Uterine Cooling during Cesarean Section to Reduce Intraoperative Blood Loss: A randomized controlled trial

Objectives: The aim was to compare uterine cooling and routine cesarean section as a means of reducing intraoperative blood loss. Materials and Methods: Pregnant women who underwent cesarean section at Khon Kaen Hospital between May and June, 2017 were randomly assigned to one of two groups: the uterine cooling (UC) group (n= 80) or the control group (n= 80). In the UC group, the uterus was wrapped using a sterile cooling swab while in the control group a routine cesarean section (CS) was performed. Results: In UC group, there was a statistically significant reduction in intra-operative blood loss compared with routine CS (252.8 ± 133.8 vs 472.9 ± 201.8 ml), mean difference 220 ml (95%CI 166.6-273.5). Uterotonic drugs use was significantly less in the UC group (1.3% vs 10%, p = 0.02). Length of hospital stay was significantly less in the UC group (3.0 ± 0.5 vs 3.2 ± 0.7 day; p = 0.01). There was no significant difference between the two groups in postpartum hemorrhage. There was no intraoperative hypothermia found. Conclusion: Uterine cooling was associated with a reduction in intraoperative blood loss among pregnant women undergoing cesarean section

Gum Chewing for Stimulating Early Recovery of Bowel Function after Postoperative Benign Gynecologic Surgery: A Randomized Controlled Trial

Objectives:To compare gum chewing and routine postoperative care on recovery of bowel function after laparotomy for benign gynecologic surgery.Materials and Methods:Patients who underwent laparotomy for benign gynecologic diseases at Khon Kaen Hospital from May to August, 2015 were randomly allocated into 2 groups: gum chewing (n= 56) and control group (n= 56). Patients chewed sugarless gum for 15 minutes after 6 hours postoperatively then every 4 hours until the first passage of flatus and the control group had the routine postoperative care.Results: Chewing gum was a statistically significant in reducing time to first flatus compare with routine postoperative care (20.3 ± 8.4 vs 27.3 ± 7.9 hrs, mean difference 6.9 hrs; p < 0.001). Time to tolerate regular diet was also significantly shorter in chewing gum group (47.5 ± 10.8 vs 49.4 ± 6.9 hr, mean difference 1.9 hr; p = 0.04). Postoperative vomiting was significantly less in chewing gum group (13 (23.6%) vs 26; p = 0.002). There were no significant differences between the groups in time to tolerate liquid diet, postoperative nausea, antiemetic drug requirement and length of a hospital stay.Conclusion: Gum chewing associated with early recovery of bowel function in patients undergo laparotomy for benign gynecologic surgery

Factors Associated with Shoulder Dystocia

Objective:To evaluate the factors associated with occurrence of shoulder dystocia. Materials and Methods: A case-control study, 67 pregnant women with shoulder dystocia between January 1st, 2009 and December 31st, 2013 and match 201 cases in control group by gestational age were analyzed. The factors that were thought to associate with shoulder dystocia were collected. Multivariate logistic regression analysis was performed to predict the factors. Results: There were 15,200 singleton delivered vaginally during that period. The incidence rate of shoulder dystocia was 0.44%. Intrapartum risk factors of shoulder dystocia were assisted vaginal delivery; the adjusted odds ratio (AOR) was 7.16 (95% CI = 3.48 – 14.72) and delivered by obstetric residents; AOR = 3.80 (95% CI = 1.02-14.09). Only neonatal birth weight was neonatal factor that associated with shoulder dystocia and the risk increased with birth weight in direct variation. Maternal factors such as age, obesity, diabetes mellitus were not associated with risk. 27 neonates had neonatal morbidity (brachial plexus injury, clavicular fracture, neonatal death) those were observed only in shoulder dystocia group. Conclusions: Neonatal birth weight, assisted vaginal delivery and delivered by obstetric residents were significantly associated with shoulder dystocia

Alternative Magnesium Sulfate Dosing Regimens for Women With Preeclampsia: A Population Pharmacokinetic Exposure-Response Modeling and Simulation Study

Magnesium sulfate is the anticonvulsant of choice for eclampsia prophylaxis and treatment; however, the recommended dosing regimens are costly and cumbersome and can be administered only by skilled health professionals. The objectives of this study were to develop a robust exposure-response model for the relationship between serum magnesium exposure and eclampsia using data from large studies of women with preeclampsia who received magnesium sulfate, and to predict eclampsia probabilities for standard and alternative (shorter treatment duration and/or fewer intramuscular injections) regimens. Exposure-response modeling and simulation were applied to existing data. A total of 10 280 women with preeclampsia who received magnesium sulfate or placebo were evaluated. An existing population pharmacokinetic model was used to estimate individual serum magnesium exposure. Logistic regression was applied to quantify the serum magnesium area under the curve-eclampsia rate relationship. Our exposure-response model-estimated eclampsia rates were comparable to observed rates. Several alternative regimens predicted magnesium peak concentration < 3.5 mmol/L (empiric safety threshold) and eclampsia rate ≤ 0.7% (observed response threshold), including 4 g intravenously plus 10 g intramuscularly followed by either 8 g intramuscularly every 6 hours × 3 doses or 10 g intramuscularly every 8 hours × 2 doses and 10 g intramuscularly every 8 hours × 3 doses. Several alternative magnesium sulfate regimens with comparable model-predicted efficacy and safety were identified that merit evaluation in confirmatory clinical trials

Abnormal uterine bleeding

Abnormal uterine bleeding (AUB) is a common and debilitating condition with high direct and indirect costs. AUB frequently co-exists with fibroids, but the relationship between the two remains incompletely understood and in many women the identification of fibroids may be incidental to a menstrual bleeding complaint. A structured approach for establishing the cause using the Fédération International de Gynécologie et d'Obstétrique (FIGO) PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system will facilitate accurate diagnosis and inform treatment options. Office hysteroscopy and increasing sophisticated imaging will assist provision of robust evidence for the underlying cause. Increased availability of medical options has expanded the choice for women and many will no longer need to recourse to potentially complicated surgery. Treatment must remain individualised and encompass the impact of pressure symptoms, desire for retention of fertility and contraceptive needs, as well as address the management of AUB in order to achieve improved quality of life

Uterine fibroids – what’s new?

Uterine fibroids are the commonest benign tumours of women and affect all races with a cumulative lifetime risk of around 70%. Despite their high prevalence and the heavy economic burden of treatment, fibroids have received remarkably little attention compared to common female malignant tumours. This article reviews recent progress in understanding the biological nature of fibroids, their life cycle and their molecular genetic origins. Recent progress in surgical and interventional management is briefly reviewed, and medical management options, including treatment with selective progesterone receptor modulators, are also discussed

Progestogens or progestogen-releasing intrauterine systems for uterine fibroids

Background Uterine fibroids are themost common premenopausal benign uterine tumours. Fibroids can cause symptoms including heavymenstrual bleeding, pelvic pressure and pain. Progestogens can be administered by various routes. Intramuscular injection of depot medroxyprogesterone acetate (DMPA) has dual actions (stimulatory or inhibitory) on fibroid cell growth. Progestogen-releasing intrauterine systems (IUS) decrease menstrual blood loss associated with fibroids by inducing endometrial atrophy and reduction of uterine fibroid size. Currently, their effectiveness for the treatment of uterine fibroids has not been evaluated. Objectives To determine the effectiveness of progestogens or progestogen-releasing intrauterine systems in treating premenopausal women with uterine fibroids. Search methods We searched theMenstrualDisorders and SubfertilityGroup Specialised Register (inception to 17 August 2012), CENTRAL (inception to 17 August 2012) and Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, MEDLINE (inception to 17 August 2012), Ovid EMBASE (1 January 2010 to 17 August 2012), Ovid PsycINFO (inception to 17 August 2012), CINAHL database, and trials registers for ongoing and registered trials.Selection criteria All identified published or unpublished randomised controlled trials (RCTs) assessing the effect of progestogens or progestogen-releasing intrauterine systems in treating premenopausal women with uterine fibroids. Data collection and analysis We assessed all potentially eligible studies identified as a result of the search strategy. Two review authors extracted data from each included study using an agreed form and assessed the risk of bias. We resolved discrepancies through discussion. Main results This review included three studies. However, data for progestogen-releasing intrauterine systems were available from only one study that compared 29 women with a levonorgestrel (LNG)-IUS versus 29 women with a combined oral contraceptive (COC) for treating uterine fibroids. There was a significant reduction of menstrual blood loss (MBL) in women receiving the LNG-IUS compared to the COC using the alkaline hematin test (mean difference (MD) 77.5%, 95% CI 71.3% to 83.67%, 58 women) and a pictorial assessment chart (PBAC) (MD 34.5%, 95% CI 14.9% to 54.1%, 58 women). The reduction in uterine fibroid size was significantly greater in the leuprorelin group at 16 weeks compared to the progestogen lynestrenol group (MD -15.93 mm, 95% CI -18.02 to -13.84 mm, 46 women). There was no RCT evaluating the effect of DMPA on uterine fibroids. Authors' conclusions Progestogen-releasing intrauterine systems appear to reduce menstrual blood loss in premenopausal women with uterine fibroids. Oral progestogens did not reduce fibroid size or fibroid- related symptoms. However, there was a methodological limitation and the one included study with data had a small sample size. This evidence is insufficient to support the use of progestogens or progestogenreleasing intrauterine systems in treating premenopausal women with uterine fibroids.Ussanee S Sangkomkamhang , Pisake Lumbiganon , Malinee Laopaiboon , Ben Willem J Mo