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Background: This study aimed to identify the characteristics, causes, perioperative anesthetic, and obstetric outcomes of patients experiencing postpartum hemorrhage (PPH) after cesarean delivery., Methods: We retrospectively analyzed patients who underwent cesarean delivery at the largest university hospital in Bangkok, Thailand, during a 5-year period (January 1, 2016-December 31, 2020). PPH was defined as an estimated blood loss (EBL) of ≥ 1000 ml within 24 hours postpartum., Results: Of 17 187 cesarean deliveries during the study period, 649 patients were included for analysis. The mean EBL was 1774.3 ± 1564.4 ml (range: 1000-26 000 ml). Among the patients, 166 (25.6%) experienced massive PPH (blood loss > 2000 ml). Intraoperative blood transfusions were necessary for 264 patients (40.7%), while 504 individuals (77.7%) needed intraoperative vasopressors. The analysis revealed uterine atony as the leading cause of PPH in 62.7% (n = 407) of the patients, with abnormal placentation following at 29.3% (n = 190). Abnormal placentation was associated with a significantly higher mean EBL of 2345.0 ± 2303.9 ml compared to uterine atony, which had a mean EBL of 1504.0 ± 820.7 ml (P < 0.001). Abnormal placentation also significantly increased the likelihood of blood transfusions and hysterectomies (P < 0.001 for both) and led to more intensive care unit admissions (P = 0.032). The risk of EBL exceeding 2000 ml was markedly higher in patients with abnormal placentation (odds ratio [OR] 5.12, 95% confidence interval [CI] 3.45-7.57, P < 0.001) and in cases involving trauma to the internal organs (OR 2.33, 95% CI 1.16-4.71, P = 0.018) than in patients with uterine atony. The study documented three instances of perioperative cardiac arrest, one of which was fatal., Conclusions: These findings highlight the importance of comprehensive perioperative management strategies, including the ready availability of adequate blood and blood products, particularly in scenarios predisposed to significant hemorrhage., Trial Registration: Clinical trial registration: Clinicaltrial.gov registration number NCT04833556 (April 6, 2021)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Nivatpumin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To compare the perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section., Methods: A retrospective analysis of 6 years of data was performed. Exclusions were cases with gestational ages <24 weeks, placenta accreta spectrum, polyhydramnios, or multiple gestations., Results: The study included 494 patients whose body mass index (BMI) exceeded 40 kg/m 2 at delivery. Of these, 469 were morbidly obese (BMI 40-49.9; mean, 42.9 ± 2.4), and 25 were super obese (BMI >50; mean, 54.5 ± 4.2). Twenty-four (5.1%) morbidly obese women received general anesthesia. The other 445 patients (94.9%) in the morbid obesity group underwent cesarean delivery under regional anesthesia; however, some (2.2%; 10/445) received general anesthesia after regional anesthesia failed. In the super-obesity group, 23 patients (92.0%) received regional anesthesia, while two patients (8.0%) received general anesthesia. There were no cases of pulmonary aspiration, maternal deaths, or difficult or failed intubation. There was one episode of cardiac arrest in a patient with a BMI of 47.9. Among the morbidly obese and super-obese women given regional anesthesia, the super-obese patients had significantly greater volumes of ephedrine and norepinephrine consumption ( p  = 0.027 and 0.030), intravenous fluids ( p  = 0.006), and bleeding during surgery ( p  = 0.017). They also had more hypotensive episodes ( p  = 0.038). The two groups' incidences of neonatal birth asphyxia, postpartum hemorrhage, blood transfusion, and uterine atony did not differ significantly. The lengths of stay in the hospital were also comparable., Conclusions: Among the women receiving regional anesthesia, the super-obese parturients had greater intraoperative bleeding, a higher proportion of hypotensive episodes, and a greater vasopressor requirement than the morbidly obese parturients. Anesthesiologists must prepare for the adverse perioperative events that such women risk experiencing during a delivery by cesarean section., www.clinicaltrials.gov ID: NCT04657692.

Objective: This study aimed to compare two methods of feedback: verbal face-to-face feedback after direct observation (F2F-feedback) versus electronic-written feedback after observation of recorded-VDO of student's performance (VDO-feedback), in terms of effectiveness in improving skill, effects on motivation and satisfaction., Background: Medical schools are responsible for teaching and ensuring proficiency of basic surgical skills. Feedback is effective in developing psychomotor skills; by providing information of learner's current performance, how to improve, and enhancing motivation., Materials and Method: Fifty-eight medical students (3 rd - 4 th year) were trained to perform vertical mattress suture in small groups. Then, during 6-week period of self-directed practice, students were randomized into group1 VDO-feedback (male:female = 21:8) and group 2 F2F-feedback (male:female = 20:9). Feedbacks were provided once every 2 weeks (Week2, Week4). End-of-rotation OSCE was at Week6, and retention tested was at Week8. Performance checklist (Cronbach's Alpha 0.72) was used to assess skill at 4 timepoints; pre- and post- small group learning, OSCE, and retention phase. Questionnaire was used to assess motivation, learning strategies and satisfaction (Cronbach's Alpha 0.83)., Result: After in-class learning, further significant improvement of skills could be gained by both F2F- and VDO- feedbacks (p < 0.0001). Both could similarly retain skill for at least 4 weeks later without additional practice. Self-efficacy, test anxiety, and cognitive strategies scores were significantly increased in both groups (p < 0.05). Extrinsic motivation was increased in VDO-feedback group. No difference in satisfaction between groups was observed., Discussion and Conclusion: VDO-feedback could be alternative to F2F-feedbacks for basic surgical skill training when limitation for simultaneous meeting of teacher and students occurs., Trial Registration: This study has been registered to Thai Clinical Trial Registry (WHO International Clinical Trial Registry Platform) on 11/07/2023 (TCTR20230711005)., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objectives: To evaluate the efficacy of postpartum tubal sterilization training program with minilaparotomy approach (PTSMA)., Study Design: From September 2020 to November 2021, 24 first-year Obstetrics and Gynecology (Ob/Gyn) residents were randomly allocated into 2 groups of traditional apprenticeship learning (watching video clip) versus apprenticeship learning plus PTSMA attending. The program consisted of didactics followed by self-practicing with 2 stations of postpartum tubal sterilization simulators (PTSS). All participants were allowed to perform their first tubal sterilization under supervision within a few days after training. Their surgical skills were blindly evaluated by 2 experts through the recorded videos. Five domains of direct observation of procedural skills (DOPS) score introduced by Royal Thai College of Obstetricians and Gynecologists were assessed. DOPS score, operative time, blood loss and post-op complication were analyzed and compared., Results: Median of total DOPS score in the PTSMA group was higher than the non-PTSMA group (93 vs. 73, p = 0.020). Concerning 2 domains of DOPS score (tubal fishing and tubal sterilization), the PTSMA group had the higher median score than the non-PTSMA group (36 vs. 24, p = 0.045 and 40 vs. 32, p = 0.020). There was no significant difference observed in the median score of 3 other domains (peritoneal cavity accessing, abdominal wall closure and complication prevention), estimated blood loss and operative time., Conclusion: Postpartum tubal sterilization training program with minilaparotomy approach using instructive simulators significantly improved the total DOPS score especially tubal fishing and tubal ligation skills in Ob/Gyn residents., Implications: The study evidently showed the benefit of PTSMA with an inexpensive and simple to prepare models. In unexperienced operators, practicing in model prior to surgery should be encouraged to improve their operative skills., Competing Interests: The authors have no relevant financial or non-financial interests to disclose., (© 2022 The Authors.)

Background: Simulation-Based Medical Education (SBME) is a teaching method commonly used in undergraduate medical education. Although Thai medical schools have developed a system that incorporates SBME, various aspects of that system require improvement. We surveyed medical school administrators, instructors, and students about SBME in their institutions and the obstacles involved in its implementation, as well as their experiences, expectations, and attitudes regarding the current system., Methods: We conducted a cross-sectional online survey between August 2019 and July 2020 among administrators, instructors, and 6th-year medical students. A structured questionnaire was developed and distributed to volunteers as an online survey. We recorded details about the SBME system as well as participant characteristics, obstacles, experiences, expectations, and attitudes. We used descriptive statistics as appropriate., Results: We received responses from 15 (68.2%) administrators, 186 instructors, and 371 (13.7%) sixth-year medical students. SBME was commonly used in teaching and evaluation but less so in research. It was mainly used to improve psychomotor tasks, knowledge, patient care, and communication skills. The expected outcomes were improvements in students' performance, knowledge, and practice. The clinical courses were longer and had fewer participants than the pre-clinical courses. Obstacles encountered included shortages of faculty and simulators, time and space limitations, inadequate faculty training, and insufficient financial support. The administrators surveyed had positive attitudes toward SBME. Medical students reported having experience with SBME and strongly agreed that it was beneficial; however, they expected fewer students per class and more learning time to be devoted to these methods., Conclusions: SBME in Thailand is focused on teaching and assessment. The system could be improved through better-trained faculty, greater available space, more simulators, and sufficient funding. There were also some aspects that failed to meet students' expectations and need to be addressed. However, participants expressed positive attitudes toward SBME., Trial Registration: TCTR20210524003 (Thai Clinical Trials Registry)., (© 2022. The Author(s).)

Background: Postcesarean delivery pain leads to several adverse maternal outcomes. The primary objective of this study was to determine the incidence of moderate-to-severe pain after the use of spinal morphine for cesarean delivery. The secondary aim was to identify factors influencing moderate-to-severe pain., Methods: This was a prospective observational study. The inclusion criteria were a patient age of ≥18 years, and undergoing elective cesarean delivery under spinal anesthesia with intrathecal morphine (200 mcg). Moderate-to-severe pain was defined as a numerical rating scale score of more than 3. Preoperative and intraoperative data were collected including parity, history of cesarean delivery, pregnancy-associated problem, anesthesia blockade level, level of surgeon experience, incision type, tubal sterilization or appendectomy, and peritoneum suture. Chi-squared or Fisher's exact tests were used to examine risk factors. Multiple logistic regression was used to analyze independent factors associated with moderate to severe pain., Results: In all, 660 patients were enrolled. As 16 were subsequently removed because they met the study withdrawal criteria, data relating to 644 patients were analyzed. The incidence of moderate-to-severe pain during the first postoperative day was 451/644 patients [70.03%; 95% confidence interval (CI): 66.38-73.44%]. The median pain score [interquartile range (IQR)] was 5 (3-6), with 176/644 (27.33%) patients needing rescue analgesics. A multivariate analysis revealed that two factors were associated with moderate-to-severe pain on the first postoperative day: gestational diabetes [adjusted OR (AOR), 1.849; 95% CI: 1.068-3.203; P=0.028] and intraoperative tubal sterilization (AOR, 1.533; 95% CI: 1.060-2.218; P=0.023). A significantly higher number of patients experienced moderate-to-severe pain on postoperative Day 1 [451/644 (70.03%)] than on Day 2 [349/644 (54.19%); P<0.001]. The median pain score [IQR] on postoperative Day 2 was 4 [3-5], which was less than on Day 1 (P<0.001)., Conclusions: A high incidence of moderate-to-severe postoperative pain was found after a single dose of spinal morphine for cesarean delivery. Adequate pain control is required in women at risk of postcesarean delivery pain. More studies are needed on the analgesic requirements of diabetic patients or patients who receive intraoperative tubal sterilization.

Objective: Maternal cardiac arrest is rare. We retrospectively reviewed and reported (1) the incidence of maternal cardiac arrests during admissions for delivery; (2) the characteristics and causes of cardiac arrest; and (3) the mortality rate and outcomes in a referral, single-university, teaching hospital in Thailand., Materials and Methods: Data on 23 cardiac arrests during admissions for delivery in the decade January 2006-December 2015 were retrospectively chart-reviewed. Patients with gestational ages under 24 weeks or cardiac arrests and death occurring before hospital arrival were excluded. The clinical characteristics of the arrests and outcomes were collected., Results: Of 89,368 deliveries during the decade, 23 women suffered cardiac arrest (incidence, 1:3885), with 3 of those arrests occurring before delivery (incidence, 1:29,789). One patient underwent a perimortem cesarean delivery in the operating theatre. The most common reasons for the arrests were hypertension during pregnancy and cardiovascular causes (30.4% and 21.7%, respectively). Amniotic fluid embolisms were suspected for 2 patients (8.7%) with unidentified causes. The incidence of maternal deaths in peripartum cardiac arrests was 20/23, representing 86.9% (95% CI, 67.9-95.5) or 1:4468 of deliveries. Three patients suffering cardiac arrests after delivery survived to discharge., Conclusions: We found a high maternal mortality rate following cardiac arrests during hospitalization for delivery. To decrease the incidence of arrests during the peripartum period and diminish the maternal mortality rate, identification of the causes and precipitating factors is vital. High-risk pregnant women require multidisciplinary care to improve the survival-to-discharge rate., Competing Interests: Declaration of competing interest The authors declare that there are no personal or professional conflicts of interest regarding any aspect of this study, and that they received no funding for the study., (Copyright © 2021. Published by Elsevier B.V.)

Aims: Adiponectin, visfatin, and omentin have been shown to be associated with insulin sensitivity and might have a role in the pathophysiology of gestational diabetes mellitus (GDM). This study aimed to (1) compare adiponectin, visfatin, and omentin mRNA expressions in placenta and their serum levels between normal pregnancy (NP) and GDM class A1 (GDMA1) pregnancy and (2) determine correlations between placental gene expressions as well as serum levels with maternal and neonatal clinical parameters in all, NP, and GDM subjects., Methods: NP subjects (n = 37), who had normal medical history during their pregnancies without diagnosis of any abnormalities and GDMA1 subjects (n = 37), who were diagnosed since they had antenatal care, were recruited when they were in labor with a gestational age of at least 34 weeks. Clinical parameters and serum adiponectin, visfatin, and omentin levels were measured in the delivery room., Results: GDMA1 subjects had higher serum visfatin and plasma glucose levels, but lower serum omentin levels (p  < 0.05 all) compared to controls, with comparable levels of placental adiponectin, visfatin, and omentin expressions, plasma insulin, and indices of insulin sensitivity and insulin resistance. Serum visfatin was negatively correlated with neonatal weight and length in the GDM group (p  < 0.05 all). Serum omentin was negatively correlated with pre-pregnancy body mass index and waist circumference only in the NP group (p  < 0.05 all). Serum adiponectin was negatively correlated with maternal age and HOMA-IR in the NP group (p  < 0.05 all) and with placental weight and serum omentin in the GDM group (p  < 0.05 all)., Conclusions: In conclusion, in GDMA1, increased serum visfatin, which has insulin-mimetic effect, might be associated with a compensatory mechanism that improves the impaired insulin function. Decreased serum omentin in GDMA1, which is normally found in visceral obesity, might lead to insulin resistance and contribute to the pathophysiology of GDM.

Impact Statement: Neuropeptide Y (NPY) has been reported as a vasoconstrictive substance which might be associated with preeclampsia. The novel findings of this study were that Y1R, Y2R, and Y5R expressions were significantly lower in the PE than the NP group. Moreover, the NPY receptor expression ratio between the PE/NP groups was lowest for Y2R (0.27) compared to Y1R (0.42) and Y5R (0.40) suggestive of a reduction of this receptor in the preeclampsia group. Our results suggested that decreased Y2R mRNA in the PE group might be associated with abnormalities of placental angiogenesis which probably contributes to the pathophysiology of preeclampsia.

Purpose: To compare the effectiveness of intravenous carbetocin to that of intravenous oxytocin for prevention of atonic postpartum hemorrhage (PPH) after vaginal delivery in high-risk singleton pregnancies., Methods: This triple-blind randomized controlled trial included singleton pregnant women who delivered at Siriraj Hospital between August 2016 and January 2017 and who were 20 years or older, had a gestational age of at least 34 weeks, had a vaginal delivery, and had at least one risk factor for atonic postpartum hemorrhage. Immediately after vaginal delivery, participants were randomly assigned to receive either 5 U of oxytocin or 100 mcg of carbetocin intravenously. Postpartum blood loss was measured objectively in mL using a postpartum drape with a calibrated bag., Results: A total of 174 and 176 participants constituted the oxytocin and carbetocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had less postpartum blood loss (146.7 ± 90.4 vs. 195.1 ± 146.2 mL; p < 0.01), a lower incidence of atonic PPH (0 vs. 6.3%; p < 0.01), less usage of additional uterotonic drugs (9.1 vs. 27.6%; p < 0.01), and a lower incidence of postpartum anemia (Hb ≤ 10 g/dL) (9.1 vs. 18.4%; p < 0.05) than the oxytocin group. No significant differences regarding side effects were evident between the groups., Conclusions: Intravenous carbetocin is more effective than intravenous oxytocin for the prevention of atonic PPH among singleton pregnancies with at least one risk factor for PPH., Clinical Trial Registration: TCTR20160715004.

Aim: The aim of this study was to determine the efficacy of a single 40-mg intravenous (i.v.) dose of parecoxib as an adjunctive analgesia to intrathecal morphine after elective cesarean delivery (CD)., Methods: A total of 82 low-risk term pregnant women who were scheduled for elective CD during the June 2014-June 2015 study period were enrolled. Two hours after surgery, subjects were randomly assigned to receive either i.v. injection of 2 mL (40 mg) parecoxib (study group; n = 41) or 2 mL normal saline solution (control group; n = 41). Patient randomization into groups was determined by the hospital's central computer system. Outcome measurements included total postoperative supplemental meperidine consumption, recorded pain score by numeric pain rating scale at 6, 12, 18, and 24 h, postoperatively, and patient satisfaction., Results: Patient characteristics and pregnancy outcomes were comparable between groups. Total postoperative meperidine consumption was not significantly different between groups (12.7 ± 18.8 mg vs 8.3 ± 16.7 mg; P > 0.05). Compared with control, the study group was significantly less likely to experience moderate to severe postoperative pain (score ≥ 4) at 6 h (0% vs 21.9%; P = 0.002). Study group patients reported higher satisfaction than control group patients (median score: 8 vs 6; P < 0.01). No patients in either group reported adverse effects from their assigned intervention., Conclusion: Parecoxib did not demonstrate effectiveness in reducing patient requirement for supplementary meperidine after CD. However, administration of a single 40-mg dose of i.v. parecoxib after elective CD demonstrated effectiveness in reducing pain scores, with a resulting increase in patient satisfaction., (© 2016 Japan Society of Obstetrics and Gynecology.)

Introduction: Immediate postpartum haemorrhage (PPH) is the most common cause of maternal mortality worldwide. Most recommendations focus on its prevention and management. Visual estimation of blood loss is widely used for the early detection of PPH, but the most appropriate method remains unclear. This study aimed to compare the efficacy of visual estimation and objective measurement using a sterile under-buttock drape, to determine the volume of postpartum blood loss., Methods: This study evaluated patients aged ≥ 18 years with low-risk term pregnancies, who delivered vaginally. Immediately after delivery, a birth attendant inserted the drape under the patient's buttocks. Postpartum blood loss was measured by visual estimation and then compared with objective measurement using the drape. All participants received standard intra- and postpartum care., Results: In total, 286 patients with term pregnancies were enrolled. There was a significant difference in postpartum blood loss between visual estimation and objective measurement using the under-buttock drape (178.6 ± 133.1 mL vs. 259.0 ± 174.9 mL; p < 0.0001). Regarding accuracy at 100 mL discrete categories of postpartum blood loss, visual estimation was found to be inaccurate, resulting in underestimation, with low correspondence (27.6%) and poor agreement (Cohen's kappa coefficient 0.07; p < 0.05), compared with objective measurement using the drape. Two-thirds of cases of immediate PPH (65.4%) were misdiagnosed using visual estimation., Conclusion: Visual estimation is not optimal for measurement of postpartum blood loss in PPH. This method should be withdrawn from standard obstetric practice and replaced with objective measurement using the sterile under-buttock drape., (Copyright: © Singapore Medical Association.)

Objective: To study the correlation of endometrial pathology, which were derived from manual vacuum aspiration (MVA) and sharp metal curettage (SMC)., Material and Method: Women aged over 35 years old who presented with abnormal uterine bleeding were enrolled. Endometrial biopsy using MVA and sharp metal curettage under paracervical nerve block were performed, respectively. Correlation of endometrial pathology from both methods and correlation between endometrial pathology from MVA and the most severe pathology were analyzed using Kappa statistics., Results: One hundred and thirty two women were enrolled Nine cases were drop out because of inability to pass the MVA's cannula through the cervical os. Mean age was 49.3 ± 8.5 years old. Mean BMI was 25.1 ± 4 kg/m². Pathological correspondence between tissue obtained from MVA and sharp metal curette was 64.2% and the Kappa agreement was 0.56 (K0 = 0.56, p-value < 0.05). Pathological correspondence between tissue obtained from MVA and the most severe pathology was 92.7% and the Kappa.agreement was 0.86 (K = 0.86, p-value < 0.05). MVA could diagnose all cases of malignancy and endometrial hyperplasia., Conclusion: Manual vacuum aspiration (MVA) can be used as an alternative diagnostic procedure in women with abnormal uterine bleeding.