Emergency Cesarean Delivery Research Articles

Outcome of pregnancy in previous cesarean section comparing elective versus trial of labor (VBAC) at KRL Hospital, Islamabad.

Objective: To determine feto maternal outcome in patients with cesarean section and comparing outcome following TOLAC and elective repeat cesarean delivery. Study Design: Descriptive, Cross-sectional study. Setting: Department of Obstetrics & Gynecology, Kahuta Research Laboratory (KRL) Hospital, Islamabad. Period: 10th September 2019 to 9th March 2020. Material & Methods: 93 pregnant women of gestational age 37-42 weeks with previous transverse cesarean section were included. Patients with a history of multiple pregnancies, ruptured uterus, placenta previa, polyhydramnios or oligohydramnios, and fetal malpresentation were excluded. In each patient, the labor trial was done; if not possible, then a cesarean section was done on the elective list. Each case was done by the researcher herself in the presence of a consultant gynecologist and the mode of delivery (vaginal/cesarean), was noted. After this fetal outcome i.e. live birth (yes/no), NICU admission (yes/no), and Apgar score >6 at 5 minutes (yes/no) was noted. Results: Maternal outcomes in a previous cesarean section was found to be a cesarean section in 60 (64.52%) and VBAC in 33 (35.48%), an APGAR score >6 at 5 minutes after VBAC was seen in 100.0% and after elective cesarean delivery in 81.67% of neonates. NICU admission is 0.0% in TOLAC compared to 20.0% with elective repeat LSCS. Live birth after emergency cesarean delivery was seen in 93.33% and 100% after VBAC. Conclusion: This study concluded that the maternal outcome in a previous cesarean section was found to be a cesarean section in 64.52% and VBAC in 35.48% of women and fetomaternal outcome following TOLAC is better.

Pregnancy, Delivery, and Neonatal Outcomes Associated With Maternal Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is associated with adverse health-related outcomes. However, pregnancy and neonatal outcomes among women with OCD have been sparsely studied. To evaluate associations of maternal OCD with pregnancy, delivery, and neonatal outcomes. Two register-based cohort studies in Sweden and British Columbia (BC), Canada, included all singleton births at 22 weeks or more of gestation between January 1, 1999 (Sweden), or April 1, 2000 (BC), and December 31, 2019. Statistical analyses were conducted between August 1, 2022, and February 14, 2023. Maternal OCD diagnosis recorded before childbirth and use of serotonin reuptake inhibitors (SRIs) during pregnancy. Pregnancy and delivery outcomes examined were gestational diabetes, preeclampsia, maternal infection, antepartum hemorrhage or placental abruption, premature rupture of membranes, induction of labor, mode of delivery, and postpartum hemorrhage. Neonatal outcomes included perinatal death, preterm birth, small for gestational age, low birth weight (<2500 g), low 5-minute Apgar score, neonatal hypoglycemia, neonatal jaundice, neonatal respiratory distress, neonatal infections, and congenital malformations. Multivariable Poisson log-linear regressions estimated crude and adjusted risk ratios (aRRs). In the Swedish cohort, sister and cousin analyses were performed to account for familial confounding. In the Swedish cohort, 8312 pregnancies in women with OCD (mean [SD] age at delivery, 30.2 [5.1] years) were compared with 2 137 348 pregnancies in unexposed women (mean [SD] age at delivery, 30.2 [5.1] years). In the BC cohort, 2341 pregnancies in women with OCD (mean [SD] age at delivery, 31.0 [5.4] years) were compared with 821 759 pregnancies in unexposed women (mean [SD] age at delivery, 31.3 [5.5] years). In Sweden, maternal OCD was associated with increased risks of gestational diabetes (aRR, 1.40; 95% CI, 1.19-1.65) and elective cesarean delivery (aRR, 1.39; 95% CI, 1.30-1.49), as well as preeclampsia (aRR, 1.14; 95% CI, 1.01-1.29), induction of labor (aRR, 1.12; 95% CI, 1.06-1.18), emergency cesarean delivery (aRR, 1.16; 95% CI, 1.08-1.25), and postpartum hemorrhage (aRR, 1.13; 95% CI, 1.04-1.22). In BC, only emergency cesarean delivery (aRR, 1.15; 95% CI, 1.01-1.31) and antepartum hemorrhage or placental abruption (aRR, 1.48; 95% CI, 1.03-2.14) were associated with significantly higher risk. In both cohorts, offspring of women with OCD were at elevated risk of low Apgar score at 5 minutes (Sweden: aRR, 1.62; 95% CI, 1.42-1.85; BC: aRR, 2.30; 95% CI, 1.74-3.04), as well as preterm birth (Sweden: aRR, 1.33; 95% CI, 1.21-1.45; BC: aRR, 1.58; 95% CI, 1.32-1.87), low birth weight (Sweden: aRR, 1.28; 95% CI, 1.14-1.44; BC: aRR, 1.40; 95% CI, 1.07-1.82), and neonatal respiratory distress (Sweden: aRR, 1.63; 95% CI, 1.49-1.79; BC: aRR, 1.47; 95% CI, 1.20-1.80). Women with OCD taking SRIs during pregnancy had an overall increased risk of these outcomes, compared with those not taking SRIs. However, women with OCD not taking SRIs still had increased risks compared with women without OCD. Sister and cousin analyses showed that at least some of the associations were not influenced by familial confounding. These cohort studies suggest that maternal OCD was associated with an increased risk of adverse pregnancy, delivery, and neonatal outcomes. Improved collaboration between psychiatry and obstetric services and improved maternal and neonatal care for women with OCD and their children is warranted.

Maternal and Perinatal Outcomes of Pregnant Patients with Coronavirus Disease 2019: Data from a University Hospital Setting in Tirana, Albania, May 2020 to November 2021.

Scientific evidence suggests an increased risk of maternal and obstetric complications in pregnant patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study is aimed at evaluating perinatal and maternal outcomes among patients with coronavirus disease 2019 (COVID-19) in a university hospital setting. This was a prospective cohort study of 177 pregnant women with confirmed SARS-CoV-2 infection at a tertiary hospital between May 2020 and November 2021. Both symptomatic and asymptomatic women with a positive reverse transcription-polymerase chain reaction test result at any time during pregnancy were included in this study. For the purpose of this study, we classified COVID-19 cases into two groups: mild and severe cases. The two groups were then compared to predict how the clinical presentation of COVID-19 affected adverse maternal and perinatal outcomes. Gestational age ≥ 20 weeks at the time of infection was significantly associated with the occurrence of severe forms of the disease (relative risk (RR) 3.98, p = 0.01). Cesarean section was the preferred mode of delivery, with 95 women (62.1%) undergoing surgery. A total of 149 neonates were delivered to women who had confirmed SARS-CoV-2 infection at any time during the course of pregnancy of which thirty-five (23.5%) were admitted to the neonatal intensive care unit (NICU). Severe forms of COVID-19 increased the risk of premature delivery (RR 6.69, p < 0.001), emergency cesarean delivery (RR 9.4, p < 0.001), intensive care hospitalization (RR 51, p < 0.001), and maternal death (RR 12.3, p = 0.02). However, severe forms of SARS-CoV-2 infection are not directly responsible for low birth weight or the need for neonatal resuscitation. Our findings suggest that pregnant women presenting with severe COVID-19 disease are at an increased risk of adverse maternal and perinatal outcomes, such as premature delivery, cesarean section, admission to the ICU, and maternal death. Infection after the 20th week of gestation increases the risk of developing severe forms of the disease.

A serious video game—EmergenCSim™—for novice anesthesia trainees to learn how to perform general anesthesia for emergency cesarean delivery: a randomized controlled trial

PurposeWe developed EmergenCSim™, a serious game (SG) with an embedded assessment, to teach and assess performing general anesthesia for cesarean delivery. We hypothesized that first-year anesthesiology trainees (CA-1) playing EmergenCSim™ would yield superior knowledge scores versus controls, and EmergenCSim™ and high-fidelity simulation (HFS) assessments would correlate.MethodsThis was a single-blinded, longitudinal randomized experiment. Following a lecture (week 3), trainees took a multiple-choice question (MCQ) test (week 4) and were randomized to play EmergenCSim™ (N = 26) or a non-content specific SG (N = 23). Participants repeated the MCQ test (week 8). Between month 3 and 12, all repeated the MCQ test, played EmergenCSim™ and participated in HFS of an identical scenario. HFS performance was rated using a behavior checklist.ResultsThere was no significant change in mean MCQ scores over time between groups F (2, 94) = 0.870, p = 0.42, and no main effect on MCQ scores, F (1, 47) = 1.110, p = 0.20. There was significant three-way interaction between time, gender and group, F (2, 90) = 3.042, p = 0.053, and significant two-way interaction between gender and time on MCQ scores, F (2, 94) = 107.77, p = 0.036; outcomes improved over time among males. There was no group difference in HFS checklist and SG scores. Both instruments demonstrated good internal consistency reliability but non-significant score correlation.ConclusionsPlaying EmergenCSim™ once did not improve MCQ scores; nonetheless scores slightly improved among males over time, suggesting gender may impact learning outcomes with SGs.

The Effects Between Spinal and General Anesthesia for Pre-Eclamptic Mothers Underwent Caesarean Delivery in a Tertiary Care Hospital- A Comparative Study

Background: Preeclampsia is a multisystem disorder characterized by new onset of hypertension systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and proteinuria &gt;300 mg/24 h arising after 20 weeks of gestation in a previously normotensive woman and associated with significant maternal and neonatal morbidity and mortality worldwide. Women with preeclampsia have an increased rate of cesarean section consequent upon the high incidence of intrauterine growth restriction, fetal distress, and prematurity. The aim of this study was to determine and compare maternal &amp; neonatal outcome among pre-eclamptic women following caesarian delivery under general and spinal anesthesia. Material &amp; Methods: This was a comparative observational study and was conducted in the Department of Anesthesiology of Holy Family red crescent Medical College Hospital, Dhaka, Bangladesh during the period from February,2020 to February,2023. In this study we included 250 preeclamptic women undergoing cesarean delivery. The patients were randomly divided into two groups – GA group (Patients who were given general anesthesia) &amp; SA group (Patients who were given spinal anesthesia). Results: In total 250 patients from both the groups completed the study. In our study we found majority (44.8%) of our patients were aged 28-32 years. The mean age was 27.13 ± 3.76 years. Majority (62.8% ) of our patients were cases of emergency caesarean delivery &amp; 37.2% were elective caesarean delivery classes. Most of the students (41.2%) used magnesium sulfate. Intraoperative systolic BP, diastolic BP was significantly lower in SA group than GA group. We found headache, vomiting, fever and wound gaping, postpartum hemorrhage &amp; lower respiratory tract infection was significantly higher in GA group. On contrary, hypotension &amp; pulmonary edema was higher in SA group. Apgar score at 1st, 5th &amp; 10th minutes was significantly higher in GA group than SA group. In GA group, neonatal mortality at 48 h was 10.4% whereas it was 4.8% in SA group. Conclusion: In our study, we found intra-operative blood pressure and pulse rate was observed significantly higher in GA group than SA. Severe preeclamptic mothers receiving general anesthesia and their babies required more critical care support. Maternal as well as neonatal mortality was significantly higher with general anesthesia. Therefore, spinal anesthesia is a safer alternative to general anesthesia among women with severe preeclampsia following caesarean delivery with less postoperative morbidity and mortality.

Effect of the Presence of Nuchal Cords on Vaginal Breech Labor.

Breech delivery has been reported to be associated with a high incidence of abnormal fetal heart rate pattern leading to neonatal asphyxia. In this study, we examined the effect of the presence of nuchal cords on perinatal outcomes of vaginal breech labor. We reviewed the obstetric records of all singleton breech labor cases at the Japanese Red Cross Katsushika Maternity Hospital between 1999 and 2011. Of the 266 breech labor cases in singleton pregnancies, the presence of nuchal cords was recognized in 50 cases (18.8%) on neonatal findings at birth. We compared the clinical characteristics and perinatal outcomes between the breech labor cases with and without nuchal cords. A chi-square test was used for categorical data, and a p-value <0.05 was considered significant. It was found that the incidence of fetal heart rate abnormality during breech labor or neonatal asphyxia in the deliveries with nuchal cords was not significantly different from that in those without nuchal cords. Also,there was no significant difference in the rate of emergent caesarean delivery between the two labors with and without nuchal cords. The current results suggest that the presence of nuchal cords may not be associated withperinatal outcomes. Our results may become one of several pieces of evidence leading to the alleviation of anxiety in pregnant women with breech presentation and fetal nuchal cords.

Thromboelastography with platelet mapping to guide anesthetic management of emergency cesarean delivery in a patient with thrombasthenia: a case report

BackgroundPerinatal management of congenital platelet dysfunction represents a challenge. One of the major concerns is whether neuraxial anesthesia can be applicable for cesarean delivery. We present a patient with thrombasthenia who underwent emergency cesarean delivery.Case presentationA 34-year-old primipara was diagnosed with autosomal dominant thrombasthenia, which was not classified as any known type. A thorough examination revealed that adenosine diphosphate aggregation and collagen aggregation were suppressed. Platelet mapping of viscoelastic testing was used to observe the trajectory of platelet function during pregnancy, which was found to be normal to hypercoagulable until 38 weeks of gestation. On the basis of the results of testing and physiological status, we commenced spinal anesthesia and avoided prophylactic platelet transfusion.ConclusionThe platelet mapping of viscoelastic testing was rapid and simple, allowing repeated examinations. We could choose the appropriate anesthesia method and determine the necessity of blood transfusion for a pregnant patient with thrombasthenia.

Relationship between Abnormal Placenta and Obstetric Outcomes: A Meta-Analysis.

The placenta has several crucial physiological functions that help maintain a normal pregnancy. Although approximately 2-4% of pregnancies are complicated by abnormal placentas, obstetric outcomes remain understudied. This study aimed to determine the outcomes and prevalence of patients with abnormal placentas by conducting a systematic review of 48 studies published between 1974 and 2022. The cumulative prevalence of circumvallate placenta, succenturiate placenta, multilobed placenta, and placenta membranacea were 1.2%, 1.0%, 0.2%, and 0.004%, respectively. Pregnancies with a circumvallate placenta were associated with an increased rate of emergent cesarean delivery, preterm birth (PTB), and placental abruption compared to those without a circumvallate placenta. The succenturiate lobe of the placenta was associated with a higher rate of emergent cesarean delivery, whereas comparative results were observed in terms of PTB, placental abruption, and placenta previa in comparison to those without a succenturiate lobe of the placenta. A comparator study that examined the outcomes of multilobed placentas found that this data is usually unavailable. Patient-level analysis (n = 15) showed high-rates of abortion (40%), placenta accreta spectrum (40%), and a low term delivery rate (13.3%) in women with placenta membranacea. Although the current evidence is insufficient to draw a robust conclusion, abnormal placentas should be recognized as a high-risk factor for adverse outcomes during pregnancy.

Quick Epidural Top-up with Alkalinized Lidocaine for emergent caesarean delivery (QETAL study): protocol for a randomized, controlled, bicentric trial

BackgroundGeneral anesthesia in pregnant women can be associated with significant maternal and fetal morbidity. Emergency caesarean section can be performed by converting labor epidural analgesia to surgical anesthesia by injecting high-dose short-acting local anesthetics through the epidural catheter. The effectiveness and the delay to obtain surgical anesthesia depends upon the protocol used. Data indicate that alkalinization of local anesthetics may shorten their onset of action and increase their effectiveness. This study investigates whether alkalinization of adrenalized lidocaine could increase the efficacy and decrease the delay of onset of surgical anesthesia via an indwelling epidural catheter, thus decreasing the necessity to resort to general anesthesia for emergency caesarean deliveries.MethodsThis study will be a bicentric, double-blind, randomized, controlled trial with two parallel groups of 66 women who require emergency caesarian deliveries and who have been receiving epidural labor analgesia. The number of subjects in groups will be unbalanced with a 2:1 ratio of experimental:control. In both groups, all eligible patients will have had an epidural catheter placed for labor analgesia with levobupicaine or ropivacaine. Patient randomization will occur when the decision is made by the surgeon that an emergency caesarean delivery is indicated. Surgical anesthesia will be obtained by injecting 20 mL of 2% lidocaine with epinephrine 1:200,000, or 10 mL 2% lidocaine with epinephrine 1:200,000 plus 2 mL sodium bicarbonate 4.2% (total of 12 mL). The primary outcome will be the rate of conversion to general anesthesia for failure of the epidural to provide adequate analgesia. This study will be powered to detect a 50% reduction in the incidence of general anesthesia, from 80 to 40%, with a confidence ratio of 90%.DiscussionSodium bicarbonate could be used to avoid general anesthesia for emergency caesarean deliveries by providing reliable and effective surgical anesthesia in women with pre-existing labor epidural catheters is promising. This randomized controlled trial seeks to determine the optimal local anesthetic mixture for converting epidural analgesia to surgical anesthesia for emergency caesarean sections. This may decrease the need for general anesthesia for emergency caesarian section, shorten the time to fetal extraction, and improve safety and patient satisfaction.Trial registrationClinicalTrials.gov NCT05313256. Registered on 6 April 2022

The interaction of maternal obesity and administered betamethasone in the development of fetal respiratory distress syndrome

IntroductionThe current study evaluated the effect of obesity on neonatal respiratory distress syndrome (RDS) in pregnant women who were administered ACSs due to the risk of preterm birth and delivered before 34 weeks of gestation.Material and methodsIn this retrospective study, 414 pregnant women who had a singleton pregnancy, were aged 18–40 years, and received two doses of ACS 24 h apart administered between 23+0/7 and 33+5/7 gestation weeks due to the risk of a preterm birth were included. For maximum fetal effect, those who completed the 48-hour steroid treatment and delivered before 34 weeks of gestation were divided into three groups according to BMI at ACS administration.ResultsGestational age at ACS administration and gestational age at delivery were similar among groups.. Neonatal RDS occurred in 17 (18.6%) newborns in the normal weight group, 40 (17.1%) newborns in the overweight group, and 23 (25.5%) newborns in the obese group. After adjusting for independent effects from maternal age, gestational age at ACS administration, gestational age at delivery, emergency cesarean delivery, fetal birth weight, and fetal gender, we found that RDS rates were significantly higher in the obese group.ConclusionsOur results suggest that maternal obesity reduces the effects of ACS and that RDS rates are higher in neonates born before 34 weeks of gestation to obese mothers to whom ACS has been administered.Therefore, pregnant women who have a high BMI and who are at risk of preterm birth are more likely to require an adjustment in ACS dosing.

Effect of Body Mass Index on Adverse Neonatal Outcomes in Patients With Emergency Cesarean Deliveries [ID: 1381091

INTRODUCTION: The objective of this study was to evaluate the association of body mass index (BMI) with adverse neonatal outcomes in pregnant patients with emergency cesarean delivery (CD). METHODS: This was a retrospective cohort study of singleton nonanomalous pregnancies between 23 and 42 weeks from 2007 to 2012 in California. Pregnancies resulting in an emergency CD were stratified based by ICD-9 codes for cord prolapse, or uterine rupture. Outcomes included neonatal intensive care unit (NICU) admission, Apgar scores less than 3 at 5 minutes, infant death, respiratory distress syndrome (RDS), neonatal seizures, and hypoglycemia. After stratifying by cause of emergency CD, multivariable logistic regression models were used to evaluate associations of BMI at delivery with adverse neonatal outcomes. Models were adjusted for maternal race and ethnicity, age, education level, insurance, parity, smoking status, and prenatal care. RESULTS: Of this cohort, 1,368 had an emergent CD in the setting of cord prolapse, and 992 had an emergent CD in the setting of a uterine rupture. Of individuals with cord prolapse, patients whose BMI was classified as obesity class II had decreased odds of NICU admission, and those whose BMI was classified as obesity class III had decreased odds of NICU admission and RDS. Of individuals with a uterine rupture, patients whose BMI was classified as overweight had decreased odds of all neonatal outcomes analyzed. Those with a BMI classified as obesity class I had decreased odds of all neonatal outcomes except for neonatal seizures. Those with a BMI classified as obesity class II had decreased odds of lower Apgar scores, NICU admission, infant death, and RDS. Those with a BMI greater than 50 had increased odds of RDS and hypoglycemia. CONCLUSION: Higher BMI was associated with decreased risk of many adverse neonatal outcomes in the setting of patients delivering emergently with cord prolapse or uterine rupture. These findings may be useful in appropriately managing patients presenting with emergent CD.

P98 Management of emergency caesarean delivery and decompressive craniectomy for parturient with an acutely decompensated glioblastoma

P98 Management of emergency caesarean delivery and decompressive craniectomy for parturient with an acutely decompensated glioblastoma

Comparison of Feto-Maternal Outcomes Between Emergency and Elective Cesarean Deliveries in Patients with Gestational Diabetes

Aim: To compare fetal and maternal outcomes between elective and emergency cesarean sections in patients with gestational diabetes&#x0D; mellitus (GDM).&#x0D; Material and Methods: Data from patients with GDM delivered by cesarean section between January 2015 and July 2020 were&#x0D; retrospectively reviewed. Patients were grouped according to whether the cesarean section was elective (n=129) or emergency (n=158).&#x0D; Results: The cesarean section rate was higher in patients with GDM (31.16%) than in patients without GDM. There were more patients&#x0D; with inadequate maternal care in the emergency cesarean section group than in the elective cesarean section group (p=0.003). One&#x0D; neonate in the elective group and six in the emergency C/S group died, but the rates of neonatal mortality were similar (p=0.198).&#x0D; Maternal morbidity (wound infection, fever, blood transfusion, and maternal intensive care) and fetal morbidity (birth asphyxia,&#x0D; respiratory morbidity, and neonatal intensive care) were higher in the emergency C/S group (p

Unintended uterine extension at the time of cesarean delivery – risk factors and associated adverse maternal and neonatal outcomes

Objective To identify risk factors, maternal and neonatal adverse outcomes related to unintended lower segment uterine extension during cesarean delivery (CD). Methods A retrospective cohort analysis in a single, university-affiliated medical center between 1 January 2018 and 31 December 2019. All singleton pregnancies delivered by CD were included. Univariate and multivariate analyses were performed to identify maternal and obstetrical predictors for uterine extension during CD. For secondary outcomes, we assessed the correlation between uterine extension and any adverse maternal or neonatal outcome. Risk factors were analyzed using ROC statistics to measure their prediction performance for a uterine extension. Results Overall, 1746 (19.3%) CDs were performed during the study period. Of them, 121 (6.9%) CDs were complicated by unintended uterine extension. There was no difference in maternal demographics and clinical data stratified by uterine extension at CD. Uterine extensions were significantly more common following induction of labor, intrapartum fever, premature rupture of membranes, a trial of labor after cesarean, advanced gestational age, emergent CD, and in particular CD during the second stage of labor (37.2% vs. 6.5%) and after failed vacuum extraction (6.6% vs. 1.1%), p < .05 for all. The incidence of postpartum hemorrhage and re-laparotomy did not differ between the groups. Most of the extensions were caudal-directed (40.4%), and were closed by a two-layer closure (92%). Mean extension size was 4.5 ± 1.7 cm. Using multivariable analysis, the only factor that remained significant was CD at the second stage of labor (adjusted odds ratio (aOR) 54.2, 95% CI 4.5–648.9, p = .002), with an area under the ROC curve 0.653 (95% CI 0.595–0.712, p < .001). Emergent CD, body mass index, birth weight, failed vacuum attempt, and trial of labor after cesarean were not significant. For secondary outcomes, an unintended uterine extension was associated with longer operation time, higher estimated blood loss, greater pre- to post-CD hemoglobin difference, increased blood products transfusion, puerperal fever, and longer hospital stay. No clinically significant neonatal adverse outcomes were observed. Conclusions In our cohort, second-stage CD was the strongest predictor for an unintended uterine extension. Following uterine extension, women had increased infectious and blood-loss morbidity.

The Implications of Multiple Repeat Cesarean Deliveries On Maternal Morbidity

OBJECTIVE: This study aimed to assess the obstetric outcomes of cesarean delivery (CD) in a cohort of pregnant women who had a history of four or more previous CDs and compared them with those who had a history of three or fewer previous CDs. STUDY DESIGN: The cohort of this retrospective study consisted of all pregnant women who gave birth in our hospital via elective or emergency CD and who had previously undergone one or more other cesarean sections. Pregnant women who had a history of four or more CDs were included in the multiple repeat CD group, and cases who had a history of fewer than 4 CDs were enrolled in the lower-order repeat CD (comparison) group. Demographic data, medical history, clinical features, intraoperative events, and postoperative complications were recorded. RESULTS: The multiple repeat CD group comprised 63 women, and the lower-order repeat CD group (comparison group) included 1097 cases. Intraabdominal dense adhesions (28.6% versus 14.1%, p=0.002), placenta previa (11.1% versus 4.1%, p=0.009), placenta accreta spectrum (PAS) (7.9% versus 2.4%, p=0.008), bladder injury (6.3% versus 1.7%, p=0.011), intraoperative massive hemorrhage (7.9% versus 2.2%, p=0.004), uterine artery ligation (4.8% versus 1.1%, p=0.012), internal iliac artery ligation (4.8% versus 1.2%, p=0.008), cesarean hysterectomy (4.8% versus 1.5%, p=0.045), blood transfusion (12.7% versus 4.1%, p=0.001), and maternal intensive care unit (ICU) admission (14.3% versus 2.0%, p&lt;0.001) were significantly more common among women in the multiple-repeat CD group compared with the lower-order repeat CD group. CONCLUSIONS: Pregnant women having multiple repeat CDs have a significantly increased risk of dense adhesions, placenta previa, PAS, intraoperative massive hemorrhage, blood transfusion, bladder injury, additional surgical interventions, including uterine artery ligation, internal iliac artery ligation, cesarean hysterectomy, and maternal ICU admission.

Ultrasonographic images of spina bifida before obstetric anesthesia: a case series

BackgroundSpina bifida is a relatively common congenital malformation. As the functional prognosis of patients with spina bifida has improved over time, the number of cases resulting in pregnancy and delivery has increased. Lumbar ultrasonography has become a standard and helpful technique before neuraxial anesthesia. We believe that it might be valuable if we use lumbar ultrasonography to evaluate pregnant women with spina bifida before obstetric anesthesia.Case presentationWe performed lumbar ultrasonography to evaluate four pregnant women with spina bifida. Patient 1 had no history of surgery. Lumbar radiography before pregnancy showed a bone defect from L5 to the sacrum as a result of incomplete fusion. Magnetic resonance imaging showed a spinal lipoma and a bone defect of the sacrum. Lumbar ultrasonography showed similar findings. We performed general anesthesia for emergency cesarean delivery. Patient 2 underwent surgical repair immediately after birth. Lumbar ultrasonography showed the same bone defect as well as a lipoma beyond the bone defect. We performed general anesthesia for cesarean delivery. Patient 3 had vesicorectal disorders but no prior surgery. Lumbar radiography before pregnancy showed congenital abnormalities such as incomplete fusion, scoliosis, rotation, and a notably small sacrum. Lumbar ultrasonography showed the same bone defect. We performed general anesthesia for cesarean section with no complications. Patient 4 complained of lumbago a few years after her first delivery and received a diagnosis of spina bifida occulta by lumbar radiography, with the incomplete fusion of only the 5th vertebra. Lumbar ultrasonography indicated the same abnormalities. We placed an epidural catheter to avoid the bone abnormality and achieved epidural labor analgesia with no complications.ConclusionsLumbar ultrasonography shows anatomic structures easily, safely, and consistently, without X-ray exposure or the need for more expensive modalities. It is a helpful technique to explore anatomic structures potentially complicated by spina bifida before anesthetic procedures.

Use of Induction of Labour and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-Level Study

ABSTRACT Care provided by maternity services requires a fine balance between support for the physiological process of birth and clinical intervention when needed. Yet, clinical guidelines for maternity care vary widely within and between countries. For singleton babies born at term in 149 hospitals of the National Health Service (NHS) in the United Kingdom alone, the rate of induction of labor varied from 16% to 44%, and the overall rate of cesarean delivery (CD) varied from 17% to 35% between April 2016 and March 2017. This suggests a lack of consensus around the indications for interventions, such as induction of labor and emergency CD. The debate often focuses on either the safety of childbirth or the women's experience to deliver good maternity care. The aim of this study was to examine the association between the rates of induction of labor and emergency CD with the risks of stillbirth, neonatal intensive care unit (NICU) admission, and need for mechanical ventilation in neonates born at term. This was a national study using data collected from electronic maternity records between 2015 and 2017. Included were singleton pregnancies delivered in NHS hospitals providing maternity care. The primary outcomes were stillbirth, NICU admission, and mechanical ventilation. The entire cohort included 1,131,719 term, singleton births in 131 hospitals. The risks of stillbirth, NICU admission, and need for mechanical ventilation in the baby were 0.15%, 5.4%, and 0.54%, respectively. Between hospitals, the rate of induction of labor ranged from 17.5% to 40.7% (interquartile range, 24.6%–32.1%), and the rate of emergency CD ranged from 5.6% to 17.1% (interquartile range, 9.4%–11.8%). In hospitals with higher induction rates, the risk of adverse perinatal outcomes was lower, but the association was statistically significant only between the rate of induction and rates of stillbirth (P = 0.002) and mechanical ventilation (P = 0.001). For each 5%-point increase in the rate of induction at a hospital, there was a 9% decrease in the risk of stillbirth (odds ratio [OR], 0.91; 95% confidence interval [CI], 3%–15%) and a 14% decrease in the risk of mechanical ventilation (OR, 0.86; 95% CI, 6%–21%). There was no association between the rate of emergency CD and the primary outcomes (all P &gt; 0.05). In the United Kingdom, the rates of induction of labor and emergency CD varied considerably between hospitals. Those hospitals with higher rates of induction had lower risks of adverse perinatal outcomes, but not for emergency CD.

Pregnancy outcomes at maternal age over 45 years: a systematic review and meta-analysis.

We aimed to identify trends in pregnancy outcomes, especially delivery mode, among pregnant patients older than 45 years. We performed a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for studies published between 1 January 2010 and 30 June 2022. The primary outcomes were cesarean delivery and assisted delivery; secondary outcomes were preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth. The inclusion criteria were studies examining the relationship between older age pregnancy and pregnancy outcomes, studies that compared pregnancy outcomes at maternal age ≥45 years and <45 years, and at least one of the primary and secondary pregnancy outcomes were included. Study screening was conducted after duplicates were identified and removed. We assessed the quality of each study and publication bias. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. The inverse variance method was used to integrate the results if studies had an adjusted analysis. Among 4209 studies initially retrieved, 24 were included in this review. All studies were retrospective, observational studies. Pregnant patients aged ≥45 years had a significantly higher cesarean delivery rate (odds ratio, 2.87; 95% confidence interval, 2.50-3.30; I2=97%) than those aged <45 years. However, the emergency cesarean delivery rate was lower in older pregnant patients (odds ratio, 0.61; 95% confidence interval, 0.47-0.79; I2=79%). Pregnancy in older individuals was associated with a lower assisted delivery rate than pregnancy in younger individuals (odds ratio, 0.85; 95% confidence interval, 0.75-0.97; I2=48%). Preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth were more likely to occur in pregnant patients aged ≥45 years than in those aged <45 years. Adjusted pooled analyses showed trends similar to those in the unadjusted pooled analyses. Adverse pregnancy outcomes, typically cesarean delivery, were more likely to occur in older (≥45 years) than in younger pregnant patients. However, the assisted delivery rate was lower in older pregnant patients.

Successful pregnancy in the blind hemicavity of Robert’s uterus: a rare case report and brief literature review

BackgroundRobert’s uterus is a rare congenital anomaly, characterized as an asymmetric septate uterus that has a blind hemicavity with unilateral menstrual fluid retention and a unicornuate hemicavity connecting to the cervix unimpededly. Patients with Robert’s uterus generally present with menstrual disorders and dysmenorrhea, and some may have reproductive problems as well, including infertility, recurrent miscarriage, preterm labor and obstetric complications. In this case, we describe a successful pregnancy implanted on the obstructed hemicavity and delivered a liveborn girl. Meanwhile, we highlight diagnostic and therapeutic difficulties in patients with atypical symptoms of Robert’s uterus.Case presentationA 30-year-old Chinese primigravida sought for emergency treatment at 26 weeks and 2 days of gestation because of preterm premature rupture of membranes (PPROM). At the age of 19, the patient was misdiagnosed with hyperprolactinemia and pituitary microadenoma for showing symptom of hypomenorrhea and was suspected to have a uterine septum in the first trimester. She was diagnosed with Robert’s uterus at 22 weeks of gestation by repetitious prenatal transvaginal ultrasonography, which was subsequently confirmed by magnetic resonance imaging. At 26 weeks and 3 days of gestation, the patient was suspected to have oligohydramnion, irregular uterine contraction, and umbilical cord prolapse, and she expressed a strong will of saving the baby. Emergency cesarean delivery was performed and a small hole, together with several weak spots, was found at the lower and back wall of the septum of the patient. The treatment was effective and both the mother and the infant, who had an extremely low birth weight, were discharged in good health conditions.ConclusionsPregnancy in the blind cavity of Robert's uterus with living neonates is incredibly rare. In our case, the favorable outcome may result from the unusual hole found at the septum, which may play a role in communicating amniotic fluid between the two hemicavities so to keep the neonate alive. we highlight the importance of early diagnosis and pre-pregnancy treatment of this uterine malformation, and the timely termination of pregnancy, for improving birth quality and reducing mortality.

Distribution and association of interpregnancy weight change with subsequent pregnancy outcomes in Asian women

The extent of interpregnancy weight change and its association with subsequent pregnancy outcomes among Asians remain unclear. We examined changes in maternal body mass index (BMI) between the first two deliveries and outcomes in the second delivery. Medical records of women with their first two consecutive deliveries between 2015 and 2020 at KK Women’s and Children’s Hospital, Singapore were retrieved. Gestational-age-adjusted BMI was determined by standardising to 12 weeks gestation and interpregnancy BMI change was calculated as the difference between both pregnancies. Pregnancy outcomes were analysed using modified Poisson regression models. Of 6264 included women with a median interpregnancy interval of 1.44 years, 40.7% had a stable BMI change within ± 1 kg/m2, 10.3% lost > 1 kg/m2, 34.3% gained 1–3 kg/m2 and 14.8% gained ≥ 3 kg/m2. Compared to women with stable BMI change, those with > 1 kg/m2 loss had higher risk of low birthweight (adjusted risk ratio [RR] 1.36; 95% confidence interval 1.02–1.80), while those with 1–3 kg/m2 gain had higher risks of large-for-gestational-age birth (1.16; 1.03–1.31), gestational diabetes (1.25; 1.06–1.49) and emergency Caesarean delivery (1.16; 1.03–1.31); these risks were higher in those with ≥ 3 kg/m2 gain. Our study strengthens the case for interpregnancy weight management to improve subsequent pregnancy outcomes.