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Bhat A, Jaffer D, Keasler P, Kamath K, Kelly J, Singh P. Uterine externalization versus in-situ repair of hysterotomy during cesarean delivery: a systematic review, equivalence meta-analysis, and trial sequential analysis. Int J Obstet Anesth 2022; 50:103271. [DOI: 10.1016/j.ijoa.2022.103271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/18/2022] [Accepted: 02/05/2022] [Indexed: 10/19/2022]
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Yang MC, Li P, Su WJ, Jiang R, Deng J, Wang RR, Huang CL. Manual Removal versus Spontaneous Delivery of the Placenta at Cesarean Section: A Meta-Analysis of Randomized Controlled Trials. Ther Clin Risk Manag 2021; 17:1283-1293. [PMID: 34880619 PMCID: PMC8648276 DOI: 10.2147/tcrm.s333557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/16/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose Several randomized clinical trials (RCTs) investigated the effects of the manual placental removal on hemorrhage or other hemorrhage-related complications compared with the spontaneous placental removal during cesarean section (CS), while the results remained controversial and were inconsistent. The purpose of this meta-analysis was to quantify the pooled effects of the methods of placental removal on hemorrhage during CS. Patients and Methods A systematic literature search was conducted using PubMed, EMBASE, Web of Science, and Google Scholar. Heterogeneity was tested by I2 statistics and Q-statistic. The random-effects model or fixed-effects model were used to calculate the pooled effect for the included studies according to heterogeneity. And the term of standardized mean difference (SMD) with 95% confidence intervals (CI) was pooled and estimated the effects across all studies. Results A total of nine RCTs were included in this meta-analysis. Compared with spontaneous group, manual placental removal increased the amount of hemorrhage (SMD = 0.53, 95% CI [0.12, 0.94]; Z = 2.54, P = 0.011) and increased the risk of endometritis (OR = 1.84, 95% CI [1.31, 2.58]; Z = 3.52, P < 0.0001). In contrast, there was no significant difference concerning the operating time (SMD = −0.30, 95% CI [−0.85, 0.24]; Z = 1.09, P = 0.276), the length of hospital stays (SMD = 0.11, 95% CI [−0.08, 0.30]; Z = 1.11, P = 0.265), and blood transfusion requirement (OR = 1.36, 95% CI [0.91, 2.04]; Z = 1.52, P = 0.129), respectively. Conclusion Comparing with spontaneous placental removal, manual placental removal appeared to be less positive effect during CS. Because of the limitations of this meta-analysis, more high-quality RCTs are needed to confirm our findings.
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Affiliation(s)
- Meng-Chang Yang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Peng Li
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Wen-Jie Su
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Rong Jiang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Jia Deng
- Department of Anesthesiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Ru-Rong Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chao-Li Huang
- Department of Internal Medicine, Eastern Hospital, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
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Tan HS, Taylor CR, Sharawi N, Sultana R, Barton KD, Habib AS. Uterine exteriorization versus in situ repair in Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2021; 69:216-233. [PMID: 34811700 DOI: 10.1007/s12630-021-02142-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/20/2021] [Accepted: 09/09/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We conducted an updated systematic review and meta-analysis on maternal outcomes associated with uterine exteriorization compared with in situ repair in women undergoing Cesarean delivery. METHODS We searched for randomized controlled trials comparing uterine exteriorization with in situ repair during Cesarean delivery. Primary outcomes were intraoperative nausea and vomiting (IONV) and perioperative decrease in hemoglobin concentration. Secondary outcomes were postoperative nausea and vomiting (PONV), estimated blood loss, fever, endometritis, wound infection, intraoperative and postoperative pain, postoperative analgesic use, duration of surgery and hospital stay, and time to return of bowel function. RESULTS Twenty studies with 20,909 parturients were included. Exteriorization was associated with higher risk of IONV (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.66 to 2.63; I2 = 0%), with no difference in perioperative hemoglobin concentration decrease (mean difference, - 0.06 g·dL-1; 95% CI, - 0.20 to 0.08; I2 = 97%) compared with in situ repair. There were no significant differences in estimated blood loss, transfusion requirement, PONV, duration of surgery, duration of hospital stay, time to return of bowel function, fever, endometritis, or wound infection. Postoperative pain (incidence of pain graded > 5/10) at six hours (OR, 1.64; 95% CI, 1.31 to 2.03; I2 = 0%) was higher with exteriorization, but there was no difference in need for rescue analgesia (OR, 2.48; 95% CI, 0.89 to 6.90; I2 = 94%) or pain scores at 24 hr compared with in situ repair. CONCLUSIONS In this updated systematic review and meta-analysis, uterine exteriorization was associated with an increased risk of IONV but no significant change in perioperative hemoglobin decrease compared with in situ repair. STUDY REGISTRATION PROSPERO (CRD42020190074); registered 5 July 2020.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Karen D Barton
- Medical Center Library and Archives, Duke University Medical Center, Durham, NC, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.
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Schrey-Petersen S, Tauscher A, Dathan-Stumpf A, Stepan H. Diseases and complications of the puerperium. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0168. [PMID: 33972015 PMCID: PMC8381608 DOI: 10.3238/arztebl.m2021.0168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 02/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery. METHODS This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics. RESULTS The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery. CONCLUSION Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.
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Affiliation(s)
| | - Anne Tauscher
- Division of Obstretics, University of Leipzig Medical Center
| | | | - Holger Stepan
- Division of Obstretics, University of Leipzig Medical Center
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Kükrer S, Pepekal Kükrer A. Delivery method of the placenta in cesarean deliveries and the effect of uterine incision repair area on morbidity: A randomized controlled study. Turk J Obstet Gynecol 2021; 18:92-102. [PMID: 34082521 PMCID: PMC8191328 DOI: 10.4274/tjod.galenos.2021.05873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective We evaluated the effects of spontaneous or manual delivery of the placenta and repair of uterine incision inside or outside the abdomen on intraoperative blood loss, postoperative infection morbidity, and postoperative hospitalization time. Materials and Methods We conducted a prospective randomized controlled study with 150 patients among 160 patients who were indicated to undergo emergency cesarean procedures in our tertiary hospital. We divided the patient population into four groups. These four groups were formed by comparing the way the placenta was delivered manually and by spontaneous traction with the repair of the uterus inside and outside the abdomen. Blood loss was determined using quantitative and gravimetric methods. A numeric rating scale was used, which is a one-dimensional method used for uterine sensitivity distribution and pain measurement. Results The amount of bleeding was 339 mL in group 1, 237 mL in group 2, 470 mL in group 3, and 490 mL in group 4, which were significantly different (p<0.001). The mean surgical time was 30.8±5.5 minutes in group 1, 30.7±4.4 minutes in group 2, 38.5±6.9 minutes in group 3, and 43.9 minutes in group 4 (p<0.001). When the distribution of uterine tenderness among the groups was examined in the fundus examinations performed on the postpartum 1st day of the patients, we found a significant difference (p<0.001). When all groups were compared, there was a significant difference between group 1 and group 4 in terms of hospital stay (p<0.004). Among the contributing factors were endometritis, maternal body weight (p<0.053), advanced gestational week (p<0.004), prolonged surgical time (p<0.009), and the presence of meconium. Conclusion Manual removal of the placenta resulted in higher blood loss, increased uterine tenderness, and longer hospitalization compared with the spontaneous separation method. The uterine incision repair site did not affect morbidity.
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Affiliation(s)
- Sadık Kükrer
- University of Health Sciences Turkey, Adana City Training and Research Hospital, Clinic of Obstetrics and Gynecology, Adana, Turkey
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Koutras A, Fasoulakis Z, Syllaios A, Garmpis N, Diakosavvas M, Pagkalos A, Ntounis T, Kontomanolis EN. Physiology and Pathology of Contractility of the Myometrium. In Vivo 2021; 35:1401-1408. [PMID: 33910817 DOI: 10.21873/invivo.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/10/2022]
Abstract
Uterine atony is a serious obstetrical complication since it is the leading cause of postpartum hemorrhage. Postpartum hemorrhage (PPH) is one of the 5 major causes of postpartum mortality; therefore, it requires immediate medical intervention, independent of whether delivery occurs normally or with a cesarean section. While in the past years most cases of postpartum hemorrhage were caused due to uterine atony following vaginal delivery, in recent years most PPH cases indicate a significant association with cesarean delivery. There are several methods used in order to avoid such a life-threatening complication, ranging from risk assessment to prevention, and finally medical intervention and management, if such an event occurs. In this scientific paper emphasis is given on the so-called "uterotonic" agents that are currently used, including oxytocin among others. It is, therefore, important to be familiar with these agents as well as understand the physiological mechanism by which they work, since they are used in everyday practice, not only for managing but also for preventing PPH. There are several potential questions that arise from the use of such "uterotonic" agents, and most specifically of oxytocin. Maybe one of the most important issues is the determination of optimal dosing of oxytocin in order to avoid PPH after a cesarean section.
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Affiliation(s)
- Antonios Koutras
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Zacharias Fasoulakis
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Athanasios Syllaios
- Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece;
| | - Nikolaos Garmpis
- Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Michail Diakosavvas
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Athanasios Pagkalos
- Consultant on Department of Obstetrics and Gynecology, General Hospital of Xanthi, Xanthi, Greece
| | - Thomas Ntounis
- Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Emmanuel N Kontomanolis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
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Changing gloves during cesarean section for prevention of postoperative infections: a systematic review and meta-analysis. Sci Rep 2021; 11:4592. [PMID: 33633326 PMCID: PMC7907110 DOI: 10.1038/s41598-021-84259-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 02/12/2021] [Indexed: 01/17/2023] Open
Abstract
This systematic review and meta-analysis was conducted to assess associations between changing gloves during cesarean section (CS) and postoperative infection. A literature search was conducted using the major electronic databases MEDLINE, Scopus, ISI Web of Science, PubMed, CINAHL, and CENTRAL from their inception to September 2020. Randomized controlled trials (RCTs) comparing glove change during CS to no glove change were included. Outcomes of interest were endometritis, febrile morbidity, and incisional surgical site infection (SSI). GRADE approach was applied to assess the quality of evidence. Ten reports of six studies involving 1707 participants were included in the analyses. Glove change was associated with a reduction in the risk of incisional SSI following CS (pooled RR 0.49, 95% CI 0.30, 0.78; moderate quality of evidence). Compared to no glove change, glove change during CS did not reduce the risks of endometritis (pooled RR 1.00, 95% CI 0.80, 1.24; low quality of evidence) or febrile morbidity (pooled RR 0.85, 95% CI 0.43, 1.71; very low quality of evidence). Changing gloves during CS was associated with a decreased risk of incisional SSI. The risks of postoperative endometritis and febrile morbidity were not altered by changing gloves.
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Wang LH, Seow KM, Chen LR, Chen KH. The Health Impact of Surgical Techniques and Assistive Methods Used in Cesarean Deliveries: A Systemic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6894. [PMID: 32967222 PMCID: PMC7558715 DOI: 10.3390/ijerph17186894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022]
Abstract
Cesarean delivery is one of the most frequently performed surgeries in women throughout the world. However, the most optimal technique to minimize maternal and fetal morbidities is still being debated due to various clinical situations and surgeons' preferences. The contentious topics are the use of vacuum devices other than traditional fundal pressure to assist in the delivery of the fetal head and the techniques of uterine repair used during cesarean deliveries. There are two well-described techniques for suturing the uterus: The uterus can be repaired either temporarily exteriorized (out of abdominal cavity) or in situ (within the peritoneal cavity). Numerous studies have attempted to compare these two techniques in different aspects, including operative time, blood loss, and maternal and fetal outcomes. This review provides an overview of the assistive method of vacuum devices compared with fundal pressure, and the two surgical techniques for uterine repair following cesarean delivery. This descriptive literature review was performed to address important issues for clinical practitioners. It aims to compare the advantages and disadvantages of the assistive methods and surgical techniques used in cesarean deliveries. All of the articles were retrieved from the databases Medline and PubMed using the search terms cesarean delivery, vacuum, and exteriorization. The searching results revealed that after exclusion, there were 9 and 13 eligible articles for vacuum assisted cesarean delivery and uterine exteriorization, respectively. Although several studies have concluded vacuum assistance for fetal extraction as a simple, effective, and beneficial method during fetal head delivery during cesarean delivery, further research is still required to clarify the safety of vacuum assistance. In general, compared to the use of in situ uterine repairs during cesarean delivery, uterine exteriorization for repairs may have benefits of less blood loss and shorter operative time. However, it may also carry a higher risk of intraoperative complications such as nausea and vomiting, uterine atony, and a longer time to the return of bowel function. Clinicians should consider these factors during shared decision-making with their pregnant patients to determine the most suitable techniques for cesarean deliveries.
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Affiliation(s)
- Li-Hsuan Wang
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
| | - Kok-Min Seow
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 10449, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 30010, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
- School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
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Faure K, Dessein R, Vanderstichele S, Subtil D. Endométrites du post-partum. RPC infections génitales hautes CNGOF et SPILF. ACTA ACUST UNITED AC 2019; 47:442-450. [DOI: 10.1016/j.gofs.2019.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Altraigey A, Ellaithy M, Atia H, Ali I, Kolkailah M, Abbas A. How can methods of placental delivery in cesarean section affect perioperative blood loss? A randomized controlled trial of controlled cord traction versus manual removal of placenta. J Obstet Gynaecol Res 2018; 45:133-140. [PMID: 30178599 DOI: 10.1111/jog.13797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 08/01/2018] [Indexed: 11/29/2022]
Abstract
AIM Of the different described methods of placental delivery during cesarean section (CS), manual removal and cord traction are the most commonly used techniques. The ideal method of placental delivery during CS is still a conflicting issue as the data derived from the previous studies are widely heterogeneous and inconsistent. This study has investigated the effect of two different methods of placental delivery, controlled cord traction and manual removal, on perioperative blood loss. METHODS This randomized controlled trial recruited 345 pregnant women scheduled for elective cesarean delivery at term. Eligible participants were randomly assigned to have their placentae delivered either by manual removal or cord traction. Perioperative blood loss was the study primary outcome measure. RESULTS A total of 300 women were included in the final analysis. The longer placental delivery time in the cord traction group (n = 150) (60 s. [45-61.25] versus 45 s. [35-60] in the manual placental delivery group, P < 0.001) was associated with a statistically significant but clinically insignificant higher visually estimated blood loss (500 mL [interquartile range, 500-700] versus 500 mL [interquartile range, 400-500] in the manual removal group, P < 0.001). Although there were statistically significant differences in the hemoglobin levels, postoperatively, these differences were clinically insignificant and were not reflected in the corresponding deficits and percentages of deficit at 12- and 48-h postoperative intervals. CONCLUSIONS Of the studied placental delivery techniques, there were no clinically significant differences in terms of the considered intraoperative and postoperative outcomes; hence, the practice of placental delivery can be left up to obstetrician's discretion and intraoperative scenario.
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Affiliation(s)
- Ahmed Altraigey
- Obstetrics and Gynecology Department, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia.,Obstetrics and Gynecology Department, Benha University, Qalubiya, Egypt
| | - Mohamed Ellaithy
- Obstetrics and Gynecology Department, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia.,Ain Shams University Maternity Hospital, Cairo, Egypt
| | - Hytham Atia
- Obstetrics and Gynecology Department, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia.,Obstetrics and Gynecology Department, Zagazig University, Zagazig, Egypt
| | - Ibrahim Ali
- Obstetrics and Gynecology Department, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia.,Ain Shams University Maternity Hospital, Cairo, Egypt
| | - Mohamed Kolkailah
- Obstetrics and Gynecology Department, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia
| | - Ahmed Abbas
- Obstetrics and Gynecology Department, Assiut University, Assiut, Egypt
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Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2015; 62:1209-20. [DOI: 10.1007/s12630-015-0448-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 06/01/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022] Open
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El-Khayat W, Elsharkawi M, Hassan A. A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery. Int J Gynaecol Obstet 2014; 127:163-6. [PMID: 25005057 DOI: 10.1016/j.ijgo.2014.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/11/2014] [Accepted: 06/12/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair. METHODS The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012-2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n=500) and in situ repair in group 2 (n=500). The primary outcome measure was the surgery duration. RESULTS Surgery duration was significantly longer in group 1 than group 2 (49.9±2.3 minutes vs 39.9±1.8 minutes; P<0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P=0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P<0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0±2.7 hours vs 14.0±1.9 hours; P<0.001). CONCLUSION In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement. ClinicalTrials.gov:NCT01723605.
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Affiliation(s)
- Waleed El-Khayat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Mohamed Elsharkawi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Doğanay M, Tonguc EA, Var T. Effects of method of uterine repair on surgical outcome of cesarean delivery. Int J Gynaecol Obstet 2010; 111:175-8. [DOI: 10.1016/j.ijgo.2010.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 06/03/2010] [Accepted: 07/09/2010] [Indexed: 11/25/2022]
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Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008; 30:1002-1007. [DOI: 10.1016/s1701-2163(16)32994-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Worldwide, caesarean section is the most common major operation performed on women. Some of the reported short-term morbidities include haemorrhage, postoperative fever and endometritis. The method of delivering the placenta is one procedure that may contribute to an increase or decrease in the morbidity of caesarean section. Two common methods used to deliver the placenta at caesarean section are cord traction and manual removal. OBJECTIVES To compare the effects of manual removal of the placenta with cord traction at caesarean section. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2007). SELECTION CRITERIA All randomised controlled trials comparing manual removal and cord traction or spontaneous of delivery of the placenta. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies and extracted data. MAIN RESULTS We included 15 studies (4694 women). There was significant heterogeneity for the duration of surgery, blood loss and haematological outcomes. The only possible contributing factor found was greater protection from blood loss in two trials in which cord traction was combined with uterine massage. A random-effects model meta-analysis was used for these outcomes. Manual removal of the placenta was associated with more endometritis (relative risk (RR) 1.64, 95% confidence interval (CI) 1.42 to 1.90; 4134 women, 13 trials); more blood loss (ml) (weighted mean difference (WMD) 94.42 ml, 95% CI 17.19 to 171.64; 2001 women, eight trials); more blood loss > 1000 ml (RR 1.81, 95% CI 1.44 to 2.28; 872 women, two trials); lower haematocrit after delivery (%) (WMD -1.55, 95% CI -3.09 to -0.01; 384 women, two trials); greater haematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00 to 0.78; 1777 women, five trials); longer duration of hospital stay (days) (WMD 0.39 days, 95% CI 0.17 to 0.61; 546 women, three trials). The duration of surgery was shorter in one trial but not overall. There were no significant differences in feto-maternal haemorrhage, blood transfusion, puerperal fever (numbers studied for these outcomes were small). AUTHORS' CONCLUSIONS Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay. Future trials should provide information on interval between the delivery of the infant and of the placenta, change in lochia, blood splashing during placental removal and uterine pain after operation, as well as the effects of delayed cord clamping.
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Affiliation(s)
- Rose I Anorlu
- Department of Obstetrics and Gynaecology, University of Lagos, College of Medicine, Surulere, Lagos, Nigeria, PMB 12003.
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Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JCA. Complications of Exteriorized Compared With In Situ Uterine Repair at Cesarean Delivery Under Spinal Anesthesia. Obstet Gynecol 2007; 110:570-5. [PMID: 17766602 DOI: 10.1097/01.aog.0000277712.67230.22] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare intraoperative complications of exteriorized and in situ uterine repair during elective cesarean delivery under spinal anesthesia. METHODS This study was a randomized, single-blinded trial in 80 women undergoing elective cesarean delivery under spinal anesthesia. Patients were randomly assigned to exteriorized or in situ uterine repair. Obstetricians were asked to perform assisted delivery of the placenta. Spinal anesthesia and oxytocin management were standardized. Phenylephrine was used to maintain systolic blood pressure within 10% of the baseline. The primary outcome was intraoperative, postdelivery nausea or vomiting. RESULTS Postdelivery nausea or vomiting (18% compared with 38%; P=.04) and tachycardia (3% compared with 18%; P=.03) were significantly reduced in the in situ group compared with the exteriorized group. The duration of uterine repair was significantly shorter in the exteriorized group (median 10 minutes [first and third quartiles 9, 13], compared with 11 minutes [9, 15]) (P=.04). The duration of surgery (36 minutes [30, 41] compared with 37 minutes [30, 45]) and estimated blood loss (mean+/-standard deviation 625+/-489 mL compared with 653+/-416 mL) were similar between the in situ and the exteriorized groups. There was no correlation between duration of uterine repair and estimated blood loss. CONCLUSION Exteriorization of the uterus for repair is associated with an increased incidence of nausea and vomiting and tachycardia during cesarean delivery under spinal anesthesia. Uterine repair should be done in situ where possible. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00452972 LEVEL OF EVIDENCE I.
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Affiliation(s)
- Mughina Siddiqui
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Onatario, Canada
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