Michael L. Stitely

Plasma and Tissue Cefazolin Concentrations in Obese Patients Undergoing Cesarean Delivery and Receiving Differing Pre-Operative Doses of Drug

BACKGROUND Patients undergoing cesarean delivery typically receive a 1-g to 2-g dose of cefazolin as pre-operative antibacterial prophylaxis. This traditional dosage may not provide an adequate tissue concentration of cefazolin in obese patients during the peri-operative period. This study compared the tissue concentrations of prophylactic cefazolin administered as a either a 2-g or a 4-g dose prior to cesarean delivery in obese patients. METHODS Twenty obese patients (first trimester body mass index [BMI] >35) who underwent cesarean delivery completed this randomized study. Eleven patients received 2 g of cefazolin, and nine received 4 g. Blood and subcutaneous tissues were collected at the times of the incision and closure. Myometrial biopsies were collected at uterine closure. A cefazolin concentration threshold of 4 mcg/g for tissue samples was used as a surrogate adequate concentration. Plasma and tissue cefazolin concentrations were compared for the two doses. RESULTS Mean plasma, umbilical cord, and myometrial cefazolin concentrations were significantly higher in the 4-g treatment group (p<0.05). Subcutaneous incision site tissue obtained at time of incision creation also was significantly higher in the 4-g group than in the 2-g group (40.11±24.10 mcg/g vs. 18.36±6.68 mcg/g; p=0.0005). Subcutaneous tissue concentrations at closure were significantly different in the two dosage groups (34.89±17.42 mcg/g vs. 21.73±16.02 mcg/g; p=0.044). All tissue samples were above the target of 4 mcg/g. Body morphometry did not correlate with the variability in cefazolin tissue concentration. No surgical site infections, endometritis, or other adverse effects were observed. CONCLUSIONS Administering a prophylactic dose of 4 g of cefazolin produced blood and tissue cefazolin concentrations that were significantly higher than concentrations obtained from a 2-g dose in patients with BMIs between 35 and 60 kg/m(2) undergoing cesarean delivery. It is unclear if the larger cefazolin dose produces a more protective anti-infective effect than that obtained with the more traditional 2-g dose for cesarean delivery in obese patients.

Shoulder dystocia: Management and documentation

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing shoulder dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency.

Assessment of a Simulation Training Exercise to Teach Intrauterine Tamponade for the Treatment of Postpartum Hemorrhage

INTRODUCTION Postpartum hemorrhage is a common complication of vaginal birth. Few midwives have experience in the performance of procedures to manage hemorrhage that fails to respond to initial management with medications and bimanual compression. METHODS A simulation model was constructed by using a half-pelvis birth simulator and a hollowed out cantaloupe. Practicing midwives and students participated in a simulation exercise by using uterine packing and placement of a uterine tamponade balloon. Pre-exercise and post-exercise self-assessments were performed. Data were analyzed by using the Wilcoxon matched pairs signed rank test. RESULTS A total of 25 learners participated in the training session. All 25 participants showed improvement in their self-assessed competency level for the placement of the Bakri Postpartum Balloon (P < .001), and 24 of 25 showed improvement in self-assessed competency levels for uterine packing (P < .001). DISCUSSION An inexpensive simulation model can be used to effectively train midwives to treat postpartum hemorrhage by using methods of exerting direct pressure to the uterine cavity.

Laparoscopic removal of a large ovarian mass utilizing planned trocar puncture.

Large cystic ovarian masses can be removed laparoscopically with intentional trocar puncture of the mass to facilitate removal without leakage of cyst fluid.

Cervical ripening agents and uterine stimulants.

Introduction Pharmacologic agents have been used to induce or stimulate labor for centuries. Ergot alkaloids, potent uterine stimulants derived from a fungus that grows on certain grains, have been used in various forms since 600 BC. In the mid-19th century, quinine was prescribed in an effort to initiate labor. Shortly thereafter, pituitary extracts were noted to stimulate contractions. In 1953 Vincent du Vigneaud synthesized oxytocin and was awarded the Nobel Prize for Chemistry. Clinical use of intravenous oxytocin to induce and augment labor soon became commonplace. The stimulation of uterine contractions may be characterized as labor induction or labor augmentation. Induction of labor implies stimulation of uterine contractions in their previous absence. Today, oxytocin is the only drug used to treat hypocontractile uterine activity once the active phase of labor has been achieved. In the mid-20th century, investigators noted that extracts from the seminal vesical and prostate gland caused contraction or relaxation of smooth muscle. Five major categories of 20-carboxylic acids, differing slightly in clinical structure were identified and named prostaglandins (PGs). By 1968, PGs were synthesized in the laboratory. Currently a variety of these compounds are administered for cervical ripening and labor induction. Thus, PG agents may stimulate uterine contractions for the delivery of a viable fetus. They may also induce contractions to evacuate the uterus in cases of intrauterine fetal death or for termination of pregnancy. Although there are surgical and medical methods to stimulate the uterus, this article will focus on pharmacologic agents that ripen the cervix and cause the uterus to contract. Correspondence: Andrew J. Satin, MD, Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814. E-mail: asatin@usuhs.mil Disclaimer: The views expressed in this article are those of the authors and do not reflect the official position of the Department of Defense, Department of the Navy, Department of the Air Force, or the United States Government. CLINICAL OBSTETRICS AND GYNECOLOGY Volume 45, Number 1, 114–124

Successful pregnancy outcome following first trimester pelvic inflammatory disease.

Summary: Pelvic inflammatory disease rarely complicates pregnancy. Although few in number, most of the previously reported cases have resulted in spontaneous abortion or intrauterine fetal demise. At 5 weeks gestation, a 20 year old gravida 2 para 1 underwent uterine curettage and diagnostic laparoscopy for a suspected ectopic gestation. Seventeen days later, she presented with severe bilateral lower abdominal pain, cervical motion tenderness, uterine tenderness, and bilateral adnexal tenderness. After 84 hours of intravenous cefazolin, gentamycin, and clindamycin, the patient had resolution of all symptoms. She then completed 14 days of outpatient antibiotic therapy with oral cephalexin. At 39 weeks gestation, she delivered a 3611 g male fetus via spontaneous vaginal delivery. Successful pregnancy outcome can occur after first trimester pelvic inflammatory disease.

Are doses of lamotrigine or levetiracetam adjusted during pregnancy

Subtherapeutic levels of lamotrigine and levetiracetam are more likely to occur during pregnancy owing to the effect of pregnancy on their pharmacokinetics. This can lead to suboptimal control of epilepsy, and guidelines recommend proactive dose adjustment in the second and third trimesters alongside therapeutic drug monitoring (TDM). This retrospective cohort study using administrative databases aimed to investigate whether prescribers adjust the dose of lamotrigine or levetiracetam during and after pregnancy and whether TDM is used to manage dose adjustment. In 460 individual pregnancies, 232 women (61.4%) had their lamotrigine dose increased in the second and third trimesters and 44 women (53.7%) had their levetiracetam dose increased. Only 57 women (12.4%) had any TDM. The dose was not always decreased postpartum, and 157 women (56.9% of those who had escalated doses during pregnancy) had dose reduced following birth. Between 2012 and 2015, 29 women had an epilepsy‐coded hospital discharge during pregnancy and were more likely to have had their dose of lamotrigine or levetiracetam increased. Overall, doses of lamotrigine and levetiracetam were not increased during pregnancy in 40% of the study population, dose changes were not often guided by TDM, and doses were not always reduced postpartum.

Patient-targeted Googling and social media: a cross-sectional study of senior medical students

BackgroundSocial media and Internet technologies present several emerging and ill-explored issues for a modern healthcare workforce. One issue is patient-targeted Googling (PTG), which involves a healthcare professional using a social networking site (SNS) or publicly available search engine to find patient information online. The study’s aim was to address a deficit in data and knowledge regarding PTG, and to investigate medical student use of SNSs due to a close association with PTG.MethodThe authors surveyed final year medical students at the Otago Medical School, University of Otago in January 2016. A subset completed focus groups that were analysed using thematic analysis to identify key themes relating to students’ attitudes towards PTG, and reasons why they might engage in PTG.ResultsFifty-four students completed the survey (response rate = 65.1%), which showed that PTG was uncommon (n = 9, 16.7%). Attitudes were varied and context dependent. Most participants saw problems with PTG and favoured more explicit guidance on the issue (n = 29, 53.7%). SNS usage was high (n = 51, 94.4%); participants were concerned by the content of their SNS profiles and who they were connecting with online. Participants showing high SNS use were 1.83 times more likely to have conducted PTG than lower use groups.ConclusionsThe diverse attitudes uncovered in this study indicated that teaching or guidelines could be useful to healthcare professionals considering PTG. Though ethically problematic, PTG may be important to patient care and safety. The decision to conduct PTG should be made with consideration of ethical principles and the intended use of the information.

Using Three-Dimensional Printing to Fabricate a Tubing Connector for Dilation and Evacuation.

BACKGROUND: This is a proof-of-concept study to show that simple instrumentation problems encountered in surgery can be solved by fabricating devices using a three-dimensional printer. The device used in the study is a simple tubing connector fashioned to connect two segments of suction tubing used in a surgical procedure where no commercially available product for this use is available through our usual suppliers in New Zealand. MATERIALS AND METHODS: A cylindrical tubing connector was designed using three-dimensional printing design software. The tubing connector was fabricated using the Makerbot Replicator 2X three-dimensional printer. The connector was used in 15 second-trimester dilation and evacuation procedures. Data forms were completed by the primary operating surgeon. Descriptive statistics were used with the expectation that the device would function as intended in all cases. EXPERIENCE: The three-dimensional printed tubing connector functioned as intended in all 15 instances. CONCLUSION: Commercially available three-dimensional printing technology can be used to overcome simple instrumentation problems encountered during gynecologic surgical procedures.

Dilation of the vaginal cuff using the Bakri Postpartum Balloon to extract the large uterus at the time of robotic hysterectomy for endometrial carcinoma.

Removal of large uterine specimens during robotic or total laparoscopic hysterectomy poses surgical challenges, particularly in cases performed for gynecologic malignancy. A 23-year-old patient with endometrioid adenocarcinoma of the endometrium underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The large uterine specimen was removed by dilating the colpotomy incision using the Bakri Postpartum Balloon™. Dilation of the colpotomy incision with the uterine tamponade balloon can allow for the intact removal of a large uterine specimen in cases of robotic or total laparoscopic hysterectomy performed for gynecologic malignancy when specimen morcellation is contraindicated.