Complete recovery after near-fatal venous air embolism during cesarean section

Uterine exteriorization versus in situ repair in Cesarean delivery: a systematic review and meta-analysis

PURPOSE

We conducted an updated systematic review and meta-analysis on maternal outcomes associated with uterine exteriorization compared with in situ repair in women undergoing Cesarean delivery.

METHODS

We searched for randomized controlled trials comparing uterine exteriorization with in situ repair during Cesarean delivery. Primary outcomes were intraoperative nausea and vomiting (IONV) and perioperative decrease in hemoglobin concentration. Secondary outcomes were postoperative nausea and vomiting (PONV), estimated blood loss, fever, endometritis, wound infection, intraoperative and postoperative pain, postoperative analgesic use, duration of surgery and hospital stay, and time to return of bowel function.

RESULTS

Twenty studies with 20,909 parturients were included. Exteriorization was associated with higher risk of IONV (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.66 to 2.63; I² = 0%), with no difference in perioperative hemoglobin concentration decrease (mean difference, - 0.06 g·dL^-1; 95% CI, - 0.20 to 0.08; I² = 97%) compared with in situ repair. There were no significant differences in estimated blood loss, transfusion requirement, PONV, duration of surgery, duration of hospital stay, time to return of bowel function, fever, endometritis, or wound infection. Postoperative pain (incidence of pain graded > 5/10) at six hours (OR, 1.64; 95% CI, 1.31 to 2.03; I² = 0%) was higher with exteriorization, but there was no difference in need for rescue analgesia (OR, 2.48; 95% CI, 0.89 to 6.90; I² = 94%) or pain scores at 24 hr compared with in situ repair.

CONCLUSIONS

In this updated systematic review and meta-analysis, uterine exteriorization was associated with an increased risk of IONV but no significant change in perioperative hemoglobin decrease compared with in situ repair.

STUDY REGISTRATION

PROSPERO (CRD42020190074); registered 5 July 2020.

Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis

OBJECTIVE

Cesarean section delivery is a commonly performed surgical procedure, and rates of cesarean delivery are increasing. Previous randomized trials that compared extraabdominal and intraabdominal uterine repair at cesarean section delivery have yielded conflicting results.

STUDY DESIGN

We conducted a metaanalysis of published randomized controlled trials that addressed the method of uterine repair at cesarean delivery. The primary outcome was incidence of perioperative complications. The secondary outcomes were operative time, estimated blood loss, and hospital stay. Pooled odds ratios were calculated for categoric variables with random effects models. Continuous variables were compared by means of weighted mean differences.

RESULTS

No significant differences in either postoperative or intraoperative complications were demonstrated between the extraabdominal (n = 1605) and intraabdominal repair (n = 1578) groups. Operative time, estimated blood loss, and hospital stay were all unaffected by repair technique. This study cannot exclude differences in rare complications, such as serious venous air embolism or maternal death.

CONCLUSION

No differences in complication rates were found between extraabdominal and intraabdominal repair at cesarean section delivery; both techniques are valid surgical options.

Venous air embolism during surgery, especially cesarean delivery

Venous air embolism (VAE) is the entrapment of air or medical gases into the venous system causing symptoms and signs of pulmonary vessel obstruction. The incidence of VAE during cesarean delivery ranges from 10 to 97% depending on surgical position or diagnostic tools, with a potential for life-threatening events. We reviewed extensive literatures regarding VAE in detail and herein described VAE during surgery including cesarean delivery from background and history to treatment and prevention. It is intended that present work will improve the understanding of VAE during surgery.

Complications of Exteriorized Compared With In Situ Uterine Repair at Cesarean Delivery Under Spinal Anesthesia

OBJECTIVE

To compare intraoperative complications of exteriorized and in situ uterine repair during elective cesarean delivery under spinal anesthesia.

METHODS

This study was a randomized, single-blinded trial in 80 women undergoing elective cesarean delivery under spinal anesthesia. Patients were randomly assigned to exteriorized or in situ uterine repair. Obstetricians were asked to perform assisted delivery of the placenta. Spinal anesthesia and oxytocin management were standardized. Phenylephrine was used to maintain systolic blood pressure within 10% of the baseline. The primary outcome was intraoperative, postdelivery nausea or vomiting.

RESULTS

Postdelivery nausea or vomiting (18% compared with 38%; P=.04) and tachycardia (3% compared with 18%; P=.03) were significantly reduced in the in situ group compared with the exteriorized group. The duration of uterine repair was significantly shorter in the exteriorized group (median 10 minutes [first and third quartiles 9, 13], compared with 11 minutes [9, 15]) (P=.04). The duration of surgery (36 minutes [30, 41] compared with 37 minutes [30, 45]) and estimated blood loss (mean+/-standard deviation 625+/-489 mL compared with 653+/-416 mL) were similar between the in situ and the exteriorized groups. There was no correlation between duration of uterine repair and estimated blood loss.

CONCLUSION

Exteriorization of the uterus for repair is associated with an increased incidence of nausea and vomiting and tachycardia during cesarean delivery under spinal anesthesia. Uterine repair should be done in situ where possible.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00452972

LEVEL OF EVIDENCE

I.