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Analgesia And Anesthesia
Published in Vincenzo Berghella, Obstetric Evidence Based Guidelines, 2022
Michele Mele, Valentina Bellussi, Laura Felder
During the first stage of labor, pain from cervical dilation (but not uterine contractions) can be blocked by a paracervical block. Studies assessing the effectiveness of paracervical block in labor are small and of poor quality. The data suggest that this block is more effective for pain relief than placebo [25]. Risks include maternal local anesthetic toxicity from IV injection, fetal local anesthetic toxicity from inadvertent fetal injection, and a strong association with fetal bradycardia.
Anesthesia and analgesia in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
During the first stage of labor, pain signals from nociceptors in the myometrium and cervix are transmitted via the paracervical and hypogastric plexi, and, traveling with sympathetic fibers of the lumbar sympathetic chain, enter the spinal cord at segments T10 to L1. These fibers synapse with secondary neurons in the Rexed laminae of the dorsal horns and are modulated by mu receptors in the substantia gelatinosa, also located in the dorsal horns of the spinal cord. The pain is perceived primarily as visceral pain. Pain signals in the second stage of labor are transmitted via the pudendal nerves, which enter the spinal cord via nerve roots S2–S4. From there, pain signals are transmitted via secondary neurons to the contralateral spinothalamic tract and on to the thalamus. Signals from the thalamus are then projected to cognitive cortical centers, where they are perceived primarily as somatic pain. Pain can be modulated or interrupted with blockade at several levels during its transmission. Paracervical block provides pain relief during the first stage of labor as does epidural and/or spinal blockade with local anesthetics or with spinal opiates either alone or in combination with local anesthetics. Pain during the second stage of labor can be managed with pudendal block, spinal (saddle) blockade, or extension of epidural blockade. Since the pain of the second stage of labor is somatic, it is not as responsive to spinal opiates as is the pain of the first stage of labor.
Termination and Contraceptive Options for the Cardiac Patient
Published in Afshan B. Hameed, Diana S. Wolfe, Cardio-Obstetrics, 2020
CHCs are Category 4 for women with severe pulmonary hypertension due to thrombotic and hypertensive risk [1]. Of note, bosentan—a dual endothelin receptor antagonist—can reduce the effectiveness of ethinyl estradiol as well as several progestin-only methods (contraceptive implant and POP). DMPA does not interact with bosentan, but women with pulmonary hypertension are often anticoagulated, which carries the theoretical concern of hematoma. IUDs may be contraindicated due to the potentially fatal consequences of a vasovagal reaction during placement. In cases where no other acceptable method is available, this risk may be mediated with the use of a paracervical block or epidural anesthesia [3].
Office hysteroscopy in removing retained products of conception – a highly successful approach with minimal complications
Published in Journal of Obstetrics and Gynaecology, 2020
Katja Jakopič Maček, Mija Blaganje, Nataša Kenda Šuster, Kristina Drusany Starič, Borut Kobal
All procedures were performed in an outpatient setting, without cervical dilation, using either 5.5 mm oval hysteroscopes or 5.0 mm hysteroscopic morcellators (TruclearTM 5.0 System). Paracervical block anaesthesia was used for initial procedures, but was later omitted due to excellent pain tolerance. The duration of the procedure, complications and surgeon’s estimation of procedure successfulness, described as completed or uncompleted, were noted. Patients were asked to assess pain during the procedure on a visual analogue scale (VAS) from 1 to 10. The removed tissue was sent for histopathological confirmation. During follow-up, patients were re-examined 1 month later with preferably a second-look OH or vaginal US. History of post-operative complications (endometritis, pain, stronger bleeding) was recorded for all. In the second-look OH, the presence of remaining RPOC and adhesions were noted and ultrasonographic finding of remaining RPOC was recorded for those followed-up by US. All patients signed informed consent with permission to publish their data prior to any procedure. Ethics committee approval was not sought, as all of the procedures and data gathering were part of accepted treatment protocols at the time.
Hysteroscopy in postmenopause: from diagnosis to the management of intrauterine pathologies
Published in Climacteric, 2020
R. Fagioli, A. Vitagliano, J. Carugno, G. Castellano, M. C. De Angelis, A. Di Spiezio Sardo
The main obstacles for office hysteroscopy in postmenopausal patients, and the number one reason for failure to complete the procedure, are cervical stenosis and pain during the procedure15. To facilitate the procedure, the administration of prostaglandin before diagnostic hysteroscopy was investigated in multiple trials. The most recent meta-analysis revealed no effects on the success rate of the procedure16. Similarly, the cervical application of local anesthetic is of uncertain efficacy. On the contrary, pre-emptive administration of intracervical or paracervical block was shown to be effective and can be considered in routine practice for postmenopausal women16.
Removal of uterine polyps: clinical management and surgical approach
Published in Climacteric, 2020
A. Ludwin, S. R. Lindheim, R. Booth, I. Ludwin
The classic approach uses reusable graspers and scissors. Standard diameter (24 and 26 Fr) monopolar and bipolar resectoscopes or smaller (22 Fr) are the most traditional and universal equipment used with general anesthesia or sedation. Their use is commonly limited to the operating room. Some surgeons use traditional resectoscopes under paracervical block anesthesia, but the reported pain experience during cervical dilatation appears to be relatively high (6 points on visual analog scale)56. This limits their use in the office setting without the use of conscious sedation or general anesthesia.