Clinical obstetrics and gynecology
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Clin Obstet Gynecol · Jun 2017
ReviewPeripartum Anesthetic Management of the Opioid-tolerant or Buprenorphine/Suboxone-dependent Patient.
Opioid abuse and dependence continues to rise in both the general population and pregnancy, with opioid overdose deaths having quadrupled in the last 15 years. Illicit drug use in last 30 days of pregnancy was over 4% with almost 0.6% documented maternal opiate use at time of birth. ⋯ Options for treatment of opioid dependence, acute pain management, and perioperative multimodal analgesia are discussed. The effects of maternal management on neonatal abstinence syndrome are also reviewed.
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Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. ⋯ In addition to nonpharmacologic alternatives, inhaled nitrous oxide and systemic opioids represent two broad classes of non-neuraxial pharmacologic labor analgesia most commonly available. This review summarizes the current published literature for these non-neuraxial labor analgesic options.
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We review and emphasize the importance of gynecologic ultrasound scan for the preoperative evaluation of adnexal masses. Transvaginal ultrasound performed by a trained clinician has a good sensitivity and specificity for discriminating benign and malignant adnexal masses. In conjunction with a carefully obtained history, assessment of risk factors, a focused physical examination and serum markers, the information obtained by a gynecologic ultrasound evaluation can assist the clinician in the diagnosis and treatment of adnexal masses.
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The provision of anesthesia to the morbidly obese parturient is technically challenging. The anesthesia provider anticipates difficulty with intravenous access, positioning, monitoring, and placement of neuraxial anesthesia. ⋯ Among obese gravidas, there is a lower risk of the development of a headache from an accidental dural puncture, due not to the body habitus, but rather to the group's higher cesarean delivery rate. It is the process of bearing down during delivery that increases the chance of the development of a headache following dural puncture.
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Obesity in pregnancy confers morbidity to both the mother and neonate. Obese women are at increased risk of cesarean delivery, operative vaginal delivery, and failed trial of labor after cesarean delivery. ⋯ The risk of these complications increases with increasing maternal body mass index. In this chapter, we discuss evidence-based strategies to mitigate these risks and to manage complications that occur at the time of delivery in obese parturients.