The urological care and outcome of pregnancy after urinary tract reconstruction

OBJECTIVE: To assess the obstetric and urological outcomes during and after pregnancy following urinary tract reconstruction, as pregnancies after such surgery can have a significant effect on the function of the reconstructed urinary tract, and the reconstruction can significantly affect the delivery of the fetus. PATIENTS AND METHODS: We retrospectively reviewed the obstetric and urological history of 11 patients (12 pregnancies; 10 singletons and one twin) with previous urinary reconstruction, delivered between 1989 and 2003. Antepartum and postpartum urological function and obstetric outcomes were investigated. RESULTS: All the patients had some difficulty with clean intermittent catheterization (CIC) during pregnancy, and four needed continuous indwelling catheters. During pregnancy 10 women had several bladder infections and all received antibiotic suppression. There were eight Caesarean sections, two vaginal deliveries and one combined delivery. Six Caesareans were elective and three were emergent. The use of CIC returned to normal in all patients after delivery. CONCLUSIONS: Women with a urinary reconstruction can have successful pregnancies. The complexity of the surgery and the concern for possible emergency Caesarean section resulted in most patients having an elective Caesarean delivery before term. Antibiotic prophylaxis is recommended and patients may require indwelling dwelling catheters while pregnant but normal CIC can be resumed after delivery.     

Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section

Background. During spinal anaesthesia for Caesarean section,the optimal phenylephrine regimen and the optimal blood pressure(BP) to which it should be titrated are undetermined. The idealregimen would balance efficacy for maintaining uteroplacentalperfusion pressure against potential for uteroplacental vasoconstriction,both of which may affect fetal acid–base status. We comparedphenylephrine infusion regimens based on three different BPthresholds. Methods. After intrathecal injection, we infused phenylephrine100 µg min^–1 for 2 min. Then, until delivery,we infused phenylephrine whenever systolic BP (SBP), measuredevery 1 min, was below a randomly assigned percentage of baseline:100% (Group 100, n=25), 90% (Group 90, n=25) or 80% (Group 80,n=24). We compared umbilical blood gases, Apgar scores and maternalhaemodynamics and symptoms. Results. Patients in Group 100 had fewer episodes [median 0(range 0–8)] of hypotension (SBP <80% baseline) comparedwith Group 80 [5 (0–18)] and Group 90 [2 (0–7)](P<0.001 in each instance). Total dose of phenylephrine wasgreater in Group 100 [median 1520 µg (interquartile range1250–2130 µg)] compared with Group 90 [1070 (890–1360)µg] and Group 80 [790 (590–950) µg]. Umbilicalarterial pH was greater in Group 100 [mean 7.32 (95% confidenceinterval 7.31–7.34)] than in Group 80 [7.30 (7.28–7.31)](P=0.034). No patient had umbilical arterial pH <7.2. InGroup 100, 1/24 (4%) patients had nausea or vomiting comparedwith 4/25 (16%) in Group 90 and 10/25 (40%) in Group 80 (P=0.006). Conclusions. For optimal management, phenylephrine should betitrated to maintain maternal BP at near-baseline values. Br J Anaesth 2004; 92: 469–74     

Maternal complications after Caesarean section in HIV-infected pregnant women

A study of maternal complications after elective Caesarean section in HIV-infected women was carried out from January 1999 to April 2001. The control group consisted of all the seronegative pregnant women who underwent the elective Caesarean section during the study period. The study group was divided into two subgroups. Subgroup 1 patients were given 600 mg zidovudine (ZDV) orally and 300 mg lamivudine (3TC) daily from 34 to 38 weeks' gestation. Subgroup 2 patients were given 600 mg ZDV orally daily from 34 to 38 weeks' gestation and 150 mg nevirapine orally on the morning of the Caesarean section day. In both groups, the elective Caesarean section was carried out at 38 weeks' gestation and ZDV syrup (2 mg/kg) was given orally to the newborn immediately in the operating theatre and then every 6 h for 4 weeks. No statistically significant differences in maternal complications were found between the HIV-infected and non HIV-infected women.     

Should obstetricians support a 'term cephalic trial'?

Recent analyses of the published data suggest that the risks of elective Caesarean delivery in an uncomplicated pregnancy may not outweigh the benefits of vaginal birth by as much as has been supposed. Indeed, this balance may be so close that the place of elective Caesarean delivery of a term cephalic baby might be considered as a worthwhile subject of a randomised controlled trial. We discuss the potential consequences of such a trial and what effect it could have on obstetric practice.     

麻黄素在预防剖宫产手术患者仰卧综合征中应用的临床观察

剖宫产手术患者因巨大子宫压迫腹主动脉，再加上麻醉药物致使交感神经抑制，部分血管扩张的作用使得患者回心血量急剧下降，因此仰卧综合征的发生率较高，为防止仰卧综合征的发生，常规采取左侧卧床30°左右，但仍然存在时有仰卧综合征的发生，除常规方法预防外，另采取当患者平卧时即刻给予麻黄素5-10mg静脉推注，起到了很好的临床效果，未见仰卧综合征的发生。     

Parietal peritoneal closure versus non-closure at caesarean section: which technique is feasible to perform?

Abstract

Objective: To evaluate short-term effects of closure versus non-closure of the parietal peritoneum at caesarean section.

Methods: A randomized controlled study of women undergoing caesarean section was conducted at the obstetrics department of a research and education hospital between October 2010 and May 2011. Patients were randomly assigned to have closure of parietal peritoneal layer (Group I, n?=?55), and non-closure of parietal peritoneal layer (Control, Group II, n?=?55). Intra-operative and post-operative outcomes were compared between the groups.

Results: Groups were similar for baseline characteristics. Although there was statistically significant difference between Group 1 and Group 2 in terms of time to oral intake and mobilization time [12 (8–12) versus 8 (8–10)?h; p?<?0.001; 12 (8–12) versus 8 (8–10)?h; p?<?0.001]; the other variables, such as drop in hemoglobin concentration, estimate of blood loss, intra-operative additional sutures, operating time and time to passage of flatus [1.13?±?0.86 versus 1.41?±?0.82?g/dL; 487.9?±?217.01 versus 544.87?±?237.64?mL; 0 (0–1) versus 0 (0–1); 30.8?±?7.63 versus 31.6?±?10.38?h; 18.2?±?6.04 versus 18.2?±?4.23?h, p?>?0.05] were not statistically different between Group 1 and Group 2.

Conclusions: Closure of the parietal peritoneum has no benefit over non-closure of parietal peritoneum and non-closure is associated with rapid post-operative recovery.     

等剂量耐乐品和布比卡因腰麻用于剖宫产的效能比较

目的比较相同剂量的耐乐品和布比卡因蛛网膜下腔阻滞用于剖宫产的效能，以探讨剖宫产的最佳局麻药。方法将120例ASAⅠ-Ⅱ级择期行剖宫产患者，随机分成二组，用0．75％耐乐品和布比卡因各1．8ml，分别用脑脊液0．7ml配成等比重溶液，用25C蛛网膜下腔阻滞穿刺针，于13～4间隙穿刺，在15S内缓慢将2．5ml药液注入蛛网膜下腔，比较两组感觉、运动阻滞的起效和恢复时间的异同点。结果在感觉阻滞起效时间上，耐乐品〉布比卡因；在恢复时间和最大阻滞时间上耐乐品〉布比卡因；在最高麻醉平面上布比卡因〉耐乐品；在运动阻滞起效时间上，耐乐品〉布比卡因；在最大运动阻滞时间和恢复时间上布比卡因〉耐乐品；在镇痛效果及肌松上布比卡因〉耐乐品；在低血压、呼吸困难等不良反应上，布比卡因〉耐乐品。结论耐乐品具有布比卡因的优点，而且能克服布比卡因的缺点，是蛛网膜下腔阻滞行剖宫产更为理想的局麻药。     

Effects of Delivery by Caesarean Section on Lung Function in Healthy Newborn Infants

ABSTRACT. With the aim of extending previous studies showing differences in lung function after birth between infants delivered vaginally (VD) and by Caesarean section (CS) we investigated lung volumes, ventilation, efficiency of ventilation, and lung mechanics in 24 healthy, full term infants with no clinical signs of respiratory disease, 12 after VD and 12 after CS. Measurements were made on two occasions: 2 and 26 hours after birth. At 2 hours no differences in any measured quantity were found between the groups. The only difference found 24 hours later was that the average thoracic gas volume (TGV), was lower in infants after CS than after VD. The difference in functional residual capacity was, however, not significant. This means that the difference in TGV, previously also found by other workers, did not affect the ventilated air space. Our results do not support the theory of general inferiority in lung performance after birth in healthy, full term infants without respiratory disease delivered by CS.     

Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital

BackgroundAt our institution, the emergency obstetric ‘code green’ activates the system for immediate birth, usually by caesarean section. This study aimed to determine the incidence of immediate birth, indications, modes of anaesthesia, and short-term neonatal and maternal outcomes.MethodA review was performed for all women at the Royal Women’s Hospital, Parkville, Australia who underwent immediate birth over a two-year period: January 1, 2013 to December 31, 2014.ResultsWithin the study period 14,115 women gave birth, of which 387 women underwent an immediate birth, the majority (83%) by caesarean section. The commonest indication for immediate birth was prolonged fetal bradycardia (53%), however cord prolapse (4%) produced the most rapid decision-to-delivery interval, with a median [IQR] time of 14 [13–16] min versus 18 [14–23] min for all immediate births (P < 0.01). Epidural top-up was the most common anaesthesia method. Conversion to general anaesthesia following inadequate neuraxial anaesthesia occurred in 6.2% of women. Among 103 general anaesthetics, there was one failed intubation (successful ventilation) and one dental injury. Nine women (2.3%) were admitted to the high dependency or intensive care units, and there were no maternal deaths. Babies born by caesarean section with a decision-to-delivery interval of less than 30 min were more likely to have longer times to establish respiration (22.6% vs 16.7%, P < 0.001).ConclusionRequest for immediate delivery is a common obstetric emergency. Epidural top-up has become the most common anaesthetic technique. Rapid delivery times can be achieved with an integrated emergency response system.