剖宫产后瘢痕子宫再次妊娠分娩方式的临床研究

目的探讨剖宫产后瘢痕子宫再次妊娠的合理分娩方式。方法对110例剖宫产术后再次妊娠孕妇,根据具体情况分为再次择期剖宫产及经阴道试产2组。对分娩方式、子宫破裂、出血、新生儿窒息等情况进行回顾性分析。结果 60例阴道试产中25例试产成功,试产成功率为41.7%。再次择期剖宫产组较经阴道分娩组出血量大,而子宫破裂、新生儿窒息发生率无明显差异。结论剖宫产术后再次妊娠分娩并非是剖宫产绝对指征,前次剖宫产有绝对指征或此次妊娠出现新的指征可行择期剖宫产,符合试产条件者在严密监护下应给予试产,因为阴道分娩可减少再次手术给患者带来的各种并发症及手术痛苦。试产失败者改急诊剖宫产。     

Factores de riesgo asociados a lesiones vesicales en cesárea

ObjectiveTo identify risk factors for bladder injury during cesarean delivery, to let patients and doctors know them and their importance.MethodsWe conducted a case-control study of women undergoing cesarean delivery at the Instituto Nacional de PerinatologíaIsidro Espinosa de los Reyes between january 2001 and december 2007. Cases were women with bladder injuries at the time of cesarean section. Two controls per case were selected randomly. Medical records were reviewed for clinical and demographic data to compare them.ResultsTwenty-one bladder injuries were identified among 24, 057 cesarean sections, (incidence 0.087%), only 19 were analized. Prior cesarean section was more prevalent among cases than controls (63% vs 42% p 0.134), with an OR of 2.35 (95% CI 0.759- 7.319), when we take only patients with one cesarea in contrast with no cesarea the OR is 3.75 (95% CI 1.002- 14.07). Statistically significant differences (P values < .05) between cases and controls were found in gestacional age (38.16 vs 37.35 weeks), prior cesareans (42% vs 18%), adhesions (79% vs 5%), Odds ratio of 67.5 (95% CI 11.14- 408), VBAC (31.5 vs 3%), median skin incisión (16% vs 68%), Pfannenstiel (84% vs 32%), blood loss (744cc vs 509cc) and length of surgery 135 vs 58 minutes). No differences were found among age, BMI, prior surgery, labor, premature rupture of membranes, station, chorioamnioitis, induction, uterine incision, timing of delivery, uterine rupture.ConclusionPrior cesarean section and adhesions are risk factors for bladder injury at the time of repeat cesarean delivery. Elective cesarean delivery is valid but it is duty of physicians to inform patients the risks of it.     

剖宫产术后再次妊娠分娩方式150例分析

目的探讨剖宫产术后再次妊娠的分娩方式,分析经阴道分娩的可能性。方法回顾性分析2009年3月～2012年9月我院收治的既往有剖宫产史的150例孕妇的分娩方式。结果 150例孕妇中,126例选择再次择期剖宫产,24例选择经阴道试产,17例阴道试产成功,阴道试产成功率70.8%,7例试产失败转行剖宫产。再次剖宫产率88.7%（133/150）。结论对于符合条件的剖宫产术后再次妊娠分娩的孕妇可以在严密监护下阴道试产。     

Spontaneous rupture of uterus

Spontaneous rupture of the uterus is a life-threatening obstetrical emergency. Diagnosis may be delayed because of the bizarre presentation or absence of significant pain and tenderness, which could have been masked by the analgesic medications used during labor. We present a case of spontaneous rupture in a multigravid female who was undergoing oxytocin-augmented labor while receiving epidural analgesia. She had had no previous cesarean deliveries or uterine surgery. Half an hour after an initial complaint of left inguinal pain, which was thought to be related to a patchy epidural block, she presented with changes in vital signs and significant fetal decelerations. At emergent cesarean section, a uterine rupture was noted. The uterine rupture extended down to the left vaginal angle, was not reparable and a hysterectomy was performed. The fetus survived.     

Refractory uterine atony: still a problem after all these years

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.     

Obstetric interventions and maternal morbidity among women who experience severe postpartum hemorrhage during cesarean delivery

BackgroundCompared to vaginal delivery, women undergoing cesarean delivery are at increased risk of postpartum hemorrhage. Management approaches may differ between those undergoing prelabor cesarean delivery compared to intrapartum cesarean delivery. We examined surgical interventions, blood component use, and maternal outcomes among those experiencing severe postpartum hemorrhage within the two distinct cesarean delivery cohorts.MethodsWe performed secondary analyses of data from two cohorts who underwent prelabor cesarean delivery or intrapartum cesarean delivery at a tertiary obstetric center in the United States between 2002 and 2012. Severe postpartum hemorrhage was classified as an estimated blood loss ≥1500 mL or receipt of a red blood cell transfusion up to 48 h post-cesarean delivery. We examined blood component use, medical and surgical interventions and maternal outcomes.ResultsThe prelabor cohort comprised 269 women and the intrapartum cohort comprised 278 women. In the prelabor cohort, one third of women received red blood cells intraoperatively or postoperatively, respectively. In the intrapartum cohort, 18% women received red blood cells intraoperatively vs. 44% postoperatively (P <0.001). In the prelabor and intrapartum cohorts, methylergonovine was the most common second-line uterotonic (33% and 43%, respectively). Women undergoing prelabor cesarean delivery had the highest rates of morbidity, with 18% requiring hysterectomy and 16% requiring intensive care admission.ConclusionOur findings provide a snapshot of contemporary transfusion and surgical practices for severe postpartum hemorrhage management during cesarean delivery. To determine optimal transfusion and management practices in this setting, large pragmatic studies are needed.     

Fundal partial placenta percreta complicated with postpartum hemoperitoneum: A case report

IntroductionThe fundus of the uterus is a rare location for abnormally invasive placenta compared with the common site of abnormally invasive placenta in the lower segment of the uterus.Presentation of caseWe report a case of a 38-year-old multipara woman who had a fundal partial placenta percreta with no prior cesarean sections, which presented as a retained placenta after preterm labor, and complicated with hemorrhagic shock due to postpartum hemoperitoneum, thus it was diagnosed after surgery and managed by subtotal hysterectomy.DiscussionWe discuss the most common risk factors for abnormally invasive placenta and its diagnosis and management. We compare the possibility of leading to invasive placenta resulting from curettage trauma and cesarean delivery scars.ConclusionHistory of uterine surgical procedures without prior cesarean delivery must raise suspicion of abnormally invasive placenta regardless of its localization, especially when associates with preterm labor or retained placenta.     

硬膜外分娩镇痛期间产时发热的相关因素

目的 分析硬膜外分娩镇痛期间产妇发热的相关因素.方法 回顾性分析2019年6—12月产房待产自愿要求硬膜外分娩镇痛产妇170例,ASAⅠ或Ⅱ级,孕期37～40周.根据体温是否≥38℃分为两组:发热组和非发热组.记录产程、胎膜破裂至分娩结束时间、阴道检查次数、分娩镇痛时间及硬膜外镇痛给药方式等,采用Logistic回归法...     

Development of clinical risk-prediction models for uterine atony following vaginal and cesarean delivery

BackgroundUterine atony is the most common cause of postpartum hemorrhage and is associated with substantial morbidity. Prospectively identifying women at increased risk of atony may reduce the incidence of subsequent adverse events. We sought to develop and evaluate clinical risk-prediction models for uterine atony following vaginal and cesarean delivery, using prespecified risk factors identified from systematic review.MethodsUsing retrospective data from vaginal and cesarean deliveries occurring at a single institution between 2010 and 2019, antepartum and intrapartum risk-prediction models for uterine atony, defined by supplementary uterotonic administration in addition to prophylactic oxytocin infusion, were developed using logistic regression. The C-statistic quantified the ability of the model to discriminate between cases and controls.ResultsData were available for 4773 atony cases and 23 933 controls. The antepartum model included 20 risk factors and exhibited moderate discriminatory ability (C-statistic 0.61, 95% confidence interval 0.60 to 0.62). The intrapartum model included 27 risk factors and showed improved discriminatory ability (C-statistic 0.68, 95% confidence interval 0.67 to 0.69).ConclusionsWe identified antepartum and intrapartum risk-prediction models to quantify patients’ risk of uterine atony. Models performed similarly for all delivery modes, races, and ethnic groups. Future work should further improve these models through inclusion of more comprehensive prediction data.     

Conservative management of vesicouterine fistula after uterine rupture

We report the closure of a vesicouterine fistula with conservative management utilizing an indwelling transurethral Foley catheter. Uterine rupture occurred during a trial of vaginal birth after cesarean section, necessitating an emergency cesarean section. Upon entry into the abdomen, the base of the bladder was noted to be involved in the uterine rupture. The bladder trigone and ureteral orifices appeared normal. A primary, two-layer bladder repair was performed. A cystogram on postoperative day 14 demonstrated a vesicouterine fistula. Conservative management involving bladder drainage for 21 days with a transurethral Foley catheter was successful in closure of the fistula.Vesicouterine fistula, a documented complication of uterine rupture due to attempted vaginal birth after previous cesarean section, can spontaneously resolve with conservative management alone.Abbreviations VBAC Vaginal birth after cesarean section     

Trial of labor: a study of 110 patients

STUDY OBJECTIVE: The purpose of the study was to determine whether epidural analgesia is unsafe for trial of labor (TOL). DESIGN: Retrospective chart review. SETTING: Inpatient obstetric department at a university medical center. PATIENTS: One hundred ten ASA physical status I and II term parturients who attempted a TOL between December 1987 and June 1988. INTERVENTIONS: All the parturients previously had low transverse uterine incisions and received continuous electronic fetal and uterine pressure monitoring throughout labor. All the parturients were offered epidural analgesia during labor with bupivacaine 0.25%. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent of the parturients had successful vaginal delivery. Fifty-one of the 110 parturients had epidural analgesia for labor. There were two complete uterine ruptures; neither had epidural catheters. Both of the complete ruptures presented with monitored fetal distress rather than abdominal pain. Both mothers and their infants recovered uneventfully. CONCLUSIONS: Uterine rupture presents as monitored fetal distress rather than abdominal pain. Thus, epidural analgesia can be used in patients attempting a TOL.     

Non-pregnant patients’ preference for delivery route

The objective of the study was to survey non-pregnant women regarding their preference for obstetric delivery route and to assess their awareness of the maternal and fetal risks of obstetric delivery. We wished to determine the percentage of non-pregnant women who would choose elective cesarean section and to correlate demographic factors. We compared women who elected cesarean delivery versus vaginal delivery. All patients presenting for routine gynecologic care were asked to complete an anonymous survey. Demographic variables analyzed were patient age, race, employment, insurance type and household income. Secondary data regarding knowledge of the risks and benefits of cesarean and vaginal delivery were assessed with a Likert Scale. Of patients surveyed, 13.3% preferred cesarean section. The only significant demographic factor was was race, with 21.7% of non-whites and 7.8% of whites choosing cesarean section. Most patients agreed that elective cesarean sections should be performed and reimbursed by insurance. The majority of women answered neutral regarding the maternal and neonatal risks of obstetrical delivery. The unique feature of this observational study is the sole participation of non-pregnant patients. The percentage of women who would elect cesarean section has significant public health implications. The only difference noted between demographic groups is that non-white women had a stronger preference for cesarean . Without counseling, most women are unsure of the risks of delivery route on maternal and neonatal health.Abbreviations VBAC Vaginal birth after cesarean sectionEditorial Comment: This cross-sectional analysis of 164 women attending a gynecology clinic for their obstetrical delivery preferences provides us with another interesting view of the growing international public debate regarding cesarean section on demand. The authors have suggested that a non-obstetrical or postpartum population offers a more objective view of the issue, but the absence of information regarding their obstetrical history and knowledge of the pros and cons of cesarean versus vaginal delivery limit generalization of this information to our obstetric populations who attempt to obtain informed consent. Despite these limitations, these data are very interesting and provocative.     

宫腔镜子宫中隔矫治术后分娩结局分析

目的探讨宫腔镜子宫中隔矫治术（transcervical resection of septum,TCRS）对分娩结局的影响。方法2006年3月-2010年12月在我院进行子宫中隔宫腔镜矫治术143例,其中73例活产分娩（1例2次分娩）,与同期2078例子宫结构正常并分娩的妇女进行比较,分析其剖宫产率、剖宫产原因、分娩期并发症及新生儿情况。结果（1）TCRS术后组剖宫产、早产、臀位或横位、前置胎盘发生率分别为81．1％（60／74）、14．9％（11／74）、20．3％（15／74）、14．9％（11／74）,明显高于对照组的42．3％（879／2078）、5．1％（107／2078）、5．5％（115／2078）、1．5％（32／2078）（χ2=43．694,11．208,24．803,58．163,P值均〈0．01）。胎儿窘迫发生率TCRS术后组2．7％（2／74）,对照组5．9％（122／2078）,2组差异无显著性（P〉0．05）。（2）TCRS术后组无指征剖宫产率为38．3％（23／60）,明显高于对照组的17．4％（153／879）（χ2=16．151,P=0．000）。（3）TCRS术后组产后出血率21．6％（16／74）,其中43．8％（7／16）需要输血,明显高于对照组的产后出血率13．4％（279／2078）（χ2=4．057,P=0．044）及输血治疗率6．8％（19／279）（χ2=21．302,P=0．000）。结论TCRS术后分娩期新生儿存活率达到正常妇女水平,但是剖宫产率明显增高。为减少剖宫产率,不仅需要加强孕期及分娩期监护,预防分娩期并发症发生,更要加强患者充分试产的信心。     

Cesarean section: Does it really prevent the development of postpartum stress urinary incontinence? a prospective study of 363 women one year after their first delivery

AIMS: Stress urinary incontinence (SUI) in young women is usually the result of pelvic floor injury during vaginal delivery. Whether cesarean section delivery may prevent such injury is questionable. We undertook a prospective study to compare the prevalence of SUI among primiparae 1 year after spontaneous vaginal delivery versus elective cesarean section, or cesarean section performed for obstructed labor. METHODS: Three hundred and sixty-three consecutive primiparae were recruited immediately after delivery and were followed for 1 year. Women were asked upon recruitment whether they had ever experienced SUI before pregnancy. Those who had SUI before pregnancy were excluded. Thus, only cases of de novo childbirth-associated SUI were analyzed. Patients were divided into three subgroups according to the mode of delivery: spontaneous vaginal delivery (n = 145), elective cesarean section (n = 118), and cesarean section performed for obstructed labor (n = 100). Patients who underwent elective cesarean section were not given a trial of labor. Cesarean sections for obstructed labor were performed at a mean cervical dilatation of 8.7 +/- 1.6 cm and arrest of 184 +/- 24 min. Prevalence, frequency, and severity of postpartum SUI, as well as demographic and obstetric parameters, were analyzed in each subgroup. RESULTS: The three subgroups were comparable with respect to maternal age, weight, and height. Prevalence of postpartum SUI was similar after spontaneous vaginal delivery (10.3%) and cesarean section performed for obstructed labor (12%). However, SUI was significantly less common following elective cesarean section with no trial of labor (3.4%, P < 0.05). Approximately half of the symptomatic patients in each subgroup reported either moderate or severe symptoms, however, only 15-18% expressed their desire for further evaluation. CONCLUSIONS: Prevalence of postpartum SUI is similar following spontaneous vaginal delivery and cesarean section performed for obstructed labor. It is quite possible that pelvic floor injury in such cases is already too extensive to be prevented by surgical intervention. Conversely, elective cesarean section, with no trial of labor, was found to be associated with a significantly lower prevalence of postpartum SUI. Whether the prevention of pelvic floor injury should be an indication for elective cesarean section is yet to be established.     

Anesthesia and blood loss in preterm cesarean section: comparison between general and regional anesthesia

Changes in maternal hemoglobin concentrations after cesarean section performed before 35 weeks gestation were analyzed according to the type of anesthesia in a case-control retrospective study. There were 30 mothers who received general anesthesia (GA group) and 30 mothers who received regional anesthesia (RA group). The groups were matched for gestational age at delivery, type of uterine incision, and the use of tocolytic therapy (isoxuprine) before delivery. The indications for delivery were preterm labor or fetal/maternal complications following premature rupture of membranes without labor. There was no significant difference between the GA and RA groups in the pre-operative hemoglobin (11.9+/-1.4 vs 11.6+/-1.1 g/dl) or postoperative hemoglobin (11.1+/-1.7 vs 11.3+/-1.2 g/dl). The GA group, however, demonstrated a significant fall in the postoperative hemoglobin (P < 0.05). The GA group also had a higher incidence of a drop in hemoglobin of > 10% compared to the RA group (46.7% vs 20.0%, P < 0.05). Our results suggest that general anesthesia may be associated with more blood loss than regional anesthesia in cesarean sections performed before 35 weeks.     

Peripartum anesthetic management in patients with left ventricular noncompaction: a case series and review of the literature

BackgroundThis retrospective review focuses on peripartum anesthetic management and outcome of a series of five pregnant women with left ventricular noncompaction (LVNC).MethodsThe Mayo Clinic Advanced Cohort Explorer medical database was utilized to identify women diagnosed with LVNC who had been admitted for delivery at the Mayo Clinic in Rochester, Minnesota, between January 2001 and September 2021. Echocardiograms were independently reviewed by two board-certified echocardiographers, and those determined by both to meet the Jenni criteria and/or having compatible findings on magnetic resonance imaging (MRI) were included. Electronic medical records were reviewed for information pertaining to cardiac function, labor, delivery, and postpartum management.ResultsWe identified 44 patients whose medical record included the term “noncompaction” or “hypertrabeculation” and who had delivered at our institution during the study period. Upon detailed review of the medical records, 36 did not meet criteria for LVNC, and three additional patients did not receive the diagnosis until after delivery, leaving five patients with confirmed LVNC who had undergone six deliveries during the study interval. All five patients had a history of arrhythmias or had developed arrhythmias during pregnancy. One patient underwent emergency cesarean delivery due to sustained ventricular tachycardia requiring three intra-operative cardioversions.ConclusionsThis case series adds new evidence to that already available about pregnancies among women with LVNC. Favorable obstetrical outcomes were achievable when multidisciplinary teams were prepared to manage the maternal and fetal consequences of intrapartum cardiac arrhythmias and hemodynamic instability.     

58例产时发热临床分析

目的:分析产时发热的相关危险因素,提出相应的处理对策.方法:选择我院2015年3-10月共1629名进入产房待产的住院孕产妇为研究对象,其中出现产时发热(体温≥37.5℃)的患者共58名(发热组),均排除非产科因素导致的发热,其余1571名孕妇设为对照组.比较两组产妇产前及产后白细胞数、中性粒细胞数、C反应蛋白水平、产程时长、破膜至分娩时长,比较其使用宫颈扩张球囊、硬膜外镇痛、人工破膜、胎膜早破、阴道感染等各种临床特征.结果:发热组与对照组比较,总产程与破膜至分娩时间明显延长(P<0.001);使用硬膜外镇痛、宫颈扩张球囊引产、人工破膜均为产时发热的危险因素(OR>1,P<0.001).结论:延长的产程与破膜至分娩时间、硬膜外分娩镇痛是产时发热的高风险因素,对这些高感染风险患者,应该尽量减少无指征的人工干预与阴道操作,产时加强对体温、白细胞及中性粒细胞计数、CRP等感染指标的监测.     

Bladder rupture associated with uterine rupture at delivery

This paper seeks to study the clinical presentation and emergency treatment of bladder rupture associated with uterine rupture at delivery. From June to December 2009, three cases of rupture of the uterus involving maternal bladder during labor at Revolutionary Hospital at Hodeidah, Yemen were reviewed. Intraoperatively, it appeared that the posterior wall of the bladder and the anterior wall of the uterus had ruptured; the laceration of the posterior bladder wall was closed in two layers. Of the patients who underwent the operations, one patient developed vesicovaginal fistula, which was repaired vaginally after 6 months, and the patient had a successful outcome. The others got uneventful recovery and there was no vesicovaginal fistula or hydronephrosis during follow-up. Uterine rupture and associated injury to the maternal bladder was rarely reported. It would be life threatening or would lead to long-term complications. Both urologists and obstetrician should keep bladder injuries in mind, as serious outcomes might occur during labor. Surgical treatment could be the preferred approach for this situation.     

Spontaneous bladder and uterine rupture with attempted vaginal delivery after cesarean section.

We report spontaneous bladder and uterine rupture in a patient undergoing oxytocin augmented labor while under epidural anesthesia after a previous cesarean section. The presenting signs were gross hematuria at placement of an indwelling catheter and fetal distress. Cesarean section produced a healthy newborn. The patient recovered satisfactorily after subtotal hysterectomy, bladder repair and transfusion.