225
Available data suggest a failure rate of 1 % and ectopic pregnancies account for 15-60% ofthese.9 4 million tubal ligations were done in India in 1985-86, and the target for 1988-89 was 5 million. We can expect 4000-5000 ectopic pregnancies as a result of these procedures. Since most would arise in rural areas where blood transfusion and emergency surgery services are inadequate, the resulting deaths would have to be set against deaths from unwanted pregnancies that were avoided. Some doctors fmd no cause for concern over the morbidity and case fatality rates that they themselves have reported, and pronounce camp sterilisations effective and safe. Income tax benefits to lure doctors to these camps have been suggested. The programme seems sacrosanct and patients’ welfare takes second place. One group has argued that laparoscopy should be avoided in medically unfit cases "to avoid complications which have a bad effect on the programme";! and another notes that because drugs for premedication are scarce "it is not unusual for the patients to feel the pain and shout during the procedure, thus alarming waiting crowd"
(our emphasis). When
women
who
are
otherwise well
are
motivated for
a
procedure that is not essential to their wellbeing, extreme vigilance is mandatory to prevent complications, big or small. Your editorial seeks to laud those camps where this principle is neglected. Durlabhji Memorial Hospital, Bhawani Singh Marg, Jaipur 302 015, India Santokba
S. G. KABRA RAMJI NARAYANAN
Sholapurkar ML, Saradesai SP, Nalgirka AJ. Organising laparoscopic stenlisation camp and factors promoting success. J Obstet Gynaecol India 1985; 35: 170-75. 2. Mhatre PN, Parulekar SV, Purandare VN. Complications of laparoscopic sterilisations in rural camps. J Obstet Gynaecol India 1986; 36: 706-08. 3. Konar HL, Chowdhury ML, Bhowmick RN. Laparoscopic camp sterilisation in the Himalayan and sub-Himalayan region: a critical review of 7,730 cases J Obstet Gynaecol India 1987; 37: 601-05. 4 Konar HL, Chowdhury ML, Bhowmick RN. Realities of laparoscopic camp sterilisation. J Obstet Gynaecol India 1987; 37: 703-09. 5. Sinha BK. Laparoscopic sterilisation vis-a-vis rural population. J Obstet Gynaecol 1.
India 1985, 35: 558-60.
Tongaonkar RR. Complications of surgery m rural India-a personal view. Ind J Surg 1987; 45 (suppl): 24-32. 7. Mehta PV. A total of 250 136 laparoscopic sterilisations by a single operator. Br J Obstet Gynaecol 1989; 96: 1024-34. 8. Guillebaud J. Mass laparoscopic sterilisations. Br J Obstet Gynaecol 1989; 96: 1019-20. 9. Prasad V, Jha RN. Position of Falope nng m laparoscopic ligation failure J Obstet Gynaecol India 1986; 36: 343-45.
(0-5-15) ml and analgesia from the single bolus lasted 48 (16-98) min. Analgesia was maintained until the episiotomy was repaired for a total time of 267 (96-620) min, and a total dose 4-8 (18-77) ml was required. All patients were able to move about within 6 h after delivery. The patients were followed for 4 days and none had post-spinal headache or other complications. Continuous subarachnoid analgesia via a 32 G catheter offers at least three major advantages over continuous epidural analgesia: it is easier to do, much less local anaesthetic is used (virtually eliminating the risk of harmful effects for both mother and fetus), and the analgesia is more predictable and controllable. This technique may warrant further investigation with a continuous infusion technique rather than repeated boluses, with different local anaesthetic concentrations and agents, and possibly with a combination of low-dose intrathecal opioid and an even lower concentration of local anaesthetic. The spinal catheters were kmdly supplied by TFX Medical. We also thank Prof John J. Bonica (University of Washington) for his encouragement and advice and of Prof G. Candiani, Prof F. Polvani, and their associates (University of Milan), for cooperation in enrolling patients for this project.
Department of Anesthesiology and Multidisciplinary Pain Center, University of Washington, Seattle, Washington 98195,USA
COSTANTINO BENEDETTI
Department of Physiopathology and Therapy of Pain, University of Milan, Milan, Italy
MARIO TIENGO
1. Lemmon WG. A method for continuous spinal anesthesia. Ann Surg 1940; 111: 141-44. 2. Carpenter SL, Ceravolo AJ, Foldes FF. Continuous-drop subarachnoidal block with dilute procaine solution for labor and delivery. Am J Obstet Gynecol 1951; 61: 1277-84. 3. Rasmussen BS, Hansen LBP, Mikkelsen SS. Postspinal headache in young and elderly patients. Anaesthesia 1989; 44: 571-73. 4. Hurley RJ, Lambert DH. Continuous spinal anesthesia with a microcatheter technique Reg Anesth 1987; 12: 53-54.
6.
Continuous subarachnoid labour
analgesia
in
SIR,-Continuous sabarachnoid block was first proposed by Lemmon in 1940.1 In 1951 Carpenter et al2 described continuous subarachnoid analgesia for labour and delivery with a catheter which could pass through an 18 G spinal needle. However, post-spinal headache developed in 10% of the patients. Attempts to prevent this incapacitating complication failed and the technique never became popular. In 1989 Rasmussen et aP reported that 25--26 G needles significantly decreased the incidence of post-spinal headache in young patients. The development of a 32 G catheter that passes through a 26 G spinal needle’ prompted us to look again at continuous subarachnoid analgesia for pain during parturition. With ethical committee approval and informed consent we studied twelve women in active, painful labour. The spinal catheter was inserted 3-5 cm in the vertebral theca through a 26 G spinal needle placed via a paramedial approach in the lumbar subarachnoid space. The patient evaluated the pain intensity of her contraction on a 10-point scale. Before analgesia pain was rated severe to moderate. After intravenous hydration with 1 litre of crystalloids, 0-5 ml of 0-25% (1-25 mg) isobaric bupivacaine was injected intrathecally; 10-15 min later another 0’5-1-0 ml was given if analgesia was not satisfactory. All patients reported that after spinal analgesia the pain became mild and acceptable. There was no significant change in physiological indices in either mother or fetus. Pain decreased from an average of 8-6 (range 7-10) points before to 2-8 (0-5) after the subarachnoid block. An 8 (4-12) dermatome spread of hypoalgesia was obtained (T8-10 to L2-S2). The single dose of bupivacaine needed to produce pain relief was 0-98
fluidity in hypertension
Platelet membrane
pregnancy
SIR,-Dr Baker and colleagues (Nov 11, p 1151) suggest that specific high-affinity binding of angiotensin II (All) to platelet membranes is enhanced in women with pregnancy-induced hypertension (PIH). It is believed that alteration in cell membrane fluidity can affect the accessibility of cell membrane proteins which act as receptors. Increasing the viscosity of a cell membrane decreases its capacity to solubilise integral proteins, displacing the proteins towards the aqueous phase on either side of the membrane. This "vertical displacement" of membrane proteins1 may have a role in the determination of receptor accessibility.2 Platelet membrane fluidity may be modified in vivo’ and in vitro.4 Dietary n-3 polyunsaturated fatty acids, which decrease cell membrane viscosity, inhibit platelet aggregation3and enrichment of platelet membranes with cholesterol in vitro increases membrane viscosity and sensitises platelets to aggregation induced by adenosine diphosphate and adrenaline.4 We have measured platelet membrane fluidity in three patients with a singleton pregnancy who were admitted to hospital with severe PIH at 27, 29, and 31 weeks’ gestation. All had 1-3 g/l proteinuria per 24 h and needed delivery within a week of admission. Blood samples were also taken from three normotensive pregnant women, matched for age, race, and gestation. Platelets were isolated and resuspended in isolation buffer;5 cell membrane fluidity was measured at 37°C in whole cells using fluorescence polarisation of the membrane probe 1,6-diphenyl1,3,5-hexatriene and relative microviscosity of the cell membranes was calculated.6,7 Relative membrane viscosity in platelets from the women with PIH was higher than it was in controls (0-853 [SD 0-023] vs 0-793 [0-004]; p < 0-01, t test). Such changes of platelet membrane fluidity are associated with altered
activity of membrane-bound
enzymes which may be
Available data suggest a failure rate of 1 % and ectopic pregnancies account for 15-60% ofthese.9 4 million tubal ligations were done in India in 1985-86, and the target for 1988-89 was 5 million. We can expect 4000-5000 ectopic pregnancies as a result of these procedures. Since most would arise in rural areas where blood transfusion and emergency surgery services are inadequate, the resulting deaths would have to be set against deaths from unwanted pregnancies that were avoided. Some doctors fmd no cause for concern over the morbidity and case fatality rates that they themselves have reported, and pronounce camp sterilisations effective and safe. Income tax benefits to lure doctors to these camps have been suggested. The programme seems sacrosanct and patients’ welfare takes second place. One group has argued that laparoscopy should be avoided in medically unfit cases "to avoid complications which have a bad effect on the programme";! and another notes that because drugs for premedication are scarce "it is not unusual for the patients to feel the pain and shout during the procedure, thus alarming waiting crowd"
(our emphasis). When
women
who
are
otherwise well
are
motivated for
a
procedure that is not essential to their wellbeing, extreme vigilance is mandatory to prevent complications, big or small. Your editorial seeks to laud those camps where this principle is neglected. Durlabhji Memorial Hospital, Bhawani Singh Marg, Jaipur 302 015, India Santokba
S. G. KABRA RAMJI NARAYANAN
Sholapurkar ML, Saradesai SP, Nalgirka AJ. Organising laparoscopic stenlisation camp and factors promoting success. J Obstet Gynaecol India 1985; 35: 170-75. 2. Mhatre PN, Parulekar SV, Purandare VN. Complications of laparoscopic sterilisations in rural camps. J Obstet Gynaecol India 1986; 36: 706-08. 3. Konar HL, Chowdhury ML, Bhowmick RN. Laparoscopic camp sterilisation in the Himalayan and sub-Himalayan region: a critical review of 7,730 cases J Obstet Gynaecol India 1987; 37: 601-05. 4 Konar HL, Chowdhury ML, Bhowmick RN. Realities of laparoscopic camp sterilisation. J Obstet Gynaecol India 1987; 37: 703-09. 5. Sinha BK. Laparoscopic sterilisation vis-a-vis rural population. J Obstet Gynaecol 1.
India 1985, 35: 558-60.
Tongaonkar RR. Complications of surgery m rural India-a personal view. Ind J Surg 1987; 45 (suppl): 24-32. 7. Mehta PV. A total of 250 136 laparoscopic sterilisations by a single operator. Br J Obstet Gynaecol 1989; 96: 1024-34. 8. Guillebaud J. Mass laparoscopic sterilisations. Br J Obstet Gynaecol 1989; 96: 1019-20. 9. Prasad V, Jha RN. Position of Falope nng m laparoscopic ligation failure J Obstet Gynaecol India 1986; 36: 343-45.
(0-5-15) ml and analgesia from the single bolus lasted 48 (16-98) min. Analgesia was maintained until the episiotomy was repaired for a total time of 267 (96-620) min, and a total dose 4-8 (18-77) ml was required. All patients were able to move about within 6 h after delivery. The patients were followed for 4 days and none had post-spinal headache or other complications. Continuous subarachnoid analgesia via a 32 G catheter offers at least three major advantages over continuous epidural analgesia: it is easier to do, much less local anaesthetic is used (virtually eliminating the risk of harmful effects for both mother and fetus), and the analgesia is more predictable and controllable. This technique may warrant further investigation with a continuous infusion technique rather than repeated boluses, with different local anaesthetic concentrations and agents, and possibly with a combination of low-dose intrathecal opioid and an even lower concentration of local anaesthetic. The spinal catheters were kmdly supplied by TFX Medical. We also thank Prof John J. Bonica (University of Washington) for his encouragement and advice and of Prof G. Candiani, Prof F. Polvani, and their associates (University of Milan), for cooperation in enrolling patients for this project.
Department of Anesthesiology and Multidisciplinary Pain Center, University of Washington, Seattle, Washington 98195,USA
COSTANTINO BENEDETTI
Department of Physiopathology and Therapy of Pain, University of Milan, Milan, Italy
MARIO TIENGO
1. Lemmon WG. A method for continuous spinal anesthesia. Ann Surg 1940; 111: 141-44. 2. Carpenter SL, Ceravolo AJ, Foldes FF. Continuous-drop subarachnoidal block with dilute procaine solution for labor and delivery. Am J Obstet Gynecol 1951; 61: 1277-84. 3. Rasmussen BS, Hansen LBP, Mikkelsen SS. Postspinal headache in young and elderly patients. Anaesthesia 1989; 44: 571-73. 4. Hurley RJ, Lambert DH. Continuous spinal anesthesia with a microcatheter technique Reg Anesth 1987; 12: 53-54.
6.
Continuous subarachnoid labour
analgesia
in
SIR,-Continuous sabarachnoid block was first proposed by Lemmon in 1940.1 In 1951 Carpenter et al2 described continuous subarachnoid analgesia for labour and delivery with a catheter which could pass through an 18 G spinal needle. However, post-spinal headache developed in 10% of the patients. Attempts to prevent this incapacitating complication failed and the technique never became popular. In 1989 Rasmussen et aP reported that 25--26 G needles significantly decreased the incidence of post-spinal headache in young patients. The development of a 32 G catheter that passes through a 26 G spinal needle’ prompted us to look again at continuous subarachnoid analgesia for pain during parturition. With ethical committee approval and informed consent we studied twelve women in active, painful labour. The spinal catheter was inserted 3-5 cm in the vertebral theca through a 26 G spinal needle placed via a paramedial approach in the lumbar subarachnoid space. The patient evaluated the pain intensity of her contraction on a 10-point scale. Before analgesia pain was rated severe to moderate. After intravenous hydration with 1 litre of crystalloids, 0-5 ml of 0-25% (1-25 mg) isobaric bupivacaine was injected intrathecally; 10-15 min later another 0’5-1-0 ml was given if analgesia was not satisfactory. All patients reported that after spinal analgesia the pain became mild and acceptable. There was no significant change in physiological indices in either mother or fetus. Pain decreased from an average of 8-6 (range 7-10) points before to 2-8 (0-5) after the subarachnoid block. An 8 (4-12) dermatome spread of hypoalgesia was obtained (T8-10 to L2-S2). The single dose of bupivacaine needed to produce pain relief was 0-98
fluidity in hypertension
Platelet membrane
pregnancy
SIR,-Dr Baker and colleagues (Nov 11, p 1151) suggest that specific high-affinity binding of angiotensin II (All) to platelet membranes is enhanced in women with pregnancy-induced hypertension (PIH). It is believed that alteration in cell membrane fluidity can affect the accessibility of cell membrane proteins which act as receptors. Increasing the viscosity of a cell membrane decreases its capacity to solubilise integral proteins, displacing the proteins towards the aqueous phase on either side of the membrane. This "vertical displacement" of membrane proteins1 may have a role in the determination of receptor accessibility.2 Platelet membrane fluidity may be modified in vivo’ and in vitro.4 Dietary n-3 polyunsaturated fatty acids, which decrease cell membrane viscosity, inhibit platelet aggregation3and enrichment of platelet membranes with cholesterol in vitro increases membrane viscosity and sensitises platelets to aggregation induced by adenosine diphosphate and adrenaline.4 We have measured platelet membrane fluidity in three patients with a singleton pregnancy who were admitted to hospital with severe PIH at 27, 29, and 31 weeks’ gestation. All had 1-3 g/l proteinuria per 24 h and needed delivery within a week of admission. Blood samples were also taken from three normotensive pregnant women, matched for age, race, and gestation. Platelets were isolated and resuspended in isolation buffer;5 cell membrane fluidity was measured at 37°C in whole cells using fluorescence polarisation of the membrane probe 1,6-diphenyl1,3,5-hexatriene and relative microviscosity of the cell membranes was calculated.6,7 Relative membrane viscosity in platelets from the women with PIH was higher than it was in controls (0-853 [SD 0-023] vs 0-793 [0-004]; p < 0-01, t test). Such changes of platelet membrane fluidity are associated with altered
activity of membrane-bound
enzymes which may be
