Over the last 5 years there has been a plethora of studies looking at the complications and feasibility of performing myomectomy at the time of caesarean section (Li et al. Acta Obstet Gynecol Scand 2009;88:183–6; Akkurt et al. J Matern-Fetal Neonatal Med 2017;30:1855–60). Few if any of these studies have come from the UK or the USA, and while the commandment ‘thou should never touch a fibroid at a caesarean section’ seems to have originated in the developed world, the rules are being questioned elsewhere, with results that universally show, despite the expected increase in operating time, no significant increase in morbidity besides an increase need for blood transfusion and, most importantly, no excess of hysterectomy being required.

Hyponatremia during peripartum period is a recognized but underreported complication. Hyponatremia has significant adverse effects on mother as well as infant. Hyponatremia can be dilutional or nondilutional. Dilutional or hypervolemic hyponatremia is more common during the labor and postpartum period. The blood sodium concentration during pregnancy is lower, 130–140 mmol/L, which is being considered normal compared to 135–145 mmol/L in nonpregnant women. Thus, when the blood sodium level is below 130 mmol/L, we should consider it as hyponatremia of pregnancy. Oxytocin can play a major role to cause dilutional hyponatremia if large volumes of hypotonic fluids are consumed or infused intravenously simultaneously. Hyponatremia during labor is such a complex problem that it can be the result of several factors. In hyponatremia, there is progressive dysfunction of the neurological system, which in association with cerebral edema results in various symptoms. Symptoms may vary from headache, nausea, vomiting, lethargy, muscle cramps, and disorientation, progressing to seizures, coma, respiratory arrest, and death. A proper clinical history and various blood tests including serum sodium are important to diagnose the severity of hyponatremia. Women in labor should be advised to drink water only up to their thirst impulse; excessive fluid intake should be avoided. The treatment depends on cause, severity, and duration of hyponatremia, as well as clinical status of patient, and associated comorbidities. Once acute water intoxication and hyponatremia have been diagnosed, it is necessary to correct the hyponatremia by water restriction and to watch sodium concentration in the blood. Severe hyponatremia (sodium <125 mmol/L + symptoms) is a medical emergency. The primary idea of treatment should be to improve symptoms instead to normalize the blood sodium level. Keywords: Fluid balance, Fluid restriction, Hyponatremia, Labor, Oxytocin, Peripartum.

Background: Cholesterol pericarditis (CP) remains a rare pericardial disease characterized by chronic pericardial effusions with high cholesterol concentrations with or without the formation of cholesterol crystals. Effusions are often large and can cause ventricular compression and subsequent pericardial adhesion formation. CP can be idiopathic but has associations with rheumatoid arthritis (RA), tuberculosis and hypothyroidism. Case summary: We present a case of a 72-year-old male with a background of seropositive RA with a finding of an incidental pericardial effusion on computed tomography thorax abdomen and pelvis. Transthoracic echocardiogram demonstrated a large effusion with echocardiographic features of tamponade. On review, he was breathless with a raised venous pressure, bilateral ankle oedema, and pulsus paradoxus was present. Pericardial drainage was performed with fluid analysis demonstrating a cholesterol concentration of 8.3 mmol/L and numerous cholesterol crystal formation. Interval imaging demonstrated recurrence of the effusion with pericardial thickening and progressive constriction. He remained asymptomatic and underwent a successful pericardial window. At present, he is under close clinical outpatient surveillance with symptoms guiding a future pericardiectomy if warranted. Discussion: CP can present as an emergent situation with signs and symptoms of acute heart failure with prompt pericardiocentesis required in cases of clinical tamponade. However, the disease course is often one of chronicity with relapsing large effusions that tend to recur following drainage, with the development of pericardial constriction necessitating pericardiectomy for definitive management.

Objective: To assess the cardiotocographic changes and maternal and neonatal outcomes in cases of chorioamnionitis and or funisitis confirmed on histopathology. Study design: A retrospective analysis of histopathology reports confirming chorioamnionitis and/or funisitis was carried out from 2014 to 2020 in a single centre. The preterm births (<37 weeks) were excluded. The maternal records were reviewed to determine the maternal and neonatal outcomes such as the mode of delivery, intrapartum and postpartum complications, umbilical cord arterial pH, and admission to the special care baby unit (SCBU). The CTG features were analysed on admission and during the intrapartum period. The study was approved by the Audit and Clinical Effectiveness department within the centre. Results: Out of the 57 cases of histologically confirmed chorioamnionitis and/or funisitis, 42 women (73.7 %) had intrapartum pyrexia and none of the mothers had an increased temperature at the point of fetal tachycardia (persistent increase in baseline fetal heart rate (FHR) by >10 % compared to the original baseline FHR). 43 (75.4 %) CTGs showed evidence of uterine tachysystole or hyperstimulation. 15 (26.3 %) cases had meconium stained amniotic fluid (MSAF). 54 (94.7 %) women had a caesarean section, and their babies were admitted to special care baby unit after delivery. 54 (94.7 %) babies had an umbilical artery of more than 7.1. 47 (87 %) of the women were readmitted with wound infection. All CTG traces showed a > 10 % increase in the baseline FHR and variable decelerations with overshoot were noted in cases where funisitis was confirmed in 25 cases (92.6 %). Loss of cycling was noted in 54 CTGs (94.7 %) and a sinusoidal pattern was identified in 27 (47.3 %). Conclusion: Rising (>10 %) baseline during labour along with loss of cycling with or without features of tachysystole or hyperstimulation should be considered in labour as features of ongoing chorioamnionitis. Chorioamnionitis confirmed on histopathology is associated with an increase in caesarean section rate due to fetal heart rate changes, increased risk of wound infection in mothers, and increased admission of the babies to SCBU.

Commentary on the adoption of minimally invasive techniques in gynaecology