The Effect of Blood Loss on Cefazolin Levels in Women Undergoing Cesarean Delivery.

OBJECTIVE: To quantify the effects of operative blood loss during cesarean on tissue and plasma cefazolin concentrations. STUDY DESIGN: This was a prospective observational study of singleton pregnancies undergoing scheduled cesarean between 34 and 40 weeks. Cefazolin administered prior to skin incision. Maternal plasma samples were obtained (Time 1[T1]: immediately, T2: 20 minutes, T3: 40 minutes, and T4: 60 minutes after cefazolin infusion). Subcutaneous adipose tissue sampled before and after fascia. Primary outcome was subcutaneous adipose cefazolin level after fascial closure. Formal quantitative blood loss (QBL) performed. Women with higher QBL, those at/above 75% of QBL in this population, were compared with those with lower QBL (QBL below 75%). Data analyzed using bivariable statistics. RESULTS: Ninety-two women were screened, 32 were eligible, and 20 enrolled. Median QBL was 630 mL (interquartile range [IQR]: 473-818) and 1,160 mL (IQR: 1,000-1,560) in the low and high QBL groups, respectively. Demographics and operative characteristics were similar. Median adipose cefazolin level after fascial closure did not differ between the groups (3.5 vs. 3.9 µg/g, p = 0.75). No differences in maternal plasma cefazolin concentrations between the groups at any time point or in pharmacokinetic parameters were seen. CONCLUSION: Intraoperative maternal plasma concentrations and adipose levels of cefazolin are similar between women with high and low blood loss at the time of cesarean delivery.

Severity of congenital heart defects associated with assisted reproductive technologies: Case series and review of the literature.

OBJECTIVE: Assisted reproductive technology (ART) has been associated with a higher incidence of congenital anomalies, including a specific increase in the rate of congenital heart defects (CHD). In this study, the rate of CHD in pregnancies resulting from ART at a single high-risk pregnancy referral center are compared to the published literature. METHODS: Pregnancies were screened by fetal echocardiography for the indication of ART over a 2-year period. CHD were classified as either mild or severe based on the need for postnatal surgical intervention. Results were compared to findings from a literature review of studies examining CHD in pregnancies resulting from ART since 1980. RESULTS: Over the course of two years, 363 fetuses in 264 pregnancies from our cohort were screened for CHD. The incidence of mild CHD in fetuses from ART pregnancies was 2.75% (10 out of 363 fetuses). None of the affected fetuses had severe CHD. Review of the literature yielded 20 studies since 1980 that examined CHD in pregnancies resulting from ART. Composite data from the studies was described based on characterization of severity of the CHD anomalies. The incidence of mild CHD in ART pregnancies was 2.2%, compared to 1% in non-ART pregnancies (out of 332,157 infants). The incidence of severe CHD in ART pregnancies and naturally conceived pregnancies was 1.4% and 1.2%, respectively (out of 661,455 infants). The incidence of unspecified CHD in ART pregnancies was 1.8%, compared to 1% in naturally conceived pregnancies (out of 1,593,277 infants). CONCLUSION: The greatest increase in risk appears to be for mild CHD (nonsurgical), which may inform counseling of patients prior to use of assisted reproductive technologies.

Closed-Incision Negative-Pressure Therapy in Obese Patients Undergoing Cesarean Delivery: A Randomized Controlled Trial.

Background Postcesarean wound morbidity is a costly complication of cesarean delivery for which preventative strategies remain understudied. Objective We compared surgical site occurrences (SSOs) in cesarean patients receiving closed-incision negative-pressure therapy (ciNPT) or standard-of-care (SOC) dressing. Study Design A single-center randomized controlled trial compared ciNPT (5-7 days) to SOC dressing (1-2 days) in obese women (body mass index [BMI] ≥ 35), undergoing cesarean delivery between 2012 and 2014. Participants were randomized 1:1 and monitored 42 ± 10 days postoperatively. The primary outcome SSOs included unanticipated local inflammation, wound infection, seroma, hematoma, dehiscence, and need for surgical or antibiotic intervention. Results Of the 92 randomized patients, 82 completed the study. ciNPT and SOC groups had similar baseline characteristics. Mean BMI was 46.5 ± 6.5 and no treatment-related serious adverse events. Compared with SOC, the ciNPT group had fewer SSOs (7/43 [16.3%] vs. 2/39 [5.1%], respectively; p = 0.16); significantly fewer participants with less incisional pain both at rest (39/46 [84.8%] vs. 20/46 [43.5%]; p < 0.001) and with incisional pressure (42/46 [91.3%] vs. 25/46 [54.3%]; p < 0.001); and a 30% decrease in total opioid use (79.1 vs. 55.9 mg morphine equivalents, p = 0.036). Conclusion A trend in SSO reduction and a statistically significant reduction in postoperative pain and narcotic use was observed in women using ciNPT.

Increase in Cesarean Operative Time Following Institution of the 80-Hour Workweek.

BACKGROUND: In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours per week. More than a decade later, the effect of the limits on resident clinical competence is not fully understood. OBJECTIVE: We sought to assess the effect of duty hour restrictions on resident performance of an uncomplicated cesarean delivery. METHODS: We reviewed unlabored primary cesarean deliveries at Duke University Hospital after 34 weeks gestation, between 2003 and 2011. Descriptive statistics and linear regression were used to compare total operative time with incision to delivery time as a function of years since institution of the 80-hour workweek. Resident training level, subject body mass index, estimated blood loss, and skin closure method were controlled for in the regression model. RESULTS: We identified 444 deliveries that met study criteria. The mean (SD) total operative time in 2003-2004 was 43.3 (14.3) minutes and 59.6 (10.7) minutes in 2010-2011 (P < .001). Multivariable regression demonstrated an increase in total operative time of 1.9 min/y (P < .001) but no change in incision to delivery time (P = .05). The magnitude of increased operative time was seen among junior residents (2.0 min/y, P < .001) compared to that of senior residents (1.2 min/y, P = .06). CONCLUSIONS: Since introduction of the 2003 duty hour limits, there has been an increase of nearly 20 minutes in the time required for a routine cesarean delivery. It is unclear if the findings are due to a change in residency duty hours or to another aspect of residency training.

Predictors of failed trial of labor among women with an extremely obese body mass index.

OBJECTIVE: The purpose of this study was to examine predictors associated with cesarean delivery (CD) among extremely obese women undergoing a trial of labor (TOL). STUDY DESIGN: Using a delivery database, we identified all pregnant women delivering at our institution from Jan. 1, 2008, through July 31, 2010, weighing >275 lb at the time of delivery who attempted a TOL with a singleton gestation >34 weeks' gestation. Demographic and obstetrical factors were compared for those having a successful vaginal delivery to those having a CD. RESULTS: During the study period, there were 357 pregnant women who weighed >275 lb (all with body mass index [BMI] >40 kg/m(2)), and among these, 248 (69.5%) attempted a TOL. Women having a CD had a greater BMI (51.6 vs 49.9 kg/m(2), P = .038), were less likely to be parous (32.2% vs 65.8%, P < .0001), and were more likely to be induced (80.5% vs 57.8%) compared to those having a vaginal delivery. Using a multivariable logistic regression model, among nulliparous women, maternal age, parity, and cervical dilation at time of admission were independent predictors for CD. Furthermore, an increase in BMI of 10 kg/m(2) was associated with a 3.5 increased odds (P = .002) for CD. CONCLUSION: Among nulliparous extremely obese women attempting a TOL, BMI was an independent predictor of CD, with the rate of CD increasing further with increasing BMI. The underlying mechanisms for failed TOL in the setting of maternal obesity remain largely unknown.

The influence of maternal body mass index on myometrial oxytocin receptor expression in pregnancy.

Obese pregnant women have higher rates of dysfunctional labor patterns, need for oxytocin augmentation, labor induction, postdates pregnancy, and cesarean delivery compared to normal weight pregnant women. We tested the hypothesis that myometrial oxytocin receptor (OXTR) gene and protein expression are affected by obesity in pregnancy. Myometrial samples were obtained at the time of cesarean delivery from the upper aspect of the uterine hysterotomy incision and processed for real-time quantitative polymerase chain reaction and Western blot. There were 63 myometrial samples available for analysis. The median body mass index (BMI) at delivery was 31.0 kg/m(2) (interquartile range, 26.0, 40.0 kg/m(2)), and the median gestational age at delivery was 38.0 weeks (interquartile range, 33.0, 39.1 weeks). The OXTR gene expression did not correlate with maternal BMI at delivery by linear regression, and the median OXTR gene expression did not differ between women with a BMI ≤ 30 kg/m(2) and those with a BMI ≥ 40 kg/m(2). The OXTR protein expression was also not affected by maternal BMI. Myometrial OXTR gene expression appears to be independent of BMI at the time of delivery. Dysfunctional labor patterns and increased oxytocin utilization seen in obese women may not be due to differences in OXTR expression, though functional studies are required.

Obesity and pregnancy: clinical management of the obese gravida.

In recent years, the prevalence of obesity in the United States has risen dramatically, especially among women of reproductive age. Research that has specifically evaluated pregnancy outcomes among obese parturients has allowed for a better understanding of the myriad adverse perinatal complications that are observed with significantly greater frequency in the obese pregnant population. The antepartum, intrapartum, intraoperative, postoperative, and postpartum periods are all times in which the obese pregnant woman is at greater risk for adverse maternal-fetal outcomes, compared with her ideal bodyweight counterpart. Comorbid medical conditions that commonly are associated with obesity further accentuate perinatal risks. All obese pregnant women should be counseled regarding these risks, and strategies should be used to improve perinatal outcome whenever possible. Obese women of reproductive age ideally should be counseled before conception and advised to achieve ideal bodyweight before pregnancy.

The Sri Lanka tsunami experience.

The Indian Ocean tsunami of 2004 killed 31,000 people in Sri Lanka and produced morbidity primarily resulting from near-drownings and traumatic injuries. In the immediate aftermath, the survivors brought bodies to the hospitals, which hampered the hospitals' operations. The fear of epidemics led to mass burials. Infectious diseases were prevented through the provision of clean water and through vector control. Months after the tsunami, little rebuilding of permanent housing was evident, and many tsunami victims continued to reside in transit camps without means of generating their own income. The lack of an incident command system, limited funding, and political conflicts were identified as barriers to optimal relief efforts. Despite these barriers, Sri Lanka was fortunate in drawing upon a well-developed community health infrastructure as well as local and international resources. The need continues for education and training in clinical skills for mass rescue and emergency treatment, as well as participation in a multidisciplinary response.