Exploring the Analgesic Efficacy and mechanisms of low-dose esketamine in pregnant women undergoing cesarean section: A randomized controlled trial.

Background: Postoperative pain is a prevalent concern following a cesarean section. This study aimed to investigate the effect and mechanism of low-dose (0.1 mg/kg) esketamine on postoperative pain management in pregnant women undergoing cesarean sections, specifically in cases where both patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) were employed. Methods: Pregnant women intending to undergo elective cesarean section were divided into four subgroups based on the intravenous administration of esketamine and the specific analgesia methods employed: E1 (0.1 mg/kg esketamine + PCEA), E2 (0.1 mg/kg esketamine + PCIA), C1 (saline + PCEA), and C2 (saline + PCIA). The primary outcome was the maximum pain score within 24 h postoperatively. Secondary outcomes included the pressure pain threshold and tolerance at 30 min and 24 h postoperatively, along with the inflammation and adverse event index scores. Results: A total of 118 pregnant women were assigned to the four groups: E1 (n = 29), E2 (n = 29), C1 (n = 30), and C2 (n = 30). Compared with those in the control groups (C1 + C2), the maximum postoperative pain scores within 24 h in the esketamine groups (E1 + E2) were significantly lower (4 [2-5] vs. 4 [4-6], P = 0.002), and the E1 group exhibited superior analgesic effects compared with other groups. No significant differences were observed in postoperative hyperalgesia or inflammation across the four groups. Notably, esketamine combined with PCIA increased the incidence of postoperative nausea and vomiting (7 [25 %] vs. 0 [0 %]; P = 0.005). Conclusion: The administration of low-dose (0.1 mg/kg) esketamine effectively alleviates pain following cesarean section, and the analgesic effect is notably enhanced in combination with PCEA. Importantly, these effects do not appear to be mediated through anti-inflammatory mechanisms or the inhibition of hyperalgesia. Clinical trial registration number: NCT05414006.

The co-occurrence of bilateral medial medullary infarction and anterior spinal artery syndrome in pregnancy: A case report.

Anterior spinal artery occlusion resulting in bilateral medial medullary infarction (bMMI) and anterior spinal artery syndrome (ASAS) simultaneously has been rarely described. To the best of our knowledge, this is the first report of such occurrence during pregnancy. A 23-year-old preeclamptic parturient at 374/7 weeks underwent an emergent cesarean section after developing gradual neurological deficits. Her symptoms started with a severe occipital headache and progressed to right-hand tingling, left-hand weakness, dyspnea, and elevated blood pressure (165/117 mmHg). Spinal anesthesia was performed by injection of bupivacaine 0.5% with no complications. Twenty minutes into the surgery, after the patient's systolic pressure fell below 85 mmHg, a bolus dose of ephedrine was administered. After a while, the patient presented with sudden respiratory distress and declining consciousness, prompting her immediate intubation. In the intensive care unit, she initially exhibited flaccid quadriplegia, sensory loss, areflexia, upward vertical nystagmus, and some cranial nerve (CN) palsy, including CN 9, 10, and 12, indicative of a medullary-level infarction extending downward. The magnetic resonance imaging (MRI) of the brain revealed a heart-shaped sign in the medulla, suggesting bMMI as a result of anterior spinal artery (ASA) occlusion. During the course of hospitalization, the patient regained the senses of vibration, touch, and proprioception; however, she has remained quadriplegic up to now.

Effect of Ondansetron on Maternal Hypotension During Spinal Anesthesia With Ropivacaine for Cesarean Sections: A Randomized, Double-Blind Trial.

INTRODUCTION: Ondansetron, a selective 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, has been proven to be effective in the prevention of spinal-induced hypotension for elective cesarean section. METHODS: A total of 138 primigravida parturients scheduled for elective cesarean section were randomly assigned to three groups. Groups ONDA4 and ONDA8, respectively, received 4 and 8 mg of ondansetron in 100 mL normal saline, before spinal anesthesia with 1.7 mL ropivacaine 0.75% and 15 mcg of fentanyl, whereas the CONTROL group received an equal volume of normal saline. Noninvasive blood pressure and heart rate were recorded upon arrival, before and after spinal injection, and thereafter every minute for a time period of 10 minutes along with total doses of phenylephrine (mcg) or ephedrine (mg). Time required for the spinal anesthesia to achieve a sensory and motor block at the T4 level and Bromage 3 scale respectively, as well as to regress to the T7 level and a Bromage 1 scale were noted. Maternal nausea/vomiting or shivering, umbilical artery pH, and neonatal Apgar score at 1 and 5 min were also recorded. RESULTS: There were no differences between groups in systolic, diastolic blood pressure, heart rate (p=0.355, p=0.550, p=0.474 respectively), doses of phenylephrine or ephedrine, (p=0.920, p=0.142 respectively), time for the block to reach T4 (p=0.889) and Bromage scale 3 (p=0.269), or to regress to T7 (p=0.273) and Bromage scale 1 (p=0.392), the incidence of nausea/vomiting (p=0.898/p=0.365), umbilical artery pH (p=0.739), neonatal Apgar score at 1 and 5 min (p=0.936 and p=0.907 respectively). CONCLUSION: Our results showed no significant effect of two different doses of ondansetron, in preventing maternal hypotension, following spinal anesthesia with ropivacaine for cesarean section.

AIDA (Artificial Intelligence Dystocia Algorithm) in Prolonged Dystocic Labor: Focus on Asynclitism Degree.

Asynclitism, a misalignment of the fetal head with respect to the plane of passage through the birth canal, represents a significant obstetric challenge. High degrees of asynclitism are associated with labor dystocia, difficult operative delivery, and cesarean delivery. Despite its clinical relevance, the diagnosis of asynclitism and its influence on the outcome of labor remain matters of debate. This study analyzes the role of the degree of asynclitism (AD) in assessing labor progress and predicting labor outcome, focusing on its ability to predict intrapartum cesarean delivery (ICD) versus non-cesarean delivery. The study also aims to assess the performance of the AIDA (Artificial Intelligence Dystocia Algorithm) algorithm in integrating AD with other ultrasound parameters for predicting labor outcome. This retrospective study involved 135 full-term nulliparous patients with singleton fetuses in cephalic presentation undergoing neuraxial analgesia. Data were collected at three Italian hospitals between January 2014 and December 2020. In addition to routine digital vaginal examination, all patients underwent intrapartum ultrasound (IU) during protracted second stage of labor (greater than three hours). Four geometric parameters were measured using standard 3.5 MHz transabdominal ultrasound probes: head-to-symphysis distance (HSD), degree of asynclitism (AD), angle of progression (AoP), and midline angle (MLA). The AIDA algorithm, a machine learning-based decision support system, was used to classify patients into five classes (from 0 to 4) based on the values of the four geometric parameters and to predict labor outcome (ICD or non-ICD). Six machine learning algorithms were used: MLP (multi-layer perceptron), RF (random forest), SVM (support vector machine), XGBoost, LR (logistic regression), and DT (decision tree). Pearson's correlation was used to investigate the relationship between AD and the other parameters. A degree of asynclitism greater than 70 mm was found to be significantly associated with an increased rate of cesarean deliveries. Pearson's correlation analysis showed a weak to very weak correlation between AD and AoP (PC = 0.36, p < 0.001), AD and HSD (PC = 0.18, p < 0.05), and AD and MLA (PC = 0.14). The AIDA algorithm demonstrated high accuracy in predicting labor outcome, particularly for AIDA classes 0 and 4, with 100% agreement with physician-practiced labor outcome in two cases (RF and SVM algorithms) and slightly lower agreement with MLP. For AIDA class 3, the RF algorithm performed best, with an accuracy of 92%. AD, in combination with HSD, MLA, and AoP, plays a significant role in predicting labor dystocia and labor outcome. The AIDA algorithm, based on these four geometric parameters, has proven to be a promising decision support tool for predicting labor outcome and may help reduce the need for unnecessary cesarean deliveries, while improving maternal-fetal outcomes. Future studies with larger cohorts are needed to further validate these findings and refine the cut-off thresholds for AD and other parameters in the AIDA algorithm.

Influence of Cesarean Section Scar on the Mean Pulsatility Index of the Uterine Artery Doppler between 20 and 34 Weeks of Gestation.

Objective: The aim of this study was to assess the influence of the cesarean section scars on the mean pulsatility index (PI) of the uterine artery Doppler between 20 and 34 weeks of gestation. A secondary objective was to assess the association between previous cesarean section and adverse maternal/perinatal outcomes. Methods: A retrospective cohort study was conducted with pregnant women who had their deliveries between March 2014 and February 2023. PI of the uterine arteries Doppler was performed transvaginally between 20-24 weeks and transabdominally between 28-34 weeks. The following variables were considered adverse perinatal outcomes: birth weight < 10th percentile for gestational age, preeclampsia, premature birth, placental abruption, perinatal death, postpartum hemorrhage, neonatal intensive care unit (NICU) admission. Results: A total of 479 pregnant women were included in the final statistical analysis, being that 70.6% (338/479) had no (Group I) and 29.4% (141/479) had at least one previous cesarean section (Group II). Pregnant women with a previous cesarean had higher median of mean PI (1.06 vs. 0.97, p = 0.044) and median MoM of mean PI uterine arteries Doppler (1.06 vs. 0.98, p = 0.037) than pregnant women without previous cesarean section at ultrasound 20-24 weeks. Pregnant women with a previous cesarean section had higher median of mean PI (0.77 vs. 0.70, p < 0.001) and mean MoM PI uterine arteries Doppler (1.08 vs. 0.99, p < 0.001) than pregnant women without previous cesarean section at ultrasound 28-34 weeks. Pregnant women with ≥ 2 previous cesarean sections had a higher median of mean PI uterine arteries Doppler than those with no previous cesarean sections (1.19 vs. 0.97, p = 0.036). Group II had a lower risk of postpartum hemorrhage (aPR 0.31, 95% CI 0.13-0.75, p = 0.009) and composite neonatal outcome (aPR 0.66, 95% CI 0.49-0.88, p = 0.006). Group II had a higher risk of APGAR score at the 5th minute < 7 (aPR 0.75, 95% CI 1.49-51.29, p = 0.016). Conclusion: The number of previous cesarean sections had a significant influence on the mean PI uterine arteries Doppler between 20-24 and 28-34 weeks of gestation. Previous cesarean section was an independent predictor of postpartum hemorrhage and APGAR score at the 5th minute < 7. Pregnancy-associated arterial hypertension and number of previous deliveries influenced the risk of composite neonatal outcome, but not the presence of previous cesarean section alone.

Impact of planned delivery mode on neonatal outcomes and costs in twin pregnancies in Kenya.

Background: Twin pregnancies are associated with higher risks of adverse neonatal outcomes compared to singleton pregnancies. The choice of delivery mode, when twin A presents cephalic, remains a subject of debate. In low- and middle-income countries, where healthcare resources are limited, the decision on the mode of delivery is even more critical. Objective: To evaluate the neonatal outcomes and the hospital costs of planned vaginal delivery compared to cesarean section (CS) in twin pregnancies with twin A presenting cephalic at Tenwek Hospital, Kenya. Study Design: This retrospective cohort study analyzed data from all twin deliveries at Tenwek Hospital, Kenya from, April 1, 2017, to March 30, 2023. Maternal data, mode of delivery, and neonatal data were collected from delivery logs, electronic health records, and neonatal records. Neonatal outcomes were a composite of either Appearance, Pulse, Grimace, Activity, and Respiration score less than seven at 5 minutes, neonatal intensive care unit admission, resuscitation, birth trauma, or neonatal complications, including death before discharge from the hospital. A logistic regression model was created to assess the impact of the planned mode of delivery on neonatal outcomes, controlling for antenatal care clinic visits, noncephalic presentation of twin B, and birth weight category. Results: The study included 177 twin deliveries: 129 (72.9%) were planned as vaginal deliveries and 48 (27.1%) were planned for CS. Among the planned vaginal deliveries, 66 (51.2%) experienced adverse outcomes, compared to 14 (29.2%) in the CS group (P=.009). Logistic regression showed that the odds of adverse outcomes were 0.35 times lower in the CS group compared to the planned vaginal delivery group (95% CI: 0.15-0.83; P=.017). The average total hospital costs for planned vaginal delivery were 104,608 Kenya Shillings (standard deviation 111,761) compared to 100,708 Kenya Shillings (standard deviation 75,468) for CS (P=.82). Conclusion: Planned cesarean deliveries in twin pregnancies with twin A presenting cephalic at Tenwek Hospital were associated with fewer adverse neonatal outcomes compared to planned vaginal deliveries. There was no significant difference in hospital costs. These findings raise the question of the safest mode of delivery for patients in a resource-constrained setting.

PREGNANCY AND DELIVERY OUTCOMES AFTER ABDOMINAL VS. LAPAROSCOPIC MYOMECTOMY: An Evaluation of an American Population Database.

OBJECTIVE: To evaluate population characteristics and obstetrical complications after abdominal myomectomy vs. laparoscopic myomectomy. DESIGN: Retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, with hospital discharge between 2004 and 2014. SETTINGS: Population-based. SUBJECT(S): 13868 and 338 pregnancies following abdominal or laparoscopic myomectomy, respectively. EXPOSURE: Obstetrics outcomes following abdominal and laparoscopic myomectomy were collected. METHODS: Multiple and Binomial logistic regression were used and adjusted in different models for age, obesity, chronic hypertension, and pre-gestational diabetes mellitus. MAIN OUTCOME MEASURE(S): Pregnancy, delivery, and neonatal outcomes were analyzed. RESULT(S): Abdominal myomectomy were characterized by younger patients, lower rates of Caucasian, chronic hypertension, pregestational diabetes, active smoking, illicit drug use, and higher rates of previous cesarean delivery, and multiple gestations when compared to laparoscopic myomectomy. Pregnant women with laparoscopic myomectomy had decreased rates of pregnancy-induced hypertension [adjusted risk ratios (aRR) 0.12, 95% confidence intervals (CI) 0.006-0.24)], gestational hypertension (aRR 0.24, 95%CI 0.08-0.76), preeclampsia (aRR 0.18, 95%CI 0.07-0.48), and preeclampsia or eclampsia superimposed on chronic hypertension (aRR 0.03, 95%CI 0.005-0.3), gestational diabetes mellitus (aRR 0.14, 95%CI 0.06-0.34), preterm premature rupture of membranes (aRR 0.14, 95%CI 0.02-0.96), preterm delivery (aRR 0.36, 95%CI 0.23-0.55), and cesarean delivery (CD) (aRR 0.01, 95%CI 0.007-0.01) and small for gestational age (aRR 0.15, 95%CI 0.005-0.04), compared to abdominal myomectomy group. Laparoscopic myomectomy group had a higher rate of spontaneous aRR 35.57, 95%CI 22.53-62.66), and operative vaginal delivery (aRR 10.2, 95%CI 8.3-12.56), uterine rupture (aRR 6.1. 95%CI 3.2-11.63), postpartum hemorrhage (aRR 3.54, 95%CI 2.62-4.8), hysterectomy (aRR 7.74, 95%CI 5.27-11.4), transfusion (aRR 3.34, 95%CI 2.54-4.4), pulmonary embolism (aRR 7.44, 95%CI 2.44-22.71), disseminated intravascular coagulation (aRR 2.77, 95% CI 1.47-5.21), maternal infection (aRR 1.66, 95%CI 1.1-2.5) and death (aRR 2.04 95%CI 1.31-3.2)) and intra-uterine fetal death (aRR 2.99, 95%CI 1.72-5.2) compared to the abdominal myomectomy group. CONCLUSIONS: Women who had a previous abdominal myomectomy have underlying risk factors for hypertension disorders of pregnancy and gestational diabetes. Women who underwent laparoscopic myomectomies have higher risks of bleeding, uterine rupture, resultant complications, and death, and should be monitored as high-risk patients, like abdominal myomectomies.

Successful management of pregnancy in Turner syndrome (Monosomy X): A rare condition-based learning experience from Vietnam.

Background: Turner syndrome (TS) is recognized with partial or complete loss of the second sex chromosome, occurring in approximately one in 2500 live births, and related to high failure of pregnancy. However, along with the advantage of assisted reproductive technology, the cases of TS pregnant women have been recently addressed worldwide. Therefore, the reproductive health of TS pregnant women should be a concern by physicians and obstetricians, particularly, in the low-middle income countries with low-resource settings. Case Presentation: Here, we describe a rare case of term pregnancy on a TS woman (45, XO) receiving oocyte donation at a private fertility center. Later, the woman was monitored uneventfully during antenatal care and hospitalized at our center for a cesarean delivery with favorable pregnancy outcomes at term. Conclusion: To our knowledge, this is the first report relating to a particular pathology in Vietnam. Through this case report, we would like to emphasize the novel opportunity for TS women desiring parents, thus raising an appropriate awareness of healthcare providers.

Pregnancy-associated fulminant type 1 diabetes: a case report and review of the literature.

Pregnancy-associated fulminant type 1 diabetes (PF) has received high clinical attention because of its low incidence and poor prognosis. It poses a great threat to the lives of mothers and infants; therefore, it is imperative to understand its characteristics and approach methods. However, no studies have described whether a cesarean section or conservative treatment should be considered at the onset of PF. We report a case of PF, review the published literature and consider a cesarean section at the onset of PF. A 39-year-old woman was admitted to our hospital with dyspnea and nausea. The patient was diagnosed with PF. Insulin Lispro and Glargine were administered to control the blood glucose levels. Six hours later, the fetus died. The fetal status due to PF probably worsened during the conservative treatment. No perioperative complications have been reported for cesarean sections under diabetic ketoacidosis due to PF and there have been cases of live birth by emergency cesarean section. Identifying the features of PF and considering and performing cesarean sections early after diagnosis is essential to save fetal life.

Fetal major anomalies and related maternal, obstetrical, and neonatal outcomes.

PURPOSE: To examine maternal, obstetrical, and neonatal outcomes of pregnancies complicated by major fetal anomalies. METHODS: A 10 year retrospective cohort study at a tertiary university hospital compared maternal and obstetrical outcomes between women with singleton pregnancies complicated by major fetal anomalies, and a control group with non-anomalous fetuses. RESULTS: For the study compared to the control group, the median gestational age at delivery was lower: 37.0 vs. 39.4 weeks (p < 0.001); and the preterm delivery rates were higher, both at < 37 weeks (46.2 vs. 6.2%, p < 0.001) and < 32 weeks (15.4 vs. 1.2%, p < 0.001). For the study compared to the control group, the placental abruption rate was higher (6.8 vs. 0.9%, p = 0.002); 87.5 vs. 100% occurred before labor. For the respective groups, the mean gestational ages at abruption were 32.8 ± 1.3 and 39.9 ± 1.7 weeks (p = 0.024); and cesarean section and postpartum hemorrhage rates were: 53.8 vs. 28.3% (p < 0.001) and 11.3 vs. 2.8% (p = 0.001), respectively. For the respective groups, hypertensive disorders of pregnancy rates were 9.5 vs. 2.1% (p = 0.004), stillbirth rates were 17.1 vs. 0.3% (p < 0.001), and neonatal death rates 12.5 vs. 0.0% (p < 0.001). Major fetal anomalies were found to be associated with adverse maternal outcomes (OR = 2.47, 95% CI 1.50-4.09, p < 0.001). Polyhydramnios was identified as an independent risk factor in a multivariate analysis that adjusted for fetal anomalies, conception by IVF, and primiparity for adverse maternal outcomes (OR = 4.7, 95% CI 1.7-13.6, p < 0.001). CONCLUSIONS: Pregnancies with major fetal anomalies should be treated as high-risk due to the increased likelihood of adverse maternal and neonatal outcomes.

Cesarean section at full dilatation in the first birth is not associated with an increased risk of subsequent miscarriage: A historical cohort study.

INTRODUCTION: Cesarean section at full dilatation has been associated with an increased risk of subsequent preterm birth. We hypothesized that there may be an increased risk of miscarriage in pregnancies that follow cesarean section at full dilatation. This study aimed to determine if a first-term (≥37 weeks) cesarean section at full dilatation is associated with an increased risk of miscarriage in the next pregnancy. MATERIAL AND METHODS: A historical cohort study was conducted using routinely collected hospital data within the Aberdeen Maternity and Neonatal Databank (AMND). The population included were women who had a first-term birth and who had a second birth recorded within the AMND. Logistic and multinomial regression was used to determine any association with miscarriage at any gestation and for early (<13 weeks gestation) and late (13-23 + 6 weeks gestation) miscarriage, with cesarean section at full dilatation defined as the exposure. Miscarriage in the second pregnancy (spontaneous loss of intrauterine pregnancy prior to 24 weeks gestation) was the primary outcome. RESULTS: In total, 33 452 women were included. Women who had a first cesarean section at full dilatation were no more likely to have a miscarriage at any gestation than women with all other modes of first birth (including all vaginal births, planned CS, and the first stage of labor (<10 cm dilated CS)) [adjusted OR 0.84 (0.66-1.08); p = 0.18]. There was no association with early or late miscarriage after a CSfd, though the sample size for late miscarriage was small. CONCLUSIONS: This is the first observational study to investigate the risk of miscarriage following first-term CSfd. We found no association between miscarriage at any gestation following a first-term CSfd compared to all other modes of first birth.

Comparative Study of Ropivacaine and Ropivacaine With Dexmedetomidine in Transversus Abdominis Plane (TAP) Block for Post-operative Analgesia in Patients Undergoing Cesarean Sections.

Background Adequate post-operative analgesia in the obstetric patient is necessary to facilitate breastfeeding and the care of the newborn. Considering the limitations of intravenous analgesic options such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, other alternatives have been tried for offering better analgesia with fewer potential side effects. Transversus abdominis plane (TAP) block is one such option that has been tried with various local anesthetic drugs, either alone or in combination with other adjuvants. The addition of dexmedetomidine to bupivacaine in TAP block has been shown to prolong the duration of post-operative analgesia when compared to local anesthetic alone. This study was conducted to determine the efficacy of dexmedetomidine, as an adjuvant to ropivacaine, when administered in TAP block in patients undergoing cesarean section. Methodology The study was a prospective, randomized, parallel assignment, triple-blinded controlled trial. Hundred patients posted for elective lower segment cesarean section, fulfilling the inclusion criteria, were randomly divided into two equal groups, group R and group RD, comprising 50 patients each. Patients in group R were administered bilateral TAP block by landmark technique using ropivacaine alone, whereas patients in group RD were administered TAP block with dexmedetomidine 1 micrograms/kg, in addition to a similar dose of ropivacaine. Mean arterial pressure (MAP), heart rate (HR), visual analog scale (VAS)-R (pain score on VAS scale at rest), VAS-C (pain score on VAS scale on coughing), nausea and vomiting, and Ramsay sedation score were recorded on admission to post-operative care unit (PACU), and at first, fourth, eighth, 12th, 18th, and 24th hours post-operatively. Rescue analgesia was provided with intravenous morphine. Short Assessment of Patient Satisfaction Score (SAPS) was noted on a five-point scale after 24 hours based on patient satisfaction regarding the quality of post-operative analgesia. Results While there was no significant difference between groups R and RD with respect to VAS-C and VAS-R immediately after shifting and at the first, fourth, and eighth hours, a significant difference was observed at the 12th and 18th hours post-operatively. After 24 hours, no significant difference was observed between groups R and RD with respect to VAS-C and VAS-R. While 50% of patients needed rescue analgesia in group R, only 28% of patients needed rescue analgesia in group RD. There was significantly better patient satisfaction measured by the Short Assessment of Patient Satisfaction Score (SAPS) with respect to the quality of analgesia in patients in group RD as compared to those in group R. Conclusions The addition of dexmedetomidine to ropivacaine increased the duration of post-operative analgesia up to 18 hours post-operatively in cases of elective lower segment cesarean section. Also, the quality of post-operative analgesia is better in such patients, as shown by a significant difference in patient satisfaction scores between the two groups.

Anesthesia management for cesarean section in a woman with chronic renal failure and heart failure: a case report.

INTRODUCTION: Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have described anesthesia methods. CASE PRESENTATION: We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed. CONCLUSION: Cesarean section was safely performed for a pregnant woman with renal and heart failure using combined spinal and epidural anesthesia.

Third-Trimester Ultrasound Diagnosis of Large for Gestational Age and Risk of Cesarean Delivery.

OBJECTIVE: Determine if knowledge of a third-trimester ultrasound diagnosis of large for gestational age (LGA) independently increases the risk of cesarean delivery (CD). STUDY DESIGN: Historical cohort comparing CD rate among patients diagnosed with an LGA fetus on a clinically indicated ultrasound from January 2017 to July 2021 with those without an LGA diagnosis at 34 weeks or later. LGA was defined as an ultrasound-estimated fetal weight greater than or equal to the 90th percentile for the gestational age. Univariate analysis was performed to identify significant confounding variables and was utilized as covariates for binary regression with CD rate as the primary outcome, and adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated. Nulliparous term singleton vertex (NTSV) and multiparous CD rates were also compared. RESULTS: There were 447 patients diagnosed with an LGA fetus and 1971 patients without an LGA diagnosis on third-trimester ultrasound. The positive predictive value of LGA diagnosis was 50.1% and the false positive rate was 10.6%. Patients with a diagnosis of LGA had higher AOR of CD (OR 2.11, 95% CI 1.56-2.83), and higher AOR of NTSV CD (OR 1.88, 95% CI 1.14-3.13) compared with those without an LGA diagnosis. There was no difference in the rates of non-medically indicated CD, multiparous primary CD, and attempted and successful TOLAC. CONCLUSION: Our results suggest third-trimester ultrasound diagnosis of LGA independently increases odds of CD, specifically among nulliparous patients, and the potential bias may be one factor contributing to excessive CDs and NTSV CDs.

Incidence of Surgical Site Infection Following Cesarean Section and Its Associated Factors in a Hospital of the Eastern Region, Saudi Arabia: A Retrospective Cohort Study.

BACKGROUND: Surgical site infections (SSIs) following cesarean sections (CS) pose significant challenges in healthcare settings, prompting this five-year investigation in a Qatif Area general hospital. The study aimed to delineate nuances in SSI occurrences, assess yearly variations, and identify associated risk factors impacting SSI rates among CS patients. METHODS: A retrospective analysis of 1584 cesarean sections conducted over five years was undertaken, and the reported SSI cases were examined to calculate the overall and yearly SSI rates. The impact of potential risk factors such as diabetes mellitus, hypertension, and postoperative antibiotic courses on SSI occurrence was examined. RESULTS: The study revealed an overall SC rate of 15.4%. The SSI rate following CS was 4.7% (N = 74), with variations across years ranging from 2.2% in 2020 to a peak of 6.7% in 2022. Notably, 2021 and 2022 demonstrated increased SSI rates compared to prior years. Diabetes mellitus and a surgery duration of more than one hour exhibited a substantial association with SSI occurrence, (OR = 10.76, p = 0.038) and (OR = 3.54, p = 0.002), respectively, signifying independent risk factors. CONCLUSIONS: The study underscores the dynamic nature of SSI rates following CS, highlighting an increasing trend in recent years. All cases were managed with the optimal hospital care. Diabetes mellitus and a surgery duration of more than one hour emerged as prominent independent risk factors for SSI, warranting heightened vigilance and tailored preventive measures in this subset of patients.

Association between the Dietary Inflammatory Index and the Risk of Cesarean Delivery.

Background: Cesarean section (CS) is one of the most important pregnancy concerns in the world. Increased inflammation is associated with increased risk factors for cesarean section. Diet plays a major role in reducing inflammation. This study aimed to investigate the relationship between dietary inflammatory index (DII) and the risk of Cesarean section in Tehranian women. Methods: This case-control study included 390 pregnant women in Tehran, Iran between 2020 and 2021 at their initial visit to pregnancy clinics, selected by a cluster sampling method. Dietary intakes were determined using valid reliable questionnaires and DII was calculated. Weight, height, and waist circumference were also measured. Results: The mean age of the subjects was 28.5 yr (± 5.02) and weight, body mass index (BMI) and waist circumference (WC) in the case group with a higher DII were higher. Odds ratio (OR) of cesarean section in DII quartiles was statistically significant. Confounding factors including age, BMI and total energy intake were adjusted in the first model and weight, waist circumference, physical activity and supplements in the second model and the relationship remained significant (P<0.001). Conclusion: High scores of dietary inflammatory index, possibly through an increase in inflammatory factors, can increase the chances of having a cesarean section.

Does Preoperative Coffee Consumption Prevent Intraoperative Hypotension in Cesarean Section Surgeries?

OBJECTIVE: In this study, we evaluated the effects of a cup of coffee given to patients before surgery in a cesarean section by means of intraoperative hypotension, ephedrine requirement, and the incidence of post-dural puncture headache (PDPH). METHODS: A total of 140 patients undergoing elective cesarean section with spinal anesthesia were included in this study. Participants who drank a single cup of filtered coffee two hours before spinal anesthesia were included in the coffee group, and those who drank water were in the control group. In each group, 70 patients were included. Hemodynamic parameters were recorded every three to five minutes after spinal anesthesia. Intraoperative use of ephedrine was recorded. The PDPH was monitored for three days. RESULTS: The incidence of intraoperative hypotension was 48.6% in the coffee group and 71.4% in the control group (p = 0.006). The rate of ephedrine usage (25.7%) was significantly lower in the coffee group (p = 0.001). The incidence of PDPH in the first 24 hours (2.9%) was significantly lower in the coffee group (11.4%). The visual analog scale (VAS) score was similar between groups (p = 0.048, p > 0.05). CONCLUSIONS: Consumption of a single cup of coffee before spinal anesthesia reduced the incidence of intraoperative hypotension and the rate of ephedrine usage in cesarean sections.

The value of routine hemoglobin level evaluation following elective cesarean section: Is it worthwhile?

OBJECTIVE: The aim of this study was to assess the usefulness of routine hemoglobin testing following elective and urgent cesarean section (CS) in patients without primary postpartum hemorrhage (PPH). METHODS: This retrospective cohort study included women who underwent vaginal delivery (VD), elective CS, and urgent CS at Carmel Medical Center from 2015 to 2020. Data were extracted from the obstetric database, excluding deliveries with PPH. Demographic and obstetric variables were recorded. Primary outcomes were the need for packed red blood cell transfusion. RESULTS: A total of 19 446 women were included, with five (0.3%) requiring a blood transfusion in the elective CS group, 27 (0.17%) in the VD group, and eight (0.4%) in the urgent CS group. Urgent CS was associated with a higher risk of blood transfusion, but there was no significant difference between elective CS and VD. Elective CS showed the lowest rates of post-delivery hemoglobin below 7 g/dL 1 (0.1%) compared to VD 16 (0.6%) and urgent CS 13 (0.7%). CONCLUSION: Routine postoperative hemoglobin testing following elective CS in asymptomatic patients without PPH appears unnecessary. This study supports reconsidering routine hemoglobin testing following elective CS, aligning with the goal of optimizing resource utilization while maintaining patient quality.