Dataset Information

Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial.

ABSTRACT: OBJECTIVE:To evaluate the feasibility of salpingectomy compared with standard bilateral tubal ligation at the time of cesarean delivery in women with undesired fertility. METHODS:We included women at 35 weeks of gestation or greater desiring permanent sterilization at the time of cesarean delivery. Patients were randomized after skin incision to bilateral salpingectomy or bilateral tubal ligation by a computer-generated scheme. If salpingectomy could not be completed on one or both sides, bilateral tubal ligation was attempted. Primary feasibility outcomes were total operative time and bilateral completion of the randomized procedure. Secondary outcomes included clinically estimated blood loss and surgical complications up to 6 weeks postpartum. We estimated that 80 patients (40 per group) would provide greater than 80% power to identify a 10-minute difference in the primary outcome (time) with a SD of 15 minutes and a two-sided ? of 0.05. Analysis was by intent to treat. RESULTS:Of 221 women screened from June 2015 to April 2017, 115 (52%) consented to the study; 80 were randomized-40 to salpingectomy and 40 to bilateral tubal ligation. Groups were similar at baseline. A total of 27 bilateral salpingectomies were successfully completed compared with 38 bilateral tubal ligations (68% compared with 95%, P=.002). Total operative time was on average 15 minutes longer for salpingectomies (75.4±29.1 compared with 60.0±23.3 minutes, P=.004). No adverse outcomes directly related to the sterilization procedure were noted in either group. Although estimated blood loss of only the sterilization procedure (surgeon estimate) was greater for the salpingectomy group (median 10 [interquartile range 5-25] compared with 5 [interquartile range 5-10] cc, P<.001), total estimated blood loss and safety outcomes were similar for both groups. CONCLUSION:Adding 15 minutes to total operative times, salpingectomy can be successfully completed in approximately two thirds of women desiring permanent contraception with cesarean delivery. CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov, NCT02374827.

SUBMITTER: Subramaniam A

PROVIDER: S-EPMC6019146 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial.

Subramaniam Akila A Blanchard Christina T CT Erickson Britt K BK Szychowski Jeff J Leath Charles A CA Biggio Joseph R JR Huh Warner K WK

Obstetrics and gynecology 20180701 1

<h4>Objective</h4>To evaluate the feasibility of salpingectomy compared with standard bilateral tubal ligation at the time of cesarean delivery in women with undesired fertility.<h4>Methods</h4>We included women at 35 weeks of gestation or greater desiring permanent sterilization at the time of cesarean delivery. Patients were randomized after skin incision to bilateral salpingectomy or bilateral tubal ligation by a computer-generated scheme. If salpingectomy could not be completed on one or bot ...[more]

PMID: 29889762

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Project description:Background: Use of an in situ epidural catheter has been suggested to be efficient to provide anesthesia for postpartum tubal ligation (PPTL). Reported epidural reactivation success rates vary from 74% to 92%. Predictors for reactivation failure include poor patient satisfaction with labor analgesia, increased delivery-to-reactivation time and the need for top-ups during labor. Some have suggested that this high failure rate precludes leaving the catheter in situ after delivery for subsequent reactivation attempts. In this study, we sought to evaluate the success rate of neuraxial techniques for PPTL and to determine if predictors of failure can be identified. Methods: After obtaining IRB approval, a retrospective chart review of patients undergoing PPTL after vaginal delivery from July 2010 to July 2016 was conducted using CPT codes, yielding 93 records for analysis. Demographic, obstetric and anesthetic data (labor analgesia administration, length of epidural catheter in epidural space, top-up requirements, time of catheter reactivation, final anesthetic technique and corresponding doses for spinal and epidural anesthesia) were obtained. Results: A total of 70 patients received labor neuraxial analgesia. Reactivation was attempted in 33 with a success rate of 66.7%. Patient height, epidural volume of local anesthetic and administered fentanyl dose were lower in the group that failed reactivation. Overall, spinal anesthesia was performed in 60 patients, with a success rate of 80%. Conclusions: Our observed rate of successful postpartum epidural reactivation for tubal ligation was lower than the range reported in the literature. Our success rates for both spinal anesthesia and epidural reactivation for PPTL were lower than the generally accepted rates of successful epidural and spinal anesthesia for cesarean delivery. This gap may reflect a lower level of motivation on behalf of both the patients and anesthesia providers to tolerate "imperfect" neuraxial anesthesia once fetal considerations are removed.

Project description:ObjectiveEvaluate completion of partial or total salpingectomy during Cesarean delivery based on intended procedure.Study designWe conducted a retrospective study of women who had a permanent contraception procedure during Cesarean delivery at an urban, academic hospital from November 2015 through April 2017. We reviewed all charts of women who had a Cesarean delivery to identify those who underwent concomitant tubal surgery, including both completed and attempted procedures. We compared demographic, medical, and obstetric characteristics of participants by planned and completed method using univariate analysis.ResultsWe identified 122 women who underwent Cesarean delivery with planned concurrent permanent contraception procedure. Thirty-two (26.2%) women preferred partial salpingectomy and 90 (73.8%) preferred total salpingectomy. All women who desired partial salpingectomy had the procedure performed. However, 17 (18.9%) women desiring total salpingectomy could not have the procedure performed bilaterally: nine underwent a mixed procedure and seven underwent bilateral partial salpingectomy because of adhesions, engorged vasculature, or unspecified reasons. One woman had significant adhesive disease preventing any procedure. Among women who planned a total salpingectomy, having ≥3 Cesarean deliveries was the only factor associated with needing an alternative procedure (P=.04).ConclusionAs interest in total salpingectomy for permanent contraception increases, surgeons should counsel women who are interested in total salpingectomy at time of Cesarean delivery that adhesions and tubal proximity to adjacent vessels may preclude completion of bilateral tubal removal and discuss alternative options prior to surgery.ImplicationsInterest in bilateral total salpingectomy for permanent contraception at the time of Cesarean delivery is increasing; accordingly, surgeons should counsel patients that adhesions and proximity to large vessels may preclude completion of bilateral total salpingectomy, especially in women who have had multiple prior Cesarean deliveries.

Project description:Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype.To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ?1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models.For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI], 4.9-99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI, 4.2-15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI, 3.4-11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI, 1.7-17.1), multiple pregnancies (aOR = 3.2; 95% CI, 1.7-6.3), and a predelivery hemoglobin ? 9.9 g/dL (aOR = 3.0; 95% CI, 1.3-6.9; reference group = predelivery hemoglobin ? 11 g/dL).Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.

Project description:BACKGROUND:The American Congress of Obstetricians and Gynecologists recommends that "the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy," resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. OBJECTIVE:The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. STUDY DESIGN:This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and ?2 test when appropriate. Questionnaire scores were compared using paired t tests. RESULTS:Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5-5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5-22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). CONCLUSION:Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.

Project description:BackgroundInpatient postpartum recovery trajectories following cesarean delivery and spontaneous vaginal delivery are underexplored.ObjectiveThis study primarily aimed to compare recovery following cesarean delivery and spontaneous vaginal delivery in the first postpartum week, and secondarily to evaluate psychometrically the Japanese version of the Obstetric Quality of Recovery-10 scoring tool.Study designFollowing institutional review board approval, the EQ-5D-3L (EuroQoL 5-Dimension 3-Level) questionnaire and a Japanese version of the Obstetric Quality of Recovery-10 measure were used to evaluate inpatient postpartum recovery in uncomplicated nulliparous parturients delivering via scheduled cesarean delivery or spontaneous vaginal delivery.ResultsA total of 48 and 50 women who delivered via cesarean delivery and spontaneous vaginal delivery, respectively, were recruited. Women delivering via scheduled cesarean delivery experienced significantly worse quality of recovery on days 1 and 2 compared with those who had spontaneous vaginal delivery. Quality of recovery significantly improved daily, plateauing at days 4 and 3 for cesarean delivery and spontaneous vaginal delivery groups, respectively. Compared with cesarean delivery, spontaneous vaginal delivery was associated with prolonged time to analgesia requirement, decreased opioid consumption, reduced antiemetic requirement, and reduced times to liquid/solid intake, ambulation, and discharge. Obstetric Quality of Recovery-10-Japanese is a valid (correlates with the EQ-5D-3L including a global health visual analog scale, gestational age, blood loss, opioid consumption, time until first analgesic request, liquid/solid intake, ambulation, catheter removal, and discharge), reliable (Cronbach alpha=0.88; Spearman-Brown reliability estimate=0.94; and intraclass correlation coefficient=0.89), and clinically feasible (98% 24-hour response rate) measure.ConclusionInpatient postpartum recovery is significantly better in the first 2 postpartum days following spontaneous vaginal delivery compared with scheduled cesarean delivery. Inpatient recovery is largely achieved within 4 and 3 days following scheduled cesarean delivery and spontaneous vaginal delivery, respectively. Obstetric Quality of Recovery-10-Japanese is a valid, reliable, and feasible measure of inpatient postpartum recovery.

Dataset Information

Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial.

Publications

Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial.

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