Advanced abdominal pregnancy: a search for consensus. Review of literature along with case report

Introduction

Intentional placental removal for abnormally invasive placenta (AIP) is fundamentally abandoned at planned surgery for it. Whether this holds true even after recent introduction of various hemostatic procedures is unclear.

Materials and Methods

We discussed on this issue based on our own experiences and also on the recent reports on various hemostatic procedures.

Results

Studies directly answering this question have been lacking. We must weigh the balance between the massive bleeding and possibility of uterus-preservation when intentional placental removal strategy is employed.

Conclusion

An almost forgotten strategy, the “intentional placental removal” for planned AIP surgery may regain its position when appropriate hemostatic procedures are concomitantly used depending on the situation. Even employing this strategy, quick decision to perform hysterectomy under multidisciplinary team may be important.

     

Myomectomy using purse-string suture during cesarean section

Background

Conventionally, myomectomy during cesarean section is reserved only for pedunculated myomas because resection of myomas at the time of cesarean section usually stimulates profuse bleeding.

Cases

Thirty-one patients underwent myomectomy using purse-string suture during cesarean section. Myoma could be excised without profuse bleeding, while an assistant maintains strong tension on the purse-string suture around the myoma. The suture was tightened and tied immediately after complete resection of the myoma and then stitches of another purse-string suture were placed alternately with each previous stitch in the inner side of the first suture. We have used this method for more than 3 years and have not observed failures and serious complications, such as late hemorrhage and uterine rupture during a subsequent pregnancy.

Conclusion

Myomectomy using purse-string suture during cesarean section is a safe, useful, and convenient technique.

     

Intrauterine Inflated Foley’s Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case–Control Study

Objective

To describe the use of intrauterine inflated Foley’s catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus.

Methods

Retrospective case–control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley’s catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38).

Results

Use of intrauterine inflated Foley’s catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit.

Conclusion

Application of an intrauterine inflated Foley’s catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

     

A PET-positive rapidly growing mass of the abdominal wall after cesarean section with an unexpected diagnosis of vernix caseosa granuloma: a case report

Background

Abdominal wall tumors are rare and include heterogeneous diseases. Among them, desmoid tumors are the most frequent and are often diagnosed in young women during or early after pregnancy; inflammatory response after trauma or microtrauma, such as after cesarean section, may favor their growth.

Results

A 37-year-old woman presented with a progressive mass in the abdominal wall after a cesarean section. Positron emission tomography imaging confirmed a positive mass with a high maximum standardized uptake value; a biopsy suggested a myofibroblastic tumor. With continued tumor growth and worsening symptoms, the mass resembled a desmoid tumor; therefore, we proceed with its resection. The final diagnosis was foreign body granuloma as a reaction to the spillage of meconium and keratinous material in the amniotic fluid during cesarean section.

Conclusions

The present case provides information on an abdominal wall foreign body granuloma arisen from meconium and vernix caseosa after cesarean section, which presented an atypical clinical picture, mimicking a desmoid, thus requiring a careful diagnostic and treatment approach.

     

Management of cesarean scar pregnancy with suction curettage: a report of four cases and review of the literature

Purpose

To present the outcomes of four cases of cesarean scar pregnancy treated with suction curettage.

Methods

Four patients were ultrasonographically diagnosed with cesarean scar pregnancies treated with suction curettage in a tertiary care center.

Results

Serum β-human chorionic gonadotropin levels ranged between 1,681 and 15,573 mU/mL, gestational sac diameter measured from 10 to 24 mm and scar thickness was between 4.7 and 6.8 mm. All patients underwent suction curettage under general anesthesia with transabdominal ultrasonography guidance. No complications were observed during or after operation.

Conclusion

Suction curettage is a viable alternative for conservative treatment in selected cases of patients who are diagnosed with CSP early in gestation and who have a myometrial thickness of more than 4.5 mm.

     

The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy

Purpose

To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure.

Methods

A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary’s Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups.

Results

A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate.

Conclusion

Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.

     

Cholecystectomy and Hysterectomy: A Least Invasive Approach

Objective

The study is to promote the least invasive approach that combines cholecystectomy and hysterectomy at the same operative sitting so as to provide maximum benefits to women.

Method

A series of 45 women between 40 and 75 years age from year 2001 to 2014 from the private practice of author and colleague surgeons in Mumbai were in need of hysterectomy as well as cholecystectomy for gynecological indication and symptomatic gallstones, respectively. Cholecystectomy was performed laparoscopically by general surgeon and was combined with hysterectomy with or without bilateral salpingo-oophorectomy (BSO) via vaginal route by gynecologist.

Result

The average surgical time was 40 min for laparoscopic cholecystectomy and 32 min for hysterectomy and 40 min for hysterectomy with bilateral salpingo-oophorectomy to 64 min when uteri needed heavy debulking. Total blood loss was approximately less than 50–100 ml for hysterectomy and up to 250 ml for hysterectomy needing fair amount of debulking. Blood loss for laparoscopic cholecystectomy was 10 ml to maximum of 80 ml.

Conclusion

Lesson for both, gynecologists and the surgeons, is to combine these two when required and possible. This provides maximum advantages through minimizing risk of anesthesia and time duration, hospital stay, cost-effectiveness.

     

Sirenomelia: a review on embryogenic enviromental theories,novel three-dimensional ultrasound imaging and first trimester diagnosis in a case of mosaic 69,XXX/46,XX fetus

Purpose

Sirenomelia is caused by atrophy of the lower extremities that is commonly associated with gastrointestinal and urogenital malformations.

Methods

Embryogenic environmental theories and systematic review of the literature are reported.

Results

Genetic basis of the condition has been demonstrated in the animal model. In humans, association with de novo balanced translocation has only recently been documented.

Conclusions

A case of triploidy mosaic fetus with sirenomelia and posterior fossa anomaly diagnosed at first trimester using novel three-dimensional ultrasound imaging techniques is presented.

     

Laparoscopic transvesical repair of recurrent vesicovaginal fistula using with fleece-bound sealing system

Background

Vesicovaginal fistula (VVF) is an epithelium-lined communication between the urinary bladder and vagina. Most of VVFs are repaired by conventional open surgery. Laparoscopic repair of VVFs is rare and so far no report is available about laparoscopic repair of persistent VVF using fleece-bound sealing system as a tissue barrier in the literature. Here we describe the operative technique and briefly review the literature.

Case

We present the case of a 37-year-old woman with recurring VVF in two times after abdominal and transvaginal repairs caused by a massive bleeding during caesarian-section due to placenta previa and underwent hysterectomy. During the laparoscopic repair of the fistula and excision of the vaginal cuff, fleece-bound sealing system (TachoSil^®) was used as tissue barrier. Laparoscopic transperitoneal transvesical repair was successfully performed by suturing the defects and fixing two TachoSil between the bladder and vagina. The postoperative period of the patient was uneventful and after a follow up of 6 months no recurrence was found.

Conclusion

We believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally invasive approach for the management of this entity. Whilst proper identification of tissue planes and good laparoscopic suturing technique are required, using fleece-bound sealing system might be convenient especially for persistent VVF.

     

Deciding the Route for Hysterectomy: Indian Triage System

Objectives

To review the limitations, major complications, and conversion rates associated with non-descent vaginal hysterectomy (NDVH); and develop a scoring system to predict the possibility of successful NDVH.

Methods

The risk analysis of conversion rates from vaginal to abdominal route while attempting NDVH was applied to formulate a scoring system for the assessment of successful NDVH. Parameters were selected based on Kovacs guidelines to determine the route of hysterectomy.

Results

From April 2005 to December 2008, NDVH was attempted in 364/1,378 women undergoing hysterectomy for benign conditions (Gp-I). Eight out of 364 cases (2.1 %) either had to be converted to the abdominal route or had major complication. Endometriosis and repeated sections had the highest risk. Scoring system was developed based on the risk analysis. Validity of this scoring system was tested in 1,177 women from January 2009 to September 2012 (Gp-II). 460 women with a score of 16 or less underwent NDVH successfully with a conversion rate of 0.2 %.

Conclusion

Careful assessment by a simple scoring system can help in deciding the feasibility of performing NDVH.

     

Hysterectomy technique and risk of pelvic organ prolapse repair: a Danish nationwide cohort study

Purpose

The purpose was to investigate, in a large cohort, how hysterectomy technique influences the incidence of subsequent pelvic organ prolapse (POP) repair among women hysterectomized for benign conditions.

Methods

From the Danish National Patient Registry, we collected data on all hysterectomies on benign indications, and all POP operations performed in Denmark from January 1, 1977 to June 10, 2016. We excluded patients with prior POP repair. We analyzed the incidence of POP surgery by cumulative incidence curves and hazard ratio (HR) for women with and without POP diagnoses or concomitant POP repair at hysterectomy.

Results

In all, 178,282 women underwent hysterectomy in the study period and were included in the cohort. When examining the crude HR for the risk of POP repair after hysterectomy, vaginal hysterectomy (VH) had a threefold rise in HR compared to total abdominal hysterectomy (TAH). When restricting the analyses to women without POP at time of hysterectomy, the HR for VH decreased to 1.25. The same tendency was noticed when stratifying by compartment. In the subgroup of women without POP at hysterectomy, we found that supravaginal abdominal hysterectomy had a small increase in risk compared to TAH. Laparoscopic hysterectomy had the same risk of POP as TAH.

Conclusions

Overall, we found only small differences in risk of POP repair between the different hysterectomy techniques after restricting the analyses to women without POP at hysterectomy.

     

Surgery in adenomyosis

Introduction

Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium. The true prevalence is unknown and has been reported to range from 1 to 70%. It has a significantly negative impact on women’s quality of life, causing abnormal uterine bleeding, dysmenorrhea, and chronic pelvic pain. The definitive treatment for adenomyosis is hysterectomy, although it does not contemplate patients who wish to preserve their fertility. The aim of this paper is to discuss the latest evidence on the surgical techniques for the treatment of adenomyosis published in medical–scientific databases.

Method

A comprehensive literature search for articles published from 1996 to 2017 related to surgery for adenomyosis was made in Pubmed, Medline, the Cochrane Library, and Google Scholar, in English, by the following MeSH terms: adenomyosis, surgery, pathogenesis, dysmenorrhea and infertility.

Results

There is extensive evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

Conclusion

The management of adenomyosis is quite complex and controversial. Complications after extensive uterine reconstruction, such as uterine rupture, should be considered and discussed with the patient. There are still limited data to support surgery effectiveness, especially for infertility, and further well-designed studies are required.

     

Effect of routine rapid insertion of Bakri balloon tamponade on reducing hemorrhage from placenta previa during and after cesarean section

Purpose

To evaluate the effectiveness of routine rapid insertion of a Bakri balloon during cesarean section for placenta previa based on a retrospective control study.

Methods

Women with singleton pregnancies who underwent cesarean section for placenta previa at our institution between 2003 and 2016 were enrolled. Between 2015 and 2016, women who routinely underwent balloon tamponade during cesarean section were defined as the balloon group. Between 2003 and 2014, women who underwent no hemostatic procedures except balloon tamponade were defined as the non-balloon group. The clinical outcomes of the two groups were retrospectively analyzed.

Results

Of the 266 women with placenta previa, 50 were in the balloon group and 216 were in the non-balloon group. The bleeding amounts were significantly smaller in the balloon group than in the non-balloon group: intraoperative bleeding (991 vs. 1250 g, p < 0.01), postoperative bleeding (62 vs. 150 g, p < 0.01), and total bleeding (1066 vs. 1451 g, p < 0.01). Furthermore, the mean surgical duration was shorter in the balloon group than the non-balloon group (30 vs. 50 min, p < 0.01). In the balloon group, five patients suffered from increasing hemorrhage due to prolapse of the balloon from the uterus after the operation, but the hemorrhage was controlled by balloon re-insertion without additional hemostatic procedures.

Conclusions

This study demonstrated that the routine rapid insertion of Bakri balloon tamponade during cesarean section significantly decreased intra- and postoperative hemorrhage and shortened the surgical duration in women with placenta previa.

     

Oligoamnios and Perinatal Outcome

Objective(s)

We aimed at evaluating the predictive value of amniotic fluid index ≤5 on perinatal outcome in terms of effect on cardiotocography, mode of delivery, meconium in liquor, birth weight, fetal distress, APGAR score at birth and neonatal admission to ICU.

Method(s)

This is a prospective study of 308 antenatal women admitted to labor ward of MIMS during February 2014–December 2015 with gestational ages between 34 and 41 weeks. All women enrolled were subjected to history taking, examination, AFI estimation and compared between those with AFI ≤5 from rest.

Results

The non-reactive CTG, cesarean section rate due to fetal distress, low birth weight, APGAR score <7 and NICU admission were significantly high among those with oligoamnios than the control group.

Conclusion

Oligoamnios has a significant correlation with adverse perinatal outcome.

     

Placenta previa and placental abruption after assisted reproductive technology in patients with endometriosis: a systematic review and meta-analysis

Background/aims

The self-quantification of patients is extending beyond the daily routine. More and more patients ask about the ‘optimal’ physical condition for an elective surgery. As the hysterectomy is one of the most common surgeries, a literature review was conducted to answer the question for the optimal surgical self preparation (prehabilitation).

Methods

A literature review with the search terms ‘physical activity’ or ‘physical exercise’ or ‘sport’ or ‘prehabilitation’ and ‘hysterectomy’ was conducted in the National Library of Medicine database (PubMed) and Web of science. The search was limited to English or German language and publishing date after 2000. Two independent researchers (SO, FE) reviewed the results and excluded irrelevant or double articles.

Results

After excluding irrelevant articles, five publications were left for review. One article published a study protocol and one a case report. Three articles reported study results. The numbers of patients reported are low. Prehabilitation programs differ depending on the primary study outcome. There seems to be a benefit for earlier discharge if patients undergo prehabilitation.

Conclusion

Unlike other disciplines where prehabilitation has been studied, a gynecologic viewpoint still needs establishing and further studies are needed to clarify the benefit for the patients.

     

Endometrial Ablation—Current Evidence for Patient Optimization and Long-Term Outcomes

Purpose of Review

Endometrial ablation is a minimally invasive surgical option to treat abnormal uterine bleeding. Here, we summarize the evidence regarding patient optimization prior to endometrial ablation and the long-term outcomes of this procedure. Patient optimization includes preoperative planning, patient selection, and preoperative predictors of postoperative failure. Long-term outcomes include postoperative bleeding patterns, frequency of additional procedures for treatment failure, patient satisfaction, risk of endometrial cancer, and pregnancy outcomes.

Recent Findings

Endometrial ablation is a safe procedure to treat abnormal uterine bleeding in high- and low-risk surgical patients. A prior low transverse cesarean section is not a contraindication to the procedure. Young age at ablation (less than 30–45 years of age) is the most significant risk factor for treatment failure. Preoperative dysmenorrhea, large uterine size, fibroids, and prior tubal ligation may also be risk factors for failure. Reduction in menstrual bleeding and patient satisfaction achieved at 12 months usually persist for 5–10 years. There is a 17–25% risk of subsequent hysterectomy that usually occurs within the first 5 years. Endometrial ablation does not appear to increase the risk for developing endometrial cancer. Lastly, outcomes of post-ablation pregnancy are poor, and preoperative counseling should include a discussion about reliable post-ablation contraception.

Summary

Endometrial ablation can effectively reduce menstrual blood loss and improve patient satisfaction with effects sustained for years after the procedure and is appropriate to use in high-risk surgical candidates. Younger women should be counseled preoperatively about the risk of treatment failure and need for additional procedures in the future.

     

Use of Condom Tamponade to Manage Massive Obstetric Hemorrhage at a Tertiary Center in Rajasthan

Introduction

Conventionally postpartum hemorrhage (PPH) has been defined as blood loss of more than 500 ml following vaginal delivery and 1000 ml following a cesarean section [Pritchard et al. in Am J Obstet Gynecol 84(10):1271–1282, (1962)]. Another definition labels PPH as any blood loss which causes a 10 % drop in hematocrit [Combs et al. in Obstet Gynecol 77:69–76, (1991)] or which threatens the hemodynamic stability of the patient and necessitates blood transfusion [Prendiville et al. in Cochrane Database Syst Rev 2:CD000007, (2000)]. The purpose of this study was to evaluate the effectiveness of condom tamponade in the management of massive obstetric hemorrhage.

Objective

To evaluate the efficacy of a condom as a tamponade for intrauterine pressure to stop massive PPH.

Methods

This prospective study was done in the Obstetrics and Gynecology Department of NIMS Medical College and Hospital, Jaipur, between December 2013 and February 2015. With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250–500 ml normal saline according to need. Vaginal bleeding was observed, and further inflation was stopped when bleeding ceased.

Results

In all but 2 (94.44 %) the cases, postpartum bleeding was stopped within 10 min of creation of tamponade. On an average, 350 ml of normal saline was required to create adequate tamponade to stop the bleeding.

Conclusion

Use of condom tamponade can effectively help in reducing both maternal morbidity and mortality associated with PPH. Our study encourages use of condom tamponade which is efficient, cost-effective, easily available and requires lesser skills as compared to the traditional surgical procedures.

     

Predicting Successful Trial of Labor After Cesarean Delivery: Evaluation of Two Scoring Systems

Background

Attempting vaginal birth after cesarean section (VBAC) places women at an increased risk of complications. Trial of labor after cesarean (TOLAC) calculators aim to predict the chance of successful vaginal birth after cesarean (VBAC) based on the patient’s preexisting demographic and clinical factors.

Objective

To assess the rate of successful TOLAC using two calculators: FLAMM and the Grobman calculator, and to compare the performance of the two calculators in the successful prediction of VBAC.

Methods

Prospective cohort study in subjects with previous one caesarean section using well-defined inclusion and exclusion criteria.

Results

A total of 280 subjects with previous one cesarean section were enrolled. One hundred thirty-nine subjects consented for TOLAC, 90 (67%) underwent successful trial of vaginal birth, and 49 (32.8) required cesarean section. Cervical dilatation (p < 0.0001) and effacement (p < 0.0001), and any prior vaginal delivery (p < 0.02) were significantly associated with a successful outcome. At a cutoff score of 5, the sensitivity of the FLAMM score was 72% and specificity was 76%. For the Grobman calculator, the best sensitivity (69%) and specificity (67%) were seen at a cutoff score of 85%.

Conclusion

Both prediction models, the FLAMM and the “close to delivery” nomogram, recommended by Grobman et al. are easy to use and could successfully estimate the chances of vaginal birth in previous caesarean, in this small cohort. The decision for women opting for TOLAC can be individualized, and patient-specific chances of success can be predicted by the use of these prediction models.

     

A dose–response relation exists between different classes of pre-gravid obesity and selected perinatal outcomes

Objective

To examine if a “dose–response” relation exists between different classes of pre-gravid obesity and selected perinatal outcomes.

Methods

We evaluated 16,566 obese mothers, including 12,064 (72.8%), 3410 (20.6%), and 1092 (6.6%) with obesity class I, II, and III, respectively. We compared maternal age, primiparity, gestational age at birth, birth weight, GDM, hypertensive disorders, and the incidence of cesarean sections.

Results

There was a significantly increased incidence (from class I to class III) for GDM (8.5–14.4%), chronic hypertension (2.8–9.0%), gestational hypertension (6.7–14.2%), and for preeclampsia (5.3–9.3%). No such relationship existed for birth weight and gestational duration.

Conclusion

Classes of obesity during pregnancy exhibit a “dose–response” relationship with maternal morbidity, but no such relationship was found with pregnancy duration and birth weight.

     

A long-standing incomprehensible matter of obstetrics: meconium-stained amniotic fluid,a new approach to reason

Objective

We sought to determine whether meconium-stained amniotic fluid is based on chronic hypoxia or not? In case of chronic hypoxia, higher red blood cell (Rbc) count and/or total hemoglobin levels (Hgb) and/or higher fetal hemoglobin (HbF) and/or lower adult hemoglobin (HbA) levels were expected when compared with controls.

Design

Case–control study.

Setting

Obstetric unit of a tertiary ministry of health hospital.

Sample

Fifty singleton pregnancies with meconium-stained amniotic fluid and 50 singleton pregnancies with clear amniotic fluid at all stages of labor.

Methods

Umbilical cord blood samples were collected for determination of total blood parameters and hemoglobin electrophoresis.

Main outcome measures

Red blood cell count, total hemoglobin, fetal and adult hemoglobin contents (HbF and HbA).

Results

Red blood cell count, total hemoglobin, fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents were not different between meconium stained and clear amniotic fluid groups.

Conclusion

These results suggest that meconium passage may not be associated with chronic fetal hypoxia as demonstrated by similar red blood cell count, total hemoglobin values and fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents.