Case Report: Anaesthetic Management of Placenta Percreta

Background: The placenta is a complicated organ and is partially understood. It is the essential part for physiological changes leading to a successful pregnancy. Placenta percreta is the most severe and least common form of placenta accreta in which villi penetrate the entire myometrial thickness and reach or traverse the serosa to encroach adjacent organs. Patients with placenta percreta are at a greater risk of life-threatening perioperative bleeding as well as massive and deadly thromboembolic events. Case report: Our patient was a 34-year-old gravida 5female who underwent elective cesarean section at 37 weeks of gestation with a diagnosis of placenta accreta or percreta. Intraoperative findings showed placenta percreta with bladder wall involvement. Hence, hysterectomy was done. Anticipated intraoperative haemorrhage and hemodynamic instability were managed properly. Discussion: Placenta percreta is the most serious among abnormal placentation, sometimes leading to catastrophic blood loss and very high maternal mortality and morbidity up to 10%. The most important risk factor in placenta percreta is placenta previa (low lying placenta) after cesarean delivery. Our patient met all these risk factors. Prenatal diagnosis of an invasive placenta is paramount for reducing maternal morbidity and mortality by implementing a multidisciplinary approach. Keywords: haemorrhage, placenta percreta, hysterectomy, high-risk pregnancy.

Comparison of the Prophylactic Effect of Propofol, Dexamethasone and Ondansetron on Post-Operative Nausea and Vomiting in Elective Cesarean Section Under Spinal Anesthesia

Nausea, and vomiting are common complications in women undergoing cesarean section with spinal anesthesia. This study aimed to compare the propofol, dexamethasone, and ondansetron effects on nausea and vomiting. In this double-blind, randomized clinical trial study, 120 women aged 15 to 35 years candidates for cesarean section under spinal anesthesia were enrolled. Patients were randomly divided into four groups (three-drug groups and control group). Patients received 0.05 mg/kg ondansetron (group O), 0.1 mg/kg dexamethasone (group D), 0.2 mg/kg propofol (group P) and normal saline in controls (group C). Nausea and vomiting in recovery and 6 hours after surgery compared between groups. In recovery and 6 hours after surgery, both nausea and vomiting were the highest in group C while they were lowest in group O. the frequency of nausea was 11(36.7%) in both recovery and 6 hours after surgery, and the frequency of vomiting was 12(40%) and 10(33.3%) in the recovery and 6 hours after surgery respectively. Among three drug groups, nausea and vomiting were higher in group D in both the recovery room and 6 hours after surgery. The frequency of vomiting was 10 (33.3%) and 5 (16.7%) in recovery and 6 hours after surgery in group D, respectively. These differences were statistically significant between the four groups (P<0.05). The preventive effect of dexamethasone is not very useful in both periods. Therefore, it can be recommended that in the short period after surgery, propofol has a beneficial effect in preventing postoperative nausea and vomiting.

The effect of transcutaneous electrical nerve stimulation (TENS) on pain control and phenylethanolamine-N-methyltransferase (PNMT) gene expression after cesarean section

Transcutaneous electrical nerve stimulation (TENS) is one of the non-pharmacological methods of pain relief that has been able to reduce pain by 70 to 90% in postoperative pain control. This study aimed to determine the effect of TENS on pain control after cesarean section and its effect on PNMT gene expression. For this purpose, a double-blind randomized clinical trial was performed on 70 Chinese patients with elective cesarean section. Patients were divided into case and control groups. In the case group, TENS and analgesic drugs were used to relieve pain, and in the control group, the only analgesic drug was used. Then the severity of pain, recurrence of pain attacks, the number of analgesic drugs used and the amount of analgesic drug used in the first 24 hours after surgery were evaluated and compared. Blood samples were also taken from patients to evaluate PNMT gene expression. The semi-quantitative RT-PCR was used to study changes in gene expression. The results showed that the group treated with TENS had less pain intensity and less recurrence of pain attacks than the group that received only analgesic medication. Also, the frequency of analgesic drug use and its dose in the TENS group were significantly lower than in the control group. TENS, on the other hand, has been able to greatly reduce the expression of the PNMT gene, which is produced during times of stress. Therefore, it is recommended that TENS be used as a non-invasive and non-pharmacological adjuvant effective in reducing pain after cesarean section.

Parity and gestational age are associated with vaginal microbiota composition in term and late term pregnancies

Vaginal microbiota and its potential contribution to preterm birth has been under intense research in recent years. However, only few studies have studied vaginal microbiota in later stages of pregnancy or at the onset of labor. We analyzed vaginal swab samples collected between 37- and 42-weeks of gestation from 324 Finnish women before elective cesarean section, at the onset of spontaneous labor, and in pregnancies continuing beyond 41 weeks of gestation. Vaginal microbiota composition associated strongly with parity, i.e. previous deliveries, and advancing gestational age. Absence of previous deliveries was a strong predictor of L. crispatus dominated vaginal microbiota, and the relative abundance of L. crispatus was higher in late term pregnancies, especially among nulliparous women. The results underscore the importance of the vaginal microbiota for improving the currently limited understanding on how the duration of gestation and timing of birth is regulated, with potentially vast clinical utilities.

Effect of Intraveous Tranexamic Acid and Sublingual Misoprostol on Reducing Post Cesarean Section Bleeding

Background and Aim: Cesarean section rates are rising around the globe and are considered as the major surgical procedure conducted on females. Cesarean-related hemorrhage contributes to increasing mortality rates around the world. Due to the rise in cesarean rate and its associated complications, post-cesarean severe bleeding without proper management is a major concern. Therefore, the present study aimed to assess the intravenous tranexamic acid (TA) and sublingual misoprostol effect on reducing post-cesarean section bleeding. Materials and Methods: This cross-sectional study was conducted on 146 term pregnant women undergoing emergency or elective cesarean section at the Department of Obstetrics and Gynaecology, Qazi Hussain Ahmad Medical Complex, Noshehra during the period from 7th September 2020 to 6th March 2021. All the participants were randomly categorized into two groups. Each group comprised of 73 participants whereas groups I and II received sublingual misoprostol (600 µg) and 500 mg intravenous tranexamic at card clamping respectively. Both groups were administrated for postoperative 48 hours and blood loss was measured. The packed cell volume and postoperative Hb were evaluated and compared with initial values before surgery. The need for blood transfusion, drug side effects, and additional uterotonics was evaluated. SPSS version 20 was used for data analysis. Results: The mean age of groups I and II were 28.32±4.73 and 28.17±4.83 years whereas the overall mean age was 28.25±4.78years. A higher reduction of hemoglobin level was observed in an intravenous tranexamic group compared to the sublingual group (-2.39±0.93 versus -2.09±1.28g/dL) (p=0.001). Moreover, the intravenous tranexamic group had significantly higher blood suction and gauze usage than sublingual misoprostol (256.73± 83.25versus 189.68± 102.4 cubic centimeter (cc) and 4.59±1.43 versus 3.19±1.27) for a significant value of 0.001. The decrease in mean blood pressure during the cesarean section procedure was significant in intravenous tranexamic than sublingual misoprostol (p=0.001). Conclusion: Our study concluded that sublingual misoprostol significantly reduced total bleeding when compared to tranexamic acid. Furthermore, hemodynamic variables were stabilized more in the misoprostol group than in the tranexamic acid group. Keywords: Cesarean Section Bleeding; Intravenous Tranexamic acid; Sublingual misoprostol.

EARLY VERSUS DELAYED ORAL INTAKE IN PATIENTS AFTER CESAREAN SECTION UNDER REGIONAL ANESTHESIA

Objective: To compare the outcome in early versus delayed oral intake in patients after cesarean section under regional anesthesia. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Obstetrics and Gynecology, Combined Military Hospital Lahore, from Dec 2017 to May 2018. Methodology: A total of 352 women undergoing elective cesarean section under regional anesthesia, nil by mouth for at least 8 hours before surgery were divided in 2 groups. In group 1, patients were given sips of clear oral fluid (water) <5 hours after cesarean section and in group 2, patients received sips of water 8 hours following surgery. Bowel motility was assessed after surgery on hourly basis. Data about time interval to first bowel movement and ileus were noted. Results: Mean age of patients was 32.329 ± 3.44 years and 33.051 ± 3.64 years in group 1 and 2 respectively. Mean gestational age and body mass index was 38.50 ± 0.93 weeks and 29.824 ± 4.97 kg/m2 in group-1 versus 37.937 ± 0.98 weeks and 27.779 ± 2.81 kg/m2 in group 2. Mean duration of surgery was 47.096 ± 6.65 minutes in group-1 and 47.647 ± 8.76 minutes in group 2. Ileus was seen in 17% patients in group-1 and 34.1% in group-2 (p<0.001). Mean time interval for first bowel movement was 8.323 ± 1.20 hours in group-1 and 13.034 ± 2.54 hours in group 2 (p<0.001). Conclusion: Early feeding after an uncomplicated cesarean section has reduced rate of ileus symptoms and mean time interval for bowel......

Sexual Function after Childbirth: A Meta-analysis base on Mode of Delivery

Background: Although many women report sexual dysfunction in the postpartum period, controversial research has been reported the relationship between delivery mode and sexual function. Objectives: This meta-analysis aimed to investigate the sexual function after childbirth and identify the difference of sexual function in women with elective cesarean section and spontaneous vaginal delivery. Search Strategy: Studies were found by searching in Medline, PubMed, Web of Science, Scopus, Google Scholar databases and considering the references of the related papers. Selection Criteria: All observational studies in English that reported the mean and SD of score of sexual function and its domains based on the mode of delivery were included in this meta-analysis. Data Collection and Analysis: Finally, 17 articles with a total population of 3410 were included in the meta-analysis. Random effect model was used to combine the results of included studies on female sexual function and its subdomains. Main Result: The subgroup analysis showed that there were no significant differences in the mean score of sexual function and subdomain among the three delivery groups(P>0.05). However, the mean score of sexual function was significantly differed in the term of time elapsed since delivery (P = 0.04) and studied country (P < 0.001). Conclusions: The result indicated that the mode of delivery are not associated with the female sexual function. As a result, women’s preference for cesarean section to avoid possible impairment of sexual function has gone almost under-questioned.

Effect of dexamethasone on daily fetal movement, umbilical and middle cerebral arteries Doppler and cardiotocogram

Background: Preterm birth is a leading cause of perinatal death and disability and is an important public health problem globally. There is more work to be done regarding steroids effect, especially with the variations among demography and pathological conditions affecting mothers. The aim of this study was to investigate the effect of dexamethasone on healthy fetuses, observing the effects on MCA and UA Doppler velocity waveforms and cardiotocography, correlating them with fetal movement.Methods: This prospective cross-sectional study was conducted in Ain Shams University Maternity Hospital, starting from April 2020 till December 2020. One hundred and ten women was recruited for the study. All women undergo elective cesarean section before 39 weeks of gestation. UA and MCA Doppler values were taken; nonstress test was recorded and fetal movements were counted after a single course of dexamethasone.Results: Our results included decrease in MCA PI, decrease in foetal movement count on the second day of dexamethasone injection, increase of short-term variability and direct correlation between the MCA RI and UA PI with the fetal movements decrease on the 5th day of dexamethasone injection.Conclusions: There are definitely cardiovascular changes that occur after dexamethasone administration, presented by increase in MCA blood flow and increase in FHR short term variability.

Successful pregnancy and term delivery after treatment of unicornuate uterus with non-communicating rudimentary horn pregnancy with local methotrexate injection followed by laparoscopic resection: a case report and literature review

Background Pregnancy in a rudimentary horn is an extremely rare type of ectopic pregnancy. A rudimentary uterine horn pregnancy is associated with a risk of spontaneous rupture and bleeding during surgery due to the increased uterine blood flow. Recent advances in imaging modalities have enabled laparoscopic surgery to be performed in cases without rupture in the early stages of pregnancy. However, there are few reports of successful pregnancies and deliveries after treatment of rudimentary horn pregnancies. We report the successful management of a case of non-communicating rudimentary horn pregnancy by local injection of methotrexate followed by complete laparoscopic excision along with a review of the literature. Case presentation The patient was a 29-year-old Japanese woman, gravida 2, nullipara. She was diagnosed with a left unicornuate uterus with a right non-communicating rudimentary horn on hysterosalpingography and magnetic resonance imaging. A gestational sac with a heartbeat was observed in the right rudimentary uterine horn at 6 weeks of gestation. A diagnosis of ectopic pregnancy in a non-communicating rudimentary horn was made. Color Doppler detected multiple blood flow signals around the gestational sac, which were clearly increased compared to the left unicornuate uterus. Her serum human chorionic gonadotropin level was 104,619 mIU/ml. A 100 mg methotrexate injection into the gestational sac was administered, and laparoscopic surgery was performed on day 48 after the methotrexate treatment. The right rudimentary horn and fallopian tube were successfully excised with minimal bleeding. A spontaneous normal pregnancy was established 6 months after the surgery. The pregnancy was uneventful, and a baby girl was born by elective cesarean section at 38w0d. Conclusion Combined local methotrexate injection and laparoscopic surgery are safe treatment options for patients with a unicornuate uterus with a non-communicating rudimentary horn pregnancy.

Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation

Background Interstitial Pregnancy (IP) is a lethal condition due to high risk of sudden onset massive hemorrhage. Such conditions are managed as soon as diagnosed almost in the first trimester. There are a few case reports of IP conditions terminated after the second trimester. Herein, we introduce a term interstitial pregnancy complicated by abnormal placentation. Case presentation In this case report, we introduce a 32-year-old lady, primigravida, with an undiagnosed IP that was in her 38 weeks of gestational with placenta increta. She developed with perforated IP presenting with acute abdomen and internal bleeding at 26 weeks of gestational age. However, with a misdiagnosis impression, she got stable in operation room. Then, the pregnancy continued till 36 weeks of gestational age that was misdiagnosed with cervical cancer in prenatal work-ups. Finally, during elective cesarean section at 38 weeks, an IP with placenta increta (placenta evading from the serosa to the myometrium of the uterus) was observed. The baby was healthy with no obvious anomaly or morbidity. Conclusions Physicians should be aware to detect IP in all trimesters and pay attention to the coexisting complications such as placenta accreta to manage them more accurately.