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Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.

SummaryWe studied the potentiation of analgesia for labour by the addition of clonidine to epidural low-concentration levobupivacaine with sufentanil in a randomised, double-blinded study. We enrolled primiparous women who were in spontaneous labour. The study solutions, made of 100 ml levobupivacaine 0.0625% plus sufentanil 0.45 lg.ml )1 and either 150 lg clonidine or no clonidine, were used for induction of analgesia, and for its maintenance with self-administered boluses and a continuous background infusion. The need for additional epidural boluses during labour was lower and analgesia and maternal satisfaction were better in the clonidine (n = 57) than in the control group (n = 58). Blood pressure was lower and the rate of instrumental delivery higher in the clonidine group. Clonidine (1.36 lg.ml) added to the epidural solution of lowconcentration levobupivacaine improves the quality of analgesia. The relevance of the haemodynamic effects should be explored in larger validation studies. To relieve pain during labour with the fewest side effects possible, different solutions have been proposed. These include lowering the concentration of local anaesthetics and ⁄ or adding opioids to the anaesthetic solution, and developing less toxic drugs than bupivacaine [1]. We recently studied the effects of two formulations of levobupivacaine (0.0625% and 0.125%) for analgesia during labour in primiparous women, both with sufentanil 0.45 lg.ml )1 [2]. The solution was patient-administered after a first injection of 15-20 ml for induction. With low-concentration levobupivacaine, analgesia was sometimes insufficient, while high-concentration levobupivacaine provided better analgesia, but doses sometimes exceeded recommended limits. We hypothesised that addition of low-dose clonidine to low-concentration levobupivacaine would improve the quality of analgesia without exceeding recommended dose limits. Clonidine is known to potentiate epidural analgesia through inhibition of nociceptive transmission in the spinal cord via a2 receptors and through local anaesthetic effects [3,4]. Although epidural clonidine for labour is usually administered as a single injection [5,6], the addition of clonidine in epidural infusions has also been shown to improve analgesia during labour [7][8][9][10][11]. However, as concentrations over 2 lg.ml )1 may lead to more side effects [8,[10][11][12], we chose a safer dose of 150 lg of clonidine, diluted in our prefilled bags,

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The combined spinal-epidural technique provided more effective analgesia during labour than epidural analgesia alone but offered no other advantage. It induced more adverse effects and this should be considered before routinely using the combined spinal-epidural technique.

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(Eur J Anaesthesiol. 2019;36:755–762) Currently about 80% of deliveries in France involve an epidural for labor analgesia. Epidural rates and programs have changed over time, but various authors have found that a programmed intermittent epidural bolus (PIEB) plus patient-controlled epidural analgesia (PCEA) demand dosing strategy for maintenance of labor analgesia decreased the rate of instrumental vaginal delivery, lessened anesthetic drug consumption and increased maternal satisfaction scores compared with a continuous background infusion+PCEA. This study aimed to investigate whether the use of a modern PIEB pump improved the mechanics of the second stage of labor compared with a conventional epidural analgesia technique.

BackgroundWe report two unusual separate complications after uterine artery embolization for a late postpartum haemorrhage. This report appeared important to us in view of the apparent absence of any other publications on this topic.Case presentationWe report the case of a 25-year-old woman, gravida 3, para 1, admitted for uterine bleeding 7 days after a spontaneous delivery at term, in our university hospital. A suction curettage and then, after persistent bleeding, uterine artery embolization were necessary. Immediately after the embolization, a bilateral ovarian thrombosis occurred, subsequently followed by amenorrhea, due to uterine synechiae, and depression. Hysteroscopic surgery was performed to remove the adhesions. A complete work-up for thrombophilia showed a heterozygous mutation of the factor V gene R506Q. The pathology examination found subinvolution of the placental bed. One month after treatment of the synechiae (and insertion of a copper IUD for contraception), the woman's menstrual cycle returned to normal. Her clinical examination 19 months later was normal.ConclusionsThis case teaches us that one rare complication can hide another! It is important to consider the diagnosis of subinvolution of the placental bed in cases of late PPH and to know the complications associated with vascular artery embolization in order to provide the most rapid and least invasive treatment.