Analgesic efficacy of continuous wound infiltration compared with continuous intravenous fentanyl after gynaecological surgery: a non-inferiority, randomised controlled trial.

OBJECTIVE: The present trial aimed to prove the non-inferiority of the analgesic efficacy of continuous wound infiltration (CWI) to that of continuous intravenous fentanyl (IV) and to compare the safety of the two methods. METHODS: This trial was a prospective, single-centre, two-arm, non-inferiority, randomised controlled trial. Patients participating in the trial were randomised to a CWI group or an IV group. The VAS (visual analogue scale), additional analgesic usage and side effects were then compared between the groups. RESULTS: In total, 61 patients were enrolled; two in CWI were excluded, leaving 59 (30 in the CWI group and 29 in the IV group) for analysis. The difference in the VAS score at 24 h (CWI group - IV group) was -3.2 (95% confidence interval [CI] -14.7 to 8.2), which was less than the non-inferiority margin of 15. The mean amount of total fentanyl use at postoperative hour 48 was 1395 (95% CI 886-1903) µg in the CWI group and 3186 (95% CI 2716-3658) µg in the IV group. The amount of other analgesics and the incidence of adverse effects did not differ significantly between the groups. CONCLUSION: CWI was non-inferior to IV in terms of its analgesic effect, and has an opioid sparing effect in open gynaecological surgery.

Patients' need for information on permanent contraception during a cesarean section: A cross-sectional questionnaire survey.

AIM: The present study aimed to explore the need for information about permanent contraception in Japanese women with repeated cesarean sections (CS). METHODS: The present, cross-sectional survey used a self-administered questionnaire mailed to women with a second or later CS at Tokyo Metropolitan Tama Medical Center between March 2010 and December 2017. Those who were pregnant, had given birth less than 1 year before the survey or had an hysterectomy were excluded. RESULTS: The present study analyzed 284 patients (60 with permanent contraception, 224 without permanent contraception). Forty-eight (80%) of women with permanent contraception, and 135 (60%) of women without permanent contraception believed that information on permanent contraception was needed before CS. Among women without permanent contraception, significantly fewer women obtained adequate information of permanent contraception from their healthcare workers before a CS compared with women with permanent contraception (8% vs. 71%, p < 0.001). A higher rate of unreliable contraceptive use (41%) and unintended pregnancies (4%) after the latest CS were found among the women without permanent contraception. CONCLUSIONS: A large portion of the study cohort wished they had received information on permanent contraception before CS; however, the patients without permanent contraception had limited access to this information. Adequate information about permanent contraception should be provided to women planning a CS to enable them to make an informed decision with respect to the treatment.

Management of labor and delivery in myasthenia gravis: A new protocol.

AIM: Pregnancy with myasthenia gravis (MG) is known to be associated with an increased cesarean section rate, presumably due to maternal fatigue during labor. Although epidural labor analgesia (ELA) appears to be a good option for circumventing maternal fatigue, a protocol for managing MG deliveries has not been established. This study, based on a review of our case series, aimed to evaluate the validity of our management protocol for maternal MG, in which ELA is used depending on MG severity. METHODS: Parturients with systemic muscle weakness or worsening symptoms were classified as Category A (A), and those without symptoms were classified as Category B (B). In A, ELA was given at the onset of labor. Immediate vacuum delivery was done once the fetal head descended to station +2. For B, spontaneous vaginal delivery was chosen. The duration, blood loss, fetal weight, Apgar score and MG symptoms on post-partum day (PPD) 1, 14 and 30 were recorded. RESULTS: Six patients were enrolled. Four were classified in A, and two were classified in B. No adverse events occurred during labor. Transvaginal delivery was successfully achieved in all the patients. Symptoms of MG were well-controlled. MG symptoms were stable on PPD 1 in all the patients although two patients complained of worsening symptoms after PPD 14. CONCLUSION: Women with MG can safely undergo spontaneous or operative vaginal delivery. ELA is a good option for circumventing the effects of maternal fatigue on delivery. Our protocol may lower the cesarean section rate in maternal MG.

Clinical features and peripartum outcomes in pregnant women with cardiac disease: a nationwide retrospective cohort study in Japan.

Although the number of pregnancies in women with cardiac disease is increasing worldwide, there are few data concerning their clinical characteristics and peripartum outcomes. Using the Diagnosis Procedure Combination database between 2008 and 2014 in Japan, we retrospectively identified pregnant women who underwent high-risk delivery due to obstetric or non-obstetric comorbidities. We classified eligible women into those with pre-existing cardiac disease (cardiac disease group) and those with non-cardiac comorbidities (non-cardiac disease group) and compared their characteristics and peripartum outcomes. Of 94,364 women undergoing high-risk delivery at 556 hospitals, 857 (0.91%) had pre-existing cardiac disease (302, congenital heart disease; 190, arrhythmia; 176, valvular heart disease; 120, ischemic heart disease; 65, cardiomyopathy; 4, pericardial disease). Women in the cardiac disease group were more likely to be treated at university hospitals (51.1 versus 28.6%; p < 0.001) and in intensive care units (33.5 versus 18.8%; p < 0.001) than those in the non-cardiac disease group. The proportion of cesarean deliveries was 69.4% (emergency, 28.4%; elective, 41.1%) in the cardiac disease group and 73.4% (emergency, 38.4%; elective, 35.0%) in the non-cardiac disease group. Epidural analgesia during vaginal delivery was used significantly more frequently in the cardiac disease than non-cardiac disease group (15.6 versus 2.3%; p < 0.001). Heart failure occurred more frequently in the cardiac disease than the non-cardiac disease group (10.2 versus 0.3%; p < 0.001). In cardiac subgroup comparisons, heart failure occurred more frequently in women with congenital heart disease (12.3%), valvular heart disease (12.5%), or cardiomyopathy (12.3%) than in women with arrhythmia (6.3%) or ischemic heart disease (5.8%). Multivariable logistic regression analysis showed a significant positive association between pre-existing cardiac disease and risk of heart failure (adjusted odds ratio, 24.7; 95% confidence interval, 17.6-34.6; p < 0.001). No woman in the cardiac disease group died, whereas 18 women (0.02%) in the non-cardiac disease group did (p = 1.000). These findings suggest that pregnant women with pre-existing cardiac disease are at a higher risk of heart failure during the peripartum period than those with non-cardiac comorbidities.

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve.

OBJECTIVE: This study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS). STUDY DESIGN: We prospectively enrolled women >35 weeks' gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count. RESULTS: We enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36-1.21} {CS only} vs 0.49 {0.32-2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58-3.13} vs 1.45 {1.04-2.25}, p = 0.79]; and 6 months [1.74 {0.93-4.45} vs 2.60 {1.41-5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count. CONCLUSION: BS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery. IMPLICATION: While our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.

Relationship between the precursors of high grade serous ovarian cancer and patient characteristics: decreased incidence of the p53 signature in pregnant women.

OBJECTIVE: To investigate the relationship between the precursors of high grade serous ovarian cancer (HGSOC) and the characteristics of patients with a low HGSOC risk in terms of the effects of pregnancy. METHODS: We prospectively examined consecutive cases in which the bilateral fallopian tubes were removed during benign gynecological or obstetric surgery and assessed the relationship between the patient characteristics, including parity and pregnancy, and the incidence of HGSOC precursors. All the fallopian tubes were examined by applying the Sectioning and Extensively Examining the Fimbriated End (SEE-FIM) Protocol. RESULTS: Of the 113 patients enrolled, 67 were gynecological and 46 were obstetric. The p53 signature was identified in 21 patients. No other precursors were identified. In a comparison of the p53 signature-positive and negative groups, parous women and pregnant women were significantly fewer in the p53 signature-positive group (53% vs. 86%, p=0.002, 10% vs. 47%, p=0.001, respectively). Current pregnancy was also associated with a significantly lower incidence of the p53 signature after multivariate adjustment (odds ratio [OR]=0.112; 95% confidence interval [95% CI]=0.017-0.731; p=0.022). Among gynecological patients, parous women were fewer in the p53 signature-positive group on univariate (47% vs. 73%, p=0.047) and multivariate analysis (OR=0.252; 95% CI=0.069-0.911; p=0.036). No other characteristics were associated with p53 signature positivity. CONCLUSIONS: The incidence of the p53 signature was significantly lower in parous women and pregnant women. This decreased incidence of early phase serous carcinogenesis may be one of the possible mechanisms underlying HGSOC risk reduction among parous women.

Adnexal torsion of mature cystic teratoma with hemorrhagic infarction: helpful findings on successive plain abdominal radiographs.

Adnexal torsion is a relatively rare cause of lower abdominal pain in women, but in many cases it leads to a serious condition. We present a case of adnexal torsion of a mature cystic teratoma in which hemorrhagic infarction was reflected by progressive enlargement and wall thickening on successive plain abdominal radiographs. There has been no other report describing such changes of adnexal torsion on plain abdominal radiographs.

3D analysis of cracking behaviour under indentation in ion-irradiated beta-SiC.

To provide a microstructural basis for evaluating fracture toughness by an indentation test, a new method to analyse three-dimensional (3D) cracking behaviour in beta-SiC is developed. As an example, the effect of ion irradiation on crack propagation was studied. The sequential cutting-out of thinned sections by focused ion beam (FIB) processing around an indentation impression enabled the reconstruction of the 3D behaviour of cracking near the indentation impression. The FIB processing has an advantage in making finely polished thin sections for scanning electron microscopy (SEM)/transmission electron microscopy without damaging the structure near cracks. In the present work, the procedure of cross-sectioning and the results of crack propagation analysis in beta-SiC by SEM inspection are described.

Application of FIB with micro pick-up to microstructural study of irradiated SiC/SiC composites.

The combination of focused ion beam (FIB) micro-processing and the lift-out technique using the micro pick-up system was applied to the preparation of TEM specimens of irradiated SiC/SiC composites. The deformation caused by microstructural evolution was observed in the pyrolitic carbon interphase, and several helium bubbles and cavities were detected in the CVI matrix.

Microstructural analysis of the deformation range under nano-indentation in beta-SiC.

As a powerful tool to analyse microstructural evolution under irradiation and the interaction of moving dislocations with radiation-induced defects, a focused ion beam (FIB) method was applied to ion-irradiated SiC followed by the nano-indentation test. An FIB method has excellent capability to prepare thin foils from the area of interest with a high accuracy of location and wide flexibility in the sampling direction. These advantages are demonstrated in the application to Si ion-irradiated SiC by transmission electron microscope observation.