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Background: Mental health conditions during delivery hospitalizations are not well characterized., Objective: This study aimed to characterize the prevalence of maternal mental health condition diagnoses and associated risk during delivery hospitalizations in the United States., Study Design: The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. Temporal trends in mental health condition diagnoses during delivery hospitalizations were determined using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. The trends in chronic conditions associated with mental health condition diagnoses, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, were analyzed. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. Regression models for each outcome were performed with unadjusted and adjusted risk ratios as measures of effects., Results: Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018 (average annual percent change, 11.4%; 95% confidence interval, 10.3%-12.6%). Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018. Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity (risk ratio, 1.88; 95% confidence interval, 1.86-1.90), preeclampsia and gestational hypertension (risk ratio, 1.59; 95% confidence interval, 1.58-1.60), preterm delivery (risk ratio, 1.35; 95% confidence interval, 1.35-1.36), postpartum hemorrhage (risk ratio, 1.37; 95% confidence interval, 1.36-1.38), cesarean delivery (risk ratio, 1.20; 95% confidence interval, 1.20-1.20), and maternal death (risk ratio, 1.31; 95% confidence interval, 1.12-1.56). The increased risk was retained in adjusted models., Conclusion: The proportion of delivery hospitalizations with mental health condition diagnoses increased significantly throughout the study period. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. The findings suggested that mental health conditions are an important risk factor in adverse maternal outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Labor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics., Methods: Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006-2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI)., Results: Of the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (-7.5%; 95% CI -2.2 to -0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching)., Conclusions: During the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Cardiac diseases are the second cause of non-obstetrical death during pregnancy in France. Bicuspid aortic valve is the most frequent congenital cardiac disease but its characteristics are little known. We report two consecutive cases of pregnant patients with aortic bicuspidy, one with a severe aortic stenosis and one with a severe dilatation of the ascending aorta. We describe the anaesthetic management of delivery for these two cases and summarize the current recommendations for management of this condition during pregnancy., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Background: Chronic stress during pregnancy has been associated with worsened maternal and fetal outcomes. Acute stress immediately before spinal anaesthesia for caesarean section may contribute to hypotension. Therefore objective measures of acute stress may help identify women at risk of adverse outcomes. Salivary alpha-amylase is a stress biomarker that has so far been poorly investigated during pregnancy. The reference change value is the difference between two sequential results that must be exceeded for a change to be considered clinically relevant. Our first aim was to determine if salivary alpha-amylase increased in pregnant patients when subjected to the stress of transfer to the operating room. Our second aim was to determine if changes in salivary alpha-amylase were likely to be clinically significant by measuring reference change value in healthy volunteers., Methods: In 15 pregnant patients undergoing planned caesarean section under spinal anaesthesia, salivary alpha-amylase, systolic blood pressure, heart rate, and immediate anxiety were measured on the morning of surgery on the ward and again in the operating room. The reference change value was calculated from 18 healthy volunteers., Results: A median 220% increase in salivary alpha-amylase activity (P=0.0015) and a 17% increase in systolic blood pressure (P=0.0006) were observed between the ward and operating room. No changes of immediate anxiety or heart rate were observed. Reference change value was ±76% in volunteers and 13 of the 15 pregnant patients had a salivary alpha-amylase increase greater than the reference change value., Conclusion: When pregnant women are taken to the operating room, a clinically and statistically significant increase in salivary alpha-amylase was observed. Further studies are required to define its clinical usefulness., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objectives: To evaluate surgical treatment for genital prolapse in patients over the age of 75., Patients and Methods: This is a continuous retrospective series of 43 patients operated for genital prolapse between March 2001 and October 2006. Surgical outcomes in terms of anatomical correction as well as urological and proctological results were analyzed. Morbidity and mortality studies were carried out. A satisfaction and quality of life assessment was carried out among 19 patients (44%) by an independent researcher at a distance from the intervention., Results: Morbidity attributable to the surgery was minimal, with no cases of mortality. Mean hospital stay was five days. Anatomical correction was good without troubling urological or proctological consequences. Two surgical options were compared: surgery with vaginal occlusion in 23 patients (53.5%) and vaginal conserving surgery in 20 patients (46.5%). Surgical outcomes and morbidity were equivalent in the two groups. Seventy-nine percent of patients surveyed at a distance from the interventions estimated that the procedure had improved their quality of life., Discussion and Conclusion: Surgical treatment for genital prolapse in the very elderly population is a reasonable therapeutic option. Postoperative evaluation demonstrates good anatomical as well as functional results in the majority of cases.

Background: In pregnancy, airway oedema and heartburn may increase cough sensitivity, whereas spinal anaesthesia (SA) with local anaesthetics and opiates may decrease it. Decreased cough sensitivity increases the risk for pneumonia or retained secretions. The aim of this study was to determine whether cough sensitivity is increased in pregnant patients and if it is decreased after planned Caesarean section (CS) under SA., Methods: Twenty-seven non-pregnant volunteers, 27 patients after vaginal delivery (VD group), and 28 patients after CS under SA (CS group) were studied. For SA, hyperbaric bupivacaine 8-12 mg, sufentanil 5 microg, and morphine 100 microg was given. Increasing concentrations of nebulized citric acid were delivered until eliciting cough. The concentration eliciting one (C1) and two coughs (C2) were recorded and log transformed for analysis (log C1 and log C2)., Results: Median (inter-quartile) log C1 was 1.3 (0.6) mg ml(-1) in the VD group, 1.6 (0.6) mg ml(-1) in the non-pregnant group (P < 0.01 vs VD group), and 2.2 (0.7) mg ml(-1) in the CS group (P < 0.0001 and P < 0.01 vs VD and non-pregnant groups, respectively). Similar results were observed with log C2. In CS group, log C1 and log C2 remained increased up to 4 h after SA., Conclusions: Cough sensitivity was increased after VD but decreased for up to 4 h after SA.

Background: Dysfunction of the cough reflex as a result of the lingering effects of anaesthetics may lead to aspiration pneumonia or retained secretions after general anaesthesia. It is unknown whether low concentrations of propofol alter the cough reflex in the early period after anaesthesia. The objective of this study was to investigate the effect of low concentrations of propofol on the cough reflex sensitivity as assessed by the cough reflex threshold to an inhaled irritant., Methods: Fifteen, ASA I-II, non-smoking patients undergoing elective colonoscopy were studied. Anaesthesia was induced and maintained with a blood target-controlled propofol infusion. Cough reflex threshold was measured with citric acid. Increasing concentrations of nebulized citric acid (2.5, 5, 10, 20, 40, 80, 160, 320, and 640 mg ml(-1)) were delivered during inspiration until a cough was evoked. The citric acid concentration eliciting one cough (C1) was defined as the cough reflex threshold. C1 was log transformed for statistical analysis (Log C1). Log C1 was measured before anaesthesia and during the recovery period with estimated decreasing propofol concentrations of 1.2, 0.9, 0.6, and 0.3 microg ml(-1)., Results: Log C1 (median; interquartile range) measured with propofol concentrations of 1.2, 0.9, 0.6, 0.3, and 0 microg ml(-1) were 1.9 (0.6), 1.9 (1.0), 1.9 (1.1), 1.9 (0.6), and 1.9 (0.7) mg ml(-1) (NS), respectively. However, light sedation was observed with propofol concentrations of 1.2 and 0.9 microg ml(-1)., Conclusion: This study indicates that residual sedation after propofol anaesthesia for colonoscopy does not adversely affect the cough reflex.

Objective: To identify parameters that indicate retained secretions and the need for tracheal suctioning (TS) in patients receiving mechanical ventilation (MV)., Design: Prospective observational study., Setting: A 14-bed medical ICU in a 946-bed university hospital., Patients: Sixty-six consecutive patients receiving MV., Interventions: Two successive tracheal suctions, TS1 and TS2, performed at a 2-h interval as usual patient care. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL., Measurements and Results: Variations between TS1 and TS2 of pulse oximetric saturation (SpO(2)), peak inspiratory pressure (Ppeak), tidal volume (VT), and Ramsay score were compared between patients with TS2 < or = 0.5 mL (group 1; n = 27) and patients with TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtooth pattern on flow-volume loop displayed on the monitor screen of the ventilator and of respiratory sounds heard over the trachea before TS2 were compared between the two groups. Variations of Ppeak, VT, SpO(2), and Ramsay score between TS1 and TS2 did not differ between the two groups. However, group 2 had a sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratory sounds (66.6% vs. 25.9%; p = 0. 001) more frequently than group 1 before TS2. For the sawtooth pattern, the likelihood ratio (LR) of a positive test was 2.70 and the LR of a negative test was 0.25, while for respiratory sounds it was 2.50 and 0.45, respectively. When the presence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative test was 0.42., Conclusions: A sawtooth pattern and/or respiratory sounds over the trachea are good indicators of retained secretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retained secretions.

We studied prospectively the effects of the technique of tracheal extubation on arterial haemoglobin oxygen saturation (SpO2) in 120 ASA I-III children, mean age 5.3 (range 0.25-16.9) yr. At completion of surgery, tracheal extubation was performed when spontaneous ventilation had resumed, children were fully awake and SpO2 was 99-100%. Children were allocated randomly to receive a single lung inflation manoeuvre with 100% oxygen before tracheal extubation (group I; n = 59) or to have the tracheal tube removed while applying suction through the tube (group S; n = 61). SpO2 was monitored during the first 5 min after tracheal extubation in the operating room. Supplementary oxygen was given if SpO2 decreased to less than 92%. The time between tracheal extubation and decrease in SpO2 to 92% (T92) was recorded. Children in group S required oxygen administration more frequently after tracheal extubation than those in group I (65.6% vs 45.8%; P = 0.04), and had a three-fold shortening of T92 (mean 25 (SD 19) s vs 85 (63) s; P = 0.0001). These effects were more pronounced in children less than 4 yr of age compared with older children. We conclude that tracheal extubation greatly impaired oxygenation and therefore administration of oxygen was appropriate. This impairment was more marked when suction was used, and in young children. Lung inflation with 100% oxygen before removal of the tracheal tube is advised before routine tracheal extubation in children.

The influence of a single dose of clonidine (5 micrograms kg-1) or hydroxyzine (1 mg kg-1) on intraoperative propofol requirements was determined in 28 male patients (ASA I) undergoing elective orthopaedic surgery. Patients were randomly allocated to receive either clonidine or hydroxyzine orally 2 h before induction of anaesthesia. After a loading dose of propofol (2.5 mg kg-1), mivacurium (0.2 mg kg-1) and alfentanil (15 micrograms kg-1), anaesthesia was maintained with a standardized propofol infusion supplemented with nitrous oxide (66%) in oxygen. During surgery, additional propofol boluses (1 mg kg-1) were administered when heart rate or mean arterial pressure increased by more than 10% compared with preinduction values. The clonidine group demonstrated a 14.5% decrease in total propofol requirements (P < 0.05) and a 52.2% reduction in additional propofol boluses (P < 0.02) in comparison with the hydroxyzine group. intraoperative heart rate and mean arterial pressure were significantly lower in the clonidine group but no patients needed treatment with ephedrine for hypotension or bradycardia. Recovery of psychomotor function and discharge from the recovery room were not delayed in the clonidine group. This study indicates that 5 micrograms kg-1 clonidine given as premedication in ASA I patients reduces intraoperative propofol requirements in comparison with 1 mg kg-1 hydroxyzine without inducing adverse effects on recovery or haemodynamic stability.

Objective: To evaluate the effects of tracheal suctioning (TS) on respiratory resistances in sedated critical care patients receiving mechanical ventilation (MV)., Setting: Surgical ICU of Bichat Hospital, Paris., Patients and Participants: Thirteen sedated critical care patients receiving MV for various conditions., Measurements and Results: Airway resistances (R1), airway and pulmonary resistances (R2), and intrinsic positive end-expiratory pressure (PEEPint) were measured according to the end-inspiratory and end-expiratory occlusion methods before and after TS. R1 and R2 increased by 49.1% and 46.3%, respectively, 0.5 min after TS (p<0.01) but returned to baseline values at 1 min without any change thereafter. PEEPint decreased progressively following TS to reach a significant level (-13.3%) at 10 min (p<0.05) and was persistently reduced at 30 min (p<0.01). Nine patients received 500 microg of inhaled albuterol before another suctioning procedure. R1 and R2 decreased by 11.5% and 9.9%, respectively, 20 min after inhalation (p<0.05), but the R1 and R2 initial increase following TS did not differ between the two suctioning procedures., Conclusions: TS evokes only a transient bronchoconstrictor response, but thereafter, does not reduce respiratory resistances below presuctioning values. However, the decrease of PEEPint following TS suggests an increase of expiratory flow. Effective beta2-adrenergic receptor blockade fails to suppress the TS-induced bronchoconstrictor response.