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American Journal of Obstetrics and... Mar 2024Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor... (Review)
Review
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Cesarean Section; Delivery, Obstetric; Fetus; Obstetrics; Labor, Obstetric
PubMed: 38462267
DOI: 10.1016/j.ajog.2022.10.037 -
Obstetrics & Gynecology Science May 2024This study aimed to describe the clinical features, associated extragenital anomalies, and management of Mayer- Rokitansky-Küster-Hauser (MRKH) syndrome in a Thai...
OBJECTIVE
This study aimed to describe the clinical features, associated extragenital anomalies, and management of Mayer- Rokitansky-Küster-Hauser (MRKH) syndrome in a Thai population.
METHODS
This retrospective study analyzed the medical records of 96 patients with MRKH syndrome diagnosed and treated at a university hospital and tertiary referral center in southern Thailand between 2000 and 2022.
RESULTS
The study included 96 patients with MRKH syndrome. The most common symptom was primary amenorrhea (88.5%), followed by difficulty or inability to engage in sexual intercourse (9.4%) and pelvic mass (2.1%). Notably, 80.3% of the patients did not have extragenital malformations and were diagnosed with MRKH type I (typical form), whereas 19.7% were categorized as MRKH type II (atypical form). Skeletal malformations were the most frequent extragenital anomalies and were present in 19.5% of patients, with scoliosis being the most common skeletal condition. Other extragenital malformations included renal (8.5%) and neurological (1.0%) abnormalities. Clinical vaginal examination revealed complete atresia in 21.8% and vaginal hypoplasia (median vaginal length, 3 cm) in 78.2% of the patients. Half of the patients did not receive treatment because they had not engaged in sexual intercourse. In this cohort, 41.7% of the patients had no difficulty performing sexual intercourse. Hence, self-dilation therapy or concomitant dilation was recommended. Only eight patients (8.3%) underwent surgical reconstruction of the vagina.
CONCLUSION
This study confirmed the complexity and heterogeneity of the phenotypic manifestations of MRKH, including the degree of vaginal atresia and types and rates of associated malformations.
PubMed: 38461809
DOI: 10.5468/ogs.23211 -
International Journal of Surgery Case... Apr 2024Spontaneous heterotopic pregnancies, concurrently occurring intrauterine and ectopic pregnancies, pose a substantial risk to maternal health and are often misdiagnosed....
INTRODUCTION AND SIGNIFICANCE
Spontaneous heterotopic pregnancies, concurrently occurring intrauterine and ectopic pregnancies, pose a substantial risk to maternal health and are often misdiagnosed. This case report details the challenges in identifying and managing an exceptionally rare case of abdominal pregnancy without assisted reproduction. The patient's initial misdiagnosis underscores the complexities in diagnosis, emphasizing the importance of comprehensive imaging techniques.
CASE PRESENTATION
We present the case of a 36-year-old gravida 5, para 3, with a history of dilation and curettage, experiencing a heterotopic pregnancy involving delayed miscarriage in both uterine and abdominal cavities. Despite presenting symptoms of pelvic pain and abnormal vaginal bleeding, the abdominal pregnancy was initially overlooked in ultrasound examinations. The accurate diagnosis was only achieved post-miscarriage, leading to a timely intervention through laparotomy.
CLINICAL DISCUSSION
The absence of identifiable risk factors, except for the patient's history of dilation and curettage, highlights the spontaneous nature of this non-assisted reproduction-related pregnancy. This case emphasizes the challenges in diagnosing and managing spontaneous heterotopic pregnancies, particularly when an abdominal pregnancy is involved. Vigilance and advanced imaging techniques are crucial for early recognition and appropriate intervention.
CONCLUSION
This unique case underscores the difficulties in diagnosing and managing spontaneous heterotopic pregnancies, especially when an abdominal pregnancy is present. Vigilance and advanced imaging are essential to identify rare occurrences like abdominal pregnancies that may go unnoticed in conventional ultrasound examinations. Early recognition and intervention are critical in averting potential life-threatening consequences associated with this uncommon condition.
PubMed: 38461586
DOI: 10.1016/j.ijscr.2024.109498 -
WMJ : Official Publication of the State... Feb 2024Opioids prescribed for postoperative pain have exceeded patient need in the United States, playing a significant role in the opioid epidemic. In the preintervention...
BACKGROUND
Opioids prescribed for postoperative pain have exceeded patient need in the United States, playing a significant role in the opioid epidemic. In the preintervention phase of this project (September 2018 - March 2019), a chart review and patient survey revealed that patients were prescribed double the number of opioids they consumed following gynecologic surgery.
OBJECTIVE
To ascertain whether an educational intervention recommending opiate prescriptions based on postoperative opioid use decreases gynecologic surgeons' opiate prescriptions.
METHODS
An educational intervention implemented in January 2021 communicated the discrepancy between patient need and medications prescribed and made prescribing recommendations for common gynecologic procedures. A postintervention (February 2021 - April 2021) retrospective chart review ascertained postoperative opioid prescribing practices. Residents were surveyed about their prescribing practices in June 2021. Descriptive statistics compared each phase.
RESULTS
For laparoscopic hysterectomy, the median morphine milligram equivalent (MME) was 150 (IQR 112.5-166.9) for preintervention and 150 (IQR 112.5-150) postintervention. For vaginal hysterectomy, median MME declined from 150 (IQR 112.5-225) to 112.5 (IQR 112.5-150). For laparoscopic surgery without hysterectomy, the median MME was 75 for both preintervention (IQR 75-120) and postintervention (IQR 60-80). For vaginal surgery without hysterectomy median MME went from 75 (IQR 75-142.5) to 54 (IQR 22.5-112.5). Median MME for hysteroscopy and dilation and curettage was 0 for both phases. When surveyed, residents reported prescribing lower amounts than actual prescribing practices.
CONCLUSIONS
Despite education informing gynecologic surgeons that their opioid prescribing exceeded patient need, prescribing practices did not change. The difference between actual and resident-reported prescribing practices warrants further investigation.
Topics: Humans; Female; Analgesics, Opioid; Retrospective Studies; Practice Patterns, Physicians'; Gynecologic Surgical Procedures; Opiate Alkaloids; Endrin
PubMed: 38436635
DOI: No ID Found -
European Journal of Obstetrics,... May 2024To assess the utility of Art & Craft - a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at...
OBJECTIVES
To assess the utility of Art & Craft - a new, hands-on course on Advanced Rotational Techniques and safe Caesarean biRth at Advanced/Full dilation Training aimed at senior Obstetrics trainees. The aims were to assess whether it improved confidence and skills in rotational vaginal birth, impacted fetal head at caesarean, and ultrasound for fetal position.
STUDY DESIGN
With ethical approval, pre- and post- course questionnaires and post- course interviews of attendees were conducted. A pre course questionnaire was emailed 1 week before the course. Attendees were asked to rate their confidence levels in performing vaginal examination and ultrasound assessment of fetal position, rotational ventouse, manual rotation, Kielland's rotational forceps, and disimpaction of the fetal head during second stage caesarean on a scale of 1 to 5. 1 = not confident at all and 5 = very confident. A post-course questionnaire with the same questions was emailed 3 days after. p values for differences in scores were calculated using the Wilcoxon signed rank test using Stata/MP 18 software.
RESULTS
32 trainees attended the course. 28 questionnaires were available for analysis. The majority 39 % were middle grade (ST3-ST5) level. Initial confidence was very low for rotational forceps (median 1/5). After attending the course and practical stations, respondents' confidence levels increased significantly (p < 0.05) across all domains; vaginal examination from 4 to 5, ultrasound for fetal position, rotational ventouse, and manual rotation from 3 to 5, disimpaction from 4 to 4.5, and Kielland's rotational forceps from 1 to 4. Nine participated in post course interviews, which were thematically analysed. Participants expressed that the course gave them the opportunity to ask specific questions from experts to improve their confidence. A barrier to learning new methods was highlighted in that it is difficult to receive practical training in Kielland's, resulting in low confidence.
CONCLUSION
A practical, hands-on course on complex operative birth significantly increases trainee confidence levels in vaginal examination, ultrasound for fetal position, disimpaction, and techniques for rotational vaginal birth. The evaluation highlights that continued education and practise is required, even when trainees are senior. Evaluation of clinical outcomes after training is needed; and planned.
Topics: Pregnancy; Humans; Female; Cesarean Section; Extraction, Obstetrical; Obstetrical Forceps; Obstetrics
PubMed: 38432018
DOI: 10.1016/j.ejogrb.2024.02.046 -
American Journal of Obstetrics and... Jul 2024The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over...
BACKGROUND
The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references for expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al, and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of labor induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making.
OBJECTIVE
This study aimed to compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using two modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method.
STUDY DESIGN
This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex-presenting fetus ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first examination in the 20 hours before delivery; dilation, effacement, and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, differences between each model's predicted value and its corresponding observed value were calculated. These prediction errors were summarized using mean absolute error and root mean squared error statistics.
RESULTS
Dilation curves based on multiple parameters were more accurate than those derived from time alone. The mean absolute error of the multifactor methods was better (lower) than those of the single-factor methods (0.826 cm [95% confidence interval, 0.820-0.832] for the multifactor machine learning and 0.893 cm [95% confidence interval, 0.885-0.901] for the multifactor mixed-effects method and 2.122 cm [95% confidence interval, 2.108-2.136] for the single-factor methods; P<.0001 for both comparisons). The root mean squared errors of the multifactor methods were also better (lower) than those of the single-factor methods (1.126 cm [95% confidence interval, 1.118-1.133] for the machine learning [P<.0001] and 1.172 cm [95% confidence interval, 1.164-1.181] for the mixed-effects methods and 2.504 cm [95% confidence interval, 2.487-2.521] for the single-factor [P<.0001 for both comparisons]). The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<.0001). The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% confidence interval, 0.509-0.515) and a root mean squared error of 0.660 cm (95% confidence interval, 0.655-0.666). External validation using independent data produced similar findings.
CONCLUSION
Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone. The mean prediction errors were reduced by more than 50%. A more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.
Topics: Humans; Female; Pregnancy; Labor Stage, First; Adult; Labor, Induced; Longitudinal Studies; Machine Learning; Cesarean Section; Cohort Studies; Labor, Obstetric; Time Factors; Young Adult
PubMed: 38423450
DOI: 10.1016/j.ajog.2024.02.289 -
Cureus Jan 2024Cervical ripening is commonly performed before oxytocin administration during labor induction in pregnant women with an unfavorable cervix. In Japan, a...
AIM
Cervical ripening is commonly performed before oxytocin administration during labor induction in pregnant women with an unfavorable cervix. In Japan, a controlled-release Dinoprostone vaginal insert (CR-DVI) was approved in 2020. Although many studies have compared the mechanical methods of ripening and prostaglandins, few have examined the impact of additional options for labor induction. This study aimed to assess the impact of CR-DVI as an additional option for labor induction in women with an unfavorable cervix.
METHODS
In this single-center retrospective study conducted in Japan, 265 participants were divided into two groups: before (January 2018 to May 2020) and after (June 2020 to November 2022) CR-DVI introduction. Before CR-DVI was introduced, hygroscopic dilators were used for all cases instead. On the other hand, after the introduction of CR-DVI, the first choice for cervical ripening was CR-DVI. The CR-DVI was retained vaginally for up to 12 hours after insertion. However, if hyper-stimulation or non-reassuring fetal status was suspected, or if a new membrane rupture occurred, it was removed immediately according to the removal criteria. Oxytocin infusions were used during both periods if needed. We compared delivery and neonatal outcomes between the groups.
RESULTS
The 265 participants were divided into two groups: before (n=116) and after (n=149) CR-DVI introduction. There were no significant differences in maternal characteristics except for the primiparous proportion. CR-DVI was used in 93% of cases after introduction. Hygroscopic dilators also continued to be used; however, their use decreased to about 34%. The vaginal delivery rate was significantly higher after the introduction of CR-DVI than before its introduction (50.9% vs. 66.4%; p=0.01). Multivariable analysis revealed a significantly higher rate of vaginal delivery after CR-DVI introduction. Of the 149 cases in which a CR-DVI was used, 111 (79.9%) were removed before 12 hours. There were no significant differences in neonatal outcomes.
CONCLUSION
The rate of vaginal delivery was higher after CR-DVI introduction than before its introduction, and adverse pregnancy outcomes did not increase. Therefore, introducing CR-DVI as an option for labor induction may increase the probability of vaginal delivery. Safety can also be ensured by adhering to the removal criteria.
PubMed: 38420080
DOI: 10.7759/cureus.53180 -
Ecancermedicalscience 2023Most cervical cancers develop in the transformation zone (TZ). Type 3 TZs, where the full circumference of the squamocolumnar junction (SCJ) is not visible pose problems...
Most cervical cancers develop in the transformation zone (TZ). Type 3 TZs, where the full circumference of the squamocolumnar junction (SCJ) is not visible pose problems during cervical screening with visual inspection methods, as (pre)cancerous lesions may be missed. Several practical strategies can be implemented to convert type 3 TZs into TZ 1 or TZ 2, including the use of an endocervical speculum or hygroscopic cervical dilators, opening the vaginal speculum more widely, skillful use of cotton-tipped applicators, performing colposcopy in midcycle, and use of oral or vaginal misoprostol and estrogen to 'ripen' the cervix. With the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) terminology, settings with better resources to manipulate the cervix for a better view of the endocervical canal may assign patients to different categories from those in low-resource settings during a colposcopic examination. Here, we propose a colposcopic revision to the current IFCPC classification by segregating TZ 2 according to the extent of endocervical involvement and TZ 3 according to whether any attempt is made to open the endocervical canal, if such attempt(s) were successful, and the extent to which the practitioner can visualise parts of the uterine cervix beyond the border of the SCJ in the endocervical canal. In this proposed reclassification, TZ 2A has no part of the SCJ extending beyond 5 mm into the endocervical canal, whereas TZ 2B has part or all of the SCJ extending beyond 5 mm into the endocervical canal. TZ 3 is further subclassified into TZ 3A if the practitioner does not attempt to open the endocervical canal or the endocervical canal is opened, but not beyond 5 mm and TZ 3B if the full circumference cannot be visualised after opening the endocervical canal beyond 5 mm. We believe this revision will improve and better standardise the classification of TZ types, with huge implications for practice in low-resource settings, due to limited options for referral and treatment, to reduce the risk of missed cervical cancers and suboptimal treatment resulting from ablating lesions that extend too far into the endocervical canal.
PubMed: 38414959
DOI: 10.3332/ecancer.2023.1612 -
Research Square Feb 2024Stress urinary incontinence (SUI) greatly affects the daily life of numerous women and is closely related to a history of vaginal delivery and aging. We used vaginal...
Stress urinary incontinence (SUI) greatly affects the daily life of numerous women and is closely related to a history of vaginal delivery and aging. We used vaginal balloon dilation to simulate vaginal birth injury in young and middle-aged rats to produce a SUI animal model, and found that young rats restored urethral structure and function well, but not the middle-aged rats. To identify the characteristics of cellular and molecular changes in the urethral microenvironment during the repair process of SUI. We profiled 51,690 individual female rat urethra cells from 24 and 48 weeks old, with or without simulated vaginal birth injury. Cell interaction analysis showed that signal networks during repair process changed from resting to active, and aging altered the distribution but not the overall level of cell interaction in the repair process. Similarity analysis showed that muscle, fibroblasts, and immune cells underwent large transcriptional changes during aging and repair. In middle-aged rat, cell senescence occurs mainly in the superficial and middle urothelium due to cellular death and shedding, and the basal urothelium expressed many Senescence-Associated Secretory Phenotype (SASP) genes. In conclusion, we established the aging and vaginal balloon dilation (VBD) model of female urethral cell anatomy and the signal network landscape, which provides an insight into the normal or disordered urethra repair process and the scientific basis for developing novel SUI therapies.
PubMed: 38410468
DOI: 10.21203/rs.3.rs-3901406/v1 -
AJOG Global Reports Feb 2024This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth... (Review)
Review
OBJECTIVE
This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth rates.
DATA SOURCES
PubMed, Medline Ovid, EBSCOhost, Embase, Scopus, and Google Scholar were queried from inception to February 2023, with the following terms: "full dilatation," "second stage," and "cesarean," with their word variations. Furthermore, an additional cohort of 353,434 cases from our recently published study was included.
STUDY ELIGIBILITY CRITERIA
Only original studies that provided sufficient information on the number of pre-second-stage cesarean deliveries, second-stage cesarean deliveries, and vaginal births were included for the calculation of different modes of delivery. Systemic reviews, meta-analyses, or case reports were excluded.
METHODS
Study identification and data extraction were independently performed by 2 authors. Selected studies were categorized on the basis of parity, study period, and geographic regions for comparison.
RESULTS
A total of 25 studies were included. The overall pre-second-stage cesarean delivery rate, the second-stage cesarean delivery rate, and the second-stage cesarean delivery-to-assisted vaginal birth ratio were 17.94%, 2.65%, and 0.19, respectively. Only 5 studies described singleton, term, cephalic presenting pregnancies of nulliparous women, and their second-stage cesarean delivery rates were significantly higher than those studies with cohorts of all parity groups (4.50% vs 0.83%; <.05). In addition, the second-stage cesarean delivery rate showed a secular increase across 2009 (0.70% vs 1.05%; <.05). Moreover, it was the highest among African studies (5.14%) but the lowest among studies from East Asia and South Asia (0.94%). The distributions of second-stage cesarean delivery rates of individual studies and subgroups were shown with that of pre-second-stage cesarean delivery and assisted vaginal birth using the bubble chart.
CONCLUSION
The overall worldwide pre-second-stage cesarean delivery rate was 17.94%, the second-stage cesarean delivery rate was 2.65%, and the second-stage cesarean delivery-to-assisted vaginal birth ratio was 0.19. The African studies had the highest second-stage cesarean delivery rate (5.14%) and second-stage cesarean delivery-to-assisted vaginal birth ratio (1.88), whereas the studies from East Asia and South Asia were opposite (0.94% and 0.11, respectively).
PubMed: 38380079
DOI: 10.1016/j.xagr.2024.100312