Patient opinion of analgesia during external cephalic version at term in singleton pregnancy.

To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it.

Induction of labor in breech presentation at term: a retrospective cohort study.

OBJECTIVE: To compare the outcome of two methods of labor induction and spontaneous onset of labor in breech presentation at term. MATERIAL: A retrospective study between 2003 and 2012. We compare obstetric (indication of induction, Bishop score, cesarean rate) and perinatal outcomes (Apgar score, umbilical artery pH, base excess ≤-12 mmol/L, admission to neonatal unit) between prostaglandins and oxytocin. We also compare labor induction versus spontaneous onset of labor. RESULTS: Of the 1684 breech deliveries, we carried out labor induction in 221 cases (76% with prostaglandins, 24% with oxytocin). The prostaglandins group had significantly lower Bishop scores and the time for induction phase was significantly higher. There were no differences in cesarean rate between both methods of induction or spontaneous onset of labor. The prostaglandins group had higher rates of base excess ≤-12 mmol/L. Compared with spontaneous onset of labor in breech presentation, induction had significant lower rates of newborn weight and higher rates of admission to the neonatal unit. CONCLUSIONS: Induction of labor in breech presentation at term is a reasonable and effective option after a careful selection of cases. It was not associated with an increase of perinatal morbidity or cesarean rate compared with spontaneous onset of labor.

Increased pain relief with remifentanil does not improve the success rate of external cephalic version: a randomized controlled trial.

INTRODUCTION: Our objective was to compare the effect of two pain relief methods (remifentanil vs. nitrous oxide) on the success rate of external cephalic version. MATERIAL AND METHODS: We conducted a randomized open label parallel-group controlled single-center clinical trial with sequential design, at Cruces University Hospital, Spain. Singleton pregnancies in noncephalic presentation at term that were referred for external cephalic version were assigned according to a balanced (1:1) restricted randomization scheme to analgesic treatment with remifentanil or nitrous oxide during the procedure. The primary endpoint was external cephalic version success rate. Secondary endpoints were adverse event rate, degree of pain, cesarean rate and perinatal outcomes. RESULTS: The trial was stopped early after the second interim analysis due to a very low likelihood of finding substantial differences in efficacy (futility). The external cephalic version success rate was the same in the two arms (31/60, 51.7%) with 120 women recruited, 60 in each arm. The mean pain score was significantly lower in the remifentanil group (3.2 ± 2.4 vs. 6.0 ± 2.3; p < 0.01). No differences were found in external cephalic version-related complications. There was a trend toward a higher frequency of adverse effects in the remifentanil group (18.3% vs. 6.7%, p = 0.10), with a significantly higher incidence rate (21.7 events/100 women vs. 6.7 events/100 women with nitrous oxide, p = 0.03). All reported adverse events were mild and reversible. CONCLUSIONS: Remifentanil for analgesia decreased external cephalic version-related pain but did not increase the success rate of external cephalic version at term and appeared to be associated with an increased frequency of mild adverse effects.

Effect of maternal intravenous fluid therapy on external cephalic version at term: a prospective cohort study.

OBJECTIVE: We sought to analyze whether maternal intravenous fluid therapy prior to external cephalic version (ECV) increases the amount of amniotic fluid and the success rate of the procedure. STUDY DESIGN: This was a prospective single-center cohort study of 200 women with a consecutive cohort of 100 pregnant women with a breech presentation at term who were administered intravenous fluid therapy with 2 L of hypotonic saline before the version attempt, compared to a control cohort of 100 pregnant women not given hydration treatment. RESULTS: The mean increase in the amniotic fluid index (AFI) after intravenous maternal hydration was 3.75 ± 2.71 cm. The amount of fluid before hydration was the only variable found to be associated with increases in amniotic fluid levels, both in absolute and relative terms (odds ratio, -0.21; 95% confidence interval, -0.37 to -0.05 and odds ratio, -4.62; 95% confidence interval, -6.17 to -3.06; P < .01, respectively). We did not observe any severe complications secondary to the intravenous fluid therapy. The ECV success rate was 43% in the study group compared to 47% in the control group (P = .67). The success rate was significantly lower the larger the relative increase in the AFI, although no correlation was found in absolute terms (χ(2) for linear trend = 0.03 and 0.34, respectively). CONCLUSION: Maternal intravenous fluid therapy with 2 L of hypotonic saline prior to ECV is an effective and safe technique for increasing the AFI. However, its use in ECV does not increase the success rate of the procedure.

Nitrous oxide for analgesia in external cephalic version at term: prospective comparative study.

OBJECTIVE: The objective of this study was to analyze the effect of using inhaled nitrous oxide (N2O) for analgesia in external cephalic version (ECV) at term on the success rate of the procedure, on pain, and on obstetric and perinatal outcomes. METHODS: A prospective comparative cohort study among 300 women with singleton pregnancy in breech presentation at term undergoing an ECV with inhaled N2O in a 50:50 mix with oxygen for analgesia and 150 ECVs with no analgesia. RESULTS: The success rate was 52.3% in the N2O cohort and 52.7% in the controls (P=0.94), whereas the median level of pain was statistically lower in women given N2O (median, 6; range, 4-7, vs. median, 7; range, 5-8; P<0.01). This improvement is mainly from a 49% decrease in severe pain. There were no significant differences in the rate of complications associated with the ECV, in the rate of cesarean sections, or in perinatal outcomes. Furthermore, there were no severe complications secondary to N2O inhalation. CONCLUSIONS: N2O inhalation at a concentration of 50% for analgesia during ECV decreases the level of severe pain experienced by women, appears to be safe both for mother and child, and has no influence on the success rate of ECV or the perinatal outcomes.

Transposición pene-escrotal completa: diagnóstico prenatal / Complete penoscrotal transposition. Prenatal diagnosis

Presentamos un caso de diagnóstico prenatal de transposición pene-escrotal completa a la semana 20 de gestación. La exploración sistemática de todos los órganos, incluidos los genitales, posibilitan el diagnóstico de estas raras e infrecuentes malformaciones (AU)

We report a case of prenatal diagnosis of complete penoscrotal transposition in a fetus at 20 weeks of gestation. Systematic exploration of all the organs, including the genitals, allowed the diagnosis of these rare malformations (AU)

Induction at 41 weeks increases the risk of caesarean section in a hospital with a low rate of caesarean sections.

OBJECTIVE: To analyse the impact of a change in the management of prolonged pregnancies from inducing labour at 42(+0) to induction at 41(0-6). DESIGN: Retrospective cohort study. METHODS: Analysis of 3563 single pregnancies with cephalic presentation of ≥ 41 weeks of gestation delivered in Cruces University Hospital (Spain). Two cohorts were compared corresponding to before and after the change in the policy on induction. MAIN OUTCOME MEASURES: Induction rate, vaginal delivery rate, newborn morbidity and mortality. RESULTS: The overall rate of caesarean sections in the patients included in the study was 12.8% (19.5% among those induced and 8.4% among those in whom the onset of labour has been spontaneous). The caesarean section rate in cohorts 41(0-6) and 42(+0) were 14.1% and 11.4%, respectively (p=0.01). Though there were more newborns with umbilical cord blood ph<7.10 in cohort 41(0-6) than in the other group (8.7% versus 4.5%; p<0.01), no significant differences were found between cohorts in 5-min Apgar score < 7, number of admissions to the neonatal care unit or perinatal mortality. CONCLUSION: The induction of labour during week 41 in prolonged pregnancies may increase the rate of caesarean sections in hospitals with low rates of caesarean sections.

Clinical score for the outcome of external cephalic version: a two-phase prospective study.

AIM: To design a score based on clinical parameters to predict the outcome of external cephalic versions (ECVs) at term. MATERIALS AND METHODS: A two-phase study was conducted (analysis/design and prospective validation) regarding 1000 versions performed between March 2002 and November 2010. The variables considered in the score were selected based on the results of multiple logistic regression models and multiple correspondence analyses published by our group. The predictive capacity was estimated through the area under the ROC curve. RESULTS: The success rates for ECV in phases 1 and 2 were 52.2 and 51.2%, respectively, making the overall success rate 51.7%. The score was designed with the variables parity, placental location, breech variety and amount of amniotic fluid giving a value for each one. A clinical recommendation, based on the result of the score, was the estimated success rate with the 95% confidence interval. The predictive capacity of the score for the outcome of ECV at term was 70.1% (95% CI 66.9-73.4). CONCLUSIONS: A score composed of four easily measurable variables enabled us to predict the outcome of ECV at term.

Oxytocin versus dinoprostone vaginal insert for induction of labor after previous cesarean section: a retrospective comparative study.

OBJECTIVE: To compare the efficacy and safety of two methods for induction of labor after previous cesarean section. METHODS: To compare 247 women with a previous cesarean section who were induced with a dinoprostone vaginal insert and 279 women with a previous cesarean section induced with oxytocin, between 2001 and 2008. We evaluated vaginal delivery rate, maternal morbidity and newborn morbidity and mortality. RESULTS: The overall rate of vaginal delivery was 65.2%. We did not find significant differences between induction with dinoprostone vaginal insert and oxytocin in the rate of cesarean section performed (35.6% vs. 34.1%, P=0.71). There were nine cases of uterine rupture (rate of 1.7%), of which four occurred with dinoprostone vaginal insert and five when using oxytocin (P=0.89). We found no significant differences in neonatal outcomes. CONCLUSIONS: Both tested methods appear to be equally safe and effective for induction of labor in women with a previous cesarean section.

A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term.

OBJECTIVE: To determine the factors associated with the success rate of external cephalic version (ECV) for breech presentation at term. METHODS: A prospective analysis of 500 ECV maneuvers. The variables maternal age, maternal weight, body mass index, previous cesarean delivery, gestational age, parity, amount of amniotic fluid, placental location, and type of breech were studied using logistic regression analysis. RESULTS: The success rate of ECV was 52.2% (n=261). The variables significantly associated with success were parity, placental location, amount of amniotic fluid, and type of breech (P<0.05). A parity of 2 had a 3.74-times higher probability of success than nulliparity (95% CI, 2.37-5.90); a posterior placenta increased the success rate by 2.85 times compared with an anterior placenta (95% CI, 1.87-4.36); and double footling breech presentation had a 2.77-times higher success rate compared with a frank breech presentation (95% CI, 1.16-6.62). The area under the ROC curve showed a predictive ability of 73.6% (95% CI, 69.2%-77.9%) for these 3 variables. CONCLUSION: Parity, placental location, amount of amniotic fluid, and type of breech presentation were associated with the success rate of ECV.

Atosiban vs. ritodrine as a tocolytic in external cephalic version at term: a prospective cohort study.

OBJECTIVE: To compare the success rate of external cephalic version (ECV) at term using ritodrine or atosiban as a tocolytic agent. STUDY DESIGN: Prospective cohort study with a sample of 236 pregnant women with a breech presentation at term, from November 2006 to March 2008. Data have been analyzed from the moment the cephalic version is performed until the time of delivery. RESULTS: ECV success rate using ritodrine as a tocolytic agent was 56.8% compared to 31.4% with atosiban. Ritodrine increases the version success potential more significantly than atosiban (P<0.05). In both cases, the use of ECV reduced the rate of cesarean sections, although a higher number of versions are required with atosiban [numbers needed to treat (NNT)=9.08] to avoid a cesarean section compared to ritodrine (NNT=3.41). CONCLUSIONS: Ritodrine seems better than atosiban as tocolytic agent for ECVs.

Análisis del dolor en la versión cefálica externa / Analysis of pain in external cephalic version

Objetivo: Analizar el dolor materno durante la versión cefálica externa. Material y métodos: Estudio prospectivo en 71 pacientes, en el Hospital de Cruces, entre abril de 2005 y abril de 2006, mediante una encuesta personal tras la versión. Esta incluía una «escala numérica» de evaluación del dolor, así como preguntas relacionadas con el procedimiento. Se han analizado los resultados en función del éxito o fracaso del procedimiento. Resultados: La tasa de éxito global fue del 50,7%. Todas las gestantes lo toleraron bien y no hubo ninguna complicación. La mediana global de dolor fue 7; fue 5 en las versiones con éxito frente a 8 en las que fracasó (p < 0,01). El 83,1% repetiría el procedimiento; siendo más del 50% por el beneficio del parto en cefálica. Conclusiones: La versión cefálica externa es un procedimiento bien tolerado, probablemente debido a su brevedad, si bien es un procedimiento no exento de dolor (AU)

Objective: To analyze the maternal perception of pain during external cephalic version. Material and methods: A prospective study was carried out on 71 patients at the Hospital de Cruces between April 2005 and April 2006, based on personal surveys conducted after the version. These surveys included a «numeric pain intensity rating scale» as well as a series of questions regarding the procedure. Results were analyzed in terms of success or failure of the procedure. Results: The overall success rate was 50.7%. The procedure was well tolerated by all pregnant women, with no complications being observed. The overall median pain stood at 7; 5 in successful versions, as opposed to 8 in unsuccessful versions (P<.01). A total of 83.1% of patients stated that they would be willing to undergo the procedure again in the future, more than 50% of them basing their decision on the benefits of cephalic delivery. Conclusions: The fact that external cephalic version is a well tolerated procedure is probably due to its brevity, although it must be noted that it is not a pain-free maneuver (AU)

Ovarian hyperstimulation secondary to ectopic secretion of follicle-stimulating hormone. Literature review prompted by a case.

OBJECTIVE: To present an exceptional clinical case of functional follicle-stimulating gonadotropin secretion by a thorax neuroendocrine carcinoid tumor. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, Cruces University Hospital, Vizcaya, Spain. PATIENT(S): A 26-year-old woman with ovarian hyperstimulation. INTERVENTION(S): Diagnosis algorithm. MAIN OUTCOME MEASURE(S): Successful management of ovarian hyperstimulation. RESULT(S): A 26-year-old woman seen with abdominal pain and swelling had bilateral multicystic ovaries. The diagnosis algorithm revealed the presence of ovarian hyperstimulation but with no due etiology. On the basis of the persistence of high levels of FSH a computed tomographic scan was taken looking for an FSH-producing neuroendocrine tumor. CONCLUSION(S): In idiopathic ovarian hyperstimulation secondary to supraphysiologic secretion of FSH, the presence of an FSH-producing neuroendocrine tumor should be considered. As far as we know, there are no similar cases with a confirmed diagnosis published in the literature.

Does fetal weight estimated by ultrasound really affect the success rate of external cephalic version?

OBJECTIVE. To determine whether fetal weight estimated by ultrasound on the day the external cephalic version (ECV) is related to the procedure's success rate. DESIGN. Retrospective cohort study. Setting. University hospital. POPULATION OR SAMPLE. Two hundred women with a singleton pregnancy undergoing an ECV attempt between March 2002 and March 2006. METHOD. Projected birthweight at delivery was calculated. Logistic regression analysis, by grams and by weight intervals, and multiple correspondence analysis were performed to determine whether or not the weight was related to the procedure's success. Specific statistical analysis was undertaken to minimize measurement bias in fetal weight estimation. MAIN OUTCOME MEASURE. Success of ECV in relation to estimated fetal weight. RESULTS. Measurement bias was ruled out because no statistically significant differences were identified with the Student's t-test (p>0.05), Bland-Altman's agreement analysis, and the interclass correlation coefficient analysis (ICC = 0.829; CI95% 0.772-0.871; p<0.01). By logistic regression analysis, a variable relation between fetal weight estimated by ultrasound and ECV success was detected, while multiple correspondence analysis suggested that variations in fetal weight are weakly related to the procedure's success or failure. No relation was identified between ECV and birthweight (p = 0.38) when the delivery took place in the same week as the version. CONCLUSIONS. Estimated fetal weight before ECV seems not to be related to the outcome of ECV.