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Pelvic endometriosis is a well-known clinical risk factor for pelvic inflammation and adhesions. We present a complex case of a woman undergoing a cesarean section where the traditional incision on the anterior lower uterine segment was not possible due to a congested pelvis. The newborn was delivered using a posterior uterine wall incision with rotation of the round ligament.
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Cesárea , Endometriosis , Humanos , Femenino , Endometriosis/cirugía , Endometriosis/complicaciones , Cesárea/efectos adversos , Embarazo , Adulto , Útero/cirugía , PelvisRESUMEN
Recent decades have seen a notable increase in cesarean section rates. Although lifesaving, cesarean delivery is associated with an elevated risk of adverse health outcomes in newborns, including respiratory diseases, atopic disorders, obesity, diabetes, and severe autoimmune conditions. The exact mechanisms underlying these associations remain elusive; however, epigenetic modifications have emerged as a plausible molecular basis linking perinatal factors with future disease susceptibility. This review summarizes current literature, revealing that the delivery method may influence epigenetic markers in neonates, primarily through alterations in global DNA methylation and gene-specific methylation patterns.
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Cesárea , Metilación de ADN , Epigénesis Genética , Humanos , Recién Nacido , Embarazo , Femenino , Cesárea/estadística & datos numéricos , Parto Obstétrico/métodosRESUMEN
Background: Bleeding is a serious cause of hypotension and tachycardia after childbirth and should always be considered. Case presentation: A healthy woman in her thirties who had previously undergone caesarean section, underwent induction and operative vaginal delivery. Postpartum, she experienced chest pain, hypotension and tachycardia, and had signs of ischaemia on electrocardiogram. A CT scan showed a large intraperitoneal haematoma. The patient underwent immediate laparotomy and received a massive blood transfusion. However, no large haematoma was found. The chest pain was attributed to a myocardial infarction caused by hypovolaemic shock. After discharge, the patient experienced significant vaginal bleeding and was transferred to a different university hospital. A CT scan revealed a large retroperitoneal haematoma. Emergency surgery was performed based on the suspicion of active bleeding, but only an older haematoma was found. Re-evaluation of the initial CT scan revealed that the haematoma was in fact located retroperitoneally and was thereby not found in the first operation. Interpretation: This case highlights the importance of bleeding as an important cause in unstable postpartum patients. Additionally, it is a reminder that retroperitoneal haematomas can occur in obstetric patients and can mask typical symptoms of uterine rupture such as abdominal pain. also hindering perioperative diagnosis.
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Dolor en el Pecho , Hematoma , Choque , Humanos , Femenino , Adulto , Hematoma/diagnóstico por imagen , Hematoma/etiología , Hematoma/diagnóstico , Dolor en el Pecho/etiología , Choque/etiología , Choque/diagnóstico , Tomografía Computarizada por Rayos X , Embarazo , Trastornos Puerperales/diagnóstico , Trastornos Puerperales/etiología , Trastornos Puerperales/diagnóstico por imagen , Espacio Retroperitoneal/diagnóstico por imagen , Cesárea/efectos adversos , Electrocardiografía , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/complicaciones , Hemorragia Posparto/etiología , Hemorragia Posparto/diagnósticoRESUMEN
BACKGROUND: Fetal weight estimation at term is a challenging clinical task. OBJECTIVES: To evaluate the association between peripheral white blood cell (WBC) count of the laboring women and neonatal birth weight (BW) for term uncomplicated pregnancies. METHODS: We conducted a single-center, retrospective cohort study (2006-2021) of women admitted in the first stage of labor or planned cesarean delivery. Complete blood counts were collected at admission. BW groups were categorized by weight (grams): < 2500 (group A), 2500-3499 (group B), 3500-4000 (group C), and > 4000 (group D). Two study periods were used to evaluate the association between WBC count and neonatal BW. RESULTS: There were a total of 98,632 deliveries. The dataset analyses showed a lower WBC count that was significantly and linearly associated with a higher BW; P for trend < 0.001 for women in labor. The most significant association was noted for the > 4000-gram newborns; adjusted odds ratio 0.97, 95% confidence interval 0.96-0.98; P < 0.001; adjusted for hemoglobin level, gestational age, and fetal sex. The 2018-2021 dataset analyses revealed WBC as an independent predictor of macrosomia with a significant incremental predictive value (P < 0.0001). The negative predictive value of the WBC count for macrosomia was significantly high, 93.85% for a threshold of WBC < 10.25 × 103/µl. CONCLUSIONS: WBC count should be considered to support the in-labor fetal weight estimation, especially valuable for the macrosomic fetus.
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Peso al Nacer , Macrosomía Fetal , Humanos , Femenino , Macrosomía Fetal/diagnóstico , Recuento de Leucocitos/métodos , Embarazo , Estudios Retrospectivos , Adulto , Recién Nacido , Trabajo de Parto/sangre , Trabajo de Parto/fisiología , Edad Gestacional , Peso Fetal , Cesárea/estadística & datos numéricos , Nacimiento a Término , Valor Predictivo de las PruebasAsunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Agujas , Humanos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Cesárea/efectos adversos , Cesárea/métodos , Femenino , Embarazo , Agujas/efectos adversos , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Adulto , Falla de EquipoRESUMEN
OBJECTIVES: This study aimed to compare plasma concentrations of anesthetic drugs administered during Cesarean section with low Apgar score in neonates deliveried under general anesthesia and analyze associated risk factors. METHODS: Data from 76 neonates undergoing Cesarean section under general anesthesia with blood concentrations of anesthetic drugs were analyzed. A low Apgar score was defined as ≤ 7. Perioperative maternal and neonatal data were collected and analyzed. Neonates were divided into a control group (Group CON, n = 65) and a low Apgar score group (Group LAS, n = 11) based on Apgar score. RESULTS: There were no significant differences in the plasma concentrations of anesthetic drugs in maternal artery, umbilical vein or umbilical artery blood between the two groups. Risk factors for neonatal low Apgar scores during Cesarean section under general anesthesia were premature delivery (aOR 10.2, 95% CI = 1.8-56.9) and preoperative fetal distress (aOR 9.6, 95% CI = 1.3-69.0). The prediction model was: probability = 1/(eY), Y= -4.607 + 2.318× (premature delivery) + 2.261× (fetal distress) (yes = 1, no = 0). The Hosmer-Lemeshow test showed χ²= 9.587, P = 0.213, and the area under the curve (AUC) was 0.850 (0.670 ~ 1.000). With a cutoff value of 0.695, sensitivity and specificity were 81.8% and 87.7%, respectively. CONCLUSIONS: There was no correlation between blood concentration of general anesthetic drugs and Apgar score or occurrence of neonatal low Apgar scores. Premature delivery and preoperative fetal distress were identified as independent risk factors for neonatal low Apgar scores after Cesarean section under general anesthesia.
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Anestesia General , Puntaje de Apgar , Cesárea , Humanos , Recién Nacido , Anestesia General/efectos adversos , Femenino , Embarazo , Factores de Riesgo , Adulto , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Masculino , Sufrimiento Fetal/sangre , Estudios Retrospectivos , Anestésicos/sangre , Anestésicos/efectos adversos , Nacimiento PrematuroRESUMEN
BACKGROUND: Group B Streptococcus (GBS) infection remains a leading cause of newborn morbidity and mortality. The study aimed to determine the adherence rate to the universal screening policy a decade after its introduction. Secondly, whether the timing of antibiotics given in GBS carriers reduces the incidence of neonatal sepsis. METHODS: Delivery records at Hong Kong Baptist Hospital in 2022 were examined to retrieve antenatal and intrapartum details regarding maternal GBS carrier status, previous maternal GBS carrier status, antibiotic treatment, timing of treatment, neonatal condition at birth and whether the neonate had sepsis. Univariate statistics was used to assess the relationship between maternal GBS carrier and neonatal sepsis overall. Incidence of neonatal sepsis was stratified according to mode of delivery and timing of antibiotic. RESULTS: The adherence rate to the universal GBS screening policy was 97%. The risk of neonatal sepsis was 5.45 (95% CI 3.05 to 9.75) times higher in women who were GBS screened positive when compared to non-GBS carriers (p < 0.001). Amongst term neonates from GBS carriers delivered by Caesarean section, the risk of neonatal sepsis significantly decreased by 70% after antenatal antibiotic treatment (p = 0.041) whereas in term neonates delivered vaginally, the risk of neonatal sepsis decreased by 71% (p = 0.022) if intrapartum antibiotic prophylaxis was given 4 or more hours. CONCLUSION: Giving antenatal antibiotic treatment before Caesarean section or intrapartum antibiotic prophylaxis for 4 or more hours before vaginal delivery may decrease the risk of neonatal sepsis in term neonates delivered from GBS carriers.
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Antibacterianos , Sepsis Neonatal , Complicaciones Infecciosas del Embarazo , Infecciones Estreptocócicas , Streptococcus agalactiae , Humanos , Infecciones Estreptocócicas/prevención & control , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/epidemiología , Recién Nacido , Sepsis Neonatal/prevención & control , Sepsis Neonatal/diagnóstico , Sepsis Neonatal/epidemiología , Sepsis Neonatal/microbiología , Femenino , Streptococcus agalactiae/aislamiento & purificación , Embarazo , Antibacterianos/uso terapéutico , Antibacterianos/administración & dosificación , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/epidemiología , Complicaciones Infecciosas del Embarazo/prevención & control , Hong Kong/epidemiología , Portador Sano/diagnóstico , Adulto , Profilaxis Antibiótica/métodos , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Incidencia , Cesárea , Tamizaje Masivo/métodos , Adhesión a Directriz/estadística & datos numéricos , Estudios Retrospectivos , Parto ObstétricoRESUMEN
PROBLEM: Cesarean scar pregnancy (CSP) is characterized by a gestational sac fully or partially implanted in the scar from a previous cesarean section. Systemic immune-inflammation indices (SIIs) have recently been discussed as additional diagnostic markers in placenta accreta and preeclampsia. CSP shares a similar pathogenesis with these diseases, suggesting that assessing the SIIs and neutrophil-to-lymphocyte ratio (NLR) could enhance additional predictability in diagnosing CSP. METHOD OF STUDY: In this study, we analyzed the complete blood counts between 264 women who were confirmed with CSP by ultrasound and 295 women who underwent elective termination. RESULTS: The mean counts of total white cells and neutrophils were significantly higher, whereas the counts of monocytes, lymphocytes, and platelets were significantly lower in the CSP group compared to the control group (p < 0.001). Additionally, the SII, systemic inflammation response index (SIRI), or NLR was significantly higher in the CSP group compared to the control group (p < 0.0001). Given the limited effect of SII and SIRI on the increased risk of developing CSP, the optimal cut-off value for NLR in predicting CSP was 2.87 (area under the curve [AUC] 0.656, 68% sensitivity). The optimal cut-off value for NLR in predicting type 2 CSP was 2.91 (AUC 0.690, 71% sensitivity). CONCLUSIONS: Although ultrasound or magnetic resonance imaging images are a gold standard for visualizing the gestational sac's location in the diagnosis of CSP, assessing peripheral blood tests is cost-effective, and NLR may provide additional diagnosis value for CSP.
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Biomarcadores , Cesárea , Cicatriz , Inflamación , Embarazo Ectópico , Humanos , Femenino , Embarazo , Cicatriz/inmunología , Adulto , Inflamación/inmunología , Biomarcadores/sangre , Embarazo Ectópico/diagnóstico , Embarazo Ectópico/inmunología , Embarazo Ectópico/sangre , Neutrófilos/inmunología , Linfocitos/inmunologíaRESUMEN
Since the last decade, iatrogenic injuries of ureter are increasingly common. We describe a case of 36-year-old young female, who underwent emergency cesarean section, presented to us after 3 weeks, with clear vaginal discharge. After evaluated with clinical examination and radiological investigations, she was found to have left uretero-uterine fistula and was successfully treated with robotic-assisted left uretero-uterine fistula repair by Lich-Gregoir technique.
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Cesárea , Procedimientos Quirúrgicos Robotizados , Enfermedades Ureterales , Fístula Urinaria , Enfermedades Uterinas , Humanos , Femenino , Adulto , Cesárea/efectos adversos , Enfermedades Ureterales/etiología , Enfermedades Ureterales/cirugía , Fístula Urinaria/etiología , Fístula Urinaria/cirugía , Embarazo , Enfermedades Uterinas/cirugía , Enfermedades Uterinas/etiología , Fístula/etiología , Fístula/cirugíaRESUMEN
OBJECTIVE: This review aims to summarize the most recent and updated data on pregnancy in patients with axial spondyloarthritis (axSpA), focusing on the recurrence of pregnancy-related complications, the disease activity throughout gestation and the postpartum, and the latest indications for the treatments of future mothers. METHODS: We have conducted a narrative review with an online literature search on Medline and PubMed. We selected only studies written in English published until January 2024, including observational and retrospective studies, meta-analyses, and systematic reviews. RESULTS: Proper preconception counseling and maternal-fetal monitoring are necessary to ensure the best outcome for both the mother and her baby. Despite the limited and conflicting evidence about the prevalence of adverse pregnancy outcomes in women with axSpA compared to healthy controls, primary findings demonstrate an increased risk of preterm delivery (PTD), low birth weight (LBW), and elective cesarean section (CS). Concerning disease activity, data suggests that 25-80% of women with ankylosing spondylitis experience disease flares during pregnancy, particularly around 20 weeks of gestation. On the contrary, the data on the postpartum disease flare are heterogeneous. The use of biological drugs in pregnancy is safe and effective in controlling disease activity. CONCLUSIONS: Data on pregnancy outcomes in patients with axSpA are scarce and discordant. Probably the difference in maternal disease classification, the evolution of treatment indications, and the differences emerging from study designs can account for these discrepancies. The main evidence shows an increased risk of PTD, LBW, and elective CS (although the latter may reflect cultural influences rather than medical needs due to axSpA itself). The majority of drugs used to treat axSpA, including TNFi, are safe in pregnancy without harming mothers or fetuses. Further data is needed to clarify many controversial aspects in this area.
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Complicaciones del Embarazo , Resultado del Embarazo , Humanos , Embarazo , Femenino , Complicaciones del Embarazo/tratamiento farmacológico , Espondiloartritis/tratamiento farmacológico , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/prevención & control , Nacimiento Prematuro/etiología , Cesárea/estadística & datos numéricos , Recién Nacido de Bajo Peso , Recién Nacido , Espondilitis Anquilosante/tratamiento farmacológicoAsunto(s)
Analgésicos Opioides , Cesárea , Dolor Postoperatorio , Humanos , Femenino , Analgésicos Opioides/uso terapéutico , Analgésicos Opioides/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Embarazo , Adulto , Manejo del Dolor/métodos , Pautas de la Práctica en Medicina , Prescripciones de Medicamentos/normasAsunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Anestésicos Locales , Cesárea , Inyecciones Espinales , Humanos , Anestesia Raquidea/métodos , Femenino , Embarazo , Anestésicos Locales/administración & dosificación , Anestesia Obstétrica/métodos , Anestesia Obstétrica/efectos adversos , Insuficiencia del Tratamiento , Factores de RiesgoRESUMEN
Maternal health is a major public health tricky globally. Cesarean section delivery reduces morbidity and mortality when certain complications occur throughout pregnancy and labor. Cesarean section subjected to the availability and use of essential obstetric services in regional factors in Ethiopia. There was a scarcity of studies that assess the spatial distribution and associated factors of cesarean section. Consequently, this study aimed to assess the spatial variation of cesarean section and associated factors using mini EDHS 2019 national representative data. A community based cross-sectional study was conducted in Ethiopia from March to June 2019. A two-stage stratified sampling design was used to select participants. A Global Moran's I and Getis-Ord Gi* statistic hotspot analysis was used to assess the spatial distribution. Kuldorff's SaTScan was employed to determine the purely statistically significant spatial clusters. A multilevel binary logistic regression model fitted to identify factors. A total of 5753 mothers were included. More than one-fourth of mothers delivered through cesarean section at private health institutions and 54.74% were not educated. The proportion of cesarean section clustered geographically in Ethiopia and hotspot areas were observed in Addis Ababa, Oromia, Tigray, Derie Dewa, Amhara, and SNNR regions. Mothers' age (AOR = 1.07, 95% CI 1.02-1.12), mother's had secondary education (AOR = 2.113, 95% CI 1.414, 3.157), mother's higher education (2.646, 95% CI 1.724, 4.063), Muslim religion followers (AOR = 0.632, 95% CI 0.469, 0.852), poorer (AOR = 1.719, 95% CI 1.057, 2.795), middle wealth index (AOR = 1.769, 95% CI 1.073, 2.918), richer (AOR = 2.041, 95% CI 1.246, 3.344), richest (AOR = 3.510, 95% CI 2.197, 5.607), parity (AOR = 0.825, 95% CI 0.739, 0.921), and multiple pregnancies (AOR = 4.032, 95% CI 2.418, 6.723) were significant factors. Therefore, geographically targeted interventions are essential to reduce maternal and infant mortality with WHO recommendations for those Muslim, poorest and not educated mothers.
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Cesárea , Humanos , Etiopía , Cesárea/estadística & datos numéricos , Femenino , Estudios Transversales , Adulto , Embarazo , Adulto Joven , Adolescente , Persona de Mediana Edad , Análisis EspacialRESUMEN
BACKGROUND: Brazil is one of the countries with the highest rates of caesarean sections (CS), reaching almost 90% of births in the private sector. A quality improvement project called "Adequate Childbirth Project (PPA)" was conceived to reduce CS in the private sector. This project consisted of four primary components: "Governance", "Participation of Women", "Reorganization of Care" and "Monitoring". This paper aims to evaluate: (1) which specific activities of the PPA had the largest effect on the probability of a woman having a vaginal delivery; (2) which primary component of the PPA had the largest effect on the probability of vaginal delivery and (3) which scenarios combining the implementation of different activities planned in the PPA had a higher effect on the probability of vaginal delivery. METHODS: A sample of 12 private hospitals participating in the PPA was evaluated. We used a Bayesian Network (BN) to capture both non-linearities and complex cause-effect relations. The BN integrated knowledge from experts and data from women to estimate 26 model parameters. The PPA was evaluated in 2473 women belonging to groups 1-4 of the Robson classification, who were divided into two groups: those participating or not participating in the PPA. RESULTS: The probability of a woman having a vaginal delivery was 37.7% higher in women participating in the PPA. The most important component of the project that led to an increase in the probability of vaginal delivery was "Reorganization of Care", leading to a 73% probability of vaginal delivery among women in labor. The activity that had the greatest effect on the type of delivery was access to best practices during labor, with a 72% probability of vaginal delivery. Considering the 12 scenarios combining the different activities of the PPA, the best scenarios included: a non-scheduled delivery, access to information about best practices, access to at least 4 best practices during labor and respect of the birth plan, with an 80% probability of vaginal delivery in the best combinations. CONCLUSION: PPA has been shown to be an effective quality improvement program, increasing the likelihood of vaginal delivery in private Brazilian hospitals.
INTRODUCTION: Brazil boasts one of the highest rates of caesarean sections (CS) globally, with nearly 90% of births in private facilities being delivered via CS. In response, the 'Adequate Childbirth Project PPA' was launched as a quality improvement initiative aimed at curbing CS rates in private healthcare. Its goal is to improve the quality of childbirth and reduce the number of CS in private healthcare. The project has four main parts: 'Governance', 'Participation of Women', 'Reorganization of Care', and 'Monitoring'. METHOD: an evaluative study was conducted across 12 private hospitals involved in the PPA, involving 2473 women who were categorized into PPA participants and non-participants. They used a method called a cause-effect network to see which parts of the PPA helped more women have vaginal deliveries. RESULTS: They found that women in the PPA were 37.7% more likely to have a vaginal delivery. Giving women access to good practices during labor and birth was really important. Also, 'Reorganization of Care' was the most important part of the project. It led to a 73% chance of vaginal delivery for women in labor. CONCLUSION: The PPA is effective in helping more women in private hospitals have vaginal deliveries. This means it's a good program for improving childbirth in Brazil's private hospitals.
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Cesárea , Hospitales Privados , Mejoramiento de la Calidad , Humanos , Femenino , Cesárea/estadística & datos numéricos , Hospitales Privados/normas , Hospitales Privados/estadística & datos numéricos , Embarazo , Brasil , Adulto , Parto Obstétrico/normas , Parto Obstétrico/estadística & datos numéricos , Teorema de BayesRESUMEN
BACKGROUND: Cesarean section (CS) rates in Indonesia are rapidly increasing for both sociocultural and medical reasons. However, there is limited understanding of the role that social media plays in influencing preferences regarding mode of birth (vaginal or CS). Social media provides a platform for users to seek and exchange information, including information on the mode of birth, which may help unpack social influences on health behavior. OBJECTIVE: This study aims to explore how CS is portrayed on Instagram in Indonesia. METHODS: We downloaded public Instagram posts from Indonesia containing CS hashtags and extracted their attributes (image, caption, hashtags, and objects and texts within images). Posts were divided into 2 periods-before COVID-19 and during COVID-19-to examine changes in CS portrayal during the pandemic. We used a mixed methods approach to analysis using text mining, descriptive statistics, and qualitative content analysis. RESULTS: A total of 9978 posts were analyzed quantitatively, and 720 (7.22%) posts were sampled and analyzed qualitatively. The use of text (527/5913, 8.91% vs 242/4065, 5.95%; P<.001) and advertisement materials (411/5913, 6.95% vs 83/4065, 2.04%; P<.001) increased during the COVID-19 pandemic compared to before the pandemic, indicating growth of information sharing on CS over time. Posts with CS hashtags primarily promoted herbal medicine for faster recovery and services for choosing auspicious childbirth dates, encouraging elective CS. Some private health facilities offered discounts on CS for special events such as Mother's Day and promoted techniques such as enhanced recovery after CS for comfortable, painless birth, and faster recovery after CS. Hashtags related to comfortable or painless birth (2358/5913, 39.88% vs 278/4065, 6.84%; P<.001), enhanced recovery after CS (124/5913, 2.1% vs 0%; P<.001), feng shui services (110/5913, 1.86% vs 56/4065, 1.38%; P=.03), names of health care providers (2974/5913, 50.3% vs 304/4065, 7.48%; P<.001), and names of hospitals (1460/5913, 24.69% vs 917/4065, 22.56%; P=.007) were more prominent during compared to before the pandemic. CONCLUSIONS: This study highlights the necessity of enforcing advertisement regulations regarding birth-related medical services in the commercial and private sectors. Enhanced health promotion efforts are crucial to ensure that women receive accurate, balanced, and appropriate information about birth options. Continuous and proactive health information dissemination from government organizations is essential to counteract biases favoring CS over vaginal birth.
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COVID-19 , Cesárea , Medios de Comunicación Sociales , Humanos , Cesárea/estadística & datos numéricos , COVID-19/epidemiología , COVID-19/prevención & control , Femenino , Indonesia/epidemiología , Embarazo , Pandemias , SARS-CoV-2RESUMEN
BACKGROUND: Pregnant women are more likely to have a higher severity of illness after being infected with coronavirus disease 2019 compared with the general population, particularly in the hyperinflammatory phase. However, immunomodulatory drugs are contraindicated and have been associated with an increased risk of fetal abnormalities. Therefore, we are reporting our experience with the use of HA330 hemoperfusion in combination with standard therapy in severe to critical coronavirus disease 2019 cases among pregnant patients. CASE PRESENTATION: From January 2020 to December 2021, four pregnant Thai women were treated with hemoperfusion using a cytokine adsorptive technique. The patients' ages ranged from 21 to 36 years old, and their gestational ages at the time of admission ranged from 18 to 38 weeks. Two patients required intubation. Extracorporeal blood purification with an adsorptive cartridge (HA330®, Jafron, China) was applied as an adjunctive strategy to standard therapy approximately one week after the onset of symptoms, and most patients received three sessions of hemoperfusion. The baseline C-reactive protein level was greater than 80 mg/dL. The results showed that hemoperfusion could decrease the C-reactive protein level by approximately 80% and improve oxygenation. The newborns were delivered by Cesarean section without complications. Neither mortality nor serious adverse events related to hemoperfusion occurred. CONCLUSION: This report may help ensure the use of the hemoperfusion strategy in pregnant patients during a cytokine storm. However, a larger cohort is needed to confirm its safety and efficacy.
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COVID-19 , Hemoperfusión , Complicaciones Infecciosas del Embarazo , SARS-CoV-2 , Humanos , Femenino , Embarazo , Hemoperfusión/métodos , COVID-19/terapia , COVID-19/complicaciones , Adulto , Complicaciones Infecciosas del Embarazo/terapia , Adulto Joven , Tailandia , Proteína C-Reactiva/análisis , Proteína C-Reactiva/metabolismo , Cesárea , Recién NacidoRESUMEN
Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5 percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.
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Servicios de Salud Materna , Países Bajos , Humanos , Femenino , Embarazo , Servicios de Salud Materna/economía , Paquetes de Atención al Paciente/economía , Parto Obstétrico/economía , Adulto , Mecanismo de Reembolso , Política de Salud , Cesárea/economía , Cesárea/estadística & datos numéricos , Prestación Integrada de Atención de Salud/economíaRESUMEN
OBJECTIVE: Aim: To clarify the association between different types of uterine contractility dysfunction and the inflammation of the uterus and chorioamniotic membranes. PATIENTS AND METHODS: Materials and Methods: The association between the inflammation of the uterine layers, chorioamniotic membranes, umbilical cord, and different types of labor activity abnormalities was examined in 382 patients with singleton pregnancies at 28-42 weeks' gestation who underwent Caesarean section (CS) for abnormal uterine contractions and other complications. Statistical analyses included the Mann-Whitney U, Chi-squared test, and logistic regression. RESULTS: Results: In the control group, slight infiltration with polymorphonuclear leukocytes (PMNs) and macrophages of the myometrium and decidua of the lower uterine segment at term pregnancy was found in 59.7% and 73.6% of cases. The main clinical risk factors for placental and decidual membrane inflammation in patients with excessive uterine activity (EUA) were prematurity, multiparity, group B streptococcus (GBS) colonization, and duration of ruptured fetal membranes before the CS. Moderate or marked myometrial inflammation of both uterine segments in the EUA group was diagnosed only in patients with cervical dilation of >6 cm and duration of labor of >8h. In women with hypotonic uterine activity (HUA), decidual and myometrial inflammation was significantly associated with nulliparity and intrapartum factors, such as protracted active first stage of labor, advanced cervical dilation, and number of vaginal examinations. In all cases, inflammation of the myometrium was accompanied by deciduitis. CONCLUSION: Conclusions: Mild inflammation of the decidual membrane and myometrium of the lower segment at term pregnancy is a common physiological phenomenon contributing to labor initiation. Uterine hyperfunction comes as the response of the unaffected myometrium to the release of high concentrations of proinflammatory cytokines produced by the inflamed decidual and chorioamniotic membranes into the bloodstream. Marked myometrial inflammation that occurs in prolonged labor is an additional factor aggravating the hypotonic uterine activity.
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Útero , Humanos , Femenino , Embarazo , Adulto , Útero/patología , Contracción Uterina , Miometrio/patología , Cesárea/efectos adversos , Corioamnionitis/patología , Complicaciones del Trabajo de Parto , Inflamación/patología , Factores de RiesgoRESUMEN
BACKGROUND: Most German hospitals do not offer a trial of labour after two caesarean sections (TOLA2C). TOLA2C is claimed to be associated with too many complications, above all the high risk of uterine rupture. The objective of this study is to review our experience with TOLA2C, with special attention paid to the risk and probability of uterine ruptures. Secondary outcomes include comparing neonatal and maternal outcomes in the group of TOLA2C with the group of elective repeat caesarean section (ERCS) and to assess the success rate for vaginal birth after two caesarean sections (VBAC-2). METHODS: The retrospective cohort study was conducted in a community hospital in North Rhine-Westphalia. Inclusion criteria were all pregnant women with two caesarean sections in their medical history, with a current vertex singleton pregnancy and the absence of morphological abnormalities of the foetus, who gave birth in our facility between January 2015 and June 2021. Descriptive statistics were calculated and Kolmogorov-Smirnov tests, Mann-Whitney U tests, Fishers exact tests, Chi2 -tests and t-tests for independent samples were performed. RESULTS: A total of 91 cases were included in the TOLA2C-group. These were compared to 99 cases that, within the same time frame, had an elective repeat caesarean section (ERCS-group). There was no statistically significant difference found in the neonatal outcome between the two groups (except for the neonatal pH-value: p 0.024). The hospital stay was significantly shorter in the TOLA2C-group, while maternal complication rates were almost similar (13.2% in the TOLA2C-Group, vs. 16.2% in the ERCS-Group). The success rate for TOLA2C was 55%. No complete uterine rupture was found, but in three cases an incomplete rupture (3.3% rate for incomplete uterine ruptures) occurred, but had no influence on the neonatal outcome. CONCLUSION: TOLA2C is not associated with a worse maternal or neonatal outcome compared to ERCS, and especially the risk of complete uterine ruptures seems to be low. TOLA2C should be more widely offered to suitable patients who are motivated for it.
Asunto(s)
Cesárea Repetida , Esfuerzo de Parto , Rotura Uterina , Parto Vaginal Después de Cesárea , Humanos , Femenino , Embarazo , Rotura Uterina/etiología , Rotura Uterina/epidemiología , Estudios Retrospectivos , Parto Vaginal Después de Cesárea/efectos adversos , Parto Vaginal Después de Cesárea/estadística & datos numéricos , Adulto , Cesárea Repetida/efectos adversos , Cesárea Repetida/estadística & datos numéricos , Alemania/epidemiología , Resultado del Embarazo/epidemiología , Cesárea/estadística & datos numéricos , Cesárea/efectos adversos , Factores de RiesgoRESUMEN
OBJECTIVE: Although the association of rheumatoid arthritis (RA) to multiple adverse pregnancy outcomes has been well-studied, the association between serum antibody levels in patients with RA and multiple adverse pregnancy outcomes has not been conclusively demonstrated. Here, we comprehensively assessed the causal impact of RA, serologic antibody-positive RA (pRA), and serologic antibody-negative RA (nRA) on the risk of 14 adverse pregnancy outcomes. METHODS: The causal impact of RA, pRA, and nRA on 14 adverse pregnancy outcomes was comprehensively assessed using two-sample Mendelian randomization (MR). Evidence maps based on the results of these two-sample MR analyses were developed. Data from the UK Biobank and FinnGen databases were utilized for this analysis. The inverse variance weighted (IVW) test was employed as the primary method to estimate causality. "TwoSampleMR" and "MR-PRESSO" packages were used for data analysis in this study. RESULTS: Using two-sample MR analysis, we found a significant positive causal association between RA and increased risk of cesarean section (p = 0.003), gestational hypertension (p < 0.001), number of spontaneous miscarriages (p = 0.041), preeclampsia (p = 0.008), premature rupture of membranes (p = 0.030), and preterm (p = 0.010). pRA had a significant positive causal association with an increased risk of cesarean section (p = 0.012), gestational hypertension (p < 0.001), preeclampsia (p = 0.002), and preterm (p = 0.007). A significant positive causal association was also established between nRA and gestational hypertension (p = 0.010), the number of spontaneous miscarriages (p = 0.024), and placental abruption (p = 0.027). In addition, we found a causal association between nRA and birth weight (p = 0.007), but not between RA and pRA and birth weight. CONCLUSION: The results of this study have important implications for the individualized treatment of RA patients, especially those with positive serum antibody levels.