Biochemical effects of intraoperative cell salvage and autotransfusion during cesarean section: A prospective pilot study

AIM

Intraoperative cell salvage and autotransfusion (ICSA) is a useful technique for women undergoing cesarean sections who are predicted to experience significant bleeding. This method can reduce allogeneic transfusions as well as its associated risks and costs. Amniotic fluid embolism (AFE) is an abnormal maternal response to ICSA similar to the classic systemic inflammatory response syndrome, but its mechanism is not well understood. This study was conducted to investigate the biochemical aspects of AFE.

METHODS

A prospective case-controlled pilot study was conducted in a general perinatal hospital in Japan. ICSA was performed using a two-step retransfusion process. Blood samples were collected presurgery, immediately postsurgery, and 24 h after surgery. Changes in sialyl Tn antigen (STN), complement C3 and C4, fibrinogen, and fibrin degradation product and D-dimer, C1 esterase inhibitor, and interleukin-8 (all considered AFE-related markers) activities were compared between patients who underwent cesarean sections with ICSA (ICSA group) versus without ICSA (control group).

RESULTS

Fibrinogen levels were significantly lower in the ICSA group than in the control group before surgery but not immediately after or 24 h after surgery. D-dimer was significantly higher immediately after surgery but not 24 h later. STN was significantly lower only before surgery. None of the AFE-related markers showed significant differences between the groups after 24 h. No adverse events were observed in the ICSA group.

CONCLUSIONS

There is no clinical evidence that ICSA alters the biochemical statuses of AFE-related markers in a manner that could lead to adverse maternal responses.

iPREFACE score: Integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring

AIM

Cardiotocography is used worldwide to evaluate fetal well-being during pregnancy and labor. In past guidelines, the management plan was determined based on the assessment of the most severe waveform. There are no guidelines for evaluating the integrated recurrent decelerations; however, we believe their assessment to be essential for predicting the status of the fetus. The objective of this study was to propose an indicator for performing medical interventions during labor by creating a scoring system that reflects integrated recurrent decelerations.

METHODS

In this retrospective cohort study, we included data for only full-term single fetus births from vaginal deliveries. The score named the iPREFACE score (integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring) was calculated using cardiotocography findings from continuing 30 min before delivery. We examined the iPREFACE score and fetal acidemia association and calculated the cut-off iPREFACE scores for acidemia using receiver operating characteristic curves.

RESULTS

The study included 469 delivery cases. Their iPREFACE scores exhibited a significant negative correlation with the umbilical artery blood pH (correlation coefficient; -0.43). The cut-off iPREFACE scores for the umbilical artery blood with pH <7.20, <7.10 and <7.0 were 44, 46 and 67, respectively (the areas under the curve were 0.776, 0.962 and 0.996, respectively).

CONCLUSION

The iPREFACE score may predict fetal acidemia and could be used as an indicator for timely medical interventions during labor. Because assessments using a cardiotocography are quick and easy to perform, the iPREFACE score could be a valuable tool in clinical practice.

DuoStim: a new option for fertility preservation for a woman with Turner syndrome

INTRODUCTION

Turner syndrome (TS) is associated with hypergonadotropic hypogonadism due to gonadal dysgenesis, which results in premature ovarian failure and subsequent infertility. Therefore, counseling and evaluation for fertility preservation are required as early as possible for women with TS.

CASE PRESENTATION

A 23-year-old unmarried woman with mosaic TS (45, X [4/30] 46, XX [26/30]) presented to the pediatric department of our hospital for fertility counseling; she was accompanied by her mother. She was referred to the reproduction center of our hospital for ovarian reserve assessment and counseling regarding fertility preservation. We decided to retrieve oocytes using DuoStim as the controlled ovarian stimulation protocol. During the first and second oocyte retrievals, a total of 17 (9 and 8, respectively) mature metaphase II oocytes were cryopreserved.

CONCLUSION

DuoStim may be a useful option for fertility preservation for women with TS and reduced ovarian reserve. This new strategy may obtain the required number of oocytes in the shortest time and preserve the future fertility of women with TS.

Apixaban therapy in a pregnant woman with heparin-induced thrombocytopenia and venous thromboembolic events caused by congenital antithrombin deficiency: A case report

We report the case of a 35-year-old pregnant woman (gravida 3, para 1) with antithrombin deficiency who was successfully treated with apixaban. She had a history of heparin-induced thrombocytopenia and venous thromboembolic events. Pregnancy was confirmed while the patient was having anticoagulant therapy for a persistent thrombus. Choice of anticoagulation during her pregnancy was limited because of her antithrombin deficiency: heparin was not an option because of her history of heparin-induced thrombocytopenia; antithrombin-dependent anticoagulant drugs were not an option because of her antithrombin deficiency, and she preferred outpatient management. Despite the fact that there are no reports of its use in pregnant women, we selected apixaban (10 mg/day), a direct Xa inhibitor, as the best solution. No progression of thrombus was noted during the pregnancy. The newborn baby had no external congenital anomalies, intracranial hemorrhage, or bleeding tendency. Thus, apixaban may be a candidate for anticoagulant therapy in pregnant women with a history of venous thromboembolic events and heparin-induced thrombocytopenia.

•

Pregnant women are at higher risk for venous thromboembolism than women who are not pregnant.

•

Anticoagulant therapy is limited for a pregnant woman with heparin-induced thrombocytopenia caused by congenital antithrombin deficiency.

•

Apixaban may be an alternative option of anticoagulant therapy during pregnancy.

Safety of uterine fundal pressure maneuver during second stage of labor in a tertiary perinatal medical center: A retrospective observational study

OBJECTIVE

This study aimed to evaluate the conformity of the indications and implementation status of uterine fundal pressure maneuver (UPFM) and to examine its safety according to the Japan Society of Obstetrics and Gynecology (JSOG) guidelines.

MATERIALS AND METHODS

We selected all the patients (n = 265) who were treated with UFPM between January 2015 and March 2017. We first evaluated the conformity of the indications and implementation status of UFPM concerning the guidelines for obstetrical practice in Japan, 2017. Second, we retrospectively examined maternal and fetal adverse events (AEs) to determine the safety of UFPM.

RESULTS

In total, 265 patients underwent UFPM; of all the UFPM-assisted deliveries, 189 patients (72%) were evaluated for conformity. Of these 189 patients, 181 (95.7%) were confirmed to be compliant. Laceration of the birth canal was the most frequently occurring maternal AE, followed by cervical laceration. No cases of uterine rupture, severe AEs leading to an extended hospital stay, and maternal deaths were observed. Although fetal AEs requiring admission to neonatal intensive care unit (NICU) were recorded for 33 patients (12.5%), all newborns developed normally without sequela.

CONCLUSION

The findings of this study may support the validity of the 2017 guidelines. Because it is difficult to find evidence of the safety of use of UFPM, it is essential to accumulate experiences and results learned in clinical practice to build a consensus in the future using the current 2017 guidelines as a standard as done in the current study.

Utility of fetal anteroposterior to transverse cerebellar diameter ratio to exclude cerebellar hypoplasia in trisomy 18

AIM

This study was aimed to determine reference ranges for fetal cerebellar hemisphere biometry, including the transverse cerebellar diameter (TCD), anteroposterior cerebellar diameter (APCD) and APCD/TCD ratio in normal fetuses. In addition, we investigated which parameter would be useful for cerebellar hypoplasia in trisomy 18.

METHODS

This retrospective study included 340 normal singleton pregnancies and 15 cases of trisomy 18, in all of which fetal cerebellar biometry was performed between 14 and 40 weeks of gestational age (GA). The TCD, APCD and APCD/TCD ratio were assessed ultrasonographically.

RESULTS

In normal fetuses, the TCD (r_s = 0.876, P < 0.001) and APCD (r_s = 0.791, P < 0.001) were strongly correlated with GA. However, the APCD/TCD ratio was not correlated with GA (r_s = 0.058, P = 0.289), with median values of 0.52. Low TCD, APCD and APCD/TCD ratio values were detected in 53%, 100% and 100% of trisomy 18 cases, respectively. The median APCD/TCD ratio for trisomy 18 was 0.39 (range, 0.30-0.43), which was significantly lower than that of normal fetuses (P < 0.001). A cut-off APCD/TCD ratio of 0.44 served as a good predictor for trisomy 18 (sensitivity 100%, specificity 95.3% and negative predictive value 100%).

CONCLUSION

This study shows that TCD and APCD are correlated with GA, while the APCD/TCD ratio is a fixed value throughout gestation. Using the APCD/TCD ratio to assess cerebellar hypoplasia in trisomy 18 is useful because it does not require the individual evaluation of the TCD and APCD.

Bupivacaine and lignocaine for ophthalmic surgery

Bupivacaine 0.5% when used as a local anaesthetic for ocular cataract surgery does not give absolute ocular akinesia but provides adequate and prolonged pain relief. In comparison lignocaine provides good ocular akinesia at operation but pain relief is short lived. The mixture of the two local anaesthetics in equal volumes eliminated the disadvantages of their individual use.

Intensive care in a developing country: a review of the first 100 cases

The role of an intensive care unit with regard to patient care and manpower training in a developing country was considered from an analysis of the first 100 admissions to the unit. The organisation and facilities available are outlined. The majority of cases admitted were post-surgical but the best results were achieved in training the nursing and medical staff to manage peritoneal dialysis and patients with eclampsia. Despite the lack of equipment and investigative facilities the overall mortality was 30%.

Entonox for casualties at 1000 m: use of nitrous oxide analgesia in Nigeria at moderate altitude

Analgesia with nitrous oxide and oxygen (Entonox) has been found to give adequate pain relief for 90 minor casualty procedures in over 90% of cases at moderate altitude. It was self administered except in six patients. Children between 6 and 10 years of age comprised 14% of patients, and the majority of the remainder were young adults. Additional analgesia was required in 11 patients, with no increase in complications. Complications were few; drowsiness occurred in 9%, dizziness was troublesome in one patient, but there was no nausea or vomiting and no one became unconscious. In situations where trained personnel are scarce, and where supervision can only be given at the time of the procedure and even at moderate altitudes Entonox is a clinically effective safe analgesic.