Inversión uterina puerperal

Introduction

Uterine inversion is a rare obstetric emergency that occurs during the third stage of labor

Objective

To describe the clinical, diagnostic and therapeutic characteristics and outcomes in patients with uterine inversion.

Material and methods

We performed a retrospective study of six patients with uterine inversion during the puerperium in the Hospital de Leon (Spain) in 2005.

Results

All inversions occurred in primiparous women with epidural anesthesia and instrumental delivery at term. Oxytocin was used in 83% during dilatation; the average duration of which was 6.5 hours. Diagnosis was mainly clinical except in one grade II inversion, which required ultrasonography and was resolved surgically. The remaining cases were resolved through manual reduction (83%). After the episode, hemoglobin levels were reduced by an average of 2.7 g/dl from prepartum levels, and only two patients required blood transfusion.

Conclusions

Factors predisposing to uterine inversion were hypotonic uterus, fundal implantation of the placenta, and placenta accreta. Sixty percent of all cases were caused by precipitous maneuvers including traction on the cord or improper fundal pressure. Diagnosis is essentially clinical. Although uncommon, uterine inversion will result in severe hemorrhage and shock if left unrecognized, leading to maternal death. Once a diagnosis is made, immediate measures must be taken to stabilize the mother. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as ritrodine, magnesium sulphate and terbutaline, or halogenated anesthetics may be administered to relax the uterus and aid its reversal. Intravenous nitroglycerin is an alternative to tocolytics. Failure of reversion or recurrence requires surgical treatment.     

Velocimetría Doppler del flujo sanguíneo de la arteria uterina y riesgo de muerte perinatal en preeclámpsicas

Objective

To determine the association between Doppler velocimetry values of uterine artery blood flow with the risk of perinatal death in preeclamptic patients.

Materials and method

We selected 80 patients with a diagnosis of preeclampsia. Preeclamptic patients were divided into those with perinatal deaths and those without. The variables analyzed were the pulsatility index, the resistance index, and the systolic/diastolic flow ratio of the uterine arteries.

Results

There were no differences in maternal age, height or weight between preeclamptic patients with or without perinatal deaths (p = ns), or between gestational age at the time of Doppler ultrasound and systolic and diastolic blood pressure (p = ns). The pulsatility index (1.206 ± 0.140) and resistance index (0.684 ± 0.098) of the uterine arteries were significantly higher in women with perinatal deaths than in those without (1.113 ± 0.109 and 0.605 ± 0.116, respectively; P<.05). No significant differences were found in mean values of the systolic/diastolic flow ratio of the uterine arteries (p = ns).

Conclusion

A high value of the pulsatility index and resistance index of the uterine arteries on Doppler velocimetry in preeclamptic patients is associated with an increased risk of perinatal death.     

Estudio retrospectivo de la hemorragia uterina excesiva en la adolescencia

Introduction

The main objective of this study was to review the casuistics of adolescent women who consulted the Unidad de Ginecología de la Adolescencia del Institut Universitari Dexeus in Barcelona, Spain, for heavy uterine bleeding, as well as their treatments and outcomes.

Material and methods

We performed a retrospective study of 178 adolescents treated between January 2005 and December 2009.

Results

The severity of uterine bleeding was classified according to hemoglobin levels as mild (53.4%), moderate (11.2%) and severe (2.2%). Symptoms improved in 43% of the patients treated with iron therapy, 48% of those treated with non-steroidal anti-inflammatory drugs, 55% of patients who received antifibrinolytic agents, 59% of those treated with progestogens, 54% of patients who received estro-progestogens and 56% of those who received combined hormonal contraceptives.

Conclusion

Heavy uterine bleeding is a common gynecological condition in adolescence, whose management and therapeutic measures are easy to apply.     

Transabdominal uterine arteries Doppler at 12–14th and 20–24th week of gestation and pregnancy outcome: A prospective study

Objective

To identify women at actual risk of pre-eclampsia and poor pregnancy outcome in a selected group of high risk patients.

Study design

Prospective study of women with previous pre-eclampsia and/or intra uterine growth retardation, intra uterine death (≥20th week), chronic hypertension, three or more previous spontaneous abortions. All subjects were followed-up till pregnancy outcome. Gestational week at delivery and birth weight were recorded. Other outcome measures were: intra uterine growth retardation, pregnancy-induced hypertension, pre-eclampsia, abruptio placenta, admission in neonatal intensive care unit.

Results

139 patients were enrolled and followed-up until the end of pregnancy. Abnormal Doppler results at 12–14th week examination were associated with intra uterine growth retardation, fetal death/spontaneous abortion and small for gestational age birth.

Conclusions

This study indicates that early evaluation of arterial uterine RI and presence of notches may be predictive of low birth weight and intra uterine growth retardation in a high risk population.     

Maternal infection rates after cesarean delivery by Pfannenstiel or Joel–Cohen incision: A multicenter surveillance study

Objective

Our purpose was to evaluate maternal nosocomial infection rates according to the incision technique used for caesarean delivery, in a routine surveillance study.

Study design

This was a prospective study of 5123 cesarean deliveries (43.2% Joel–Cohen, 56.8% Pfannenstiel incisions) in 35 maternity units (Mater Sud Est network). Data on routine surveillance variables, operative duration, and three additional variables (manual removal of the placenta, uterine exteriorization, and/or cleaning of the parieto-colic gutter) were collected. Multiple logistic regression analysis was used to identify independent risk factors for infection.

Results

The overall nosocomial infection and endometritis rates were higher for the Joel–Cohen than Pfannenstiel incision (4.5% vs. 3.3%, 0.8% vs. 0.3%, respectively). The higher rate of nosocomial infections with the Joel–Cohen incision was due to a greater proportion of patients presenting risk factors (i.e., emergency delivery, primary cesarean, blood loss ≥800 mL, no manual removal of the placenta and no uterine exteriorization). However, the Joel–Cohen technique was an independent risk factor for endometritis.

Conclusion

The Joel–Cohen technique is faster than the Pfannenstiel technique but is associated with a higher incidence of endometritis.     

Outcomes of subsequent pregnancies after conservative treatment for placenta accreta

Objective

To estimate the association between conservative treatment for placenta accreta and subsequent pregnancy outcomes.

Methods

In a retrospective study, data were analyzed on women who received conservative treatment for placenta accreta (removal of the placenta with uterine preservation) at a tertiary hospital in Jerusalem, Israel, between 1990 and 2000. Data were collected on subsequent pregnancies and neonatal outcomes until 2010, and compared with those from a matched control group of women who did not have placenta accreta.

Results

A total of 134 women were included in both groups. Placenta accreta occurred in 62 (22.8%) of 272 subsequent deliveries in the study group for which data were available and 5 (1.9%) of 266 in the control group (relative risk [RR] 12.13; 95% confidence interval [CI] 4.95–29.69; P < 0.001). Early postpartum hemorrhage occurred in 23 (8.6%) of 268 deliveries in the study group and 7 (2.6%) of 268 in the control group (RR 3.29; 95% CI 1.43–7.53; P < 0.001). The odds ratio for recurrent placenta accreta in subsequent deliveries in the study group was 15.41 (95% CI 6.09–39.03; P < 0.001).

Conclusion

Although subsequent pregnancies after conservative treatment for placenta accreta were mostly successful, the risk of recurrent placenta accreta and postpartum hemorrhage is high in future deliveries.     

Rotura uterina tras parto vaginal con distocia de hombros

Objective

To describe a case uterine rupture after vaginal delivery associated with shoulder dystocia. This case is of interest due to the seriousness and low incidence of this event.

Subjects and methods

Risk factors for uterine rupture and its typical symptoms were analyzed.

Result

We present the differential diagnosis to be performed when postpartum course is poor, as well as the complementary tests and the procedure to be carried out.

Conclusions

We emphasize the importance of including uterine rupture in the differential diagnosis after a dystocic delivery. Early diagnosis is essential since uterine rupture is a potentially catastrophic event and is one of the most important causes of maternal mortality.     

Conservative versus radical management in cases of placenta accreta: a historical study

Objective

To compare the impact of conservative and radical strategies for placenta accreta on maternal morbidity and mortality.

Methods

We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta admitted to our tertiary center from January 1993 through October 2005. Two consecutive periods, A and B, were compared: during period A (january 1993 to June 1997), our written protocol called for the systematic manual removal of the placenta, to leave the uterine cavity empty. In period B (July 1997 to October 2005), we changed our policy and attempted to treat patients with a placenta accreta conservatively. The following outcomes over the two periods were compared: need for blood product transfusion, hysterectomy, intensive care admission, duration of stay in intensive care unit, sepsis and disseminated intravascular coagulation.

Results

Fifty-one cases of placenta accreta were observed among 40 281 deliveries (1.3/1000). Period B saw a reduction in the hysterectomy rate (11/13 versus 10/38; P < 0.01), the mean red blood cells transfused (3230 ± 2170 versus 1081 ± 1370 ml; P < 0.01) and disseminated intravascular coagulation (5/13 versus 1/38; P < 0.01) compared with period A. Seven cases of maternal infection were recorded during period B and none during period A (p = 0.22).

Conclusion

Conservative management of placenta accreta appears to be a safe alternative to radical management.     

Evaluation of healthcare professionals’ understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision

Objective

To evaluate whether eponymous maneuvers and mnemonics taught for the management of shoulder dystocia, vaginal breech delivery, and uterine inversion were remembered and understood in practice.

Methods

A questionnaire was distributed to obstetricians and midwives collecting information about the HELPERR and PALE SISTER mnemonics. Three extended matching questions evaluated participants’ knowledge of the correct maneuvers, with their matching eponyms, used in the management of shoulder dystocia, vaginal breech delivery, and uterine inversion.

Results

Of the 112 participants, 90% were familiar with the HELPERR mnemonic, with 79% using it in their practice. Of those who used it, only 32% could correctly decipher it (P = 0.032). PALE SISTER was mostly unfamiliar. The percentages of correct maneuvers used for managing shoulder dystocia, breech delivery, and uterine inversion were 84.6%, 58.3%, and 28.6%, respectively. However, the eponyms were correctly matched to their maneuvers in only 33.3%, 14.3%, and 0% of cases, respectively (P < 0.01).

Conclusion

The meanings of the mnemonics for obstetric emergencies were frequently recalled incorrectly. This, together with the poor correlation between knowledge of maneuvers and their eponyms, limits their usefulness and indicates that teaching should focus on learning without relying on mnemonics and eponyms.     

The consequences of previous uterine scar dehiscence and cesarean delivery on subsequent births

Objective

To determine whether women with a previous uterine scar dehiscence are at increased risk of adverse perinatal outcomes in the following delivery.

Methods

A retrospective cohort study was conducted of all subsequent singleton cesarean deliveries performed at the Soroka University Medical Center, Beer-Sheva, Israel, between January 1, 1988, and December 31, 2011. Clinical and demographic characteristics, maternal obstetric complications, and fetal complications were evaluated among women with or without a previous documented uterine scar dehiscence.

Results

Of the 5635 pregnancies associated with at least two previous cesarean deliveries, 180 (3.2%) occurred among women with a previous uterine scar dehiscence. Women with this condition in a prior pregnancy were more likely than those without previous uterine scar dehiscence to experience subsequent preterm delivery (86 [47.8%] vs 1350 [24.7%]; P < 0.001), low birth weight (47 [26.1%] vs 861 [15.8%]; P < 0.001), and peripartum hysterectomy (5 [2.8%] vs 20 [0.4%]; P < 0.001). Nevertheless, previous uterine scar dehiscence did not increase the risk of uterine rupture, placenta accreta, or adverse perinatal outcomes, such as low Apgar scores at 5 minutes and perinatal mortality.

Conclusion

Uterine scar dehiscence in a previous pregnancy is a potential risk factor for preterm delivery, low birth weight, and peripartum hysterectomy in the following pregnancy.     

On what scale does it benefit the patients if uterine arteries were preserved during ART?

Objective

To guarantee a better perfusion, the preservation of the uterine arteries during ART has sometimes been performed but has seldom been tested. We share the results of our tests to provoke a potentially different point of view on such uses of ART.

Methods

Using computed tomography angiography (CTA), we identified the uterine blood supply in patients who underwent ART with uterine artery preserved and sacrificed.

Results

We included 26 consecutive post-ART patients from the outpatient service. The uterine arteries were preserved in 16 patients (61.5%) and ligated in 10 patients (38.5%). Out of the 26 patients studied, 17 (65.4%) were supplied by only the ovarian arteries; seven (26.9%) by one uterine artery and the contralateral ovarian artery; and only 2 (7.6%) by the uterine artery supply alone. No recanalization of the ligated uterine artery or other newly formed compensatory circulation was observed. Among the 16 patients who had preserved uterine arteries, only two (12.5%) showed identifiable bilateral uterine arteries, whereas seven (43.6%) had unilateral uterine artery occlusion and another seven (43.6%), bilateral occlusion. We had three obstetric outcomes, two of which came from the ovarian artery supplying group and one from the hybrid supplying group.

Conclusions

The ovarian artery became the dominant supplying vessel after ART. The anatomically preserved uterine artery had an 87.5% chance of occlusion after the procedure. Moreover, the contributing uterine artery did not show any functional superiority. Thus, the benefit of preserving the uterine arteries during ART is probably very limited.     

The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa

Objective

To evaluate the success rate of the Bakri balloon in the event of uncontrollable hemorrhage due to placenta previa.

Study design

We evaluated 25 patients who were treated with the Bakri balloon who had severe postpartum hemorrhage with placenta previa and failed medical treatment with uterotonic agents.

Results

The Bakri balloon was inserted abdominally during cesarean section in 24 of 25 cases. In only one case was it inserted vaginally. The Bakri tamponade was effective in 22 cases (88%). There were three cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch suture) and one patient needed hysterectomy.

Conclusions

The Bakri balloon is the least invasive, rapid method in the management of bleeding due to placenta previa with minimal complications.     

The risk of placental abruption and placenta previa in pregnant women with chronic hepatitis B viral infection: A systematic review and meta-analysis

Introduction

Several epidemiological studies have found a positive association between chronic hepatitis B virus (CHB) infection and the risk of placental abruption and placenta previa, but various studies have reported conflicting findings. The objective was to systematically review the literature to determine a possible association between CHB infection and these two placental complications.

Methods

We conducted a computerized search in electronic database through March 1, 2014, supplemented with a manual search of reference lists, to identify original published research on placental abruption and placenta previa rates in women with CHB infection. Data were independently extracted, and relative risks were calculated. The meta-analysis was performed using Stata version 10.0 software.

Results

Five studies involving 9088 placenta previa cases were identified. No significant association between CHB infection and placenta previa was identified (OR = 0.98, 95% CI = 0.60–1.62). Five studies involving 15571 placental abruption cases were identified. No significant association between CHB infection and placental abruption was identified (OR = 1.42, 95% CI, 0.93–2.15).

Discussion

The immune response against the virus represents a key factor in determining infection outcomes. No observation of significant increased risk of the placental complications could be partially explained by the complex immune response during CHB infection.

Conclusions

Our meta-analysis found no evidence of significant associations between CHB infection and increased risk of placental abruption as well as placenta previa. Further well-designed studies were warranted to assess any potential association between CHB infection and increased risk of placental abruption as well as placenta previa.     

Bariatric surgery decreases the risk of uterine malignancy

Objective

To describe the risk of uterine malignancy among women who have had weight loss surgery.

Methods

We performed a retrospective cohort study among inpatient admissions of women 18 years, or older, registered in the University HealthSystem Consortium (UHC) dataset. The rate of uterine malignancy per hospital admission was calculated. Rates were compared according to whether diagnoses at the time of discharge included history of bariatric surgery, and further, according to whether there was a diagnosis of obesity.

Results

In admissions of patients who did not have a history of prior bariatric surgery, the rate of uterine malignancy was 599/100,000 (95% CI 590 to 610). Among obese women who had not previously undergone bariatric operations, the rate was 1409/100,000 (95% CI 1380 to 1440). Of women admitted who had a history of bariatric surgery, the rate of uterine malignancy was 408/100,000 (95% CI 370 to 450). The relative risk of uterine malignancy in all admissions for women who had prior bariatric surgery, compared to obese women who had not had bariatric surgery, was 0.29 (95% CI 0.26–0.32). Among women who had bariatric surgery and were not currently obese, the relative risk of uterine malignancy was 0.19 (95% CI 0.17–0.22) compared to obese women who had not undergone bariatric surgery.

Conclusion

A history of bariatric surgery is associated with a 71% reduced risk for uterine malignancy overall, and an 81% reduced risk if normal weight is maintained after surgery. This finding suggests that obesity may be a modifiable risk factor related to development of endometrial cancer.     

The role of loop electrosurgical excisional procedure in the management of adenocarcinoma in situ of the uterine cervix

Objectives

To evaluate the occurrence of residual or recurrent disease after loop electrosurgical excisional procedure (LEEP) for adenocarcinoma in situ (AIS) of the uterine cervix.

Study design

Records of 78 patients with a histological diagnosis of AIS of uterine cervix on LEEP who were treated and followed at our center between 1992 and 2008 were, retrospectively, reviewed.

Results

Of 78 patients who underwent LEEP, 47 had negative and 31 had positive resection margins. Of the 47 patients with negative margins, 30 underwent subsequent hysterectomy and residual AIS, including 1 invasive adenocarcinoma, was present in 17% (5/30) of patients. The remaining 17 had no additional procedures. Of the 31 patients with positive margins, 29 patients underwent subsequent hysterectomy and residual AIS, including 4 invasive adenocarcinomas, was present in 48% (14/29) of patients. The remaining two had no additional procedures. After a mean follow-up time of 28 months (range, 1–74 months), no recurrences were observed among the 19 patients who did not undergo hysterectomy.

Conclusions

The incidence of residual disease in patients with negative margins after LEEP for AIS of the uterine cervix is low but not negligible. Therefore, conservative management in these patients seems to be feasible but careful surveillance is required. However, positive resection margin carries a higher risk for residual AIS or occult invasive adenocarcinoma, warranting additional LEEP or hysterectomy in these patients.     

Real increasing incidence of hysterectomy for placenta accreta following previous caesarean section

Objective

Placenta accreta, morbid adherence to the uterus to the myometrium, is commonest in association with placenta previa in women previously delivered by caesarean section (CS). It has become proportionally a greater cause of major maternal morbidity and mortality as the frequency of other serious obstetric complications has declined. The aim of this study was to examine the incidence of placenta accreta in the context of a rising caesarean delivery rate.

Study design

Retrospective review of the incidence of placenta accreta in parous women during the 36 years 1975–2010. Cases were identified from hospital records and then correlated with pathological reports. The incidence of placenta accreta was analysed in the context of women previously delivered by CS.

Results

During the 36-year period in our unit, 157,162 multiparous women delivered, of whom 15,151 (9.6%) had a previous CS scar. The institutional incidence of CS rose from 4.1% in 1975 to 20.7% in 2010. Twenty-five parous women, all with a previous CS, had placenta accreta requiring hysterectomy. The overall incidence of placenta accreta was 1.65 per 1000 parous women with a previous CS, but was low (1.06/1000) until 2002. From 2003 to 2010 the incidence rose to 2.37/1000 previous CS deliveries (OR 2.2; 95% CI 1.05–5.1).

Conclusion

The frequency of placenta accreta correlated steadily with the CS rate until 2000. Since then, the incidence has nearly doubled in women with previous CS scars, suggesting an additional causative influence on risk.     

Near-miss o casi pérdida en un hospital de referencia

Objectives

To analyze maternal health from direct mortality and the concept of near-miss at La Fe University Hospital in Valencia (Spain) from 1991 to 2007.

Material and methods

We calculated the direct maternal mortality ratio (DMMR) from 1971-2007 and the severe obstetric morbility-mortality ratio from 1991-2007, and analyzed their causes.

Results

A significant DMMR decrease (rho = - 1), with a significant reduction in mortality due to cardiovascular disease was found. When analyzing severe maternal morbidity, we observed an increase of placenta previa (OR = 1.79), abruptio placentae (OR = 1.35), uterine rupture (OR = 2.48) and anesthetic complications (OR = 6.20), with a significant decrease of postpartum hemorrhage (OR = 0.63) and severe puerperal infection (OR = 0.32).The prevalence of hypertensive disorders of pregnancy, thromboembolic disease, intrauterine fetal death and severe morbidity/mortality ratio remained stable during the study period.

Conclusions

Estimating the severe obstetric morbidity-mortality ratio due to different near-miss definitions in the literature is difficult. The DMMR decreased, while the morbidity/mortality ratio remained stable.