Continuous vs intermittent induction of labor with oxytocin in nulliparous patients: a randomized controlled trial

BACKGROUND

Oxytocin is considered the drug of choice for the induction of labor, although the optimal protocol and infusion duration remain to be determined.

OBJECTIVE

This study aimed to assess whether the duration of oxytocin infusion increases 24-hour delivery rates and affects the length of time-to-delivery and patient's experience.

STUDY DESIGN

A randomized controlled trial was performed at a single tertiary medical center, between January 1, 2020 and June 30, 2022. Nulliparous patients with a singleton pregnancy at a vertex presentation and a Bishop score ≥6 were randomly assigned to receive either continuous (16 hours, with a 4 hours pause in between infusions) or intermittent (8 hours, with a 4 hours pause in between infusions) oxytocin infusion, until delivery. In both groups, infusion was halted when signs of maternal or fetal compromise were observed. Randomization was conducted with a computer randomization sequence generation program. The primary outcome was delivery within 24 hours from the first oxytocin infusion and the secondary outcome included time-to-delivery, mode of delivery, and additional maternal and neonatal outcomes. Seventy-two patients per group were randomized to reach 80% statistical power with a 20% difference in the primary outcome according to previous studies.

RESULTS

A total of 153 patients were randomized, 72 to the continuous oxytocin infusion group and 81 to the intermittent infusion group. The total oxytocin infusion time was similar between the groups. Patients in the continuous arm were more likely to deliver within 24 hours from oxytocin initiation (79.73% vs 62.96%, P<.05), and had a shorter oxytocin-to-delivery time interval, compared with patients receiving intermittent treatment (9.3±3.7 hours vs 21±11.7 hours, P<.001). Furthermore, time from ruptured membranes to delivery was shorter (9.3±3.7 hours vs 21±11.7 hours; P<.0001) and chorioamnionitis was less frequent (9.46% vs 21%; P<.05) in the continuous compared with the intermittent arm. Cesarean delivery rate was 20% in both groups (P=.226). There was no difference in postpartum hemorrhage, or adverse neonatal outcomes between the groups. Patients receiving continuous oxytocin infusion were more satisfied with the birthing experience.

CONCLUSION

Continuous infusion of oxytocin for labor induction in nulliparous patients with a favorable cervix may be superior to intermittent oxytocin infusion, because it shortens time-to-delivery, decreases chorioamnionitis rate, and improves maternal satisfaction, without affecting adverse maternal or neonatal outcomes.

Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study

OBJECTIVES

To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD).

METHODS

A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate.

RESULTS

The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure.

CONCLUSIONS

Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.

Associations of maternal and placental extracellular vesicle miRNA with preeclampsia

Introduction: Gestational vascular complications (GVCs), including gestational hypertension and preeclampsia, are leading causes of maternal morbidity and mortality. Elevated levels of extracellular vesicles (EVs), in GVC have been linked to vascular injury. This study aims to characterize placental and circulating EV miRNA in GVCs, and explores the involvement of EV-miRNA in GVC, and whether they may be used to distinguish between placental and maternal pathologies. Methods: Blood samples were obtained from 15 non-pregnant (NP), 18 healthy-pregnant (HP), and 23 women with GVC during the third trimester. Placental sections were obtained after caesarian section. Platelet-poor-plasma (PPP) and EV pellets were characterized: EV size/concentration, protein content and miRNA expression were measured by nanoparticle tracking analysis, western blot, nano-string technology and RT-PCR. The effects of EVs on trophoblasts and EC miRNA expression were evaluated. Results: Higher EVs concentrations were observed in HP-PPP and GVC-PPP (p < 0.0001) compared to the NP-PPP. The concentration of large EVs (>100 nm) was higher in PPP and EV pellets of HP and GVC compared to the NP group. EV pellets of pregnant women demonstrated lower expression of exosomal markers CD63/CD81 compared to NP-EVs. GVC-EVs expressed more human placental lactogen (hPL) hormone than HP-EVs, reflecting their placental origin. Screening of miRNAs in EV pellets and in PPP identified certain miRNAs that were highly expressed only in EVs pellets of the HP (13%) and GVC groups (15%), but not in the NP group. Differences were detected in the expression of hsa-miR-16-5p, hsa-miR-210, and hsa-miR-29b-3p. The expression of hsa-miR-16-5p and hsa-miR-210 was low in EV pellets obtained from NP, higher in HP-EVs, and significantly lower in GVC-EVs. Except for hsa-miR-29b-3p, which was upregulated in GVC, no significant differences were found in the levels of other miRNAs in placental sections. Exposure to GVC-EVs resulted in higher expression of hsa-miR-29b-3p compared to cells exposed to HP-EVs in villous trophoblasts, but not in EC. Conclusion: Expression of hsa-miR-16-5p and hsa-miR-210 reflects maternal pathophysiological status, while hsa-miR-29b-3p reflects placental status. These findings suggest that EV-miRNA are involved in GVC, and that they may be used to distinguish between pathologies of placental and maternal origins in preeclampsia.

Vaginal fluid index - The fifth amniotic pocket

OBJECTIVE

The forebag is a pocket of amniotic fluid preceding the fetal presenting part. Herein we describe the feasibility of transvaginal measurements of the forebag and assess its correlation with the standard amniotic fluid index (AFI).

METHODS

A prospective study was carried out between January 2019 and July 2020. Eligible cases were women with singletons, vertex presentation, and normal AFI at term. We assessed the implementation and acceptance of a novel process in the clinical practice setting. Feasibility was assessed by using transvaginal ultrasound to measure the three orthogonal planes of the forebag. The vaginal fluid index (VFI) was defined as the volume composite of the three orthogonal planes. Correlations of the forebag measurements with both AFI and maximal vertical pocket were then calculated.

RESULTS

In total, 292 out of 305 (95.7%) women were enrolled. All participants completed both transabdominal and transvaginal ultrasound, of which the vaginal pocket was demonstrated in 266 (91.1%) cases. We found significant correlations, in both nulliparas and multiparas, between the vaginal pocket measurements and the VFI to both the AFI and maximal vertical pocket measurements (R = 0.38, P < 0.001; R = 0.3, P < 0.001, respectively).

CONCLUSION

We introduced a new ultrasound variable, the VFI, with a high feasibility rate. This may provide invaluable information for future decision making around the time of delivery.

Case of fetal ovarian juvenile granulosa cell tumor: Complications and management

A prenatal ovarian juvenile granulosa cell tumor (JGCT) is a rare entity which may present as an intra-abdominal cyst. Due to its low incidence, optimal management and timing for intervention remain uncertain. This report presents a case of an intra-abdominal cystic structure in a female fetus, one of the two fetuses in a dichorionic-diamniotic twin pregnancy, detected during routine fetal sonographic surveillance at 30 weeks of gestation. Further fetal evaluation detected the sonographic triad of an ovarian cystic mass, polyhydramnios and signs of fetal virilizations, requiring us to consider the presence of an atypical, ovarian androgen secreting tumor. Following delivery, acute ovarian torsion and intracystic hemorrhage required emergent surgical intervention, confirming the diagnosis of JGCT. Following surgical treatment, laboratory, clinical, and morphological features improved progressively.

[IS IT APPROPRIATE TO CHANGE THE NAMES OF SURGICAL PROCEDURES AND EXAMINATIONS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY WHICH GIVE EPONYMS DISTINCTION TO NAZI DOCTORS?]

The majority of the German medical institutions and nearly half of the clinicians during the Nazi regime provided unwavering support to the distorted Nazi views on health and disability. Leading physicians were an integral part of the atrocities carried out during that era, with some of them having a vital role in executing the ideology of the "final solution". The names of Carl Clauberg and Walter Stoeckel, two notable doctors in the fields of obstetrics and gynecology, were also linked with the third Reich. Both of these physicians, collaborated, each in his own way, with the Nazi regime, which tainted their legacy indefinitely. The two received professional honor for their contribution to the fields of obstetrics and gynecology, which were unrelated to their Nazi past, after their names were linked in the form of eponyms to surgical procedures and examinations, which they developed. In recent years, as a consequence of their disturbing past, there are increasing arguments which call for erasing their eponyms from the medical lexicon. We, on the contrary, believe that the opposite is true and that maintaining these eponyms will actually enable teaching future generations and serve a dual educational role to both highlight professional and scientific achievements as well as serve as a mark of Cain and warning that professional achievements do not prevent ethical decline. Preserving the name will provide an educational opportunity to teach about the responsibilities that come with professional leadership, which these doctors abused carelessly, in order to prevent history from repeating itself.

The Possibility of Transmitting Infections with Vaginal Ultrasound Probes: Why We Cannot Meet the Guidelines

The use of ultrasound endovaginal probes is common practice in the fields of gynecology and obstetrics. The vagina serves as a host environment for many microorganisms, contributing greatly to its defensive mechanisms. It is not known whether the introduction of other microorganisms into the vaginal region are detrimental or require intensive preventative measures. Several national ultrasonography societies, as well as the Israel Ministry of Health, have addressed the proper and adequate handling of sonographic endovaginal probes, including the use of high-level disinfecting agents following cleansing and prior to using probe covers between patients. However, many obstetrics and gynecology ultrasound units in Israel find it difficult to adhere to these strict disinfecting requirements. While most of the guidelines are based on the theoretical risk of contaminations when ultrasound endovaginal probes are used, the rate of nosocomial infections linked to the use of these probes has yet to be verified. Based on the information available, there is an urgent need to find a solution that enables gynecological ultrasound users to properly disinfect endovaginal probes between patients. Currently, it is almost impossible to pragmatically adhere to the Israel Ministry of Health guidelines.

Hidradenitis suppurativa associated with systemic lupus erythematosus: A case report

RATIONALE

Hidradenitis suppurativa (HS) is a chronic inflammatory condition characterized by recurrent swollen, deep, and painful abscesses. Several autoimmune conditions have been shown to be associated with HS including inflammatory bowel disease and spondyloarthropathies.

PATIENT CONCERNS

40-year-old female with systemic lupus erythematous (SLE) presented with recurrent abscesses and nodules on her extremities.

DIAGNOSIS

Early considerations related the described dermatologic findings to the dermatologic manifestations of SLE, however findings from lesion biopsy were suggestive of HS.

INTERVENTIONS

Prednisone and antibiotic therapy with clindamycin were started. Subsequently upon discharge, the patient was also treated with rifampicin and azathioprine.

OUTCOME

In this communication, we demonstrate a case of HS in a patient with SLE that significantly improved under antibiotic and immunosuppressant therapy.

LESSONS

HS can coexist in patients with SLE. Evidence pertinent to the etiology of HS and its association with other autoimmune conditions implies a possible denominator in the disease etiopathogenesis. Increased awareness of the co-occurrence of the two conditions calls for increased efforts to devise better treatment modalities.

Typhoid fever in children: a forgotten disease?

All indexed cases of typhoid fever occurring in children over a ten-year period in Jacksonville, Fla, were studied retrospectively. This review revealed that anorexia was the most common gastrointestinal complaint and that neurologic symptoms and signs were nearly as common as gastrointestinal signs. There was a significant delay in diagnosis in most cases because typhoid fever was not included in the differential diagnosis upon admission. This is probably due to the decline in the incidence of typhoid fever in the United States and the resultant lowering of the index of suspicion for the disease on the part of physicians in general. Representative cases are presented in detail.