Non-obstetrical indications for cesarean section: a state-of-the-art review

A State-of-the-Art Review of Ophthalmological Indications for a Cesarean Section: Is There a Patient for Whom a Cesarean Section Is Really Indicated?

Purpose: Our purpose was to review the current literature regarding ophthalmologic indications for cesarean section (CS). Methods: A literature search was conducted using MEDLINE, Embase, and the Cochrane Library from inception through October 2024. The databases were searched using the following keywords: "Caesarean section" OR "Caesarean section" OR "delivery" OR "pregnancy" AND "eyes" OR "eye disorders" OR "ocular disease" OR "diabetic retinopathy" OR "myopia" OR "retinal detachment" OR "glaucoma" OR "keratoconus". Studies were considered eligible if they described pregnancy management in women affected by an eye disorder, with insight into the mode of delivery. Results: A total of 8383 results were identified, including only 1 specific guideline and no randomized controlled trials. After a manual review, 38 manuscripts were selected for inclusion. Based on the available evidence, an elective CS may be considered on a case-by-case basis in the presence of specific ophthalmic conditions, such as high-grade myopia with subretinal neovascularization, proliferative diabetic retinopathy, advanced glaucoma, or advanced keratoconus. These conditions are rare among women of childbearing age. Conclusions: Currently, only a limited number of highly specific ophthalmic conditions may benefit from an elective CS. Considering the potential short- and long-term implications of a CS, and in line with the current World Health Organization recommendations, this surgical procedure should be reserved for cases with a clear indication. Given the paucity of data in the available literature, further prospective randomized controlled trials are necessary to enhance the quality of evidence.

A Correlation Study of Birthing Ball Technique and Sacral Massage on Maternal and Fetal Well-being Among Parturient Women: A Non-Randomized Clinical Trail

Background

A woman's pregnancy might be challenging because there are so many changes happening at the time. Most women who give birth have severe labor pain. Women typically use a number of coping strategies, including both pharmaceutical and non-pharmacological, or more natural, techniques, to minimize labor discomfort. "Non-pharmacological coping strategies" refers to methods other than using medications to alleviate labor pain.

Objective

The present study was conducted to correlate birthing ball exercise and sacral massage on maternal and fetal well-being among prim parturient women.

Methods

A quasi-experimental design was adopted. A total of 300 primigravidae with 150 each in the experimental and control groups were selected by purposive sampling. Primigravidae in the experiment group underwent birthing ball exercises and sacral massage during their active phase of labor. The control group received routine hospital standard care. The Visual Analog Pain Scale, GAD-7 Anxiety Severity Scale, Apgar score, and Rating scale on Satisfaction were used to collect the data. Descriptive and inferential statistics were used to analyze the collected data.

Results

The findings of the study showed that the mutual correlation coefficients of the level of satisfaction, pain perception, anxiety, cervical dilatation, uterine contraction, and fetal heart rate of the control group post-test-2 are given.

Conclusion

As a non-pharmacological intervention, the birthing ball technique and sacral massage are necessary to decrease pain perception and reduce anxiety level, which will increase cervical dilatation.

Congenital Syphilis: A Re-Emerging but Preventable Infection

Congenital syphilis presents a significant global burden, contributing to fetal loss, stillbirth, neonatal mortality, and congenital infection. Despite the target established in 2007 by the World Health Organization (WHO) of fewer than 50 cases per 100,000 live births, the global incidence is on the rise, particularly in low- and middle-income regions. Recent data indicate a rate of 473 cases per 100,000 live births, resulting in 661,000 total cases of congenital syphilis, including 355,000 adverse birth outcomes such as early fetal deaths, stillbirths, neonatal deaths, preterm or low-birth-weight births, and infants with clinical congenital syphilis. Alarmingly, only 6% of these adverse outcomes occurred in mothers who were enrolled, screened, and treated. Unlike many neonatal infections, congenital syphilis is preventable through effective antenatal screening and treatment of infected pregnant women. However, despite available screening tools, affordable treatment options, and the integration of prevention programs into antenatal care in various countries, congenital syphilis remains a pressing public health concern worldwide. This review aims to summarize the current epidemiology, transmission, and treatment of syphilis in pregnancy, as well as to explore global efforts to reduce vertical transmission and address the reasons for falling short of the WHO elimination target.

Transient osteoporosis of the hip in pregnancy - a case series

OBJECTIVE

Transient Osteoporosis of the Hip is a self-limiting disorder of severe hip joint pain presenting in pregnancy or postpartum, of which magnetic resonance imaging (MRI) is the modality of choice for diagnosis. Clinical data regarding transient osteoporosis of the hip is limited, precluding evidence-based decision-making such as recommended mode of delivery. In this case-series retrospective study, we aim to describe the natural course of transient osteoporosis of the hip during pregnancy and the postpartum period including implications of the mode of delivery.

METHODS

All women diagnosed with unilateral/bilateral transient osteoporosis of the hip by MRI during pregnancy or postpartum between 2010 and 2019 at a single tertiary medical center were retrospectively studied. All MRI scans were reviewed by an experienced radiologist at the same single tertiary medical center. Data obtained from patients' electronic medical records and telephone questionnaires included maternal baseline characteristics, obstetric history, and current pregnancy obstetric and clinical outcome characteristics. Outcomes of normal vaginal delivery (NVD) and cesarean delivery (CD) were compared and analyzed.

RESULTS

Thirty-four women were diagnosed with unilateral or bilateral transient osteoporosis of the hip during pregnancy (17 women) and postpartum (17 women). The mean maternal age was 34.18 ± 4.75 years. A family history of osteoporosis was reported in a rate of 29.4%. The rate of smokers was 47.1%, 32.4% of pregnancies were conceived by in-vitro fertilization (IVF), pre-pregnancy and term body mass index (BMI) were 22.03 and 27.6, respectively. No significant differences were found between NVD and CD in all parameters evaluated. Of 15 women with a sequential pregnancy, two were diagnosed with transient osteoporosis of the hip (13.3%).

CONCLUSION

Women diagnosed with transient osteoporosis of the hip had advanced maternal age, low BMI, family history of osteoporosis, prevalent smoking and IVF pregnancies. Transient osteoporosis of the hip was bilateral in 25% and presented postpartum in 50% of cases. There was no significant difference in maternal outcomes between NVD and CD. Higher awareness of this potential diagnosis during pregnancy and postpartum may improve patient management and outcomes.

Bloody Amniotic Fluid and Neonatal Outcomes

Information on the effect of bloody amniotic fluid during labor at term is scarce. This study assessed risk factors and adverse outcomes in labors with bloody amniotic fluid. During the six years of this study, all nulliparas in our institution, with a trial of labor, were included. Multiple pregnancies and preterm deliveries were excluded. Outcomes were compared between the bloody amniotic fluid group and the clear amniotic fluid group. Overall, 11,252 women were included. Among them, 364 (3.2%) had bloody amniotic fluid and 10,888 (96.7%) had clear amniotic fluid. Women in the bloody amniotic fluid group were characterized by shorter duration of the second stage and higher rate of cesarean section due to non-reassuring fetal heart rate. In addition, there were higher rates of low cord pH (<7.1) and NICU admissions in the bloody amniotic fluid group. In multivariate logistic regression analysis, cesarean delivery, cord blood pH < 7.1, and NICU admission were independently associated with increased odds ratio for bloody amniotic fluid. Bloody amniotic fluid at term is associated with adverse outcomes and must be considered during labor.

Cost-effectiveness of mechanical thromboprophylaxis for cesarean deliveries in Brazil

OBJECTIVE

To evaluate the cost-effectiveness of using mechanical thromboprophylaxis for patients undergoing a cesarean delivery in Brazil.

METHODS

A decision-analytic model built in TreeAge software was used to compare the cost and effectiveness of intermittent pneumatic compression to prophylaxis with low-molecular-weight heparin or no prophylaxis from the perspective of the hospital. Related adverse events were venous thromboembolism, minor bleeding, and major bleeding. Model data were sourced from peer-reviewed studies through a structured literature search. A willingness-to-pay threshold of R$15,000 per avoided adverse event was adopted. Scenario, one-way, and probabilistic sensitivity analyses were performed to evaluate the impact of uncertainties on the results.

RESULTS

The costs of care related to venous thromboembolism prophylaxis and associated adverse events ranged from R$914 for no prophylaxis to R$1,301 for low-molecular-weight heparin. With an incremental cost-effectiveness ratio of R$7,843 per adverse event avoided. Intermittent pneumatic compression was cost-effective compared to no prophylaxis. With lower costs and improved effectiveness, intermittent pneumatic compression dominated low-molecular-weight heparin. The probabilistic sensitivity analyses showed that the probability of being cost-effective was comparable for intermittent pneumatic compression and no prophylaxis, with low-molecular-weight heparin unlikely to be considered cost-effective (0.07).

CONCLUSIONS

Intermittent pneumatic compression could be a cost-effective option and is likely to be more appropriate than low-molecular-weight heparin when used for venous thromboembolism prophylaxis for cesarean delivery in Brazil. Use of thromboprophylaxis should be a risk-stratified, individualized approach.

Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis

Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.

Maternal Psychopathological Profile during Childbirth and Neonatal Development during the COVID-19 Pandemic: A Pre-Posttest Study

The coronavirus SARS-CoV-2 generated an alert that became a state of emergency in health issues worldwide, a situation that affected the entire population, including pregnant women. The present study aims to understand the effect of the psychopathological profile of a sample of pregnant women at the time of the COVID-19 pandemic on themselves during childbirth (Phase 1) and after childbirth and the anthropometric measures of the neonate at birth (Phase 2). The total sample comprises 81 pregnant women aged 32.07 years (SD = 5.45) and their neonates. Sociodemographic and obstetric data of the sample were collected. During pregnancy, psychopathology was measured by means of the SCL-90, as well as other psychological measures on stress and social support. Cluster k-means techniques were used to uncover the heterogeneous profiles of psychopathology in Phase 1. Two main psychopathological profiles were found (Cluster 1: High psychopathological symptoms; Cluster 2: Low psychopathological symptoms). The clusters generated show significant differences in all the SCL-90-R subscales used and in the general index at Phase 1. After childbirth, high psychopathology profile membership was associated with a greater probability of having a non-eutocic delivery. On the other hand, the low psychopathological symptoms cluster shows higher levels of depressive symptoms, hostility, paranoid ideation, and psychotic symptoms in Phase 2. In conclusion, there seemed to exist two heterogeneous profiles of psychopathology in pregnant women during the pandemic; the stress related to the pandemic seemed uninfluential on the development of a profile of high psychopathological symptoms and the psychopathology profile may influence delivery and postpartum outcomes.

Pregnancy and the eye

PURPOSE OF REVIEW

The aim of this study was to summarize common eye changes that may occur during pregnancy, and how pregnancy may affect preexisting eye conditions such as glaucoma and diabetic retinopathy. Challenges and complexities surrounding the treatment of these eye conditions during pregnancy are also highlighted.

RECENT FINDINGS

Refractive changes are common and may persist in the postpartum in patients with keratoconus. Although new medical and surgical glaucoma treatments are available, their safety in pregnancy is unknown. Limited use of topical and systemic glaucoma therapies is recommended, with a preference for selective laser trabeculoplasty as first line treatment in appropriate cases. The impact of pregnancy on diabetic retinopathy remains unclear. Although anti-vascular endothelial growth factor agents are first-line treatment for sight-threatening diabetic retinopathy, their effect on the developing foetus remains unknown and are therefore best avoided in the first and second trimesters. Noninfectious uveitis tends to become less active during pregnancy, allowing the potential tapering of systemic therapy and the use of local topical or injected corticosteroid treatment for active disease as required.

SUMMARY

Significant changes can occur to the eye during pregnancy, wherein the optimal treatment for many ocular conditions remains uncertain, highlighting the need for further research to develop clear recommendations that best balance the need to preserve the mother's sight, and the health of the developing foetus. The need for preconception planning, and collaborative multidisciplinary care between the obstetrician, physician, ophthalmologist and paediatrician is paramount.

Pregnancy associated transient osteoporosis of the hip (PR-TOH): A non-obstetric indication to caesarean section. A case report with literature review

Pregnancy related transient osteoporosis of the hip (PR-TOH) is a rare condition that manifests with sudden pain located in the groin region, anterior thigh and buttocks. It is a benign and in the majority of cases self-limiting disease, related to bone marrow oedema. It occurs during the third trimester of pregnancy or less frequently during the post-partum period. Hip movements are usually restricted by pain and it often becomes a non-obstetric indication for Caesarean delivery. Here, we report a case of unilateral PR-TOH diagnosed by magnetic resonance imaging (MRI) and a literature review.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.

Difficult caesarean section: A literature review

BACKGROUND

Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications.

METHODS

We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English.

FINDINGS

The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation.

CONCLUSIONS

Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies.

Evolution of the human pelvis and obstructed labor: new explanations of an old obstetrical dilemma

Without cesarean delivery, obstructed labor can result in maternal and fetal injuries or even death given a disproportion in size between the fetus and the maternal birth canal. The precise frequency of obstructed labor is difficult to estimate because of the widespread use of cesarean delivery for indications other than proven cephalopelvic disproportion, but it has been estimated that at least 1 million mothers per year are affected by this disorder worldwide. Why is the fit between the fetus and the maternal pelvis so tight? Why did evolution not lead to a greater safety margin, as in other primates? Here we review current research and suggest new hypotheses on the evolution of human childbirth and pelvic morphology. In 1960, Washburn suggested that this obstetrical dilemma arose because the human pelvis is an evolutionary compromise between two functions, bipedal gait and childbirth. However, recent biomechanical and kinematic studies indicate that pelvic width does not considerably affect the efficiency of bipedal gait and thus is unlikely to have constrained the evolution of a wider birth canal. Instead, bipedalism may have primarily constrained the flexibility of the pubic symphysis during pregnancy, which opens much wider in most mammals with large fetuses than in humans. We argue that the birth canal is mainly constrained by the trade-off between 2 pregnancy-related functions: while a narrow pelvis is disadvantageous for childbirth, it offers better support for the weight exerted by the viscera and the large human fetus during the long gestation period. We discuss the implications of this hypothesis for understanding pelvic floor dysfunction. Furthermore, we propose that selection for a narrow pelvis has also acted in males because of the role of pelvic floor musculature in erectile function. Finally, we review the cliff-edge model of obstetric selection to explain why evolution cannot completely eliminate cephalopelvic disproportion. This model also predicts that the regular application of life-saving cesarean delivery has evolutionarily increased rates of cephalopelvic disproportion already. We address how evolutionary models contribute to understanding and decision making in obstetrics and gynecology as well as in devising health care policies.

Ultrasound in labor admission to predict need for emergency cesarean section: a prospective, blinded cohort study

OBJECTIVE

To assess whether assessment with ultrasound could improve the detection of emergency cesarean section (ECS) in laboring women.

METHODS

Women who presented with symptoms of active labor or women in need of labor induction were invited to participate in the study. Women included in the study were evaluated with ultrasonography for fetal biometry and vaginal examinations for Bishop score assessment. The main aim in this study was determining factors associated with ECS due to fetal distress and obstructed labor.

RESULTS

No fetal biometry variable was associated with ECS due to any indication (fetal distress and obstructed labor combined) in the univariate analysis. In multivariate analyses, biometry variables were adjusted for Bishop score at admission and only abdominal circumference percentile showed a significant association with the odds of ECS due to any indication (OR:1.02, 95% CI: 1.01-1.03). Biparietal diameter and abdominal circumference variables were associated with the odds of ECS due to obstructed labor in both univariate and multivariate analyses (p < .05 for all). However, the predictive accuracy of biparietal diameter percentile (area under the curve (AUC): 0.55, 95% CI: 0.46-0.63) and abdominal circumference percentile (AUC: 0.56, 95% CI: 0.48-0.64) without adjunct variables were poor. Moreover, the addition of fetal biometry parameters to Bishop score did not improve the predictive accuracy of Bishop score.

CONCLUSION

Ultrasound assessment at admission, in addition to Bishop score assessment, did not significantly improve the prediction of ECS. Also, the fetal biometry alone had poor predictive capability for ECS. Routine ultrasound assessment at labor admission appears to be ineffective for predicting ECS.PrecisFetal biparietal diameter and abdominal circumference showed an association with emergency cesarean due to obstructed labor but the predictive accuracy of fetal biometry was low. Routine ultrasound examination at admission, in addition to Bishop score assessment, may not useful for assessing the risk of emergency section in unselected populations.

Ehlers-Danlos syndrome and other heritable connective tissue disorders that impact pregnancies can be detected using next-generation DNA sequencing

Ehlers-Danlos syndromes (EDS) are a genetically heterogeneous group of inherited connective tissue disorders classified into six major types with a variable collection of findings and different inheritance patterns. Although complications occur in about one-half of pregnancies in women with EDS, the majority can have a good outcome if managed appropriately. Classic EDS is characterized by joint hypermobility, loose skin with poor healing and easy bruising, musculoskeletal problems with chronic pain and at risk for pre-term delivery. In addition, the vascular form of EDS can have cardiac anomalies, aneurysms, gastrointestinal perforation and uterine rupture during pregnancy. Due to overlapping features among the connective tissue disorders, it is difficult to categorize the disorder into specific types without detailed genetic testing which is now available through advanced genomic technology using next-generation DNA sequencing, searching genomic databases and bioinformatics approach. Therefore, obstetrical complications are variable but relate to specific connective tissue disorders requiring an exact diagnosis. There are several dozen genes causing connective tissue disorders that are currently available for testing using next-generation sequencing and bioinformatics to provide pertinent care, treatment and surveillance of the affected pregnant woman but also for her at-risk fetus related to the specific heritable condition.

Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations

OBJECTIVES

This study aimed at describing the use of a prospective database on hospital deliveries for analysing caesarean section (CS) practices according to the WHO manual for Robson classification, and for developing recommendations for improving the quality of care (QoC).

DESIGN

Observational study.

SETTING

University Obstetric Unit at De Soysa Hospital for Women, the largest maternity unit in Sri Lanka.

DATA COLLECTION AND ANALYSIS

For each childbirth, 150 variables were routinely collected in a standardised form and entered into a database. Data were routinely monitored for ensuring quality. Information on deliveries occurring from July 2015 to June 2017 were analysed according the WHO Robson classification manual. Findings were discussed internally to develop quality improvement recommendations.

RESULTS

7504 women delivered in the hospital during the study period and at least one maternal or fetal pathological condition was reported in 2845 (37.9%). The CS rate was 30.0%, with 11.9% CS being performed prelabour. According to the Robson classification, Group 3 and Group 1 were the most represented groups (27.0% and 23.1% of population, respectively). The major contributors to the CS rate were group 5 (29.6%), group 1 (14.0%), group 2a (13.3%) and group 10 (11.5%). The most commonly reported indications for CS included abnormal cardiotocography/suspected fetal distress, past CS and failed progress of labour or failed induction. These suggested the need for further discussion on CS practices. Overall, 18 recommendations were agreed on. Besides updating protocols and hands-on training, activities agreed on included monitoring and supervision, criterion-based audits, risk management meetings and appropriate information for patients, and recommendations to further improve the quality of data.

CONCLUSIONS

This study provides an example on how the WHO manual for Robson classification can be used in an action-oriented manner for developing recommendations for improving the QoC, and the quality of data collected.