Hemodynamic, ventilatory and gas exchange responses to exercise using a cycle ergometer and the incremental shuttle walk test in pregnant women.

BACKGROUND: Cardiovascular disease, including hypertension, in pregnant women is a leading cause of morbidity and mortality globally. The development of reference intervals for cardiovascular responses using exercising testing to measure oxygen utilisation (V̇O2) with cardiopulmonary exercise testing (CPET), and distances walked using the incremental shuttle walk test (ISWT), may be promising methods to assess and stratify pregnant women regarding their risk of adverse pregnancy outcomes, to encourage exercise during pregnancy, and to improve exercise prescriptions during pregnancy. We aimed to determine the reference intervals for V̇O2 at rest, anaerobic threshold (AT), and submaximal exercise using CPET, and the reference interval for the ISWT, to develop a correlation equitation that predicts submaximal V̇O2 from the distance walked in the ISWT, and to explore the relationship between hemoglobin (Hb) and ferritin concentration and V̇O2 at AT in women in second trimester. METHODS: After prospective IRB approval (HREC 15/23) and clinical trials registration (ANZCTR ACTRN12615000964516), and informed written consent, we conducted CPET and the ISWT according to international guidelines in a university associated tertiary referral obstetric and adult medicine hospital, in healthy pregnant women in second trimester (14 to 27 gestational weeks). Hemoglobin and ferritin concentrations were recorded from pathology results in the participants' medical records at the time of exercise testing. Adverse events were recorded. RESULTS: About 90 participants undertook CPET, 28 of which also completed the ISWT. The mean ± SD age and body mass index (BMI) were 32 ± 3.2 years, and 25 ± 2.7 kg/m2. Median (IQR) gestation was 23 (22-24) weeks. One in 4 women were 24 weeks or greater gestation. The reference intervals for V̇O2 at rest, AT, and submaximal exercise were 2.9 to 5.3, 8.1 to 20.7, and 14.1 to 30.5 mL/kg/min respectively. The reference interval for the ISWT was 218 to 1058 meters. The correlation equation to predict submaximal V̇O2 from the distance walked in the ISWT was submaximal V̇O2 (mL/kg/min) = 0.012*distance walked in ISWT (m) + 14.7 (95%CI slope 0.005-0.070, Pearson r = 0.5426 95%CI 0.2126-0.7615, P = .0029). Hemoglobin concentration was positively correlated with V̇O2 at AT (AT V̇O2 (mL/kg/min) = 0.08*Hb (g/L) + 4.9 (95%CI slope 0.0791-0.143, Pearson r = 0.2538 95%CI 0.049-0.438, P = .016). There was no linear association between ferritin and submaximal V̇O2 (Pearson r = 0.431 P = .697). There were no maternal or fetal complications. CONCLUSIONS: CPET and ISWT are safe and feasible in women in second trimester including those at or beyond 24 weeks gestation. We have established the reference interval for V̇O2 at rest, AT, and submaximal exercise by CPET, the reference interval for the distance walked for the ISWT, and a correlation equation to predict submaximal V̇O2 for use in clinical practice and research. Hemoglobin rather than ferritin is likely correlated with exercise capacity in pregnancy suggesting vigilance to correct lower hemoglobin levels may positively impact maternal health. CLINICAL TRIALS REGISTRY: The study was prospectively registered with the Australian and New Zealand Clinical Date of registration - 15/9/2015; Date of initial participant enrolment - 4/11/2015; Clinical trial identification number; ACTRN12615000964516; URL of the registration site - https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369216.

Pregnancy reference intervals and exertion and breathlessness ratings for the six minute walk test in healthy nulliparous people.

Background: The Six Minute Walk Test (6MWT) is a simple, non-invasive, well-validated test that assesses cardiorespiratory fitness however is rarely used in pregnant people. It may have clinical utilization to assess fitness, breathing and exertion in pregnancy however no reference intervals exist for people 14+0 to 35+6 weeks gestation. We determined the reference intervals for distance walked for the 6MWT, including exertional and breathlessness ratings for this group. Method: We conducted a prospective observational cohort study of 196 healthy nulliparous pregnant people in earlier pregnancy (EP) 14+0 to 23+6 weeks, and middle pregnancy (MP) 24+0 to 35+6 gestation, who performed a standardized 6MWT protocol including rating exertion and breathlessness (Rating Perceived Exertion (RPE) scale (1 none -15 maximal) and Modified Borg Dyspnea (MBD) scale (0 none - 10 maximal)). Results: The mean ± SD distance walked was 548 ± 80.9 (EP) versus 547 ± 87.3 (MP) meters (m) P = 0.928. 6MWT reference intervals for the distance walked for the 6MWT were 392-704 m (EP) and 376-718 m (MP). Median (IQR) exertion and breathlessness ratings with exercise for the EP and MP group were 6 (4,7) and 0.5 (0,1) and 6 (4,8) and 0.5 (0,1) respectively. There were no adverse events. Conclusion: The 6MWT is safe, feasible and acceptable in pregnant people. The reference intervals for the 6MWT are 392-704 m in people 14+0 to 23+6 weeks gestation and 376-718 m for people 24+0 to 35+6 weeks gestation. Exertion was light and breathlessness was just noticeable with the 6MWT.

Perioperative Exercise Testing in Pregnant and Non-Pregnant Women of Reproductive Age: A Systematic Review.

BACKGROUND: Women have classically been excluded from the development of normal data and reference ranges, with pregnant women experiencing further neglect. The incidence of Caesarean section in pregnant women, and of general operative management in young women (both pregnant and non-pregnant), necessitates the formal development of healthy baseline data in these cohorts to optimise their perioperative management. This systematic review assesses the representation of young women in existing reference ranges for several functional exercise tests in common use to facilitate functional assessment in this cohort. METHODS: Existing reference range data for the exercise tests the Six Minute Walk Test (6MWT), the Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary Exercise Testing (CPET) in young women of reproductive age were assessed using the MEDLINE (Ovid) database, last searched December 2023. Results were comparatively tabulated but not statistically analysed given underlying variances in data. RESULTS: The role of exercise testing in the perioperative period as an assessment tool, as well as its safety during pregnancy, was evaluated using 65 studies which met inclusion criteria. CONCLUSION: There is a significant lack of baseline data regarding these tests in this population, especially amongst the pregnant cohort, which limits the application of exercise testing clinically.

Perioperative Complications in Patients with Preeclampsia Undergoing Caesarean Section Surgery.

Caesarean section has risks of bleeding, infection and thromboembolism, and neuroendocrine-metabolic, and inflammatory-immune responses that may worsen outcomes in patients with preeclampsia. There is little research examining perioperative, as opposed to peripartum, outcomes in patients with preeclampsia. We conducted a single-centrecentre retrospective cohort study of perioperative patients with preeclampsia over an eight-month period to determine the rate of perioperative complication. Seventy-two patients were included. The maternal complication rate was 59.7 per 100 operations (95% CI 48.2 to 70.3%). Severe complications included pulmonary oedema 2 (2.8%), haemorrhage > 1000 mL 5 (6.9%), and blood transfusion 2 (2.8%). Twenty (27.8%) patients had a hospital length of stay ≥7 days. The rate of anaemia (haemoglobin < 110 g/L) on hospital discharge was 42 per 100 operations (95% CI 31.0 to 53.2%). Patient representation rate to hospital after discharge was 23.6% per 100 operations (95% CI 15.3 to 34.6%). There were no maternal deaths. The neonatal complication rate was 38.9 per 100 operations (95% CI 28.9 to 51.1%) with one foetal death. Patients with preeclampsia undergoing caesarean section are a very high-risk surgical group who experience significant perioperative complications. Urgent action is needed to confirm these findings and improve outcomes in these patients.

Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022.

Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications.

The prevalence of perioperative iron deficiency anaemia in women undergoing caesarean section-a retrospective cohort study.

BACKGROUND: Caesarean section is a common surgery, with almost 23 million procedures performed globally each year. Postpartum haemorrhage, in association with caesarean section surgery, is a leading global cause of maternal morbidity and mortality. Perioperative iron deficiency anaemia is a risk factor for intraoperative bleeding. Therefore, anaemia is an important and modifiable risk factor for bleeding during caesarean section surgery. Recent recommendations advise that all preoperative patients with anaemia (defined as haemoglobin concentration (Hb) < 130 g/L), regardless of sex, be assessed and treated to normalise haemoglobin levels. It is unclear how this recommendation translates to pregnant women where the World Health Organization (WHO) defines anaemia at a much lower threshold (Hb < 110 g/L). We aimed to determine the prevalence, and characterization, of Hb levels < 130 g/L perioperatively in women undergoing caesarean section. METHOD: We conducted a retrospective cohort study of 489 consecutive women who underwent caesarean section over a 12-week period, in a single-centre tertiary referral maternity unit in Australia. We calculated the proportion of women who were anaemic (Hb < 130 g/L) at four time points-first hospital appointment, third trimester, preoperatively and on discharge from hospital. The proportion of women who were iron deficient (ferritin level < 30 µg/L) at their first hospital appointment was determined. RESULTS: Haemoglobin was measured in 479 women. Ferritin was measured in 437 of these women. The mean (SD) Hb at the first hospital appointment, third trimester, preoperatively, and postoperatively on discharge was 126.7 (11.4) g/L, 114.6 (10.6) g/L, 124.1 (12.4) g/L, and 108.0 (13.6) g/L respectively. Iron deficiency was present in 148 (33.9%) women at their first hospital appointment; 107 of 248 (43.1%) women with anaemia and 41 of 189 (21.7%) with no anaemia. 29 women were found to have moderate anaemia (Hb 80-109 g/L) with 18 of these 29 (62.1%) women having iron deficiency. Only 68 (45.9%) women with iron deficiency at their first hospital appointment received treatment. The prevalence of anaemia classified as Hb < 130 g/L versus the WHO classification of Hb < 110 g/L from all causes was 57.4% versus 6.1% at first hospital appointment, 94% versus 26.1% in third trimester, and 66.0% versus 12.2% preoperatively. Postoperatively at least 40% of women had Hb < 130 g/L on hospital discharge versus at least 23% of women using WHO definition of Hb < 110 g/L. Of the 112 women with hospital discharge Hb < 110 g/L, 35 (31.3%) women were iron deficient at their first hospital appointment. CONCLUSION: Over one in three women were iron deficient at their first hospital appointment. 62% of women with moderate anaemia (Hb 80-109 g/L) also had iron deficiency. At least four in 10 women were anaemic (Hb < 130 g/L) on hospital discharge. Less than half of the women with anaemia were treated. Our data suggests that 30% of postoperative anaemia may be prevented with intensive treatment of iron deficiency in early pregnancy. Large prospective studies, are needed to determine outcomes after caesarean section in women, stratified by preoperative Hb and ferritin levels. The prevalence of anaemia in our data suggests it is a moderate public health problem.

The use of transthoracic echocardiography in caesarean section surgical patients in the intensive care unit: A retrospective cohort study.

Data regarding transthoracic echocardiography (TTE) application to obstetric patients are scant. Often, anaesthetists preparing for caesarean section are unaware of the proportion of obstetric patients who have relevant cardiac disease. This audit aimed at undertaking a retrospective analysis of TTE performed in intensive care unit patients after caesarean section. Over five years, 56 women were eligible. Echocardiographic abnormalities were deemed relevant if graded as of moderate severity. The most common reason was dyspnoea (41%). Echocardiography demonstrated structural abnormality in 29% or functional abnormality in 38%. It may be appropriate to undertake preoperative echocardiography more commonly in high-risk obstetric patients.

Surgical anatomy of microsurgical 3-level anterior cervical discectomy and fusion C4-C7.

Anterior cervical discectomy and fusion (ACDF) is one of the most common spinal procedures, frequently used for the treatment of cervical spine degenerative diseases. It was first described in 1958. Interestingly, to our knowledge, 3-level ACDF has not been previously published as a peer-reviewed video case with a detailed description of intraoperative microsurgical anatomy. In this video, we present the case of a 33-year-old male who presented with a combination of myelopathy (hyperreflexia and long tract signs in the upper and lower extremities) and bilateral radiculopathy of the upper extremities. He had been previously treated conservatively with physical therapy and pain management for 6 months without success. We performed 3-level microsurgical ACDF from C4 to C7. All 3 levels were decompressed, and bone allografts were placed to achieve intervertebral body fusion. A titanium plate was utilized from C4 to C7 for internal fixation. The patient was discharged home on the first postoperative day. His pain, numbness and tingling resolved, as well as his myelopathy. No perioperative complications were encountered. Herein we present the surgical anatomy of our operative technique including certain technical tips. Written consent was obtained directly from the patient.

Combined spinal-epidural versus spinal anaesthesia for caesarean section.

BACKGROUND: Single-shot spinal anaesthesia (SSS) and combined spinal-epidural (CSE) anaesthesia are both commonly used for caesarean section anaesthesia. Spinals offer technical simplicity and rapid onset of nerve blockade which can be associated with hypotension. CSE anaesthesia allows for more gradual onset and also prolongation of the anaesthesia through use of a catheter. OBJECTIVES: To compare the effectiveness and adverse effects of CSE anaesthesia to single-shot spinal anaesthesia for caesarean section. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies (search date: 8 August 2019). SELECTION CRITERIA: We considered all published randomised controlled trials (RCTs) involving a comparison of CSE anaesthesia with single-shot spinal anaesthesia for caesarean section. We further subgrouped spinal anaesthesia as either high-dose (10 or more mg bupivacaine), or low-dose (less than 10 mg bupivacaine). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We identified 18 trials including 1272 women, but almost all comparisons for individual outcomes involved relatively small numbers of women. Two trials did not report on this review's outcomes and therefore contribute no data towards this review. Trials were conducted in national or university hospitals in Australia (1), Croatia (1), India (1), Italy (1), Singapore (3), South Korea (4), Spain (1), Sweden (1), Turkey (2), UK (1), USA (2). The trials were at a moderate risk of bias overall.CSE versus high-dose spinal anaesthesiaThere may be little or no difference between the CSE and high-dose spinal groups for the number of women requiring a repeat regional block or general anaesthetic as a result of failure to establish adequate initial blockade (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.05 to 1.97; 7 studies, 341 women; low-quality evidence). We are uncertain whether having CSE or spinal makes any difference in the number of women requiring supplemental intra-operative analgesia at any time after CSE or spinal anaesthetic insertion (average RR 1.25, 95% CI 0.19 to 8.43; 7 studies, 390 women; very low-quality evidence), or the number of women requiring intra-operative conversion to general anaesthesia (RR 1.00, 95% CI 0.07 to 14.95; 7 studies, 388 women; very low-quality evidence). We are also uncertain about the results for the number of women who were satisfied with anaesthesia, regardless of whether they received CSE or high-dose spinal (RR 0.93 95% CI 0.73 to 1.19; 2 studies, 72 women; very low-quality evidence). More women in the CSE group (13/21) experienced intra-operative nausea or vomiting requiring treatment than in the high-dose spinal group (6/21). There were 11 cases of post-dural puncture headache (5/56 with CSE versus 6/57 with SSS; 3 trials, 113 women) with no clear difference between groups. There was also no clear difference in intra-operative hypotension requiring treatment (46/86 with CSE versus 41/76 with SSS; 4 trials, 162 women). There were no babies with Apgar score less than seven at five minutes (4 trials, 182 babies).CSE versus low-dose spinal anaesthesiaThere may be little or no difference between the CSE and low-dose spinal groups for the number of women requiring a repeat regional block or general anaesthetic as a result of failure to establish adequate initial blockade (RR 4.81, 95% CI 0.24 to 97.90; 3 studies, 224 women; low-quality evidence). Similarly, there is probably little difference in the number of women requiring supplemental intra-operative analgesia at any time after CSE or low-dose spinal anaesthetic insertion (RR 1.75, 95% CI 0.78 to 3.92; 4 studies, 298 women; moderate-quality evidence). We are uncertain about the effect of CSE or low-dose spinal on the need for intra-operative conversion to general anaesthesia, because this was not required by any of the 222 women in the three trials (low-quality evidence). None of the studies examined whether women were satisfied with their anaesthesia.The mean time to effective anaesthesia was faster in women who received low-dose spinal compared to CSE, although it is unlikely that the magnitude of this difference is clinically meaningful (standardised mean difference (SMD) 0.85 minutes, 95% CI 0.52 to 1.18 minutes; 2 studies, 160 women).CSE appeared to reduce the incidence of intra-operative hypotension requiring treatment compared with low-dose spinal (average RR 0.59, 95% CI 0.38 to 0.93; 4 studies, 336 women). Similar numbers of women between the CSE and low-dose spinal groups experienced intra-operative nausea or vomiting requiring treatment (3/50 with CSE versus 6/50 with SSS; 1 study, 100 women), and there were no cases of post-dural puncture headache (1 study, 138 women). No infants in either group had an Apgar score of less than seven at five minutes (1 study; 60 babies). AUTHORS' CONCLUSIONS: In this review, the number of studies and participants for most of our analyses were small and some of the included trials had design limitations. There was some suggestion that, compared to spinal anaesthesia, CSE could be associated with a reduction in the number of women with intra-operative hypotension, but an increase in intra-operative nausea and vomiting requiring treatment. One small study found that low-dose spinal resulted in a faster time to effective anaesthesia compared to CSE. However, these results are based on limited data and the difference is unlikely to be clinically meaningful. Consequently, there is currently insufficient evidence in support of one technique over the other and more evidence is needed in order to further evaluate the relative effectiveness and safety of CSE and spinal anaesthesia for caesarean section.More high-quality, sufficiently-powered studies in this area are needed. Such studies could consider using the outcomes listed in this review and should also consider reporting economic aspects of the different methods under investigation.

Optic nerve sonography and ophthalmic artery Doppler velocimetry in healthy pregnant women: an Australian cohort study.

PURPOSE: Maternal ocular sonography offers a window into cerebrovascular and intracranial pressure changes in pregnancy. This study aimed to determine the Doppler velocimetric variables of the ophthalmic artery, and the mean diameter of the optic nerve sheath (ONSD), in an Australian cohort of healthy pregnant women. METHODS: A prospective observational cohort study of healthy women with uncomplicated singleton pregnancies in the third trimester was undertaken in a tertiary maternity service. A single prenatal ultrasonographic examination was performed on all participants, with a postnatal examination performed on a subgroup with uncomplicated deliveries. RESULTS: Fifty women were examined at a mean gestation of 35 weeks. The mean ± SD Doppler variables in the ophthalmic artery were peak systolic velocity (PSV) 41.89 ± 13.13 cm/s, second peak velocity 20.63 ± 8.97 cm/s, end diastolic velocity 9.29 ± 5.13 cm/s, pulsatility index 1.97 ± 0.53, resistive index 0.78 ± 0.07, peak ratio (second peak velocity/PSV) 0.49 ± 0.12, while the mean ONSD was 4.34 ± 0.4 mm. None of these variables had a demonstrable relationship with gestation or mean arterial pressure (MAP), nor did the sheath diameter have a relationship with any of the Doppler variables. CONCLUSIONS: The ocular sonographic variables observed in this population are similar to those reported in other cohorts. No clear relationship could be identified in this cohort between ophthalmic artery Doppler variables and the ONSD, and between each of these variables and gestation or MAP.

Resting Hemodynamics and Response to Exercise Using the 6-Minute Walk Test in Late Pregnancy: An International Prospective Multicentre Study.

BACKGROUND: Cardiac disease is the leading cause of maternal death. Assessment of cardiovascular fitness is important in pregnant women because it is linked to increased risk of cardiac disease but is rarely undertaken or studied. The 6-Minute Walk Test (6MWT) is a safe exercise test but is not used in pregnancy. We determined the 95% reference interval for resting heart rate (HR) and distance walked for the 6MWT, as well as hemodynamic recovery variables, and quantified expectations and actual experiences of exertion and breathlessness with exercise in late pregnancy. METHODS: After institutional research board approval (Australian and New Zealand Clinical Trials Registry Number: 12615000964516), 300 healthy term nulliparous pregnant women performed the 6MWT at 3 tertiary referral obstetric hospitals using a standardized protocol. Each woman underwent two 6MWT with maximum 15-minute recovery period after each test. Hemodynamic variables were measured at rest and after exercise. Participants were asked 4 questions, 2 regarding expectation and 2 regarding actual experience, using the Rating of Perceived Exertion scale and Modified Borg Dyspnea scale. RESULTS: Participant characteristics and resting variables were mean (standard deviation [SD]); age, 31 years (4.2 years); body mass index, 27 kg/m (2.9 kg/m); gestational age, 37 weeks (1.3 weeks); HR, 85 bpm (10.8 bpm) with 95% reference interval 64-106 bpm; systolic blood pressure, 112 mm Hg (10.2 mm Hg); diastolic blood pressure, 72 mm Hg (8.6 mm Hg); oxygen saturation, 98% (0.9%); and respiratory rate, 18 breaths/min (5.7 breaths/min). The mean (SD) average distance walked was 488 m (94.9 m) with a speed of 3.0 mph (0.64 mph) with a 95% reference interval of 302-674 m. The mean (SD) HR increase with exercise was 12 bpm (11.0 bpm) with a median [quartile] recovery time of 5.0 minutes [1-8 minutes]. A lower resting HR was associated with increased distance walked (r = -0.207; 95% confidence interval, -0.313 to -0.096; P < .001). A greater HR change with exercise was associated with increased recovery time from exercise (r = 0.736; 95% confidence interval, 0.697-0.784; P < .001). Sixty-three percent and 83% of participants, respectively, expected to be more exerted and breathless than they actually were with exercise. CONCLUSIONS: The 6MWT is feasible and applicable in term pregnant women. The reference intervals for resting HR and distance walked in the 6MWT have been generated. HR increases by approximately 12 bpm with submaximal exercise, and half of the women recovered within 5 minutes of submaximal exercise. Women expected to be more exerted and breathless than they actually were with exercise.

Microsurgical Decompression of Trigeminal Neuralgia Caused by Simultaneous Double Arterial (SCA and AICA) and Petrosal Vein Complex Compression.

Trigeminal neuralgia is a chronic pain disorder affecting the face. In approximately 80% of cases, it is most commonly caused, when the root entry zone (REZ) of the trigeminal nerve is compressed by the superior cerebellar artery (SCA). The etiology of the remaining 20% of cases is distributed among venous, arteriovenous malformations, posterior fossa tumors, multiple sclerosis plaque compressions, and other pathologies. Combinations of those compressive factors are very rare. 1 2 3 4 Herein, we present a video clip of microvascular decompression (MVD) in a 73-year-old female, who has failed conservative treatment with 6 medications over 10 years. She was affected by a unique triple compression of the right REZ by the SCA, anterior inferior cerebellar artery (AICA), and petrosal vein complex ( Fig. 1A ). Right-sided microsurgical decompression of the REZ of the trigeminal nerve through standard retrosigmoid craniotomy was performed by the senior author (K.I.A.). The SCA and AICA were separated from the nerve using Teflon pledgets. The petrosal vein complex was coagulated and divided, freeing up the right trigeminal nerve ( Fig. 1B ). The patient was discharged home on the third postoperative day with complete resolution of trigeminal neuralgia. The link to the Video can be found at: https://youtu.be/PYVvImGW0yE .

The prone position in healthy pregnant women and in women with preeclampsia - a pilot study.

BACKGROUND: The prone position is rarely used in medical settings in pregnancy. There is no published information about the prone position in women with preeclampsia. This study examined the feasibility and acceptability of the prone position in pregnant women, and the short-term effect of the prone position on blood pressure (BP) in term healthy pregnant women and in women with preeclampsia. METHODS: After ethics approval, written consent and trial registration (ACTRN:12615000160538 registered 18/02/2015, date of first participant enrolled 03/03/2015), 50 healthy term pregnant women and 15 women with preeclampsia had BP, heart rate (HR), oxygen saturation (SpO2), respiratory rate (RR), fetal heart rate (FHR) and comfort levels measured in two positions: left lateral, and prone. Measurements were after five minutes rest in each position. RESULTS: Mean ± SD age, gestation and body mass index for healthy pregnant women was 33 ± 4.1 years, 38 ± 1.0 weeks and 27 ± 3.2 kg.m- 2 and for women with preeclampsia was 32 ± 4.7 years, 36 ± 3.4 weeks, 31 ± 5.6 kg.m- 2 respectively. No clinically significant changes occurred in healthy pregnant women in the prone position. Systolic BP was reduced in the prone position in women with preeclampsia (P = 0.019, mean difference - 6.6 mmHg, 95% confidence interval - 11.9 to - 1.3 mmHg). 33% of women with preeclampsia experienced a 10 mmHg or greater reduction in systolic BP in the prone position. 42% of healthy pregnant women and 47% of women with preeclampsia preferred the prone position to lateral. CONCLUSIONS: This is the first study to examine the prone position in women with preeclampsia. For short periods of time the prone position is feasible and comfortable in pregnant women including those at term. The prone position may reduce systolic BP in women with preeclampsia without obvious adverse effects. Larger studies with women lying for longer periods in the prone position are required. Pregnancy should not be a contraindication to the prone position for short periods of time. TRIAL REGISTRATION: ACTRN:12615000160538.

Baby-directed umbilical cord clamping: A feasibility study.

INTRODUCTION: Over five percent of infants born worldwide will need help breathing after birth. Delayed cord clamping (DCC) has become the standard of care for vigorous infants. DCC in non-vigorous infants is uncommon because of logistical difficulties in providing effective resuscitation during DCC. In Baby-Directed Umbilical Cord Clamping (Baby-DUCC), the umbilical cord remains patent until the infant's lungs are exchanging gases. We conducted a feasibility study of the Baby-DUCC technique. METHODS: We obtained antenatal consent from pregnant women to enroll infants born at ≥32 weeks. Vigorous infants received ≥2 min of DCC. If the infant received respiratory support, the umbilical cord was clamped ≥60 s after the colorimetric carbon dioxide detector turned yellow. Maternal uterotonic medication was administered after umbilical cord clamping. A paediatrician and researcher entered the sterile field to provide respiratory support during a cesarean birth. Maternal and infant outcomes in the delivery room and prior to hospital discharge were analysed. RESULTS: Forty-four infants were enrolled, 23 delivered via cesarean section (8 unplanned) and 15 delivered vaginally (6 via instrumentation). Twelve infants were non-vigorous. ECG was the preferred method for recording HR. Two infants had a HR < 100 BPM. All HR values were >100 BPM by 80 s after birth. Median time to umbilical cord clamping was 150 and 138 s in vigorous and non-vigorous infants, respectively. Median maternal blood loss was 300 ml. CONCLUSIONS: It is feasible to provide resuscitation to term and near-term infants during DCC, after both vaginal and cesarean births, clamping the umbilical cord only when the infant is physiologically ready.

Pregnancy in a woman with a Fontan circulation: A review.

More women with congenital heart disease survive to childbearing ages, due to improvements in surgical practice and postoperative care. This review discusses pregnancy in women with a single ventricle, describing maternal obstetric and cardiovascular complications and the increased risks of prematurity and adverse neonatal outcomes. Recommendations are made based on current understanding, guidelines and published literature, with recognition that there is much knowledge yet to be gained.

Reducing Maternal Mortality in Papua New Guinea: Contextualizing Access to Safe Surgery and Anesthesia.

Papua New Guinea has one of the world's highest maternal mortality rates with approximately 215 women dying per 100,000 live births. The sustainable development goals outline key priority areas for achieving a reduction in maternal mortality including a focus on universal health coverage with safe surgery and anesthesia for all pregnant women. This narrative review addresses the issue of reducing maternal mortality in Papua New Guinea by contextualizing the need for safe obstetric surgery and anesthesia within a structure of enabling environments at key times in a woman's life. The 3 pillars of enabling environments are as follows: a stable humanitarian government; a safe, secure, and clean environment; and a strong health system. Key times, and their associated specific issues, in a woman's life include prepregnancy, antenatal, birth and the postpartum period, childhood, adolescence and young womanhood, and the postchildbearing years.

Associations between maternal size and health outcomes for women undergoing caesarean section: a multicentre prospective observational study (The MUM SIZE Study).

OBJECTIVES: To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m2 higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS). DESIGN: A prospective multicentre observational study. SETTING: Seven secondary or tertiary referral obstetric hospitals. PARTICIPANTS: One thousand and four hundred and fifty-seven women undergoing all categories of CS. DATA COLLECTION: Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs. RESULTS: Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m2. Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women. CONCLUSIONS: Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider these clinical risks, time implications and financial costs when managing pregnant women.