Planned cesarean delivery vs planned vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: There are over 145 million births worldwide, with over 30 million cesarean deliveries yearly. There are limited data comparing the perinatal and maternal outcomes between planned cesarean delivery and planned vaginal delivery. This study aimed to evaluate perinatal and maternal morbidity and mortality by meta-analysis of randomized controlled trials that randomly assigned patients to either planned cesarean delivery or planned vaginal delivery. DATA SOURCES: Scopus, PubMed, CINAHL, Cochrane Library, and the World Health Organization clinical trial databases were searched from inception through August 2022. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that compared planned cesarean delivery with planned vaginal delivery at any gestational age and for any delivery indication were included. METHODS: Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. The primary outcome was perinatal mortality. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals. Pooled odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel random-effects models for outcomes. RESULTS: In 15 primary randomized controlled trials, 3265 patients were randomized to planned cesarean delivery and 3353 to planned vaginal delivery. The incidence of perinatal deaths was not different (1.3% vs 1.3%; relative risk, 0.71; 95% confidence interval, 0.33-1.52). Planned cesarean delivery was associated with lower neonatal incidences of low umbilical artery pH (0.3% vs 2.4%; relative risk, 0.18; 95% confidence interval, 0.05-0.67), birth trauma (0.3% vs 0.7%; relative risk, 0.46; 95% confidence interval, 0.22-0.96), tube feeding requirement (2.5% vs 7.1%; relative risk, 0.36; 95% confidence interval, 0.19-0.66), and hypotonia (0.4% vs 3.5%; relative risk, 0.11; 95% confidence interval, 0.03-0.47), compared to planned vaginal delivery. Chorioamnionitis was less frequent in the planned cesarean delivery group (0.3% vs 1.0%; relative risk, 0.27; 95% confidence interval, 0.08-0.98). Wound infection was more common in the planned cesarean delivery group (1.9% vs 1.1%; relative risk, 1.61; 95% confidence interval, 1.04-2.52). Lower rates were observed in the planned cesarean delivery group for urinary incontinence at both ≤3 months (8.7% vs 12.2%; relative risk, 0.71; 95% confidence interval, 0.59-0.85) and 1 to 2 years (16.9% vs 22%; relative risk, 0.77; 95% confidence interval, 0.67-0.88) and for a painful perineum at 2 years (4% vs 6.2%; relative risk, 0.64; 95% confidence interval, 0.47-0.87) compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death (0.69% vs 1.81%; relative risk, 0.45; 95% confident interval, 0.21-0.93). CONCLUSION: Planned cesarean delivery and planned vaginal delivery were associated with similar rates of perinatal and maternal mortality in this meta-analysis of randomized controlled trials. Planned cesarean delivery was associated with significant decreases in adverse neonatal outcomes such as low umbilical artery pH, birth trauma, tube feeding requirement, and hypotonia, and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. Planned vaginal delivery was associated with significant decreases in need for general anesthesia and wound infection. Further randomized trials are needed to assess the risks and benefits of planned cesarean delivery vs planned vaginal delivery in lower-risk patients and in the general population.

A Novel Simulation Model for Resident Education in Mechanical Cervical Ripening.

INTRODUCTION: This study aims to evaluate resident satisfaction with a novel simulation model for learning transcervical balloon catheter placement for mechanical cervical ripening. STUDY DESIGN: A descriptive pretest and post-test survey study of Obstetrics and Gynecology (OBGYN) residents was conducted at a single academic medical center using a low-cost model. RESULTS: Of 28 residents, 14 (50%) were recruited. 100% of participants completed the pretest and post-test survey. Residents agreed that both learning and achieving correct placement of a transcervical balloon catheter are difficult. Pretest and post-test comparisons were statistically different with respect to comfort (2.8 ± 1.5 vs. 4.0 ± 1.0, p = 0.03) and ease of learning (3.1 ± 0.8 vs. 4.1 ± 0.6, p ≤ 0.001). DISCUSSION: We present a novel simulation model that can be used by OBGYN residents in training for learning transcervical balloon catheter placement for mechanical cervical ripening. KEY POINTS: · There is no current validated model for teaching placement of mechanical cervical ripening.. · This study outlines a novel and simple simulation model.. · This model is easily made, accessible, and of a low cost design..

Two cases of coronavirus 2019-related cardiomyopathy in pregnancy.

At our institution, 2 of the initial 7 pregnant patients with confirmed coronavirus disease 2019 severe infection (28.6%; 95% CI, 8.2%-64.1%) developed cardiac dysfunction with moderately reduced left ventricular ejection fractions of 40%-45% and hypokinesis. Viral myocarditis and cardiomyopathy have also been reported in nonpregnant coronavirus disease 2019 patients. A case series of nonpregnant patients with coronavirus disease 2019 found that 33% of those in intensive care developed cardiomyopathy. More data are needed to ascertain the incidence of cardiomyopathy from coronavirus disease 2019 in pregnancy, in all pregnant women with coronavirus disease 2019, and those with severe disease (eg, pneumonia). We suggest an echocardiogram in pregnant women with coronavirus disease 2019 pneumonia, in particular those necessitating oxygen, or those who are critically ill, and we recommend the use of handheld, point-of-care devices where possible to minimize contamination of staff and traditional large echocardiogram machines.

Posterior reversible encephalopathy with late postpartum eclampsia and short-term memory loss: a case report.

BACKGROUND: Late postpartum eclampsia is more frequently recognized than past reports indicate. This report describes the association of a reversible encephalopathy in a woman with late postpartum eclampsia. CASE: A woman with lupus nephritis presented 7 days postpartum with eclampsia. Postseizure findings included dramatic short-term memory loss. Although a computed tomography scan was negative, subsequent magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) demonstrated vascular changes associated with a reversible encephalopathy. Conservative treatment with analeptic and antihypertensive therapy allowed a rapid resolution of all symptomatology. CONCLUSION: In women with eclampsia and unusual neurologic findings, an MRI/MRA may be useful even in the presence of a negative computed tomography scan.

Severe Hyperlipidemia Induced Hemorrhagic Pancreatitis during Pregnancy.

Background. We report a case of familial hyperlipidemia in pregnancy that resulted in hemorrhagic pancreatitis. Case. A patient at 27-week gestation was admitted for recurrent pancreatitis secondary to severe hyperlipidemia. With conservative care, the patient improved but on the fourth day of admission she experienced a sudden onset of hypotension and was diagnosed with hemorrhagic pancreatitis. Conclusion. Pancreatitis caused by hyperlipidemia is an uncommon event during pregnancy. A familiarity with the severe complications associated with this potentially life-threatening condition is important.

Fetal gastroschisis: a report of 2 cases.

BACKGROUND: The risk of stillbirth in fetuses diagnosed with gastroschisis may range from 6% to 12%. Currently there is no agreement on the role of antepartum fetal surveillance, as fetal death within days of reassuring antepartum fetal testing has been reported. CASES: In 2 cases of fetal gastroschisis, fetal gastric distension was associated with decreased fetal movements and nonreactive nonstress tests. Despite reassuring biophysical profile and normal umbilical artery Doppler sonograms, 1 fetus underwent intrauterine death. CONCLUSION: Poor prognostic factors in fetal gastroschisis may include a new finding of persistent fetal gastric distension in association with decreased fetal movements or a nonreactive nonstress test.

Fetal/neonatal supraventricular tachycardia.

At 38 weeks of gestation, a woman with a previously unremarkable pregnancy was noted to have fetal tachycardia without obvious cause. Fetal echocardiography resulted in a presumptive diagnosis of fetal atrial flutter with a 2:1 block. The newborn resumed the same rhythm. The neonate underwent transesophageal incremental overdrive pacing. A normal sinus rhythm was restored. The infant had no recurrence to age 6 months.

Atypical variable decelerations and intrauterine growth restriction.

Variable decelerations of the fetal heart rate are the most common changes noted during continuous fetal monitoring. In general, they are presumed to represent a normal response to fetal baroceptor stimulation. When atypical features are present, other considerations are warranted.