Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience

Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome.

Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally.

Results: During the study period, 44?263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n?=?23) were compared with those delivered twin B vaginally (n?=?198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p?<?0.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p?<?0.001), and dichorionic–diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p?=?0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p?=?0.003).

Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.     

Experimental repair of tracheal defects using a new biodegradable membrane

BACKGROUND: The increasing number of newborns requiring intubation and artificial ventilation in the sophisticated premature and intensive care units of recent years has been followed by a concomitant increase in the number of children who develop tracheal stenosis as a sequela of prolonged intubation, with a consequent increasing need for tracheal surgical repair. This study was designed to evaluate the ability of a new tissue-engineered biodegradable membrane to tightly seal significant tracheal defects. MATERIALS AND METHODS: A surgically induced tracheal defect of 10 x 5 mm was repaired in rabbits using the NVR-7 membrane--a cross-linked copolymer derived from a dextran sulphate gelatin construct. The unique features of this new membrane are biocompatibility, biodegradability, elasticity, and suturability, as well as a smooth sterilization process. The animals were sacrificed and the tracheas examined at 2, 3, 4, and 8 weeks postsurgery. RESULTS: Seven (7) of 8 rabbits undergoing tracheal surgery survived, with a tight air seal and an almost normal airway. Macroscopic and microscopic studies of the removed specimens showed variable degrees of immunogenic reaction toward the membrane. In the long term (2-3 months), a complete regeneration of all the tracheal layers occurred, simulating the original structure and orderly arrangement of a normal trachea. CONCLUSIONS: The surgical correction using the above membrane enabled the operated animals to overcome any respiratory distress, adequately correcting the induced tracheal defect. From this experimental study, we conclude that the new NVR-7 membrane appears to be a promising therapeutic adjunct in the treatment of patients with tracheal defects.     

Ultrashort intracorporeally maneuverable cryoprobes for laparoscopic renal cryoablation in the porcine model

AIM: To determine the feasibility and efficacy of laparoscopic renal cryosurgery using a novel ultrathin ultrashort intracorporeal cryoprobe in a porcine model. MATERIAL AND METHODS: Novel cryoprobes 4 cm in length and 1.5 mm in diameter were manipulated intracorporeally after insertion via a designated 15 mm laparoscopic port. Renal cryoablative lesions were induced laparoscopically in four 40 kg female piglets. We correlated between intraoperative temperature, ice ball geometry, intraoperative ultrasonographic properties, and histology. RESULTS: Laparoscopic manipulation of the cryoprobes was straightforward. No port site bleeding occurred during insertion, freezing, thawing or upon removal of the probes. The 0 degrees C, -20 degrees C, and -40 degrees C isotherms were measured at 6, 8, and 12 mm from the probe circumferentially. Ice-ball volume stabilization as determined by ultrasound occurred after 10 min of activation. Lower temperatures were reached after 10 min of probe activation as compared with 5 min (ice ball diameter 30 mm, DeltaT = 13-21 degrees C). Using a second 10-min-long freeze cycle resulted in a 14-22 degrees C lower temperature within the ice ball compared to a single cycle. Full coagulative necrosis was noted in the areas between the inserted probes with an additional 1-2 mm circumferential rim of severe tubular damage and apoptosis. CONCLUSIONS: Our novel cryoprobe can be used effectively and conveniently in laparoscopic renal cryosurgery. Considering the size of the cryogenic lesion, using a cluster of probes may be advisable.     

The analgesic effect of botulinum-toxin A on postwhiplash neck pain

BACKGROUND: The effectiveness of botulinum neurotoxin type A (BTXA) injections in relieving the neck pain and reduced motion that evolve after whiplash injury (WI) has been controversial. AIM OF STUDY: To test the long-term efficacy of a tender point injection of BTXA in relieving neck pain in patients with WI. METHODS: Twenty patients with cervical myofascial pain, 2 to 48 weeks after WI, were randomly assigned to receive either 200 U of BTXA or placebo at 4 tender points and were seen during the follow-ups 3, 6, 9, 12, and 24 weeks after the injections. Outcome measures included the intensity of pain as evaluated by a 10-cm Visual Analog Scale (VAS) and a 5-point Verbal Rating Scale (VRS), quality of life as evaluated by the SF-36 questionnaire, treatment efficacy as per the global assessment of the physician and patient, intensity of pain in response to mechanical pressure, range of cervical motion, and use of other therapies and their adverse effects. RESULTS: A time-dependent improvement in all the parameters was found in both groups, which was consistently larger in the BTXA-treated group, but mostly not at a significant level. Significant differences between the groups were found only in the percentages of patients who achieved 50% or more of reduction in intensity (VAS and average VRS) at 24 weeks (50% vs. 0%, P>0.05 and 70% vs. 11%, P>0.05, respectively). Systemic adverse effects tended to be more common in the BTXA-treated group (40% vs. 0%, P=0.07). CONCLUSIONS: Study results suggest that BTXA treatment has some efficacy when administered within 1 year of the WI. However, a large, well-designed clinical trial is needed to draw final conclusions.     

Isolated polyhydramnios in the third trimester: is a gestational diabetes evaluation of value?*

We evaluated implications of testing for gestational diabetes mellitus (GDM) in pregnancies complicated by third trimester isolated polyhydramnios with previous negative diabetes screening test. In this retrospective cohort study of 104 pregnant women with polyhydramnios between 2005 and 2013, all had normal first trimester fasting glucose and normal glucose challenge test (GCT?p?=?0.38) or fasting glucose values (82 vs. 86?mg/dL, p?=?0.29) between women in the polyhydramnios group with and without late GDM diagnosis. Moreover, no significant difference was found in relation to the mode of delivery or birth weight between the studied groups (3437?±?611 vs. 3331?±?515?g, p?=?0.63). Diagnosis of third trimester polyhydramnios was not associated with increased risk for GDM or neonatal complications.     

Continuous glucose monitoring for the evaluation of gravid women with type 1 diabetes mellitus

OBJECTIVE: To compare the daily glycemic profile reflected by continuous and intermittent blood glucose monitoring in pregnant women with type 1 diabetes and to compare the treatment protocols based on the two monitoring methods. METHODS: The study sample consisted of 34 gravid patients at gestational weeks 16-32, with type 1 diabetes being treated by multiple insulin injections. Data derived from the continuous glucose monitoring system for 72 hours were compared with finger stick glucose measurements performed 6-8 times per day. During the study period, patients documented the time of food intake, insulin injections, and hypoglycemic events. Data on demographics, gravidity, parity, body mass index, hemoglobin A1c, and fructosamine levels were collected for each patient. RESULTS: An average (+/- standard deviation) of 780 +/- 54 glucose measurements was recorded for each patient with continuous glucose monitoring. The mean total time of hyperglycemia (glucose level greater than 140 mg/dL) undetected by the finger stick method was 192 +/- 28 minutes per day. Nocturnal hypoglycemic events (glucose level less than 50 mg/dL) were recorded in 26 patients; in all cases, there was an interval of 1-4 hours before clinical manifestations appeared or the event was revealed by random blood glucose examination. Based on the additional information obtained by continuous monitoring, the insulin therapeutic regimen was adjusted in 24 patients (70%). CONCLUSION: Continuous glucose monitoring can diagnose high postprandial blood glucose levels and nocturnal hypoglycemic events that are unrecognized by intermittent blood glucose monitoring and may serve as a basis for determining treatment regimens. A large, prospective study on maternal and neonatal outcome is needed to evaluate the clinical implications of this new monitoring technique.     

Use of new technologies for monitoring and treating diabetes in pregnancy

During the last century, there were two breakthroughs in diabetes management and monitoring that changed the course of treatment: the discovery of insulin and the progress in the understanding of glucose monitoring. As technology evolved, glucose monitoring and insulin administration can now be achieved in a continuous fashion. In this review, the authors focus on the utility of new technologies in the management and monitoring of diabetes in pregnancy.