum, one worsened, and two remained stable. Four had cesarean deliveries during general anesthesia: One died 3 weeks postpartum, one worsened, and two remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: One died 1 week postpartum, and four remained stable. There were two fetal deaths: one related to therapeutic abortion at 21 weeks' gestation and one stillbirth at 36 weeks' gestation followed by the death of the mother 1 week later. Conclusions Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

Background This study was designed to determine and compare the minimum local analgesic concentrations of levobupivacaine and ropivacaine when used in epidural obstetric analgesia. Methods In a double-blind study, healthy women requiring epidural analgesia for labor pain were randomized to receive either ropivacaine or levobupivacaine. Drugs were administered as a 20-ml epidural bolus. The concentration of each started at 0.11% and increased or decreased at intervals of 0.01%, depending on the response of the previous patient, using the technique of up-down sequential allocation. Minimum local analgesic concentrations were calculated using the formula of Dixon and Massey. Efficacy was assessed using visual analog pain scores and motor and sensory block assessments, and safety was assessed by recording maternal and fetal/neonate vital signs and adverse events. Results Forty-seven patients received levobupivacaine, and 47 received ropivacaine. Minimum local analgesic concentrations for levobupivacaine (0.077%; 95% CI, 0.058-0.096%) were lower than those for ropivacaine (0.092%; 95% CI, 0.082-0.102%). The 0.015% difference was not statistically significant. There was no notable difference between treatment groups in the proportion of patients reporting drug-related adverse events. Conclusions Levobupivacaine was 19% more potent than ropivacaine and provided similar safety results.

Background Preliminary studies have suggested that the addition of clonidine to intrathecal sufentanil prolongs analgesia without producing motor blockade. Methods Fifty-three nulliparous women in painful labor were included in this prospective, randomized, double-blinded study. Parturients at 2- to 5-cm cervical dilation received either 5 microg sufentanil plus 30 microg clonidine or 5 microg sufentanil intrathecally, followed by 5 mg bupivacaine epidurally. The primary outcome was time until first request for additional analgesia. Visual analog pain scores, sensory changes, blood pressure, heart rate, ephedrine requirements, motor blockade, sedation, pruritus, and nausea were also recorded. Results All parturients but one had effective analgesia in both groups, with similar sensory levels never exceeding T2. The duration (mean +/- SD) of analgesia was longer in the sufentanil-clonidine group: 125+/-46 versus 97+/-30 min (P = 0.007). The incidence of hypotension and the ephedrine requirements (median with range) were higher in the sufentanil-clonidine group: 63% versus 12% (P < 0.001) and 7.5 mg [range, 0-25.5 mg] versus 0 mg [range, 0-6 mg] (P < 0.0001). The incidence of fetal heart rate abnormalities during the first 30 min after intrathecal injection was similar in both groups (17% vs. 19%). No parturient had motor blockade. Conclusions The addition of 30 microg clonidine to 5 microg intrathecal sufentanil extended the duration of labor analgesia without producing motor blockade. However, as previously reported with 100-200 microg clonidine, the incidence of hypotension and the ephedrine requirements were also increased, even when 30 microg clonidine only was added.

Available literature on pregnant women with severe pulmonary hypertension (PH) relies mainly on anecdotal case reports and two series only.The authors reviewed the charts of all pregnant women with severe PH who were followed up at their institution during the past 10 yr, to assess the multidisciplinary treatment and outcome of these patients.Fifteen pregnancies in 14 women with severe PH were managed during this period: There were 4 cases of idiopathic pulmonary arterial hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of mixed connective tissue-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks' gestation. Four patients had vaginal deliveries with regional anesthesia: One died 3 months postpartum, one worsened, and two remained stable. Four had cesarean deliveries during general anesthesia: One died 3 weeks postpartum, one worsened, and two remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: One died 1 week postpartum, and four remained stable. There were two fetal deaths: one related to therapeutic abortion at 21 weeks' gestation and one stillbirth at 36 weeks' gestation followed by the death of the mother 1 week later.Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

Background Because ephedrine infusion (2 mg/min) does not adequately prevent spinal hypotension during cesarean delivery, the authors investigated whether adding phenylephrine would improve its efficacy. Methods Thirty-nine parturients with American Society of Anesthesiologists physical status I-II who were scheduled for cesarean delivery received a crystalloid preload of 15 ml/kg. Spinal anesthesia was performed using 11 mg hyperbaric bupivacaine, 2.5 microg sufentanil, and 0.1 mg morphine. Maternal heart rate and systolic blood pressure were measured at frequent intervals. A vasopressor infusion was started immediately after spinal injection of either 2 mg/min ephedrine plus 10 microg/min phenylephrine or 2 mg/min ephedrine alone. Treatments were assigned randomly in a double-blind fashion. The infusion rate was adjusted according to systolic blood pressure using a predefined algorithm. Hypotension, defined as systolic blood pressure less than 100 mmHg and less than 80% of baseline, was treated with 6 mg ephedrine bolus doses. Results Hypotension occurred less frequently in the ephedrine-phenylephrine group than in the ephedrine-alone group: 37% versus 75% (P = 0.02). Ephedrine (36+/-16 mg, mean +/- SD) plus 178+/-81 microg phenylephrine was infused in former group, whereas 54+/-18 mg ephedrine was infused in the latter. Median supplemental ephedrine requirements and nausea scores (0-3) were less in the ephedrine-phenylephrine group (0 vs. 12 mg, P = 0.02; and 0 vs. 1.5, P = 0.01, respectively). Umbilical artery pH values were significantly higher in the ephedrine-phenylephrine group than in the group that received ephedrine alone (7.24 vs. 7.19). Apgar scores were similarly good in both groups. Conclusion Phenylephrine added to an infusion of ephedrine halved the incidence of hypotension and increased umbilical cord pH.