Continuous wound infusion with ropivacaine for 48 hours after cesarean delivery was associated with better analgesia, a lower incidence of side effects, less need for nursing care, and shorter duration of stay compared with epidural morphine analgesia.

This is one of the few cases of myocardial infarction and angioplasty reported during pregnancy. The authors discuss the decisions taken by the multidisciplinary team consisting of anesthesiologists, obstetricians, neonatologists and cardiologists, particularly with regard to dual antiplatelet therapy, the type of delivery and anesthesia.

report of pain and first postpartum analgesic dose. Statistically significant differences in systolic and diastolic blood pressures occurred. In groups B and BF systolic pressures fell 47 and 39 mm Hg, respectively. Diastolic pressures fell 37 and 31 mm Hg, respectively. The incidence of hypotension was 96% in group B compared with 84% in group BF. The relative risk for developing hypotension was 1.1 (95% CI 1.01 to 1.28) for women who received bupivacaine alone. The rate of vasopressor use and the mean dose of phenylephrine administered did not differ between groups. Pain scores did not differ significantly, but nausea occurred more frequently in group B with a relative risk of 1.7 (59% vs. 35%, B vs. BF, respectively). Hypotension associated with nausea occurred in 75% of patients in group B and 63% of those in group BF. The 2 groups did not differ in other secondary outcomes.The results indicate that hyperbaric bupivacaine alone, 15 mg, provides an equivalent degree of sensation at 20 minutes after the intrathecal injection compared with the combination of intrathecal bupivacaine 12 mg and fentanyl 15 mg. Given the frequent drug shortages encountered by anesthesiologists, these results provide an effective practice alternative should fentanyl be unavailable for spinal administration. COMMENTAnesthesiologists frequently mix hyperbaric bupivacaine, fentanyl and morphine for spinal anesthesia for cesarean delivery. Previous study indicates that the addition of a lipid soluble opioid to the local anesthesia results in superior (more dense) anesthesia and allows a lower dose of local anesthetic. 1 Dense anesthesia is associated with a lower incidence of nausea as a result of visceral manipulation. The lower dose of local anesthetic is associated with less hypotension (which also results in less nausea and vomiting). The disadvantage of the local anesthetic/opioid "cocktail" is that it requires time to mix (which might be lacking in an emergency), and may be associated with a higher risk of drug error or contamination. Intrathecal opioids are also associated with an increased incidence of pruritus. Thus, the authors of this study hypothesized that bupivacaine alone, without fentanyl, albeit in a higher dose, might provide equivalent anesthesia without the attendant disadvantages of mixing the local anesthetic with lipid soluble opioid. This is a valid, clinical question of interest to anesthesia providers.The authors were careful to conclude that the study showed equivalence of sensory sensation of the two techniques at 20 minutes after the intrathecal injection. However, this does not mean that the two techniques are equivalent. The difficulty in designing this study was choosing the primary outcome and important secondary outcomes, and in defining a clinically significant delta (d) between the two techniques. I am concerned that sensation at 20 minutes after the intrathecal injection was not the optimal primary outcome. The authors did not report any surgical data; we do not know what surgical events were occurrin...

Summary: Duarte FP, O'Neill P, Centeno MJ, Ribeiro I, Moreira J -Myocardial Infarction in the 31st Week of Pregnancy -Case Report. Background and objectives:The occurrence of acute myocardial infarction (AMI) during pregnancy is rare. The authors describe the case of MI in a 31-week pregnant woman and the importance of a multidisciplinary team for its approach.

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