Zeitschrift für Geburtshilfe und Neonatologie
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Z Geburtshilfe Neonatol · Dec 2010
Case Reports[Epidural anesthesia in obstetrics: an accidentally placed intrathecal catheter--remove it or use it?].
Epidural anesthesia is an established method in obstetrics. Despite constant practical experiences and established techniques, accidental penetrations of the dura and therefore malpositioning of the catheter in the intrathecal space are still present. This can result in post spinal headaches, a higher dispersion of the local anesthetic followed by life-threatening respiratory insufficiency and loss of overall conscious delivery. ⋯ There was no change in tonicity. It resulted in a normal unproblematic vaginal birth. After an initial irritation due to the high dispersion the patient described a noticeable alleviation of pain during the adequate controlled labor.
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Z Geburtshilfe Neonatol · Dec 2010
Review[Thromboprophylaxis during pregnancy and the puerperium: highlights from current guidelines].
Venous thromboembolism (VTE) is one of the leading causes of maternal deaths worldwide. Mortality and morbidity of VTE are potentially preventable, since two-thirds of these women have identifiable risk factors and may benefit from appropriate thromboprophylaxis. Individual and careful assessment of the personal and family history as well as the assessment of pre-existing and new-onset/transient risk factors during pregnancy and after delivery are mandatory for an effective prevention of VTE. ⋯ At the onset of labour, in case of any vaginal bleeding, prior to induction of labour or 12 h before an elective Caesarean section, antenatal LMWH prophylaxis should be discontinued, LMWH prophylaxis can be continued for 4-6 h after vaginal and for 6-12 h after Caesarean delivery when the women do not have an increased risk of haemorrhage. Current guidelines recommend than LMWH are the agents of choice for antenatal thromboprophylaxis; in comparison to unfractionated heparin, LMWH are associated with a substantially lower risk of heparin-induced thrombocytopenia and osteoporosis. Both oral anticoagulants and heparin are safe when breast-feeding.
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INTRODUCTION Based on the data of the Institut für das Entgeltsystem im Krankenhaus (InEK) cost and revenue data for deliveries in Germany can be compared. The InEK calculates the cost data for each individual diagnosis-related group (DRG) on the basis of those hospitals that deliver their individual cost data, so-called "Kalkulationshäuser". The InEK only publishes data for patients with standard lengths of stay. It does not deliver data for short- and long-stay patients. Beside these cost data, the InEK publishes the nationwide case volume for each DRG. Having a knowledge of the individual base rate (Landesbasisfallwert), which differs from province (Bundesland) to province and, in addition, the nationwide case weight for each DRG, the average revenues for deliveries in general, vaginal deliveries, and Cesarean sections can be calculated. These revenue data differ not only from province to province, but from hospital to hospital because of the individual hospital-specific base rates. ⋯ In relation to the average base rate over all provinces the 2005 costs are higher than the revenues in each province. Even in Rhineland-Palatinate, the county with the highest base rate, costs and revenues are at par. Only the declining costs from 2005-2007 balance the costs and revenues nationwide. But in provinces with low base rates the revenues stay lower than costs. These data demonstrate the pressure of rationalisation on German perinatal medicine and their hospitals. Cost and revenue comparisons with other countries are of lesser interest. Most countries have totally different systems for financing hospitals. In Germany, the published data show only the running costs financed by public and private health-care insurances. Infrastructure costs are financed by the government. In other countries not only the running costs but also the investment costs must be financed by running revenues too.
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Z Geburtshilfe Neonatol · Aug 2010
Case Reports[Patient-controlled intravenous analgesia with remifentanil as an alternative to epidural analgesia during labor: case series and discussion of medicolegal aspects].
Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified. ⋯ Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.
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Z Geburtshilfe Neonatol · Jun 2010
Sensitivity, specificity, receiver-operating characteristic (ROC) curves and likelihood ratios for electronic foetal heart rate monitoring using new evaluation techniques.
Hypoxia and acidosis adversely influence many foetal organ functions. We wanted to know how foetal heart rate (FHR) patterns are mirrored by the fetal acid-base status and if they could serve for predicting the actual pH in umbilical artery (UA) blood. For this purpose we condensed the FHR phenomena into one figure which was to be used as a testing variable and to analyse the performance of the new testing procedure. ⋯ Computer-aided evaluation of FHR patterns leads to a novel index (WAS score) which predicts foetal acidaemia with a high level of accuracy. Therefore online WAS scoring is proposed as an ancillary test procedure for future evaluation of FHR patterns. The conventional EFM remains untouched.