394 spa Abstracts

432 PETHIDINE COMPARED WITH DIAMORPHINE FOR PAIN RELIEF IN

LABOUR. EM.Fairlie, L. Marshall x, J.J. Walker The Perinatal Centre, Glasgow Royal Matern~y Hosp~al, Glasgow, Scotland. UK

433

Despite its proven inefficiency, intramuscular (1M) pethidine is widely selected for pain relief in labour. Diamorphine has been shown to be more effective but there has been a reluctance to use this powerful analgesic in labour. This study was designed to compare the analgesic properties and side effects of 1M pethidine with 1M diamorphine in active labour. Method: 50 nulliparous and 50 multiparous women in active labour (Bishop score ;;'5) were randomly assigned to receive e~her 1M pethidine or 1M diamorphine. Nulliparous women received either 150mg pethidine or 7.5mg diamorphine, mu~iparous women received e~her 100mg pethidine or 5mg diamorphine: Pain sever~y was assessed by a visual analogue score and a 5 point verbal scale. Assessments were made immediately before analgesia and at intervals of 30 minutes post analgesia until delivery or until additional analgesia (epidural blockade) was requested. Results: For each par~y group there was no difference between those receiving pethidine compared with those receiving diamorphine w~h respect to bishop score at the time of drug administration, duration of labour or subsequent epidural analgesia. For the nulliparous group, pethidine was associated with a significant reduction in pain severity at 30 minute (p=0.03 Wilcoxon signed rank test) and 60 minutes (0.01) post drug administration. Reduction in pain severity was more marked in the diamorphine group (0.001 at 30 minutes and 0.008 at 60 minutes). The need for neonatal resucitation was significantly less for the diamorphine group (p=0.03). The mu~iparous group showed similar differences. Conclusion: This data suggests that 1M diamorphine is associated with less neonatal sedation compared with 1M pethidine and there appeared to be a trend towards greater pain relief in the diamorphine group.

IIIIWELLlIG SPIIIA!. CATHETERS All) POST DIIIAl. PIIICTIIIE HEMACIE. s. Cohen, x N.Singer, x D. Amar, x M. Divon, Depts. of Anesthesia and Obstetrics/Gynecology, Albert Einstein College of Medicine. Bronx, NY.

PLnCture of the dura mater for regionaL anesthesia is occasionally associated with post dural pulCture headache (POPH). It has been suggested that continuous spinal anesthesia (CSA) is associated with a low incidence of PDPH in non-obstetric patients. The purpose of this study was to determine the incidence of POPH following inadvertent dural plnCture in term pregnant patients and to assess the effect of continuous spinal anesthesia on PDPH. An epidural block (EB) was att"""ted in 63 patients. Three groups were identified: Group I (n=24) had a dural puncture on the first att"""t of EB followed by a successful EB on the second att"""t. Group Il (n=26) had a dural puncture inmediately converted to CSA with the catheter left in situ <24 hours. Group III (n=13) same as Group I I, but the catheter left in situ >24 hours. ResuLts:

Group I Group I I Group Il I

PDPH Durat i on of Spi na 1 Catheterization (hrs)

""""iOI241 0 12/26*1 8.3 ± 4.7 **

o 1 37 ± 9.7

p<.OI Group [[ I vs. Group I or [[ ** p<O.OOI Group [[ vs. Group [[ I.

In conclusion, continuous spinal catheterization following accidental dural puncture may be an adequate method of POPH prophylaxis in pregnant patients.

434

January 1992 Am J Obstet Gynecol

THE EFFECTS OF CONTINUOUS BUPIVACAINE/FENTANYL EPIDURAL ON FETAL HEART RATE CHARACTERISTICS. E.R. Newton, B. Schroeder,' K. Higby' and B. Bennett,' Dept. of 0Ii7CiYrl. The Univ. ofTx. HSC, San Antonio, Tx.

The effects of epidural anal!!esia on fetal heart rate patterns (FHR) are controversial. The dIfferences in maternal and fetal conditions between patients obscure the direct effect of epidurals on FHR. We evaluated the effects of epidural analgesia on FHR usin!;l each fetus as its own control. Thirty~seven successful continuous labor epidurals using bupivacaine and fentanyl were matched with the next two consecutive patients of the same parity who delivered without epidural analgesia. Fetal heart tracings, one hour before and after epidural placement, or at a correspondin!il cervical dilation in the control patients were evaluated by In a blinded fashion. Six (16%) epidural patients required ephedrine for hypotension and epidural patients received more IV fluids than controls (2075 vs. 952 cc, P <O.Ot). FHR characteristics within fetuses in the presence or absence of epidural analgesia, were compared.

Mean change between periods - ---------

Characteristics Epidural Control

Baseline heart rate (BPM) 1.4 \/ -1.1

Variability (BPM) -0.9 -1.7

Maximum oscillation (BPM) 0.32 -1.3

Accelerations -0.81 p=ns -1.88

Moderate variables 0.81 0.82

Severe variables 0.00

/\

0.47

0.54

Deterioration or improvement in FHR characteristics are not related to continuous bupivacaine/fentanyllabor epidurals.

Late decelerations 0.20

435 ANONYMOUS URINE TOXICOLOGY SCREEN IN A RURAL STATE RA WrightX, F ByfordX, S Carterx, MA Morgan, KM ParkerX, PC

Toubasx , D Blousex, Oklahoma Univ. Health Sciences Center, Oklahoma State Health Dept., Indian Health Services, Oklahoma City, OK and Univ. of California, Irvine, Orange, CA.

Although substance abuse in inner~city pregnant populations is reported to be high, the frequency of abuse in a rural state remains unknown. The purpose of this study was to anonymously screen urine specimens of consecutive deliveries during one month from three hospitals, in different cities and geographic areas of a rural state and determine perinatal outcomes. Specimens were conected on admission from 435 patients in labor (57% teaching hospital, 25% public hospital and 19% private hospital) and tested at a NIDA certified laboratory for amphetamine, barbiturate, benzodiazepine, marijuana, cocaine, opiate and phencyclidine. Positive screens were observed in 90 patients (86% one substance; 12% two; 2% three). Babriturate(51 %) was most frequently seen, followed by opiate (19%), amphetamine (14%), marijuana (13%), benzodiazepine (2%) and cocaine (0.9%). However, the barbiturate positives were prescribed. The patients with positive and negative results were similar in age, parity, race, delivery gestational age, mode of delivery, neonatal birthweight, apgar scores, low birth weight and perinatal mortality. The three different participating hospitals had similar positive results. However, those positive for opiates were observed to deliver at a significantly earlier gestational age than negatives (37.9±3.6 vs. 39.2±2.3, p<0.025). Although these hospitals in a rural state have a similar frequency of positive toxicology screens at delivery as reported for inner·city hospitals, the distribution of substances is drastically different, with a low frequency of cocaine. Similar studies from other rural settings are needed to determine where to concentrate therapy efforts for substance abuse during perinatal period.