Cesarean Delivery Research Articles

MORTALIDADE NO PERÍODO GESTACIONAL POR COMPLICAÇÕES ANESTÉSICAS: NÚMEROS NACIONAIS DOS ÚLTIMOS 10 ANOS

Brazil stands out globally for the number of cesarean sections performed annually, with figures far exceeding the recommendations of the WHO – World Health Organization. Cesarean delivery requires appropriate anesthetic blockade, with various techniques possible, the most common being spinal anesthesia and, less frequently, general anesthesia techniques. Both regional and general anesthesia techniques have advanced significantly in recent years but are not free from complications, which are associated with both maternal history and the anesthetic procedure itself. Maternal morbidity and mortality during the gestational period is a public health issue, which is also linked to the appropriate choice of delivery method and necessary anesthesia procedure. Therefore, the aim of this study is to examine the national number of maternal deaths related to anesthetic procedures over the past 10 years – from 2014 to 2023 – and to compare national data with international data, based on the most recent scientific literature.

Hemoglobin concentrations in early pregnancy and their associations with adverse pregnancy outcomes in Western China: a population-based study.

Despite the global standardization of hemoglobin (Hb) testing in early pregnancy, the impact of first trimester Hb concentrations on pregnancy outcomes remains inadequately understood. Also, the early pregnancy Hb concentrations have not been well documented in Western China. Therefore, this study aimed to assess the Hb concentrations during early pregnancy and their associations with adverse pregnancy outcomes in Western China. This cross-sectional study used data from the Chengdu Maternal and Child Health Information System for pregnant women who delivered between January 1, 2019, and December 31, 2023. A total of 454,815 Chinese females aged 15 to 49 years with available first trimester Hb data, including those with singleton or multiple gestations, were included in the analysis. Multivariable logistic regression models were performed to estimate the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between Hb categories and adverse pregnancy outcomes. The average first trimester Hb concentration was 126.0 (SD 10.5) g/L, with 5.8% of pregnant women experiencing anemia during early pregnancy. Multivariable logistic regression analyses revealed significantly increased odds of developing gestational diabetes mellitus (GDM) and gestational hypertensive disorders (GHD) across increasing Hb concentration categories. Compared to Hb concentrations of 110-119g/L, Hb ≥ 140g/L was associated with elevated risk of GDM (aOR: 1.57, 95% CI: 1.52, 1.62) and GHD (aOR: 1.87, 95% CI: 1.79, 1.96). Moreover, both Hb ≤ 99g/L (aOR: 1.15, 95% CI: 1.03, 1.29) and Hb ≥ 140g/L (aOR: 1.20, 95% CI: 1.13, 1.26) were associated with higher odds of preterm birth compared to Hb concentrations of 110-119g/L. In addition, the restricted cubic spline demonstrated a U-shaped relationship for cesarean delivery, low birthweight and small for gestational age (p < 0.001). However, no significant associations were found between first trimester Hb concentrations and the odds of stillbirth, Apgar score < 7 at 5min, or Apgar score < 7 at 10min (p > 0.05). Our research findings suggest associations between first trimester Hb concentrations and various adverse pregnancy outcomes. We recommend interventions for early pregnancy anemia, particularly moderate to severe cases, and emphasize monitoring females with high Hb concentrations to reduce adverse outcomes.

Length of stay and determinants of early discharge and extended stay after cesarean delivery in a resource-limited setting: southern Ethiopia, 2023

BackgroundFor mothers and newborns to obtain the recommended postnatal care follow-up and package, the healthcare facility has to provide a minimum length of stay following delivery. Early discharge may result in a shortened recovery time, less access to resources and support, and a prolonged stay, resulting in a greater risk of postpartum depression and financial constraints. In Ethiopia, there has been no study conducted on the length of hospital stays following a cesarean delivery. Therefore, this study aimed to determine the average length of stay and identify factors influencing both early discharges and prolonged stays after cesarean delivery in southern Ethiopia.MethodsA facility-based cross-sectional study was conducted between November 23, 2022, and March 23, 2023. A systematic sampling method was used to select 367 participants, and data were collected using the Kobo Toolbox mobile application. The mean length of stay was calculated in hours, and descriptive statistics were used to summarize the data. Multinomial logistic regression was employed to analyze the determinants of length of stay, with significance set at a p-value of &amp;lt;0.05.ResultsThe mean duration of the length of stay of mothers in health facilities after cesarean delivery is 65 h or approximately 2.71 days (SD ± 0.77). Determinants of shorter stay included women aged 20–24 years [AOR = 5.19; 95%CI 1.51–8.23], distance from hospital 30–60 min [AOR = 2.51; 95% CI 1.12–5.73], first antenatal booking [AOR = 0.16; 95%CI 0.05–0.25], monthly income &amp;lt;2,000 birr [AOR = 3.11; 95%CI 1.18–6.05], had health insurance [AOR = 0.35; 95% CI 0.26–0.37] and had counseled [AOR = 0.09; 95%CI 0.07–0.154]. Extended stays were associated with severe pre-eclampsia [AOR = 2.80; 95%CI 2.41–3.27], multiple births [AOR = 2.51; 95%CI 1.34–4.71], and postoperative complications [AOR = 3.52; 95%CI 1.35–5.01].ConclusionThe average post-cesarean hospital stay is 2.71 days, with duration influenced by factors such as age, distance to the hospital, access to antenatal care, income, insurance, and the presence of complications. Targeted interventions, such as improving access to antenatal care, providing financial support, and proactively managing complications, can improve outcomes.

Comparison of Phenylephrine Bolus and Infusion Regimens on Maternal and Fetal Outcomes During Cesarean Delivery: A Systematic Review and Meta-Analysis

BACKGROUND: A systematic review and meta-analysis was conducted to compare phenylephrine boluses versus prophylactic infusion in parturients undergoing cesarean delivery under spinal or combined spinal-epidural anesthesia on feto-maternal outcomes. METHODS: Medline, Embase, Cochrane, and US Clinical registry databases were searched. Studies comparing phenylephrine boluses (both therapeutic and prophylactic) with infusion (both fixed- and variable-rate) assessing various feto-maternal outcomes were included. The primary outcome was the incidence of maternal hypotension. Secondary maternal outcomes included the incidence of reactive hypertension, bradycardia, nausea, or vomiting; secondary neonatal outcomes included umbilical arterial pH, partial pressure of oxygen (paO2), umbilical venous pH, fetal acidosis, Apgar Scores at 1 and 5 minutes. All outcomes were quantitatively analyzed using the random effects model. Risk of bias was assessed using the Cochrane Collaboration R0B 2.0 tool. RESULTS: We included 15 studies with 2153 parturients. The parturients receiving phenylephrine bolus during cesarean delivery under spinal or combined spinal-epidural anesthesia had a significant increase in the incidence of predelivery hypotension compared to phenylephrine infusion (risk ratio [RR], 2.34, 95% confidence interval [CI], 1.72–3.18). Reactive hypertension (RR, 0.48, 95% CI, 0.29–0.79) and bradycardia (RR, 0.57, 95% CI, 0.41–0.79) were less common in the parturients receiving phenylephrine bolus; whereas, vomiting (RR, 2.15, 95% CI, 1.53–3.03) was more common compared to the infusion group. No statistically significant difference was observed in the incidence of nausea or any fetal outcomes (umbilical artery pH, paO2, umbilical venous pH, fetal acidosis, and Apgar scores at 1 and 5 minutes) between either of the groups. Three studies had a high risk of bias. CONCLUSIONS: A prophylactic phenylephrine infusion significantly reduces the incidence of predelivery hypotension in parturients undergoing cesarean delivery under neuraxial anesthesia in comparison to the therapeutic or prophylactic phenylephrine bolus group. A prophylactic phenylephrine infusion may be considered in all parturients without preexisting hypertensive disorder or cardiovascular disorders to reduce the risk of predelivery hypotension. More evidence is needed to guide optimal hemodynamic management for patients with hypertensive or cardiovascular disorders.

Effect of dexmedetomidine as an adjuvant to bupivacaine in bilateral posterior quadratus lumborum block for postoperative analgesia after cesarean delivery: A prospective randomized double-blinded study

Effect of dexmedetomidine as an adjuvant to bupivacaine in bilateral posterior quadratus lumborum block for postoperative analgesia after cesarean delivery: A prospective randomized double-blinded study

Comparative study on maternal and fetal outcomes in emergency versus elective caesarean section

: The progressive increase in the incidence of caesarean section during the last few decades has been constant worldwide, increasing; at the same time, the indications, many of them unnecessary, resulting in indiscriminate practice, becoming the most frequent surgical intervention performed in health institutions, both private and public. Caesarean section is preferred as an emergency or elective procedure depending on the maternal and fetal conditions. It has been seen that risk of surgical complications is greater with emergency as compared with elective caesarean section. : Present study is a retrospective study, designed to evaluate maternal and fetal outcomes in elective versus emergency caesarean sections performed at our hospital from January 2023 to December 2023.: Out of total 2573 deliveries conducted, 1496 were normal deliveries, 116 were instrumental and 961 were caesarean deliveries, 446 were emergency and 515 were elective caesarean section. In our study overall operative complications were 114(11.8%) which was mainly contributed to emergency group.: The elective caesarean section shows less maternal and perinatal complications as compared to emergency caesarean sections.

Chronic Low Back Pain Post-Caesarean Delivery: A Physiotherapist’s Perspective

This short review investigated the connection between neuraxial anaesthesia and chronic low back pain (CLBP) following caesarean sections, highlighting an important area of concern as the prevalence of such surgeries increases. Several risk factors for developing CLBP were identified, including needle size and patient posture during the procedure. Emphasis was placed on the crucial role of physiotherapists in distinguishing between pregnancy-related back pain and pain resulting from anaesthesia, as well as monitoring postoperative symptoms. Effective physiotherapy interventions were discussed, focusing on improving posture, enhancing mobility, and addressing psychosocial factors that may impact recovery. By advocating for a multidisciplinary approach, the review highlighted the necessity for comprehensive strategies that consider both physical and psychological aspects of recovery, ultimately aiming to optimise outcomes for women after caesarean delivery. Keywords: Chronic low back pain, Neuraxial anaesthesia, Caesarean section, Physiotherapy interventions, Risk factors, Multidisciplinary approach

Enhanced recovery after surgery (ERAS) a multimodal perioperative care pathway in cesarean deliveries

Enhanced Recovery After Surgery (ERAS) is an evidence based perioperative program applied for early recovery of patients after surgery to reduce the postoperative surgical stress and hasten early physiological and functional recovery. The present study is focused on application of ERAS protocol in the branch of obstetrics following cesarean sections.The primary objective is to compare the efficacy between post-operative recommendations of ERAS protocols and traditional post-operative care in cesarean sections. A total of 300 patients were included in this study from November 2020 to October 2022 from the inpatient department of Obstetrics and Gynaecology of Pradyumna Bal Memorial hospital, KIMS, Bhubaneswar. Out of 300 patients, 150 were in ERAS group and 150 were in control (conventional) group. The median Length of stay (LOS) of ERAS and control group were 3 and 5 days respectively (p&amp;#60;0.01). The median patient satisfaction score on Likert scale was 4 and 3 for ERAS and control group respectively (p&amp;#60;0.01).The application of ERAS in post-operative period after cesarean has showed significant results in decreasing length of stay and better patient satisfaction score.

How does chronic endometritis influence pregnancy outcomes in endometriosis associated infertility? A retrospective cohort study.

Endometriosis (EMS) and chronic endometritis (CE) frequently coexist. This study aimed to examine the impact of CE on reproductive outcomes in patients with EMS. We enrolled 685 patients with endometriosis-associated infertility from January 2018 to December 2020. The patients were divided into CE (318) and non-CE (367) groups. A subset of 123 clinically pregnant women from the CE group and 369 from the non-CE group was selected for detailed comparison. Pregnancy and delivery data were meticulously collected from hospital records and through telephone interviews. CE was diagnosed in 46.42% of EMS patients. Higher pregnancy rates were observed in patients with Endometriosis Fertility Index (EFI) scores of 7-10. EMS patients with CE had increased risks of placenta previa (13.01%), gestational hypertension (5.69%), and cesarean sections (59.34%). CE, which is prevalent among EMS patients, is linked to increased risks of pregnancy complications, including placenta previa, gestational hypertension, and cesarean delivery. Although combined hysteroscopy and laparoscopy improve pregnancy rates, they demand careful management of these complications.

The effect of acupressure on postpartum pain and comfort after cesarean delivery: a randomized controlled trial

ABSTRACT This randomized controlled study aims to investigate the effect of acupressure on pain and postpartum comfort following a cesarean section. The study was conducted with 60 women who underwent cesarean delivery. The participants were randomly assigned to either the intervention or control group. In the intervention group, acupressure was applied to the LI4, SP6, and P6 points for 15 minutes at the 2nd and 4th hours after the cesarean section. In the control group, acupressure was not applied and only routine nursing care was given. Data was collected using a personal information form, Visual Analog Scale (VAS), and Postpartum Comfort Questionnaire (PCQ). Acupressure application was applied to the intervention group at the 2nd and 4th hour after cesarean section. All data collection forms were filled out by women in the intervention group before starting acupressure application at 2 hours after cesarean section. VAS was filled out again after acupressure application at 2 hours. VAS was filled out before and after acupressure application at 4 hours after cesarean section. PSQ was filled out in both groups before discharge. In the study, the intervention group’s 2nd (3.03 ± 1.24, p < .001) and 4th (4.06 ± 1.22, p < .001) hour posttest VAS scores were lower and PCQ posttest scores (140.6 ± 9.01, p < .001) were higher than the control group. The results indicate that acupressure intervention applied to points LI4, SP6, and P6 was a useful nonpharmacological treatment for postpartum pain and comfort for the study group.

Evidence-based Cesarean Delivery: Intraoperative management following placental delivery until skin closure (Part 9): Evidence based care during cesarean delivery.

This expert review provides recommendations for the cesarean technique after placental delivery to skin closure. Following placental delivery during cesarean, sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable with some possible benefits with decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, one versus two-layer closure. Double layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness and full thickness bites (including endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and prior to closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion-prevention barriers, peritoneal closure, and rectus muscle re-approximation. Based on non-cesarean evidence, fascial closure bites should be at least 5 × 5 mm with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia either supra- or sub-fascial. Prior to closure, subcutaneous irrigation may be performed with saline, and routine use of subcutaneous drains is not recommended. Though closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥ 2cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the CD skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision the following may be considered: a DACC-impregnated dressing if available, otherwise a standard gauze dressing is appropriate. Prophylactic negative pressure would therapy can be considered in patients with obesity. Vaginal seeding at CD is not recommended.

KNOWLEDGE REGARDING MODE OF DELIVERY IN PRIMARY GRAVIDA WOMEN

In Pakistan, childbirth knowledge among primary gravida women—those experiencing pregnancy for the first time—plays a crucial role in shaping their decisions regarding the mode of delivery. Misconceptions, cultural beliefs, and social pressures significantly influence these women’s preferences, often leading to an increased rate of elective caesarean sections (CS) without medical necessity. Understanding the knowledge level regarding delivery options in this population is essential to improve maternal and neonatal outcomes. Objective: This study aimed to assess the level of knowledge regarding the mode of delivery among primary gravida women attending antenatal care at Jinnah Hospital, Lahore, and to identify gaps that may influence their decision-making. Methods: A descriptive cross-sectional study design was employed, targeting 150 primary gravida women at Jinnah Hospital, Lahore. A purposive sampling technique was used, and data were collected using a structured questionnaire comprising demographic questions and items related to knowledge and perceptions of vaginal and caesarean deliveries. Data were analyzed using SPSS version 22, with descriptive statistics used to summarize findings. The questionnaire’s reliability was confirmed with a Cronbach’s Alpha of 0.986, and validity was established through the Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s Test of Sphericity. Results: The findings indicated that 34.7% of participants had poor knowledge regarding the mode of delivery, 62.0% had moderate knowledge, and only 3.3% demonstrated good knowledge. Most participants preferred CS due to fear of labor pain and misconceptions about vaginal delivery risks. A majority (90%) of respondents viewed seeing the baby immediately after vaginal delivery positively, and 44% believed that the emotional relationship with the baby is enhanced following vaginal delivery. Informal sources, primarily relatives and friends, were the main sources of delivery-related information, contributing to persistent knowledge gaps and misconceptions. Conclusion: The study reveals significant knowledge gaps among primary gravida women regarding delivery options in Pakistan, with many women favoring CS due to fear and lack of accurate information. Structured antenatal education programs are necessary to address misconceptions and empower women to make informed decisions about their delivery mode. Improved education could reduce unnecessary CS rates and support healthier maternal and neonatal outcomes.

Should we restrict food intake during labor? A randomized controlled trial.

To evaluate whether consuming food during labor influences its outcomes. This randomized controlled study included healthy, laboring patients at 37-41weeks of gestation. After epidural anesthesia, patients were randomized into groups of eating at will versus drinking clear fluids only. The primary composite outcome included unplanned cesarean delivery, the need for general anesthesia, asphyxia, postpartum fever, and prolonged postpartum admission (more than 5days). Secondary outcomes included the need for oxytocin, length of the second stage of labor, postpartum analgesia requirements, and early maternal and neonatal outcomes. Sample size analysis indicated that 126 patients needed to be randomized to detect a statistically significance difference between the groups. A total of 129 patients were randomized: 58 to the fluids-only group and 71 to the food group. The groups had similar basic characteristics. The composite outcome of complications attributed to eating during labor and delivery was comparable between groups. Labor progression and the need for oxytocin augmentation were similar in both groups. The groups had comparable fetal heart rate tracings, modes of delivery, maternal and neonatal outcomes, and complications. None of the patients in the study experienced aspiration or an indication for general anesthesia. While our data suggest that eating during labor does not adversely affect labor progression or outcomes, we recommend a cautious approach, allowing patients autonomy while considering individual risk factors. The study has been registered in the primary clinical trial registry on 02/12/2023. ISRCTN trial number ISRCTN11794106, registration number 44513. https://www.isrctn.com/ISRCTN11794106 .

Antepartum Cardiotocography and Feto-maternal Outcome Among Admitted Patients in Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka, Bangladesh

Background: Admission Cardiotocography (CTG) a noninvasive procedure, is used to indicate the state of oxygenation of the fetus on admission into the labor ward. This study is performed to assess the association of admission CTG findings with feto-maternal outcome at a tertiary health facility in Bangladesh. Materials and methods: A prospective, observational study of 50 pregnant women who were admitted into the labor ward with singleton live pregnancies in Bangabandhu Sheikh Mujib Medical University. Information on the demographic characteristics, obstetrics and medical history, admission CTG tracing and neonatal outcome was obtained using a structured data collection form. Data were analyzed using the SPSS software version 20.0 with the level of significance set at p&lt; 0.05. Results: The admission CTG findings were normal in 72% and abnormal in 28% of the women. The occurrence of low birth weight, asphyxiated neonates and Special Care Neonatal Unit (SCANU) admission was significantly more frequent among those with abnormal admission CTG results compared with normal results (p&lt;0.001 for each). The incidence of cesarean delivery was more common when the CTG findings were abnormal, whereas all women with normal CTG result had a vaginal delivery (p&lt;0.001). Conclusion: Admission CTG was effective in identifying fetuses with a higher incidence of perinatal asphyxia. Neonatal outcome such as low birth weight, APGAR score and SCANU admission was significantly associated with pathological CTG findings. In the absence of facilities for further investigations, prompt intervention for delivery should be ensured if admission CTG is pathological. IAHS Medical Journal Vol 7(1), June 2024; 50-53

Anesthetic Management of Cesarean Delivery for a Parturient With Dextro-Transposition of the Great Arteries Post-Senning Procedure: A Case Report

The Senning procedure is a palliation technique for addressing dextro-transposition of the great arteries; deoxygenated blood is redirected to the left ventricle, making the right ventricle the systemic ventricle. The physiologic increase in cardiac output during pregnancy may place additional stress on the right ventricle and given the existence of atrial scar tissue, trigger arrythmias. Because the technique was gradually abandoned starting in the 1970s, few remaining patients of child-bearing age remain. We emphasize here the importance of interdisciplinary team planning for delivery. Preparation for possible arrhythmia and potential decompensation in right ventricular function are essential.

Effect of crystalloidsolution co-loading infusion rate on the dose requirements of prophylactic phenylephrine for preventing hypotension following combined spinal-epidural anesthesia for cesarean delivery.

Intravenous fluid administration and prophylactic vasopressor infusion are the primary methods for preventing spinal anesthesia-induced hypotension during cesarean delivery. However, evidence regarding the impact of different volumes of crystalloid solution on the phenylephrine infusion dosage for preventing this hypotension remains inconclusive. This study aimed to determine the effect of two IV fluid infusion rates (10 or 20 mL/kg/h) on phenylephrine requirement for preventing spinal anesthesia-induced hypotension. Eighty healthy parturients undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled. Participants were randomly assigned to receive either 10 mL/kg/h (group 10) or 20 mL/kg/h (group 20) of lactated Ringer's solution. The first patient in each group received 0.5µg/kg/min of phenylephrine infusion immediately after intrathecal injection. The phenylephrine dose in subsequent patients was adjusted by increments or decrements of 0.05µg/kg/min based on the previous patient's response. The ED50 of phenylephrine infusion for preventing spinal-induced hypotension for cesarean delivery was estimated using a modified up-down sequential analysis, with probit analysis applied as a backup sensitivity analysis. The ED50 values for preventing spinal anesthesia-induced hypotension were 0.30µg/kg/min (95% CI, 0.29-0.32µg/kg/min) for group 10, and 0.19µg/kg/min (95% CI, 0.16-0.22µg/kg/min) for group 20, respectively. The estimated relative potency for phenylephrine in group 10 compared to group 20 was 1.52 (95%CI, 1.24-1.97), showing a significant difference in the ED50 values between the two groups. This study found that a higher crystalloid co-loading rate significantly reduces prophylactic phenylephrine requirement for preventing spinal anesthesia induced hypotension. https://www.chictr.org.cn/showproj.html?proj=125918 (Trial number: ChiCTR2100048002).

The Immunohistochemical and Bioinformatics Analysis of the Placental Expressions of Vascular Cell Adhesion Protein 1 (VCAM-1) and High Mobility Group Box 1 (HMGB1) Proteins in Gestational Diabetic Mothers.

We aimed to examine both the expression levels of high mobility group box 1 (HMGB1) and vascular cell adhesion molecule-1 (VCAM-1) proteins in the placentas of pregnant women with gestational diabetes mellitus (GDM) and control groups by immunohistochemical (IHC) method. An experimental case-control study was conducted, including 40 pregnant women complicated with GDM and 40 healthy pregnant women. Placental tissues obtained following cesarean delivery were subjected to routine tissue monitoring. The placental sections were stained with VCAM-1 and HMGB1 immunostains and subjected to IHC examination under a light microscope. H-score (HS) was used to evaluate the results of IHC staining by semi-quantitative analysis. Pathway analysis in Cytoscape software identified GDM-associated proteins within HMGB1 and VCAM-1 interaction networks, followed by GO analysis to explore associated biological processes. Placental HGMB1 expression was significantly increased in the GDM group compared to the control group (p<0.001). However, placental VCAM-1 expression was found to be statistically similar in GDM and control groups (p=0.584). The shared 19 proteins were identified between HMGB1 and GDM, and 13 between VCAM-1 and GDM, with notable GO biological process terms such as immune system activation for HMGB1 and interleukin-6 regulation for VCAM-1 associated with GDM. We consider that GDM-related inflammation and oxidative stress may contribute to tissue damage and inflammation by increasing placental HMGB1 expression. The blockade of HMGB1 and its receptors might represent a promising therapeutic approach to control inflammation in GDM. Understanding the distinct roles of HMGB1 and VCAM-1 may provide valuable insights for the development of targeted therapies aimed at mitigating the inflammatory processes associated with GDM and improving maternal and fetal outcomes.

Progress in High Intensity Focused Ultrasound Ablation for Fertility Preservation Therapy of Uterine Fibroids and Adenomyosis.

High intensity focused ultrasound (HIFU) is an effective and safe non-invasive treatment method, widely used in the treatment of uterine fibroids and adenomyosis in the field of gynecology. The side effects in HIFU is low in incidence and mild. HIFU can significantly alleviate the symptoms of patients, reduce lesion volumes, improve quality of life, and has good cost-effectiveness. HIFU can accurately ablate the uterine fibroids and adenomyosis lesions, without destroying normal myometrium and endometrium, and thus HIFU is a promising alternative to myomectomy in uterine fibroids patients with fertility desire. Several studies have shown that in terms of ovarian endocrine function protection, HIFU treatment is superior to uterine artery embolization, and similar to myomectomy. Existing limited researches show that patients with uterine fibroids have a favorable pregnancy rate and live birth rate, as well as a lower natural abortion rate after HIFU treatment. Pregnancy rate after HIFU treatment for uterine fibroids is not lower than myomectomy, and higher than uterine artery embolization. HIFU may have significant advantages in shortening pregnancy interval compared with myomectomy. However, the proportion of cesarean section delivery after HIFU treatment is relatively high, and gestational uterine rupture after HIFU treatment exist in literature. Higher quality clinical data is needed to confirm the pregnancy outcomes and safety after HIFU treatment in future.

Abstract 4135893: The Importance of Genetic Testing in Diagnosis and Management of Peripartum Cardiomyopathy: A Case Study

Introduction: At least 15% of women diagnosed with peripartum cardiomyopathy (PPCM) are found to have a pathogenic genetic variant associated with dilated cardiomyopathy. We present a patient with PPCM who required orthotopic heart transplantation (OHT) for cardiogenic shock. Her explant pathology and genetic testing played a critical role in identifying the etiology of her cardiomyopathy. Case Description: A 22-year-old primigravid woman with a history of asthma presented in labor and underwent a Cesarean delivery for non-reassuring fetal heart tones. She had noted exertional dyspnea, a dry cough, and orthopnea in her final weeks of pregnancy but had an otherwise uncomplicated pregnancy. Immediately following delivery, she suffered a cardiac arrest with pulseless electrical activity and developed cardiogenic shock. She was found to have severe biventricular systolic dysfunction with a left ventricular (LV) ejection fraction of 10%. She was cannulated on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and transferred to our center. She was transitioned from VA-ECMO to an axillary Impella 5.5 device but continued to require inotropic support without evidence of LV recovery. Therefore, she was listed for and successfully underwent OHT. Explant pathology (Figure 1) revealed arrhythmogenic cardiomyopathy (ACM). Her family history was significant for a maternal grandfather who died of an unspecified arrhythmia at age 57. Genetic testing via a commercial arrhythmia and cardiomyopathy panel revealed a pathogenic desmoplakin ( DSP) truncating variant ( DSP tv) p.Ser1894Leufs*34 in the N-terminal constitutive NMD-competent region, confirming the diagnosis of ACM. The patient had minor cutaneous findings, including curly hair, consistent with the clinical presentation of DSP -mediated ACM. Discussion: This case highlights the importance of genetic testing in all patients with PPCM, as well as attention to the explant pathology in those who undergo OHT. These practices can elucidate the mechanism of cardiomyopathy, inform the risks of disease progression and of relapse with subsequent pregnancy, and allow for cascade testing of family members.

Abstract 4137145: Aortic Stenosis in Pregnancy: A Multidisciplinary Team Approach

Introduction: The hemodynamic adaptations that occur during pregnancy can have significant effects on patients with aortic stenosis (AS). These changes can lead to structural changes identified on echocardiogram even during uncomplicated pregnancies. While some cases can be managed with medical therapy and activity modification, others may require valve intervention in the gestational period. Case: A 29-year-old female with history of congenital bicuspid aortic valve, G1P0 presented at 42+2 weeks of pregnancy and was admitted to cardiac intensive care unit for continuous hemodynamic monitoring via use of arterial line. Her prior aortic valve disease was treated by valve repair with valvotomy, removal of tissue from pseudo raphe, removal of calcified scar tissue from both commissures, and a mitral valve repair for closure of an iatrogenic tear in her anterior leaflet. She followed closely with maternal fetal medicine and cardiology but became symptomatic at week 28 with lightheadedness, shortness of breath and decreased exercise tolerance (NYHA Class II). By week 33 she noticed lower extremity edema. Despite recommendations for planned delivery, she opted to wait until full term for delivery. Surveillance echoes revealed rising velocities yet stable valve area by planimetry. She ultimately underwent an uncomplicated Cesarean delivery of baby boy in week 42. At 6 months post partum she had successful transcatheter aortic valve replacement. Discussion: As the severity of valvular disease worsens there is a higher risk of complications during pregnancy. In our case, aortic valve velocities were elevated due to the expected hemodynamic changes of pregnancy. Thus, echocardiography monitoring should be used to assess the left ventricle’s ability to tolerate and compensate for these changes, while intervening based on symptoms and NYHA classification. We highlight the importance of multidisciplinary collaboration for safe and successful delivery in patients with AS.