American Journal of Obstetrics & Gynecology Mfm最新文献

Intravenous fluid (IVF) administration is a ubiquitous medical intervention. Although there are clear benefits to IVF in certain obstetric scenarios, IVF is often given in unindicated circumstances; the ongoing IVF shortage highlights an opportunity to reduce unindicated IVF in obstetrics. This document provides evidence-based recommendations to reduce IVF use within general obstetric practice. The three sections address IVF use within (1) antepartum care, (2) intrapartum care, and (3) postpartum care, including postpartum hemorrhage (PPH) risk reduction. Using the GRADE framework, we provide a summary of the available evidence surrounding use of IVF in obstetrics and recommend strategies to reduce IVF. We recommend transitioning intravenous (IV) antibiotics to IV push or oral when possible, discontinuing IVF bolus prior to neuraxial anesthesia or for the treatment of preterm labor, and avoiding unnecessary continuous IVF infusions. There may be further opportunities for fluid conservation with IV medications that could be given intramuscularly. These suggestions for IVF use reduction should be evaluated based on local need and capabilities as well as the characteristics and risk factors of the population. Patients with sepsis, PPH, burns, diabetic ketoacidosis, and hemodynamic instability should not have a reduction in IVF administration as these diagnoses have evidence-based resuscitation guidelines that include IVF. The recommendations presented may be applicable beyond the immediate IVF shortage and should be considered as an area for future research.

The scope of fetal therapy has evolved over the last several decades to include interventions intended to treat or mitigate morbidities of complex fetal disorders. As a result, maternal-fetal surgery centers have been established across the country to better meet the needs of this patient population. Centers offering fetal interventions need to utilize a multidisciplinary approach to optimally balance the pregnant patient's autonomy and safety while striving to optimize fetal health. Although there is literature highlighting the components that an experienced maternal-fetal surgery center should contain, there are limited publications illustrating the process of creating a maternal-fetal surgery center. The journey of building a maternal-fetal surgery center is often as complex as the care delivered. The convergence of resources from both adult and pediatric medicine along with extensive hospital executive support are necessary. As a group of centers with diverse experience and geographic locations, we present a staged approach to building a comprehensive maternal-fetal surgery center and the lessons learned along the way.

The research and implementation process for a new screening test should involve two steps. First, one has to demonstrate that the test can predict a certain outcome or appropriately stratify the patients based on risk for the outcome. The second step requires evidence of clinical utility. The Food and Drug Administration has approved screening tests for risk stratification or progression of preeclampsia despite the absence of data on clinical utility. Introduction into clinical practice and eventual integration into the standard of care might follow quickly, making a clinical utility trial challenging to accomplish. This manuscript provides an overview of the research and regulatory pathways used for screening and diagnostic tests in medicine in general and obstetrics in particular. For illustration purposes, we review the relevant data gathered so far regarding tests that are promoted for prediction, risk stratification, and progression of preeclampsia. We then discuss the importance of proving clinical utility before introducing tests into clinical practice and the potential unintended consequences of adoption prior to proving clinical utility.

Background: Various interventions have been applied to reduce perineal trauma and obstetric anal sphincter injuries (OASIS). The efficacy of warm compresses during the second stage of labor for reducing the occurrence of perineal tears is controversial.

Objective: We aimed to compare rates of spontaneous perineal tears requiring suturing, between women who received warm compresses plus perineal massage vs. perineal massage alone.

Study design: Women admitted to a single tertiary university-affiliated hospital between June 2023 and January 2024 were randomized to receive warm compresses and perineal massage (n=206) or perineal message only (n=206) during the second stage of labor. Excluded were women with a history of third-degree perineal tear, nut allergy, fetal death, Crohn's disease with perineal involvement, or delivery number >5. Participant allocation was concealed until the second stage of labor. The allocated perineal management was implemented at the time of active fetal descent and when the participant felt the need to push. During active maternal pushing, gentle perineal massage with almond oil was performed in both study groups. In one group, warm compresses were applied between contractions, for a minimum of 10 minutes and a maximum of 30. The temperature of the warm compresses was kept in the range of 45-59°C. The perineum was protected during delivery with a hands-on technique. After delivery, the perineum was assessed by an intervention-blinded senior midwife and rectal examination was performed for ruling out OASIS. The primary outcome was the rate of perineal tears requiring suturing. Secondary outcomes included the rates of OASIS and episiotomies. A sub-analysis according to parity and an intention-to-treat analysis were performed.

Results: Similar proportions of women treated and not treated with warm compresses had spontaneous perineal tears requiring suturing: 43.7% vs 45.1%, p-value=0.766. The groups did not differ in the proportions with first-degree tears, 22.8% vs 21.4%, p-value=0.722; second-degree tears, 21.4% vs 23.8%, p-value=0.566; and OASIS rates, 0.5% in each. In a sub-analysis according to parity, the proportion with perineal tears did not differ between the two groups.

Conclusion: For women treated during the second stage of labor with warm compresses and perineal massage, compared to perineal massage alone, the rate of spontaneous perineal tears requiring suturing was similar. VIDEO ABSTRACT.

This expert review provides recommendations for the cesarean technique after placental delivery to skin closure. Following placental delivery during cesarean, sponge curettage may be omitted as it has not been shown to decrease the risk of retained products of conception. Uterine irrigation and mechanical cervical dilation cannot be recommended. Either intra-abdominal or extra-abdominal repair of the hysterotomy is acceptable with some possible benefits with decreased postoperative pain and nausea/vomiting with intra-abdominal repair. There is insufficient evidence to recommend one uterine closure technique over the other with regards to suture type, continuous versus interrupted, locking or non-locking, one versus two-layer closure. Double layer uterine closure has been shown to be more beneficial with regards to residual myometrial thickness and full thickness bites (including endometrium) should be considered. Glove change by the surgical team is recommended after placental delivery and prior to closure of the abdominal wall. The following techniques are not recommended: intra-abdominal irrigation, use of adhesion-prevention barriers, peritoneal closure, and rectus muscle re-approximation. Based on non-cesarean evidence, fascial closure bites should be at least 5 × 5 mm with monofilament suture for vertical incisions. As an adjunct to postoperative pain control, surgeons may consider wound infiltration with local anesthesia either supra- or sub-fascial. Prior to closure, subcutaneous irrigation may be performed with saline, and routine use of subcutaneous drains is not recommended. Though closure of the subcutaneous layer can be considered in all patients, it should occur when the depth is ≥ 2cm. A monofilament absorbable suture, such as poliglecaprone, should be used to close the CD skin incision. There is no level 1 evidence evaluating the potential benefit of additional skin adhesive or sterile strips after suture skin closure. If a dressing is preferred over the skin incision the following may be considered: a DACC-impregnated dressing if available, otherwise a standard gauze dressing is appropriate. Prophylactic negative pressure would therapy can be considered in patients with obesity. Vaginal seeding at CD is not recommended.

Background: Preeclamptic women, in addition to traditional anti-hypertensive medications, often receive magnesium supplementation and are at increased risk of post-spinal hypotension Post-spinal hypotension increases the risk of fetomaternal morbidity. Calcium is a physiological antagonist of magnesium in vascular smooth muscle. Therefore, the study hypothesized that calcium is better suited for preserving systemic vascular resistance and preventing post-spinal hypotension during cesarean delivery.

Objectives: The study aimed to evaluate the effect of prophylactic calcium administration on post-spinal hypotension in preeclamptic women receiving magnesium supplementation.

Methods: This prospective, randomized, placebo-controlled, double-blinded, two-arm parallel trial was conducted in preeclamptic women receiving magnesium sulfate supplementation undergoing cesarean delivery. The women were randomized to receive intravenous calcium or a placebo (normal saline) before spinal anesthesia. The study drug (calcium gluconate 500 mg or normal saline) was administered over 15 minutes and ended immediately before spinal anesthesia. The primary outcome measure was the incidence of post-spinal hypotension, and secondary outcome measures were postpartum blood loss and maternal and neonatal outcomes.

Results: 100 women (50 each calcium and placebo arm) completed the study. The baseline demographic variables, mean blood pressure and heart rate were comparable. The incidence of post-spinal hypotension was significantly lower in the calcium arm compared to the placebo arm {(32% vs 60%; Relative risk (95% CI); 1.87 (1.18-2.97); p=0.007)}. The mean phenylephrine requirement (5.60±14.59 vs 14.80 ±22.42 mcg; p=0.01) and mephentermine requirement (3.30 ±5.11 mg vs 5.82 ±4.97 mg; p=0.008) was significantly lower in the calcium group. Furthermore, the calcium group's mean postpartum blood loss was significantly lower (406.90 ±94.34 vs 472.20±122.49 ml, p= 0.004). However, the Neonatal Intensive Care Unit admission rate, Apgar score, umbilical artery PH, and maternal serum calcium were comparable.

Conclusion: Prophylactic calcium infusion significantly reduces the incidence of post-spinal hypotension during cesarean delivery in preeclamptic women receiving magnesium supplementation. Furthermore, the effect of prophylactic calcium in decreasing postpartum blood loss is encouraging. However, large trials are required to validate the findings of this study.