1
|
Bhatia K, Columb M, Knight M, Vause S. Re-exploration following caesarean birth: a prospective national case-control study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. Anaesthesia 2024. [PMID: 39083680 DOI: 10.1111/anae.16392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Re-exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors. METHODS We conducted a prospective observational case-control study across 194 UK consultant-led maternity units in women whose caesarean birth was complicated by a re-exploration. Independent factors for re-exploration were analysed using multivariable multi-level mixed effects logistic regression. RESULTS Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re-exploration, giving an incidence of one re-exploration per 1282 caesarean births (95%CI 1:1099-1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re-exploration. Median (IQR [range]) time interval to re-exploration following the caesarean birth was 1 (0-4 [0-28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re-exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66-25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61-6.88)); pre-eclampsia (adjusted OR (95%CI) 3.27 (1.55-6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39-7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81-4.37)); use of anticoagulants or antiplatelet drugs pre-caesarean birth (adjusted OR (95%CI) 2.26 (1.35-3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01-3.57)). CONCLUSION Re-exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high-risk women postpartum.
Collapse
Affiliation(s)
- Kailash Bhatia
- Department of Anaesthesia and Peri-operative Medicine, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Malachy Columb
- Department of Intensive Care Medicine, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Vause
- Saint Mary's Managed Clinical Service, Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|
2
|
Antony KM, McDonald RC, Gaston L, Hetzel S, Li Z. Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial. Am J Obstet Gynecol MFM 2024; 6:101273. [PMID: 38154599 PMCID: PMC10990562 DOI: 10.1016/j.ajogmf.2023.101273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown. OBJECTIVE This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine. STUDY DESIGN This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test. RESULTS Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar. CONCLUSION Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.
Collapse
Affiliation(s)
- Kathleen M Antony
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Dr Antony); Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston).
| | - Ryan C McDonald
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston); Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs McDonald and Gaston)
| | - Luther Gaston
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston); Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs McDonald and Gaston)
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr Hetzel and Dr Li)
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr Hetzel and Dr Li)
| |
Collapse
|
3
|
Basany K, Chaudhuri S, Shailaja P. L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India. PLoS One 2024; 19:e0286165. [PMID: 38271389 PMCID: PMC10810521 DOI: 10.1371/journal.pone.0286165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates. MAIN OBJECTIVES To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India. METHODS A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity. RESULTS The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%). CONCLUSION The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.
Collapse
Affiliation(s)
- Kalpana Basany
- Department of Obstetrics and Gynecology, Society for Health Allied Research and Education, INDIA MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sirshendu Chaudhuri
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Lakshmi Shailaja P.
- Department of Obstetrics and Gynecology, Fernandez Hospital, Hyderabad, Telangana, India
| | - Varun Agiwal
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Neelima Angaali
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Nirupama A. Y.
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Shailendra D.
- Department of Pharmacology, SHARE INDIA, MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Catherine Haggerty
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - P. S. Reddy
- Department of Obstetrics and Gynecology, Society for Health Allied Research and Education, INDIA MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| |
Collapse
|
4
|
Plume A, Bartusevicius A, Paskauskas S, Malakauskiene L, Bartuseviciene E. Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:190. [PMID: 38276068 PMCID: PMC10819516 DOI: 10.3390/medicina60010190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024]
Abstract
Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.
Collapse
Affiliation(s)
- Agne Plume
- Department of Obstetrics and Gynaecology, Riga Stradins University, LV-1007 Riga, Latvia
| | - Arnoldas Bartusevicius
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.B.); (S.P.); (L.M.); (E.B.)
| | - Saulius Paskauskas
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.B.); (S.P.); (L.M.); (E.B.)
| | - Laura Malakauskiene
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.B.); (S.P.); (L.M.); (E.B.)
| | - Egle Bartuseviciene
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (A.B.); (S.P.); (L.M.); (E.B.)
| |
Collapse
|
5
|
Verweij EJ, De Proost L, van Laar JOEH, Frank L, Obermann-Borstn SA, Vermeulen MJ, van Baalen S, van der Hout-van der Jagt MB, Kingma E. Ethical Development of Artificial Amniotic Sac and Placenta Technology: A Roadmap. Front Pediatr 2021; 9:793308. [PMID: 34956991 PMCID: PMC8694243 DOI: 10.3389/fped.2021.793308] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
In this paper we present an initial roadmap for the ethical development and eventual implementation of artificial amniotic sac and placenta technology in clinical practice. We consider four elements of attention: (1) framing and societal dialogue; (2) value sensitive design, (3) research ethics and (4) ethical and legal research resulting in the development of an adequate moral and legal framework. Attention to all elements is a necessary requirement for ethically responsible development of this technology. The first element concerns the importance of framing and societal dialogue. This should involve all relevant stakeholders as well as the general public. We also identify the need to consider carefully the use of terminology and how this influences the understanding of the technology. Second, we elaborate on value sensitive design: the technology should be designed based upon the principles and values that emerge in the first step: societal dialogue. Third, research ethics deserves attention: for proceeding with first-in-human research with the technology, the process of recruiting and counseling eventual study participants and assuring their informed consent deserves careful attention. Fourth, ethical and legal research should concern the status of the subject in the AAPT. An eventual robust moral and legal framework for developing and implementing the technology in a research setting should combine all previous elements. With this roadmap, we emphasize the importance of stakeholder engagement throughout the process of developing and implementing the technology; this will contribute to ethically and responsibly innovating health care.
Collapse
Affiliation(s)
- E J Verweij
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Lien De Proost
- Department of Obstetrics and Gynaecology, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Neonatology, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center (MC), Rotterdam, Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands.,Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Lily Frank
- Department of Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, Netherlands
| | | | - Marijn J Vermeulen
- Department of Neonatology, Erasmus Medical Center (MC), Rotterdam, Netherlands.,Care4Neo, Rotterdam, Netherlands
| | | | - M Beatrijs van der Hout-van der Jagt
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands.,Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Elselijn Kingma
- Department of Philosophy, King's College London, London, United Kingdom
| |
Collapse
|