Search Results (23)

Pregnancy (HP), defined as the coexistence of intrauterine and ectopic gestations, is a rare condition, especially in spontaneous conception, but it is a life-threatening obstetric emergency when rupture occurs, with a reported maternal mortality rate of 0.03%. Diagnosis is often delayed because confirmation of an intrauterine pregnancy can mask clinical signs of a concurrent ectopic gestation. Early recognition and prompt surgical intervention are therefore critical to maternal safety and preservation of intrauterine viability. This case highlights the diagnostic challenges and successful management of a spontaneous ruptured heterotopic pregnancy. Case presentation: A 34-year-old Middle Eastern woman, gravida 4, with a spontaneous conception, presented with sudden severe lower abdominal pain and signs of acute hemoperitoneum (hypotension, tachycardia, and marked peritoneal signs). Transvaginal ultrasound demonstrated a viable intrauterine pregnancy at 9 weeks 4 days gestation, together with a ruptured left tubal ectopic pregnancy of similar gestational age. The patient underwent urgent laparoscopic left salpingectomy with evacuation of approximately 1200 mL of intraperitoneal blood and clots. Postoperatively, she developed significant anemia (hemoglobin drop from 11.2 g/dL on admission to 6.5 g/dL) requiring transfusion of four units of packed red blood cells. Serial ultrasonographic follow-up confirmed ongoing viability of the intrauterine pregnancy, which ultimately resulted in a live birth at term. Progressive resolution of the postoperative pelvic hematoma was also noted. Conclusions: Ruptured heterotopic pregnancy remains a diagnostic and therapeutic challenge. This case, along with a synthesis of the contemporary literature, demonstrates that a high clinical index of suspicion, timely ultrasound diagnosis, and immediate minimally invasive surgical management are paramount. Furthermore, rigorous postoperative monitoring and resuscitation, including targeted transfusion, are essential to achieve maternal stabilization while allowing continuation of a viable intrauterine pregnancy, with reported live birth rates exceeding 70% following timely intervention. Full article

Data on cardiac and hemodynamic parameters associated with preeclampsia (PE), particularly changes occurring in the immediate perioperative period, remain scarce. These changes are clinically important for the management of patients with severe PE or underlying cardiac dysfunction. Maternal hemodynamics undergo substantial alterations during cesarean section (CS) as a result of sympathetic blockade induced by spinal anesthesia, the vasodilatory effects of general anesthetics, and changes in blood flow related to aortocaval compression in the supine position and during delivery. Massive hemorrhage represents an additional factor contributing to these alterations. In routine clinical practice, maternal heart rate (HR) and blood pressure (BP) are monitored to assess circulatory status. However, a more precise evaluation can be achieved by measuring stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR). These parameters are particularly relevant in cases of severe hemorrhage or hypertension, as they may facilitate targeted hemodynamic management. Overall, hemodynamic responses to cesarean delivery under spinal anesthesia appear to differ between normotensive and hypertensive pregnancies. Normotensive parturients seem to be more susceptible to pronounced hypotension following sympathetic blockade, whereas hypertensive disorders of pregnancy are associated with altered vascular reactivity and modified intraoperative hemodynamic responses. Nevertheless, interpretation of these findings remains limited by the heterogeneity of the available studies and the lack of quantitative evidence synthesis. Full article

Background/Objectives: Ephedrine and cafedrine/theodrenaline (C/T) are established treatments for spinal anesthesia-induced hypotension during cesarean section. Both aim to stabilize maternal blood pressure and enhance neonatal oxygenation. We compared their effects on maternal hemodynamics and neonatal acid-base status using population kinetic/pharmacodynamic (K/PD) modeling and multiple regression analysis. Methods: The multicenter, prospective, open-label, two-armed, non-interventional HYPOTENS study included 243 parturients undergoing spinal anesthesia for elective cesarean section in Germany. Hypotension was treated with intravenous boluses of either C/T (10–200 mg, 55.6%) or ephedrine (5–40 mg, 44.4%), with dosing determined by the attending anesthesiologist. Maternal mean arterial pressure (MAP), systolic blood pressure (SBP), and heart rate (HR) were recorded for 30 min after treatment. Neonatal acidosis biomarkers included umbilical arterial pH, base excess (BE), and lactate. Results: A population K/PD model captured an initial increase followed by a plateau in MAP, SBP and HR after treatment. Maximum HR (MAX_HR) was 15% higher after ephedrine than after C/T (p < 0.001). BMI and spinal block height significantly influenced maternal hemodynamics (both p < 0.001). Neonatal biomarkers were associated with the duration of maternal MAP below pre-surgery levels, gestational age, spinal block height, antihypotensive treatment, bupivacaine dose, and MAX_HR (all p < 0.05). Conclusions: Ephedrine was associated with higher maternal MAX_HR. Notably, higher maternal MAX_HR was correlated with lower neonatal BE, suggesting that lower maternal peak HR may benefit. These findings may support the use of substances that are largely inert with respect to maternal HR. Full article

Background/Objectives: The bolus dose of norepinephrine (NE) for the treatment of spinal anesthesia-induced maternal hypotension remains unclear. The aim of this study was to compare the efficacy and safety of two different bolus doses of NE in the treatment of spinal anesthesia-induced maternal hypotension during cesarean section (CS). Methods: This study has a prospective, randomized and double-blinded design. A total of 150 patients with ASA physical status I and II who underwent CS included the study at a tertiary-care university hospital. Patients were randomly assigned to either the 6 µg NE bolus (Group 6 µg, n = 75) or 8 µg NE bolus (Group 8 µg, n = 75) group. The primary outcome of this study was to determine the success rate of treatment using a 6 or 8 µg NE bolus in cases of maternal hypotension. Secondary outcomes included comparing fetal umbilical blood gas values and APGAR scores in neonates born to mothers who received a NE bolus before delivery, determining the incidence of NE-induced reactive bradycardia and hypertension, and comparing the groups for intraoperative nausea and vomiting. Results: The 8 µg group showed fewer hypotensive episodes (245 vs. 174 episodes, p = 0.012) and required fewer norepinephrine boluses. Additionally, the success rate of hypotension treatment was higher in the 8 µg group (61.2% vs. 78.5%, p < 0.001). There was no difference in APGAR scores between the groups of neonates born to women who received norepinephrine before delivery. However, in the group with 8 µg NE, slightly better results were obtained in blood gas samples, excluding the pH value. Nausea was more frequently observed in the 6 µg group (p = 0.046). Conclusions: We concluded that an 8 µg bolus administration of NE was more effective than a 6 µg bolus administration in treating maternal hypotension induced by spinal anesthesia, without any increase in the rate of side effects. Full article

Molar incisor hypomineralisation (MIH) is a developmental defect affecting permanent first molars and often the incisors too. Hypomineralised second primary molars (HSPM) have been proposed as potential early indicators of MIH. Aim: The aim was to identify potential aetiological factors associated with MIH and assess their relationship with HSPM in a pilot study. Methods: A cross-sectional case–control study was conducted with 120 patients (60 cases and 60 controls), aged 7–15 years, from the Paediatric Dentistry Postgraduate Programme. MIH was diagnosed following European Academy of Paediatric Dentistry (EAPD) guidelines. Parents completed a structured questionnaire on potential aetiological factors. Results: MIH was significantly associated with maternal smoking during pregnancy (p = 0.013), birth hypoxia (p = 0.013) and the use of amoxicillin and inhalation therapy during infancy (p < 0.001). It was also associated with tonsillitis (p = 0.022), bronchiolitis (p = 0.005) and other respiratory disorders (p = 0.049). HSPM was associated with anaemia and hypotension during pregnancy (p = 0.001), bottle-feeding (p = 0.044) and urinary tract infections (p = 0.003). No statistically significant association was found between MIH and HSPM. Conclusions: This pilot study has identified specific prenatal, perinatal, and postnatal factors associated with MIH and HSPM. The findings emphasise the clinical relevance for early diagnosis and management and highlight the need for studies with larger sample sizes to validate these associations. Full article

Background/Objectives: Fetoscopic repair of open spinal dysraphism (OSD) is a rare intrauterine procedure performed in specialized fetal surgery centers. Conducted under restrictive fluid management and continuous tocolysis, it poses substantial challenges to maternal hemodynamic stability. Blood pressure optimization with vasopressor boluses is often required, yet intraoperative hemodynamic data remain limited. Methods: This prospective observational study was conducted between December 2023 and January 2025 during fetoscopic repair of OSD at Marburg University Hospital, Germany. Maternal hemodynamics were continuously monitored using pulse contour analysis with the Acumen IQ sensor and HemoSphere platform (Edwards Lifesciences, Irvine, CA, USA). To stabilize arterial pressure, cafedrine/theodrenaline (Akrinor, Ratiopharm, Ulm, Germany) was administered as intravenous boluses. Hemodynamic parameters were analyzed immediately before and after each bolus. Fetal heart rate was assessed as a secondary parameter at predefined intraoperative time points when available. Results: A total of 13 patients and 110 vasopressor boluses were analyzed. Reported values reflect median percent changes; parentheses indicate the total range. Following maternal blood pressure optimization, mean arterial pressure increased by 13.7% (5.9–21.6), systemic vascular resistance index by 23.1% (8.3–36.7), and dP/dtmax by 21.7% (6.3–29.9): p < 0.001 for all. Cardiac index and stroke volume index decreased by −6.7% (−11.8 to −0.6), p < 0.001, and −4.3% (−9.8 to 1.8), p = 0.048, respectively. Fetal heart rate remained stable (+0.4% (−0.8 to 1.5); p = 0.470). A total of 38 HPI alerts were followed by hypotension, with a median latency of 120 s (80–235); 73 alerts were not followed by hypotension during the observation period. Conclusions: Intermittent cafedrine/theodrenaline boluses significantly increased arterial pressure, dP/dtmax, and systemic vascular resistance under conditions of fluid restriction and tocolysis-induced vasodilation. Maternal heart rate remained stable, and cardiac output showed only minor reductions. Fetal heart rate was unchanged following maternal blood pressure treatment, indicating no adverse fetal response to C/T within the observed intraoperative period. Full article

Background: Locoregional anesthesia (LRA) during cesarean section (CS) is effective but frequently causes hypotension, affecting maternal hemodynamics and fetal outcomes. We investigated whether baseline hemodynamic characteristics predict post-LRA changes, vasopressor needs, and neonatal outcomes. Methods: Women undergoing elective CS with LRA were monitored with USCOM^® (Ultrasonic Cardiac Output Monitor), recording cardiac output (CO), cardiac index (CI), stroke volume (SV), stroke volume index (SVI), and systemic vascular resistance (SVR) every five minutes. Maternal demographics, vasopressor use, and neonatal outcomes were analyzed using multilevel linear regression. Results: LRA caused significant reductions in blood pressure and heart rate (p < 0.001). SV initially declined but recovered, while SVR showed minimal variation. Vasopressors were required in 63%, with choice guided by heart rate. Lower baseline SVI predicted greater vasopressor need (37.9 ± 6.7 vs. 34.5 ± 6.6, p = 0.050). Lower CO and CI before fetal extraction correlated with reduced neonatal pH, with CI significantly associated with pH < 7.20 (p = 0.043). Conclusions: USCOM^® enables real-time, non-invasive monitoring, supporting individualized management during CS. Full article

Background and Objectives: Spinal anesthesia is a common anesthetic method for cesarean delivery. However, it is associated with spinal hypotension, which can negatively impact both the mother and the fetus. We hypothesized that parturients with preoperatively prolonged corrected QT interval (QTc) would have a lower incidence of developing spinal hypotension. Materials and Methods: This prospective observational study analyzed eighty-five parturients undergoing cesarean delivery. The participants were divided into two groups based on their baseline QTc, which was measured automatically using a patient monitor in the operating room rather than using a standardized 12-lead electrocardiogram: <440 ms (n = 42) or ≥440 ms (n = 43). Following combined spinal-epidural anesthesia, the incidence of spinal hypotension until delivery was analyzed and the vasopressor requirements within 30 min were compared between the QTc groups. The area under the receiver operating characteristic curve was measured to identify the optimal QTc cut-off for predicting spinal hypotension. Results: Spinal hypotension was observed in 37/43 parturients (86.0%) with QTc < 440 ms, compared to 17/42 (40.5%) with QTc ≥ 440 ms (p < 0.001). The total amount of phenylephrine significantly differed between groups (300 μg [100–400] vs. 100 μg [0–300], p = 0.009). The area under the ROC curve for spinal hypotension prediction was 0.75 (95% confidence interval [CI] 0.64–0.86). The optimal QTc cut-off interval, determined using the maximum Youden index (J = 0.510), which corresponded to the best combination of sensitivity and specificity, was 441 ms. Conclusions: These preliminary patient-monitor-based findings indicate an association between preoperative QTc and spinal hypotension, which should be validated using standardized electrocardiographic methods. Full article

Background/Objectives: Hypotension is a common complication of spinal anesthesia for cesarean section. Although phenylephrine has replaced ephedrine as the first-line vasopressor, comparative data on neonatal outcomes remain important in clinical decision-making. The objective of this study was to compare the effects of prophylactic phenylephrine infusion versus interventional ephedrine boluses on umbilical artery pH and maternal hemodynamic stability in women undergoing cesarean section under spinal anesthesia. Methods: In this retrospective case-control study we analyzed perioperative and neonatal data of elective cesarian section cases where either ephedrine boluses (total dose of more than 15 mg) or prophylactic phenylephrine infusion were employed for blood pressure control following spinal anesthesia. Demographic, hemodynamic, obstetric and neonatal data were extracted from medical records. Ninety-four elective cesarean section cases were included. Umbilical artery pH, base excess, and Apgar scores were assessed as primary and secondary neonatal outcomes. The lowest recorded systolic blood pressure (SBP), mean arterial pressure (MAP), and incidence of nausea and vomiting were evaluated as maternal outcomes. Results: Umbilical artery pH and other blood gas parameters did not differ significantly between groups. Neonatal acidosis (pH < 7.2) occurred in two cases in the ephedrine group while none were noted in the phenylephrine group. Maternal hemodynamic stability was significantly better in the phenylephrine group, with higher nadir SBP and MAP (p < 0.001). Nausea was more common with ephedrine (42.5% vs. 10.6%, p < 0.001), and vomiting occurred only in this group. Conclusions: Prophylactic phenylephrine infusion provides superior maternal hemodynamic stability and better tolerance during cesarean delivery compared to interventional ephedrine boluses, without change in neonatal acid–base status. Full article

Background: Hypotension following epidural labor analgesia (ELA) is its most common complication, affecting approximately 20% of patients and posing risks to both maternal and fetal health. As digital tools and predictive analytics increasingly shape perioperative and obstetric anesthesia practices, real-world implementation data are needed to guide their integration into clinical care. Current monitoring practices rely on intermittent non-invasive blood pressure (NIBP) measurements, which may delay recognition and treatment of hypotension. The Hypotension Prediction Index (HPI) algorithm uses continuous arterial waveform monitoring to predict hypotension for potentially earlier intervention. This clinical trial evaluated the feasibility, acceptability, and efficacy of continuous HPI-guided treatment in reducing time-to-treatment for ELA-associated hypotension and improving maternal hemodynamics. Methods: This was a prospective randomized controlled trial design involving healthy pregnant individuals receiving ELA. Participants were randomized into two groups: Group CM (conventional monitoring with NIBP) and Group HPI (continuous noninvasive blood pressure monitoring). In Group HPI, hypotension treatment was guided by HPI output; in Group CM, treatment was based on NIBP readings. Feasibility, appropriateness, and acceptability outcomes were assessed among subjects and their bedside nurse using the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM) instruments. The primary efficacy outcome was time-to-treatment of hypotension, defined as the duration between onset of hypotension and administration of a vasopressor or fluid therapy. This outcome was chosen to evaluate the clinical responsiveness enabled by HPI monitoring. Hypotension is defined as a mean arterial pressure (MAP) < 65 mmHg for more than 1 min in Group CM and an HPI threshold < 75 for more than 1 min in Group HPI. Secondary outcomes included total time in hypotension, vasopressor doses, and hemodynamic parameters. Results: There were 30 patients (Group HPI, n = 16; Group CM, n = 14) included in the final analysis. Subjects and clinicians alike rated the acceptability, appropriateness, and feasibility of the continuous monitoring device highly, with median scores ≥ 4 across all domains, indicating favorable perceptions of the intervention. The cumulative probability of time-to-treatment of hypotension was lower by 75 min after ELA initiation in Group HPI (65%) than Group CM (71%), although this difference was not statistically significant (log-rank p = 0.66). Mixed models indicated trends that Group HPI had higher cardiac output (β = 0.58, 95% confidence interval −0.18 to 1.34, p = 0.13) and lower systemic vascular resistance (β = −97.22, 95% confidence interval −200.84 to 6.40, p = 0.07) throughout the monitoring period. No differences were found in total vasopressor use or intravenous fluid administration. Conclusions: Continuous monitoring and precision hypotension treatment is feasible, appropriate, and acceptable to both patients and clinicians in a labor and delivery setting. These hypothesis-generating results support that HPI-guided treatment may be associated with hemodynamic trends that warrant further investigation to determine definitive efficacy in labor analgesia contexts. Full article

Background: Among patients with congenital heart disease, particularly those with a history of undergoing the Fontan operation, pregnancy presents a significant maternal–fetal risk, especially when complicated by severe valvular dysfunction. Lung reperfusion syndrome (LRS) is a rare but life-threatening complication occurring following valve intervention. Multidisciplinary management, including by Cardio-Obstetrics teams, is essential for optimizing outcomes in such high-risk cases. Methods: We present the case of a 37-year-old pregnant patient with previously repaired tetralogy of Fallot (via the Fontan procedure) who presented at 24 weeks gestation with worsening severe pulmonary stenosis and right-ventricular dysfunction. The patient had been lost to cardiac follow-up for over a decade. She experienced recurrent arrhythmias, including supraventricular and non-sustained ventricular tachycardia, prompting hospital admission. A multidisciplinary team recommended transcatheter pulmonic valve replacement (TPVR), performed at 28 weeks’ gestation. Results: Post-TPVR, the patient developed acute hypoxia and hypotension, consistent with Lung Reperfusion Syndrome, necessitating intensive cardiopulmonary support. Despite initial stabilization, progressive maternal respiratory failure and fetal compromise led to an emergent cesarean delivery. The neonate’s neonatal intensive care unit (NICU) course was complicated by spontaneous intestinal perforation, while the mother required intensive care unit (ICU)-level care and a bronchoscopy due to new pulmonary findings. She was extubated and discharged in stable condition on postoperative day five. Conclusions: This case underscores the complexity of managing severe congenital heart disease and valve pathology during pregnancy. Lung reperfusion syndrome should be recognized as a potential complication following TPVR, particularly in pregnant patients with Fontan physiology. Early involvement of a multidisciplinary Cardio-Obstetrics team and structured peripartum planning are critical to improving both maternal and neonatal outcomes. Full article

Background: Spinal anesthesia is considered the method of choice for elective cesarean sections; however, it is not without maternal–fetal risks. Materials and Methods: This study compared the effects on maternal hemodynamics of intrathecal administration of fentanyl or morphine in parturients undergoing spinal anesthesia with 0.5% hyperbaric bupivacaine, with doses varied between 7.5 and 11 mg, depending on the patient’s height. Data from a cohort of 170 parturients were analyzed. The administered doses were intrathecal morphine at 0.1 mL (100 µg, solution of 1 mg/mL) or fentanyl at 0.25 mL (25 µg, solution of 50 µg/mL). This study included 80 patients in the fentanyl (F) group and 90 in the morphine (M) group. Results: Group F showed significantly higher post-intervention systolic blood pressure values than group M (95.30 ± 12.99 mmHg vs. 90.58 ± 14.75 mmHg, p = 0.032). The incidence of vomiting was significantly less frequent in group F compared to group M (1, 1.3% vs. 10, 11.1%, p = 0.011). The total dose of ephedrine required for hypotension correction was significantly lower in the F group (12.75 ± 13.26 mg vs. 17.72 ± 16.73 mg, p = 0.035). Conclusions: The addition of fentanyl as an adjuvant alongside the local anesthetic in cesarean section is associated with enhanced hemodynamic stability compared to morphine, requiring lower doses of ephedrine and contributing to increased patient safety during elective cesarean surgery. Full article

Hydrotherapy, including the use of therapeutic showers and bathtubs, has been studied for its potential benefits in labor pain management. Previous research has indicated that hydrotherapy can alleviate pain, but comparative studies between therapeutic showers and bathtubs are scarce. Objective: This study aims to compare the effects of therapeutic showers and bathtubs on pain perception, labor duration, use of epidural analgesia, and maternal and neonatal outcomes during labor. Methods: A total of 124 pregnant women were included in this study. Participants were divided into two groups: those who used a therapeutic shower and those who used a bathtub during labor. Pain levels were measured using a visual analog scale (VAS). Labor duration, use of epidural analgesia, types of delivery, maternal outcomes (postpartum hemorrhage, perineal status, maternal hypotension, fever, and breastfeeding), and neonatal outcomes (APGAR scores, fetal heart rate, complications, and neonatal unit admissions) were recorded and analyzed. Results: Both the therapeutic shower and the bathtub effectively reduced pain perception, with the bathtub showing a greater reduction in VAS scores. The therapeutic shower group experienced a significantly shorter labor duration compared to the bathtub group. The majority of participants in both groups did not require epidural analgesia, with no significant differences between the groups. There were no significant differences in the types of delivery. Maternal outcomes indicated a lower incidence of perineal tears and episiotomies in the therapeutic shower group. Neonatal outcomes, including APGAR scores and fetal heart rate, were similar between the groups, with no significant differences in complications or neonatal unit admissions. Conclusions: Both therapeutic showers and bathtubs are effective for pain relief during labor, with the bathtub showing a higher reduction in pain intensity. The therapeutic shower is associated with a shorter labor duration and a lower incidence of perineal tears and episiotomies. Both methods are safe for neonatal well-being, making hydrotherapy a viable non-pharmacological option for pain management in labor. However, the therapeutic shower may offer additional benefits in terms of labor duration and maternal outcomes. Full article

Background: The aim of our study was to investigate the prevalence of perioperative hypotension after spinal anesthesia for cesarean section using non-invasive continuous hemodynamic monitoring and its correlation with neonatal well-being. Methods: We included 145 patients. Spinal anesthesia was performed with a combination of hyperbaric bupivacaine 0.5% (according to a weight/height scheme) and fentanyl 20 μg. Hypotension was defined as a mean arterial pressure (MAP) < 65 mmHg or <60 mmHg. We also evaluated the impact of hypotension on neonatal well-being. Results: Perioperative maternal hypotension occurred in 54.5% of cases considering a MAP < 65 mmHg and in 42.1% with the more conservative cut-off (<60 mmHg). Severe neonatal acidosis occurred in 1.4% of neonates, while an Apgar score ≥ 9 was observed in 95.9% at 1 min and 100% at 5 min. Conclusions: Continuous non-invasive hemodynamic monitoring allowed an early detection of maternal hypotension leading to a prompt treatment with satisfactory results considering neonatal well-being. Full article

Background: Hydrotherapy is a technique used for pain management during labour, but its safety for both the mother and foetus remains uncertain. Objective: The main aim of this study is to determine whether the use of hydrotherapy in the first stage of labour is safe for both the mother and newborn. Methods: A retrospective observational study was conducted to collect data from the partogram, maternal and neonatal history. Results: A total of 377 women who gave birth at the Costa del Sol Hospital in Malaga between January 2010 and December 2020 were randomly selected. They were divided into a control group (253 women) and an intervention group (124 women) that used hydrotherapy in the first stage of labour. There were no significant differences between the groups in terms of age, history of previous miscarriages, type of delivery, or newborn weight. The results showed that most women who opted for hydrotherapy were nulliparous, and the use of hydrotherapy during labour was safe for both the mother and foetus. There were no significant differences in the variables of maternal arterial hypotension, postpartum haemorrhage, postpartum maternal fever, foetal complications, neonatal admission, 1 and 5 min Apgar scores, umbilical arterial or venous pH, or foetal cardiotocographic recording. However, there was a significant difference (p = 0.005) in the rate of breastfeeding among mothers who opted for hydrotherapy (96% vs. 85.7%). Conclusions: The use of hydrotherapy during the first stage of labour is safe and is associated with increased breastfeeding rates compared to conventional delivery. Full article