Safety of laparoscopic surgery during pregnancy: a Korean nationwide population-based study.

BACKGROUND: The optimal surgical approach to perform during pregnancy is still controversial. This study evaluated pregnancy and operative outcomes in women undergoing an appendectomy or cholecystectomy during pregnancy, and compared them between the laparoscopic and open approach using nationwide population-based data. METHODS: Between 2009 and 2019, a total of 2941 pregnant women with procedure codes for an appendectomy or cholecystectomy were extracted from the Korean National Health Insurance claims data (laparoscopy: 1504; open: 1437). Surgical outcomes [length of stay (LOS), anesthesia time, 30-day readmission rates, transfusion rates, second laparotomy, and 30-day mortality rates] and pregnancy outcomes (live birth rate, overall and spontaneous abortion rates, threatened abortion rate, type of delivery, preterm labor, stillbirth, fetal screening abnormalities, and intrauterine growth retardation) were compared between the open and laparoscopic groups. RESULTS: The laparoscopic group had a significantly shorter LOS than the open group, and transfusions were less frequent in the laparoscopic group. Mortality, 30-day readmission rates, and second laparotomy were not statistically significant between the two groups. There were no significant differences in fetal loss and live birth rates between the two groups in all gestational ages. Preterm labor within 30 days of surgery was more frequent in the laparoscopy group than in the open surgery group, especially for those in their first and third trimesters. Open procedures were associated with an increased rate of cesarean sections. CONCLUSIONS: Laparoscopic surgery was found to be feasible and safe without adverse postoperative outcomes. Careful observation of postoperative preterm labor is necessary, especially for women who undergo laparoscopic surgery in their first and third trimesters.

Necrotizing Funisitis as an Intrauterine manifestation of Cryopyrin-Associated Periodic Syndrome: a case report and review of the literature.

BACKGROUND: Cryopyrin-associated periodic syndrome (CAPS) is a life-long, autoinflammatory disease associated with a gain-of-function mutation in the nucleotide-binding domain, leucine-rich repeat family, pyrin domain containing 3 (NLRP3) gene, which result in uncontrolled production of IL-1ß and chronic inflammation. Chronic infantile neurologic cutaneous and articular (CINCA) syndrome/neonatal-Onset multisystem inflammatory disease (NOMID) is the most severe form of CAPS. Although the first symptoms may be presented at birth, there are few reports on the involvement of the placenta and umbilical cord in the disease. Therefore, we present herein a preterm case of CINCA/NOMID syndrome and confirms intrauterine-onset inflammation with conclusive evidence by using fetal and placental histopathological examination. CASE PRESENTATION: The female patient was born at 33weeks of gestation by emergency caesarean section and weighted at 1,514 g. The most common manifestations of CINCA/NOMID syndrome including recurrent fever, urticarial rash, and ventriculomegaly due to aseptic meningitis were presented. She also exhibited atypical symptoms such as severe hepatosplenomegaly with cholestasis. The genetic analysis of NLRP3 revealed a heterozygous c.1698 C > G (p.Phe566Leu) mutation, and she was diagnosed with CINCA/NOMID syndrome. Further, a histopathological examination revealed necrotizing funisitis, mainly inflammation of the umbilical artery, along with focal neutrophilic and lymphocytic villitis. CONCLUSIONS: The necrotizing funisitis, which only involved the artery, was an unusual observation for chorioamnionitis. These evidences suggest that foetal inflammation, probably due to overproduction of IL-1ß, caused tissue damage in utero, and the first symptom of a newborn with CINCA/NOMID.

Parto pré-termo espontâneo sem rotura de membranas: intervenções para evitar o parto pré-termo / Spontaneous preterm birth without rupture of membranes: interventions to prevent preterm birth

A prematuridade é uma síndrome com múltiplos fatores de risco e cuja causa permanece desconhecida, mas, independentemente da etiologia, a parturição converge para uma via final comum de esvaecimento, dilatação e encurtamento do colo uterino. Do ponto de vista hormonal, o responsável por esse processo é a progesterona. A prevenção de quadros de prematuridade pode basear-se em tratamentos medicamentosos como a administração diária de comprimidos de progesterona; intervenções cirúrgicas para a contenção da cérvice uterina com fios inabsorvíveis mantidos até o termo, a cerclagem cervical; e o pessário cervical, dispositivo de silicone que envolve e inclina o colo uterino, evitando sua abertura. Para propor qualquer intervenção profilática ou terapêutica, a avaliação ultrassonográfica via transvaginal no segundo trimestre gestacional desempenha papel crucial. Apresentamos neste terceiro e último artigo da série sobre parto pré-termo espontâneo as intervenções terapêuticas e o rastreamento do colo uterino.(AU)

Preterm birth is a syndrome with multiple risk factors, with unknown etiology. Parturition converges to a final path with uterine cervix effacement, dilation and shortening and progesterone is the hormone responsible for this process. Preterm birth prevention relies on daily administration of progesterone pills; cerclage as a surgical intervention; or cervical pessary, a vaginal silicone device that enfolds and deflects the cervix, avoiding its opening. To propose any of these interventions it is crucial to evaluate the cervix during the second trimester by transvaginal ultrasound. Here, in the third and last article regarding preterm birth without membrane disruption, we present therapeutic interventions and ultrasound screening.(AU)

Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31 weeks' gestation: The EPIPAGE-2 cohort study.

INTRODUCTION: The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation. MATERIAL AND METHODS: Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association. RESULTS: The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16). CONCLUSIONS: Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Mode of Delivery in Previable Births.

OBJECTIVE: Preterm birth before 23 weeks of gestation typically results in neonatal death (5% survival). Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists published consensus guidelines recommending cesarean delivery (CD) not be performed for fetal indications between 20 and 226/7 weeks given the lack of proven benefit. We sought to quantify the previable CD rate and identify characteristics associated with previable CD. METHODS: We performed a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of previable CD was stratified by week of gestation, defined as delivery between 16 and < 23 weeks of gestation. Maternal, obstetric, and neonatal characteristics were compared between women who underwent vaginal delivery versus CD. Multivariable logistic regression estimated the relative influence of maternal and fetal factors on the outcome of CD among previable live births. RESULTS: Of 1,463,506 live births in Ohio during the 10-year study period, 2,865 births (0.2%) occurred during the previable period of 16 to 22 weeks. Nearly 1 in 10 live births at less than 23 weeks was delivered by cesarean (n = 273/2,865), CD rate 9.5% (95% confidence interval, 8.5-10.7). At 16 to 22 weeks of gestation, the CD rates were 0, 5.5, 7.6, 3.5, 5.4, 10.1, and 15.1%, respectively. Factors associated with CD included increasing parity, increasing birth weight, maternal corticosteroid administration, and fetal malpresentation. Previable neonates born by CD were more likely to be admitted to the NICU, receive ventilator support, and more likely to be living at the time of birth certificate filing. CONCLUSION: Nearly 1 out of 10 births during the previable period was delivered via cesarean. Factors associated with previable CD suggest intent for neonatal interventions, such as NICU admission and supportive therapies. Our findings support that education and adherence with guidelines for care of previable births are a potential area of focus for perinatal quality improvement efforts.

Clinical and Microbiologic Characteristics of Early-onset Sepsis Among Very Low Birth Weight Infants: Opportunities for Antibiotic Stewardship.

BACKGROUND: Most very low birth weight (VLBW, birth weight <1500 g) infants receive empiric antibiotics for risk of early-onset sepsis (EOS). The objective of this study was to determine the characteristics of VLBW infants with culture-confirmed EOS at a single center during 25 years and to identify opportunities for antibiotic stewardship. METHODS: Retrospective cohort study includes VLBW infants admitted from 1990 to 2015. EOS was defined as isolation of a pathogen in blood or cerebrospinal fluid culture obtained at <72 hours of age. Clinical and microbiologic characteristics of EOS case infants were obtained by review of medical, laboratory and administrative records. Blood culture, antibiotic initiation and maternal discharge code data were available for all VLBW infants born between 1999 and 2013. RESULT: One-hundred nine EOS cases (20.5/1000 VLBW births) occurred during the study period. Preterm labor, preterm rupture of membranes and/or the obstetrical diagnosis of chorioamnionitis were present in 106/109 cases (97%). Obligate anaerobic organisms accounted for 16% of cases. Time to culture positivity was 36 hours for 88% and 48 hours for 98% of cases. From 1999 to 2013, 97% of VLBW infants were evaluated for EOS and 90% administered empiric antibiotics; 22% of these infants were born by cesarean section to mothers with preeclampsia and without preterm labor or chorioamnionitis and had a 12-fold lower incidence of EOS compared with the remaining infants. CONCLUSION: Decisions to initiate and discontinue empiric antibiotics among VLBW infants can be informed by the delivery characteristics of infected infants and by local microbiologic data.

Maternal and fetal arterial blood gas data during general anaesthesia for caesarean delivery of preterm twin lambs.

Much remains to be understood with regards the effects of prolonged anaesthesia on maternal and fetal haemodynamics and oxygenation. With the aim of improving anaesthetic management of pregnant sheep undergoing recovery surgery under anaesthesia, paired maternal and fetal arterial blood samples were collected during caesarean delivery of twin preterm lambs to document the blood gas status of the ewe and fetus. Twenty-one Merino twin pregnant ewes at 126 (±1) days of gestation were anaesthetized for caesarean delivery of their fetuses. Arterial blood samples were collected from the radial artery of the ewe and umbilical artery of the fetus at the point of delivery. There was a significant difference between maternal PaCO2 and end-tidal CO2 and alveolar and arterial PaO2, indicating ventilation perfusion mismatch. Interestingly, the ewes were anaemic but the fetuses were not. These data underscore the need to undertake further work to determine the optimal anaesthetic regimen for twin pregnant ewes at different gestational ages in a biomedical research setting.

Placenta accreta in a patient with a history of uterine artery embolization for postpartum hemorrhage.

Uterine artery embolization (UAE) is used to treat various conditions from uterine leiomyoma to uncontrollable bleeding. We describe a case of placenta accreta after a prior delivery, which required UAE to control a postpartum hemorrhage. This case highlights the importance of both antenatal evaluation of placentation and heightened precaution for delivery in subsequent pregnancies for women who have undergone this procedure.

Comparison of 2 stitches vs 1 stitch for transvaginal cervical cerclage for preterm birth prevention.

OBJECTIVE: The objective of the study was to compare the efficacy and outcomes of 2 vs 1 stitch at the time of cervical cerclage placement for preterm birth prevention. STUDY DESIGN: This was a retrospective cohort study of women with singleton gestation undergoing history- or ultrasound-indicated transvaginal cervical cerclage prior to 24 weeks. The primary outcome was delivery at less than 37 weeks. The secondary outcomes included gestational age at delivery at less than 35, less than 34, less than 32, less than 28, and less than 24 weeks, perioperative details at the time of cerclage placement and removal, and maternal and neonatal outcomes. Comparison was made between patients with 2 vs 1 stitch at the time of cerclage placement. History- and ultrasound-indicated cerclages were analyzed separately. RESULTS: Four hundred forty-four patients met inclusion criteria, 237 being history indicated (2 stitches, n = 86, 1 stitch, n = 151), and 207 ultrasound indicated (2 stitches, n = 117, 1 stitch, n = 90). Gestational age at delivery at less than 37 weeks was not significantly different between the 2 groups for both history- and ultrasound-indicated cerclage, even after adjusting for demographic differences and suture type (39% vs 35%; adjusted odds ratio, 1.38; 95% confidence interval, 0.64-3.01; and 44% vs 49%; adjusted odds ratio, 0.66; 95% confidence interval, 0.27-1.61, respectively). CONCLUSION: Two stitches at the time of cerclage do not appear to improve pregnancy outcome either in the history- or the ultrasound-indicated procedures, compared with 1 stitch.

Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of laparoscopic abdominal cerclage placement in the prevention of recurrent preterm birth. STUDY DESIGN: We conducted a multicenter cohort study with retrospective Dutch (32 patients) and Boston (34 patients) cohorts who had undergone preconceptional laparoscopic abdominal cerclage placement. Eligible patients had at least 1 second/third trimester fetal loss or delivered at <34 weeks of gestation because of cervical insufficiency and/or a short or absent cervix. Primary outcome was delivery of an infant at ≥ 34 weeks of gestation with neonatal survival. Secondary outcome measures included surgical and pregnancy outcomes and patients' satisfaction (Dutch cohort). RESULTS: Surgical outcomes of 66 patients were excellent, with 3 minor complications. After preconceptional laparoscopic abdominal cerclage, 35 pregnancies were evaluated. Twenty-five patients (71.4%) delivered at ≥ 34 weeks of gestation; 3 patients (8.6%) experienced a second-trimester fetal loss. The total fetal survival rate was 90.0%. CONCLUSION: Preconceptional laparoscopic abdominal cerclage shows encouraging and favorable perinatal outcomes in patients with a poor obstetric history.

Cervical cerclage: one stitch or two?

OBJECTIVE: We sought to determine whether routine placement of a second stitch at the time of cervical cerclage improves its efficacy. STUDY DESIGN: This is a retrospective cohort study of patients who had cervical cerclage placement at a single institution. Operative reports, ultrasound images, and delivery records were reviewed. Pregnancy outcomes of patients receiving a two-stitch cerclage were compared with those who received a one-stitch cerclage, with a primary outcome of spontaneous preterm delivery at <35 weeks' gestation. Univariable, multivariable, and Kaplan-Meier survival analyses were performed. RESULTS: Of 146 patients, 63 had two stitches and 83 had one. Baseline characteristics and indications for cerclage were similar except for differences in history of prior cerclage and multiple gestations. The two-stitch approach was associated with a greater median cerclage height (20 mm versus 17 mm, p = 0.008), but there was no difference in spontaneous preterm delivery at <35 weeks' gestation (47.6% versus 41.0%, adjusted odds ratio 1.22, p = 0.630). CONCLUSION: A two-stitch approach to cervical cerclage increases cerclage height, but may not improve efficacy.

Does increasing body mass index affect cerclage efficacy?

OBJECTIVE: To study the relationship between body mass index (BMI) and gestational age (GA) at delivery in patients with cervical insufficiency (CI) undergoing cerclage. STUDY DESIGN: We accessed a database of patients with singleton gestations undergoing cerclage (N=168) for a well-characterized history of CI, shortened cervix <2.5 cm with a history of prior preterm delivery or prolapse of membranes through the external os. Univariate and multivariate logistic regression analysis were performed to compare obstetrical outcomes between obese and normal-weight patients. RESULT: Prior preterm delivery <35 weeks in obese vs normal-weight patients was significantly higher (44% vs 9%), odds ratio=6.9 (95% CI: 2.5, 18.5), with lower mean GA at delivery (32.6±7.0 vs 37.2±3.4 weeks, P<0.001). After controlling for confounders, BMI remained significantly predictive of prematurity (coefficient: -0.12, adjusted R (2)=0.24), such that every additional 1 unit of BMI was associated with a 1-day reduction in GA at delivery (P=0.03). CONCLUSION: An inverse correlation exists between BMI and GA at delivery in patients with CI receiving cerclage. The findings are unexpected given the protective effect of obesity on spontaneous preterm delivery.

Re-evaluation of the subgroup analysis from the Royal College of Obstetricians and Gynaecologists randomized controlled trial of cervical cerclage.

History-indicated cervical cerclage is offered to patients who are at risk of spontaneous preterm birth (SPTB), though the indications are controversial. A common practice of offering cerclage after three prior SPTBs or midtrimester losses (MTLs) is based on findings of the subgroup analysis of the 1993 Royal College of Obstetricians and Gynaecologists (RCOG) randomized trial of cervical cerclage. The subgroup analysis was performed by repeating the primary analysis within individual subgroups, which can lead to erroneous conclusions. We repeated the subgroup analysis by evaluating the interaction between the characteristic of interest and treatment allocation in a regression model. The interaction between cerclage and any prior PTB as a binary variable was non-significant. Among subjects delivering at <37 weeks, there was a significant interaction between cerclage and prior PTBs as a continuous variable or ≥ 3 (p-values 0.04 and 0.03, respectively). There were no significant interactions between cerclage and the aforementioned outcomes among women who delivered at <33 weeks, though this may have been secondary to a smaller number of SPTB in this range. Our findings lend credence to the current recommendations regarding the use of history-indicated cerclage, though they remain subject to the inherent limitations of subgroup analyses.

Perioperative complications of history-indicated and ultrasound-indicated cervical cerclage.

OBJECTIVE: To evaluate perioperative complications of history- and ultrasound-indicated cerclage. METHODS: We performed a retrospective observational study of a cohort of patients who underwent history- (n = 198) or ultrasound-indicated (n = 89) cerclage procedures. We evaluated the rates of perioperative complications based on indication for cerclage. The χ(2) was used for categorical variables and Student t test for continuous data. RESULTS: One patient (0.35%) had an intraoperative complication (unsuccessful regional anesthesia) and 1 patient (0.35%) had a postoperative complication (contractions and bleeding 2 weeks after cerclage placement, delivered a nonviable infant). Peripartum complications included chorioamnionitis (6.2%), preterm premature rupture of membranes (11%), preterm delivery (20%), and delivery before 32 weeks' gestational age (8%), and they were similar in the history-indicated and ultrasound-indicated groups. CONCLUSION: History- and ultrasound-indicated cerclages are associated with a 0.6%; 95% confidence interval, -0.26 to 1.66 risk of perioperative complications. There was no difference in perioperative complications or outcome between the 2 groups.

Upregulated amniotic fluid cytokines and chemokines in emergency cerclage with protruding membranes.

PROBLEM To identify the prognostic factors for pregnancy outcome in women who received emergency cerclage for dilated cervix with protruding membranes. METHOD OF STUDY A prospective cohort study was performed, and a total of 14 women who received emergency cerclage were included. Clinical features and laboratory findings including amniotic fluid cytokines and chemokines were compared between women who had successful pregnancy (survival group, n = 6) and those who had perinatal death (non-survival group, n = 8). Five healthy pregnant women served for normal controls for amniotic fluid study. RESULTS The overall neonatal survival was 42.9% in women with emergency cerclage. Serum C-reactive protein levels on postoperative day 3 and 7 were significantly higher in non-survival group when compared with those in survival group (P = 0.002, P = 0.01). Amniotic fluid levels of interleukin (IL)-1α, IL-1ß, IL-6, IL-8, IL-10, tumor necrosis factor-α, and monocyte chemoattractant protein-1 levels of the patients were significantly higher than those of normal controls. Amniotic fluid levels of IL-1α, IL-1ß, and IL-8 were significantly increased in the non-survival group when compared with those of the survival group. CONCLUSION Systemic and local inflammatory markers including proinflammatory cytokines and chemokines may predict pregnancy outcome in women with emergency cerclage for dilated cervix with protruding membranes.

Transection of the pelvic or vagus nerve forestalls ripening of the cervix and delays birth in rats.

Innervation of the cervix is important for normal timing of birth because transection of the pelvic nerve forestalls birth and causes dystocia. To discover whether transection of the parasympathetic innervation of the cervix affects cervical ripening in the process of parturition was the objective of the present study. Rats on Day 16 of pregnancy had the pelvic nerve (PnX) or the vagus nerve (VnX) or both pathways (PnX+VnX) transected, sham-operated (Sham) or nonpregnant rats served as controls. Sections of fixed peripartum cervix were stained for collagen or processed by immunohistochemistry to identify macrophages and nerve fibers. All Sham controls delivered by the morning of Day 22 postbreeding, while births were delayed in more than 75% of neurectomized rats by more than 12 h. Dystocia was evident in more than 25% of the PnX and PnX+VnX rats. Moreover, on prepartum Day 21, serum progesterone was increased severalfold in neurectomized versus Sham rats. Assessments of cell nuclei counts indicated that the cervix of neurectomized rats and Sham controls had become equally hypertrophied compared to the unripe cervix in nonpregnant rats. Collagen content and structure were reduced in the cervix of all pregnant rats, whether neurectomized or Shams, versus that in nonpregnant rats. Stereological analysis of cervix sections found reduced numbers of resident macrophages in prepartum PnX and PnX+VnX rats on Day 21 postbreeding, as well as in VnX rats on Day 22 postbreeding compared to that in Sham controls. Finally, nerve transections blocked the prepartum increase in innervation that occurred in Sham rats on Day 21 postbreeding. These findings indicate that parasympathetic innervation of the cervix mediates local inflammatory processes, withdrawal of progesterone in circulation, and the normal timing of birth. Therefore, pelvic and vagal nerves regulate macrophage immigration and nerve fiber density but may not be involved in final remodeling of the extracellular matrix in the prepartum cervix. These findings support the contention that immigration of immune cells and enhanced innervation are involved in processes that remodel the cervix and time parturition.