Implementation of French AmbUlatory Cesarean Section (FAUCS): Establishment of a Learning Curve and Short-term Outcomes.

BACKGROUND: The French AmbUlatory Cesarean Section (FAUCS) technique was introduced to the Galilee Medical Center in September 2021. FAUCS was performed electively for interested women who meet the criteria. OBJECTIVES: To evaluate the learning curve of senior surgeons performing FAUCS, the procedure short-term outcomes, and complications. METHODS: This retrospective study included 50 consecutive women who underwent FAUCS from September 2021 until March 2022 at our facility. Preoperative, intraoperative, postoperative, and demographic data were retrieved from patient electronic charts. RESULTS: The mean duration of surgery was 53.26 ± 11.62 minutes. This time decreased as the surgical team's experience increased: from a mean 58.26 ± 12.25 minutes for the first 15 procedures to a mean 51.17 ± 9.73 minutes for subsequent procedures. The mean visual analogue scale score for 24 hours was 1.08 ± 0.84 (on a 10-point scale). The rate of neonatal cord pH < 7.2 was 6%, and there were 11.3% cases of vacuum assisted fetal extraction. In total, 44% of the women were able to mobilize and urinate spontaneously by 4-6 hours. Complications included bladder injury (n=1), endometritis (n=1), and incisional hematoma (n=1). Overall, the maternal satisfaction rate was high; 94% of the women would recommend FAUCS to others. CONCLUSIONS: FAUCS is a feasible procedure with a high satisfaction rate. Following the first 15 procedures performed by one surgical team, the operative time decreased considerably. Further randomized controlled studies are needed to compare this procedure to regular cesarean section and evaluate neonatal outcomes.

The association between acute lower abdominal pain over a previous caesarean scar and uterine rupture.

Pregnant women with previous caesarean delivery might suffer from acute lower abdominal pain located at the site of previous caesarean scar (CS). The association between this complaint and uterine rupture (UR) is not fully understood. Therefore, we aimed to examine the risk of UR in women with acute persistent abdominal pain (APAP) over a previous CS and to investigate all the women with UR, with or without APAP and with or without previous CS, in order to determine risk factors, clinical presentation and management. We performed a retrospective analysis on two study groups: women who had APAP over previous CS and women who had UR. We found an incidence of UR in patients with APAP over the previous CS was 0.7%; which doubled the total UR rate among women with previous caesarean in our medical centre (0.35%). Forty percent of the women with APAP over a previous CS had preterm delivery. Twenty percent of the cases of UR occurred in preterm weeks. To conclude, APAP over a previous CS is associated with a doubled risk of UR. Considering this symptom as a preliminary sign of UR might lead to elevated rate of iatrogenic preterm deliveries.Impact statementWhat is already known on this subject? Women with UR may present with abdominal pain which may vary from non-specific mild discomfort to severe acute abdominal pain. Additionally, these women may suffer from acute persistent abdominal pain (APAP) located over the previous caesarean scar. The clinical significance of APAP in these women has not been fully investigated.What do the results of this study add? Lower abdominal pain located at the site of previous CS is associated with a doubled risk of UR. Considering this complaint as a major sign of UR might lead to an elevated rate of iatrogenic preterm deliveries.What are the implications of these findings for clinical practice and/or further research? Further studies are needed to explore whether women with a single complaint of APAP over CS could be managed expectantly and even offered a trial of labour after caesarean delivery (CD).

Intrahepatic cholestasis of pregnancy - prevalence and ethnic distribution in northern Israel.

OBJECTIVES: Intrahepatic cholestasis of pregnancy (ICP) is charachterized by pruritis and elevated serum bile acids (BA) and is associated with adverse obstetrical outcomes. ICP etiology is poorly understood and its incidence varies with ethnicity and geographical distribution. OBJECTIVES: Explore the prevalence and characteristics of ICP in the different Northern Israeli ethnic groups and compare maternal and perinatal outcomes according to disease severity. MATERIAL AND METHODS: Single-center retrospective study. Women who were diagnosed with ICP based on clinical presentation and elevated fasting BA (≥ 10 µmol/L) were included. Disease incidence, maternal and neonatal complications were explored according to ethnic subgroups analysis and obstetrical complications were examined according to disease severity. RESULTS: The incidence of ICP in the study population was 0.58%. Higher ICP incidence was found in our cohort compared with other reports arising from Central Israel (p < 0.001). The Christian patients had a higher incidence of ICP (1.1%) and preeclampsia (23.1%). A higher rate of neonatal intensive care unit (NICU) admissions was found in the Arab Muslim and Christian groups compared with the Jewish and Druze groups (p = 0.007). A higher rate of preeclampsia was found in the severe (BA ≥ 40 µmol/L) ICP group (p < 0.001). Patients in the severe ICP group had earlier gestational age at delivery (37 versus 38.14 weeks, p < 0.001). Birth weight was significantly lower in the severe ICP group (p = 0.018). CONCLUSIONS: The incidence of ICP at our institution was 0.58%, which is higher compared with previous reported Israeli incidence. Higher ICP and preeclampsia incidence were found among Arab Christian patients.

The Hormonal Milieu by Different Labor Induction Methods in Women with Previous Cesarean Section: a Prospective Randomized Controlled Trial.

The physiological pattern of hormonal and signaling molecules associated with labor induction is not fully clear. We conducted a preliminary study in order to investigate hormonal changes during labor induction in women with previous cesarean section. Eighty-seven women at term, with previous cesarean section, were randomized to undergo induction of labor by breast stimulation or intracervical balloon and compared with spontaneous labor (controls). Maternal serum levels of oxytocin, prostaglandin F2α, prostaglandin E2, prolactin, estradiol, and cortisol were analyzed at 0, 3, and 6 h post-induction initiation. Fetal umbilical cord hormones were measured. No significant difference was found in the induction-to-delivery time or mode of delivery between the induction groups. Maternal serum oxytocin levels decreased to a lesser extent in the breast stimulation group vs. the control group (p=0.003, p<0.001). In the breast stimulation and control groups, prostaglandin E2 levels increased as labor progressed (p=0.005, 0.002, respectively). Prostaglandin F2α levels decreased over time in the balloon group (p=0.039), but increased in the control group (p=0.037). Both induction methods had similar outcomes. The hormonal studies ascertained the hypothesized mechanisms, with oxytocin level higher during breast stimulation and lower in balloon induction. These observations could help clinicians determine the appropriate method for cervical ripening in women with previous cesarean section. Larger future studies are needed to examine the effect of these hormonal trends on the rate of successful labor induction and complications, such as uterine rupture, in women with previous uterine scars. ClinicalTrials.gov Identifier NCT04244747.

Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon.

Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35-37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.

Optimal continuous support accompanying labor - the midwives' and laboring women's point of view.

BACKGROUND: Women who have continuous intrapartum support are more likely to have a shorter labor and spontaneous vaginal birth, and are less likely to need intrapartum analgesia than women who receive usual care without support. We aimed to determine what women in labor and midwives regard as the optimal number of labor supporters and whether they should be present during medical interventions. METHODS: A questionnaire was distributed to midwives participating in a national midwifery conference in June 2015. In addition, an anonymized questionnaire concerning the preferred number and type of supporters was distributed to laboring women at the beginning of labor and repeated post-partum in the maternity unit of a single tertiary medical center between March 2017 and January 2018. RESULTS: Of 124 midwives from 18 hospitals throughout Israel attending the conference, 92 (74%) completed the questionnaire. Eighty-three percent of the midwives who responded felt that more than two supporters interferes with their work. Eighty percent of the midwives work in obstetrical units that allow up to two labor supporters, and 82% of them felt that one or two supporters is optimal. Similarly, of the 140 laboring women surveyed, 84% preferred one or two supporters. There was no difference in the preferred number of supporters between the maternal pre- and post-partum questionnaires. The laboring women and midwives had differing opinions regarding supporter presence during vacuum extraction and perineal suture. Sixty-four percent of the midwives preferred that the supporter not be present during vacuum extraction, and 45% of them preferred that the supporter not be present during perineal suture. In contrast, among the laboring women, 78% preferred supporter presence during vacuum extraction, 76% during perineal suture and 74% during vaginal examination. Interestingly, even among the midwives, 82% preferred that the supporter remain during vaginal examination and 84% preferred the supporter remain during medical rounds. CONCLUSIONS: Serious consideration should be given to restricting the number of labor supporters to two, as both laboring woman and midwives consider that to be the optimal number. In light of the difference of opinion regarding presence of supporters during certain medical procedures, additional surveys concerning the points of view of obstetricians and laboring women in additional hospitals should be considered before establishing a national policy.

Colposcopy in Evaluating Bleeding During the Second and Third Trimesters: Short-Term and Postpartum Implications.

BACKGROUND: The etiology of vaginal bleeding during pregnancy may be obstetric or non-obstetric. Though colposcopy is generally not part of the routine evaluation of 2nd- or 3rd-trimester vaginal bleeding without obvious obstetrical cause, our department does perform colposcopy and cervical cytology testing in these patients. This study assessed the need and possible contribution of colposcopy in diagnosing the etiology of 2nd- and 3rd-trimester bleeding. METHODS: Retrospective analysis of colposcopy findings from 2012-2015 in patients with 2nd- or 3rd-trimester bleeding where an obstetrical cause was not found. Data collected included demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details. RESULTS: Of the 168 patients who underwent colposcopy, 29 (17.3%) complained of postcoital bleeding (PCB). The following were the colposcopy results: 5 (3%) had abnormal colposcopy findings, 14 (8.3%) ectropion, 4 (2.4%) polyps, and 1 (0.6%) vaginal varices. Postpartum follow-up of women with PCB or pathologic cervical cytology testing diagnosed 1(0.6%) patient with high-grade cervical intraepithelial neoplasia 2-3, human papillomavirus 18 and 45 positive. CONCLUSIONS: Colposcopy diagnosed the origin of bleeding in 24 cases (13.7%). These findings support the use of colposcopy in evaluating vaginal bleeding of undetermined obstetric origin during pregnancy.

The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta.

INTRODUCTION: The incidence of placenta accreta (PA) has markedly increased in the United States, from 1/30 000 in 1950 to 1/731 deliveries in 2011. Although placenta praevia after prior caesarean sections (CS) is the most important risk factor for PA, other risk factors make up 1-5% of PA occurrences. At our referral hospital, we use the pre-caesarean prophylactic balloon catheter with or without post-surgery embolisation in a hybrid room. Here, we evaluate the role of prior CS and placenta praevia on the outcome of this procedure. MATERIALS AND METHODS: This retrospective cohort analysis included 61 women during the years 2004-2016 with sonographic suspicion of PA who underwent balloon catheterisation prior to CS. RESULTS: Eleven women had no previous CS (18%). Mean previous CS rate was 1.85. Six women (9.8%) had previous dilatation and curettage (D&C); 36.4% of women with no previous CS had previous D&C compared with 4% of women with previous CS (P = 0.008). Placenta praevia was sonographically diagnosed in 55 women (90.2%). There was a higher rate of caesarean hysterectomy in women with previous CS than in those without (32% vs 0%, P = 0.052) but no significant difference in blood product requirements (45.5% vs 66%, P = 0.303). There was no significant difference in hysterectomy rate, blood transfusion or surgery duration between women with and without placenta praevia (P = 0.648, 0.594, 0.995, respectively). CONCLUSION: Previous CS rather than placenta praevia is a strong indicator of hysterectomy in cases of PA. Different risk factors for PA do not affect blood transfusion rates or surgery duration.

Labor progress indices and dynamics of the individual uterine contraction during the active stage of labor.

AIM: To obtain and study new data on the dynamics of the labor process and to develop a contraction-based index of labor progress. METHODS: This study was carried out at the Delivery Room, Department of Obstetrics and Gynecology, Western Galilee Hospital, Nahariya, Israel, using a new device (Birth Track). We continuously monitored cervical dilatation (CD) and head descent (HD) in 30 nulliparaous women during active labor with (augmented group) and without (study group) oxytocin augmentation. This led to the development and validation of progress indices based on features extracted from continuous monitoring. RESULTS: There were no significant differences between the average of each parameter in the study and augmented groups, except for HD velocity. Average HD velocity was faster in the study group. Linear regression analyses demonstrated that head station (HS) amplitude and Toco amplitude were the best parameters for predicting HD velocity in both groups. In the study group, average HD velocity was also significantly related to Toco rate and contraction efficiency. In the augmented group, only a weak correlation with Toco rate was seen, and no correlation with contraction efficiency. CONCLUSION: With the assistance of the Birth Track device, we can obtain continuous data on the labor process and indices to estimate the labor progress process without the use of vaginal (manual) examination.

Effectiveness of a novel home-based testing device for the detection of rupture of membranes.

We evaluated the ability of a testing panty liner (TPL) embedded with a pH/ammonia indicator polymer to differentiate amniotic fluid leakage from urine. A multicenter, open-label study in which 339 pregnant women (age 18 to 45 years, minimum 16 weeks' gestation, presenting with unexplained vaginal wetness) were enrolled. The TPL was worn and the results read by the subject and a health care provider (HCP) who was blinded to the subject's reading. Results were compared with the standard clinical diagnosis, as determined by direct visualization of vaginal pooling, crystallization (ferning), and nitrazine tests, performed by a second blinded HCP. Subject experience with the test was assessed with a brief questionnaire. The TPL accurately detected 154 of the 161 subjects found to have amniotic fluid leakage by the standard diagnosis; thus, the sensitivity of the TPL was 95.65%. The specificity was 84.46% (% true negative readings), as the TPL demonstrated a negative result for 125 of the 148 subjects whose clinical diagnosis was negative for amniotic fluid leakage. The overall agreement between the TPL readings of the clinician and that of the subject was 97.40%. The TPL is a reliable test to determine the presence of amniotic fluid leakage.

Cord blood lipids concentrations and their relation to body size at birth: possible link between intrauterine life and adult diseases.

Umbilical plasma levels of lipoproteins-cholesterol were measured in 480 normal newborns delivered by spontaneous vaginal delivery at 39 to 40 weeks of gestation. Plasma concentrations of lipids were related to fetal weight, abdominal and head circumference, and ponderal index at birth. Plasma concentration of low-density lipoprotein cholesterol (LDL-C) correlated negatively with abdominal circumference (AC), birth weight, and head circumference of newborns (p < 0.021, p < 0.023, p < 0.044, respectively). The baby with the smallest AC had the highest plasma concentration of LDL-C (p < 0.015). In the 165 neonates with ponderal index < 10th percentile, LDL-C was substantially elevated (p < 0.018). These findings suggest that disproportionate size at birth is associated with altered lipid metabolism. These abnormalities, if they persist, might lead to metabolic diseases in adulthood.