Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy. SUMMARY BACKGROUND DATA: Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking. METHODS: We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link. RESULTS: We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%). CONCLUSIONS: Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

Induction of labour in patients with prior caesarean births or uterine surgery.

The current evidence favours trial of labour after one caesarean in the absence of any other contraindications, recognizing that risks with both trial of labour after caesarean (TOLAC) and elective repeat caesarean section (ERCS) birth are relatively uncommon. When the need for induction of labour (IOL) following a previous caesarean arises, shared decision-making should be based on the current available evidence. This approach, however, needs to be tailored, taking into account the individual's history, initial examination and response to the ongoing process of induction to optimize the maternal and foetal outcomes. This paper aims to review the evidence and provide guidance on decision making surrounding labour induction in a pregnancy following a prior caesarean or uterine surgery.

Cardiac Risk Score to Predict Small for Gestational Age Infants in Pregnant Women With Heart Disease.

BACKGROUND: One of the most common fetal complications in pregnant women with cardiovascular disease is a small for gestational age (SGA) neonate, which is associated with a higher risk of perinatal morbidity/mortality and poor long-term health outcomes. The objective of this study was to identify cardiac determinants and derive a risk score for clinically relevant SGA < 5th percentile (SGA-5th). METHODS: A prospective cohort of 1812 pregnancies in women with heart disease were studied. SGA-5th was the outcome of interest, defined as birth weight < 5th percentile for gestational age and sex. Multivariable logistic regression analysis was used to identify predictors for SGA-5th. Based on the regression coefficients, a weighted risk score was created. RESULTS: SGA-5th complicated 10% of pregnancies, 11 predictors of SGA-5th were identified, and each was assigned a weighted score: maternal cyanosis (8), Fontan palliation (7), smoking (3), moderate or severe valvular regurgitation (3), ß-blocker use throughout pregnancy (4) or only in the 2nd and 3rd trimesters (2), high baseline ß-blocker dose (4), body mass index < 18.5 kg/m2 (3) or 18.5-24.9 kg/m2 (1), Asian/other ethnicity (2), and significant outflow tract obstruction (1). In the absence of these identified risk factors, the risk of SGA-5th was approximately 4%. Pregnancies with risk scores of 1 had a rate of 5%; 2, 7%; 3, 9%; 4, 12%; 5, 14%; 6, 18%; 7, 23%; 8, 28%; and ≥ 9, 34%. CONCLUSIONS: There are a number of cardiac predictors that are associated with increased risk of SGA-5th. This is a prognostically important outcome, and consideration should be given to routinely predicting and modifying the risk whenever possible.

A novel "video-game" simulator for training fetoscopic laser coagulation of anastomoses in twin-to-twin transfusion syndrome.

 : We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis.

INTRODUCTION: Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery. MATERIAL AND METHODS: MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859. RESULTS: The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results. CONCLUSIONS: Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

Correlation of Clinicopathological Features of Breast Cancer with Molecular Subtypes Taking Ki-67 into Consideration: Single Institution Experience Over 5 Years.

BACKGROUND: Molecular classification of breast cancer is commonly done to determine response to therapy and cancer prognosis. Aim of the study was to compare prevalence of molecular subtypes of breast cancer in our institute using immunohistochemistry, including Ki-67, and correlate it with clinical and pathological prognostic factors. RESULTS: 300 cases of invasive breast cancer were included in the study. Average age at time of diagnosis was 44 years and average size of tumor was 3.4cms. Invasive ductal carcinoma was the most common histological type (75.3%). The most common molecular subtype was triple negative (34.3%) followed by Luminal B (33.4%), luminal A (17%) and Her-2 positive (15.3%). Large size and poorly differentiated tumors were predominantly triple negative tumors while lymph node metastasis was most commonly seen in Her-2 positive tumors. CONCLUSION: Molecular subtype of breast carcinoma should routinely be done for all cases of carcinoma breast as it allows to identify aggressive tumors and target therapy accordingly.

Brainstem gliomas in pregnancy: a systematic review†.

Introduction: Although brainstem gliomas are a rare group of neoplasias, when they affect pregnant women, there can be challenges with diagnosis and management. This study describes a case of brainstem glioma diagnosed in pregnancy and systematically reviews the literature on brainstem gliomas in pregnancy to provide guidance for management.Material and methods: We searched five databases from inception until October 2016 using subject headings and keywords related to pregnancy and brainstem glioma, and included original research articles that described pregnancy outcomes in women with brainstem glioma. Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Checklist for case reports were performed in duplicate. Outcomes were reported as proportions. The study protocol was registered with the Prospero International Prospective Register of Systematic Reviews (CRD42017060196).Results: We screened 2737 titles and abstracts, and 89 full-texts. Twelve articles describing 17 pregnancies in 16 women were included in the analysis. The median gestational age at presentation was 23 weeks. All but one case presented with neurologic deficit. Magnetic resonance (MRI) imaging conclusively diagnosed all cases. Surgical tumor resection (n = 4) and radiation therapy (n = 3) were successfully undertaken during pregnancy. There were no reported sequelae of maternal oncological management on neonatal wellbeing. Maternal mortality was high (8/16, 50%) both during (n = 5) and within 4 weeks (n = 3) of pregnancy. Pregnancy losses included one pregnancy termination and four miscarriages (associated with maternal mortality). Of the 12 live-born babies, five were premature. Two of these were the result of spontaneous preterm labor and three were delivered prematurely to facilitate glioma management. There was one case of fetal growth restriction.Conclusions: Although the symptoms of brainstem gliomas often mimic those commonly encountered in pregnancy, neurologic deficits warrant urgent investigation. MRI is the diagnostic modality of choice in pregnancy. Brainstem gliomas are associated with high maternal mortality and appropriate management, including surgical tumor resection and radiation therapy, should not be delayed on account of pregnancy. Pregnancy outcomes are favorable although there is a risk of preterm birth.Key messageBrainstem gliomas are associated with high maternal mortality and timely diagnosis using magnetic resonance imaging and treatment including surgical resection and radiation therapy should not be delayed during pregnancy. Pregnancy outcomes are generally favorable except for risk of preterm birth.

A Systematic Literature Review of the Safety and Efficacy of Eustachian Balloon Tuboplasty in Patients with Chronic Eustachian Tube Dysfunction.

Eustachian tube dysfunction (ETD) is a common condition afflicting 1% of the adult population and is said to be higher in the pediatric population. Currently, it is primarily managed with medical therapy. However, newer management techniques like balloon tuboplasty have been introduced. To systematically review the available evidence on eustachian tube balloon dilation for treating chronic ETD covering indications, efficacy, safety, short term, and long term outcomes, a literature search was conducted on Google Scholar and Pubmed. 21 publications met the inclusion criteria. Based on the literature review the procedure was found to be effective in alleviating symptoms in adult and pediatric patients immediately postoperatively and long term, up to 5 years. The adverse event rate was 3% and these were mostly minor self-resolving complications. The perioperative protocol varies from center to center. Balloon tuboplasty was found to be safe and efficacious in the short and long term post operatively in select patients with chronic ETD.

Reported Outcomes in Perinatal Iron Deficiency Anemia Trials: A Systematic Review.

BACKGROUND/AIMS: Iron deficiency (ID) and iron deficiency anemia (IDA) are global health concerns associated with adverse perinatal effects. Despite efforts taken at the international level, there is no consensus on unified prevention/treatment strategies, largely stemming from inconsistencies of outcome reporting. Our objective was to comprehensively assess outcome reporting perinatal iron intervention trials as Phase 1 of core outcome set (COS) development to inform future research. METHODS: Systematic search in MEDLINE, EMBASE, Cochrane Databases, and CINAHL (January 2000 - April 2016), with inclusion of trials involving pregnant or postpartum women with ID/IDA confirmed before recruitment. Articles were independently screened and selected by 2 reviewers; data were extracted in duplicate. Quality was assessed using published scoring systems. Outcome definitions and measurement methods were tabulated. RESULTS: Of 7,046 citations, 33 randomized controlled trials were included. Sixty-nine reported outcomes were categorized into 8 domains. High methodological quality characterized 25 (76%) studies. Reporting quality was low in 16 (49%), moderate in 13 (39%), and high in 4 (12%) studies. Variation was greatest for outcome definition, timing of assessment and measurement methods. CONCLUSION: This review identifies a comprehensive long-list of outcomes reported of perinatal iron interventions for ID/IDA. Beyond highlighting existing variation in outcome reporting, it provides a foundation for development of a COS for future trials.

Wound Disruption Following Caesarean Delivery in Women With Class III Obesity: A Retrospective Observational Study.

BACKGROUND: This study sought to identify risk factors associated with wound disruption following Caesarean section (CS) in women with class III obesity and to determine the value of individualized perioperative care plans in reducing its incidence. METHODS: The study included women with class III obesity who underwent CS after 24 weeks of gestation at Mount Sinai Hospital, Toronto, Ontario between 2011 and 2015 and collected data on demographics, clinical history, and perioperative details. Multivariable logistic regression analysis was performed to identify factors likely to contribute to a higher incidence of wound disruption (level of evidence II-3B). RESULTS: Of the 334 identified cases, in women with a mean BMI of 48.20 ± 7.52 kg/m2, there were 60 cases of wound disruption (18%). The most common perioperative interventions involved Pfannenstiel skin incisions (75.6%), subcutaneous tissue closure (65.4%), use of pressure dressings (65%), and thromboprophylaxis (71.8%). On bivariable analysis, surgical time >1 hour (24.2% vs. 13.5%; OR 2.03; P = 0.017) and the use of thromboprophylaxis (20.1% vs. 10.6%; OR 2.22, P = 0.031) were associated with increased wound disruption, but these associations were attenuated on multivariable regression analysis. CONCLUSIONS: No single risk factor or perioperative intervention was independently associated with wound disruption. However, the use of individualized perioperative care plans resulted in fewer wound disruptions in our cohort when compared with published literature.

Breast Cancer in Pregnancy: A Retrospective Cohort Study.

Gestational breast cancer (GBC) is the second most commonly occurring malignancy affecting pregnant women. Management is complex due to potential foetal risks in the setting of maternal treatment. We report on the maternal, foetal, short-term neonatal and placental histopathologic findings of a retrospective cohort of pregnant women with either pre-gestational (group 1) or GBC (group 2) from a tertiary-level maternity care centre. Of the 69 women identified over 12 years, there were 47 in group 1 and 22 in group 2. Demographics, stage of breast cancer at diagnosis were similar in the 2 groups. Women with GBC (group 2) were more likely to receive surgery and chemotherapy or surgery alone as compared to those in group 1. No women with GBC received radiation during pregnancy, but 2 received this treatment postpartum. With regard to pregnancy outcomes, induction of labour was more common in women with GBC, as was preterm birth. Most preterm birth in women with GBC was late preterm, iatrogenic in nature to facilitate postpartum treatment. We conclude comparable pregnancy outcomes for women with GBC as compared to those with pregestational breast cancer.

Cytokine Changes in Maternal Peripheral Blood Correlate With Time-to-Delivery in Pregnancies Complicated by Premature Prelabor Rupture of the Membranes.

Premature prelabor rupture of the membranes (PPROM) causes one-third of preterm births worldwide and is most likely caused by subclinical intrauterine infection and/or inflammation. We proposed that women with systemic inflammation at the time of PPROM would have shorter latency. Peripheral blood samples were collected from 20 singleton pregnant women with PPROM between 23 ± 1 and 33 ± 6 weeks. The first sample was drawn within 48 hours of admission, followed by weekly blood draws until delivery. Pregnancies complicated with acute chorioamnionitis, preeclampsia, intrauterine growth restriction, obesity, substance abuse, and chronic maternal disease were excluded. Twenty uncomplicated, gestational age-matched pregnancies served as controls. Plasma concentration of 39 cytokines was measured longitudinally using Luminex assays to investigate their value as predictive biomarkers of latency. Women with PPROM exhibited significantly lower plasma concentration of interferon-γ-inducible protein 10-Chemokine (c-x-c motif; IP10/CXCL10), Chemokine (c-x-c motif) Ligand 9 (MIG/CXCL9), Platelet-derived growth factor BB (PDGFbb), and cutaneous T cell-attracting chemokine, also known as CCL27/CCL27 than controls at admission but significantly elevated interleukin (IL)1RA, tumor necrosis factor α, monocyte chemotactic protein-1/CCL2 at delivery compared to admission. Women with PPROM who delivered within 7 days had significantly lower plasma concentration of anti-inflammatory cytokine IL1RA than those with latency periods >7 days. The IL1RA and endotoxin activity in conjunction with clinical parameters results in excellent prediction of latency to delivery (area under the receiver-operating characteristic curve = 0.91). We concluded that higher levels of anti-inflammatory cytokines in women with PPROM were associated with increased latency until delivery, likely due to counterbalancing of proinflammatory load. When used in conjunction with other predictive characteristics of time until delivery, cytokines may further assist clinical decision-making and optimize pregnancy outcomes in women with PPROM.

Pregnancy outcomes following single and repeat liver transplantation: An international 2-center cohort.

Due to advances in obstetric and transplant medicine, women with a history of liver transplantation can have successful pregnancies. However, data on pregnancy outcomes is still limited, especially for women who have had a repeat liver transplant following graft rejection. This retrospective study compares pregnancy outcomes in women with single and repeat liver transplants managed at 2 tertiary hospitals in Toronto, Canada and Leuven, Belgium. We identified 41 pregnancies in 28 transplanted women, 6 of whom conceived following a second liver transplant after the first was rejected. Mean maternal age at delivery was 30 ± 7 years, and transplant-to-pregnancy interval was 8.5 ± 5.1 years. All women had normal liver function upon conception. Immunosuppressants included tacrolimus ± azathioprine (n = 26), cyclosporine (n = 4), and prednisone with immunosuppressants (n = 11). There were no maternal deaths. Maternal complications included hypertensive disorders of pregnancy (n = 10), deterioration in renal function (n = 6), gestational diabetes (n = 4), graft deterioration (n = 2), and anemia requiring blood transfusion (n = 1). Fetal/neonatal adverse outcomes included 2 miscarriages, 3 stillbirths, 1 neonatal death, 5 small-for-gestational-age infants, and 1 minor congenital anomaly. Mean gestational age at delivery was 36.7 ± 4.2 weeks. There were 14 (38.9%) preterm births. Outcomes in women with a second transplant were similar to those with a single transplant, except for a higher incidence of hypertensive disorders. In conclusion, with appropriate multidisciplinary care, stable graft function at pregnancy onset, and adherence to immunosuppressive regimens, women with single and repeat liver transplants have low rates of graft complications but remain at increased risk for pregnancy complications. Immunosuppressants and high-dose glucocorticoids can be safely used for maintenance of graft function and management of graft deterioration in pregnancy. Liver Transplantation 24 769-778 2018 AASLD.

Low Back Pain in Pregnancy: Investigations, Management, and Role of Neuraxial Analgesia and Anaesthesia: A Systematic Review.

BACKGROUND: Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There is much ambiguity in diagnostic work-up, appropriate management and decision-making regarding the use of neuraxial analgesia and anaesthesia during labour and delivery in these patients. This systematic review summarises the evidence regarding investigations, management strategies and considerations around performing neuraxial blocks for pregnant women with LBP. METHODS: We searched 3 databases and reviewed literature concerning LBP in pregnancy with regards to diagnostic modalities, management strategies and use of neuraxial techniques for facilitating labour and delivery. RESULTS: In all, we included 78 studies in this review, with 32 studies concerning diagnostic investigations, 56 studies involving management strategies, and 4 studies regarding the use of neuraxial techniques for labour and delivery. SUMMARY: MRI is the safest investigative modality for LBP in pregnancy. Antenatal educational programmes, exercise and steroid injections into the epidural space or sacroiliac joints may help with pain management. Worsening neurological deficits, vertebral fractures and tumours may need surgical management. There is limited evidence on challenges of performing neuraxial blocks in the peripartum period for analgesia and anaesthesia, but there is a potential for increased risk of neurological complications in parturients with pre-existing neurological deficits.

Pregnancy in women with congenital heart disease.

Due to advances in paediatric congenital heart surgery, there are a growing number of women with congenital heart disease (CHD) reaching childbearing age. Pregnancy, however, is associated with haemodynamic stresses which can result in cardiac decompensation in women with CHD. Many women with CHD are aware of their cardiac condition prior to pregnancy, and preconception counselling is an important aspect of their care. Preconception counselling allows women to make informed pregnancy decisions, provides an opportunity for modifications of teratogenic medications and, when necessary, repair of cardiac lesions prior to pregnancy. Less commonly, the haemodynamic changes of pregnancy unmask a previously unrecognised heart lesion. In general, pregnancy outcomes are favourable for women with CHD, but there are some cardiac lesions that carry high risk for both the mother and the baby, and this group of women require care by an experienced multidisciplinary team. This review discusses preconception counselling including contraception, an approach to risk stratification and management recommendations in women with some common CHDs.

Low birth weight infants do not have capillary rarefaction at birth: implications for early life influence on microcirculation.

Low birth weight predicts adult essential hypertension and is linked to increased cardiovascular mortality in adult life. A reduction in capillary density (ie, rarefaction) is a hallmark of essential hypertension, and evidence suggests that rarefaction precedes the onset of the rise in blood pressure, because it is found in normotensive individuals at high risk of developing hypertension, suggesting that rarefaction is likely to be a primary structural abnormality. We hypothesized that low birth weight infants would have significant capillary rarefaction at birth. We studied 44 low birth weight infants born to normotensive mothers (33 were born preterm, birth weight: 1823±446 g; and 11 were born at term, birth weight: 2339±177 g) and compared them with 71 infants born at term with normal weight (birth weight: 3333±519 g). We used orthogonal polarized spectroscopy to measure basal (ie, functional) and maximal (ie, structural) skin capillary densities. Low birth weight infants, whether born preterm or at term, had significantly higher functional capillary density (mean difference of 10.5 capillaries per millimeter squared; 95% CI: 6.6-14.4 capillaries per millimeter squared; P<0.0001) and higher structural capillary density (mean difference of 11.1 capillaries per millimeter squared; 95% CI: 7.6-14.5 capillaries per millimeter squared; P<0.0001) when compared with normal weight term infants. We conclude that low birth weight infants born to normotensive mothers do not have capillary rarefaction at birth. These results contradict what might have been predicted from the concept of the intrauterine origins of adult disease and suggest that microcirculatory abnormalities observed in individuals of low birth weight occur in postnatal life rather than during their intrauterine existence.

Phytoextraction potential of Prosopis juliflora (Sw.) DC. with specific reference to lead and cadmium.

Root and shoot samples of Prosopis juliflora were assessed for their heavy metal content to evaluate the species as a green solution to decontaminate soils contaminated with lead and cadmium. The highest uptake of both the metals was observed in plants from industrial sites. Sites with more anthropogenic disturbance exhibited reduced chlorophyll levels, stunted growth, delayed and shortened reproductive phase. The ratios of lead and cadmium in leaves to lead and cadmium in soil were in the range of 0.62-1.46 and 0.55-1.71, respectively. Strong correlation between the degree of contamination and concentrations of lead and cadmium in plant samples identifies P. juliflora as an effective heavy metal remediator coupled with environmental stress.