Elective Cesarean Delivery Research Articles

A Study of the Pharmacokinetics and Pharmacodynamics of Oxytocin at Elective Cesarean Delivery

A Study of the Pharmacokinetics and Pharmacodynamics of Oxytocin at Elective Cesarean Delivery

Comapring a lower dose of carbetocin to the standard dose of carbetocin in the prevention of postpartum hemorrhage during elective cesarean delivery: A randomised parallel group trial

Prophylactic use of uterotonic is a universal practice in vaginal and cesarean delivery. Heat stable carbetocin is a relatively new uterotonic. Lower doses of uterotonics are as effective as standard doses in elective cesarean deliveries. This study aimed to compare the effectiveness and safety of 50 mcg carbetocin (lower dose) to 100mcg carbetocin (standard dose) for the prevention of postpartum hemorrhage during elective cesarean delivery. A total of 212 term pregnant women were randomized to two group. Group I received 50 mcg of carbetocin and Group II received 100 mcg of carbetocin. The blood loss, tone of the uterus, use of additional uterotonics or styptics, requirement of blood transfusions and adverse effects of the drug in both the groups were compared. There were no statistically significant differences in both the groups with respect to blood loss, uterine tone, blood transfusions or additional use of uterotonics or styptics.(p>0.05).: A lower dose of 50 mcg is as effective as the standard dose of 100 mcg of carbetocin in elective caesarean delivery in preventing post-partum hemorrhage.

The correlation between quality of recovery and parturient outcomes after Cesarean delivery: a cohort study.

Recent studies have reported the use of the obstetric-specific quality of recovery tool (ObsQoR-10) to assess the quality of recovery in parturients after childbirth; however, the correlation between ObsQoR-10 scores and important postpartum outcomes are unclear. The primary aim of the present study was to investigate the correlations between ObsQoR-10 scores at 24hr after Cesarean delivery and breastfeeding, depressive symptomatology, overall health, and pain at seven days postpartum. We recruited parturients who underwent elective Cesarean delivery at KK Hospital in Singapore. Parturients provided responses to post-Cesarean questionnaires at 1) 24hr (ObsQoR-10, EuroQol EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale), 2) 48hr (ObsQoR-10, EQ-Visual Analogue Scale), and 3) seven days after Cesarean delivery (ObsQoR-10, Breastfeeding Self-Efficacy Scale-Short form, EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale, pain survey). We enrolled 222 participants, 200 (90%) of whom completed the seven-day follow-up between September 2022 and April 2023. There was limited correlation between ObsQoR-10 at 24hr with the Edinburgh Postnatal Depression Scale (r = 0.135), EQ-Visual Analogue Scale (r = 0.158), Breastfeeding Self-Efficacy Scale-Short form (r = 0.225), and averaged pain scores (r = -0.107) at seven days postpartum. ObsQoR-10 breastfeeding sub-score at 24hr was weakly correlated with Breastfeeding Self-Efficacy Scale-Short form at seven days postpartum (r = 0.307). ObsQoR-10 at 24hr postpartum had limited correlation with breastfeeding, depressive symptomatology, overall health, and pain at seven days. ClinicalTrials.gov ( NCT04989894 ); first submitted 4 July 2021.

Post-dural Puncture Headache: A Comparative Study Using 25 G Quincke's Needle in Midline and Paramedian Approaches in Patients Undergoing Elective Cesarean Section.

Background and objectives Spinal anesthesia (SA) has become a preferred anesthetic technique for elective cesarean sections due to its rapid onset, profound sensory and motor blockade, and minimal impact on the newborn. It lowers the risk of development of thrombus in the veins and pulmonary vessels and permits early ambulation. The most popular technique used to reach the subarachnoid space is the midline technique, though it can be challenging to use in some cases, including those involving elderly patients with degenerative abnormalities in the vertebral column, patients who are unable to flex the vertebral column, noncooperative patients, and hyperestheticpatients. The paramedian technique resolves the challenges posed by the midline technique. It is also relatively easy to carry out. Based on the midline technique's inadequacies, we hypothesized that the paramedian method of SA would be less complicated than the midline approach, with a relatively low occurrence of post-dural puncture headaches (PDPH). Methodology Using the midline and paramedian approaches during cesarean surgeries, we performed an observational descriptive longitudinal study to assess the occurrence and magnitude of PDPH. During an elective cesarean delivery, the seated patient received 2.0-2.5 ml of hyperbaric bupivacaine using the midline or paramedian approaches and a 25 G Quincke's needle at the L3-L4 level. Eighty-four pregnant females with American Society of Anesthesiologists (ASA) physical status II, aged 18 to 35 (n = 42 in each group), were included in this research. The occurrence and severity of PDPH were compared among thegroups during a period of five days. Result In comparison to the paramedian group (7.1%), the midline group had a higher incidence of PDPH (14.3%). There was a significant correlation between the technique and the occurrence of PDPH (p = 0.041). The visual analogue scale (VAS) was employed to quantify pain five days after surgery. Pain levels in Group B (paramedian) were consistently less than those in Group A (midline). On day 1, Group B had a mean score of 0.49 ± 1.16 (p = 0.030) compared to Group A's mean VAS score of 1.27 ± 1.95. Day 5 (p = 0.032): Because this tendency persisted through day 5, the p-values for days 2, 3, 4, and 5 remained significant. These findings suggest that the midline technique is linked to a higher occurrence and magnitude of PDPHthan the paramedian approach. Conclusion Employing a paramedian technique has been associated with a noteworthy decline in the frequency of PDPH and a decrease in the need for additional analgesics, which could lead to a less severe case of PDPH. The paramedian approachneeded fewer attempts and needle passes, which leads to a lower incidence of headache, backache, and injection site pain and better patient satisfaction.

Comparative hemodynamic effects of carbetocin vs oxytocin in mothers with stenotic valvular heart disease undergoing cesarean delivery: a randomized controlled trial

Background & objective: Postpartum hemorrhage (PPH) is quite common an obstetric emergency, and is a nightmare for the anesthesiologist as well as the obstetrician. We compared the hemodynamic profiles of oxytocin and carbetocin for prevention of postpartum hemorrhage during elective cesarean delivery in patients with mild to moderate mitral or aortic stenosis. Methodology: This randomized controlled trial included full term pregnant women with known mild to moderate mitral or aortic valve stenosis and undergoing elective cesarean delivery. After delivery of the shoulder of the baby, the participant received either oxytocin or carbetocin. Patients’ hemodynamic parameters, including blood pressure, heart rate, cardiac output, and systemic vascular resistance, were recorded. The primary outcome was the 5-min average cardiac output after the drug administration. Secondary outcomes were cardiac output, systolic blood pressure, heart rate and systemic vascular resistance, blood loss, and the need for rescue uterotonics. Results: Forty-five patients (23 patients in the carbetocin group and 22 in the oxytocin group) were analyzed. The 5-min average cardiac output after drug injection was comparable between the two groups. The number of participants needing rescue uterotonic boluses were significantly more in the oxytocin group than in the carbetocin group (P = 0.022). Conclusion: In full-term pregnant women with stenotic valvular pathologies, carbetocin showed superior uterotonic effect compared to oxytocin; however, both drugs resulted in the equivalent hemodynamic effects. Trial registration: Clinical trial registration with clinicaltrials.gov No. NCT05110482 Keywords: oxytocin; carbetocin; mitral stenosis; aortic stenosis; cesarean delivery; hemodynamics Citation: Refaat S, Amin S, Tarek H, El Regal EA, Eissa AA, Zayed M, Ibrahim M. Comparative hemodynamic effects of carbetocin vs oxytocin in mothers with stenotic valvular heart disease undergoing cesarean delivery: a randomized controlled trial. Anaesth. pain intensive care 2024;28(4):681−686; DOI: 10.35975/apic.v28i4.2369 Received: January 03, 2024; Reviewed: May 05, 2024; Accepted: June 11, 2024

Television Viewing Frequency and Mode of Delivery Preferences among Primiparous Women in Nairobi, Kenya

Purpose: This study aims to establish television viewing frequency and mode of delivery preferences among primiparous women in Nairobi Kenya, aiming at developing informed strategies to minimize health risks and costs, promoting safer childbirth choices in a media-driven urban environment. Methodology: The study utilized a sequential mixed-methods approach, which involved 300 purposefully selected primiparous women from eleven sub-counties in Nairobi during routine child immunization schedules. Among the participants, 150 had vaginal deliveries, while the remaining underwent elective caesarean deliveries. Data collection was carried out through interviewer-administered questionnaires, focus group discussions, and in-depth interviews. Quantitative analysis involved the use of mean-weight scores, Chi-square tests, and Cramer's V using SPSS version 28.0.1.1(15). Thematic analysis was employed for qualitative data using Nvivo 14 to comprehensively understand the research topic. The findings were presented through both numerical analysis and narrative exploration. Findings: Respondents who underwent elective caesarean deliveries had higher mean TV viewing frequencies on both weekdays and weekends, compared to those who had vaginal deliveries. Both for weekdays and weekends had significant associations with moderate effect sizes. The null hypothesis was rejected due to the significant correlation and linear regression explaining 81.3% of the variability. Each additional weekday TV-watching hour increased the odds in preferring a particular mode of delivery by 40%, and on weekends, by 39%. Qualitative analysis confirmed that viewing frequency is influenced by factors such flexible schedules, cost-effectiveness, accessibility, and content preferences. Unique Contribution to Theory, Practice and Policy: The study uses cultivation and medicalization theory to establish that television viewing frequency shapes perceptions and subsequent childbirth preferences among urban women, adding to existing body of knowledge on media effects theories. To promote informed childbirth choices, recommendations include encouraging women to critically evaluate media information and seek reliable sources. Additionally, integrating media literacy into antenatal care, implementing targeted campaigns, and researching other media forms beyond television are essential.

Microbial Etiology, Antimicrobial Resistance, and Risk Factors of Surgical Site Infections in Gestational Diabetes Mellitus Patients Undergoing Elective Pre-Labor Cesarean Deliveries.

Gestational Diabetes Mellitus (GDM) significantly increases the risk of adverse pregnancy outcomes, including elective pre-labor cesarean deliveries. Postoperative surgical site infections (SSIs) pose a significant concern, underscoring the need for a detailed investigation into their causes and preventative measures. The aim of this study is to systematically identify and analyze the microbial etiology and antimicrobial resistance profiles of pathogens responsible for SSIs in GDM patients undergoing elective pre-labor cesarean deliveries. Additionally, this research aims to elucidate the risk factors contributing to SSIs, with a specific focus on operation duration, amniotic fluid contamination, and genital tract inflammation, and their correlation with the incidence of SSIs. A retrospective analysis was conducted at our Hospital between September 2018 and July 2023, involving 150 GDM patients who underwent elective pre-labor cesarean deliveries. Patients were categorized into infected and uninfected groups based on postoperative SSIs. Clinical data were meticulously collected and analyzed using SPSS software (version 27.0). Independent sample t-tests and chi-square tests were employed for statistical analysis. Microbial profiling revealed that Gram-negative bacteria, primarily E. coli, constituted approximately 59.46% of the isolated strains, exhibiting significant resistance to commonly used antibiotics such as ampicillin and cefotaxime. Elevated levels of biomarkers, including Procalcitonin (PCT) and Hemoglobin A1c (HbA1c), were significantly associated with SSIs. Multivariate logistic regression analysis identified operation time ≥1-hour, amniotic fluid contamination, and genital tract inflammation as significant risk factors. This study highlights the microbial etiology, resistance patterns, and risk factors for SSIs in GDM cesarean patients, emphasizing the need for tailored preoperative evaluations.

Risk factors for postpartum hemorrhage after elective cesarean deliveries for twin pregnancies.

To identify the high-risk factors associated with postpartum hemorrhage (PPH) after an elective cesarean delivery of twins. This retrospective cohort study included all women with twin gestations who chose to have an elective cesarean delivery after 28 weeks of gestation at at the Women's Hospital, School of Medicine, Zhejiang University between September 2014 and April 2019. Women with an intrauterine fetal demise of one or both twins were excluded. PPH was defined as an estimated blood loss of ≥ 1,000 mL within 24 h of birth. A total of 532 women were analyzed and classified into the PPH group (n = 70) and the no-PPH group (n = 462). Univariate and multivariate logistic regression analyses were performed to assess the independent risk factors. Among the 532 women pregnant with twins, PPH occurred in 13.2% women (n = 70). There were statistically significant differences in preeclampsia (p = 0.005), premature rupture of membrane (PROM, p < 0.001), placenta previa (p < 0.001), anemia [hemoglobin (Hb) < 100 g/L; p = 0.003], and antenatal magnesium sulfate (MgSO₄) use (p < 0.001) between the two groups. However, the following were the independent risk factors for PPH after an elective cesarean delivery for a twin pregnancy: preeclampsia [odds ratio (OR): 2.91; 95% confidence interval (CI): 1.33-6.36], PROM (OR: 8.57; 95% CI: 2.54-28.89), placenta previa (OR: 9.46; 95% CI: 3.59-24.89), antenatal MgSO₄ use (OR: 7.64; 95% CI; 3.18-18.41), and anemia (Hb < 100 g/L; OR: 2.68; 95% CI: 1.42-5.06). Preeclampsia, PROM, placenta previa,and antenatal MgSO₄ use were the risk factors for PPH after an elective cesarean delivery for twin pregnancies. Risk factor identification and prevention should be a priority.

Incidence of neonatal respiratory morbidity after vaginal and caesarean delivery in the late-preterm and term period - a retrospective cohort study.

Respiratory distress syndrome is a leading cause of neonatal intensive care unit admissions for late preterm (34-36 weeks gestational age) and term infants (37-41 weeks). The risk for respiratory morbidity appears to increase after an elective caesarean delivery and might be reduced after antenatal corticosteroids. However, before considering antenatal corticosteroids for women at high risk of preterm birth after 34 weeks, the incidence of respiratory distress syndrome and the effect of delivery mode on this incidence requires further evaluation. Therefore, this study aimed to investigate the relationship between respiratory distress syndrome incidence and delivery mode in late preterm and term infants. In this retrospective cohort study, the clinical databases of the University Hospitals of Zurich and Basel were queried regarding all live births between 34 + 0 and 41 + 6 weeks. Neonatal intensive care unit admissions due to respiratory distress syndrome were determined and analysed in regard to the following delivery modes: spontaneous vaginal, operative vaginal, elective caesarean, secondary caesarean and emergency caesarean. After excluding malformations (n = 889) and incomplete or inconclusive data (n = 383), 37,110 infants out of 38,382 were evaluated. Of these, 5.34% (n = 1980) were admitted to a neonatal intensive care unit for respiratory distress syndrome. Regardless of gestational age, respiratory distress syndrome in infants after spontaneous vaginal delivery was 2.92%; for operative vaginal delivery, it was 4.02%; after elective caesarean delivery it was 8.98%; following secondary caesarean delivery, it was 8.45%, and after an emergency caesarean it was 13.3%. The risk of respiratory distress syndrome was higher after an elective caesarean compared to spontaneous vaginal delivery, with an odds ratio (OR), adjusted for gestational age, of 2.31 (95% CI 1.49-3.56) at 34 weeks, OR 5.61 (95% CI 3.39-9.3) at 35 weeks, OR 1.5 (95% CI 0.95-2.38) at 36 weeks, OR 3.28 (95% CI 1.95-5.54) at 37 weeks and OR 2.51 (95% CI 1.65-3.81) at 38 weeks. At 39 weeks, there was no significant difference between the risk of respiratory distress syndrome after an elective caesarean vs. spontaneous vaginal delivery. Over the study period, gestational age at elective caesarean delivery remained stable at 39.3 ± 1.65 weeks. The incidence of respiratory distress syndrome following an elective caesarean is up to threefold higher in infants born with less than 39 weeks gestational age compared to those born by spontaneous vaginal delivery. Therefore - and whenever possible - an elective caesarean delivery should be planned after 38 completed weeks to minimise the risk of respiratory morbidity in neonates.

Establishing a risk score for prediction of intrapartum cesarean delivery among older women: A retrospective cohort study

ObjectiveTo determine risk factors and to develop a risk prediction score for intrapartum cesarean delivery (CD) in women over 40 years old. Study designA retrospective cohort study, in a single university-affiliated tertiary medical center. All women aged 40 years or more who planned a trial of labor between 2012 and 2022. Women who opted for an elective CD and those with non-viable fetuses were excluded. Maternal and neonatal characteristics of women who delivered vaginally were compared to those who underwent an intrapartum CD. Risk factors were examined using univariate and multivariate analysis. A score was developed to predict the need for intrapartum CD. We assessed a receiver operating characteristic curve to evaluate the performance of our model. Main outcome measureAn unplanned intrapartum cesarean section. ResultsDuring the study period, 122,583 women delivered at our center, of whom 6122 (4.9 %) aged 40 years or more attempted a trial of labor. Of them, 428 (7 %) underwent intrapartum CD. Several independent risk factors were identified, including nulliparity, regional anesthesia, induction of labor, use of antibiotics during labor, multiple gestation, previous cesarean delivery, and the presence of gestational diabetes or preeclampsia. A risk score model, employing a cut-off of 7, demonstrated successful prediction of intrapartum CD, with an area under the curve of 0.86. ConclusionThe score model for intrapartum CD can be used by caregivers to offer a more informed consultation to women aged 40 years or more deciding on the mode of delivery.

Intravenous initial bolus during prophylactic norepinephrine infusion to prevent spinal hypotension for cesarean delivery: A randomized controlled, dose-finding trial

BackgroundPrevious studies have shown that a 0.05 μg/kg/min of norepinephrine infusion in combination with an initial bolus reduces the incidence of spinal hypotension during cesarean delivery. The initial norepinephrine bolus influences the incidence of spinal hypotension during continuous norepinephrine infusion; however, the ideal initial bolus dose for 0.05 μg/kg/min of continuous infusion remains unknown. MethodsThis randomized, controlled, dose-finding study randomly allocated 120 parturients scheduled for elective cesarean delivery to receive initial bolus doses of 0, 0.05, 0.10, and 0.15 μg/kg of norepinephrine, followed by continuous infusion at a rate of 0.05 μg/kg/min. The primary outcome was the dose-response relationship of the initial norepinephrine bolus in preventing the incidence of spinal hypotension. Spinal hypotension was defined as systolic blood pressure (SBP) decreased to <80% of the baseline value or to an absolute value of <90 mmHg from intrathecal injection to delivery, and severe spinal hypotension was defined as SBP decreased to <60% of the baseline value. The secondary outcomes included the incidence of nausea and/or vomiting, hypertension, and bradycardia, as well as the Apgar scores and results of the umbilical arterial blood gas analysis. The effective dose (ED) 90 and ED95 were estimated using probit regression. ResultsThe per-protocol analysis included 117 patients. The incidence of spinal hypotension varied significantly among the groups: Group 0 (51.7%), Group 0.05 (44.8%), Group 0.10 (23.3%), and Group 0.15 (6.9%). The ED90 and ED95 values were 0.150 μg/kg (95% confidence interval [CI], 0.114–0.241 μg/kg) and 0.187 μg/kg (95% CI, 0.141–0.313 μg/kg), respectively. However, the ED95 value fell outside the dose range examined in this study. The incidence of severe spinal hypotension differed significantly (P = 0.02) among Groups 0 (17.2%), 0.05 (10.3%), 0.10 (3.3%), and 0.15 (0.0%); however, the incidence of hypertension and bradycardia did not. The incidence of nausea and/or vomiting decreased with an increase in the initial bolus dose (P = 0.03). The fetal outcomes were comparable among the groups. ConclusionsAn initial bolus of 0.150 μg/kg of norepinephrine may be the optimal dose for preventing spinal hypotension during cesarean delivery with a continuous infusion rate of 0.05 μg/kg/min, and does not significantly increase the incidence of hypertension but substantially reduces the risk of nausea and/or vomiting.

Comparative Study of Prophylactic Vs Conventional Phenylephrine Administration in Preventing Spinal Anaesthesia-Induced Hypotension in Elective caesarean Section Patients: A Quasi Experimental Trial

Objective: To determine the prophylactic effect of phenylephrine in patients undergoing spinal anaesthesia in comparison to the conventional group. Study design: Quasi experimental trial. Place and duration of study: HIT Hospital Taxila in the period of 6 months. Materials and methods: This quasi-experimental trial was conducted in HIT Hospital. Total 68 females were divided into two groups: Control group and Experimental group. Each group consisted of 34 patients aged between 20 to 40 years. The patients were scheduled for elective cesarean section deliveries under spinal anaesthesia. All patients of the experimental group were given prophylactic dose of phenylephrine 100mcg diluted in normal saline after undergoing spinal anaesthesia before the start of procedure. Control group patients were only given normal saline as a placebo after undergoing spinal anaesthesia before the start of procedure. Control group patients were given phenylephrine as conventional treatment only if they experienced hypotension during the procedure. Results: Among the patients in the experimental group none experienced hypotension. Their blood pressure remained fairly constant in the normal range. In the control group, 4 out of 34 patients (11.7%) had their blood pressure dropped below the cutoff point of 90/60 mmHg. Conclusions: Our results show that a prophylactic dosage regimen i.e., 100mcg of phenylephrine is effective in controlling spinal -anaesthesia -induced hypotension in patients undergoing Caesarean-section. In comparison with conventional group where hypotension occurs only in few patients.

A Comparative Study of the Cardiovascular Effects of a Lower Dose of Heat-Stable Carbetocin Versus the Standard Dose in the Prevention of Postpartum Hemorrhage During Elective Cesarean Delivery: A Single-Blinded, Randomized, Parallel-Group Trial.

Oxytocin is a uterotonic drug that acts on receptors in the myometrium, causing uterine contractions. However, oxytocin receptors are also present in other organs, including the myocardium.Heat-stable carbetocin, a long-acting analog of oxytocin, is also known to act on these oxytocin receptors. As carbetocin has a long half-life of 40 minutes, its duration of action on the myocardium may be relatively longer than that of oxytocin. Therefore, this study aimed to study the cardiovascular effects of using a lower dose of carbetocin (50 mcg) compared to the standard dose (100 mcg) during elective cesarean delivery. A total of 212 full-term pregnant women were randomized into two groups: group I received 50 mcg of intravenous carbetocin, and group II received 100 mcg of intravenous carbetocin. Heart rate, blood pressure (BP), oxygen saturation, electrocardiogram changes, and pre- and postoperative (12 hours after cesarean delivery) high-sensitivity cardiac troponin I levels were compared between the groups. No statistically significant differences were observed between the groups with respect to heart rate, BP, electrocardiogram changes, or difference in pre- and postoperative high-sensitivity cardiac troponin I levels (p> 0.05). Carbetocin's cardiovascular effects were similar in both groups. None of the participants had adverse cardiovascular effects from the drug, and there were no differences in cardiovascular effects between the groups.

Neonatal Outcomes of Infants Diagnosed with Fetal Growth Restriction during Late Pregnancy versus after Birth.

Objective: The aim of this study was to investigate the potential differences in the outcomes of neonates in whom FGR was diagnosed late in pregnancy as compared to those in whom growth restriction was diagnosed after birth. Methods: A retrospective study was conducted in a tertiary medical center between 2017 and 2019. The study included women carrying a single infant with an estimated fetal weight below the tenth percentile in whom FGR was diagnosed during late pregnancy, after 32 gestational weeks (known late-onset FGR; study group) or only after birth (unknown FGR; control group). Data were collected by review of the electronic health records. The primary outcome measure was the rate of composite adverse neonatal outcome. Results: A total of 328 women were included, 77 (23.47%) in the known-FGR group and 251 (75.53%) in the unknown-FGR group. In the known-FGR group, an etiology for the FGR was identified in 28.57% cases, most commonly placental insufficiency (21.74%). Compared to the unknown-FGR group, the known-FGR group was characterized by significantly higher rates of elective cesarean delivery (15.58% vs. 9.96%, p < 0.001), preterm birth (18.18% vs. 3.98%, p < 0.01), and labor induction (67.53% vs. 21.51%, p < 0.01). A significantly higher proportion of neonates in the known-FGR group had a positive composite adverse outcome (38.96% vs. 15.53%, p < 0.01). For multivariate regression analysis adjusted for maternal age, gestational age at delivery, and mode of delivery, there was no difference between groups in the primary outcome (aOR 1.73, CI 0.89-3.35, p = 0.1). Every additional gestational week at delivery was a protective factor (aOR = 0.7, 95% CI 0.56-0.86, p < 0.01). Conclusions: A prenatal diagnosis of late-onset FGR is associated with higher intervention and preterm birth rates as compared to a diagnosis made after birth. Fetuses diagnosed with late-onset FGR during pregnancy should undergo specific and personalized assessment to determine the cause and severity of the growth delay and the best management strategy. This study highlights the importance of careful decision-making regarding the induction of labor in late-onset FGR.

Effect of Intravenous Ondansetron on Spinal Anaesthesia-Induced Hypotension During Caesarean Section

Background: Spinal anaesthesia has become the preferred method for elective caesarean sections due to its simplicity, speed, and reliability. However, a significant challenge with this technique is maternal hypotension, which can lead to nausea, vomiting, and decreased cardiac output, necessitating effective preventive measures. Ondansetron, a 5-HT3 receptor antagonist, is commonly used to prevent nausea and vomiting, and recent studies suggest its potential efficacy in reducing hypotension during spinal anaesthesia. Objective: To compare the frequency of hypotension during spinal anaesthesia for elective caesarean delivery between two groups: one receiving intravenous ondansetron and the other receiving normal saline as a placebo. Methods: This randomized controlled trial was conducted at the Department of Anaesthesia, Combined Military Hospital Sialkot, over six months (May 6, 2016, to November 6, 2016). A total of 60 pregnant women scheduled for elective caesarean delivery under spinal anaesthesia, aged 18-35 years, classified as ASA I or II, and carrying a singleton pregnancy at 37-42 weeks, were included. Exclusion criteria included contraindications to spinal anaesthesia, history of heart or lung disease, known hypersensitivity to the study medication, diabetes with blood sugar &gt;180 mg/dl, hypertension with blood pressure &gt;160/90 mmHg, morbid obesity, and fetal abnormalities. Participants were randomly assigned to Group A (intervention) receiving 4 mg ondansetron intravenously in 10 ml saline 5 minutes before spinal anaesthesia, or Group B (control) receiving 10 ml saline intravenously. Baseline vitals, including heart rate, mean arterial pressure, systolic and diastolic blood pressure, were recorded. Spinal anaesthesia was administered using a 25-gauge needle with 2.5 ml of hyperbaric 0.5% bupivacaine solution. Hypotension was managed with intravenous bolus of 100 mcg phenylephrine and 100 ml normal saline. Data were analyzed using SPSS version 25.0, with qualitative variables compared using chi-square tests and significance set at p ≤ 0.05. Results: The mean age of participants was 27.95±5.68 years, and the mean BMI was 24.12±3.30 kg/m². Baseline systolic blood pressure averaged 129.00±11.24 mmHg, diastolic blood pressure 71.67±6.99 mmHg, and mean arterial pressure 114.67±7.93 mmHg. In Group A, 8 out of 30 participants (26.7%) experienced hypotension compared to 17 out of 30 participants (56.7%) in Group B (p=0.036). Stratification by age revealed a significant difference in hypotension incidence in participants &gt;26 years (p=0.028). No significant differences were observed when stratified by BMI &lt;24 kg/m² (p=0.056) and &gt;24 kg/m² (p=0.300). Conclusion: Administration of 4 mg intravenous ondansetron 5 minutes prior to spinal anaesthesia for elective caesarean delivery significantly reduces the frequency of hypotension compared to placebo, especially in patients older than 26 years. Ondansetron appears to be a practical and cost-effective prophylactic measure against spinal anaesthesia-induced hypotension, warranting further large-scale, multi-centre trials to validate these findings.

Marginal cord insertion in the first trimester is associated with furcate cord insertion

ObjectivesTo evaluate the potential connections between marginal cord insertion during the first trimester and furcate cord insertion later in pregnancy.MethodsThis is a prospective study of screening data on the cord insertion site in 3178 singleton pregnancies. The cord insertion site was examined in two stages. The first stage was screening for the cord insertion site between 10–13 weeks of gestation, the purpose is to determine the category of umbilical cord insertion. The second stage, performed at 22–28 weeks of gestation, was to follow up on the relationship between the cord insertion site and the placenta and to identify any changes in the category of umbilical cord insertion. This was performed to diagnose or exclude furcate cord insertion by identifying whether the umbilical cord trunk separated or branched before it reached the placenta. Factors influencing progression to furcate cord insertion and perinatal complications were assessed.ResultsFourteen cases (0.44%) with progression to furcate cord insertion, all of which showed marginal cord insertion on ultrasound in the first trimester (p < 0.001). without progression to furcate cord insertion, there were no changes in the category of umbilical cord insertion in 3050 cases (96.40%) compared to the early pregnancy. 114 cases (3.60%) with changes in the category of umbilical cord insertion that was not consistent with furcate cord insertion. A total of 14 cases progressed to furcate cord insertion, all showed the cord insertion site were in close proximity, and 11 (78.57%) cases showed a low insertion site (p < 0.001). Regarding the choice of mode of delivery, elective caesarean delivery was done in 8/14 (57.14%). The incidences of spontaneous vaginal delivery were 5/14 (35.71%) (p < 0.001). One (7.14%) case of progression to furcate cord insertion due to haematoma at the root of the umbilical cord ended with an emergency caesarean section. In terms of perinatal complications, marginal cord insertion that progressed to furcate cord insertion had higher incidences of SGA infants, abnormal placental morphology, retention of the placenta, and cord-related adverse pregnancy outcomes than not progressed to furcate cord insertion (p < 0.05).ConclusionsMarginal cord insertion in the first trimester has the potential to progress to furcate cord insertion. We suggest that ultrasound-diagnosed marginal cord insertion in the first trimester should be watched carefully in the second trimester, which is clinically useful to accurately determine the category of cord insertion and to improve the rate of prenatal diagnosis of furcate cord insertion.

Randomized Double-Blind Study of the Effect of Injectate Temperature on Intrathecal Bupivacaine Dose Requirement in Spinal Anesthesia for Cesarean Delivery.

Increasing the temperature of intrathecal local anesthetics has been shown to increase the speed of onset and block height of spinal anesthesia. However, how this influences dose requirement has not been fully quantified. The aim of this study was to determine and compare the effective dose for anesthesia for cesarean delivery in 50% of patients (ED50) of intrathecal bupivacaine given at temperatures of 37 °C (body temperature) or 24 °C (room temperature). Eighty healthy parturients having elective cesarean delivery under combined spinal-epidural anesthesia were randomly assigned to receive intrathecal hyperbaric bupivacaine stored at 37 °C (body temperature group) or 24 °C (room temperature group). The first subject in each group received a bupivacaine dose of 10 mg. The dose for each subsequent subject in each group was varied with an increment or decrement of 1 mg based on the response (effective or noneffective) of the previous subject. Patients for whom the dose was noneffective received epidural supplementation after data collection with lidocaine 2% as required until anesthesia was sufficient for surgery. Values for ED50 were calculated using modified up-down sequential analysis with probit analysis applied as a backup sensitivity analysis. These values were compared and the relative mean potency was calculated. The ED50 (mean [95% confidence interval, CI]) of intrathecal hyperbaric bupivacaine was lower in the body temperature group (6.7 [5.7-7.6] mg) compared with the room temperature group (8.1 [7.7-8.6] mg) (P < .05). The relative potency ratio for intrathecal bupivacaine for the room temperature group versus the body temperature group was 0.84 (95% CI, 0.77-0.93). Warming hyperbaric bupivacaine to body temperature reduced the dose requirement for spinal anesthesia for cesarean delivery by approximately 16% (95% CI, 7%-23%).

The Effect of Preoperative Carbohydrate-containing Fluid Consumption on Maternal Oxidative Stress Markers During Elective Cesarean Delivery

PurposeThe purpose of this study was to evaluate the effect of carbohydrate loading prior to the cesarean surgery under spinal anesthesia on thiols and ischemia-modified albumin (IMA) levels. DesignProspective, randomized placebo-controlled study. MethodsSeventy-nine pregnant women planned for cesarean sections under spinal anesthesia at Karaman Training and Research Hospital were randomized into a control group (group C) (n = 42), and an oral carbohydrate preloading group (group OCH) (n = 37). OCH loading requires consuming 400 mL the night before surgery and 200 mL up to 2 hours before anesthesia. Group OCH consumed an oral carbohydrate-rich beverage (Nutricia-Fantomalt), and group C consumed an equal volume of water. This study investigated thiol-disulfide homeostasis after preoperative carbohydrate consumption. Preoperative gastric fluid, volume, antral cross-sectional area, hypotension following the birth, and fetal blood gas parameters were compared across groups. FindingsThiols and IMA levels did not differ across groups before and after surgery (P > .05). Gastric ultrasonography showed similar antral cross-sectional area and stomach volume between groups (P = .172, P = .128, respectively). When surgery caused hypotension, group OCH received more ephedrine for surgery-induced hypotension, although this difference is not statistically significant (P = .704). A clustered error bar (95% confidence interval) plot with an interpolation line was used for a time-based comparison of mean differences in heart rate and mean arterial pressure between the groups. ConclusionsThis study supports that mothers' thiols and IMA levels were unaffected by preoperative OCH loading before cesarean surgery. We did not examine thiol and its derivatives in umbilical cord blood; hence, we can not comment on thiol/disulfide homeostasis levels in neonates.

YouTube as a Source of Patient Information on External Cephalic Version: Cross-Sectional Study.

With the global increase of cesarean deliveries, breech presentation is the third indication for elective cesarean delivery. Implementation of external cephalic version (ECV), in which the position of the baby is manipulated externally to prevent breech presentation at term, remains suboptimal. Increasing knowledge for caretakers and patients is beneficial in the uptake of ECV implementation. In recent decades, the internet has become the most important source of information for both patients and health care professionals. However, the use and availability of the internet also bring about concerns since the information is often not regulated or reviewed. Information needs to be understandable, correct, and easily obtainable for the patient. Owing to its global reach, YouTube has great potential to both hinder and support spreading medical information and can therefore be used as a tool for shared decision-making. The objective of this study was to investigate the available information on YouTube about ECV and assess the quality and usefulness of the information in the videos. A YouTube search was performed with five search terms and the first 35 results were selected for analysis. A quality assessment scale was developed to quantify the accuracy of medical information of each video. The main outcome measure was the usefulness score, dividing the videos into useful, slightly useful, and not useful categories. The source of upload was divided into five subcategories and two broad categories of medical or nonmedical. Secondary outcomes included audience engagement, misinformation, and encouraging or discouraging ECV. Among the 70 videos, only 14% (n=10) were defined as useful. Every useful video was uploaded by educational channels or health care professionals and 80% (8/10) were derived from a medical source. Over half of the not useful videos were uploaded by birth attendants and vloggers. Videos uploaded by birth attendants scored the highest on audience engagement. The presence of misinformation was low across all groups. Two-thirds of the vloggers encouraged ECV to their viewers. A minor percentage of videos about ECV on YouTube are considered useful. Vloggers often encourage their audience to opt for ECV. Videos with higher audience engagement had a lower usefulness score compared to videos with lower audience engagement. Sources from medically accurate videos should cooperate with sources with high audience engagement to contribute to the uptake of ECV by creating more awareness and a positive attitude of the procedure, thereby lowering the chance for a cesarean delivery due to breech presentation at term.

Accuracy of sonographic lower segment thickness and prediction of vaginal birth after caesarean in a resourced-limited setting; Prospective study.

To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource-limited setting. Prospective study. Obstetrics and Gynaecology department in a tertiary hospital in Ghana. Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD. Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements. Lower uterine segment findings at laparotomy, successful vaginal birth. A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI -0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80-1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03-1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5-99.8%) and specificity of 81.8% (95% CI 75.8-86.8%). Accurate TVUS measurement of the LUS is technically feasible in a resource-limited setting. This approach could help in making safer decisions on mode of birth in limited-resource settings.