Simple sonographic marker helps predicts the risk of intra-abdominal adhesions in patients with previous Cesarean section

A simple sonographic marker ‘sliding sign’ of the uterus during the last trimester of pregnancy can help physicians to distinguish between patients who have a high probability of intraabdominal adhesions during repeat cesarean section reports the results of an observational study published in the Journal of Ultrasound in Obstetrics & Gynecology (UOG). 

Presence of Intra-abdominal adhesions complicate the repeat surgical procedure and increase the chances of bladder and bowel trauma and bleeding. About 24% to 46% of patients will develop adhesions after one cesarean and the rate increases to 43% to 75% at the third, and up to 83% at the fourth cesarean delivery.

Italian researcher Baron and colleagues selected 59 patients who had a history of one or more previous cesarean section and evaluated them during the third trimester of ongoing pregnancy by abdominal ultrasound. To know about the risk of the presence of adhesions, the researcher looked at the sliding of gravid uterus under the inner part of the fascia of abdominal muscles.

Women who demonstrated easy and obvious sliding during deep breathing were predicted to be at low to moderate risk of the presence of intraabdominal adhesions (positive sliding sign), while in women whom the sliding was very little or absent (negative sliding sign), were at high risk of severe adhesions.

The prediction was confirmed at surgery, 16 out of 19 women who displayed a negative ‘sliding sign’ had severe intra-abdominal adhesions while 35 out of 40 women with positive ‘sliding sign’ had very few adhesions.

The sensitivity and specificity of the sliding sign in predicting the presence of intra‐abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively.

Thus, a simple sonographic sign can help physicians to know about the patient’s risk of having adhesions and be prepared for adhesions related complications during the repeat cesarean delivery.

Here is UOGJournal video clip illustrating the simple sonographic marker ‘sliding sign.’

Abstract 

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ERAS releases its guidelines for Antenatal and Peri-operative care in Cesarean Delivery

The Enhanced Recovery After Surgery (ERAS®) Society recently released its evidence-based, based practice recommendations to accelerate recovery after cesarean delivery (CD).

The recommendations published online ahead of print in the American Journal of Obstetrics and Gynecology involve interventions that start 30-60 minutes before skin incision and extends till the patient is discharged from hospital spanning the pre-operative, intra-operative, and post-operative phases of the CD.

The ERAS protocols were first introduced 15 years ago by Wilmore and Kehlet for colorectal surgery and are now successfully applied in other surgical disciplines like breast, urological, pancreatectomy, liver resection, and gynecologic surgery.

The ERAS team used Embase and PubMed to look at studies spanning 51 years (1966-2017) to gather evidence for developing the protocols and recommendations. The team created maternal FOCUSED pathways that involve protocols for the preoperative, intraoperative, and postoperative phase of the CD. GRADE system was used to assess the quality of studies.

The preoperative recommendations start 30-60 minutes before the skin incision for both elective and emergency cesarean sections and include a one on one communication with the patient about oral intake before surgery, what to expect during the surgery, postoperative pain, initiation of lactation, and recovery.  The Antenatal recommendations mainly focus on patient education about nutrition, supplements, delivery, what to expect during a CD and breastfeeding. 

Antenatal and Preoperative recommendations include:

Patient education

Six- to eight-hour fasting for solids and clear oral fluid intake up to two hours before the induction of anesthesia

Use of antacids and histamine H2 receptor antagonists

Hemoglobin optimization

Contact with patient 24 hours before elective CD

Intraoperative recommendations include:

A single dose of broad-spectrum antibiotics before the skin incision

skin preparation with chlorhexidine-alcohol

Fluid balance with 2L crystalloid and prophylactic phenylephrine infusion initiated at 50 mcg/minute

Maintaining perioperative normothermia (forced warm air, warmed IV fluids, room temperature),

Use of neuraxial anesthesia with neuraxial opioids

Prophylaxis against postoperative nausea and vomiting (PONV)

Delayed cord clamping for 30-60 sec

Initializing early skin to skin contact

Preventing PPH by low dose oxytocin infusion

Postoperative recommendations include :

Encouraging early oral intake within 2 hours

Early mobilization

Early removal of urinary catheter

Regular use of multimodal pain reliever

No VTE prophylaxis with heparin

Pneumatic compression stocking for VTE prophylaxis

Consultation with a lactational expert

Complete neonatal evaluation by the neonatal team

Abstract

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Sonographically measured fetal head circumference ≥35 cm at term increases the odds of cesarean delivery.

Sonographically measured fetal head circumference ≥35 cm, within a week of delivery increases the odds of unplanned cesarean section by 75% reports the results of multicenter observational study accepted for publication in American Journal of Obstetrics and Gynecology.

Currently, In US, one in every third baby is born by cesarean section and the high rate is a cause of concern for healthcare industry.

Physicians and patients will be greatly benefited by knowing more about factors that can predict the risk of cesarean section, in terms of better patient counselling and individual labor planning. Besides obstetrics factors, earlier studies have focused on estimated baby weight as a predictor of increased risk of operative and instrumental delivery.

This medical record based study looked at labor outcome of 11,500 primiparous women, presenting at term (37-42 weeks) with singleton fetuses in cephalic presentation for ultrasound with fetal biometry within one week of delivery.

All the patients who had an elective cesarean section were excluded from the study.

It was seen that head circumference ≥35 cm increased the odds of cesarean section by 2.5 times and increased the risk of instrumental intervention by 48%.

Increased head circumference and EFW ≥3900 also increased the risk of prolonged second stage of labor in the study cohort. At the same time head circumference ≥35 cm was significantly associated with improved Apgar score (p=0.01).

The authors concluded that Sonographic fetal head circumference ≥35 cm increased the second stage of labor and is also an independent risk factor for cesarean delivery.

Paired with EFW, increased head circumference ≥35 cm, can be useful for patient counselling and planning the labor. 

Abstract 

Prophylactic negative pressure wound therapy may help cut down surgical wound infections after cesarean

Prophylactic negative pressure wound therapy (NPWT) at cesarean delivery may reduce the surgical site infections (SSI) and overall wound complications says the results of a systematic review and meta-analysis published ahead of print in American journal of obstetrics and gynecology.

Morbidly obese women have a very high rate of SSIs and readmission to hospitals.

The researchers conducted a literature review and included RCTs and observational studies comparing surgical outcome between prophylactic negative pressure wound closure and standard cesarean wound closure.  

The investigators were mainly looking at difference in SSI because of NPWT besides other minor outcomes like composite wound complications, wound gaping, hematoma, endometritis and readmission to the hospital.

Six RCTs and three cohort study met the inclusion criteria. It was seen that women with NPWT faced a 55% lower risk of SSI as compared to women with standard dressing (pooled RR 0.45; 95% CI 0.31- 0.66). The Number Need to Treat (NNT) was 17.

Women with NPWT also had a 22 lower risk of composite wound complications, while the other minor outcomes were comparable in both the groups.

The authors concluded that although the studies were heterogenous, use of NPWT decreases the SSIs after  cesarean, larger clinical trials are awaited to fully understand the impact of the intervention.

Abstract

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Prophylactic Use of Azithromycin brings down Postcesarean Infections.

Clinical pearls:

• Among women undergoing non-elective cesarean section, addition of azithromycin to the standard protocol of prophylactic antibiotic reduces the risk of postoperative infection significantly. (P<0.001).
• A single dose of 500 mg used Intravenously before the skin incision.

According to data by CDC, out of nearly 4 million children born in USA, 1,284,551 are delivered by cesarean sections. The Cesarean section rate in US is 32.2%.[1] Women who undergo cesarean delivery are 5-10 times more at risk for puerperal infection as compared to women undergoing a natural birth. [2]Puerperal infection is responsible for 10% of pregnancy-related mortality. 

Postoperative infectious morbidity also encompasses other causes like mastitis, septic pelvic thrombophlebitis, drug fever, urinary tract infection/pyelonephritis and pneumonia but two major contributors to maternal morbidity and mortality are endometritis (incidence without prophylaxis, 4 to 18%) and of surgical-site infections (incidence without prophylaxis, 7 to 10%.).

To prevent surgical site infections ACOG recommends the use of a single dose of a narrow spectrum first-generation cephalosporin (cefazolin), or a single-dose combination of clindamycin with an aminoglycoside for those with a significant penicillin allergy, as prophylaxis for cesarean delivery.[3]

A large randomized trial published in the September 29 issue of the New England Journal of Medicine presents the result of adding Azithromycin (a macrolide antibiotic) to standard prophylaxis for cesarean deliveries at 14 U.S. hospitals.[4]

The study was also presented in part at the 36th annual meeting of the Society for Maternal–Fetal Medicine, Atlanta, February 1–6, 2016.

The study included 2013 women who were at least 24+ weeks into pregnancy, with singleton fetus, undergoing an emergency section in labor with or without rupture of membranes. Women with elective or planned cesarean sections were excluded from the study. The study cohort was divided into 2 groups. The study group received single 500-mg dose of azithromycin intravenously before the cesarean incision, in addition to the intravenous dose of cefazolin that is standardized protocol followed at each center.

The control group received cefazolin plus placebo.

Data Analysis showed that the occurrence of primary composite outcome like surgical site infection, endometritis (measured 6 weeks postpartum) and other infection were significantly lower in the group receiving Azithromycin (6.1% vs. 12.0%, P<0.001).

Secondary outcome like readmissions, emergency visit to hospital and need for antibiotics postpartum were also less in the study group. 

Neonatal outcomes were similar in both the groups. "Pharmacologic data indicating that azithromycin only minimally crosses the placenta into the fetal circulation suggest limited exposure for the infant," write Dr Weinstein and Dr Boyer in an accompanying editorial.

The study results also showed that 17 women need to be treated to prevent the occurrence of primary study outcome, while the number for preventing one case of endometritis and wound infections is 43 and 24 respectively.

The number of eligible women who would need to be treated to prevent one study outcome was 17 for the primary outcome, 43 for endometritis, and 24 for wound infections. 

The editorial authors hypothesized that Azithromycin is effective against some of vaginal microbiota. Earlier studies have shown that genital or placental colonization with Ureaplasma urealyticum increases the risks of endometritis/ wound site infection.

Azithromycin is also concentrated and retained for many days in myometrium and adipose tissue, hence a single dose preoperatively works well for this surgery.

So, does the study implicate the routine use of Azithromycin as a preoperative prophylaxis in cesarean section?  The editorial authors opine that it is too early to make any recommendation. "Time will tell whether such findings result in changes in routine antibiotic prophylaxis before cesarean deliveries," write Dr Weinstein and Dr Boyer. 

However, on the basis of the results, the addition of azithromycin "would reduce a number of infectious complications for some women without established infections who are undergoing nonelective cesarean section."

The emergence of antibiotic resistant organism after long use also has to be kept in mind, but a single I/V dose is unlikely to do so.

The study findings show that by adding prophylactic azithromycin to the routine protocol for cesarean delivery extends   the spectrum of coverage and decreases the chances of puerperal infection without compromising maternal or neonatal safety.    

---

[1] http://www.cdc.gov/nchs/fastats/delivery.htm

[2] Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol 1980;55:5 Suppl:178S-184S

[3] American College of Obstetricians and Gynecologists (ACOG), authors Use of prophylactic antibiotics in labor and delivery. [Accessed May 13, 2012]. Practice Bulletin No. 120, June 2011. US Department of Health & Human Services Web site.

[4] http://www.nejm.org/doi/full/10.1056/NEJMoa1602044

Elective Induction of labor (IOL) at 39 weeks is in the best interest for mother and baby-- News from ACOG Annual Clinical and Scientific Meeting 2016.

The ideal time for delivery in low risk pregnancies has been debated since very long. ACOG efforts to stop elective induction before 39 weeks in well dated pregnancies have decreased neonatal morbidity and mortality.  So, this year’s debaters for The Edith Louise Potter Memorial Lecture at the ACOG annual conference tried to answer a difficult question by offbeat approach: If recommendation say no elective induction before 39 weeks, why not induce every well dated patient at 39 weeks?

The debaters were Dr. Errol Norwitz, MD, PhD, chairman of the Department of Obstetrics and Gynecology, and professor at Tufts University School of Medicine and Dr. Charles Lockwood, MD, senior vice president, USF Health, dean of the Morsani College of Medicine, University of South Florida, professor of obstetrics and gynecology at Morsani College of Medicine, and professor of health policy and management at the College of Public Health, University of South Florida.

Interestingly both the debaters agreed that continuing pregnancy beyond 39 weeks is risky for the fetus.

Several studies from USA and UK were cited to support the argument. Dr Norwitz said “Continuing the pregnancy beyond 39 weeks is riskier than previously believed for the fetus. In addition, risks to the mother associated with routine induction "are lower than appreciated." 

Dr. Lockwood also seconded the opinion saying "I was absolutely opposed" to the elective induction of labor at 39 weeks but after much reading it's overwhelmingly evident that elective induction of labor is the logical strategy."

Dr Norwitz stressed that higher rates of stillbirths after 39 weeks have been known since 1980’s but the research was always overlooked. According to a study published in BMC Pregnancy Childbirth. 2015; 15(Suppl 1): A11 late stillbirths (pregnancies 28 weeks or later) occur twice a common as deaths due to congenital anomalies; twice as common as deaths due to preterm complications, and ten times more common that Sudden Infant Deaths.

Another retrospective study of 171,527 notified births published in BJOG, evaluated gestation-specific risks of stillbirth, neonatal and post-neonatal mortality. The study concluded that with each passing week the risk of still births and neonatal mortality increases by nearly 11 fold to that at 37weeks.  Multiple factors like the effects of parity, multiple pregnancy, congenital abnormality, meconium aspiration and uteroplacental insufficiency may be responsible for it but, requires further detailed analysis.

Several other studies and meta-analysis have reiterated these findings.

The major risk factor for induction at 39 weeks is failed induction leading to an operative intervention, but surprisingly both Dr. Norwitz and Dr. Lockwood did not see any increased rate of cesarean delivery, albeit they found a decrease.  Because of paucity of data on routine induction at 39 weeks, Dr Norwitz extrapolated data from IOL vs. expectant management (EM) at 41 weeks and it showed a decrease in cesarean section rate.

He and his colleagues performed a comparative-effectiveness analysis and the model consisted of 60 probable outcomes. The team then also created a Monte Carlo microsimulation to map out head-to-head effectiveness.

It was seen that expectant management were associated with higher operative intervention and clear increase in perinatal mortality.  Maternal rates were the same for the two groups, but complications rates were more for mother and infant in the expectant management group.

To conclude Dr Lockwood said “elective IOL at 39 weeks was always the superior decision strategy to expectant EM with IOL at 41 weeks.”

Both the debaters agreed that to induce the patient successfully at 39 weeks requires accurate gestational dating otherwise it may not be beneficial as planned.

In a nutshell Dr. Lockwood concludes “Elective induction of labor at 39 weeks reduces the number of cesarean deliveries, reduces the occurrence of stillbirth, reduces severe complication rates for infants and reduces severe complication rates for mothers in a very highly statistically significant fashion.

References:

http://www.acogdailynews.com/support-for-elective-iol-at-39-weeks-growing/

http://www.acogdailynews.com/support-for-elective-iol-at-39-weeks-growing/

http://www.acogdailynews.com/potter-memorial-lecture-elective-induction-of-labor-at-39-weeks/

http://www.medscape.com/viewarticle/863383

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413558/

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb10047.x/full

When and How to Induce Labor in Nulliparous Women-- News from ACOG Annual Clinical and Scientific Meeting 2016.

Induction of labor is a major component of obstetrics practice with nearly one third of multiparous women   and 43 percent of nulliparous women undergoing induction.

Mary Catherine Tolcher, MD, MS, assistant professor of obstetrics, Mayo Clinic Rochester said “Induction of labor is likely to become more common with increasing maternal age, hypertensive disorders and obesity,” at Saturday afternoon Clinical Seminar at the conference.

The leading indications for induction of labor at the Mayo Clinic are late-term pregnancy, fetal indications, PROM, gestational hypertension and diabetes.

She further added that benefits of induced labor are clear, Induced labor avoids maternal and fetal risks of continuing pregnancy, avoids risks of late-term pregnancy, allows the timing of labor to be controlled in cases where delivery in a particular facility is appropriate and may be an alternative to cesarean delivery.

The risks are equally clear too, which means prolonged hospitalization before delivery, increased likelihood of more intrusive interventions, increased risk of postpartum hemorrhage and increased likelihood of cesarean delivery.

Answering the key question of whether induction increases the risks of cesarean section she said that it is like a lot of other things in medicine, and depends on your comparison group. 

Results based on retrospective cohort data show the following conclusions.

Depending upon studies the odds ratio for undergoing a cesarean delivery was somewhere between 1.9 and 3.5 when comparing spontaneous labor and induction. 

But compared to expectant management, induction does not seem to be associated with an increased risk of cesarean delivery. 

The first randomized control trial of induction vs expectant (ARRIVE TRIAL) management is currently recruiting participants and will be completing the data collection at the end of 2016.

Since the inception of induction of labor, many methods have been in use like mechanical ripening by Foleys catheter, pharmacological use of prostaglandins and oxytocin. These are either used alone or in combination with or without amniotomy.    

According to Dr. Tolcher, clinical trials have shown all of them to be effective. Cervical ripening is definitely more effective than oxytocin alone, while prostaglandins and Foleys catheter seems to have the same outcome.  Recent data reported at annual meeting of Society for Maternal-Fetal Medicine in 2016, concluded that time to delivery is shortened by using combination methods than using each of the method alone with no increase in cesarean section rates.

Amniotomy is also effective in augmenting the labor, but when early amniotomy (Cervix < 5 cm dilated) was compared to late amniotomy (Cervix > 5 cm dilated), the latter seemed more appropriate. Early amniotomy does results in shorter labor time but it comes with higher incidences of chorioamnionitis and increased fetal cord compression.

Dr. Tolcher also said that Mayo clinic has its own protocols for induction and the cases scheduled for induction in the coming week are reviewed in a staff meeting on Friday and Labor and Delivery nurse also has a significant say to put a stop to non-indicated cases.

Current indication for inductions include advanced maternal age, cholestasis, diabetes, fetal issues, hypertensive disorders, obesity, preterm premature rupture of membranes, prolonged pregnancy, prior stillbirth and unstable presentation. Depending on the indication, the pregnancy must be in week 37 and later.

Cervical ripening is the initial step, followed by oxytocin as needed and amniotomy at the discretion of physician. A failed induction is 24 hours of oxytocin or 18 hours of oxytocin plus rupture of membranes.

Before the decision for induction is taken, the physician should have a very good discussion with patient about the procedure, the expected time to delivery and slightly higher odds of having a cesarean delivery.

References:

http://www.acogdailynews.com/when-and-how-to-induce-labor-in-nulliparous-women/

http://www.acog.org/Womens-Health/Labor-Induction

Revisiting the 30 years old doctrine of Cesarean Delivery Rate.

Revisiting the 30 years old doctrine of Cesarean Delivery Rate. 

The World Health Organization (WHO) recommended in 1985 that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes.

A study by Molina G. et al published in December edition of JAMA concludes that higher Higher Cesarean Delivery Rates May Be OK.

This cross sectional, ecological study was carried out to estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.

Data was collected from all 194 WHO member states from year 2005 to 2012, including cesarean section rates, health expenditure per capita, fertility rate, and life expectancy.

For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years.

The main outcome studied was the relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100,000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births).

Among the 172 countries with observed data, variability in the international cesarean delivery rate between countries ranged from  (12.6 per 100 live birth to  24.0 per 100 live births; South Sudan had the lowest cesarean delivery rate (0.6%), while Brazil had the highest (55.6%).

Mean National Estimates for Countries According to Cesarean Delivery Rates, With Total Volume of Cesarean Deliveries for Each Category---JAMA December 1, 2015, Vol 314, No. 21

In 2013, almost one third of the babies in US were delivered by LSCS, while Canada and Australia have a CS rate of 27.3 and 32.3 respectively.

CS rates are rising globally and it is driven by number of factors like almost complete elimination of vaginal breech delivery, as well as a significant decrease in operative vaginal deliveries and vaginal birth after cesarean. Many women also specifically request cesarean delivery.

Increased level of fetal surveillance has led to increase in intrapartum CS due to presumed fetal distress, but it has not improved the overall rate of perinatal mortality and cerebral palsy.

The estimated global number of cesarean deliveries for 2012 was 22.9 million, yielding a global cesarean delivery rate estimate of 19.4 per 100 live births, which was higher than recommended 10% to 15% by WHO.

The authors say that due to ecological nature of the study it can only document association and no cause and effect result can be inferred.

The study is important as it challenges a 30 year old message that a cesarean rate of less than 15% should be an optimal target of all health care institutions.

Hence, National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

It also suggests that efforts to reduce cesarean section rates may not improve patient outcomes.

In an accompanying editorial, Mary E. D'Alton, MD, and Mark P. Hehir, MD, from Columbia University College of Physicians and Surgeons in New York City write that "The optimal level of cesarean delivery cannot be as simple as a one-fits-all figure to be applied to all institutions and health care systems, and the obstetrical community must accept the fact that 'the appropriate' cesarean delivery rate remains unknown. However, it is not whether the cesarean delivery rate is high or low that really matters, but rather whether appropriate performance of cesarean delivery is part of a system that delivers optimal maternal and neonatal care after consideration of all relevant patient and health system information."

References:

1. http://jama.jamanetwork.com/article.aspx?articleid=2473490

2. http://jama.jamanetwork.com/article.aspx?articleid=2473470

3. http://www.un.org/millenniumgoals/maternal.shtml

4. United Nations sustainable development knowledge platform. Open Working Group proposal for sustainable development goals. https://sustainabledevelopment.un.org/sdgsproposal. Accessed December, 2015

5. World Health Organization.  Appropriate technology for birth. Lancet. 1985;2(8452):436-437.
   PubMed

6. World Bank. World development indicators. http://data.worldbank.org/indicator. Accessed December, 2015

7. http://www.medscape.com/viewarticle/855283