Single versus double-balloon catheters for the induction of labor of singleton pregnancies: a meta-analysis of randomized and quasi-randomized controlled trials

Objective

To compare the efficacy of single- versus double-balloon catheter (SBC vs. DBC) for cervical ripening and labor induction with an unfavorable cervix.

Methods

Systematic review and meta-analysis of randomized controlled trials (RCTs) or quasi-RCTs (qRCT) regarding the use of SBC or DBC for labor induction of live singleton cephalic pregnancies (≥ 35 weeks) of any parity with an unripe cervix (Bishop score ≤ 6). Nine research databases were searched for original articles published in all languages up to November 2017 comparing both devices for labor induction. Five RCTs and one qRCT were included. Primary outcome measures were time from intervention (device placement) to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction with the procedure. Risk of bias was evaluated with the Cochrane tool. Random effects models were used to combine data for meta-analyses. Summary measures were reported as mean differences and risk ratios (RR) with 95% confidence intervals.

Results

Regardless of parity, pooled analyses of the six trials (n = 1060 women) found that mean intervention to birth time, vaginal delivery and cesarean section rates, and maternal satisfaction to the procedure were similar for both studied groups (SBC vs. DBC).

Conclusion

Measured primary outcome measures were similar regardless of the type of device used for labor induction of singleton pregnancies.

     

Intrauterine Inflated Foley’s Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case–Control Study

Objective

To describe the use of intrauterine inflated Foley’s catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus.

Methods

Retrospective case–control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley’s catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38).

Results

Use of intrauterine inflated Foley’s catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit.

Conclusion

Application of an intrauterine inflated Foley’s catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

     

Use of Condom Tamponade to Manage Massive Obstetric Hemorrhage at a Tertiary Center in Rajasthan

Introduction

Conventionally postpartum hemorrhage (PPH) has been defined as blood loss of more than 500 ml following vaginal delivery and 1000 ml following a cesarean section [Pritchard et al. in Am J Obstet Gynecol 84(10):1271–1282, (1962)]. Another definition labels PPH as any blood loss which causes a 10 % drop in hematocrit [Combs et al. in Obstet Gynecol 77:69–76, (1991)] or which threatens the hemodynamic stability of the patient and necessitates blood transfusion [Prendiville et al. in Cochrane Database Syst Rev 2:CD000007, (2000)]. The purpose of this study was to evaluate the effectiveness of condom tamponade in the management of massive obstetric hemorrhage.

Objective

To evaluate the efficacy of a condom as a tamponade for intrauterine pressure to stop massive PPH.

Methods

This prospective study was done in the Obstetrics and Gynecology Department of NIMS Medical College and Hospital, Jaipur, between December 2013 and February 2015. With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250–500 ml normal saline according to need. Vaginal bleeding was observed, and further inflation was stopped when bleeding ceased.

Results

In all but 2 (94.44 %) the cases, postpartum bleeding was stopped within 10 min of creation of tamponade. On an average, 350 ml of normal saline was required to create adequate tamponade to stop the bleeding.

Conclusion

Use of condom tamponade can effectively help in reducing both maternal morbidity and mortality associated with PPH. Our study encourages use of condom tamponade which is efficient, cost-effective, easily available and requires lesser skills as compared to the traditional surgical procedures.

     

Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems

Background

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective

To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods

Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results

A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion

Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

     

Myomectomy using purse-string suture during cesarean section

Background

Conventionally, myomectomy during cesarean section is reserved only for pedunculated myomas because resection of myomas at the time of cesarean section usually stimulates profuse bleeding.

Cases

Thirty-one patients underwent myomectomy using purse-string suture during cesarean section. Myoma could be excised without profuse bleeding, while an assistant maintains strong tension on the purse-string suture around the myoma. The suture was tightened and tied immediately after complete resection of the myoma and then stitches of another purse-string suture were placed alternately with each previous stitch in the inner side of the first suture. We have used this method for more than 3 years and have not observed failures and serious complications, such as late hemorrhage and uterine rupture during a subsequent pregnancy.

Conclusion

Myomectomy using purse-string suture during cesarean section is a safe, useful, and convenient technique.

     

Does antenatal steroids treatment prior to elective cesarean section at 34–37 weeks of gestation reduce neonatal morbidity? Evidence from a case control study

Objective

To determine whether antenatal corticosteroids administration prior to an elective cesarean section (ECS) at 34–37 weeks gestation is associated with improved neonatal outcome.

Materials and methods

A case control study of women with singleton pregnancies who underwent ECS between 34 and 37 weeks of gestation including two groups: (1) study group in which patients were treated with betamethasone prior to ECS (n = 58) and (2) control group matched for gestational age at delivery in which patients did not receive betamethasone (n = 107). Neonatal measures including respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), oxygen requirement, admission to the special care unit, hypoglycemia, hyperbilirubinemia and length of hospitalization were determined in both groups. Composite respiratory morbidity was defined as the presence of either RDS, TTN, mechanical ventilation or oxygen requirement.

Results

There was no significant difference in the rate of composite respiratory morbidity nor its components between patients with and without betamethasone treatment (25.9 vs. 25.2%, respectively, p = 0.9).

Conclusion

Antenatal treatment with corticosteroids prior to ECS at 34–37 weeks of gestation did not result in significant reduction in neonatal respiratory morbidity in our cohort of patients.

     

Management of cesarean scar pregnancy with suction curettage: a report of four cases and review of the literature

Purpose

To present the outcomes of four cases of cesarean scar pregnancy treated with suction curettage.

Methods

Four patients were ultrasonographically diagnosed with cesarean scar pregnancies treated with suction curettage in a tertiary care center.

Results

Serum β-human chorionic gonadotropin levels ranged between 1,681 and 15,573 mU/mL, gestational sac diameter measured from 10 to 24 mm and scar thickness was between 4.7 and 6.8 mm. All patients underwent suction curettage under general anesthesia with transabdominal ultrasonography guidance. No complications were observed during or after operation.

Conclusion

Suction curettage is a viable alternative for conservative treatment in selected cases of patients who are diagnosed with CSP early in gestation and who have a myometrial thickness of more than 4.5 mm.

     

Labor Pattern Among Primigravida in Local Population

Objectives

In this study, we tried to make the customized labor curve by studying the labor pattern among the primigravidas and we compared the cervicograph with Zhang’s and Suzuki’s curves. This study may be a motivator for future research to create own labor norms for our Indian population which may help in reducing the cesarean section rates, principally in primigravidas.

Materials and Methods

It was a prospective observational study, which included 156 primigravidas with uncomplicated term singleton pregnancy with spontaneous onset and progression of labor, who had normal vaginal delivery with good maternal and neonatal outcome.

Results

The shape of the labor curve of this study was similar to Zhang’ and Suzuki–Horiuchi’s curves which had slower progression. The active phase started from 5 to 6 cm of cervical dilatation onwards which was similar to Suzuki–Horiuchi’s curve. In the present study, the mean rate of cervical dilatation in the active phase was 1.5 cm/hour in contrast to Friedman’s study which had a mean rate of cervical dilatation of 3 cm/hour with lower limit of 1.2 cm/hour as 5th centile.

Conclusion

In the present study the mean rate of cervical dilatation in active phase in Indian women was approximately equivalent to the lowest acceptable rate of cervical dilatation in Friedman’s study. If we continued to follow Friedman’s labor norms, it could result in increasing c-sections. Hence, it would be prudent to create a customized labor curve for the local population served based on their individual characteristics features.

     

Single-Step First Trimester Screening “Sooner the Better”

Purpose

To evaluate the role of single-step universal screening in first trimester and its effectiveness.

Materials and methods

Three thousand women attending antenatal clinic of Pt JNM Medical College, Raipur, were screened with 75 gm OGTT in their first trimester irrespective of their last meal, and those who were screened negative were again subjected to OGTT at 24–28 weeks. The women were followed throughout pregnancy till delivery. Any maternal or perinatal complications were noted.

Result

Overall incidence of GDM was 5.2 %. About 61.54 % women screened positive in first trimester. At 24–28 weeks, 38.46 % women were diagnosed with GDM. Women diagnosed in first trimester showed significantly low incidence of cesarean section rate (20.83 %), PIH (2.08 %), and macrosomia (14.44 %), in comparison to women diagnosed later in pregnancy.

Conclusion

The role of first trimester screening was found effective in reducing adverse maternal and perinatal outcomes in GDM.

     

Prediction of vaginal birth after one ceasarean delivery for non-progressive labor

Purpose

A model exists that predicts the probability of vaginal birth after cesarean (VBAC). That model is not stratified by indication at first cesarean. The aim of the study was to identify factors that may predict successful VBAC in patients operated for arrest of dilatation or descent at their first cesarean.

Methods

Retrospective analysis of all women with trials of labor after one cesarean (TOLAC) for non-progressive labor between November 2008 and October 2015 was performed (n = 231). A multivariate logistic regression analysis was carried out to generate a prediction model for VBAC at hospital admission for planned TOLAC.

Results

During the study period, we had 231 parturient women who chose to undergo TOLAC following one previous cesarean delivery for non-progressive labor. Successful VBAC occurred in 155 (67.0%) parturient women. A model consisting of previous successful VBAC, lower head station on decision at previous cesarean delivery, lower newborn weight at previous cesarean delivery and larger cervical effacement on admission at delivery planned for TOLAC correctly classified 75.3% of cases (R ² = 0.324, AUC 0.80, 95% CI 0.70–0.89, p < 0.001).

Conclusion

A predictive model, which incorporates four variables available at hospital admission for the planned TOLAC, has been developed that allows the determination of likelihood of successful VBAC following one cesarean delivery for non-progressive labor.

     

Examining Cesarean Delivery Rates Using the Robson’s Ten-group Classification

Background

To examine Cesarean delivery rates based on the Robson’s Ten-group classification system (TGCS), over a 10-year period.

Methods

All Vaginal Deliveries and cesarean sections (CSs) performed over a 10-year period from 2004 to 2013 were included in the analysis. The data were compiled according to Robson’s TGCS of cesarean section for every year. Risk Ratios (crude RRs) with 95 % confidence intervals for delivery by cesarean section were calculated for each Robson’s group.

Results

The TGCS was easily applied in this large dataset of 40,086 deliveries. The 10-year overall cesarean section rate (CSR) was 25.17 %. Groups 1 and 3 represented 60 % of the total obstetric population. The largest contributions to the total CSR are group 1 (37.62 %) and group 5 (17.06 %). Group 3 which was the second largest group contributed 15 % to the overall CSR. Group 2 and group 4 had high group CSRs of 47.28 and 34.74 % respectively, although the total group size was small (n = 1375;3.43 %). Maternal age and presentation were found to have an independent association with mode of delivery on logistic regression.

Conclusion

The Ten-group classification helped to identify the main groups of subjects who contribute most to the overall CSR. It also helped to identify subgroups requiring closer monitoring for more in-depth analyses of the indications for caesarean section. It is important to focus on the first four TGCS groups which constitute about 75 % of all deliveries. It is in the low-risk groups that one is likely to find the highest and most inappropriate indications for cesarean sections.

     

Effect of routine rapid insertion of Bakri balloon tamponade on reducing hemorrhage from placenta previa during and after cesarean section

Purpose

To evaluate the effectiveness of routine rapid insertion of a Bakri balloon during cesarean section for placenta previa based on a retrospective control study.

Methods

Women with singleton pregnancies who underwent cesarean section for placenta previa at our institution between 2003 and 2016 were enrolled. Between 2015 and 2016, women who routinely underwent balloon tamponade during cesarean section were defined as the balloon group. Between 2003 and 2014, women who underwent no hemostatic procedures except balloon tamponade were defined as the non-balloon group. The clinical outcomes of the two groups were retrospectively analyzed.

Results

Of the 266 women with placenta previa, 50 were in the balloon group and 216 were in the non-balloon group. The bleeding amounts were significantly smaller in the balloon group than in the non-balloon group: intraoperative bleeding (991 vs. 1250 g, p < 0.01), postoperative bleeding (62 vs. 150 g, p < 0.01), and total bleeding (1066 vs. 1451 g, p < 0.01). Furthermore, the mean surgical duration was shorter in the balloon group than the non-balloon group (30 vs. 50 min, p < 0.01). In the balloon group, five patients suffered from increasing hemorrhage due to prolapse of the balloon from the uterus after the operation, but the hemorrhage was controlled by balloon re-insertion without additional hemostatic procedures.

Conclusions

This study demonstrated that the routine rapid insertion of Bakri balloon tamponade during cesarean section significantly decreased intra- and postoperative hemorrhage and shortened the surgical duration in women with placenta previa.

     

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome

Objectives

The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients.

Methods

This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014.

Results

The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26–28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000–2000 mL.

Conclusion

Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.

     

Risk factors for post-partum hemorrhage following vacuum assisted vaginal delivery

Objective

To identify risk factors for post-partum hemorrhage (PPH) following vacuum assisted vaginal delivery (VAVD).

Study design

A retrospective study of all women with singleton pregnancies who underwent VAVD in a tertiary hospital (2012–2014). PPH was defined as any of the following: ≥500 ml estimated blood loss, hemoglobin drop ≥3 g/dl (difference between pre- and post-VAVD hemoglobin levels) or the need for blood products transfusion. Characteristics of women with PPH following VAVD were compared to those of women with no PPH following VAVD.

Results

Of 1,154 VAVDs, 295 (25.6 %) had PPH. Women in the PPH group were more often nulliparous (83.1 vs. 70.5 %, p = 0.001) and had higher rate of hypertensive disorders (4.4 vs. 1.4 %, p = 0.001). The rate of episiotomy (87.8 vs. 81.6 %, p = 0.01) was higher in the PPH group. In multivariate analysis, risk factors for PPH were (Odds Ratio, 95 % Confidence Interval) hypertensive disorders (2.40, 1.03–5.58, p = 0.04), induction of labor (1.42, 1.01–2.10, p = 0.04) and longer second (1.003, 1.001–1.006, p = 0.03) and 3rd (1.02, 1.01–1.04, p = 0.004) stages of labor.

Conclusion

Risk factors for PPH following VAVD can be identified and should be taken into consideration at the immediate post-partum period.

     

Mifepristone combined with ethacridine lactate for the second-trimester pregnancy termination in women with placenta previa and/or prior cesarean deliveries

Purpose

This study was aimed to evaluate the safety and efficacy of the second-trimester medical abortions using mifepristone and ethacridine lactate in women with placenta previa and/or prior cesarean deliveries.

Methods

The patients who underwent a second-trimester pregnancy termination from January 2009 to December 2015 were retrospectively analyzed. The eligible patients were assigned to four groups based on placentation and cesarean history. The abortion interval (AI), blood loss, hospital stays, incidence of curettage, and transfusion were reviewed.

Results

Two women underwent cesarean sections for placenta increta. Finally, 443 patients were enrolled in this study, including 92 with placenta previa, 153 with prior cesarean deliveries, 36 with the both factors, and 236 with normal placentation and no cesarean delivery history. All the included cases had a successful vaginal delivery. There was no significant difference in AI, hospital stay, rate of hemorrhage, and transfusion among the four groups. Patients with prior cesarean section had higher blood loss than the normal group (P = 0.0017), as well as patients with both placenta previa and prior cesarean (P = 0.0018). However, there was no obvious blood loss in patients with placenta previa when compared with normal placetal patients (P = 0.23). No uterine rupture occurred in all patients.

Conclusions

Mifepristone combined with ethacridine lactate is safe and effective for patients with low placentation or/and prior cesarean in the second-trimester pregnancy termination.

     

Effect of intra-operative glove changing during cesarean section on post-operative complications: a randomized controlled trial

Purpose

To compare the rates of wound-related complications among women undergoing a cesarean section when the surgical team used intra-operative glove changing versus usual care.

Methods

All women undergoing a cesarean section at a single, county hospital were randomized to usual care or intra-operative glove changing prior to abdominal closure. Participants were randomized at the time of decision for cesarean section; surgeons were not blinded to the randomization arm. The primary outcome was any wound-related complication, including wound hematoma, seroma, skin separation of at least 1 cm, wound infection, or other incisional abnormality requiring treatment within 8 weeks of surgery. To detect a reduction in the primary outcome from 17% in the control group to 9% in the intervention group with 80% power, a total of 554 women (277 per group) were required. Secondary outcomes included other infectious complications including endometritis and other superficial or deep soft tissue infections.

Results

From August 2015 to November 2016, 277 women were randomized to usual care and 276 women were randomized to intra-operative glove changing. The two groups were well balanced in terms of demographic data, comorbid conditions and surgical characteristics. Intra-operative glove changing led to a significant decrease in composite wound complications from 13.6% in the control group to 6.4% in the intervention group (p?=?0.008).

Conclusion

Intra-operative glove changing prior to abdominal closure during cesarean section significantly reduced the incidence of post-operative wound complications.

     

A PET-positive rapidly growing mass of the abdominal wall after cesarean section with an unexpected diagnosis of vernix caseosa granuloma: a case report

Background

Abdominal wall tumors are rare and include heterogeneous diseases. Among them, desmoid tumors are the most frequent and are often diagnosed in young women during or early after pregnancy; inflammatory response after trauma or microtrauma, such as after cesarean section, may favor their growth.

Results

A 37-year-old woman presented with a progressive mass in the abdominal wall after a cesarean section. Positron emission tomography imaging confirmed a positive mass with a high maximum standardized uptake value; a biopsy suggested a myofibroblastic tumor. With continued tumor growth and worsening symptoms, the mass resembled a desmoid tumor; therefore, we proceed with its resection. The final diagnosis was foreign body granuloma as a reaction to the spillage of meconium and keratinous material in the amniotic fluid during cesarean section.

Conclusions

The present case provides information on an abdominal wall foreign body granuloma arisen from meconium and vernix caseosa after cesarean section, which presented an atypical clinical picture, mimicking a desmoid, thus requiring a careful diagnostic and treatment approach.

     

Intravenous carbetocin versus intravenous oxytocin for preventing atonic postpartum hemorrhage after normal vaginal delivery in high-risk singleton pregnancies: a triple-blind randomized controlled trial

Purpose

To compare the effectiveness of intravenous carbetocin to that of intravenous oxytocin for prevention of atonic postpartum hemorrhage (PPH) after vaginal delivery in high-risk singleton pregnancies.

Methods

This triple-blind randomized controlled trial included singleton pregnant women who delivered at Siriraj Hospital between August 2016 and January 2017 and who were 20 years or older, had a gestational age of at least 34 weeks, had a vaginal delivery, and had at least one risk factor for atonic postpartum hemorrhage. Immediately after vaginal delivery, participants were randomly assigned to receive either 5 U of oxytocin or 100 mcg of carbetocin intravenously. Postpartum blood loss was measured objectively in mL using a postpartum drape with a calibrated bag.

Results

A total of 174 and 176 participants constituted the oxytocin and carbetocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had less postpartum blood loss (146.7?±?90.4 vs. 195.1?±?146.2 mL; p?<?0.01), a lower incidence of atonic PPH (0 vs. 6.3%; p?<?0.01), less usage of additional uterotonic drugs (9.1 vs. 27.6%; p?<?0.01), and a lower incidence of postpartum anemia (Hb?≤?10 g/dL) (9.1 vs. 18.4%; p?<?0.05) than the oxytocin group. No significant differences regarding side effects were evident between the groups.

Conclusions

Intravenous carbetocin is more effective than intravenous oxytocin for the prevention of atonic PPH among singleton pregnancies with at least one risk factor for PPH.

Clinical trial registration

TCTR20160715004.

     

Comparison of Outcome of Normal and High-Risk Pregnancies Based Upon Cerebroplacental Ratio Assessed by Doppler Studies

Objectives

To evaluate the cerebroplacental ratio which is the ratio of pulsatility index of fetal middle cerebral and umbilical arteries, in normal and high-risk pregnancies during 30–36 weeks of gestation.

Methods

In this study, we included 70 patients, who were scanned for Doppler parameters of Middle cerebral artery and Umbilical artery pulsatility index ratio of fetus, between 30 and 36 weeks, and then were followed till delivery. Thirty-five patients with normal pregnancy and 35 patients with high-risk pregnancy were included. Perinatal outcome was evaluated in relation to indices ratio.

Results

There was cerebroplacental ratio of <1.00 in eight cases of the study group in comparison with the control group in which there is no case of <1.00 value. It was associated with poor perinatal outcome in terms of need for lower segment cesarean section for fetal distress, Apgar <8 at 5 min, and admission to nursery.

Conclusion

Cerebroplacental ratio is highly sensitive in diagnosing hemodynamically compromised fetuses and very useful for the prediction of adverse perinatal outcome in these fetuses.