Underwent Emergency Cesarean Section Research Articles

Successful management of fatal peripartum cardiomyopathy in a young pregnant woman: A case report.

Rationale:Peripartum cardiomyopathy (PPCM) is a rare and life-threatening form of pregnancy associated myocardial disease.Patient concerns:In the present report, we describe a case of a patient with PPCM at 33 weeks of gestation with stillbirth and cardiorespiratory failure.Diagnoses:Peripartum cardiomyopathy.Interventions:The patient underwent emergency cesarean section (CS) and comprehensive medical treatments, including bromocriptine, as well as positive inotropic agents and diuretics after the CS.Outcomes:She had an uneventful recovery period, and was discharged 9 days after surgery. Her heart function was restored within 6 months after CS, and follow-up echocardiographies indicated normal heart function.Lessons:This case highlights that early diagnosis and timely termination of pregnancy are crucial in the management of PPCM.

Bladder Distension As A Cause Of Abdominal Compartment Syndrome

Abdominal compartment syndrome (ACS) is increasingly identified in critically ill patient and its harmful effects are well documented. The disparity among the pressure, volume in abdominal cavity and its contents, results in ACS. The actual incidence of ACS is not known. However, it has been observed predominantly in patients with severe blunt and penetrating abdominal trauma, ruptured abdominal aortic aneurysms, retro- and intra-peritoneal hemorrhage, pneumoperitoneum, neoplasm, pancreatitis, ascites and multiple bone fracture. We present a case of 40-year female who underwent emergency cesarean section and developed abdominal compartment syndrome due to urinary bladder distension secondary to blockade of urinary catheter with blood clots. This is a very unusual cause of ACS.

Management of emergency caesarean section in a patient with decompensated critical aortic stenosis

Increasing numbers of congenital heart disease patients are now surviving to child bearing age. This complex patient cohort present a great challenge to the obstetric anaesthetist and multidisciplinary teams. This report describes a rare case of a patient undergoing emergency caesarean section at 31 weeks gestation due to decompensated critical congenital aortic stenosis. The physiological effects of pregnancy in patients with aortic stenosis are discussed along with principles of managing anaesthesia for caesarean section in the presence of this cardiac lesion.

A comparative study of phenylephrine and ephedrine combination to ephedrine and phenylephrine alone for maintenance of blood pressure for caesarean delivery and their effects on foetal acid base status

Introduction: Spinal anaesthesia is the preferred technique for caesarean section. Around 80% of which is complicated by maternal hypotension. Vasopressors are currently the treatment of choice for spinal-induced hypotension but these may individually have significant maternal or foetal side effects. Aim: To compare ephedrine and phenylephrine infusion with ephedrine and phenylephrine combination for preventing the hypotension in patients undergoing emergency caesarean section under spinal anaesthesia. Materials and Methods: A prospective randomized double blind study of 90 parturients beyond 32 weeks of pregnancy for caesarean section under spinal anaesthesia. Assuming a potency ratio of 80:1 ephedrine to phenylephrine, the patients were divided into the following three groups: Group E - received infusions of ephedrine 8 mg/ml, Group P - received infusions of 100 mcg/ml phenylephrine and Group E + P received infusion of ephedrine 4 mg/ml + phenylephrine 50 mcg/ml. A predefined algorithm was used to adjust the infusion rate according to the systolic blood pressure (SBP). After spinal injection, SBP, diastolic blood pressures (DBP), heart rate (HR) were recorded every one minute until the cord was clamped. Also, the vasopressor infusion rates were collected till clamping of umbilical cord in each group. Foetal parameters were analyzed from umbilical blood gas. Results: The incidence of hypotension was significantly higher in ephedrine group. The mean rate of infusion was higher for group E (P 0.05) as compared to others. Complications of bradycardia were observed in 30% of patients receiving phenylephrine. Conclusions: Combination of both phenylephrine and ephedrine is efficacious for spinal-induced hypotension with least maternal or foetal side effects.

Effectiveness of Intravenous Metoclopramide Prophylaxis on the Reduction of Intraoperative and Early Postoperative Nausea and Vomiting after Emergency Caesarean Section under Spinal Anaesthesia

Background: Nausea and vomiting is a common problem after spinal anaesthesia after cesarean section. Metoclopramide is reported to be effective in reducing the incidence and severity of nausea and vomiting (NV). However, its effectiveness as monotherapy remains unexplored. Aims: We aimed to assess the effectiveness of metoclopramide prophylaxis on the prevention of nausea and vomiting after emergency cesarean section under spinal anaesthesia. Methods and material: A prospective non-controlled study was conducted at a referral hospital. Patients classified as metoclopramide group who received 10 mg IV prophylaxis versus no prophylaxis group. Pre-tested checklist and patient interview were employed to collect the data during operation, at 2 h, 4 h and 6 h after cesarean section. Student’s t-test or Mann-Whitney U tests were used to compare the incidence and severity of nausea and vomiting between the groups. Chi-square and Fisher exact tests were used to compare the proportion of categorical variables between the groups. Results: The overall incidence of intraoperative and early postoperative nausea and vomiting were 25.8% and 48.5% in the treatment (n=66) group and non-treatment (n=66) group respectively. Prophylactic metoclopramide significantly reduced the overall incidence of intraoperative and early postoperative nausea and vomiting (25.8% vs. 48.5%, p=0.012) compared with non-treatment group. The median score for nausea on numeric rating scale was also reduced in the prophylaxis at the end of CS, 2 h and at 4 h after CS. Conclusion: The incidences of nausea and vomiting were high. The administration of prophylactic metoclopramide remarkably reduced the incidence and severity of intraoperative and early postoperative nausea and vomiting compared to the non-treatment group. We recommend metoclopramide prophylaxis for parturients undergoing emergency cesarean section under spinal anaesthesia. In addition, preoperative risk stratification strategies and perioperative nausea and vomiting management protocols need to be established in the hospital.

Emergency laparotomy with synchronous Caesarean section for life-threatening strangulated Petersen's hernia

Introduction Bariatric surgery is the most effective treatment for morbid obesity and its co-morbidities. Women are advised against becoming pregnant in the first 12-18 months after surgery due to the potential nutritional compromise induced by weight loss. An increasingly recognised complication following bariatric surgery are Petersen-type internal hernias. We present a case of life-threatening Petersen’s hernia at 31 weeks of pregnancy in a patient who had previously undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity. Case description A 31-week pregnant 28-year-old (G2P1) presented as an emergency with abdominal pain, vomiting and absolute constipation. Two years previously she had undergone a laparoscopic Roux-en-Y gastric bypass and had lost 31kg. She was tachycardic, tachypnoeic and pyrexial. Blood tests performed showed a raised white cell count 14.4x109/L, haemoglobin 114g/L, C-reactive protein 36mg/L, urea 4.1mmol/L, creatinine 64μmol/L and lactate 1.94mmol/L. An abdominal ultrasound scan showed free fluid in the abdomen and confirmed a viable intra-uterine foetus. A targeted abdominal computer tomographic (CT) scan showed a closed loop obstruction of the jejunum and proximal ileum around the Roux-en-Y reconstruction, most likely an internal hernia of Petersen. The herniated small bowel was non-enhancing, distended and fluid-filled, therefore thought to be non-viable radiologically. Results and Conclusions The patient underwent emergency Caesarean section followed by laparotomy, small bowel resection and formation of laparotomy. She was returned to theatre 24 hours later for a second-look laparotomy. The intra-operative findings demonstrated healthy common channel measuring 270cm, bilio-pancreatic limb measuring 80cm and a long narrow gastric pouch and a small alimentary limb remnant. The gastric bypass was reversed by excising the remnant alimentary limb and fashioning gastro-gastrostomy and anastomosing the bilio-pancreatic limb to the common channel. The patient made an uneventful recovery. Clinicians involved in the management of patients with previous gastric bypass should be aware of the potential complications. We suggest that obstetric care of post-operative bariatric patients requires early liaison with the bariatric surgical team. Take home message Obstetric care of post-operative bariatric patients requires early liaison with the bariatric team. Clinical presentations of Petersen’s hernia are non-specific and clinicians should have a high index of suspicion of this diagnosis when assessing patients with previous surgery involving Roux-en-Y reconstruction.

The decision delivery interval in emergency caesarean section and its associated maternal and fetal outcomes at a referral hospital in northern Tanzania: a cross-sectional study

BackgroundDecision delivery interval (DDI) is the time line between a decision to conduct an emergency caesarean section and actual delivery of the baby. Prolong DDI constitute a third phase delay in provision of emergency obstetric care. Intervention designed to minimize DDI are vital, in attempt to prevent maternal morbidity and neonatal morbidity and mortality. The feasibility and practicability of the recommended DDI in recent studies have been questioned especially in limited resource setting and therefore the objective of our study was to determine the DDI and its associated fetalmaternal outcomes at a tertiary referral hospital in Tanzania.MethodsThis was a retrospectivecross-sectional study of inpatient cases who underwent emergency caesarean section from January to September 2014. Data were collected from birth registry and case files of patients. Data analysis was performed using statistical package for social science (SPSS) version 22.0. Odds ratio (ORs) and 95% confidence interval for maternal and fetal outcomes associated with DDI were estimated using Logistic regression models. A p-value of less than 5% was considered statistically significant.ResultsA total of 598 women who underwent emergency caesarean section were recruited. The median Decision Delivery Interval was 60 min [IQR 40–120]. Only 12% were operated within 30 min from decision time. Shortest DDI was seen in patients with Cephalopelvic Disproportion (CPD) and uterine rupture (40 min and 45.5 min) as compared to other conditions. Cases with impending uterine rupture, cord prolapse, APH and fetal distress showed to have shorter DDI. There was no significant association between DDI and neonatal transfer,1st and 5thminute Apgar score, maternal blood loss (OR: 5.79; 95% CI 0.63–1.64) and hospital stay (OR: 1.02; 95% 0.63–1.64).ConclusionsContrary to the recommended DDI by ACOG & AAP of 30 min is not feasible in our setting, time frame of 75 min could be acceptable but clinical judgment is required to assess on the urgency of caesarean section in order to prevent maternal and neonatal morbidity and mortality.

Recurrent Cerebral Hemorrhage in Normal Pregnancy Secondary to Mycotic Pseudoaneurysms Related to Choriocarcinoma.

Choriocarcinoma coexisting with or after normal pregnancy is extremely rare. To our knowledge, our case report is the first time cerebral mycotic pseudoaneurysms from choriocarcinoma have been proven angiographically. A 38-week pregnant 26-year-old woman presented with an acute left frontal hemorrhage. She underwent emergency cesarean section, followed by hematoma evacuation and resection of what grossly appeared to be a medium-sized arteriovenous malformation at the time of surgery. Angiogram before and after resection showed no obvious vascular pathology. One month later, she returned with status epilepticus, and an acute parenchymal hematoma posterior to the surgical resection cavity was identified. Angiography showed a multilobulated pseudoaneurysm along the left middle cerebral artery. This was resected and found on histopathology to have choriocarcinoma within and around the blood vessels. Serum human chorionic gonadotrophin levels increased daily. Pan computed tomography showed a left lung lobular mass. The diagnosis was stage 4 World Health Organization score 9 high-risk metastatic choriocarcinoma requiring radiation followed by multiagent chemotherapy. Two weeks later, she had another seizure. An angiogram showed an unruptured pseudoaneurysm along the right posterior cerebral artery, which was embolized. Metastatic choriocarcinoma is rarely considered during a viable pregnancy but is almost always fatal if unrecognized. Early recognition enhances the chances of cure with chemotherapy. Arteriovenous malformations are typically considered in young women with intracerebral hemorrhages and have higher risk of rupture in pregnant women, but physicians should also be aware of metastatic choriocarcinoma and the development of mycotic aneurysms in peripartum women with intracerebral hemorrhages.

Bilateral rupture of the renal pelvis as a complication of placental abruption in multiparous female

A non-traumatic rupture of renal pelvis during pregnancy is an extremely rare complication. The authors report a case of bilateral rupture of the renal pelvis in a multiparous female who underwent emergency cesarean section during vaginal birth after previous cesarean section, owing to abrupt and massive vaginal bleeding and prolonged fetal late deceleration. During surgery, a disproportionately enlarged uterus was noted and postoperatively severe oliguria was complicated with a sustainable amount of packed RBCs transfusion. CT revealed extravasation of contrast media around bilateral perinephric space. Treatment course and review of the cause of renal pelvis rupture is discussed along with literature study.

Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda

BackgroundIn low-resource settings, access to emergency cesarean section is associated with various delays leading to poor neonatal outcomes. In this study, we described the delays a mother faces when needing emergency cesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda.MethodsThis retrospective study included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labor prior to hospital admission, travel time from health center to district hospital, time from admission to surgical incision, and time from decision for emergency cesarean section to surgical incision. Neonatal outcomes were categorized as unfavorable (APGAR <7 at 5 min or death) and favorable (alive and APGAR ≥7 at 5 min). We assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression.ResultsIn our study, 9.1% (40 out of 401) of neonates had an unfavorable outcome, 38.7% (108 out of 279) of neonates’ mothers labored for 12–24 h before hospital admission, and 44.7% (159 of 356) of mothers were transferred from health centers that required 30–60 min of travel time to reach the district hospital. Furthermore, 48.1% (178 of 370) of cesarean sections started within 5 h after hospital admission and 85.2% (288 of 338) started more than 30 min after the decision for cesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health center to the district hospital compared to mothers referred from health centers located on the same compound as the hospital (aOR = 5.12, p = 0.02). Neonates with cesarean deliveries starting more than 30 min after decision for cesarean section had better outcomes than those starting immediately (aOR = 0.32, p = 0.04).ConclusionsLonger travel time between health center and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.

Management of placenta accreta in an Australian tertiary referral centre: a ten-year experience

To report a ten-year experience in management of a highly morbid obstetrical condition in placenta accreta (PA) at a tertiary referral centre, uniquely equipped with an integrated Interventional Radiology theatre, with a primary aim to guide best practice. Retrospective analysis of all histologically proven PA cases at a tertiary centre in Australia between January 2004 and December 2013. Medical records were reviewed for obstetrics history, operative details, post-operative management and neonatal outcome. Sixteen cases of PA were identified during the tinie period; 75% had identifiable risk factors for PA and 87.5% of patients were diagnosed antenatally. Mean gestational age at time of delivery was 34 ±3.4 weeks. Ten cases were performed electively, while the remaining underwent emergency caesarean section. One patient was managed conservatively with placenta left insitu; time to complete resolution of placenta was 71 days. Among patients who underwent hysterectomy (15/16), the proportion of total (n=8) vs. subtotal (n=7) hysterectomy was similar. Average operating time was 123 ± 45.9 minutes. Compared to emergency cases, patients who underwent elective surgery had significantly lower blood loss (2.2 vs. 3.1 L, p < 0.05). Common iliac artery balloons were deployed in eight cases, with a non-statistically significant reduction in intraoperative blood loss (2 vs. 3.2 L, p < 0.05). Fifty percent of patients required ICU admission. Neonatal survival at six months was 93.75% (15/16). The present report demonstrates the importance of timely diagnosis and comprehensive preparation in the surgical management of patients with placenta accreta. The availability of relevant services in the peri-operative phase, including: obstetricians, interventional radiology facility and personnel, intensive care, and neonatology teams, are crucial in achieving optimal outcome for the patient and neonate. In line with reports in the literature, the authors advocate a team-based multidisciplinary approach in a tertiary-level centre for management of this high-risk condition.

Women's self-reported experience of unplanned caesarean section: Results of a Swedish study

Backgroundwomen´s experience of emergency caesarean section is often described as less positive compared to a vaginal birth or a planned caesarean section. Midwifery care for women where deviations from a normal birth process are present is a challenge. The aim of study was to compare self-reported birth outcomes for women undergoing birth through spontaneous onset of labour between those who actually had a vaginal birth and those who eventually had an emergency caesarean section. Design and settingthe study was part of a prospective longitudinal cohort study of parents' experiences, attitudes, and beliefs related to childbirth. Method and findingsquestionnaires were answered by 870 women in midpregnancy, two months postpartum and one year after birth. 766 women (88%) had a vaginal birth, and 104 (12%) had an emergency caesarean section. The most common indications of emergency caesarean section were dystocia, foetal distress, and malpresentation. Women in the emergency caesarean group were more likely to be primiparous (59.6%) and have a body mass index > 30 (10.7%). Childbirth fear was twice as common among these women, and they were more likely to have preferred a caesarean delivery when asked about birth preference in the middle of pregnancy (OR 3.7, Cl 1.8–7.5). Induction of labour (OR 2.5, Cl 1.6–4.0), the use of oxytocin for augmentation (OR 1.9, Cl 1.3–2.9), and the use of epidural as pain relief during labour (OR 5.6, Cl 3.6–8.7) were more common among women having an emergency caesarean section. Transport of the new-born to a neonatal intensive care unit was three times as common. More than a third (37%) of the women in the caesarean group preferred a caesarean section in case of another birth. Childbirth fear was more common one year after birth with 32% of these women describing their fear as moderate or strong (OR 3.6, CI 2.1–6.0). Key conclusionswomen undergoing emergency caesarean section are more likely to experience fear and to have a negative birth experience. It is essential for the midwife to promote a sense of control, involve the woman in the procedure, and create security in a threatening situation. This is made possible in relationship characterized by mutuality, trust, on-going dialogue, shared responsibility, and enduring presence.

Rebound hyperkalemia after cessation of ritodrine in a parturient undergoing cesarean section

A 36-year-old parturient with a suspicion of placenta accreta under tocolytic therapy with ritodrine infusion underwent emergency cesarean section under general anesthesia with propofol, ketamine, and remifentanil because massive bleeding was anticipated. The ritodrine infusion was discontinued 1 h before cesarean section. The baby was delivered 6 min after induction of anesthesia. However, after the manual removal of the placenta from the uterus, the bleeding was massive and uncontrollable. We rapidly transfused crystalloid, colloid, and red blood cells through potassium removal filter. Hyperkalemia (5.8 mmol/L) was detected just before blood transfusion. One hour later, hemostasis was still difficult, and hyperkalemia was promoted (6.1 mmol/L). Thus, glucose insulin therapy started with intravenous furosemide to treat hyperkalemia. Gynecologists decided to induce the Bakri balloon tamponade for the treatment of postpartum hemorrhage. At the end of surgery, plasma potassium level also reduced to 5.5 mmol/L. In the ICU, the bleeding still continued, and then radiologists performed bilateral internal iliac artery embolization for full hemostasis. Postoperative plasma potassium level was stable and 3.3 mmol/L in the next morning. Although one of the common adverse reactions of ritodrine is hypokalemia, we should also beware of a rebound hyperkalemia after its cessation.

Respiratory Morbidity in Term Infants delivered by Elective Cesarean Section at a Tertiary Care Hospital in India: A Randomized Controlled Trial

ABSTRACTObjectives(1) To investigate the association between term elective cesarean sections and neonatal respiratory morbidity and the importance of timing of the cesarean. (2) To assess the maternal morbidity when emergency lower segment cesarean section (LSCS) was required.ParticipantsAll women with singleton term (37—41 + 6 weeks) pregnancies and planned for elective cesarean section in Christian Medical College, Vellore, India.Outcome measuresThe primary outcome measures were neonatal morbidities such as transient tachypnea of newborn (TTN) and respiratory distress syndrome (RDS). The secondary outcome measures were emergency cesarean section and maternal morbidities such as scar dehiscence, urinary tract infection (UTI), endometritis, peritonitis, and hemoperitoneum in the mother.ResultsThe percentage of TTN in the infants in group I was 1.3% while there were none in group II. No infants were diagnosed to have RDS. Out of the 150 women who were planned for elective cesarean section, 55 women underwent emergency cesarean section. Among this, 19 (25.3%) of women were from group I as compared with 36 (48.0%) in group II. The difference in proportion between the two groups was –22.7 [95% confidence interval (CI): –37.7, –7.7], which was statistically significant (p &lt; 0.01). The incidence of scar dehiscence, UTI, endometritis, and hemoperitoneum in the mothers of group II was marginally higher than that in the mothers of group I. There was one woman with peritonitis in group I while none was reported in the other group. All the maternal morbidities occurred to women who underwent emergency cesarean section. Out of the 19 women in group I and 36 women in group II who underwent emergency cesarean section, 1 (5.3%) and 6 (16.7%) women had morbidities.ConclusionWomen requiring elective cesarean section can safely be done between 37 and 39 weeks with no further significant increase in the rates of neonatal morbidity such as TTN and RDS.How to cite this articleRoy P, Jeyaseelan L, Ruby J, Garg R. Respiratory Morbidity in Term Infants delivered by Elective Cesarean Section at a Tertiary Care Hospital in India: A Randomized Controlled Trial. J South Asian Feder Obst Gynae 2017;9(4):312-317.

Anaesthetic management for combined emergency caesarean section and craniotomy tumour removal

AbstractPresentation of primary intracranial tumour during pregnancy is extremely rare. Symptoms of brain tumour include nausea, vomiting, headache and seizures which mimic symptoms of pregnancy-related hyperemesis or eclampsia. In very few cases, craniotomy tumour removal is performed earlier or even simultaneously with foetal delivery. A 40-year-old woman at 32 weeks of gestation in foetal distress presented to the emergency room with decreased level of consciousness Glasgow Coma Scale 6 (E2M2V2). Computed tomographic scan revealed a mass lesion over the left temporoparietal region with midline shift and intratumoural bleeding. In view of high risk of herniation and foetal distress, she underwent emergency caesarean section followed by craniotomy tumour removal. In parturient with brain tumour, combined surgery of tumour removal and caesarean section is decided based on clinical symptoms, type of tumour and foetal viability. Successful anaesthetic management requires a comprehensive knowledge of physiology and pharmacology, individually tailored to control intracranial pressure while ensuring the safety of mother and foetus.

Evaluation of decision-to-delivery interval in emergency cesarean section: A 1-year prospective audit in a tertiary care hospital.

Background and Aims:The American College of Obstetricians and Gynecologists (ACOG) committee on professional standards and the National Institute of Clinical Excellence (NICE) guidelines suggest that decision-to-delivery interval (DDI) and emergency cesarean section (CS) should not be more than 30 min, and a delay of more than75 min in the presence of maternal or fetal compromise can lead to poor outcome. This prospective 1-year study was conducted on emergency CS in a tertiary care hospital to evaluate the DDI, factors affecting it and to analyze their effects on maternal and neonatal outcome.Material and Methods:A structured proforma was used to analyze the data from all women undergoing emergency CS, during a 1-year period, included in Category 1 and 2 of NICE guidelines for CS.Results:A total of 453 emergency CSs were evaluated, with a mean DDI of 36.3 ± 17.2 min for Category 1 CS and 38.1 ± 17.7 min for Category 2 CS (P > 0.05). Only 42.4% emergency CSs confirmed to the 30 min DDI while 57.6% had a DDI of more than 30 min. Reasons of delay were identified as a delay in shifting the patient to operation theater (22.1%), anesthesia factors (18.1%), and lack of resources or manpower (16.1%). Maternal complications occurred in 15 (3.3%) patients with 3 (0.7%) nonsurvivors having a DDI of 91.0 ± 97.0 min as compared to survivors with a DDI of 36.8 ± 15.7 min, P = 0.001. There was no significant association between DDI and occurrence of neonatal complications.Conclusion:Failure to meet the current recommendations was associated with adverse maternal outcomes, but not with adverse neonatal outcome.

Reciprocal Feedback Between miR-181a and E2/ERα in Myometrium Enhances Inflammation Leading to Labor

The initiation of term and preterm labor is associated with an up-regulated inflammatory response in myometrium; however, the underlying signaling pathways remain incompletely defined. To define the regulatory mechanisms that mediate the increased myometrial inflammatory response leading to labor, we investigated the roles of microRNAs (miRNA/miR). Human myometrial tissues, isolated smooth muscle cells, and animal models were used to study miR-181a regulation of uterine inflammatory pathways and contractility. Myometrial tissues from 15 term pregnant women undergoing elective cesarean section (not in labor) and 10 term pregnant women undergoing emergency cesarean section (in labor) were used. Expression of the highly conserved microRNA, miR-181a, was significantly decreased in mouse and human myometrium during late gestation. By contrast, the putative miR-181a targets, TNF-α, and estrogen receptor (ER)-α, and the validated target, c-Fos, key factors in the inflammatory response leading to parturition, were coordinately up-regulated. In studies using human myometrial cells, overexpression of miR-181a mimics repressed basal as well as IL-1β-induced TNF-α, C-C motif chemokine ligand 2 and 8 expression, whereas the expression of the antiinflammatory cytokine, IL-10, was increased. Overexpression of miR-181a dramatically inhibited both spontaneous and IL-1β-induced contraction of human myometrial cells. Notably, miR-181a directly targeted ERα and decreased its expression, whereas estradiol-17β reciprocally inhibited expression of mature miR-181a in myometrial cells. Thus, increased estradiol-17β/ERα signaling in myometrium near term inhibits miR-181a, resulting in a further increase in ERα and proinflammatory signaling. This escalating feedback loop provides novel targets and therapeutic strategies for the prevention of preterm labor and its consequences.

Effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.

PurposeCesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.Patients and methodsThirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively.ResultsElevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively.ConclusionLow-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia.

Carbetocin versus oxytocin to reduce additional uterotonic use at non-elective caesarean section: a double-blind, randomised trial

Objective: We compared the efficacy of Carbetocin (long-acting oxytocin receptor agonist) versus Oxytocin given at non-elective caesarean section.Method: We performed a double-blind, randomised, single-centre study. Eligible women were ≥37 weeks of gestation undergoing emergency caesarean section. Participants received either carbetocin of 100 μg or oxytocin 5 international units. The primary outcome was the need to administer additional uterotonics, as determined by the clinician. Secondary outcomes included estimated blood loss, haemoglobin drop pre–post operation and the need for a blood transfusionResults: From August 2012 to February 2013, 114 women were enroled. Two were excluded from analysis as they received a general anaesthetic. Fifty-nine patients received 100-μg carbetocin; 53 received 5 international units oxytocin. There was no statistically significant difference in the number of women requiring additional uterotonics between the two groups: Carbetocin group 22% and Oxytocin group 13% (p = 0.323). There were no significant differences in the fall in haemoglobin, estimated blood loss, rates of post-partum haemorrhage or blood transfusions.Conclusion: Oxytocin and carbetocin have similar requirements for additional uterotonics, estimated blood loss, haemoglobin drop and blood transfusions. There was a trend towards requiring additional uterotonics in patients receiving Carbetocin which was not statistically significant. This study found no benefits in using carbetocin over oxytocin.

Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise

BackgroundMost studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise. MethodsHealthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100mmHg patients received phenylephrine 100μg or ephedrine 8mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded. ResultsThere was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1–2] and 2 [1–2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60beats/min after vasopressor administration (P=0.001). ConclusionsBoth phenylephrine 100μg and ephedrine 8mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.