Cesarean delivery is both a major surgical procedure and a momentous and miraculous event in the life of a family. Historically, the rituals and processes common to major surgical procedures have dominated the cesarean birth process. For vaginal delivery, many obstetrical units have developed mother, baby and family-centered birth processes that emphasize immediate skin-to-skin (STS) contact and the early initiation of breastfeeding. The gentle, or “family centered” cesarean delivery is an approach to operative delivery that reduces the emphasis on surgical rituals and processes and increases the clinical focus on the mother, the baby and the family. Is it possible to transform a surgical procedure such as a cesarean delivery into a mother, baby and family-centered experience? For many cesarean delivery procedures the answer is a resounding “Yes”. Refocusing the clinical processes that surround the cesarean delivery requires the commitment and cooperation of many disciplines. Obstetricians, anesthesiologists, pediatricians, and maternity nurses are the leaders who must work together to facilitate this important practice change.
Initial treatment is crucial for saving the lives of patients with primary postpartum hemorrhage (PPH). Interventional radiology (IR) has become a major focus as a potential treatment for primary PPH because of its prompt hemostasis, low invasiveness, and the possibility of preserving fertility. Establishing and disseminating a management algorithm that allows for smooth communication between medical staff involved in the treatment is essential for prompt IR. IR for primary PPH consists of transcatheter arterial embolization (TAE) and balloon occlusion. Emergency introduction of infrarenal intraaortic balloon occlusion (IABO) can be useful for achieving temporary hemostasis in patients in critical condition. TAE has a high chance of successful hemostasis in cases of atonic bleeding. IR can also be introduced for other bleeding etiologies, but the order of priority — with respect to surgery and IR — has to be evaluated appropriately according to bleeding etiology, hemodynamic stability, human resources, and accessibility to operating and angiographic rooms. Patient transportation must also be considered for intensive and invasive treatment if conservative treatment is not successful.
Aim: We examined women complicated by stroke or eclampsia occurring in our institute during labor at term, with particular attention to changes in their blood pressure.
Methods: We identified all pregnant women who were hospitalized for labor and delivery between April 1, 2002, and November 30, 2015.
Results: During this period, there were 14 cases of eclampsia and 3 cases of stroke associated with hypertensive disorders of pregnancy. In 16 (94%) of these cases, systolic blood pressure was normal (<140 mmHg) at 3–7 days before admission for delivery at term. In 6 of these cases (35%), systolic blood pressure was normal (<140 mmHg) at admission. Severe hypertension (systolic blood pressure ≥160 mmHg) was observed immediately after the onset of eclampsia or stroke in all cases.
Conclusions: Regular measurement of blood pressure in all women during labor is important.
Aim: Rebound hypertension after termination of nicardipine intravenous (IV) infusion in cesarean section (C/S) patients with hypertensive disorders of pregnancy was investigated.
Methods: Twenty-nine patients with gestational hypertension (GH) and 37 with preeclampsia (PE) after C/S were enrolled. After termination of nicardipine IV infusion, 12 GH and 24 PE patients were treated with oral nifedipine or labetalol, while 17 GH and 13 PE patients received no antihypertensive agents. The average systolic blood pressure (SBP) was calculated for 0–24 h after IV termination, and the incidence of a rebound SBP increase (≥160 mmHg) within 8 h after IV termination was investigated.
Results: A transient rebound increase in SBP was observed in 25% of GH and 21% of PE patients with oral administration of antihypertensive agents and in 35% of GH and 15% of PE patients without oral administration of antihypertensive agents. A daily average SBP of ≥160 mmHg was observed in 17% of GH and 4% of PE patients with oral administration of antihypertensive agents and 12% of GH and 0% of PE patients without oral administration of antihypertensive agents.
Conclusions: In managing the characteristic rebound BP increase after nicardipine IV infusion, the daily average SBP could be maintained at <160 mmHg in most patients with GH and PE despite transient hypertension.
Aim: To assess the risks of developing gestational hypertension (GH) and preeclampsia (PE) during pregnancy based on clinical information.
Methods: Using the Perinatal Database of the Japan Society for Obstetrics and Gynecology between 2001 and 2010, we calculated logit scores of GH and PE by multivariate analysis to estimate their individual risk ratios.
Results: The logit score of PE was calculated with the equation −6.45797+0.0308815×(maternal age)−0.673456×(parity: 0 or 1)+0.13388×(fetal gender: boy 0 or girl 1)+1.95706×(pre-existing hypertension: 0 or 1)+1.16486×(pre-existing renal disease: 0 or 1)+0.0891015×(pre-pregnancy body mass index [BMI]). The estimated risk ratios predicted subsequent GH and PE with sensitivities of 61.5% and 67.0%, and specificities of 67.0% and 64.4%, respectively. The areas under the receiver operating characteristic curves for GH and PE were 0.70 and 0.68, respectively.
Conclusions: The estimated risk ratios determined in this study may identify women at high risk of GH or PE before disease onset.
Aim: To evaluate whether there are any women with postpartum hemorrhage (PPH) showing a hemoglobin (Hb) concentration of <7.0 g/dl in cases with estimated blood loss of <1,500 ml or a shock index (SI) of >1.5 in cases with estimated blood loss of <2,500 ml.
Methods: We reviewed the records of 36 women transferred due to PPH in our tertiary center in 2002-2005. We collected the patients’ information including the estimated blood loss, Hb concentration, and SI on arrival.
Results: In the group of 500–1,499 ml, 13% (2/16) showed Hb concentrations of <7.0 g/dl. In the group of 1,500–2,499 ml, one woman with uterine inversion whose estimated blood loss was 1,600 ml showed SI of 1.9 with a Hb concentration of 6.3 g/dl. SI in women with uterine inversion was significantly higher than in those with atonic bleeding, retention of placenta/accreta, and vaginal/cervical lacerations, respectively. SI in all women with uterine inversion was >1.0, although in three quarters of the cases, the blood loss was reported as <2,500 ml.
Conclusions: Our chart review clearly demonstrates that there are some PPH cases showing mismatch between the reported estimated blood loss and the Hb concentration and/or SI. Especially, SI may be clinically useful for judging transfusion in women with uterine inversion. We should identify the factors in such mismatching cases, and reveal the pitfalls of the current guideline for critical obstetrical hemorrhage mainly based on SI.
Aim: To compare the safety and efficacy of Utemerin, an original ritodrine hydrochloride drug formulation, with those of generic Ritodrine.
Methods: We examined patients who developed side effects, targeting 400 cases in which either Ritodrine or Utemerin was administered intravenously between 2006 and 2011.
Results: The number of cases with side effects was significantly greater in the Ritodrine group than in the Utemerin group (96 cases [48%] vs. 55 cases [27.5%], respectively; P<0.001). The most common side effect with both drugs was rash, which was significantly more frequent in the Ritodrine group than in the Utemerin group (40 cases [20%] vs. 25 cases [12.5%], respectively; P=0.04). The number of cases with mid-treatment changes owing to side effects did not significantly differ between groups (Ritodrine: 32 cases [16%] vs. Utemerine: 24 cases [12%]; P=0.31).
Conclusions: Side effects were more frequent with Ritodrine than with Utemerin. It has not been long since the introduction of generic drugs in Japan, and post-use studies conducted shortly after their introduction are insufficient. However, the use of generic drugs that are detrimental to patients are contraindicated, and thus post-use studies are needed to confirm generic drug safety and efficacy.
Background: The Japan Society of Obstetrics and Gynecology (JSOG) guidelines, revised in 2013, recommend that the numbers of traction should be at most five repetitions in vacuum extraction. Forceps extraction is less likely to fail compared with vacuum extraction and requires less equipment and preparation. At our institution, forceps delivery was not a standard procedure, but in response to revisions of the JSOG guidelines, we launched an education program on forceps delivery for residents in January 2013. We report the results of introduced delivery at our institution.
Methods: An education program for residents covering forceps delivery was introduced at our institution in January 2013. We conducted a retrospective review of medical records of 108 patients who had deliveries by either forceps or vacuum extraction from January 2013 through July 2015 in our institution. We compared maternal and neonatal outcomes between forceps and vacuum deliveries for all cases as well as those delivered by trainees.
Results: The rates of forceps and vacuum deliveries performed by trainees were 60.9% and 50.0%, respectively. Two or more tractions were required in 18/62 (29.0%) of vacuum deliveries vs. 3/46 (6.5%) of forceps deliveries. There was significantly more bleeding in forceps deliveries compared with vacuum deliveries (616.3±322.3 g vs. 465.2±274.9 g). There was one failed vaginal delivery in each group. The rate of cephalohematoma was significantly higher in vacuum deliveries (12/62, 19.4%) vs. forceps deliveries (1/46, 2.17%). Facial abrasion caused by the equipment was significantly more frequent in forceps deliveries (6/46, 13.0%) vs. vacuum deliveries (1/62, 1.6%). Similar results were found between all cases and cases delivered by trainees.
Conclusion: Forceps delivery was introduced as a clinical practice that is as safe as vacuum delivery. It is conceivable that training and indication for forceps delivery were of importance.
Very little is known about atypical HELLP syndrome in relation to uteroplacental insufficiency. A 41-year-old primigravida with fetal growth restriction due to uteroplacental insufficiency suddenly experienced severe right upper quadrant pain at 28 weeks gestation without preeclampsia. Although laboratory abnormalities were not evident, the symptoms persisted for 2 hours. Elective cesarean section was performed because atypical HELLP syndrome was highly suspected. On postpartum day 1, a marked elevation of liver enzymes, low platelet count, and anemia without hypertension and proteinuria were noted, but these parameters spontaneously improved within a week. Our experience highlights instances where atypical HELLP syndrome might occur in uteroplacental insufficiency cases.
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