International journal of obstetric anesthesia最新文献

Background: Oxytocin is widely used for prevention of postpartum hemorrhage, whereas carbetocin provides a longer uterotonic effect. We compared their effectiveness as routine prophylaxis during cesarean delivery.

Methods: We conducted a retrospective before-and-after cohort study at a single academic center. Women undergoing cesarean delivery received oxytocin (3-5 IU bolus followed by 20 IU in 1000 mL over 3 h) during the first study period (February-April 2022) or carbetocin (100 µg bolus) during the second period (February-April 2023). All consecutive cesarean deliveries were included; patients with missing outcome data or protocol deviations were excluded. Primary outcome was need for additional uterotonics. Secondary outcomes included postoperative change in hemoglobin (measured within 24 ± 6 h), packed red blood cell transfusion, intensive care admission, relaparotomy, and length of hospital stay. Groups were compared with univariable tests, and multivariable logistic regression estimated the independent association of treatment with additional uterotonics.

Results: We identified 1,349 cases; 659 received oxytocin and 690 received carbetocin. Additional uterotonics were used in 32.2% (212/659) in the oxytocin group vs. 20.4% (141/690) in the carbetocin group (P < 0.001). The oxytocin group was associated with a greater median postoperative hemoglobin decrease (1.2 g/dL [IQR 0.6-2.0] vs. 1.0 g/dL [IQR 0.4-1.6]; P < 0.001), though this 0.2 g/dL difference is of uncertain clinical significance. Red blood cell transfusion occurred in 4.2% (28/659) of oxytocin cases vs. 2.2% (15/690) of carbetocin cases (P = 0.030). In adjusted analysis, carbetocin was associated with lower odds of additional uterotonics administration compared with oxytocin (OR 0.53, 95% CI 0.41-0.68; P < 0.001).

Conclusions: In this single-center retrospective cohort, carbetocin was associated with reduced administration of additional uterotonics, a lower decrease in postoperative hemoglobin, and reduced transfusion compared with an oxytocin regimen of single bolus plus infusion during cesarean delivery. While these associations were statistically robust after adjustment for measured confounders, the before-and-after study design and potential unmeasured confounding limit causal inference. These findings support carbetocin as an effective option for PPH prophylaxis during cesarean delivery, particularly in settings where sustained uterotonic effect from a single bolus is desirable, though confirmation through randomized trials in diverse settings would strengthen the evidence base.

Background: Intravenous dexmedetomidine may be given to reduce shivering and discomfort during cesarean delivery under neuraxial anesthesia. Dexmedetomidine lowers heart rate and blood pressure, reduces catecholamine release, may have a uterotonic effect, which could reduce intraoperative bleeding during cesarean delivery.

Methods: We conducted a single-center retrospective cohort study of cesarean delivery cases under neuraxial anesthesia conducted at a tertiary hospital in Japan between January 2012 and December 2016. Dexmedetomidine infusion was started after umbilical cord clamping at 6 μg/kg/h to reduce visceral pain over 10 min, followed by a dose reduction to 0.4 μg/kg/h until peritoneal closure. The primary outcome was quantitative intraoperative blood loss. Secondary outcomes were calculated blood loss (Gross and hemoglobin-balance methods), and intraoperative transfusion. Stabilized inverse-probability weighting based on a propensity score constructed from prespecified pretreatment covariates and estimated adjusted mean differences was conducted.

Results: Among 790 cases (dexmedetomidine n=374; no dexmedetomidine n=416), covariate balance after weighting was good. Dexmedetomidine was not associated with blood loss (weighted mean difference + 57 mL; 95% confidence intervals - 39 to 153). Results were directionally consistent for calculated blood-loss measures; transfusion of blood products did not differ.

Conclusions: In this propensity-weighted cohort, intraoperative dexmedetomidine after cord clamping did not reduce blood loss during cesarean delivery.

Background: Spinal needle fracture during spinal anaesthesia is a rare but potentially serious complication, particularly in obstetric practice where neuraxial techniques are frequently used. We report a series of three cases of spinal needle fracture during attempted spinal anaesthesia for caesarean delivery and describe a common technical mechanism and management approach.

Case series: Three patients with obesity had an attempted spinal anaesthetic for caesarean delivery with a fine-gauge pencil-point spinal needle through an introducer. In all cases, fracture occurred during needle redirection while the introducer remained stationary. The neuraxial attempt was abandoned and caesarean delivery proceeded under general anaesthesia in all three cases. Postpartum imaging with computed tomography was used to localise the retained fragments, which were subsequently removed surgically. Neurologic assessment during admission and follow-up at two weeks and one month demonstrated no neurologic deficits in any patient.

Conclusion: Spinal needle fracture can occur when redirection of a fine spinal needle is attempted through a fixed introducer. Awareness of this mechanism, careful technique, and early imaging are essential to reduce risk and guide management in this rare complication.

Introduction: Optimal fluid resuscitation strategies in PPH are unknown. This planned secondary analysis describes fluid resuscitation during OBS Plus, a study designed to characterise PPH coagulopathy. The hypothesis was that the volume of fluid resuscitation equalled the volume of blood loss. Primary outcome was the ratio of clear fluid infused: blood loss.

Methods: Patients recruited into the OBS Plus study with available fluid infusion data and measured blood loss ≥ 1000 mL were included. Clinical management was guided by a PPH care bundle incorporating bedside testing of coagulation. Fluid resuscitation was at the discretion of the clinical team. Infusions commenced 1 h before to 1 h after PPH were analysed.

Results: Between 2017 and 2019, 495 patients with PPH ≥ 1000 mL were recruited. 67/495 (13.5%) were excluded for missing data. Clear fluid infusions were crystalloid, 426/428 (99.5%) and colloid, 39/428 (9.1%). Blood product transfusions were red blood cells, 40/428 (9.4%); fresh frozen plasma 3/428 (0.7%); platelets 5/428 (1.1%). Overall median ratio clear fluids: blood loss was 858:1000 mL with blood products contributing to resuscitation volumes in massive PPH (≥ 2500 mL). Fluid volumes ≥ 3500 mL were only infused in massive PPH. No patients required renal replacement therapy or respiratory support for fluid overload.

Discussion: Inappropriate clear fluid resuscitation may cause fluid overload or renal injury. In this report, no patient required respiratory or renal support and median fluid resuscitation volume was approximately equal to blood loss. The incidence of coagulopathy in OBS Plus should be interpreted in this context.