Protocolized oxytocin infusion for elective cesarean delivery: a retrospective before-and-after study.

PURPOSE: To elucidate the clinical impact of the novel oxytocin protocol using a syringe pump with a stratified dose compared with the conventional practice of putting oxytocin into the bag. METHODS: This is a retrospective cohort study. We collected the data of the patients who underwent elective cesarean delivery under neuraxial anesthesia between June 2019 and May 2020. The patients were allocated to two groups according to oxytocin administration methods; the control group (the attending anesthesiologist put oxytocin 5-10 units in the infusion bag and adjusted manually after childbirth) and the protocol group (the oxytocin protocol gave oxytocin bolus 1 or 3 units depending on the PPH risk, followed by 5 or 10 unit h-1 via a syringe pump). We compared the total amount of oxytocin within 24 h postpartum, estimated blood loss, and adverse clinical events within 24 h postpartum between the two groups. RESULTS: During the study period, 262 parturients were included. Oxytocin doses of intraoperative and postoperative were significantly lower in the protocol group (9.7 vs. 11.7 units, intraoperative, 15.9 vs. 18 units, postoperative). The subgroup analyses showed that the impact was more remarkable in the low PPH risk than in the high PPH risk. The multivariate linear regression analyses also confirmed the difference. The groups had no significant difference in blood loss, requirement of additional uterotonics, and other adverse events. CONCLUSIONS: Our oxytocin infusion protocol significantly reduced oxytocin requirements in elective cesarean delivery under neuraxial anesthesia without increasing blood loss. However, we could not find other clinical benefits of the novel protocol.

Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study.

PURPOSE: General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan. METHODS: In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients. RESULTS: The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55). CONCLUSION: Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.

RéSUMé: OBJECTIF: L'anesthésie générale pour l'accouchement par césarienne affecte les issues maternelles et néonatales. Notre objectif était d'évaluer les tendances temporelles de la prise en charge anesthésique pour les accouchements par césarienne sur 16 ans et d'analyser les variations interinstitutionnelles dans l'utilisation de l'anesthésie générale au Japon. MéTHODE: Dans cette étude de cohorte rétrospective, nous avons obtenu des données sur les patient·es à partir de la base de données nationale des réclamations d'assurance maladie contenant des données pour dix millions de personnes. Nous avons inclus les personnes ayant bénéficié d'un accouchement par césarienne entre le 1er janvier 2005 et le 31 août 2021. Le critère d'évaluation principal était le taux d'utilisation de l'anesthésie générale. Nous avons évalué les variations institutionnelles dans l'utilisation de l'anesthésie générale dans les établissements médicaux à l'aide d'analyses de régression logistique hiérarchique à deux niveaux avec des rapports de cotes médians et des coefficients de corrélation intraclasse. RéSULTATS: La cohorte comprenait 86 793 patient·es ayant bénéficié de 102 617 accouchements par césarienne dans 2496 établissements. L'anesthésie générale a été utilisée dans 3,7 % (intervalle de confiance [IC] à 95 %, 3,6 à 3,9) de tous les accouchements par césarienne. La tendance temporelle de l'utilisation de l'anesthésie générale a diminué graduellement, passant de 10,8 % en 2005 à 2,9 % en 2021 (P pour la tendance < 0,001). Le rapport de cotes médian ajusté pour les établissements médicaux était de 6,1 (IC 95 %, 5,9 à 6,7), et le coefficient de corrélation intraclasse était de 0,52 (IC 95 %, 0,51 à 0,55).

Postpartum recovery of nulliparous women following scheduled cesarean delivery and spontaneous vaginal delivery: a prospective observational study.

BACKGROUND: Inpatient postpartum recovery trajectories following cesarean delivery and spontaneous vaginal delivery are underexplored. OBJECTIVE: This study primarily aimed to compare recovery following cesarean delivery and spontaneous vaginal delivery in the first postpartum week, and secondarily to evaluate psychometrically the Japanese version of the Obstetric Quality of Recovery-10 scoring tool. STUDY DESIGN: Following institutional review board approval, the EQ-5D-3L (EuroQoL 5-Dimension 3-Level) questionnaire and a Japanese version of the Obstetric Quality of Recovery-10 measure were used to evaluate inpatient postpartum recovery in uncomplicated nulliparous parturients delivering via scheduled cesarean delivery or spontaneous vaginal delivery. RESULTS: A total of 48 and 50 women who delivered via cesarean delivery and spontaneous vaginal delivery, respectively, were recruited. Women delivering via scheduled cesarean delivery experienced significantly worse quality of recovery on days 1 and 2 compared with those who had spontaneous vaginal delivery. Quality of recovery significantly improved daily, plateauing at days 4 and 3 for cesarean delivery and spontaneous vaginal delivery groups, respectively. Compared with cesarean delivery, spontaneous vaginal delivery was associated with prolonged time to analgesia requirement, decreased opioid consumption, reduced antiemetic requirement, and reduced times to liquid/solid intake, ambulation, and discharge. Obstetric Quality of Recovery-10-Japanese is a valid (correlates with the EQ-5D-3L including a global health visual analog scale, gestational age, blood loss, opioid consumption, time until first analgesic request, liquid/solid intake, ambulation, catheter removal, and discharge), reliable (Cronbach alpha=0.88; Spearman-Brown reliability estimate=0.94; and intraclass correlation coefficient=0.89), and clinically feasible (98% 24-hour response rate) measure. CONCLUSION: Inpatient postpartum recovery is significantly better in the first 2 postpartum days following spontaneous vaginal delivery compared with scheduled cesarean delivery. Inpatient recovery is largely achieved within 4 and 3 days following scheduled cesarean delivery and spontaneous vaginal delivery, respectively. Obstetric Quality of Recovery-10-Japanese is a valid, reliable, and feasible measure of inpatient postpartum recovery.

Clinical Images: Symmetrical Gyriform Restricted Diffusion in Severe Reversible Cerebral Vasoconstriction Syndrome.

A 45-year-old woman with chronic depression and currently receiving dual serotonergic therapy was transferred to our department with sudden dysbasia; she also reported an antecedent thunderclap headache. Magnetic resonance imaging (MRI) revealed a symmetrical bilateral acute infarction in the medial parietal lobe and severe vasoconstriction in the cerebral arteries. We diagnosed reversible cerebral vasoconstriction syndrome (RCVS) and stopped the serotonergic drug regimen. Her symptoms improved after receiving a calcium blocker and magnesium sulfate, and she was discharged after 20 days. Cerebral infarctions developed in 30%-40% of reversible cerebral vasoconstriction syndrome (RCVS) cases, mostly within watershed regions; however, these atypical infarctions were bilateral and symmetrical, potentially because of hypoperfusion caused by long-lasting severe vasoconstriction in the anterior cerebral arteries. Rare bilateral neurologic deficits can be mistaken for hypochondriac delusions, particularly in patients with depression. Since serotonergic drugs are the main cause of RCVS, primary care psychiatrists must be aware of drug-induced RCVS.

Comparison between neonatal outcomes of labor and delivery with labor neuraxial analgesia and without analgesia: A propensity score-matched study.

AIM: This single-center observational study aimed to investigate the association between labor neuraxial analgesia (LNA) and neonatal outcomes. METHODS: We conducted a retrospective cohort study at a tertiary perinatal center and included all vaginal deliveries performed between November 2015 and December 2021. Obstetric and neonatal outcomes were compared between deliveries with LNA (LNA group) and without analgesia (control group). Propensity score (PS) matching was used for statistical analysis. RESULTS: We included 2343 singleton deliveries performed in 1367 nulliparous and 976 multiparous women, in whom LNA was induced in 352 and 178 deliveries, respectively. After PS matching, the nulliparous LNA group had a significantly higher incidence of Apgar scores <7 at 1 (7.1% vs. 3.6%, p = 0.0139) and 5 min (2.3% vs. 0.7%, p = 0.0397) and meconium staining (29.8% vs. 23.2%, p = 0.0272) than the nulliparous control group. Other neonatal outcomes, including umbilical artery pH and neonatal intensive care unit admission rate, were comparable between the nulliparous LNA and control groups. No significant differences in neonatal outcomes were seen in multiparous women. Regarding fetal heart rate abnormalities, severe late deceleration (4.8% vs. 1.7%, p = 0.0036) and severe prolonged deceleration (17.0% vs. 11.9%, p = 0.0224) were more common in the nulliparous LNA group than in the nulliparous control group, and the multiparous LNA group exhibited more severe variable deceleration (21.3% vs. 14.3%, p = 0.0485) than the multiparous control group. CONCLUSION: Our findings suggest that LNA is associated with short-term adverse neonatal and obstetric outcomes in vaginal deliveries. LNA should be performed with precautionary measures and adequate medical resources.

Short-term clinical and radiographic outcomes of chemonucleolysis with condoliase for painful lumbar disc herniation and analysis regarding intradiscal injection area.

Percutaneous chemonucleolysis with condoliase has been available for painful lumbar disc herniation since 2018 in Japan. This study investigated clinical and radiographic outcomes three months after the administration because the secondary surgical removal is most required during this period for the insufficient pain relief, and analyzed whether the differences of intradiscal injection areas affected the clinical outcomes. We retrospectively investigated 47 consecutive patients (males, 31; median age, 40 years) three months after the administration. Clinical outcomes were evaluated using the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), a visual analog scale (VAS) score for low back pain, and VAS scores for pains and numbness in the lower limbs. Radiographic outcomes were analyzed in 41 patients, using parameters such as mid-sagittal disc height and maximal protrusion length of herniation on MRI preoperatively and at the final follow-up. Postoperative median evaluation period was 90 days. The effective rate of low back pain based on the pain-related disorders at baseline and the last follow-up in the JOABPEQ reached 79.5%. The postoperative proportion of VAS scores recovery ≥ 2 points and ≥ 50% for pains in the lower limbs were 80.9% and 66.0%, respectively, revealing satisfactory effectiveness. Preoperative median mid-sagittal disc height significantly reduced from 9.5 to 7.6 mm postoperatively. There were no significant differences in pain relief in the lower limbs by injection areas in the center and the dorsal 1/3rd near the herniation of nucleus pulposus. Chemonucleolysis with condoliase revealed satisfactory short-term outcomes after the administration regardless of intradiscal injection areas.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020.

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Current Epidemiology of the General Anesthesia Practice for Cesarean Delivery Using a Nationwide Claims Database in Japan: A Descriptive Study.

The current status of general anesthesia practice for cesarean delivery in Japan remains unknown. Therefore, using a nationwide claims database, we aimed to investigate general anesthesia use for cesarean delivery over a period of 15 years, and to analyze the general anesthesia practice in Japan. Patients who claimed the Japanese general anesthesia claim code (L008) for cesarean delivery between 1 January 2005, and 31 March 2020, were analyzed. Primary endpoint was the prevalence of general anesthesia use. We used two definitions of general anesthesia: L008 code only (insurance definition) and combination of the L008 code with muscle relaxant use (clinical definition). The general anesthesia claim cohort (L008) included 10,972 cesarean deliveries at 1111 institutions from 2005 to 2020. Muscle relaxants were used in 27.3% of L008 claims cases. The rate of general anesthesia use for cesarean delivery ranged from 3.9% in clinical definition to 14.4% in insurance definition of all cesarean deliveries. We observed a temporal trend of gradual decrease in general anesthesia use, regardless of its definition (p for trend < 0.001). We recommend the clinical definition of general anesthesia as the combination of L008 code and muscle relaxant use in a claims-based approach.

Acute-Phase Intraoperative Findings of Traumatic Spinal Cerebrospinal Fluid Leakage.

The acute-stage intraoperative findings of the spinal dural laceration in patients with traumatic cerebrospinal fluid (CSF) leakage have not been clearly revealed so far. Herein, we report an interesting case of traumatic CSF leakage in a patient who underwent acute-stage direct closure for a dural laceration similar to a stab at the C1/2 level. Because a 41-year-old man strongly twisted his neck, he had a typical orthostatic headache. Whole-spine T2 fat-saturated magnetic resonance imaging and computed tomographic myelography were examined, and fluid collection between the intrathecal site and epidural dorsal space, including soft tissue, was confirmed as a direct CSF leakage at the C1/2 level. Direct surgical closure was performed 13 days after the onset of symptoms, and dural laceration with sharp edges was detected on the right side at the C1/2 level. The laceration was sutured and coated with dural sealant. Finally, the patient's orthostatic headache was relieved completely after the operation.

Diagnosis and Surgical Management of Exophytic Suprasellar Pituitary Adenoma Extending Over the Diaphragma Sellae and Mimicking Craniopharyngioma: A Case Report.

Pituitary adenomas developing from the lateral surface of the pituitary gland are referred to as exophytic pituitary adenomas. When an exophytic pituitary adenoma extends into the suprasellar region, the tumor exhibits an atypical growth pattern that makes it difficult to distinguish it from craniopharyngiomas or other parasellar lesions on MRI. A 53-year-old woman who presented with general malaise and visual disturbances was diagnosed with a brain tumor. MRI showed a suprasellar tumor presenting as superior lobulation with reticular enhancement and partial calcification. Subsequently, endoscopic transsphenoidal surgery was performed on the patient. The suprasellar tumor was found to originate from the superior surface of the normal pituitary gland and it extended into the supra-diaphragm region. Subtotal tumor resection was achieved, and her clinical symptoms subsequently improved. Exophytic suprasellar pituitary adenomas (SPAs) are extremely rare and may be mistaken for ectopic SPAs in some cases. Contrast-enhanced fast imaging employing steady-state acquisition (CE-FIESTA) can clearly depict the connection between an exophytic SPA and the normal pituitary gland via a diaphragma sellae defect. During surgery, it was seen that the exophytic SPA and anterior lobe of the pituitary gland connected with each other directly. The tumor originated from the superior surface of the pituitary gland and extended into the supra-diaphragm region. These findings clearly confirmed the difference between exophytic SPAs and ectopic SPAs. In surgical management, an exophytic SPA needs careful consideration for resecting the tumor from encased surrounding structures without vascular and nerve injury. Ultrasonic aspiration devices may be useful for safely resecting the tumor from important structures due to tissue selection. Exophytic SPAs are distinguished from ectopic SPAs with respect to the direct connection between the tumor and the normal pituitary gland. These findings can be clearly depicted using CE-FIESTA and should be confirmed during surgery. Clinicians should be aware of the risk that exophytic SPA may extend into the supra-diaphragm region and of the difficulties of resecting the tumor encasing surrounding structures in the suprasellar region.

Perinatal outcomes of intrauterine transfusion for the surviving twin in monochorionic twin gestation involving a single fetal demise.

AIM: This study aimed to evaluate the feasibility and outcome of intrauterine transfusion (IUT) for the surviving co-twin in monochorionic diamniotic (MCDA) twin gestations involving single intrauterine fetal death (sIUFD). METHODS: Cases of MCDA twin gestations involving emergent IUT for co-twins experiencing acute feto-fetal hemorrhage (AFFH) subsequent to sIUFD during the second trimester were reviewed. Fetal anemia was confirmed via fetal blood sampling, and perinatal data were retrieved from medical charts to determine the outcomes of surviving co-twins. A poor outcome at 28 days of age was defined as fetal death, neonatal death or neurological impairment such as severe intraventricular hemorrhage or cystic periventricular leukomalacia (PVL). RESULTS: This study included 16 cases of sIUFD diagnosed at a median of 22.5 weeks of gestation (range: 18-25 weeks). The median interval in hours between diagnosis of fetal demise and IUT was approximately 4.2 (0-22) hours. All cases achieved IUT without significant intraoperative complications. Four cases experienced a fetal loss of the co-twin, whereas 12 co-twins were born alive (including 9 preterm births), with only 1 poor outcome in a preterm infant with PVL. CONCLUSION: IUT may be a feasible prenatal intervention for surviving co-twins with AFFH. However, more extensive or pooled studies are needed to determine the efficacy of this intervention.

The first national survey of anesthesia techniques for fetal therapies in Japan.

PURPOSE: The aim of this study was to survey the frequency of various anesthetic techniques used in the anesthetic management of both the mother and fetus during fetal therapies in Japan. METHODS: We sent a postal survey to the institutions with physicians who held membership of the Japan Society of Fetal Therapy to describe maternal and fetal anesthetic management during fetal therapies performed from January 2016 to March 2017. The therapies included were thoracoamniotic shunting (TAS), intrauterine transfusion (IUT), radiofrequency ablation (RFA), fetoscopic laser photocoagulation (FLP), fetoscopic endotracheal occlusion (FETO), and ex utero intrapartum treatment (EXIT). Survey respondents were asked to specify the standard anesthetic technique used in each of these procedures done during the study period. RESULTS: The most common anesthetic techniques used in each therapy were sedation/analgesia with local anesthesia in TAS (31%), local anesthesia alone in IUT (47%), neuraxial anesthesia in RFA (50%), FLP (66%) and FETO (100%), and general endotracheal anesthesia in EXIT. Fetal analgesia was utilized in 61% of TAS, 33% of IUT, 10% of RFA, 22% of FLP, 100% of FETO, and 50% of EXIT. In all fetal therapies, the most common route of administration for fetal anesthesia was maternal administration. CONCLUSION: In this first published description of the frequency of various anesthetic techniques used during fetal therapies in Japan, we found that anesthetic techniques varied depending on the degree of invasiveness to the mother and fetus. Fetal anesthesia was not always performed, and the most common route for fetal anesthesia was maternal administration.

Embryo transfer is a risk factor for severe postpartum hemorrhage and blood transfusion requirement.

PURPOSE: This study aimed to investigate the risk factors for severe postpartum hemorrhage (PPH) and blood transfusion requirement that are recognizable during any period of pregnancy. MATERIALS AND METHODS: We retrospectively reviewed the medical data of 4829 pregnant women who received care and delivered at our institution between July 2010 and March 2015. The cohort was divided into patients with and without severe PPH. Multivariate logistic regression analysis was performed to assess risk factors associated with severe PPH. The same analysis was repeated for blood transfusion requirement. RESULTS: A total of 127 (2.7%) patients had severe PPH and 43 (0.87%) required blood transfusion. The multivariate logistic regression analysis demonstrated that embryo transfer (odds ratio [OR] 2.6; p < .001), uterine myoma (OR 2.0; p < .01), prior uterine surgery (OR 1.9; p = .03), prior cesarean section (OR 1.8; p = .01), and maternal age (OR 1.5; p = .03) were independent risk factors for severe PPH. Embryo transfer was an independent risk factor for blood transfusion requirement (OR 3.1, p < .001). CONCLUSIONS: Embryo transfer is a risk factor for both severe postpartum hemorrhage and blood transfusion requirement.