Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

BACKGROUND: The issues related to safety of induction of labour in women with previous caesarean section remain controversial. The main adverse outcome fuelling this debate is a "small" risk of uterine rupture that is potentially devastating for both the mother and the fetus. OBJECTIVE: To estimate the risk of uterine rupture or dehiscence in women who require induction of labour with previous caesarean sections. DESIGN: Five year retrospective review of computerised hospital records and case note review of index cases. SETTING: Large inner city teaching hospital. POPULATION: Two hundred and five women who had their labour induced with history of one lower segment caesarean section. METHODS: This study was conducted at Liverpool Women's Hospital, a tertiary referral centre, with approximately 6000 births per annum. We searched the hospital's computerised records of deliveries from June 1997 to June 2002 and reviewed all indications and outcomes of induction of labour in women with one previous caesarean section. Women with singleton pregnancy and cephalic presentation were then divided into three groups: those with one previous caesarean section and no previous vaginal deliveries, those whose last delivery was a caesarean section but had delivered vaginally before and those whose last delivery was by vaginal route, but had had one caesarean section in the past. MAIN OUTCOME MEASURES: Uterine rupture or dehiscence, adverse neonatal outcome. RESULTS: Two hundred and five women were included. There were four cases of uterine rupture and one dehiscence (2.4%, 95% CI 0.8-5.6%). Two babies were profoundly acidotic at birth, but all five neonates were healthy when discharged from hospital with no long term morbidity. All five cases occurred in the group of women with no previous vaginal deliveries. The intrauterine pressure catheter recordings had contributed to the diagnosis of uterine rupture/dehiscence in three out of five cases. CONCLUSION: In women with previous caesarean section and no vaginal deliveries, induction of labour carries a relatively high risk of uterine rupture/dehiscence despite all precautions, including intrauterine pressure monitoring.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Summary. Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1·5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0·3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Oxytocin augmentation in dysfunctional labour after previous caesarean section

Uterine activity was quantified in women with a previous caesarean scar and a slow progress of labour who needed oxytocin augmentation. Of the 63 women 49 (78%) progressed well (mean cervical dilatation rate of 1.5 cm/h) and were delivered vaginally. Fourteen women had slow progress of labour (0.3 cm/h) and were delivered by caesarean section despite adequate and similar augmented uterine activity to that in the women who were delivered vaginally. Those who were delivered by caesarean section had a significantly higher mean maximum dose of oxytocin and a longer period of augmentation. All caesarean sections were for cephalopelvic disproportion and the mean birthweight of babies born by caesarean section (3598 g) was significantly higher than that of babies born vaginally (3230 g). Satisfactory rate of cervical dilatation in the presence of optimal uterine activity is predictive of favourable outcome when oxytocin is used for dysfunctional labour after previous caesarean section.     

Hayman uterine compression stitch for arresting atonic postpartum hemorrhage: 5 years experience

ObjectivesThe present study was planned to access the efficacy of Hayman uterine compression stitch which is easy, can be applied faster and avoids the performance of a lower segment hysterotomy in patients with atonic postpartum hemorrhage.Materials and MethodsIt is a study carried out from January 2004 to December 2008 at a tertiary care center and included 48 women who had intractable atonic PPH not managed with medical treatment and who were wishing to preserve their fertility. Hayman stitch which is a simplified approach to uterine compression sutures was performed by tying two parallel vertical sutures from just above the bladder reflection to the fundus of the uterus.ResultsWith Hayman stitch hysterectomy was avoided in 93.75% (45 out of the 48) patients with PPH. The postoperative course was uncomplicated, six women conceived spontaneously within 12 month after uterine compression suturing. Four delivered vaginally and two underwent cesarean section in view of fetal distress. The uterine cavity was found to be normal during caesarean section.ConclusionTwo parallel vertical compression sutures (Hayman stitch) placed in the uterus controls bleeding effectively. The technique is easy, rapid and requires less skill and this simple procedure be tried first before other complex measures like uterine artery ligation are undertaken particularly for those obstetricians who lack sufficient training and skill.     

Poor uterine contractility in obese women

OBJECTIVE: The aim of the study was to elucidate the reason for the high rate of caesarean section in obese women. We examined the following hypotheses: (1) obese women have a high incidence of complications related to poor uterine contractility--caesarean section for dysfunctional labour and postpartum haemorrhage. 2) The myometrium from obese women has less ability to contract in vitro. DESIGN: First, a clinical retrospective analysis of data from 3913 completed singleton pregnancies was performed. Secondly, in a prospective study the force, frequency and intracellular [Ca(2+)] flux of spontaneously contracting myometrium were related to the maternal body mass index. SETTING: Liverpool Women's Hospital and University of Liverpool. POPULATION: The clinical study involved all women who delivered in one hospital in 2002. The in vitro study myometrial biopsies were obtained from 73 women who had elective caesarean section at term. RESULTS: Maternal obesity carried significant risk of caesarean section in labour that was highest for delay in the first stage of labour (OR 3.54). The increased risk of caesarean section in obese women largely occurred in women with normal- and not with high-birthweight infants. Obese women delivering vaginally had increased risk of prolonged first stage of labour and excessive blood loss. Myometrium from obese women contracted with less force and frequency and had less [Ca(2+)] flux than that from normal-weight women. CONCLUSIONS: We suggest that these findings indicate that obesity may impair the ability of the uterus to contract in labour.     

子宫畸形合并妊娠母儿妊娠结局临床分析

目的探讨妊娠合并子宫畸形对于母儿妊娠结局的影响。方法选取北京大学人民医院收治的妊娠合并子宫畸形患者108例,并以372例正常子宫妊娠患者作为对照,对其临床资料进行回顾性分析。结果①在29245例分娩的病例中,妊娠合并子宫畸形共108例,发生率约为0.4%。其中以子宫纵膈最为常见,占49.1%,其次为双子宫,占21.3%;②子宫畸形合并妊娠的患者中,胎位异常发生率（46.3%）及剖宫产率（73.2%）均显著升高;③子宫畸形组的平均孕周（37.2周）,新生儿平均出生体重（2873g）显著低于对照组,而早产率（24.1%）及足月低体重儿发生率（6.5%）均显著高于对照组;④纵膈子宫、单角子宫（83.3%合并残角子宫）、双角子宫、及双子宫在终止妊娠方式上存在差异,剖宫产率在纵膈子宫为最低（64.2%）。各组在早产率、孕周、胎儿体重方面差异无统计学意义（P〉0.05）。结论子宫畸形对于妊娠结局可产生不良影响,临床医生应加强孕前及孕期管理。     

Rupture of the gravid uterus

Seventeen cases of uterine rupture in late pregnancy managed over an eight-year period in one hospital in Hong Kong were analysed. Labour was associated with rupture in 16 cases, including ten with one or more previous caesarean section scars. Rupture occurring in an unscarred uterus was associated with high fetal losses and all required hysterectomy. All of these patients had at least one previous vaginal delivery, in contrast to the patients with a scarred uterus. Labour should be closely monitored in multiparous patients with or without a uterine scar, and oxytocics should be used carefully. Patients with previous sections who are scheduled for repeat elective sections should be delivered before 39 weeks.     

Fertility after the demonstration of intravasation during hysterosalpingography

Intravasation of contrast medium was found in 28 women out of 450 women (6.25%) who underwent hysterosalpingography (HSG). Ten of these women had an otherwise normal uterine cavity and patent tubes. In six patients (66%) out of nine who underwent a repeated HSG within 2 months no intravasation was demonstrated. Seven of the 28 patients with intravasation (25%) of whom four were among the 10 patients with normal uterine cavity and patent tubes (40%) conceived and delivered later.It is concluded that in cases in which no other uterine pathology is demonstrated on HSG intravasation is not a persistent occurrence, and by itself does not affect the prognosis of fertility.     

Hysteroscopic metroplasty for septate uterus and repetitive abortions: reproductive outcome

OBJECTIVES: The aim of this study is to assess fertility outcome and obstetrical prognosis of 63 patients after hysteroscopic section of uterine septa. MATERIALS AND METHODS: This is a retrospective study about 63 patients consulting for septate uterus and repeated pregnancy loss or abnormal fetal presentation between January 1988 and December 1996 in La Conception hospital in Marseille. Septal lysis was performed with microscissors or resectoscope. Statistical analysis was performed using the CHI2-test. RESULTS: The anatomical result was considered satisfactory in 57.1% of cases. Forty-five pregnancies were obtained, two after an IVF-program in 56 patients. Twenty-eight living children were born: twenty-six at term. Twenty patients delivered normally. Two women are still pregnant. Obstetrical prognosis of these patients is statistically improved by the treatment (P=0.001). CONCLUSION: Obstetrical prognosis of patients presenting repeated pregnancy loss and septate uterus is statistically improved by hysteroscopic metroplasty.     

The role of postnatal x-ray pelvimetry after caesarean section in the management of subsequent delivery

Summary. The purpose of this study was to investigate the influence of postnatal x-ray pelvimetry after caesarean section on the management of the subsequent pregnancy. The case records of 331 women delivered by casearean section in their first pregnancy were reviewed. By standard radiological criteria, the pelvis was considered to be inadequate in 248 (75%) of them and adequate in 83 (25%). Of the women with a radio-logically inadequate pelvis, 172 underwent an elective caesarean section. Seventy-six were allowed vaginal delivery: 51 of these women delivered vaginally and 25 required an emergency caesarean section. Of the women with a radiologically adequate pelvis, 61 achieved a vaginal delivery and 22 were delivered by caesarean section. All of the three cases of uterine rupture occurred in women with a radiologically adequate pelvis. This study suggests that x-ray pelvimetry is not a good predictor of the outcome of a trial of vaginal delivery. We conclude that the practice of routine postnatal pelvimetry should be abandoned.     

The role of postnatal x-ray pelvimetry after caesarean section in the management of subsequent delivery

The purpose of this study was to investigate the influence of postnatal x-ray pelvimetry after caesarean section on the management of the subsequent pregnancy. The case records of 331 women delivered by casearean section in their first pregnancy were reviewed. By standard radiological criteria, the pelvis was considered to be inadequate in 248 (75%) of them and adequate in 83 (25%). Of the women with a radiologically inadequate pelvis, 172 underwent an elective caesarean section. Seventy-six were allowed vaginal delivery: 51 of these women delivered vaginally and 25 required an emergency caesarean section. Of the women with a radiologically adequate pelvis, 61 achieved a vaginal delivery and 22 were delivered by caesarean section. All of the three cases of uterine rupture occurred in women with a radiologically adequate pelvis. This study suggests that x-ray pelvimetry is not a good predictor of the outcome of a trial of vaginal delivery. We conclude that the practice of routine postnatal pelvimetry should be abandoned.     

Embolisation of uterine arteries or laparascopic uterine artery ligation as possible treatment of uterine leiomyoma

Background Many women with symptomatic uterine leiomyomata wish to preserve their uterus. Novel organ- and fertility-preserving treatment options such as embolisation of uterine arteries or laparascopic uterine artery ligation have frequently been discussed as viable alternatives to myomectomy. This article strives to bring together the conclusions of major studies on novel organ-preserving treatment alternatives for uterine myoma.Methods Minimally invasive organ-preserving laparascopic myomectomy remains the best treatment option for patients with symptomatic fibroids who wish to retain their uterus. However, in certain cases other options such as embolisation or laparascopic ligation of uterine arteries can serve as viable alternativesResults A failure rate of up to 39% and complications such as reduced fertility because of ovarian failure after transcatheter embolisation of uterine arteries might restrict the use of this method.Conclusions For postmenopausal women, transcatheter embolisation of uterine arteries is a possible treatment alternative. Laparascopic ligation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries might also be viable for young women who desire to preserve future fertility. Further data and studies on the long-term follow-up after ligation are yet to come.     

Fetal survival following posterior uterine wall rupture during labour with intact previous caesarean section scar

Introduction Posterior wall rupture of the uterus in presence of previous caesarean scar is an extremely rare and unpredictable event. Case report A 26-year old lady in her second pregnancy went into spontaneous labour at 41 weeks gestation. She had emergency caesarean section in her previous pregnancy. She made slow progress in labour to full dilatation without augmentation, but was noted to have fresh vaginal bleeding and breakthrough pain despite an epidural. Uterine scar rupture was suspected and an emergency lower segment caesarean section was carried out. Fresh intraperitoneal bleeding was noted but with an intact previous scar. The baby was delivered in good condition. A vertical posterior uterine wall rupture of the lower segment, 5 cm in length, was found to be bleeding profusely and was successfully repaired. Discussion Uterine rupture is a rare but serious complication. Usually the rupture occurs through the previous uterine scar. There are only four reported cases in the literature of posterior uterine rupture in labour through “healthy” uterine tissue in women with previous caesarean section. This is the first instance of fetal survival. The exact mechanism is unknown but likely to be a combination of factors including prostaglandin use, element of obstruction and strong inelastic scar. Conclusion Strict vigilance is required during labour in women with previous scar. Early recognition of imminent scar rupture should speed delivery and improve the outcome for mother and baby.     

Obstetric and perinatal outcome of women para > or = 5 including one lower segment cesarean section

OBJECTIVE: To study the prevalence of antenatal, intrapartum and postnatal complications and their perinatal outcome in women who are delivering for the 6th time and have also had one cesarean section. METHODS: The records of all women para > or = 5 with one previous cesarean section (n = 238) delivered at King Fahd Hospital of the University between the January 1 1994 and December 31 2000 were reviewed and compared with women who delivered at the hospital in the year 2000 (n = 2470). This data was analyzed for the peripartum and perinatal outcome. RESULTS: The incidence of malpresentation was higher in the study group. The incidence of uterine rupture and uterine scar dehiscence was significantly higher in the study group, but there was no perinatal or maternal death associated with this and in all cases the uterus was preserved. More women managed to deliver vaginally after the cesarean section in the grandmultiparous women compared with the women in the control group (81.5% vs 63.0%) P < 0.00006, where the cesarean section rate was significantly higher (P < 0.02). There were no significant differences in the incidences of preterm labor, lethal malformations, stillbirths and neonatal deaths in the two groups of women. There was one case of cesarean hysterectomy in each group due to placenta accreta and atonic postpartum hemorrhage, and one maternal death in the control group. CONCLUSION: Grandmultiparous women with one previous cesarean section have an increased risk of operative delivery, scar dehiscence, but there is no increase in perinatal or maternal mortality.     

Unique case of successful twin pregnancy after spontaneous conception in a patient with uterus bicornis unicollis

Introduction Abnormal fusion of the mullerian ducts or failure of absorption of the septum causes varying degrees of congenital uterine malformation. Twin gestation in a case of bicornuate uterus is extremely rare. We are reporting this case because of its extremely rare presentation, where twins have managed to reach term after spontaneous conception. Case report A 28-year-old second gravida, para one was initially diagnosed to have diamniotic dichorionic twins on ultrasound. At term, she was referred to us with severe pre-eclamptic toxaemia. On examination, she was found to have a bicornuate uterus with one fetus in each horn. Both siblings were successfully delivered by caesarean section. So far, only one similar case has been reported following in vitro fertilisation. Conclusion Although poor reproductive performance has been documented in previous reports of bicornuate uterus with twin gestation, our patient managed to reach term with delivery of healthy siblings by caesarean section.     

Uterine rupture and subsequent pregnancy outcome – how safe is it? A 25-year study

Objectives.?(a) To review the cases of ruptured uterus over the last 25 years and analyze the causative factors with a view to its prevention (b) To analyze subsequent pregnancy outcome with a view to its safety.

Method.?The case notes were reviewed for all patients with ruptured uterus over a period of 25 years from January 1982 to January 2007. Relevant dates relating to the characteristics of labor, delivery, maternal, perinatal, and subsequent pregnancy outcomes were assessed.

Results.?The incidence of ruptured uteri was calculated to be 0.03%. Total deliveries included in the study were 152,426. There were 46 cases of ruptured uteri and 44 were available for study. Twenty-two (52%) ruptured uteri occurred in patients with previous caesarean scars, of which 10 occurred in women with previous four or more caesarean sections. In 12 cases (27%), uterine rupture occurred due to oxytocin; PGE2 and oxytocin were used in 3 of these 12 cases. Two (4.5%) ruptures occurred due to non-removal of cervical cerclage during labor. Two (4.5%) primigravidae ruptured their uterus following road traffic accident, resulting in maternal and fetal deaths. Malpresentation in labor resulted in eight (18%) ruptures. Rupture occurred at the fundus in 10 cases and in the lower segment in the remaining 34. Fetal heart abnormalities were observed in all cases in which the uterus ruptured during labor. Abdominal hysterectomy was performed in 20 cases (45%) of which 13 were subtotal and 7 (10%) were total. Of the remaining 24 (55%) patients, 10 had suture repair and in addition 14 patients underwent hypogastric artery ligation. Later, 22/24 (92%) women became pregnant. Twenty (91%) were delivered by planned caesarean section. There were no maternal or fetal complications. The remaining two women had previous classical scar, undetected malpresentation, and sparse antenatal care. Their uteri ruptured spontaneously at 32 and 35 weeks at home. They died intra-operatively due to intractable hemorrhage along with their fetus.

Conclusion.?In the previous caesarean section, the indiscriminate use of oxytocin and malpresentation are the risk factors for uterine rupture. Child birth after uterine rupture is not to be recommended routinely. Most women with a previous uterine rupture with meticulous tertiary level antenatal care had a favorable outcome in subsequent pregnancies.     

Results of mostly vaginal deliveries of breech presentation

This report presents results of a retrospective study of infants delivered by the breech, which were according the attitude of this hospital mainly delivered vaginally. This mode of delivery was chosen for primiparae as well as for multiparae and independent of the fetal size measured by ultrasound. Indication for primary caesarean section was seen in only 45 cases out of 568 infants in breech situation. In most of these cases additional indications so as bleedings, placental insufficiency etc, were responsible for the decision of primary caesarean section. Breech presentations are associated to specialties during pregnancy and labour although being more often not related to breech presentation of the fetus as this study shows. Difficulties of spontaneous breech delivered infants were seen rarely. Within the reported cases were 5 of elevated arms, 2 with difficulties in developing the arms and 3 with difficulties in developing the after coming head. Indication for secondary caesarean section were mainly caused by standstill within delivery because of relative disproportion, imminent intrauterine hypoxia and cord prolapse being more often associated to breech presentation. Most important for the possibility of spontaneous breech delivery is the coming deeper of breech during expulsive period. The well known fact of increased number of congenital malformations and anomalies associated to breech presentation were also described in this study. The comparison of the Apgar scores of infants being delivered vaginally or by caesarean section did not show any negative influence of the vaginal mode. This results are independent of different birth weight groups. Therefore there is no evidence to support the recommendation to increase caesarean section rate. Cases of neonatal death--only 13 out of 568 breech infants are discussed casuistically. As a conclusion the authors are confirmed in their conservative attitude and they think the endeavour of spontaneous delivery of breech presentation is justified in all cases unless there are additional indications for caesarean section.     

2 cases of symmetrical double abnormality

Two cases of symmetric incomplete two-headed four-handed conjoined twins who were delivered in the 37th and the 32nd gestational week have been demonstrated. The first case was delivered by caesarean section and the other one was delivered by forceps. These malformations are very seldom. Questions about teratogenicity and diagnosis are discussed.