Unintentional extension of uterine incision is a known complication during cesarean delivery estimated to occur in 4-8% of cesarean deliveries. The aim of this study was to examine risk factors ...associated with unintentional uterine incision extension and to assess which of them are independent risk factors for this condition.
We conducted a retrospective cohort study at a large public university tertiary referral center between 2003 and 2017. Included were women who underwent cesarean delivery during this time period. Demographic, medical, obstetrical and surgical data were collected. The primary outcome was the presence of uterine incision extension during cesarean delivery. Secondary outcomes included detection of risk factors associated with uterine incision extension. A multivariate analysis was additionally performed to identify general and labor related risk factors for unintentional extension of uterine incision among patients that underwent cesarean delivery during second stage of labor
During the study period, 25,879 cesarean deliveries performed in our medical center were assessed. Out of them, 731 (2.8%) cases of unintended uterine incision extension were identified. Women in this group had high rates of full cervical dilatation and increased maternal hemorrhage. Assessment of incision extension direction revealed that two-thirds of extensions were lateral, mostly unilateral. Median size of the extension was 2.7 ± 1.2 cm.
Independent parameters associated with unintended uterine incision extension included nulliparity, vertex presentation, epidural anesthesia and cesarean section indication. Further analysis including cesarean deliveries performed during the second stage of labor revealed 397 (15.3%) cesarean deliveries in which incision extension was noted and 2205 (84.7%) cesarean deliveries without incision extension. Following multivariate analysis performed in women who underwent cesarean delivery during second stage of labor, two independent parameters associated with unintended uterine incision extension remained significant - past cesarean delivery and failed vacuum attempt.
Vacuum extraction attempt and previous cesarean delivery are independent risk factors for uterine incision extension in women undergoing cesarean delivery during the second stage of labor. We also showed the majority of these extensions to be lateral.
The efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) in preventing post thrombotic syndrome (PTS) for pregnancy related deep vein thrombosis (DVT) is unknown.
An observational ...cross section study of women with pregnancy related proximal (femoral/iliofemoral) DVT who underwent PCDT followed by anticoagulation (study group), and women who were treated with anticoagulation alone (control group). Women were evaluated for PTS using the Villalta scale (primary outcome) and VEINES-QOL/Sym questionnaires.
Eleven women with iliofemoral DVT underwent PCDT, two during their first trimester and nine postpartum; 18 women were treated with anticoagulation only. There were no significant differences in age, number of previous pregnancies, and duration of anticoagulation or thrombophilia between the groups. The time between DVT diagnosis and study inclusion was longer in the study group median 50.5 (range 16-120) months compared to the control group median 27 (range 11-64) months, p = .4. None of the women in the PCDT group developed PTS, compared to six (33.3%, p = .03) in the control group, four of whom developed severe PTS. One patient in each group developed recurrent DVT, and one patient in the study group developed a calf hematoma. A reduced frequency of lower extremity symptoms was observed in the PCDT group (VEINES-Sym questionnaire), but no differences in quality of life (VEINES-QOL questionnaire) were reported.
This study suggests that PCDT may reduce the incidence of PTS in women with pregnancy related proximal DVT.
Bullet points
DVT involving the iliofemoral veins and development of post thrombotic syndrome is frequent among pregnant or postpartum women
Studies of pharmacomechanical catheter-directed thrombolysis (PCDT) for deep vein thrombosis did not include pregnant or postpartum women
In our observational cross section study women who underwent PCDT (mainly in the postpartum period) had reduced frequency of post-thrombotic syndrome compared to women who received anticoagulation only
Larger studies are required to confirm the use of PCDT for prevention of PTS in this population
Objectives: The objective of this study is to evaluate patterns of use and outcomes of retrievable inferior vena cava filters (rIVCF) in obstetric patients.
Methods: A single center review of ...consecutive patients who underwent rIVCF placement during pregnancy/postpartum in 2005-2016. A pooled analysis of the relevant cases in the English literature was conducted.
Results: The current cohort comprised 24 women, median age 27 interquartile range 24-30 years. Among 10 filters placed during pregnancy, the most common indication (n = 4) was the need to withhold anticoagulation therapy before delivery, in the presence of acute thrombosis. In the postpartum period, most filters (64%, 9/14) were an adjunct to catheter-directed thrombolytic therapy. Inferior vena cava filters (IVCF)-related complications occurred in seven (29.2%). Retrieval was attempted in 21 patients (87.5%), and was technically successful in 19 (90.5%), for an overall removal rate of 79.1%. Pooled analysis of the literature (n = 98) showed comparable rates for filter removal and complications (81.6%, p = .78 and 24.2%, p = .60, respectively). Suprarenal placement (p = .12) and elective cesarean section (p = .19) did not reduce overall complication and retrieval rates. The estimated radiation dose among pregnant patients who underwent rIVCF placement without adjunct catheter directed thrombolysis (CDT) (mean 695 Gy cm
2
) was significantly lower than the radiation dose used in postpartum patients (1863 Gy cm
2
) or in pregnant patients in whom adjunct CDT was utilized (4059 Gy cm
2
) (p = .001 for both comparisons).
Conclusions: Frequent rIVCF-related complications, radiation exposure, and removal failure call for their cautious utilization in obstetric patients. The role of suprarenal placement and elective cesarean section to improve outcomes has yet to be established.
Although delivery timing is physician dictated in indicated preterm births, suboptimal antenatal corticosteroids (ACS) administration occurs in most cases. We aimed to characterize the patterns of ...use of ACS in indicated preterm births and identify missed opportunities of optimal ACS administration.
We reviewed the records of women who received ACS and were delivered due to maternal or fetal indications at 24-34 weeks of gestation during 2015-2017 at a university hospital. Optimal ACS timing was defined as delivery ≥24 h ≤7 d from the previous ACS course.
Overall, 188 pregnancies were included. The median gestational age at delivery was 32 weeks. Considering only the initial ACS course, the rate of optimal timing was 32.4%. Of 105 (55.8%) women eligible (delivery >7 d since the initial ACS course), only a third (n = 38) received a rescue ACS course. Among women who did not receive rescue ACS course despite their eligibility (n = 67), the decision-to-delivery was ≥3 h in 36 (53.7%), and ≥24 h in 20 (29.9%), representing 19.1 and 10.6% of the entire cohort, respectively. The urgency of the decision to deliver (i.e. in the upcoming 24 h and later) and allowing a trial of labor, were both positively associated with decision-to-delivery interval ≥3 h and ≥24 h. The rate of delivery within any optimal window (either initial or rescue course) was 40.4%, with gestational hypertensive disorders (OR 95% CI: 2.40 (1.23, 4.72), p = .01) and decision to deliver made at first hospitalization (OR 95% CI: 2.27 (1.04, 4.76), p = .04) as independent positive predictors of optimal ACS timing. The rate of composite adverse neonatal outcome was significantly lower in those with optimal ACS administration as compared to those with suboptimal timing (32.9 versus 50.9%, OR 95% CI: 0.47 (0.26, 0.87), p = .02).
Suboptimal ACS administration occurred in most indicated preterm births. Underutilization of rescue ACS course and a substantial rate of missed opportunities for optimal ACS administration were identified as potentially modifiable contributors to improve ACS timing.
Maternal age is an established determinant of successful trial of labor after cesarean (TOLAC). While an increasing proportion of parturients are aged 40 years and older, and previously underwent a ...cesarean section, little data regarding TOLAC success for this age group is available. This study assessed TOLAC success, and its associated characteristics, among women >40 years who never delivered vaginally.
A retrospective case-control study of all women who never delivered vaginally aged ≥40 years with a history of previous cesarean delivery, who delivered at our hospital during 2006-2017. Maternal, neonatal, and delivery characteristics were compared between women with successful and unsuccessful TOLAC.
Of 335 older women who never delivered vaginally with a history of one cesarean delivery, 61 (18.2 %) elected TOLAC (18.2 %); the median age was 4140–42 years and the inter-delivery interval 34 25–50 months. Overall, 38/61 (62.3 %) had a successful TOLAC. Women with successful TOLAC had a higher rate of a non-recurrent indication for cesarean delivery in their previous cesarean delivery (42.1 % vs. 13.0 %, P = 0.01), whereas dysfunctional labor at previous delivery was more common in the failed TOLAC group (47.8 % vs. 15.8 %, P = 0.007). Failed TOLAC was associated with the presence of gestational diabetes (13.0 % vs. 0 %, P = 0.02) and having a comorbidity (47.8 % vs. 21.0 %, P = 0.02). Induction of labor at TOLAC was more common in the failed TOLAC group (34.8 % vs. 2.6 %, P < 0.001). Birthweight was higher in the failed TOLAC group (3330 vs. 3107 g, P = 0.04), as well as the birthweight difference between deliveries (212 g vs. 82 g, P = 0.03). Neonatal and maternal outcomes were comparable between groups, except for longer length of stay (5 vs. 4 days, P = 0.04) in the failed TOLAC group. In a multivariable logistic regression analysis, only two factors were independently associated with TOLAC failure: previous cesarean delivery due to dysfunctional labor (OR 95 % CI: 13.40 (1.29, 138.71), P = 0.03) and higher inter-delivery birthweight difference (OR 95 % CI: 1.18 (1.11, 1.39), P = 0.02).
TOLAC in older women who never delivered vaginally is associated with a moderate success rate. The indication for cesarean delivery at the first delivery and inter-delivery birthweight difference were identified as having strong predictive value for TOLAC outcome.
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