Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial.

OBJECTIVE: Our objective was to determine whether an enhanced recovery after surgery pathway at the time of cesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction compared to standard perioperative care. MATERIALS AND METHODS: Patients undergoing nonemergent cesarean delivery at ≥37 weeks of gestation were randomized to enhanced recovery after surgery or standard care. Enhanced recovery after surgery involved multiple evidence-based interventions bundled into 1 protocol. The primary outcome was discharge on postoperative day 2. Secondary outcome variables included pain medication requirements, breastfeeding rates, and various measures of patient satisfaction. RESULTS: From September 27, 2017, to May 2, 2018, a total of 58 women were randomized to enhanced recovery after surgery and 60 women to standard care. The groups were similar in medical comorbidities and in demographic and perioperative characteristics. Enhanced recovery after surgery was not associated with a significantly increased rate of postoperative day 2 discharges when compared with standard care (8.6% vs 3.3%, respectively; odds ratio, 2.74; 95% confidence interval, 0.51-14.70), but it was associated with a significantly reduced postoperative length of stay when compared with standard care, with a median length of stay of 73.5 hours (interquartile range, 71.08-76.62) vs 75.5 hours (interquartile range, 72.86-76.84) from surgery, difference in median length of stay (-1.92; 95% confidence interval, -3.80 to -0.29). Enhanced recovery after surgery was not associated with a reduction in postoperative narcotic use (117.16 ± 54.17 vs 119.38 ± 47.98 morphine milligram equivalents; mean difference, -2.22; 95% confidence interval, -20.86 to 16.42). More subjects randomized to the enhanced recovery after surgery protocol reported breastfeeding at discharge (67.2% vs 48.3%; P = .046). When patients were surveyed 6 weeks postpartum, those in the enhanced recovery after surgery group were more likely to feel that their expectations were met and that they had achieved their postoperative milestones earlier, and to report continued breastfeeding. CONCLUSION: Enhanced recovery after surgery at cesarean delivery was not associated with an increase in the number of women discharged on postoperative day 2, but that may have been related to factors other than patients' medical readiness for discharge. Evidence that enhanced recovery after surgery at cesarean delivery may have the potential to improve outcomes such as day of discharge is suggested by the observed reduction in overall postoperative length of stay, improved patient satisfaction, and an increase in breastfeeding rates. Even better results may accrue with more provider and patient experience with enhanced recovery after surgery.

Pregnancy after Prosthetic Aortic Valve Replacement: How Do We Monitor Prosthetic Valvular Function during Pregnancy?

BACKGROUND: With modern medicine, many women after structural heart repair are deciding to experience pregnancy. There is a need for further study to identify normal echocardiographic parameters to better assess prosthetic valvular function in pregnancy. In addition, a multidisciplinary approach is essential in managing pregnant patients with complex cardiac conditions. CASE: A 22-year-old nulliparous woman with an aortic valve replacement 18 months prior to her pregnancy presented to prenatal care at 20-week gestation. During her prenatal care, serial echocardiography showed a significant increase in the mean gradient across the prosthetic aortic valve. Multidisciplinary management and a serial echocardiography played an integral role in her care that resulted in a successful spontaneous vaginal delivery without complications. CONCLUSION: Further characterization of the normal echocardiographic parameters in pregnant patients with prosthetic valves is critical to optimize prenatal care for this patient population. This case report is novel in that serial echocardiograms were obtained throughout prenatal care, which showed significant changes across the prosthetic aortic valve. TEACHING POINTS: (1) Further study is needed to identify normal echocardiographic parameters to best assess prosthetic valvular function in pregnancy. (2) Multidisciplinary management is encouraged to optimize prenatal care for women with prosthetic aortic valve replacements.

A single-cell survey of the human first-trimester placenta and decidua.

The placenta and decidua interact dynamically to enable embryonic and fetal development. Here, we report single-cell RNA sequencing of 14,341 and 6754 cells from first-trimester human placental villous and decidual tissues, respectively. Bioinformatic analysis identified major cell types, many known and some subtypes previously unknown in placental villi and decidual context. Further detailed analysis revealed proliferating subpopulations, enrichment of cell type-specific transcription factors, and putative intercellular communication in the fetomaternal microenvironment. This study provides a blueprint to further the understanding of the roles of these cells in the placenta and decidua for maintenance of early gestation as well as pathogenesis in pregnancy-related disorders.

Comparison of Subcuticular Suture Type for Skin Closure After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To compare the rate of wound complications among women who underwent cesarean delivery through a Pfannenstiel skin incision followed by subcuticular closure with either poliglecaprone 25 suture or polyglactin 910 suture. METHODS: Patients undergoing nonemergent cesarean delivery at or beyond 37 weeks of gestation were randomized to undergo subcuticular skin closure with either poliglecaprone 25 or polyglactin 910. The primary outcome was a wound composite outcome of one or more of the following: surgical site infection, wound separation, hematoma, or seroma within the first 30 days postpartum. To detect a reduction in the primary outcome rate from 12% to 4%, with a power of 0.90 and a two-tailed α of 0.05, 237 women per study group were required. Analysis was performed according to the intent-to-treat principle. RESULTS: From May 28, 2015, to August 5, 2016, 275 women were randomized to poliglecaprone 25 and 275 to polyglactin 910, of whom 520 (95%) were included in the final analysis: 263 in the poliglecaprone 25 group [of whom 231 (88%) actually underwent poliglecaprone 25 closure) and 257 in the polyglactin 910 group [of whom 209 (81%) actually underwent polyglactin 910 closure]. The groups were similar in demographic characteristics, medical comorbidities, and perioperative characteristics. Poliglecaprone 25 was associated with a significantly decreased rate of overall wound complications when compared with polyglactin 910, 8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04). CONCLUSION: Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02459093.

Universal Cervical Length Screening and Antenatal Corticosteroid Timing.

OBJECTIVE: To evaluate the relationship between universal transvaginal screening for short cervical length in the second trimester and the timing of antenatal corticosteroids. METHODS: We performed a retrospective cohort study of patients with nonanomalous singleton gestations and spontaneous preterm birth between 24 and 34 weeks of gestation after the initiation of a universal transvaginal cervical length screening program between October 2012 and August 2015. Our primary outcome was antenatal corticosteroid administration to a delivery interval of fewer than 7 days. Secondary outcomes were delivery 24 hours to 7 days after the initial steroid injection, steroid administration to delivery interval, neonatal survival, neonatal intensive care unit length of stay, and respiratory distress syndrome. Multivariable logistic regression was used to estimate the association between antenatal corticosteroid timing and the diagnosis of a short cervix adjusted for potential confounders. RESULTS: Among 266 eligible patients, 69 with a short cervical length and 197 without a short cervical length were identified. There were no statistically significant differences in baseline characteristics between the groups. During the study period, 64 of 69 (92.8%) of patients with a short cervix and 176 of 197 (89.3%) without a short cervix received at least one steroid injection before delivery (P=.411). Steroids were given within 7 days of delivery in 33 of 69 (47.8) patients with a short cervix compared with 126 of 197 (64%) patients in the no short cervix group (P=.015; adjusted odds ratio 0.51, 95% confidence interval 0.29-0.9). Median interval between steroid administration and delivery was 8 days in patients diagnosed with a short cervix compared with 3 days for those without a short cervical length (P<.001). CONCLUSION: Patients identified as having a short cervical length by universal transvaginal ultrasound screening were at greater risk of delivering more than 7 days after the initiation of corticosteroids for fetal lung maturation compared with women without a short cervical length.