The anesthetic approach to repeated cesarean sections: A prospective cohort study.

Objective: Each repeat cesarean section (CS) potentially adds surgical complexity. The determination of appropriate anesthesia strategy to meet the surgical challenge is of crucial importance for the maternal and neonatal outcome. Study design: This prospective cohort study was conducted from 1-Jan-2021 to 31-Dec-2021 at a single large obstetric centre of all repeat CS. We compared the characteristics and the appropriateness of the anesthesia techniques for low-order repeat CS (LOR-CS) (1 or 2 previous CS) and high order repat CS (HOR-CS) group (3 or more repeat CS). Results: During the study period, 1057 parturients met the study entry criteria, with 821 parturients in the LOR-CS group and 236 parturients in the HOR-CS group. The use of spinal anesthesia was more common for HOR-CS 84.3%. Overall surgical time varied between LOR-CS (38 min, 29-49) and HOR-CS (42 min, 31-57) (p = 0.004).The rate of moderate and severe adhesions was relatively high in HOR-CS and the duration of overall surgical time for cases with mild adhesions was 38 min (29-48), for moderate adhesions was 44 min (34.8-56.5), and for severe adhesions was 56 min (44.8-74.3). There was no significant difference in the Estimated Blood Loss (EBL) between LOR-CS and HOR-CS, with values of 653 ± 292 ml vs. 660 ± 285 ml, respectively. Conclusion: Our data indicate that spinal anesthesia, standard monitoring and regular anesthetic setup are safe and suitable for the majority of HOR-CS, except in cases with high suspicion of placental accreta spectrum.

Peripartum anesthetic management of women with SARS-CoV-2 infection in eight medical centers across three European countries: prospective cohort observation study.

OBJECTIVE: Several reports of obstetric anesthesia management have been published since the onset of the COVID-19 pandemic. We aimed to collect high-quality broad and detailed data from different university medical centers in several European Society of Anesthesiologist countries. METHODS: This prospective observational survey was performed in eight medical centers in Spain, Israel and Portugal from 1st April to 31st July 2020. Institutional review board approval was received at each participating center. Inclusion criteria: all women with a positive test for COVID-19. Retrieved data included maternal, delivery, anesthetic, postpartum details, and neonatal outcomes. Descriptive data are presented, and outcomes were compared for women with versus without respiratory signs and symptoms. RESULTS: Women with respiratory symptoms (20/12.1%) had significantly higher mean (standard deviation) temperature (37.2 °C (0.8) versus 36.8 °C (0.6)), were older (34.1 (6.7) years versus 30.5 (6.6)) and had higher body mass index kg m-2 - (29.5 (7.5) versus 28.2 (5.1)). Women with respiratory symptoms delivered at a significantly earlier gestational age (50% < 37 weeks) with a 65% cesarean delivery rate (versus 22.1% in the group without respiratory symptoms) and 5-fold increased rate of emergency cesarean delivery, 30% performed under general anesthesia. A higher rate of intrauterine fetal death (3%) was observed than expected from the literature (0.2-0.3%) in developed countries. There was no evidence of viral vertical transmission. CONCLUSION: Well-functioning neuraxial analgesia should be available to manage laboring women with respiratory symptoms, as there is a higher frequency of emergency cesarean delivery. We report a higher rate of undiagnosed parturient and intrauterine fetal death.

Anesthesia in Parturients Presenting with Marfan Syndrome.

BACKGROUND: Pregnant women with Marfan syndrome (MS) have a high risk of aortic dissection around delivery and their optimal management requires a multi-disciplinary approach, including proper cardio-obstetric care and adequate pain management during labor, which may be difficult due to the high prevalence of dural ectasia (DE) in these patients. OBJECTIVES: To evaluate the multidisciplinary management of MS patients during labor. METHODS: Nineteen pregnant women (31 pregnancies) with MS were followed by a multi-disciplinary team (cardiologist, obstetrician, anesthesiologist) prior to delivery. RESULTS: Two patients had kyphoscoliosis; none had previous spine surgery nor complaints compatible with DE. In eight pregnancies (7 patients), aortic root diameter (ARd) before pregnancy was 40 to 46 mm. In this high-risk group, one patient underwent elective termination, two underwent an urgent cesarean section (CS) under general anesthesia, and five had elective CS; two under general anesthesia (GA), and three under spinal anesthesia. In 23 pregnancies (12 patients), ARd was < 40 mm. In this non-high-risk group three pregnancies (1 patient) were electively terminated. Of the remaining 20 deliveries (11 patients), 14 were vaginal deliveries, 9 with epidural analgesia and 5 without. Six patients had a CS; four under GA and two2 under spinal anesthesia. There were no epidural placement failures and no failed responses. There were 2 cases of aortic dissection, unrelated to the anesthetic management. CONCLUSIONS: The optimal anesthetic strategy during labor in MS patients should be decided by a multi-disciplinary team. Anesthetic complications due to DE were not encountered during neuraxial block.

Human cytomegalovirus UL97 kinase and nonkinase functions mediate viral cytoplasmic secondary envelopment.

Previous studies have revealed critical roles for the human cytomegalovirus (HCMV) UL97 kinase in viral nuclear maturation events. We have shown recently that UL97 affects the morphology of the viral cytoplasmic assembly compartment (AC) (M. Azzeh, A. Honigman, A. Taraboulos, A. Rouvinski, and D. G. Wolf, Virology 354:69-79, 2006). Here, we employed a comprehensive ultrastructural analysis to dissect the impact of UL97 on cytoplasmic steps of HCMV assembly. Using UL97 deletion (ΔUL97) and kinase-null (K355M) mutants, as well as the UL97 kinase inhibitor NGIC-I, we demonstrated that the loss of UL97 kinase activity resulted in a unique combination of cytoplasmic features: (i) the formation of pp65-rich aberrant cytoplasmic tegument aggregates, (ii) distorted intracytoplasmic membranes, which replaced the normal architecture of the AC, and (iv) a paucity of cytoplasmic tegumented capsids and dense bodies (DBs). We further showed that these abnormal assembly intermediates did not result from impaired nuclear capsid maturation and egress per se by using 2-bromo-5,6-dichloro-1-(ß-d-ribofuranosyl) benzimidizole (BDCRB) to induce the artificial inhibition of nuclear maturation and the nucleocytoplasmic translocation of capsids. The specific abrogation of UL97 kinase activity under low-multiplicity-of-infection conditions resulted in the improved release of extracellular virus compared to that of ΔUL97, despite similar rates of viral DNA accumulation and similar effects on nuclear capsid maturation and egress. The only ultrastructural correlate of the growth difference was a higher number of cytoplasmic DBs, tegumented capsids, and clustered viral particles observed upon the specific abrogation of UL97 kinase activity compared to that of ΔUL97. These combined findings reveal a novel role for UL97 in HCMV cytoplasmic secondary envelopment steps, with a further distinction of kinase-mediated function in the formation of the virus-induced AC and a nonkinase function enhancing the efficacy of viral tegumentation and release.

Sulfation of extracellular polysaccharides of red microalgae: preparation, characterization and properties.

Polysaccharides are natural polymers with a variety of properties that may be translated into significant commercial applications. A program of chemical modifications of the extracellular polysaccharides of red microalgae, such as Porphyridium sp. and Rhodella reticulata, has been undertaken by our group in order to tailor new properties and hence to broaden the spectrum of potential applications. These algal biopolymers are anionic in nature due to the presence of uronic acids (about 10%) and sulfate half esters (about 7%). In the current study, the sulfate content of these biopolymers was increased to 35-40% by means of sulfation agents such as pyridine SO(3), DMF.SO(3) and ClSO(3)H. Reaction conditions were optimized in a model system based on potato starch as the model polysaccharide (type of reagent, temperature and time of reaction). After work-up procedures, the highest sulfate content was obtained by sulfation of the polysaccharide of Porphyridium sp. with a mixture of ClSO(3)H and pyridine at 70 degrees C for 1 h. The sulfated products were characterized by chemical and rheological analyses, IR spectroscopy, and GPC-HPLC chromatography. "Oversulfated" polymers (having sulfate contents exceeding 20%) with high molecular weights were found to inhibit mammalian cell growth when used at certain concentrations; for example, over 80% inhibition was obtained when oversulfated polymers at a concentration of 200 microg/ml were tested on T-cell lymphoma line 24-1. These preliminary results indicate that the modified polysaccharides do indeed exhibit potential therapeutic properties.