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Lomas S, Minton Z, Daniels J. Systematic review of the effectiveness of remifentanil in term breech pregnancies undergoing external cephalic version. Int J Obstet Anesth 2023; 54:103649. [PMID: 36989876 DOI: 10.1016/j.ijoa.2023.103649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/09/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND External cephalic version (ECV) is a moderately painful procedure used to turn a fetus from a non-vertex to cephalic position. This systematic review and meta-analysis compared intravenous remifentanil with other analgesia or no analgesia or placebo on the success rate and associated pain of ECV. METHODS Systematic searches for randomised controlled trials using remifentanil during ECV for non-cephalic term singleton pregnancies were conducted in EMBASE, MEDLINE and Cochrane Library to October 2021. The primary outcomes were successful ECV and maternal pain; secondary outcomes included mode of delivery and adverse effects. The Cochrane Risk of Bias tool was used and meta-analysis undertaken if there were ≥2 comparable studies. RESULTS Four trials were identified, three placebo-controlled and one vs no analgesia, totalling 482 participants. Comparisons against nitrous oxide or neuraxial anaesthesia were not analysed. Two studies had a low overall risk of bias, and two had some concern for bias. Remifentanil compared with placebo increased the success of ECV by 43% (risk ratio [RR] 1.43; 95% confidence interval [CI] 1.14 to 1.78). Pain scores (0-10) were lower (mean difference -1.97; 95% CI -2.49 to -1.46) whilst there was no impact on caesarean delivery rate (RR 0.97; 95% CI 0.81 to 1.17). Adverse events were rare, with fetal bradycardia observed less often with remifentanil than placebo. CONCLUSIONS Remifentanil increases the procedural success of ECV and reduces pain compared with placebo. Trials were at low risk of bias and contained a sufficient number of participants to have reasonable confidence in this finding.
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2
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Wängberg Nordborg J, Svanberg T, Strandell A, Carlsson Y. Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2022; 101:564-576. [PMID: 35633052 DOI: 10.1111/aogs.14333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term. MATERIAL AND METHODS The population (P) was pregnant women with a child in breech presentation, from gestational week 34+0 . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546. RESULTS Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence). CONCLUSIONS Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.
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Affiliation(s)
- Julia Wängberg Nordborg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Therese Svanberg
- HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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3
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Carbillon L, Benbara A, Tigaizin A, Murtada R, Fermaut M, Belmaghni F, Bricou A, Boujenah J. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 2020; 20:263. [PMID: 32359354 PMCID: PMC7196223 DOI: 10.1186/s12884-020-2831-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/20/2020] [Indexed: 11/29/2022] Open
Abstract
Background The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. Main body In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. Conclusion The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.
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Affiliation(s)
- Lionel Carbillon
- Department of Obstetrics and Gynecology, Sorbonne Paris Nord University, Assistance Publique - Hopitaux de Paris, Avenue du 14 juillet, Hôpital Jean Verdier, 93140, Bondy Cedex, France. .,Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France.
| | - Amelie Benbara
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Ahmed Tigaizin
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Rouba Murtada
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Marion Fermaut
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Fatma Belmaghni
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Alexandre Bricou
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Jeremy Boujenah
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
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4
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Rodríguez L, Osuna C, Pijoan JI, Cobos P, Centeno MM, Serna R, Jiménez A, Artola I, Melchor I, Martínez-Astorquiza T, Melchor JC, Burgos J. Patient opinion of analgesia during external cephalic version at term in singleton pregnancy. J OBSTET GYNAECOL 2019; 40:767-771. [PMID: 32648534 DOI: 10.1080/01443615.2019.1647522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it.
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Affiliation(s)
- Leire Rodríguez
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Carmen Osuna
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - José I Pijoan
- Clinical Epidemiology Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain.,CIBER Epidemiology and Public Health (CIBERESP), Spanish Clinical Research Network (SCReN), Madrid, Spain
| | - Patricia Cobos
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - María M Centeno
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Rosa Serna
- Anesthesia Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Antonia Jiménez
- Anesthesia Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Izaskun Artola
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Iñigo Melchor
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Txantón Martínez-Astorquiza
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Juan C Melchor
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
| | - Jorge Burgos
- Obstetrics and Gynecology Department, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bizkaia, Spain
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Fischbein SJ, Freeze R. Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births. BMC Pregnancy Childbirth 2018; 18:397. [PMID: 30305050 PMCID: PMC6180643 DOI: 10.1186/s12884-018-2033-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/27/2018] [Indexed: 01/17/2023] Open
Abstract
Background Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting. Methods This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity. Results 50 breech and 102 cephalic presentations were still in the obstetrician’s care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group. Conclusions A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.
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Affiliation(s)
| | - Rixa Freeze
- Wabash College, 211 Center Hall, Crawfordsville, IN, 47933, USA.
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6
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Burgos J, Arana I, Garitano I, Rodríguez L, Cobos P, Osuna C, Del Mar Centeno M, Fernández-Llebrez L. Induction of labor in breech presentation at term: a retrospective cohort study. J Perinat Med 2017; 45:299-303. [PMID: 27105484 DOI: 10.1515/jpm-2015-0426] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/21/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the outcome of two methods of labor induction and spontaneous onset of labor in breech presentation at term. MATERIAL A retrospective study between 2003 and 2012. We compare obstetric (indication of induction, Bishop score, cesarean rate) and perinatal outcomes (Apgar score, umbilical artery pH, base excess ≤-12 mmol/L, admission to neonatal unit) between prostaglandins and oxytocin. We also compare labor induction versus spontaneous onset of labor. RESULTS Of the 1684 breech deliveries, we carried out labor induction in 221 cases (76% with prostaglandins, 24% with oxytocin). The prostaglandins group had significantly lower Bishop scores and the time for induction phase was significantly higher. There were no differences in cesarean rate between both methods of induction or spontaneous onset of labor. The prostaglandins group had higher rates of base excess ≤-12 mmol/L. Compared with spontaneous onset of labor in breech presentation, induction had significant lower rates of newborn weight and higher rates of admission to the neonatal unit. CONCLUSIONS Induction of labor in breech presentation at term is a reasonable and effective option after a careful selection of cases. It was not associated with an increase of perinatal morbidity or cesarean rate compared with spontaneous onset of labor.
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Affiliation(s)
- Jorge Burgos
- Obstetrics and Gynecology Service, BioCruces Health Research Institute, Hospital Universitario Cruces, C/Plaza de Cruces 12, 48903, Baracaldo, Biscay
| | - Itziar Arana
- University of the Basque Country (UPV/EHU), Biscay
| | | | | | | | - Carmen Osuna
- University of the Basque Country (UPV/EHU), Biscay
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7
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Hoffmann J, Thomassen K, Stumpp P, Grothoff M, Engel C, Kahn T, Stepan H. New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae. PLoS One 2016; 11:e0161028. [PMID: 27532122 PMCID: PMC4988813 DOI: 10.1371/journal.pone.0161028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 07/28/2016] [Indexed: 11/23/2022] Open
Abstract
Background Even if lower vaginal delivery success rates and impaired neonatal short-term outcomes have been reported for primiparous women with breech presentation, vaginal breech delivery remains an option for carefully selected patients. Because Magnetic resonance imaging (MRI) pelvimetry can provide additional information on maternal pelvic morphology, we sought to identify new MRI parameters that predict successful vaginal breech delivery. Methods In this retrospective unicentre study, 240 primiparous women with breech presentation at term underwent MRI pelvimetry. For all patients vaginal delivery was planned, according to German guidelines and if the conjugata vera (CV) was ≥12 cm. The patients with uneventful vaginal deliveries and the patients who underwent a secondary caesarean section were compared according to pelvimetric parameters and outcomes. Regression analyses were performed. Results In the vaginal delivery group (n = 162, (67.5%)), the distance between the spinae ischiadicae (interspinous diameter, ISD) was significantly enlarged. The ISD significantly influenced the mode of delivery in the regression analyses. The CV did not significantly differ between the groups. The patients with successful vaginal deliveries were significantly younger than the patients who underwent caesarean section. In the receiver operating characteristic (ROC) analysis, the area under the curve (AUC) for ISD was 67.7% (p<0.001, 95% CI [0.303–0.642]) and was higher considering the mother’s age (AUC = 73.1%, p<0.001, 95% CI [0.662–0.800]). The neonatal short-term outcomes were comparable in both groups. Conclusion The additional use of ISD may predict successful vaginal breech delivery and may be superior to the CV, which is more commonly used. Trial Registration DRKS00009957
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Affiliation(s)
- Janine Hoffmann
- University of Leipzig, Department of Obstetrics, Liebigstrasse 20a, 04103 Leipzig, Germany
- * E-mail:
| | - Katrin Thomassen
- University of Leipzig, Department of Obstetrics, Liebigstrasse 20a, 04103 Leipzig, Germany
| | - Patrick Stumpp
- University of Leipzig, Department of Radiology, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Matthias Grothoff
- University of Leipzig—Heart Center, Department of Radiology, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Christoph Engel
- University of Leipzig, Institute for Medical Informatics, Statistics and Epidemiology, Haertelstrasse 16–18, 04107 Leipzig, Germany
| | - Thomas Kahn
- University of Leipzig, Department of Radiology, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Holger Stepan
- University of Leipzig, Department of Obstetrics, Liebigstrasse 20a, 04103 Leipzig, Germany
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Burgos J, Pijoan JI, Osuna C, Cobos P, Rodriguez L, Centeno MDM, Serna R, Jimenez A, Garcia E, Fernandez-Llebrez L, Melchor JC. Increased pain relief with remifentanil does not improve the success rate of external cephalic version: a randomized controlled trial. Acta Obstet Gynecol Scand 2016; 95:547-54. [DOI: 10.1111/aogs.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/16/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jorge Burgos
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - José I. Pijoan
- Clinical Epidemiology Unit; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
- Spanish Clinical Research Network (SCReN); Madrid Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP); Madrid Spain
| | - Carmen Osuna
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Patricia Cobos
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Leire Rodriguez
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - María del Mar Centeno
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Rosa Serna
- Anesthesia Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Antonia Jimenez
- Anesthesia Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Eugenia Garcia
- Anesthesia Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Luis Fernandez-Llebrez
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
| | - Juan C. Melchor
- Obstetrics and Gynecology Service; BioCruces Health Research Institute; Cruces University Hospital (UPV/EHU); Barakaldo Spain
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