Biomedical subjects

R Jouppila

Publications and source records attributed to R Jouppila.

At least 19 recordsLinked to original sources

PubMed1996

Maternal and uteroplacental haemodynamic state in pre-eclamptic patients during spinal anaesthesia for Caesarean section.

We have studied the effects of crystalloid (Ringer's acetate 1 litre) preloading and subsequent spinal anaesthesia in 12 pre-eclamptic parturient patients undergoing elective Caesarean section. Maternal placental uterine artery circulation was measured using a pulsed colour Doppler technique with simultaneous measurement of maternal haemodynamic state. Despite preloading, mean maternal systolic arterial pressure (SAP) decreased significantly and marked maternal hypotension (SAP < 80% of baseline value) was recorded in two patients after induction of spinal anaesthesia. Mean central venous pressure increased significantly after preload, but decreased to baseline shortly after induction of spinal anaesthesia. Mean pulsatility index (PI) in the uterine artery did not change during preload or spinal block. In one patient, uterine artery PI increased significantly when SAP decreased to 71% of the baseline value, 14 min after induction of spinal anaesthesia. These results suggest that preload with crystalloid solution does not prevent maternal hypotension in pre-eclamptic patients, and that changes in uterine artery velocity waveforms were minor when SAP was 80% or more of baseline during spinal anaesthesia. These changes did not appear to have any major effect on the clinical condition of the neonate, as assessed by Apgar score and umbilical artery pH values.

Adult↗

PubMed1996

Single bolus compared with a fractionated dose injection technique of bupivacaine for extradural Caesarean section: effect on uteroplacental and fetal haemodynamic state.

We studied 26 healthy parturients undergoing elective Caesarean section, allocated randomly to receive extradural block with 0.5% plain bupivacaine in a double-blind manner in either a single bolus or fractionated doses. After a 3-ml test dose, an additional 20 ml of bupivacaine were given over a 5-min period in the single bolus group (n = 13) and over a 25-min period in the fractionated dose group (n = 13). We studied the effects of bupivacaine on blood flow velocities in the maternal placental and non-placental uterine and fetal umbilical arteries before and four times during establishment of extradural block using a pulsed colour Doppler technique. Median sensory block reached T3 in the single-dose group compared with T4 in the fractionated-dose group. Two subjects in each group required i.v. ephedrine to correct transient hypotension (systolic arterial pressure < 90 mm Hg). Blood flow velocity waveform indices of the uterine and umbilical arteries did not differ significantly within or between groups during the study. There was no significant difference in neonatal outcome, as assessed by Apgar scores and umbilical artery pH values. In conclusion, we observed no deterioration in uteroplacental circulation after administration of a single bolus dose of bupivacaine.

Adult↗

PubMed1996

The intensity of labor pain in grand multiparas.

BACKGROUND: The purpose of the current study was to investigate differences in pain experiences and requirements for pain control in parturients with different birth experience. Previous studies have shown that the labor pain experience is significantly less intense in multiparas than in primiparas and requirements for analgesic treatment have therefore been assumed to be minimal in this group. METHODS: The pain experience during labor was assessed by 70 consecutive grand multiparas (a minimum of five previous deliveries) compared to that of primiparous (n=70) and II-V parous women (n=70). Pain intensity was repeatedly assessed on a pain intensity scale (0-10) according to the progress of cervical dilatation at the first and second stage of labor. RESULTS: During the latent phase of cervical dilatation (0-3 cm) grand multiparas had a median pain score of 3 compared to 4 in II-V paras and 6 in primiparas (p<0.001). At the end of the first stage and during the second stage the intensity of pain in grand multiparas was significantly higher compared to that in primiparas (median scores 7 to 8 vs 6 to 7, p<0.05). Epidural blocks were administered to 40% of primiparas, 3% of II-V paras and to no grand multiparas (p<0.0001). Twenty-one percent of grand multiparas rated their pain as intolerable (pain scores 9-10) during the second stage compared to 10% of primiparas (p<0.05%). On the third day after delivery, 47% of grand multiparas regarded their analgesia insufficient. CONCLUSIONS: The majority of parturients, including grand multiparas, suffered from intense pain during labor. After delivery, a significant number of grand multiparas felt that they had received insufficient pain relief.

Analgesia, Obstetrical↗

PubMed1995

Effect of crystalloid and colloid preloading on uteroplacental and maternal haemodynamic state during spinal anaesthesia for caesarean section.

We have studied the effects of crystalloid 1 litre (lactated Ringer's) or colloid 0.5 litre (hydroxyethyl starch) preloading in 26 healthy parturients undergoing elective Caesarean section under spinal anaesthesia. Maternal placental uterine artery circulation was measured using a pulsed colour Doppler technique with simultaneous measurement of maternal haemodynamics. A high incidence of maternal hypotension was observed during spinal anaesthesia in the crystalloid group (62%) but the incidence was lower in the colloid group (38%). Central venous pressure was increased significantly in both groups after preload but decreased shortly after induction of spinal anaesthesia to baseline values. The mean pulsatility index (PI) in the uterine arteries did not change during preload or spinal block. A surprising finding was the widespread variation and some high values for the uterine artery PI after spinal anaesthesia. These individual increases in PI were transient and always returned to baseline values within 2 min. These results suggest that preloading with either solution is ineffective in preventing maternal hypotension and that changes in maternal heart rate, systolic arterial pressure and central venous pressure during spinal anaesthesia were not associated with rapid individual increases in uteroplacental vascular resistance. These changes seemed not to have any major effect, however, on the clinical condition of the newborn, as assessed by Apgar scores and umbilical artery pH values.

Adult↗

PubMed1995

The effects of epidural ropivacaine and bupivacaine for cesarean section on uteroplacental and fetal circulation.

BACKGROUND: Ropivacaine is a new long-acting amide local anesthetic that has been shown in animal studies to have less dysrhythmogenic and cardiotoxic potential than bupivacaine. The intravenous administration of ropivacaine has not been associated with any detrimental effects on uterine blood flow in pregnant ewes. The purpose of this randomized, double-blind study was to examine the effects of epidural ropivacaine for cesarean section on blood flow velocity waveforms in uteroplacental and fetal arteries with color Doppler ultrasound and to assess whether the block modified fetal myocardial function. METHODS: Healthy parturient women with singleton, uncomplicated pregnancies at term received 115-140 mg 0.5% ropivacaine (n = 11) or 0.5% bupivacaine (n = 10) in incremental epidural doses. The first ultrasound measurement was performed before injection of the study drug. Pulsatility indexes (PI) were derived for the blood flow velocity waveforms of the maternal placental and nonplacental uterine arteries; the placental arcuate artery; and the fetal umbilical, middle cerebral, and renal arteries. The fetal heart then was examined by echocardiography. The PI of the maternal uterine arteries and the fetal umbilical artery were measured 5 min after the injection of the local anesthetic. When sensory analgesia had reached the T6-T4 level, the ultrasound measurement was repeated with the same methods and targets as in the baseline measurement. RESULTS: Both drugs provided adequate surgical anesthesia for cesarean section. In the bupivacaine group, the PI values for the maternal placental and nonplacental uterine arteries increased significantly 5 min after the main dose (P = 0.01, P = 0.002) and when sensory analgesia had reached the T6-T4 level (P = 0.004, P = 0.01) as compared with the baseline measurement. Simultaneously, the PI in the fetal middle cerebral artery decreased significantly (P = 0.02). The PI for the maternal uterine artery increased significantly (P = 0.01) after ropivacaine administration but only on the nonplacental side and not until sensory analgesia had reached the T6-T4 level. No effect on the Doppler indexes obtained from the umbilical artery was observed in either group. There were no significant differences relative to baseline values in any fetal myocardial measurement or in any ultrasound measurement between the groups. Neither drug had any detrimental effect on Apgar scores or umbilical cord acid-base status. None of the neonates' conditions was markedly depressed according to neurobehavioral testing. CONCLUSIONS: Within this small study, epidural 0.5% ropivacaine for cesarean section did not compromise the utero-placental circulation in healthy parturient women with uncomplicated pregnancies. It provided surgical anesthesia that was equally effective as that provided by 0.5% bupivacaine.

Adult↗

PubMed1995

The effect of maternal obesity on labour and labour pain.

Consecutive obese (n = 53) and non-obese parturients (n = 609) were prospectively evaluated during labour to analyse the influence of maternal obesity on labour pain and outcome. Excessive pre-pregnancy weight was classified as a body mass index of 30 kg.m-2 or more. Pain intensity was measured using an 11 point visual scoring scale. Obese parturients had more complicated pregnancies (hypertension and diabetes) and their babies weighed significantly more (3865 g versus 3592 g, p < 0.001). These differences did not affect labour pain experience, or the duration or mode of delivery. Eighty-five percent of the obese parturients and 83% of the controls had high maximal pain scores during the first stage (> 7). Both groups received similar analgesia. More technical problems (p = 0.03) were experienced in establishing epidural analgesia for obese parturients, but this did not influence the success of pain treatment. After delivery, obese women were significantly more content with the pain relief received; only 12% vs 23% in the control group complained of poor pain control (p = 0.03). In this study, obesity and increased fetal size did not complicate labour or its outcome. Critical patient assessment should be emphasised, however, due to the physiological and medical problems present in obese parturients.

Adult↗

PubMed1995

Maternal expectations and experiences of labour pain--options of 1091 Finnish parturients.

A prospective survey of 1091 Finnish parturients was conducted in order to ascertain mothers' expectations for labour pain relief, to measure the actual pain during all three stages of labour and to question their satisfaction and the adequacy of pain relief on the third day following delivery. Antenatal expectations for pain relief were surveyed. Mothers were questioned on pain levels in the delivery room and 3 days after giving birth. Pain levels were ascertained using a visual pain score method. Antenatally, 90% of all parturients anticipated a need for pain relief during labour. In the delivery room over 80% of all parturients described their pain as very severe to intolerable, only 4% of the multiparous had low pain scores (0-2). After pain treatment 50% of multiparous women still had pain scores from 8 to 10, which reflects a lack of effective pain relief. Dissatisfaction with the childbirth experience was very low, and was associated with instrumental deliveries, but not with the usage of analgesia. 51% of all parturients complained of inadequate pain relief during childbirth, which, in multiparous women, was significantly associated with the second stage of labour.

Analgesia, Epidural↗

PubMed1995

Paracervical block--a viable alternative for labor pain relief?

BACKGROUND: Two hundred and forty-eight consecutive deliveries with a 0.25% bupivacaine paracervical block (PCB) using a superficial injection technique were studied prospectively during the progress of labor in the three month study period. Parturients with signs of fetal distress were excluded. Pain level and the maternal, fetal and neonatal effects related to PCB were evaluated. METHODS: Pain intensity level was assessed on a visual scoring scale (0-10). The intrapartum fetal heart rate patterns were recorded and reviewed to correlate the incidence of paracervical fetal bradycardia. RESULTS: Parturients with PCB were provided a significant reduction (p < 0.001) in pain levels and the change in pain scores could be maintained until the beginning of the second stage. After the block, bradycardia patterns were noted in five (2.0%) fetuses, a fetal heart rate ranged from 60 to 105 beats per minute with an onset time of 2-20 minutes after the block and a duration of 4-12 minutes. All newborns in the bradycardia group were delivered vaginally without signs of asphyxia. CONCLUSIONS: PCB in selected parturients with a low-dose superficial technique has been shown to be an effective analgesic modality with minimal fetal and neonatal side-effects, but post-blockade fetal bradycardia cannot be wholly eliminated.

Adult↗

PubMed1994

Uteroplacental haemodynamics during spinal anaesthesia for caesarean section with two types of uterine displacement.

The effects of two types of uterine displacement, on uterine and umbilical artery blood flow waveforms were investigated in 22 healthy parturients undergoing elective caesarean section. Displacement was accomplished with either a wedge under the right hip or a mechanical displacer plus 5 degrees left lateral tilt of the operating table. The first 14 patients were assigned randomly into one of the two displacement methods and the left (underlying) uterine and umbilical artery blood flow waveforms were recorded. In a further 8 patients the displacer was used and flow velocity waveforms for both the right and left uterine arteries and the umbilical artery were recorded. Arterial resistance was expressed in terms of the pulsatility index (PI). There were no significant changes in Doppler velocimetry recordings after preloading in either group, but blood flow velocity waveform indices for the underlying left uterine artery increased significantly (P < 0.001) following spinal anaesthesia when the mechanical device was used. This finding indicates increased vascular resistance in the left uterine artery and is probably due to mechanical compression. A wedge as a method for displacing the gravid uterus seems preferable since its use had no effect on the blood flow indices. The unaltered umbilical artery index values in the groups suggest a great tolerance of minor changes in maternal uterine circulation on the part of the fetus.

Journal Article↗

PubMed1994

Parturients' assessment of water blocks, pethidine, nitrous oxide, paracervical and epidural blocks in labour.

This prospective study evaluated the extent to which the analgesic procedures available resulted in efficient pain relief in 833 Finnish parturients. Their pain ratings were recorded according to their own assessment of pain intensity during labour before and after pain management and according to their total pain experience recalled on the third day after delivery. Only regional blocks significantly diminished pain scores during labour and a striking decrease in pain level (P < 0.0001) was maintained until the second stage by epidural analgesia (EDA) alone. The EDA-group consisted mainly of the primiparous (71%) with induced (17%) and most painful deliveries. After delivery 60% of parturients in this group recalled labour pain as being very severe or intolerable. This was partly due to delays in receiving epidural blockade and partly due to the parturient's reticence in requesting analgesia. Pain relief was rated as excellent or good by 94% of the EDA group but by only 50% of the remaining patients.

Journal Article↗

PubMed1994

Uteroplacental and fetal haemodynamics and cardiac function of the fetus and newborn after crystalloid and colloid preloading for extradural caesarean section anaesthesia.

We have studied the effects of randomized preloading with either a crystalloid (lactated Ringer's) 15 ml kg-1 or colloid (hydroxyethyl starch) 7.5 ml kg-1 solution in 20 parturients undergoing elective Caesarean section under extradural anaesthesia, on blood flow in maternal placental and non-placental uterine and placental arcuate arteries and in fetal umbilical, renal and middle cerebral arteries, using a pulsed colour Doppler technique. Simultaneously, fetal and neonatal myocardial function were investigated by pulsed Doppler and M-mode echocardiography. We found no changes in maternal or fetal blood velocity waveform indices after crystalloid preloading, but the pulsatility index of the maternal non-placental uterine artery increased significantly after colloid preloading. Fetal heart rate decreased after preloading with crystalloid solution. There were no differences in fetal or neonatal myocardial function between the groups, and the outcome of the newborn infants were uneventful in all cases. These results suggest that preloading with either a crystalloid or colloid solution may lead to different uterine and fetal haemodynamics but these solutions had only minimal effects on fetal and neonatal myocardial performance and no effect on the clinical condition of newborns in uncomplicated pregnancies.

Adult↗

PubMed1993

Uteroplacental and fetal circulation during extradural bupivacaine-adrenaline and bupivacaine for caesarean section in hypertensive pregnancies with chronic fetal asphyxia.

We have studied the effects of an extradural block during Caesarean section using either bupivacaine plain or with adrenaline 85-100 micrograms on blood velocity waveforms of maternal uterine and placental arcuate arteries and fetal umbilical, renal and middle cerebral arteries, in 20 hypertensive parturients with chronic fetal asphyxia. Fetal myocardial function was investigated at the same time by M-mode echocardiography. Extradural anaesthesia resulted in a significant decrease in maternal mean systolic and diastolic arterial pressures in both groups, but this was more marked after plain bupivacaine. There were no significant differences in any of the Doppler recordings relative to baseline values after plain bupivacaine, but after bupivacaine with adrenaline there were significantly increased blood flow velocity indices for the maternal uterine and placental arcuate arteries and significantly decreased indices in the fetal renal and middle cerebral arteries. Neonatal outcome as evaluated by Apgar scores and acid-base values in the umbilical cord were similar in the two groups. The results suggest that adrenaline added to the solution of bupivacaine increased vascular resistance in the uteroplacental circulation, indicating impaired blood flow.

Anesthesia, Epidural↗

PubMed1993

Epidural sufentanil and bupivacaine for labor analgesia and Doppler velocimetry of the umbilical and uterine arteries.

BACKGROUND: The pain of parturition is associated with major physiologic alterations mediated by neurohumoral factors and increased activation of the sympathetic nervous system. Epidural local anesthetics abolish or alleviate many of the pain-mediated responses by reducing maternal catecholamine levels, inducing sympathectomy and consequent vasodilatation. The hormone response to surgical stress is not attenuated after epidural opioids as efficiently as after local anesthetics. Opioid receptors may modulate sympathetic outflow at a spinal level. This study was performed to compare the effects of epidural sufentanil and bupivacaine on the uterine and placental circulation. METHODS: Utilizing a prospective randomized, double-blind study design, 30 healthy women at term were examined employing a color Doppler technique to assess and compare the effects of analgesia using sufentanil or bupivacaine epidurally during the first stage of labor on blood flow velocity waveforms in the uterine and umbilical arteries. RESULTS: Effective analgesia was provided by both drugs, bupivacaine and sufentanil. Uterine and umbilical blood velocity waveform indices did not change significantly. There was, however, a significantly greater incidence of fetuses with changes in heart rate tracings in the sufentanil group, decreased variability being the most frequent. Maternal side effects attributable to sufentanil were common but mild. No patient became hypotensive in either group. CONCLUSIONS: Epidural sufentanil and bupivacaine provide effective analgesia with acceptable side effects during the first stage of labor in healthy parturients. Neither drug had any detrimental effects on blood flow indexes reflecting peripheral vascular resistance in the umbilical and uterine arteries in healthy parturients.

Adult↗

PubMed1992

Ephedrine and phenylephrine for avoiding maternal hypotension due to spinal anaesthesia for caesarean section. Effects on uteroplacental and fetal haemodynamics.

The effects of i.v. vasopressors on Doppler velocimetry of the maternal uterine and placental arcuate arteries and the fetal umbilical, renal and middle cerebral arteries were studied during spinal anaesthesia in 19 healthy parturients undergoing elective caesarean section. Fetal myocardial function was investigated at the same time by M-mode echocardiography. The patients were randomized into two groups, to be given either ephedrine or phenylephrine as a prophylactic infusion supplemented with minor boluses if systolic arterial pressure decreased by more than 10 mmHg from the control value. Both the vasopressors restored maternal arterial pressure effectively. The ephedrine group showed no significant differences in any of the Doppler velocimetry recordings relative to the baseline values, but during the phenylephrine infusion the blood flow velocity waveform indices for the uterine and placental arcuate arteries increased significantly and vascular resistance decreased significantly in the fetal renal arteries. Healthy fetuses seem to tolerate these changes in uteroplacental circulation well, however, since the Apgar scores for the newborns and the acid-base values in the umbilical cord were within the normal range in both groups. The results suggest that some caution is required when selecting the specific vasopressor agent, the dosage and the mode of administration for the treatment of maternal hypotension secondary to spinal anaesthesia for caesarean section.

Journal Article↗

PubMed1991

The effects of ephedrine and etilefrine on uterine and fetal blood flow and on fetal myocardial function during spinal anaesthesia for caesarean section.

The effects of two vasopressors, ephedrine and etilefrine, on blood flow in maternal uterine, fetal umbilical, middle cerebral and renal arteries and on fetal myocardial function were studied by colour Doppler and M-mode echocardiography techniques during spinal anaesthesia for caesarean section. There were 7 healthy pregnant women in each treatment group. The vascular resistance of maternal uterine arteries increased significantly after both of the vasopressors while the vascular resistance of the umbilical artery remained unchanged. Ephedrine decreased the blood velocity waveform indices in the fetal middle cerebral and renal arteries, increased fetal right ventricular contractility and decreased left ventricular inner end-diastolic dimension. Fetal heart rate was unchanged. Etilefrine caused no detectable changes in fetal haemodynamics or in fetal myocardial function. These findings demonstrate that vasopressors administered for the treatment of minor maternal arterial pressure fall produce vasoconstriction in the uterine circulation during spinal anaesthesia, yet healthy fetuses seem to tolerate these haemodynamic alterations well. On the other hand, ephedrine caused changes in fetal myocardial function and in the vascular resistance of fetal middle cerebral and renal arteries, which demonstrates the potential modifying effect of vasoactive drug given to the mother on fetal haemodynamics.

Journal Article↗

PubMed1991

Uteroplacental and fetal haemodynamics during extradural anaesthesia for caesarean section.

We have studied the effects of extradural anaesthesia with bupivacaine (plain) in eight healthy parturients undergoing elective Caesarean section, on blood flow in maternal uterine and placental arcuate arteries and in fetal umbilical, renal and middle cerebral arteries, using a colour Doppler technique. Simultaneously, fetal myocardial function was investigated by M-mode echocardiography. Maternal and fetal blood velocity waveform indices did not change significantly. We found no changes in fetal myocardial function with extradural anaesthesia, except for an increase in the right ventricular inner end-diastolic dimensions. These results suggest that extradural anaesthesia has no detrimental effects on uteroplacental and fetal circulations in the uncomplicated pregnancy when maternal hypotension is avoided with rapid prehydration.

Anesthesia, Epidural↗

PubMed1991

Effects of extradural bupivacaine with adrenaline for caesarean section on uteroplacental and fetal circulation.

We have studied the effects of an extradural block using bupivacaine with adrenaline 90-100 micrograms on blood flow in the maternal uterine and placental arcuate arteries and the fetal umbilical, renal and middle cerebral arteries, using a colour Doppler technique in eight healthy parturients undergoing elective Caesarean section. Fetal myocardial function was investigated simultaneously by M-mode echocardiography. Maternal heart rate increased and diastolic arterial pressure decreased after extradural administration of bupivacaine with adrenaline. The latter effect was relieved by increasing the infusion rate in every case and none of the patients required vasopressors. There were no significant differences in maternal or fetal blood velocity waveforms, and no significant changes were found in any of the fetal myocardial measurements relative to control values. These observations suggest that extradural anaesthesia using bupivacaine with adrenaline does not have an adverse effect on vascular resistance in the uteroplacental or fetal circulations or on fetal myocardial function in normal pregnancy when bupivacaine-adrenaline is administered fractionally and maternal hypotension is prevented by rapid crystalloid volume loading.

Anesthesia, Epidural↗

PubMed1990

Does ephedrine influence newborn neurobehavioural responses and spectral EEG when used to prevent maternal hypotension during caesarean section?

The recovery of 16 infants born by elective caesarean section with spinal anaesthesia, in which either ephedrine or fluid load was used to prevent maternal hypotension, were studied using Scanlon's neurobehavioural tests and a computerized EEG. Neurobehavioural testing showed no differences between the ephedrine and the non-ephedrine groups of infants at ages of 3 h, 1 day, 2 days and 4-5 days, whereas the spectral EEG showed significant differences between the two groups during the first 2 h after delivery, which had disappeared 24 h later. It is suggested that small doses of ephedrine given to the mother i.v. to prevent hypotension during spinal anaesthesia have short-lived effects on the neonate's central nervous system, which will be detected in the spectral EEG, but not in neurobehavioural tests.

Adult↗