Clinical management of uterine contraction abnormalities; an evidence-based intrapartum care algorithm.

AIM: To develop algorithms as decision support tools for identifying, managing and monitoring abnormal uterine activity during labour. POPULATION: Women with singleton, term (37-42 weeks) pregnancies in active labour at admission. SETTING: Institutional birth settings in low- and middle-income countries (the algorithm may be applicable to any health facility). SEARCH STRATEGY: PubMed was searched up to January 2020 using keywords. We also searched The Cochrane Library, and international guidelines from World Health Organization (WHO), National Institute for Health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG) and French College of Gynaecologists and Obstetricians (CNGOF). CASE SCENARIOS: Algorithms were developed for two case scenarios: uterine hypoactivity and excessive uterine contractions. Key themes in the algorithm are: diagnosis, identification of probable causes, assessment of maternal and fetal condition and labour progress, monitoring and management. CONCLUSION: The algorithms for uterine hypoactivity and excessive uterine contractions have been developed to facilitate safe and effective management of abnormal uterine activity during labour. Research is needed to assess the views of healthcare professionals and women accessing healthcare to explore the feasibility of implementing these algorithms, and impact on labour outcomes. TWEETABLE ABSTRACT: An evidence-based algorithm to support clinical management of abnormal uterine activity during labour.

Constructing evidence-based clinical intrapartum care algorithms for decision-support tools.

AIM: To describe standardised iterative methods used by a multidisciplinary group to develop evidence-based clinical intrapartum care algorithms for the management of uneventful and complicated labours. POPULATION: Singleton, term pregnancies considered to be at low risk of developing complications at admission to the birthing facility. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: Literature reviews were conducted to identify standardised methods for algorithm development and examples from other fields, and evidence and guidelines for intrapartum care. Searches for different algorithm topics were last updated between January and October 2020 and included a combination of terms such as 'labour', 'intrapartum', 'algorithms' and specific topic terms, using Cochrane Library and MEDLINE/PubMED, CINAHL, National Guidelines Clearinghouse and Google. CASE SCENARIOS: Nine algorithm topics were identified for monitoring and management of uncomplicated labour and childbirth, identification and management of abnormalities of fetal heart rate, liquor, uterine contractions, labour progress, maternal pulse and blood pressure, temperature, urine and complicated third stage of labour. Each topic included between two and four case scenarios covering most common deviations, severity of related complications or critical clinical outcomes. CONCLUSIONS: Intrapartum care algorithms provide a framework for monitoring women, and identifying and managing complications during labour and childbirth. These algorithms will support implementation of WHO recommendations and facilitate the development by stakeholders of evidence-based, up to date, paper-based or digital reminders and decision-support tools. The algorithms need to be field tested and may need to be adapted to specific contexts. TWEETABLE ABSTRACT: Evidence-based intrapartum care clinical algorithms for a safe and positive childbirth experience.

First trimester maternal serum PAPP-A levels and associated pregnancy complications in intrahepatic cholestasis of pregnancy.

PURPOSE: To investigate first trimester maternal serum pregnancy associated plasma protein A (PAPP-A) multiple of the median (MoM) in cases with intrahepatic cholestasis of pregnancy (ICP). Obstetric complications and relation with PAPP-A MoM were also evaluated. MATERIALS AND METHODS: This was a retrospective case-control study. After exclusions, for each ICP case, two controls with uncomplicated singleton pregnancies were randomly selected. PAPP-A MoM of ICP cases with and without obstetric complications, and the control group were compared with each other. RESULTS: Total incidence of ICP was 0.99 % (138/13988). The study included 113 singleton pregnant women. Rates of gestational diabetes mellitus (GDM), preeclampsia (PE), fetal growth restriction (FGR), preterm labor (PTL), and hypothyroidism in cases with ICP were 21.2%, 7.9%, 10.6%, 18.6%, and 5.3%, respectively. Median PAPP-A MoM were 0.93 in ICP group and 1.10 in control group (p > 0.05). PAPP-A MoM levels were not significantly different either between the ICP group with complicated pregnancies and the control group or between the ICP group without complicated pregnancies and the control group (p >0.05). CONCLUSION: ICP incidence was similar to other European countries. Rates of obstetric complications expecially GDM were higher than expected in general pregnant population. ICP is not considered as pregnancy complications that have low PAPP-A MoM levels.

Does carbon dioxide pneumoperitoneum altering pressure levels lead to ultrastructural damage of fallopian tube and ovary?

AIM: To assess carbon dioxide pneumoperitoneum and its different pressure levels related to cellular injury on ovarian surface epithelium, endothelium, and fallopian tube ciliated epithelium in laparoscopic rat model. MATERIALS AND METHODS: Twenty-four Wistar-Albino female rats were randomized into three groups. Laparotomy was applied for Group 1 (control). Groups 2 and 3 had laparoscopy with pneumoperitoneum pressures at 10 mmHg and 15 mmHg, respectively. After 150 minutes (last 30 minutes was after desufflation for Group 2 and 3) in all groups, bilateral ovariectomy and salpingectomy were performed. The ultrastructures of ovarian surface epithelium, ovarian endothelium, and fallopian tube ciliated epithelium were evaluated by transmission electron microscope. Ovarian surface epithelium changes were divided into three groups, apical surface changes, lateral surface chances, and organelle modification/damage. RESULTS: No apical or lateral surface changes or organelle modifications in ovarian surface epithelium were observed in the control group. Apical ovarian surface epithelium changes were statistically significant in Groups 2 and 3 in comparison to the control group. No significant differences were observed with regards to lateral surface changes in all groups. The organelle modification was only significant in Group 3 compared to the control group. The authors revealed that the ultrastructures of the ovarian endothelium and fallopian tube epithelium were not affected by pneumoperitoneum. CONCLUSIONS: Pneumoperitoneum may cause ischemia-reperfusion damage in ovarian cortex correlated with the amount of pressure.