Elective Delivery Research Articles

Magnesium Sulfate and Clonidine; Effects on Hemodynamic Factors and Depth of General Anesthesia in Cesarean Section.

BackgroundMaking stable hemodynamic and also durable unawareness is a daily challenge in the setting of general anesthesia in women who undergo surgical delivery of neonate and have limitations to receive opioids derivatives.ObjectivesWe aimed to evaluate the effects of magnesium sulfate and clonidine on hemodynamic changes and depth of anesthesia and in mentioned mothers and also in neonatal APGAR index.MethodsCurrent randomized, double-blind controlled trial study was conducted among a total of 360 pregnant females (38 - 41 weeks of gestation) who underwent elective cesarean section. Participants were randomly divided into three drug-receiving groups (equal 120 members): magnesium sulfate (30 mg/kg), clonidine (3 µg/kg), and placebo (0.9% NaCl). Patients’ blood pressure, heart rate, cerebral state index (CSI) in specific time zones, and also late 24-hour recall were recorded. The CSI is an electroencephalographic monitoring method helping to assess the depth of anesthesia. Neonatal parameters, including APGAR score and umbilical venous blood sampling, were measured.ResultsMean patients’ age was 28 ± 4.5. A significant decreasing and stabilizing effect of magnesium sulfate and clonidine on hemodynamic parameters (blood pressure and heart rate) was revealed (P < 0.001). Evidence implied on deeper anesthesia (lower CSI) among drug receivers comparing to placebo (P < 0.001). None of the participants experienced a late 24-hour recall postoperatively. All neonates were healthy, and no decrease was reported in APGAR score at minutes 1 and 5. Umbilical blood gas analysis showed no signs of acidosis and/or hypoxemia.ConclusionsAdjuvant administration of either magnesium sulfate or clonidine is associated with hemodynamic stability and favorable unawareness in the setting of elective surgical delivery.

Oral Gabapentin versus Pregabalin for Postoperative Pain Relief in Elective Cesarean Section Patients under Spinal Anesthesia

Background: Pain after Cesarean delivery is the main postoperative complain in parturients, pregabalin and gabapentin have been shown to decrease acute postoperative pain in parturient. Objective: The aim of the study was to compare gabapentin and pregabalin as oral premedication in patients for elective cesarean section under spinal anesthesia for postoperative pain relief and the need to rescue analgesia. Methods: This study was carried out at Obstetric Operating Rooms, Zagazig University Surgical Hospitals. The study included 54 consenting women aging 20–40 yrs old with uncomplicated pregnancies that were scheduled to undergo elective Cesarean section delivery under spinal anesthesia. They were randomly allocated into three equal groups. Group (P) received 300 mg pregabalin, group (G) received 900 mg gabapentin, and control group (C). The study medication given orally one hour before the anticipated time of the surgical incision, and data measured included visual analogue scale (VAS), the total doses of analgesia, the incidence of post-operative nausea and vomiting (PONV) and the level of sedation. Results: The VAS was comparatively low in patients of group P as compared to G and C groups (P value < 0.05). Total analgesic requirement of pethidine in first 24 h was significantly lower in groups P as compared to groups G & C (P value < 0.001). We found that there was statistically significant increase in the sedation scores of the patients in P group as compared to G & C groups. Conclusion: Pregabalin 300 mg was more effective than gabapentin300 mg in reducing post Cesarean section pain, opioid consumption, nausea, and vomiting.

Uterine conservation in placenta accrete spectrum (PAS) disorders: A retrospective case series: Is expectant management beneficial in reducing maternal morbidity?

ObjectiveTo examine whether expectant management confers any benefit on operative morbidity for the management of placenta accrete spectrum (PAS) disorders. Study designThis was a single center retrospective cohort study at a tertiary referral center In Singapore. Women with PAS disorder between January 2006 and December 2017 were identified from the hospital register.Antenatal features, surgical factors and post-operative morbidity were compared between women having caesarean hysterectomy, those having caesarean section with placental removal and women having expectant management, defined as caesarean section with retention of placenta using the student’s t and Chi square tests. The natural course, complications and preservation of fertility were examined for women having expectant management. ResultsNinety women with PAS were included. The incidence of PAS was 0.064 %. Mean gestational age (GA) at diagnosis was 26.4 weeks. Elective and emergency deliveries were performed at 36.7 and 32.4 weeks respectively (p = <0.0001).Caesarean hysterectomy, Caesarean section with placenta removal and expectant management (EM) were performed in 51(56.7 %),16(17.8 %) and 23(25.6 %) women respectively. The mean blood loss (MBL) and surgical time for EM were significantly lower than those for caesarean hysterectomy 0.52 L vs 3.17 L (p < 0.0001) and 70.8 min vs 171.6 min (p < 0.0001). The advantage of lower blood loss with expectant management persisted even after blood loss at delayed hysterectomy was considered (1284.09 mL vs 3168.72 mL (p-value <0.0001)).Uterine preservation with EM was successful in 61 % (14/23) women. Although nine women (39 %) in this group needed hysterectomy most complications were minor and presented within three months. The mean follow up overall was 13 months. ConclusionTraditionally caesarean hysterectomy has been the main surgical approach for PAS. Our study consolidates existing evidence for expectant management being an option for a select group of patients to avoid complications associated with hysterectomy and allow uterine preservation.

Delivery of monochorionic twins: lessons learned from the Twin Birth Study

The current literature regarding the recommended mode of delivery of monochorionic-diamniotic twins is limited to small numbers, retrospective studies, and comparisons of outcomes of monochorionic-diamniotic twin pregnancies with those of dichorionic-diamniotic twin pregnancies instead of outcomes of trial of labor vs elective cesarean delivery of monochorionic-diamniotic twins. This study aimed to compare perinatal and maternal outcomes of planned cesarean delivery and planned vaginal delivery of monochorionic-diamniotic twins using the Twin Birth Study data. This study is a secondary analysis of the Twin Birth Study. Women were randomized from 32 weeks and 0 days gestation to 38 weeks and 6 days gestation to planned cesarean delivery or planned vaginal delivery. Twin A in the cephalic presentation and estimated weight of each twin between 1500 and 4000 grams were the inclusion criteria. Pregnancies complicated by fetal reduction after 13 weeks of gestation, lethal fetal anomaly, or contraindication to vaginal delivery were excluded. Elective delivery was planned between 37 weeks and 5 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation. Perinatal and maternal outcomes of monochorionic-diamniotic twin pregnancies were compared between those randomized for planned cesarean delivery and those randomized for planned vaginal delivery. In addition, outcomes of monochorionic-diamniotic twin pregnancies were compared with those of dichorionic-diamniotic twin pregnancies. Out of the 1393 women in each arm, 346 (24.9%) women in the planned cesarean delivery arm and 324 (23.3%) women in the planned vaginal delivery arm had monochorionic-diamniotic twin pregnancies and were eligible for the first analysis. The rate of cesarean delivery was 39.2% in the planned vaginal delivery arm and was 91.3% in the planned cesarean delivery arm. There was no significant difference in gestational age at delivery between the groups (34.4±1.8 weeks vs 34.5±1.8 weeks; P=.78). No difference was found in maternal outcomes. As for perinatal outcomes, the rate of the primary adverse neonatal composite outcomes in twins A or twins B was similar in both the planned vaginal delivery and the planned cesarean delivery arms (twins A, 1.2% vs 1.2% [P=.92]; twins B, 1.2% vs 3.2% [P=.09]). Within the planned cesarean delivery arm, the rate of primary adverse neonatal composite outcome was higher in twins B than twins A (3.2% vs 1.2%; P=.03). There was no difference in the primary adverse neonatal composite outcome between twins A in the monochorionic-diamniotic group and the dichorionic-diamniotic group (1.2% vs 1.3%; P=.89) or between twins B in similar groups (2.3% vs 2.7%; P=.47). In monochorionic-diamniotic twin pregnancy between 32 weeks and 0 to 7 days of gestation and 38 weeks and 6 to 7 days of gestation, with twin A in a cephalic presentation, planned cesarean delivery did not decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity, as compared with planned vaginal delivery.

Management of pregnancy after fertility-sparing surgery for cervical cancer.

Cervical cancer is increasingly diagnosed in women who have not yet completed their reproductive plans. For women with early-stage disease (FIGO stage IA1-IB1), fertility-sparing procedures, such as conization, trachelectomy or radical trachelectomy, represent the treatments of choice. However, women who undergo repeated conization or trachelectomy represent a challenge for obstetricians because they are at increased risk of infertility, mid-trimester miscarriage, preterm premature rupture of membranes and preterm delivery. So far, the evidence-based guidance on the management of these pregnancies is limited. This article reviews the literature discussing pregnancy management in women after fertility-sparing surgery for early cervical cancer. Although the evidence is limited, certain measures are desirable, including screening and treatment of asymptomatic bacteriuria, screening for cervical incompetence and progressive cervical shortening by transvaginal ultrasonography, and fetal fibronectin testing. Vaginal progesterone supplementation should be primary prevention for all women after trachelectomy. Women with a history of preterm delivery or late miscarriage may benefit from cervical cerclage. Elective delivery by cesarean section in the early-term period is desirable.

SPONTANEOUS PNEUMOTHORAX DURING PREGNANCY: A RARE CHALLENGE

TYPE: Abstract Publication TOPIC: Disorders of the Pleura PURPOSE: Primary spontaneous pneumothorax (PSP) during pregnancy is a rare condition with serious risks to the mother and the fetus, so rapid recognition and treatment are essential. Since few cases has been described, symptoms of dyspnea and chest pain can be easily misdiagnosed. The aim is to describe a case of a pregnant patient with PSP, managed with chest tube drainage. METHODS: A 30-year-old woman on 28th gestational week (gravida 1/ parity 0), non-smoker, presented at urgency department with sudden pleuritic chest pain and dyspnea. No history of respiratory pathology or trauma. On physical examination, hemodynamically stable, no fever, tachypneic with oxygen saturation 97% on ambient air. Pulmonary auscultation with decreased vesicular murmur on the left hemithorax. No analytic alterations. No fetal distress. The chest radiography showed findings of large left pneumothorax, without mediastinum deviation. A chest drain was placed with reduction of pneumothorax. Given the absence of pulmonary re-expansion, suction treatment was made. RESULTS: The patient had progressive recovering and was hospital discharged asymptomatic. A caesarean section was performed on 39th gestational week, under epidural anesthesia, without complications. The patient maintains a pulmonology follow-up, without new episodes of pneumothorax. CONCLUSIONS: PSP during pregnancy should be part of chest pain and dyspnea differential diagnosis and promptly recognized to prevent severe complications. CLINICAL IMPLICATIONS: Given the symptomatic large pneumothorax, a chest tube was placed. Since the high risk of recurrence during delivery, it is recommended elective assisted delivery with forceps or ventouse extraction to lessen maternal efforts, despite some authors consider the caesarean section a safe option. DISCLOSURE: No significant relationships. KEYWORDS: pneumothorax, pregnancy

Foetal outcome by the weeks of gestation in spontaneous vaginal delivery at term

The gestational age at which the delivery occurs is important in determining the perinatal outcome. In this study, the foetal outcome was analysed according to the gestational age in weeks in spontaneous vaginal delivery occurring between 36 completed weeks to 40 completed weeks of gestation. To study the foetal outcome according to the weeks of gestation in spontaneous vaginal delivery occurring between 36 completed weeks to 40 completed weeks of gestation. A retrospective study of women who spontaneously delivered vaginally, at gestational age between 36 completed weeks to 40 completed weeks from 1 July 2019 to 30 September 2019 was conducted at GMERS Medical College and Hospital, Sola.Total 390 cases were studied.Foetal outcome in terms of birth weight, APGAR score at 1 minute, and NICU admissions were noted and analysed according to the weeks of gestation at delivery, and entered into a database.The results were analysed and presented in the form of tables and graphs. The average birth weight increased with increase in the weeks of gestation at the time of the spontaneous delivery. The average birth weight of neonates born in 36th, 37th and 38th week was 2.314Kg, 2.623Kg and 2.704Kg, respectively. 14.28% of the babies born in the 36th week of gestation were admitted to the NICU. 4.705% and 4.347% of the babies born in the 37thand 38th week of gestation respectively, were admitted to the NICU.The Mean APGAR score of the neonates born in 36th, 37th, 38th and 39th week were 8.714, 9.235, 9.347, and 9.645, respectively. Thus, the mean APGAR score increased by the weeks of gestation at the time of the spontaneous delivery. Unnecessary induction of labour or elective LSCS before 39 weeks should be discouraged. In case of elective deliveries, unless there is a health risk to the mother or baby, it is best to wait to deliver until reaching full term at 39 weeks.

Development of a prenatal clinical care pathway for uncomplicated gastroschisis and literature review.

Gastroschisis is an abdominal wall defect wherein the bowel is herniated into the amniotic fluid. Controversy exists regarding optimal prenatal surveillance strategies that predict fetal well-being and help guide timing of delivery. Our objective was to develop a clinical care pathway for prenatal management of uncomplicated gastroschisis at our institution. We performed a review of literature from January 1996 to May 2017 to evaluate prenatal ultrasound (US) markers and surveillance strategies that help determine timing of delivery and optimize outcomes in fetal gastroschisis. A total 63 relevant articles were identified. We found that among the US markers, intraabdominal bowel dilatation, polyhydramnios, and gastric dilatation are potentially associated with postnatal complications. Prenatal surveillance strategy with monthly US starting at 28weeks of gestational age (wGA) and twice weekly non-stress testing beginning at 32wGA is recommended to optimize fetal wellbeing. Timing of delivery should be based on obstetric indications and elective preterm delivery prior to 37wGA is not indicated. Close prenatal surveillance of fetal gastroschisis is necessary due to the high risk for adverse outcomes including intrauterine fetal demise in the third trimester. Decisions regarding the timing of delivery should take into consideration the additional prematurity-associated morbidity.

Subcutaneous Tissue Irrigation with Povidone Iodine in Decreasing the Rate of Surgical Site Infection Following Cesarean Section: (Randomized Control Trial)

Abstract Background Cesarean section remains to be one of the most common surgical procedures performed worldwide and available data indicate that surgical interventions constitute approximately 0.4%–40.5% of all deliveries. Surgical site infections (SSIs) are reported to occur in up to 8.4% of women having a caesarean section (CS) with many negative effects, including pain, prolonged hospitalisation or readmission, need for antibiotics, return to theatre and increasing costs. Objective In women undergoing elective caesarian section, subcutaneous tissue irrigation with povidone Iodine may decrease the rate of surgical site infection. Patients and Methods The study included any female from 20 to 35 years old of gestational age 38 week or older with viable fetus, BMI 20-30 Kg/m2. Patient excluded were those with preoperative haemoglobin less than 10, prolonged rupture of membranes, diabetic, hypertensive or with any medical disorder including autoimmune diseases. Results The result of our study demonstrated that the use of povidone iodine 1% solution doesn’t have an added benefit in decreasing the incidence of SSI. Conclusion We conclude that the use of povidone iodine 1% solution in irrigation of subcutaneous tissue prior to skin closure in elective caesarian deliveries does not have an added benefit in decreasing the incidence of SSI and is, thus, not recommended at time being.

Determination of the ED50 and ED95 of intravenous bolus of norepinephrine for the treatment of hypotension during spinal anesthesia for cesarean delivery.

Norepinephrine is considered as a potential alternative for blood pressure stabilization during spinal anesthesia for cesarean delivery, as it maintains a better maternal heart rate and cardiac output compared with phenylephrine. However, its use as a bolus dose for hypotension treatment remains largely unexplored. Therefore, the present study investigated the ED50 and ED95 of norepinephrine as a bolus for maternal hypotension during cesarean delivery. In the present prospective trial, 42 patients were enrolled for elective delivery under spinal anesthesia. The dose of norepinephrine was decided by the up-and-down sequential allocation method (UDM) with an initial dose of 0.075 µg/kg and a 0.025 µg/kg increment. The 42 patients received a bolus of norepinephrine when systolic blood pressure fell to <80% of baseline. The ED50 was calculated by the sequential method and the probit regression model. The ED95 was then calculated using the probit regression model. The ED50 of norepinephrine, which was determined by the UDM, was 0.067 µg/kg (95% CI, 0.056–0.081). The probit regression model calculated an ED50 of 0.072 µg/kg (95% CI, 0.056–0.088) and an ED95 of 0.121 µg/kg (95% CI, 0.1–0.207). In summary, the present results suggested the ED50 of a bolus norepinephrine for preventing hypotension in elective CD is 0.067 µg/kg (95% CI, 0.056–0.081), with an ED95 of 0.121 µg/kg (95% CI, 0.1–0.207).

Elective delivery at 34 weeks vs routine obstetric care in fetal gastroschisis: randomized controlled trial.

To evaluate whether elective preterm delivery (ED) at 34 weeks is of postnatal benefit to infants with isolated gastroschisis compared with routine obstetric care (RC). Between May 2013 and September 2015, all women with a sonographic diagnosis of fetal gastroschisis referred to a single tertiary center, before 34 weeks' gestation, were invited to participate in this study. Eligible patients were randomized to ED (induction of labor at 34 weeks) or RC (spontaneous labor or delivery by 37-38 weeks, based on standard obstetric indications). The primary outcome measure was length of time on total parenteral nutrition (TPN). Secondary outcomes were time to closure of gastroschisis and length of stay in hospital. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat. Twenty-five women were assessed for eligibility, of whom 21 (84%; 95% CI, 63.9-95.5%) agreed to participate in the study; of these, 10 were randomized to ED and 11 to RC. The trial was stopped at the first planned interim analysis due to patient safety concerns and for futility; thus, only 21 of the expected 86 patients (24.4%; 95% CI, 15.8-34.9%) were enrolled. Median gestational age at delivery was 34.3 (range, 34-36) weeks in the ED group and 36.7 (range, 27-38) weeks in the RC group. One patient in the ED group delivered at 36 weeks following unsuccessful induction at 34 weeks. Neonates of women who underwent ED, compared to those in the RC group, showed no difference in the median number of days on TPN (54 (range, 17-248) vs 21 (range, 9-465) days; P = 0.08), number of days to closure of gastroschisis (7 (range, 0-15) vs 5 (range, 0-8) days; P = 0.28) and length of stay in hospital (70.5 (range, 22-137) vs 31 (range, 19-186) days; P = 0.15). However, neonates in the ED group were significantly more likely to experience late-onset sepsis compared with those in the RC group (40% (95% CI, 12.2-73.8%) vs 0%; P = 0.03). This study demonstrates no benefit of ED of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that ED is detrimental to infants with gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Management and perinatal outcome of selective intrauterine growth restriction in monochorionic pregnancies

Introduction Selective intrauterine growth restriction (sIUGR) is a complication observed in about 10–15% of all monochorionic (MC) pregnancies, causing a significant increase in perinatal mortality and morbidity. Objective To evaluate clinical management options and perinatal outcomes of sIUGR in MC pregnancies monitored in a single tertiary center. Methods A retrospective study was performed on 55-MC pregnancies with sIUGR between January 2012 and May 2018 at the Fetal Medicine Unit of La Paz Hospital. Cases were classified according to the umbilical artery (UA) Doppler pattern as type I (positive end-diastolic flow; n = 25), type II [persistently absent or reversed end-diastolic flow (AREDF); n = 5] and type III [intermittently absent or reversed end-diastolic flow (iAREDF); n = 25]. Types II and III were then merged together as severe sIUGR cases. Subsequently, two possible approaches were considered: expectant management (EM) with elective preterm delivery in case of fetal deterioration, or in-utero therapy via fetoscopic laser photocoagulation (FLP) of intertwin anastomosis or selective umbilical cord occlusion (CO) of the growth-restricted fetus. Results Gestational age (GA) at diagnosis was progressively lower with each type. Severe sIUGR cases delivered significantly earlier than type I, showing lower birth weights and higher intertwin biometric discordance. Unintended fetal demise occurred in 14% (6/25) of severe sIUGR pregnancies as opposed to 0% (0/19) in type I, p = .028. A significantly higher proportion of twins was admitted in NICU in severe cases when compared to type I [87% (33/38) versus 47% (18/38), p < .001]. In addition, brain damage at birth was also found to be more prevalent in this group [21% (8/38) versus 11% (4/38), p = .346], especially in the larger twin, when comparing any short-term neurological sequel [30% (7/23) versus 0% (0/19), p = .011] or specifically periventricular leukomalacia [PVL; 22% (5/23) versus 0% (0/19), p = .053]. Although the overall mortality rate was significantly higher in severe sIUGR that underwent CO instead of EM [58% (7/12) versus 11% (4/36), p = .002], NICU admissions were higher in the latter [94% (17/18) versus 40% (2/5), p = .021]. Neurological sequels at birth were similar in both groups [39% (7/18) versus 40% (2/5), p = 1.000], similarly when considering only the larger twin for any brain lesion [28% (5/18) versus 40% (2/5), p = .621] or just PVL [22% (4/18) versus 20% (1/5), p = 1.000]. Conclusion Given the good prognosis of type I sIUGR, expectant management is the first approach to consider. However, due to the poorer clinical evolution of types II and III sIUGR, the decision-making is challenging and needs to be individualized depending on the UA Doppler pattern, GA at diagnosis, severity of growth restriction and biometric discordance, technical issues and parents’ preferences.

Association of Widespread Adoption of the 39-Week Rule With Overall Mortality Due to Stillbirth and Infant Death

To improve neonatal morbidity, efforts have been made to reduce elective deliveries prior to 39 weeks' gestation, also known as the 39-week rule. Prolonging pregnancies also prolongs exposure to the risk of stillbirth. The true association of a 39-week rule with mortality is unknown and studies to date have shown conflicting results. To determine if widespread adoption of a 39-week rule, limiting elective deliveries prior to 39 weeks' gestation, is associated with an increase or decrease in overall mortality when considering both stillbirths and infant deaths. This historical cohort study used birth certificate and infant death certificate data in the United States to compare years before and after the adoption of the 39-week rule. Births between 2008 and 2009 were considered to be in the preadoption period (n = 7 322 234), and those between 2011 and 2012 were considered to be in the postadoption period (n = 6 972 626). Included births were singleton, nonanomalous births between 37 0/7 weeks' and 42 6/7 weeks' gestation. Statistical analysis was performed from July 19, 2016, through June 27, 2019. The exposure of interest was the Joint Commission adoption of the 39-week rule as a quality measure. The primary outcomes of interest were stillbirth and infant death. A total of 7 322 234 births (49.0% girls and 51.0% boys) were included in the preadoption period and 6 972 626 births (49.1% girls and 50.9% boys) were included in the postadoption period. Compared with the preadoption period, there was a decrease in the proportion of deliveries at 37 weeks (-0.06%) and 38 weeks (-2.5%) and an increase in the proportion of deliveries at 39 weeks (6.8%) and 40 weeks (0.2%) in the postadoption period (P < .001). The stillbirth rate increased in the postadoption cohort compared with preadoption (0.09% vs 0.10%; P < .001). The infant death rate decreased in the postadoption period compared with preadoption (0.21% vs 0.20%; P < .001). An overall mortality rate of 0.31% was calculated for the preadoption period and 0.30% for the postadoption period (P = .06). Additional analysis in a counterfactual model suggests that up to 34.2% of the difference in mortality could be associated with the 39-week rule. Stable overall perinatal mortality rates were observed in the 2-year period immediately after adoption of the 39-week rule, despite an increase in stillbirth.

The Effect of Adding Low-Dose Naloxone to Intrathecal Morphine on Postoperative Pain and Morphine Related Side Effects after Cesarean Section: A Double-Blind, Randomized, Clinical Trial

BACKGROUND:Nowadays, spinal anaesthesia is a suitable choice for most elective and emergency cesarean section (C-section) deliveries.AIM:This study aimed to determine the effect of adding low-dose naloxone to intrathecal morphine on postoperative pain and morphine related side effects after C-section.MATERIAL AND METHODS:In the present double-blind, randomised clinical trial, 70 women aged over 18 years, who were candidates for elective medical C-section under spinal anaesthesia were selected and randomly assigned to either the study group or the control group. For spinal anaesthesia, 10 mg of Bupivacaine plus 100 μg of morphine was administered for all patients. However, patients in the study group received 20 µg of naloxone intrathecally; but the patients in the control group only received normal saline as a placebo. After surgery, patient-controlled analgesia (PCA) pump with paracetamol (Apotel®) was connected to each patient. The intensity of postoperative pain in the patients was evaluated and recorded using Visual Acuity Screening (VAS) at 2, 4, 6 and 24 hours after the surgery. The patients were also examined for postoperative nausea and pruritus.RESULTS:Regardless of the groups to which the patients were assigned, a significant difference in pain intensity was observed during the study period (time effect; p < 0.001). Although the intensity of pain was lower in the study group, the difference was not statistically significant (group effect; p = 0.84). Also, there was no group time interaction between pain intensity and the times studied (p = 0.61). The incidence rates of postoperative nausea and pruritus were significantly lower in the study group compared to the control group (p < 0.001).CONCLUSION:According to the results of this study, adding low dose naloxone to intrathecal morphine did not significantly change postoperative pain intensity in the patients undergone elective C-section using spinal anaesthesia; however, significantly decreased the severity of postoperative nausea and pruritus.

Delivery timing after laser surgery for twin-twin transfusion syndrome.

To compare outcomes of twin-twin transfusion syndrome (TTTS) patients who underwent early elective delivery vs. expectant management. Retrospective study of monochorionic diamniotic twins who underwent laser surgery for TTTS and had dual survivors at 32 weeks. Patients who underwent elective delivery between 32 0/7 to 35 6/7 weeks ("early elective group") were compared with all patients who delivered ≥36 0/7 weeks ("expectant management group"). The primary outcome was a composite of fetal and neonatal morbidity. The final study population was comprised of 15 early elective and 119 expectant management patients. Those in the early elective group were seven times more likely to experience the primary outcome (OR 7.38 [2.01-27.13], p = 0.0026). Among patients who underwent laser surgery for TTTS who had dual survivors at 32 weeks, elective delivery prior to 36 weeks did not appear to be protective.

Influence of the options for the induction of general anesthesia for elective abdominal delivery on condition of newborns

Objective: to evaluate and compare the influence of the options for the induction of general anesthesia for elective abdominal delivery on the condition of newborns. Materials and Methods: The study included 160 newborns, which were born via elective cesarean section under general anaesthesia. All newborns were divided into 4 groups, 40 in each, depending on the anesthetics used for the induction of general anesthesia. In the 1st group, thiopental sodium 5 mg/kg was used; in the 2nd - sodium thiopental 7 mg/kg; in the 3rd - propofol 2,5 mg/kg; in the 4th- sodium thiopental 5 mg/kg with sevoflurane (0,5 MAC). The influence of anesthesia on condition of newborns was evaluated by the Apgar scale and the neurological and adaptive capacity scale NACS.Results: statistically significant differences were not found in assessing newborns on scales. Conclusion: All the researched drugs and their doses used for the induction of general anesthesia during elective abdominal delivery do not adversely effect on the neurological and somatic status of the newborn.

Application of the laryngeal mask airway in cesarean section

Spinal anesthesia is considered the standard anesthetic technique for elective cesarean section, but it is contraindicated in some cases. General anesthesia in pregnant women is associated with a significant increase in frequency of complications, primarily related to airway management. In this article, we propose to use a laryngeal mask airway as an alternative to endotracheal intubation during elective operative delivery, subject to certain conditions. We present two clinical cases of general combined anesthesia with the installation of a second-generation laryngeal mask airway and mechanical ventilation — in a patient with the Arnold-Chiari type I malformation and in a patient with IV grade scoliosis.

Prevalence and Analysis of Inborn Birth Defects in A Tertiary Level Hospital in Bangladesh

Objective: To assess the prevalence of congenital defects and to investigate the maternal and perinatal aspects in relation to the detailed ICD-10 coding of each individual case using The New Born Data base NBBD data collection system under Global surveillance in collaboration with Center for Disease Control CDC, Atlanta and All India Institute of Medical Science AIMS, New Delhi and Bangabandhu Sheikh Mujib Medical University BSMMU as the Focal point of investigation. Methods: All births and terminations of pregnancy beyond 24 weeks with structural and sonographically detectable birth defects from October,2014 to October, 2018 in the Department of Obstetrics and Gynaecology of Bangladesh Medical College and Hospital were carefully scrutinized and detailed information regarding the maternal and associated clinical risk factors were compiled using the NBBD (New Born Birth Defects) surveillance system. Among that period all births (Live birth and still birth) were counted to have a prevalence data of birth defects using the total number of births as the denominator and the number of birth defects as the numerator. Results: The prevalence of detectable birth defects among the 2002 total births (which includes 110 still births) was found to be 4.34% (87/2002 x 100). According to birth defect category using the ICD-10 coding system, 11 broad categories were found. Musculoskeletal deformities Q65-Q79 were the highest (25/87), followed by congenital malformation of the nervous system Q00-Q07(15/87) and congenital malformation of eye, ear, face and neck Q10-Q18(14/87). The birth defects were categorized as isolated, syndrome and sequence; among the 87 cases, 44 were isolated defects, 40 were syndromic / multiple birth defects and 3 were result of Potter sequence. Regarding maternal variables, maternal age&lt;18 years was 23.4%, 18-25 years was 48.93% ,26-33 years was 23.4% and ≥ 34 years was 6.4%; father’s age &lt; 35 yearswas 74.5% and ≥ 35 years 25.5%%, parental consanguinity was present in 4.3% of case. Analyzing the variables relating to labour conditions, majority of pregnancies were singletons 95.7% leaving only 4.3% of pregnancies being Twin pregnancies. Reviewing babies according to gestational age, 69 (73.4%%) of babies were less than 34 weeks and 26.6% remaining were equal to/more than 34 weeks of gestation reflecting a higher frequency of prematurity or pre-term delivery either induced or spontaneous onset. Regarding the mode of delivery, vaginal birth was conducted in approximately 74% of cases and C-Section was performed in remaining cases, the indication of C-section was guided by obstetric causes such as previous C-section and maternal desire for an elective abdominal delivery. Results of the foetal variables by sex distribution showed a significant male predominance (51/87) 51 male, 26 female and 10 ambiguous. Reviewing babies according to gestational age, 64 (73.4%%) of babies were less than 34 weeks and 26.6% remaining were more than 34 weeks of gestation reflecting a higher frequency of prematurity. The studied foetal variable as categorized by weight, as ≤1500gm (extreme low birth weight ELBW) was 23.4%, 1501-2499gm (Low birth weight LBW) was 50% and ≥2500g (Average birth weight) was 26.6 %. The studied foetal variable as categorized by percentage of babies that were born live birth was 87%, 17 % were stillbirth: a significant portion of those terminated late were found macerated. Data was also compiled regarding the following risk factors: Previous history of birth defects/ previous still birth/ previous spontaneous abortions/ terminations for birth defects which did not reveal significant differences.

Clinical analysis of delivery mode of 576 cases of re-pregnancy after cesarean section

Objective To explore the choice of re-pregnancy delivery mode after cesarean section. Methods From January 2015 to December 2017, a retrospective study was performed on 576 pregnant women who received re-pregnancy after cesarean section in National Nuclear Corporation 416 Hospital and randomly selected 40 cases of vaginal birth after cesarean delivery(VBAC), 40 cases of cesarean section after trial of labor after cesarean delivery(TOLAC) and 40 cases of elective repeat cesarean delivery(ERCD) for comparative analysis.The postpartum hemorrhage, neonatal Apgar score, hospitalization time, hospitalization expenses and complication were compared. Results All the 159 pregnant women chose transvaginal trials and 112 had successful vaginal delivery.The success rate of delivery was 70.4%.Compared with the other two groups, the VBAC group had less postpartum hemorrhage [(172.50±59.86)mL, (281.25±192.05)mL, (260.00±125.68)mL], less average hospital stay [(3.9±0.9)d, (5.7±1.5)d, (4.6±0.7)d] and lower medical expenses [(6 491.79±1 104.78), (11 871.96±1 784.30), (10 724.69±1 843.63)], and the differences were statistically significant (F=7.086, 26.243, 123.488; P=0.001, 0.000, 0.000). The neonatal Apgar score, incidence rates of complications (incomplete uterine rupture, postpartum hemorrhage, urinary retention, thrombotic disease and neonatal conversion) had no statistically significant differences between the two groups (all P>0.05). The TOLAC failed to change to the cesarean section group compared with the ERCD group, the average hospitalization cost was more [(11 871.96±1 784.30)CNY, (10 724.69±1 843.63)CNY], the average hospitalization days was longer [(5.7±1.5)d, (4.6±0.7)d], the difference was statistically significant (P=0.000, 0.005). The postpartum hemorrhage volume, neonatal Apgar score, complications had no statistically significant differences between the two groups(all P>0.05). Conclusion It is safe and feasible to perform vaginal trials under close monitoring without vaginal trials.It is safe and feasible to perform vaginal trials under strict monitoring.Even if the vaginal trial fails to change to cesarean section, it will not increase the occurrence of serious complications.Infant outcomes are good. Key words: Cesarean section; Pregnancy; Mode of delivery

One day is not as good as another\u2026at least not across the entire territory of Italy: an analysis of the differences in the daily distribution of births across Italian macro-regions, 1999\u20132016

The concentration of births on working days compared to a relative lack of events at weekends or during public holidays has been interpreted in literature as evidence of an excessive appeal to elective delivery. The World Health Organization has repeatedly expressed concerns about the abuse of this practice. We investigate the daily distribution of births in Italy in the period 1999–2016 to answer the following question: In addition to the weekend effects found in other countries, do popular beliefs about “unlucky” days also influence the calendar of births?We assume that without the effects exerted by the working calendar and/or by popular beliefs, the births should be equally distributed between the days of a month. We interpret the equal distribution as the expected one. This allows us to calculate a daily excess of births with respect to the expected number. We evaluate, by the means of multivariate regression, the impact of public holidays and of popular beliefs on the daily excess of births. In addition to working calendar effects, we found a depressing effect exerted by the 17th day of each month in all Italian territories. Indeed, the number 17 is considered extremely unlucky by popular tradition in Italy. We believe that these findings are indicative of a systemic abuse of elective delivery, especially in Southern Italy. To the best of our knowledge, this work is the first to analyze the effect of irrational beliefs on the calendar of births.