Does the timing of neuraxial analgesia initiation in elective induction of multiparous women prolong the duration of delivery?

AIM: To investigate whether the early initiation of neuraxial analgesia prolongs the duration of electively induced labor in Japanese multiparous women. METHODS: This retrospective study included multiparous term women who underwent elective induction of labor using combined spinal-epidural analgesia at the Showa University Hospital between October 2018 and March 2021. The participants were divided into two groups: early and late. If neuraxial analgesia was initiated when the cervical dilation was ≤3 cm, the patient was included in the early group. The remaining patients were included in the late group. The obstetric and neonatal outcomes were compared between the two groups. The primary outcome was the duration of delivery. The secondary outcomes were the rates of instrumental and cesarean deliveries. RESULTS: Two hundred and ninety-seven women (early group = 139, late group = 158) were included in the analysis. The duration of the first stage of labor did not differ significantly between the early and late groups (median: 232 vs. 260 min, p = 0.35). Similarly, there was no significant difference in the duration of the second stage (37 vs. 40 min, p = 0.20). Moreover, the rates of instrumental and cesarean deliveries did not differ significantly between the groups, and the neonatal outcomes were comparable. CONCLUSION: Early initiation of neuraxial analgesia in the elective induction of parous Japanese women did not prolong the duration of delivery. Our results suggest that neuraxial analgesia may be initiated whenever a parturient desires it.

Anesthetic management of cesarean hysterectomy using intra-aortic balloon occlusion in a patient with Fontan circulation and placenta increta: a case report.

BACKGROUND: In patients with Fontan circulation, hemorrhage can cause life-threatening circulatory collapse, since Fontan circulation strongly depends on the preload. Furthermore, parturients with placenta accreta spectrum are at a high risk of rapid and massive hemorrhage. Herein, we report the case of an intra-aortic balloon occlusion used for a Fontan-palliated parturient with placenta increta with successful anesthetic management. CASE PRESENTATION: A 35-year-old-female with Fontan circulation diagnosed with placenta increta underwent a cesarean hysterectomy. The main goal during anesthetic management was to maintain sufficient preload. Infrarenal intra-aortic balloon occlusion was used to reduce intraoperative hemorrhage. The hemodynamic changes caused were well tolerated in this case. CONCLUSIONS: Intra-aortic balloon occlusion was used in a Fontan-palliated parturient with placenta increta with successful anesthetic management.

Maternal cardiopulmonary resuscitation.

The perinatal resuscitation history in Japan is short, with the earliest efforts in the field of neonatology. In contrast, the standardization and dissemination of maternal resuscitation is lagging. With the establishment of the Maternal Death Reporting Project and the Maternal Death Case Review and Evaluation Committee in 2010, with the aim of reducing maternal deaths, the true situation of maternal deaths came to light. Subsequently, in 2015, the Japan Council for the Dissemination of Maternal Emergency Life Support Systems (J-CIMELS) was established to educate and disseminate simulations in maternal emergency care; training sessions on maternal resuscitation are now conducted in all prefectures. Since the launch of the project and council, the maternal mortality rate in Japan (especially due to obstetric critical hemorrhage) has gradually decreased. This has been probably achieved due to the tireless efforts of medical personnel involved in perinatal care, as well as the various activities conducted so far. However, there are no standardized guidelines for maternal resuscitation yet. Therefore, a committee was set up within the Japan Resuscitation Council to develop a maternal resuscitation protocol, and the Guidelines for Maternal Resuscitation 2020 was created in 2021. These guidelines are expected to make the use of high-quality resuscitation methods more widespread than ever before. This presentation will provide an overview of the Guidelines for Maternal Resuscitation 2020.

A Case of Breast Cancer in a Patient with a Congenital Pectoralis Muscle Defect.

Congenital pectoral muscle defects are very rare, and when accompanied by limb defects, they are called Poland syndrome. A woman in her 70s, 4 years after partial mastectomy for breast cancer, underwent mastectomy for a local recurrence. During the operation, the pectoralis major and minor muscles were found to be defective. However, the patient did not have any limb defects. Although congenital pectoral muscle defects are very rare, it would be better to confirm defects of the pectoral muscle by preoperative diagnostic imaging such as CT because the postoperative treatment may be affected.

The concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in Japanese parturients.

Background: The accurate identification of an intervertebral lumbar level is essential to avoid neuraxial anesthesia and analgesia-related spinal cord injury. It has been shown that estimation of L3/4 intervertebral lumbar level based on the intercristal line determined by palpation (palpated L3/4) is often inaccurate. However; studies evaluating intervertebral lumbar level concordance based on palpation vs. ultrasonography were conducted in Western populations (i.e. in North America and/or Europe). Radiological studies suggest that the intercristal line intersects at a lower level of the spine in Japanese women than in Western women. Therefore, we hypothesized that differences exist in intervertebral levels based on the palpated intercristal line between Asian and Western women. Herein we present the results of the first study in Japan comparing the concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in pregnant Japanese women.Study objective: The objective of this study was to evaluate the accuracy of palpated L3/4 in Japanese parturients assessed by ultrasonography (US).Design: A prospective, observer-blinded study.Setting: Labor and delivery room at the Kitasato University Hospital, Sagamihara, Kanagawa, Japan.Patients: Sixty-three term parturients underwent induction of labor and requested neuraxial labor analgesia.Interventions: With the patients in the sitting position, an attending anesthesiologist marked the intervertebral space estimated as L3/4 based on intercristal line with palpation. Another attending anesthesiologist who was blinded to the marker performed US to identify L3/4.Results: The overall agreement rate of palpated and US L3/4 was 69.8% (44/63). Palpated L3/4 was US L2/3 in 8/63 (12.7%) and US L4/5 in 11/63 (17.5%). In comparison with women with palpated L3/4 agreed with US L3/4, women with palpated L3/4 agreed with US L2/3 were more frequently multiparous (52 vs. 100%, p < .05) and women with palpated L3/4 identified as L4/5 were younger (36 ± 4 years vs. 33 ± 4 yrs, p < .05) and gained less weight during pregnancy (10 ± 4 kg vs. 7 ± 4 kg, p < .05). The patients whose palpated L3/4 were found to be US L2/3 were all multiparous.Conclusion: The accuracy rate of palpated L3/4 intervertebral lumbar level in pregnant women included in our study was 69.8%. Pregnancy-related weight gain, parity, and maternal age can all influence an estimation of L3/4 intervertebral lumbar level by palpation. In addition, we believe that this is the first study to analyze the correlation between maternal parity and interspace estimation by palpation in pregnant women.

Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia.

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

Cough Headache Presenting with Reversible Cerebral Vasoconstriction Syndrome.

Cough headache can be a primary benign condition or secondary to underlying etiologies. We herein describe a case of a 52-year-old woman with cough headache that presented as reversible cerebral vasoconstriction syndrome (RCVS). Some cases of RCVS are caused by an aberrant sympathetic response to activities that cause an intracranial pressure surge. Therefore, cough headache should be recognized as a possible presentation of RCVS, even without thunderclap headache or neurological deficits.

A young female case of primary renal carcinoid tumor mimicking fat-poor angiomyolipoma.

Renal mass biopsy is useful for the pathological diagnosis of a small renal mass difficult to distinguish fat-poor angiomyolipoma from renal cell carcinoma radiologically. Here, we report a young female case of a small renal mass suspected as fat-poor angiomyolipoma in imaging studies. The patient received a renal mass biopsy to obtain the correct pathological information. Unexpectedly, the pathological diagnosis was neuroendocrine tumor. She, finally, underwent a right radical nephrectomy as a curative treatment. This case indicates that the radiological findings of primary renal carcinoid tumor can be similar to those of fat-poor angiomyolipoma.

A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150µg.

INTRODUCTION: Delayed respiratory depression is a feared complication of intrathecal morphine in patients undergoing cesarean delivery. The incidence, timing and risk factors for hypoxia in this population are not known. METHODS: Patients undergoing cesarean delivery under spinal anesthesia at a tertiary care center from October 2012 to March 2016 were included in the study. The Berlin sleep apnea Questionnaire was completed before surgery. Oxygen saturation was recorded every second for 24hours after the initiation of spinal anesthesia. Desaturation events were defined as a median saturation of <90% (mild) or <85% (severe) across a 30-s period. Multivariable logistic regression was used to determine predictors of a desaturation event. RESULTS: A total of 721 patients were included in the analysis. Within this cohort, 169 women (23%) experienced at least one mild desaturation event, 91 (13%) experienced two or more mild desaturations, and 26 (4%) suffered a severe desaturation event. After the administration of intrathecal morphine, the median times to first mild or first severe desaturation were 7.4 (IQR 4.1-13.5)h and 12.0 (IQR 5.4-19.6)h, respectively. Patients who screened positive for sleep apnea had increased odds of having a mild desaturation event (OR 2.31, 95% CI 1.40 to 3.79, P=0.001), as did patients who were obese (OR 1.80, 95% CI 1.05 to 3.09, P=0.033). CONCLUSIONS: Mild hypoxemia occurred frequently in women receiving intrathecal morphine 150µg for post-cesarean analgesia. Desaturations were observed most frequently 4-8hours after administration of intrathecal morphine. Obesity and a positive Berlin Questionnaire were risk factors for hypoxemic events.

Medical certification reduces the number of children requiring allergen elimination diets for school lunches.

BACKGROUND: Following the increase in the number of children with food allergies, support systems are now required for school lunches, but a large-scale factual investigation has not been carried out. OBJECTIVE: We evaluated the features of elimination diet due to food allergy and the support system in kindergartens and schools. METHODS: A prefecture-based questionnaire survey regarding measures for food allergies in school lunches of all kindergartens, public elementary schools, and public junior high schools (631 facilities) was conducted in Oita Prefecture, Japan. RESULTS: The recovery rate of the questionnaire was 99.5%, which included 106,008 students in total. A total of 1,562 children (1.5%) required elimination diets. The rate of children on elimination diets in kindergartens and elementary/junior high schools that required medical certification by a physician was 1.2% (324 among 27,761 children), which was significantly lower than the 1.8% of children (1,227 among 68,576 students) on elimination diets at the request of guardians without the need for medical certification (p < 0.0001). A total of 43.9% of the kindergartens and schools said that they would contact guardians if symptoms were observed after accidental ingestion, while a low 8.1% stated that they provided support to children themselves, including the administration of adrenaline auto-injectors. CONCLUSION: Medical certification reduces the number of children requiring elimination diets, but it has not been adequately implemented. Furthermore, waiting to contact guardians after symptoms are observed may lead to the delayed treatment of anaphylaxis. Cooperation between physicians and teachers is desired to avoid the overdiagnosis and undertreatment of children with food allergies.

Heparan sulfate storage in the cardiac conduction system triggers atrioventricular block.

OBJECTIVE: To elucidate the novel biological functions of heparan sulfate (HS) by clinic-pathologically studying a patient with paroxysmal atrioventricular (AV) block. PATIENT: A long-surviving male patient with Sanfilippo syndrome type A presented with paroxysmal AV block at age 33years. He then survived another 2.5years after the onset of paroxysmal AV block and pacemaker implantation. METHODS AND RESULTS: His cardiac histopathological examination at autopsy showed HS storage in the cardiac conduction system (CCS), especially in the atrioventricular node (AVN)-His bundle branches. CONCLUSION: HS storage in the CCS might trigger AV block, arising from below the AVN-His bundle branches. This is the first description to indicate that HS might be an essential constituent of life-long CCS plasticity and that its storage in the CCS results in AV block.

Continuous spinal labor analgesia for two deliveries in a parturient with severe subvalvular aortic stenosis.

Various degrees of left ventricular outflow tract (LVOT) obstruction have been seen in patients with subvalvular aortic stenosis (SAS). Regional analgesia during labor for parturients with SAS is relatively contraindicated because it has a potential risk for hemodynamic instability due to sympathetic blockade as a result of vasodilation by local anesthetics. We thought continuous spinal analgesia (CSA) using an opioid and minimal doses of local anesthetic could provide more stable hemodynamic status. We demonstrate the management of a 28-year-old pregnant patient with SAS who received CSA for her two deliveries. For her first delivery (peak pressure gradient (∆P) between LV and aorta was approximately 55 mmHg), intrathecal fentanyl was used as a basal infusion, but we needed a small amount of bupivacaine to provide supplemental intrathecal analgesia as labor progressed. Although there were mild fluctuations in hemodynamics, she was asymptomatic. For her second delivery (∆P between LV and aorta was approximately 90 mmHg), minimal doses of continuous bupivacaine were used as a basal infusion. For her additional analgesic requests, bolus co-administration of fentanyl was effective. There were no fluctuations in her hemodynamics. Although her SAS in her second pregnancy was more severe than in the first, her hemodynamics exhibited less fluctuation during the second delivery with this method. In conclusion, CSA using fentanyl combined with minimal doses of bupivacaine provided satisfactory analgesia and stable hemodynamics in parturient with severe SAS.

[Retrospective Review of Labor Analgesia for Parturients with Moyamoya Disease.]

BACKGROUND: Moyamoya disease (MD) is an occlu- sive cerebrovascular disease with risks of cerebral ischemia or hemorrhage. Although cesarean section (CS) is the prevailing delivery mode for these parturi- ents to stabilize cerebral circulation, the preferable mode remains controversial. We have conducted vagi- nal delivery with neuraxial analgesia (NA) because safety with the procedure is equivalent to that with CS. The aim of this study is to investigate peripartum outcomes, particularly delivery mode and occurrence of cerebrovascular events, in women with MD. METHODS: We retrospectively analyzed the data of parturients with MD for the previous 8 years. RESULTS: Among 13 pregnancies during this period, eight were vaginal deliveries with NA, while CS was executed in five cases according to obstetric indica- tions. Instrumental deliveries were conducted in five among eight vaginal delivery cases. No cerebrovascular event occurred during delivery. A transient ischemic attack in one case of vaginal delivery and cerebral ischemia in CS were noted in the postpartum period. CONCLUSIONS: We successfully managed vaginal deliveries in the eight patients with MD using NA. NA provides pain relief and assures maternal hemody- namic and respiratory stability during delivery. Instru- mental delivery plays a key role in reducing the dura- tion of the second stage of labor.

[A Case of Preeclampsia Diagnosed with CADASIL after Emergency Cesarean Section].

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a rare inherited disease which begins with migraine and later develops repeated cerebral subcortical infarction and dementia. We present an anesthetic experience of an undiagnosed CADASIL woman complicated with preeclampsia. She developed headache, slurred speech, cognitive dysfunction and restlessness at 35 weeks' gestation and was diagnosed as hypertensive encepha- lopathy. Urgent cesarean section was decided. After ruling out meningitis by physical examination, and intracranial hemorrhage, cerebral swelling and hydro- cephalus by brain CT, spinal anesthesia was chosen. Mild sedation was necessary because the patient became restless and uncooperative during surgery. The anesthetic course was uneventful otherwise. She was either restless or lethargy and had hallucinatory episodes on 1st post-operative day. The neurologist suspected CADASIL because of multiple lacunar infarct lesions on MRI and her family history. The diagnosis was confirmed by skin biopsy and a genetic test.

Vaginal Delivery under Epidural Analgesia in Pregnant Women with a Diagnosis of Moyamoya Disease.

BACKGROUND: Moyamoya disease more commonly occurs in young people and women, so patients with this disease may experience pregnancy and delivery. Cesarean section (CS) is often chosen as the mode of delivery for these patients in Japan. No appropriate mode of delivery has yet been established for pregnant women with moyamoya disease in terms of stroke prevention. We have used vaginal delivery under epidural analgesia (EA) in such patients unless CS has been indicated for the maternal or fetal reasons. This study retrospectively analyzed our patients with moyamoya disease who gave birth to confirm the safety of vaginal delivery under EA. METHODS: Twelve consecutive patients diagnosed with moyamoya disease had 14 deliveries at our hospital between September 2004 and January 2013. The incidences of intrapartum stroke were compared between cases of vaginal delivery under EA and CS cases. RESULTS: Ten vaginal deliveries under EA and 4 elective CSs were performed. No intrapartum stroke was observed during either vaginal delivery under EA or CS. Among the patients who underwent vaginal delivery under EA, 1 parturient who experienced 2 deliveries suffered transient ischemic attack during both postpartum periods. All 14 infants were healthy without sequelae. CONCLUSIONS: Vaginal delivery under EA is an option for patients with moyamoya disease, provided that close cooperation with neurosurgeons, obstetricians, and anesthesiologists is assured.

The synergistic effect of 1'-acetoxychavicol acetate and sodium butyrate on the death of human hepatocellular carcinoma cells.

It has been suggested that the combined effect of natural products may improve the effect of treatment against the proliferation of cancer cells. In this study, we evaluated the combination of 1'-acetoxychavicol acetate (ACA), obtained from Alpinia galangal, and sodium butyrate, a major short chain fatty acid, on the growth of HepG2 human hepatocellular carcinoma cells and found that treatment had a synergistic inhibitory effect. The number of HepG2 cells was synergistically decreased via apoptosis induction when cells were treated with both ACA and sodium butyrate. In ACA- and sodium butyrate-treated cells, intracellular reactive oxygen species (ROS) levels and NADPH oxidase activities were increased significantly. The decrease in cell number after combined treatment of ACA and sodium butyrate was diminished when cells were pretreated with catalase. These results suggest that an increase in intracellular ROS levels is involved in cancer cell death. AMP-activated protein kinase (AMPK), a cellular energy sensor, plays an essential role in controlling processes related to tumor development. In ACA- and sodium butyrate-treated cells, AMPK phosphorylation was induced significantly, and this induction improved when cells were pretreated with catalase. These results suggest that the increase in intracellular ROS is involved in the increase of AMPK phosphorylation. In normal hepatocyte cells, treatment with ACA and sodium butyrate did not decrease cell numbers or increase ROS levels. In conclusion, combined treatment with ACA and sodium butyrate synergistically induced apoptotic cell death via an increase in intracellular ROS and phosphorylation of AMPK. Our findings may provide new insight into the development of novel combination therapies against hepatocellular carcinoma.

Transversus abdominis plane block provides postoperative analgesic effects after cesarean section: additional analgesia to epidural morphine alone.

AIM: The aim of our study was: (i) to investigate whether transversus abdominis plane (TAP) block confers additional analgesic effects to epidural morphine alone; and (ii) to determine plasma levels of local anesthetics after TAP block in post-cesarean women. MATERIAL AND METHODS: The subjects were parturients undergoing cesarean section under combined spinal-epidural anesthesia. Morphine (2 mg) was administered to the epidural space close to the end of surgery. Women who desired TAP block were allocated to the TAP group. Women who did not undergo TAP block were allocated to the control group. In the TAP group, 20 mL of either 0.375% ropivacaine or 0.3% levobupivacaine was infused to both sides of the transversus abdominis plane after surgery. All patients were placed on a patient-controlled i.v. analgesia regimen with morphine after surgery. Time to the first morphine request and amount of morphine consumption within 24 h after surgery were compared in patients with and without TAP block. Plasma concentrations of local anesthetics were determined at 15, 30 and 60 min after TAP block. RESULTS: Forty and 54 patients were allocated to the control and TAP group, respectively. The median time to the first morphine request was longer (555 vs 215 min), and the median cumulative morphine consumption within 24 h was lower (5.3 vs 7.7 mg) in the TAP group than in the control group. The maximum median concentrations of ropivacaine and bupivacaine after TAP block were 784 and 553 ng/mL, respectively. CONCLUSION: TAP block had additional analgesic effects to epidural morphine alone.

Functional analysis of nocturnin, a circadian deadenylase, at maternal-to-zygotic transition in mice.

Degradation of maternally stored mRNAs after fertilization is an essential process for mammalian embryogenesis. Maternal mRNA degradation depending on deadenylases in mammalian early embryos has been mostly speculated, rather than directly demonstrated. Previously, we found that gene expression of nocturnin, which functions as a circadian clock-controlled deadenylase in mammalian cells, was clearly changed during the maternal-to-zygotic transition (MZT). Here, we investigated the possible role of nocturnin during mouse MZT. First, we examined the expression profile and localization of nocturnin in mouse oocytes and early embryos. The abundance of Nocturnin mRNA level was significantly decreased from the MII to 4-cell stages and slightly increased from the 8-cell to blastocyst stages, whereas the Nocturnin protein level was almost stable in all examined cells including GV and MII oocytes and early embryos. Nocturnin was localized in both the cytoplasm and the nucleus of all examined cells. We then examined the effect of loss or gain of Nocturnin function on early embryonic development. Knockdown of Nocturnin by injection of Nocturnin antisense expression vector into 1-cell embryos resulted in the delay of early embryonic development to the early blastocyst stage. Moreover, Nocturnin-overexpressed embryos by injection of Nocturnin expression vector impaired their development from the 1-cell to 2-cell or 4-cell stages. These results suggest that precise expression of nocturnin is critical to proper development of early mouse embryos. Functional analysis of nocturnin may contribute to the understanding of the possible role of the deadenylase at mouse MZT.

[Prompt resuscitation by obstetric anesthesiologists saved a parturient with amniotic fluid embolism: a case report].

Amniotic fluid embolism (AFE) is a disorder with a high mortarity rate, because it often causes sudden respiratory failure, circulatory collapse and disseminated intravascular coagulation (DIC). We present a case of AFE in which an obstetric anesthesiologist promptly initiated resuscitation of a parturient and saved her without any sequelae. Her fetus was diagnosed as intrauterine fetal demise on 25th gestational week and vaginal delivery under epidural analgesia was planned. One hundred and five minutes after induction of labor with prostaglandine E1, sudden tetanic convulsion occurred with a loss of consciousness. An obstetric anesthesiologist immediately started to resuscitate her and her consciousness was restored. However, noncoagulable vaginal bleeding followed. As the hemorrhage persisted, AFE was suspected. Anesthesiologists gave effective massive transfusion therapy, and she recovered from coagulopathy. Total blood loss was 5,524 g. This case was diagnosed as AFE with high serum sialyl-Tn antigen and zinc-coproporphyrin. The obstetric anesthesiologists are one of the best groups of physicans for resuscitation because they have skills in managing obstetric emergencies such as AFE. In this case, the crucial points for successful resuscitation were prompt obstetric anesthesiologist involvement and good communications with obstetricians and midwives.

[Preoperative oral hydration for pregnant women].

Preoperative oral hydration is an important component of "enhanced recovery after surgery" strategies. This was originally developed for patients undergoing colon surgery. The Obstetric Anesthesia Practice Guideline issued by American Society of Anesthesiologists states that intake of minimum amount of clear fluid 2 hours prior to surgery may be safe. However, anesthesiologists have to consider physiological changes that parturients undergo during pregnancy, such as increased risk of aspiration and impaired glucose tolerance. We also have to consider the potential effect of glucose loading on neonates. Mothers are more likely to develop ketosis by glucose loading. It also stimulates insulin release in the fetus, which can result in neonatal hypoglycemia. In addition, sodium overloading may deteriorate intra-vascular dehydration and cause lung edema to mothers. On the other hand, oral hydration can alleviate a sense of thirst and increase maternal satisfaction. Our data showed that maternal urinal ketone body at delivery tended to decrease with oral hydration during labor. Moreover, some articles suggest that oral hydration may improve utero-placental perfusion. Therefore, we have to balance risks and benefits of oral hydration in parturients. Further investigations are needed among this specific subgroup of patients in order to establish the safe application of preoperative oral hydration.