Postpartum obstetric complications: a guide for radiologists.

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

Association between the Dietary Inflammatory Index and the Risk of Cesarean Delivery.

Background: Cesarean section (CS) is one of the most important pregnancy concerns in the world. Increased inflammation is associated with increased risk factors for cesarean section. Diet plays a major role in reducing inflammation. This study aimed to investigate the relationship between dietary inflammatory index (DII) and the risk of Cesarean section in Tehranian women. Methods: This case-control study included 390 pregnant women in Tehran, Iran between 2020 and 2021 at their initial visit to pregnancy clinics, selected by a cluster sampling method. Dietary intakes were determined using valid reliable questionnaires and DII was calculated. Weight, height, and waist circumference were also measured. Results: The mean age of the subjects was 28.5 yr (± 5.02) and weight, body mass index (BMI) and waist circumference (WC) in the case group with a higher DII were higher. Odds ratio (OR) of cesarean section in DII quartiles was statistically significant. Confounding factors including age, BMI and total energy intake were adjusted in the first model and weight, waist circumference, physical activity and supplements in the second model and the relationship remained significant (P<0.001). Conclusion: High scores of dietary inflammatory index, possibly through an increase in inflammatory factors, can increase the chances of having a cesarean section.

Does Preoperative Coffee Consumption Prevent Intraoperative Hypotension in Cesarean Section Surgeries?

OBJECTIVE: In this study, we evaluated the effects of a cup of coffee given to patients before surgery in a cesarean section by means of intraoperative hypotension, ephedrine requirement, and the incidence of post-dural puncture headache (PDPH). METHODS: A total of 140 patients undergoing elective cesarean section with spinal anesthesia were included in this study. Participants who drank a single cup of filtered coffee two hours before spinal anesthesia were included in the coffee group, and those who drank water were in the control group. In each group, 70 patients were included. Hemodynamic parameters were recorded every three to five minutes after spinal anesthesia. Intraoperative use of ephedrine was recorded. The PDPH was monitored for three days. RESULTS: The incidence of intraoperative hypotension was 48.6% in the coffee group and 71.4% in the control group (p = 0.006). The rate of ephedrine usage (25.7%) was significantly lower in the coffee group (p = 0.001). The incidence of PDPH in the first 24 hours (2.9%) was significantly lower in the coffee group (11.4%). The visual analog scale (VAS) score was similar between groups (p = 0.048, p > 0.05). CONCLUSIONS: Consumption of a single cup of coffee before spinal anesthesia reduced the incidence of intraoperative hypotension and the rate of ephedrine usage in cesarean sections.

Successful management of pregnancy in Turner syndrome (Monosomy X): A rare condition-based learning experience from Vietnam.

Background: Turner syndrome (TS) is recognized with partial or complete loss of the second sex chromosome, occurring in approximately one in 2500 live births, and related to high failure of pregnancy. However, along with the advantage of assisted reproductive technology, the cases of TS pregnant women have been recently addressed worldwide. Therefore, the reproductive health of TS pregnant women should be a concern by physicians and obstetricians, particularly, in the low-middle income countries with low-resource settings. Case Presentation: Here, we describe a rare case of term pregnancy on a TS woman (45, XO) receiving oocyte donation at a private fertility center. Later, the woman was monitored uneventfully during antenatal care and hospitalized at our center for a cesarean delivery with favorable pregnancy outcomes at term. Conclusion: To our knowledge, this is the first report relating to a particular pathology in Vietnam. Through this case report, we would like to emphasize the novel opportunity for TS women desiring parents, thus raising an appropriate awareness of healthcare providers.

The value of routine hemoglobin level evaluation following elective cesarean section: Is it worthwhile?

OBJECTIVE: The aim of this study was to assess the usefulness of routine hemoglobin testing following elective and urgent cesarean section (CS) in patients without primary postpartum hemorrhage (PPH). METHODS: This retrospective cohort study included women who underwent vaginal delivery (VD), elective CS, and urgent CS at Carmel Medical Center from 2015 to 2020. Data were extracted from the obstetric database, excluding deliveries with PPH. Demographic and obstetric variables were recorded. Primary outcomes were the need for packed red blood cell transfusion. RESULTS: A total of 19 446 women were included, with five (0.3%) requiring a blood transfusion in the elective CS group, 27 (0.17%) in the VD group, and eight (0.4%) in the urgent CS group. Urgent CS was associated with a higher risk of blood transfusion, but there was no significant difference between elective CS and VD. Elective CS showed the lowest rates of post-delivery hemoglobin below 7 g/dL 1 (0.1%) compared to VD 16 (0.6%) and urgent CS 13 (0.7%). CONCLUSION: Routine postoperative hemoglobin testing following elective CS in asymptomatic patients without PPH appears unnecessary. This study supports reconsidering routine hemoglobin testing following elective CS, aligning with the goal of optimizing resource utilization while maintaining patient quality.

The effect of neurolinguistic programming and progressive muscle relaxation exercises on breastfeeding success and breastfeeding self-efficacy: A randomized controlled trial.

INTRODUCTION: This research was to determine the effect of neurolinguistic programming (NLP) and progressive muscle relaxation exercises (PMRE) on breastfeeding success and breastfeeding self-efficacy in primiparous women after cesarean section. MATERIAL AND METHODS: This is a single-blind, three-arm, parallel-group, randomized controlled trial. Data were collected between 01 October 2023, and 18 December 2023. The sample of the study consisted of 99 primiparous women who gave birth by cesarean section (NLP=33, PMRE=33, and control=33). Women were randomly assigned to the groups. Starting from the first mobilization time after cesarean section, NLP was applied to the NLP group and PMRE was applied to the PMRE group every eight hours for 48 h. In the control group, NLP or PMRE was not applied and the women were allowed to rest on their backs. The primary outcomes of the study were breastfeeding success and breastfeeding self-efficacy. RESULTS: The mean scores of breastfeeding success and breastfeeding self-efficacy measured over time were highest in the NLP group and lowest in the control group (p<.05). The mean scores of breastfeeding success and breastfeeding self-efficacy measured over time increased by 78.4 %, and 97.7 %, respectively, in the NLP group compared to the control group, 74.7 %, and 88.1 %, in the PMRE group compared to the control group, and 13.5 %, and 90.2 %, respectively, in the NLP group compared to the PMRE group (p<.05). CONCLUSION: NLP intervention may have a more positive effect on breastfeeding success and breastfeeding self-efficacy than PMRE intervention. TRIAL AND PROTOCOL REGISTRATION: ClinicalTrials.gov, NCT06070792.

A common problem between gynecology, obstetrics, and reproductive medicine: Cesarean section scar defect.

Approximately 60% of patients undergoing Cesarean sections may develop Cesarean Scar Defect (CSD), presenting a significant clinical challenge amidst the increasing Cesarean section rates. This condition, marked by a notch in the anterior uterine wall, has evolved as a notable topic in gynecological research. The multifactorial origins of CSD can be broadly classified into labor-related factors, patients' physical conditions, and surgical quality. However, conflicting influences of certain factors across studies make it challenging to determine effective preventive strategies. Additionally, CSD manifests with diverse symptoms, such as abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, secondary infertility, and Cesarean scar pregnancy. Some symptoms are often attributed to other diagnoses, leading to delayed treatment. The quandary of when and how to manage CSD also adds to the complexity. Despite the development of various therapies, clear indications and optimal methods for specific conditions remain elusive. This longstanding challenge has troubled clinicians in both identifying and addressing this iatrogenic disease. Recent studies have yielded some compelling consensuses on various aspects of CSD. This review aims to consolidate the current literature on every facet of CSD. We hope to raise awareness among clinicians about this clinical problem, encouraging more relevant research to unveil the complete picture of CSD.

A randomized controlled trial reducing cesarean delivery rates in China by introducing trial of labor after cesarean and electrohysterography.

OBJECTIVE: A cesarean delivery (CD) can affect health of both mother and child and future pregnancies. Since the abandonment of the one-child policy in China, obstetricians tend to perform a repeat CD rather than a trial of labor after cesarean (TOLAC). This study aims to reduce CD rates by increasing vaginal births after cesarean (VBAC) rates and introducing electrohysterography (EHG) for accurate monitoring. METHODS: In total, 82 women received counseling regarding TOLAC at the Shijiazhuang Sixth Hospital in China. Women opting for TOLAC were randomized for either external tocodynamometry (TOCO, i.e. standard care) or EHG. The primary outcome was the VBAC rate. Secondary outcomes were indications for CD, percentage of assisted vaginal deliveries, labor duration, maternal blood loss, complications and neonatal outcomes. RESULTS: After accounting for preterm delivery and dropouts, all counseled women opted for a TOLAC (100%). After randomization, 42 women were included in the TOCO-group and 37 in the EHG-group. Women did not receive pain medication and labor was not augmented with oxytocin. The VBAC rate was 71.4% in the TOCO-group, versus 78.4% in the EHG-group (p = .48). Birth was assisted with forceps in 11.9% of TOCO-group versus 2.7% of EHG-group (p = .21). One secondary CD (i.e. a shift from intended vaginal delivery to surgical delivery within the same labor) was performed because of a suspicion of uterine rupture (TOCO-group). Other indications for CD were: fetal distress, labor dystocia, fetal position, cephalopelvic disproportion. There were no significant differences in secondary study outcomes. No complications were reported. CONCLUSION: This study showed an average VBAC rate of 75%, without any complications, in a hospital with no previous experience with TOLAC. The VBAC rate with EHG-monitoring was higher than TOCO, although this difference was not significant. To demonstrate a significant difference, larger clinical studies are necessary. TRIAL REGISTRATION: The Daily Board of the Medical Ethics Committee of The Maternal and Child Hospital of Shijiazhuang approved the study protocol (number 20171018, Dutch Trial Register NL8199).

Maternal outcomes of conservative management and cesarean hysterectomy for placenta accreta spectrum disorders: a systematic review and meta-analysis.

BACKGROUND: Cesarean hysterectomy as a traditional therapeutic maneuver for placenta accreta spectrum (PAS) has been associated with serious morbidity, conservative management has been used in many institutions to treat women with PAS. This systematic review aims to compare maternal outcomes according to conservative management or cesarean hysterectomy in women with placenta accreta spectrum disorders. METHODS: A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and four Chinese databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Wanfang database and VIP database) to May 2024. Included studies were to be retrospective or prospective in design and compare and report relevant maternal outcomes according to conservative management (the placenta left partially or totally in situ) or cesarean hysterectomy in women with PAS. A risk ratio (RR) with 95% confidence interval (95% CI) was calculated for categorical outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. The Newcastle-Ottawa Quality Assessment Scale was used to assess the observational studies. All analyses were performed using STATA version 18.0. RESULTS: Eight studies were included in the meta-analysis. Compared with cesarean hysterectomy, PAS women undergoing conservative management showed lower estimated blood loss [WMD - 1623.83; 95% CI: -2337.87, -909.79], required fewer units of packed red blood cells [WMD - 2.37; 95% CI: -3.70, -1.04] and units of fresh frozen plasma transfused [WMD - 0.40; 95% CI: -0.62, -0.19], needed a shorter mean operating time [WMD - 73.69; 95% CI: -90.52, -56.86], and presented decreased risks of bladder injury [RR 0.24; 95% CI: 0.11, 0.50], ICU admission [RR 0.24; 95% CI: 0.11, 0.52] and coagulopathy [RR 0.20; 95% CI: 0.06, 0.74], but increased risk for endometritis [RR 10.91; 95% CI: 1.36, 87.59] and readmission [RR 8.99; 95% CI: 4.00, 12.21]. The incidence of primary or delayed hysterectomy rate was 25% (95% CI: 19-32, I2 = 40.88%) and the use of uterine arterial embolization rate was 78% (95% CI: 65-87, I2 = 48.79%) in conservative management. CONCLUSION: Conservative management could be an effective alternative to cesarean hysterectomy when women with PAS desire to preserve the uterus and are informed about the limitations of conservative management. PROSPERO ID: CRD42023484578.

Do Not Get Your Uterus Twisted: A Case Report of a 180-Degree Torsion of Term Gravid Uterus and a Review of the Literature.

Gravid uterine torsion less than 45 degrees is a common phenomenon of the third trimester. Torsion greater than 45 degrees represents a rare, pathologic, and obstetric emergency. The rotation of the uterus on a longitudinal plane can result in vascular compromise, and it has potential for catastrophic maternal-fetal complications. We report the case of a 22-year-old G3P1011, third pregnancy with history of one full-term live newborn, one spontaneous abortion, and presented at 38 weeks gestation with complaints of abdominal pressure and recurrent transverse fetal presentation. She underwent an external cephalic version (ECV), which resulted in fetal distress necessitating an emergency cesarean section. After successful delivery of the live newborn, an inspection of the uterus identified a uterine torsion of 180 degrees with delivery through a posterior hysterotomy incision. She had no postoperative complications and carried a subsequent pregnancy to term that was delivered via repeat cesarean section five years later. Gravid uterine torsion should be included in the differential diagnosis for patients presenting with abdominal pain and fetal intolerance to labor. A higher suspicion should be held for patients with a known history of uterine abnormalities or those having undergone an ECV. Our case also highlights a safe repeat cesarean section after this rare complication and brief narrative review of existing literature on this rare obstetrical emergency.

Comparing the Efficacy of Foot Reflexology and Benson's Relaxation on Anxiety and Physiologic Parameters After Cesarean Surgery.

OBJECTIVE: To compare the efficacy of foot reflexology and Benson's relaxation on anxiety and physiologic parameters after cesarean surgery. DESIGN: Randomized controlled trial with three parallel arms. SETTING: Gynecologic ward of the Persian Gulf Martyrs Hospital in Bushehr, Iran, in 2020. PARTICIPANTS AND INTERVENTIONS: Women undergoing cesarean surgery (n = 135) were selected by convenience sampling and divided via block randomization into three groups of foot reflexology, Benson's relaxation interventions, and control group (n = 45 in each group). Interventions were performed 2 hours after cesarean surgery. MEASUREMENTS: Spielberger's State-Trait Anxiety Inventory, mercury sphygmomanometer, and pulse oximeter were used to collect the data. Anxiety was measured before and 30 minutes after the intervention. Physiologic parameters were measured before the intervention and immediately, 30 minutes, and 60 minutes after the intervention. Data were analyzed using inferential statistics. RESULTS: The mean score of situational anxiety after the intervention was significantly lower than before the intervention in the reflexology (t = 6.171; 95% confidence interval [CI] [5.66, 11.14]) and Benson's relaxation groups (t = 7.362; 95% CI [5.91, 9.85]). However, changes in the control group were not significant (t = 1.674; 95% CI [-0.24, 2.55]). Decreases in anxiety scores were similar in the two intervention groups. After intervention, in most measurement times, respiratory rate and pulse rate decreased in the two intervention groups compared to the control group, and arterial oxygen saturation and systolic blood pressure increased. CONCLUSION: Considering the effect of both interventions on decreasing anxiety and improving most physiologic parameters, it seems that foot reflexology and Benson's relaxation can be recommended after cesarean surgery.

The effect of cesarean delivery on the neonatal gut microbiome in an under-resourced population in the Bronx, NY, USA.

BACKGROUND: Neonatal and early-life gut microbiome changes are associated with altered cardiometabolic and immune development. In this study, we explored Cesarean delivery effects on the gut microbiome in our high-risk, under-resourced Bronx, NY population. RESULTS: Fecal samples from the Bronx MomBa Health Study (Bronx MomBa Health Study) were categorized by delivery mode (vaginal/Cesarean) and analyzed via 16 S rRNA gene sequencing at four timepoints over the first two years of life. Bacteroidota organisms, which have been linked to decreased risk for obesity and type 2 diabetes, were relatively reduced by Cesarean delivery, while Firmicutes organisms were increased. Organisms belonging to the Enterococcus genus, which have been tied to aberrant immune cell development, were relatively increased in the Cesarean delivery microbiomes. CONCLUSION: Due to their far-reaching impact on cardiometabolic and immune functions, Cesarean deliveries in high-risk patient populations should be carefully considered.

Early first-trimester transvaginal ultrasound screening for Cesarean scar pregnancy in patients with previous Cesarean delivery: analysis of the evidence.

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last two decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of Cesarean scar pregnancy. There is a growing body of evidence suggesting that Cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, Cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous Cesarean delivery. This Opinion article evaluates the scientific and clinical basis of whether Cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by Cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

A Retrospective Exploration of Pre-operative Antibiotic Prophylaxis with Cefazolin in Cesarean Sections: Implications for Obstetrics and Gynecologic Surgery.

Background: Post-partum infection is a major contributor to maternal mortality and is responsible for approximately 10% of maternal fatalities worldwide. The risk of infection is substantially higher in cesarean section procedures. Approximately 8% of women who undergo cesarean sections are susceptible to infection. Although the body of evidence supporting the regular pre-operative utilization of prophylactic antibiotic treatment is steadily expanding, its usefulness in cesarean sections has not yet been standardized, and post-partum infection is still a serious medical challenge. We aimed to retrospectively assess the prophylactic effectiveness of cefazolin in combination with other antibiotic agents in cesarean sections. Materials and Methods: Both uni-variable and multi-variable analyses were conducted to identify factors that may affect cefazolin pre-operative antibiotic prophylaxis in elective cesarean section operations. The uni-variable analysis included timing of administration, operation duration, body mass index (BMI), and wound type. A multi-variable logistic regression model was then created to determine which variables provide independent information in the context of other variables. Results: Time of administration did not affect prophylactic cefazolin efficacy. However, prophylactic cefazolin was 1.43 and 1.77 times more effective when the operation lasted for 45 minutes or more, compared with operations that were shorter than 45 minutes. Patients with a BMI ranging from 18 to 29 kg/m2 showed increased efficacy of prophylactic cefazolin compared with obese patients with a BMI exceeding 30 kg/m2. The effectiveness of prophylactic cefazolin decreased by 95% in patients with clean-contaminated surgical incisions compared with those with clean surgical incisions. Conclusions: Our findings demonstrate that administering pre-operative prophylactic antibiotic agents to women undergoing cesarean section resulted in a reduction in post-partum infections, thereby reducing maternal mortality. Furthermore, optimal timing of administration, re-dosing if necessary, length of prophylactic medication, and dosing adjustments for obese patients are crucial factors in preventing surgical site infections and promoting antimicrobial stewardship.

Striking rise of cesarean section rates in Türkiye: there is a need for a whole new perspective.

Since 2003, the Turkish Ministry of Health (TMOH) has activated a reformed system called Health Transformation Program (HTP) which has assertive goals. Health transformation program has brought about important improvements in many health topics. However, at the beginning of HTP, cesarean section (C-section) rate was approximately 30%, having exceeded 50% in 2013 which reflected the highest rate in Organization for Economic Cooperation and Development (OECD). Currently, most of the deliveries are carried out via C-section in Türkiye which started disputes about whether the high rate of C-section is Achilles' heel of HTP. To overcome high C-section rate, TMOH has been making intensive efforts and taking serious measures in recent years including passing a law to ban elective C-sections. Despite the strict measures taken C-section rate didn't decrease instead increased gradually. The current situation shows that the problem is more complicated than the authorities figure out, and a whole new perspective on the issue is needed.

Up-and-Down Determination of Different Crystalloid Coload Volumes on the ED 90 of Prophylactic Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension During Cesarean Section.

Background: Fluid loading improves hemodynamic stability and reduces the incidence rate of post-spinal anesthesia hypotension when prophylactic vasopressors are administered. We investigated the impact of different crystalloid coload volumes on the 90% effective dose (ED) of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension in non-hypertensive patients undergoing cesarean section. Methods: Patients were randomly allocated to receive one of the different crystalloid coload volumes (0mL/kg [0mL/kg Group], 5mL kg [5mL/kg Group], and 10mL kg [10mL/kg Group]) in combination with prophylactic norepinephrine infusion immediately after the induction of spinal anesthesia. The prophylactic norepinephrine infusion doses were determined using the up-and-down sequential allocation methodology, with an initial dose of 0.025 µg/kg/min and a gradient of 0.005 µg/kg/min. The primary endpoint was the effective dose at which 90% (ED 90) of patients responded to prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension. Results: The estimated effective dose of norepinephrine infusion, at which 90% (ED 90) of patients responded, was found to be 0.084 (95% CI, 0.070 to 0.86), 0.074 (95% CI, 0.059 to 0.077), and 0.063 (95% CI, 0.053 to 0.064) µg/kg/min in the three groups, respectively. Conclusion: A crystalloid coload of 5 mL/kg or 10 mL/kg, as opposed to the groups receiving 0 mL/kg crystalloid coloads, resulted in a reduction of approximately 11.9% and 25.0%, respectively, in the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean section.

Paradoxical air embolism in patients undergoing hysteroscopic surgery for cesarean scar pregnancy: A case report and review of the literatures.

Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low-resistant, high-velocity blood vessels.