Cardiac Function and Hemodynamic Changes during Minimally Invasive Hysterectomy with Pneumoperitoneum and Steep Trendelenburg Position for Patients with Endometrial Cancer Who Are Obese.

STUDY OBJECTIVE: To assess the effect of carbon dioxide (CO2) pneumoperitoneum and steep Trendelenburg position on patients' cardiac function and hemodynamics during minimally invasive staging surgery for endometrial cancer. DESIGN: Single-center prospective longitudinal study. SETTING: University-affiliated tertiary hospital. PATIENTS: Patients with endometrial cancer undergoing minimally invasive surgery. INTERVENTIONS: After consent, the patients' hemodynamic parameters were assessed by the Non-Invasive Cardiac System (NI Medical, Petah Tikva, Israel) at 5 time points: before general anesthesia, after induction of general anesthesia, after CO2 insufflation of the peritoneum, after steep Trendelenburg position, and at the end of surgery. MEASUREMENTS AND MAIN RESULTS: Twenty-three women were recruited. The median age of the patients was 68 years (interquartile range [IQR] 62-75), with a median body mass index of 34.9 kg/m2 (IQR 31.2-39.5) and an American Society of Anesthesiologists score ≥2. The initial median mean arterial pressure was 108 mmHg (IQR 101-113), and the baseline median cardiac output was 7.2 L/min (IQR 5.6-8.7). The median mean arterial pressure significantly decreased by 18% after insufflation (p = .001), again after Trendelenburg position (p = .003), and did not fully recover at the end of surgery in comparison with the preanesthesia baseline (p = .001). The median stroke volume significantly decreased by 17% after insufflation compared with the baseline (p = .01) and then gradually recovered to the baseline levels by the end of surgery. The median cardiac power significantly decreased by 35% after insufflation (0.009), remained low during Trendelenburg position (p = .009), and recovered by the end of surgery to 18% below the baseline levels (p = .035). CONCLUSION: Significant hemodynamic changes occur during minimally invasive staging surgery for endometrial cancer. CO2 insufflation is accompanied by the most dramatic hemodynamic deterioration during surgery, and this does not get affected much with Trendelenburg. Knowledge of the hemodynamic values of women classified as high risk when using a noninvasive technique during surgery is obtainable and may assist both surgeon and anesthesiologist to ensure a safer procedure.

Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12-year single-center experience.

OBJECTIVE: To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. METHODS: A retrospective single-center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not. RESULTS: Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699). CONCLUSION: Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks.

Laparoscopic management of suspected postpartum uterine rupture: a novel approach.

BACKGROUND: Exploratory laparotomy is considered the gold standard treatment for women with suspected uterine rupture. We aimed to investigate the feasibility and safety of laparoscopy as an alternative for laparotomy for the management of hemodynamically stable women with suspected postpartum uterine rupture. STUDY DESIGN: We conducted a case series study including all women who were diagnosed with postpartum uterine rupture following vaginal delivery in a university-affiliated tertiary hospital, between November 2012 and July 2021. Until 2016, all women with suspected post-partum uterine rupture underwent laparotomy. Following 2016, a new tailored protocol based on laparoscopy for the management of postpartum uterine rupture in hemodynamically stable women was implemented. A comparison was made between women who underwent emergent laparoscopy to laparotomy. RESULTS: During the study period 17 women were diagnosed with postpartum uterine rupture. From January 2012 to January 2016, four cases of uterine rupture were diagnosed, all of whom underwent laparotomy. Since 2016, thirteen cases of uterine rupture were diagnosed, of whom seven women (54%) underwent laparoscopy and 6 (46%) laparotomy. The median time interval from delivery to surgery was 70.5 min IQR (40-179) in the laparotomy group and 202 min IQR (70-485) in the laparoscopy group. The median operative time for laparoscopic surgery was 80 min (IQR 60-114) and 78 min (IQR 58-114) for the laparotomy group. Four women who underwent laparotomy (40%) and one who underwent laparoscopy (14.2%) were admitted to the intensive care unit following surgery. Blood products transfusion was required in six women who had laparotomy (60%) and one who had laparoscopy (14.2%). Median hospitalization period was 5 d IQR (4-5) in the laparotomy group as compared to 3 d IQR (3-4) in the laparoscopy group. There were no conversions to laparotomy in the laparoscopy group. CONCLUSIONS: In hemodynamic stable women laparoscopic surgery for suspected postpartum uterine rupture is feasible and safe.

The effects of time and temperature on umbilical cord gas analysis.

OBJECTIVE: Our objective was to evaluate the effects of time and temperature on umbilical-cord blood analysis. METHODS: This prospective study included the term spontaneous vaginal deliveries. One venous and seven arterial samples were drawn from each umbilical cord within 5 min from delivery. Three samples were immediately refrigerated (3 °C), while all other samples were stored at room temperature (23-26 °C). Samples were analyzed in pairs (refrigerated and room-temperature samples) at 0, 20, 40, and 60 min after delivery for pH and lactate levels. Repeated-measures analysis using a generalized linear model was used to compare the change in pH and lactate values over time. RESULTS: 518 samples from 74 women were analyzed. The mean gestational age was 39.1 ± 1.1 weeks. All neonates had an Apgar score of ≥9 in the 1st and 5th minutes. Mean arterial pH and lactate levels at delivery (time 0) were 7.32 ± 0.07 and 4.00 ± 1.36 mmol/L, respectively. Over time, a statistically significant decrease in pH and a reciprocal increase in lactate levels were observed. The mean change in arterial pH following 60 min was 0.021 ± 0.028 (room-temperature) and 0.016 ± 0.023 (refrigerated); p < 0.001. Compared to pH, a greater change was demonstrated in lactate levels over time; the mean change in lactate following 60 min was -0.896 ± 0.535 (room temperature) and -0.512 ± 0.450 mmol/L (refrigerated). Temperature significantly altered both pH and lactate levels, but lactate levels were altered at earlier time points. CONCLUSION: Both time and temperature have significant effects on cord blood analysis. Yet, these changes are minor and may not have any clinical significance unless in extreme cases in which medicolegal aspects emerge.