Inversión uterina puerperal: experiencia en nuestro centro

Objective

To assess the incidence, outcomes, and risk of recurrence of puerperal uterine inversion in our hospital.

Material and methods

A retrospective study was carried out in 22 cases of puerperal uterine inversion from January 1993 to December 2013 in our hospital. We analyzed different risk factors.

Results

The mean age of the patients was 28 years (18-41). Nineteen (86%) were nulliparous. Four (18%) had undergone previous uterine surgery. Delivery was through cesarean section in 6 patients (27%) and through the vaginal route in 16 (73%). The mean birthweight was 3111 grams (2130-3950). Retained placenta occurred in 8 patients (36.4%) and uterine atony in 3 (13.6%). Uterine inversion was acute in all patients. Complications and management consisted of severe hemorrhage in 7 patients, 20 cases (91%) were resolved by the Johnson procedure, and 22 hysterectomies (9%) were performed. There were no deaths and no recurrences.

Conclusions

In our study, important risk factors were nulliparity and placenta accreta. Early diagnosis and treatment are of the utmost importance. Surgery should be the last option.     

Mola hidatiforme parcial en gestante de 17 semanas con preeclampsia

Objectives

To report a case of partial hydatidiform mole presenting as preeclampsia at 17 weeks of gestation and to review the data on the diagnosis and management of this entity.

Case Rrport

The patient was admitted for severe preeclampsia. Ultrasound and cytogenetic studies revealed a partial hydatiform mole. Abdominal uterine evacuation was performed and the patient was monitored until the process resolved.

Discussion

Partial hydatiform mole usually manifests as first-trimester metrorrhagia. This entity is not generally associated with specific fetal anomalies, but retarded fetal growth is almost always present. These moles rarely present with a picture of early-onset preeclampsia, as in the present case. Diagnosis is based on ultrasound, human chorionic gonadotropin (HCG) measurements and fetal karyotype, although the definitive diagnosis is histological. Partial hydatiform mole is considered a localized disease that usually resolves with uterine evacuation. However, in some patients, there can be persistent trophoblastic disease.

Conclusion

Diagnosis of partial hydatiform mole should be taken into account in patients with early onset preeclampsia.     

Decreasing margins to the uterine serosa as a method for increasing the volume of fibroids ablated with magnetic resonance-guided focused ultrasound surgery

Objective

To demonstrate the safety of magnetic resonance-guided focused ultrasound surgery (MRgFUS) treatments regardless of the distance between the treatment region and the uterine serosa.

Study design

83 pre-menopausal women with symptomatic uterine fibroids were treated with MRgFUS in 88 treatments. Treatment data was analyzed, measuring the distance between the treatment spots (sonications) and the serosa. Patients were followed up for 1 year and adverse events were collected.

Results

79% and 37% of the sonications were less than 15 mm and 10 mm from the serosa, respectively. Treatment was always confined to the fibroid capsule. There were no unexpected or serious adverse events.

Conclusion

Reducing the margin between the fibroid treatment area and the uterine serosa, when possible, enables MRgFUS treatment of greater fibroid volume, while maintaining a high safety profile. Special attention should be paid when the uterus lies adjacent to other sensitive organs to avoid unintentional heating of these organs, using the planning and real-time MR images.     

Rectovesical ligament and fusion defect of the uterus with or without obstructed hemivagina and ipsilateral renal agenesis

Objective

The rectovesical ligament is a peritoneal band in women with failure of fusion of the two Müllerian ducts. The aim was to evaluate existence of this abnormal structure in women with dysfused uterus and its possible relations to concomitant vaginal and renal anomalies.

Study design

The study group comprised 47 women with uterine fusion defect (37 didelphic and 10 bicornuate uterus). They had undergone laparoscopy or laparotomy to visualize the pelvic cavity, and imaging for renal evaluation. The rectovesical ligament was present if inspection of the pelvic cavity revealed a broad peritoneal band between the two hemiuteri, attached anteriorly to the bladder and posteriorly to the sigmoid. Presence or absence of the ligament was reported, and concomitant renal and vaginal anomalies were evaluated.

Results

The rectovesical ligament was not visualized in 14 patients with didelphic or complete bicornuate uterus associated with unilateral renal agenesis: of these 13 had a previously treated obstructive longitudinal vaginal septum. A peritoneal band was found in 27 women with didelphic uterus with longitudinal vaginal septum with no obstruction and normal bilateral kidneys. Six women with bicornuate uterus had normal kidneys and an identified rectovesical ligament between the uterine hemicorpora, except for one with partial bicornuate uterus.

Conclusion

The rectovesical ligament is not merely a consequence of the failed fusion of two Müllerian ducts, but its relation to uterine malformation with or without vaginal and renal anomalies indicates some share of this structure in the early development of the urogenital system.     

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.     

A comparison of uterine peristalsis in women with normal uteri and uterine leiomyoma by cine magnetic resonance imaging

Objective

The non-pregnant uterus shows wave-like activity (uterine peristalsis). This pilot study was intended to determine: (1) whether uterine peristalsis during the menstrual cycle is detectable by cine magnetic resonance imaging (MRI); (2) the effects of leiomyoma on uterine peristalsis.

Study design

Mid-sagittal MRI was performed sequentially with T2-weighted single-shot fast spin-echo (SSFSE) in 3 normal ovulatory volunteers and 19 premenopausal women with uterine leiomyoma. Direction and frequency of movement of the junctional zone were evaluated using a cine mode display.

Results

Junctional zone movement was identified in all subjects. Direction of uterine peristalsis in normal volunteers was fundus-to-cervix during menstruation, cervix-to-fundus during the periovulatory phase, and isthmical during the mid- and late-luteal phases. Abnormal peristaltic patterns were detected in three of five patients with uterine leiomyoma during menstruation and in the mid-luteal phase of the cycle, respectively.

Conclusion

Cine MRI is a novel method for evaluation of uterine peristalsis. Results of this pilot study suggest that abnormal uterine peristalsis during menstruation and the mid-luteal phase might be one of the causes of hypermenorrhea and infertility associated with uterine leiomyoma.     

Pregnant woman and road safety: a numerical approach. Application to a restrained third trimester pregnant woman in frontal impact

Objectives

The goal of our work is the development of a numerical model of pregnant woman in driving position. We present an application to the study of injury mechanisms during a frontal car crash for a seat belt restrained pregnant woman in driving position.

Materials and methods

We integrated a digital representation of a pregnant uterus, foetus and placenta in a previous existing numerical model of non pregnant Human body in driving position, the Humos model^®. The realization of a numerical simulation of a frontal car crash enabled us to analyze the part played by the safety belt in the organic traumatisms.

Results

Three phases were highlighted. The first phase consists of a translation forwards of the pregnant uterus during the impact. The second phase is a rotation forwards in the sagittal plan of the pregnant uterus with for axis of rotation the posterior wall of the pubis. The third phase is a vertical adjustment coupled to a translation of the uterus towards the back. This translation leads the uterus to impact the spine.

Conclusion

The development of a pregnant numerical model in the field of accidentology allows the analysis of organic traumatisms. That makes it possible to study the role played by the existing safety systems. This model might make it possible to develop safety systems specific to the pregnant woman.     

Éxito en el manejo conservador del acretismo placentario mediante embolización y metotrexato

Introduction

The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery.

Case report

A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional vessel was performed and methotrexate was administered. Three days after the embolization, the placental mass was expelled.

Conclusions

Selective embolization of a nutritional vessel and adjuvant treatment with methotrexate are conservative techniques that allow preservation of both the uterus and fertility. According to previous reports in the literature, the time interval between delivery and definitive placental expulsion was lower in our case than in other conservatively managed cases.     

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.     

Tratamiento conservador del acretismo placentario

Introduction

Placental accreta has increased because of the greater use of prior uterine surgery, especially cesarean section. Treatment has evolved from a radical surgical approach to conservative management.

Case report

A woman at 26.1 weeks of pregnancy was admitted to hospital because of premature rupture of membranes. Three days after a cesarian section was performed for suspected fetal distress, we observed placenta accreta. A fragment of placenta was left in the cornual bed. Given the absence of bleeding, an expectant attitude was adopted. Subsequent follow-up showed no abnormalities. Ultrasound and hysteroscopic monitoring showed a progressive reduction of placental size until its disappearance at 5 months postpartum.

Discussion

The optimal management of placenta accreta remains controversial in the literature. In selected cases, we should offer the possibility of conservative treatment, reducing morbidity and preserving the fertility of the patient.     

The outcome of singleton pregnancies after IVF/ICSI in women before and after hysteroscopic resection of a uterine septum compared to normal controls

Objective(s)

To evaluate the effect of hysteroscopic resection of a large uterine septum (Class V according to the American Fertility Society (AFS) classification) and of a small partial uterine septum (Class VI according to AFS classification or arcuate uterus) on the abortion rate in pregnancies after IVF and ICSI.

Study design

The retrospective matched control study included 31 women who conceived following IVF or ICSI before hysteroscopic resection of a large (12 women) or small partial (19 women) uterine septum and 106 women who conceived following IVF or ICSI after hysteroscopic resection of a large (49 women) or small partial (57 women) uterine septum. For each pregnancy in the study group, we found two consecutive pregnant control women from the IVF/ICSI registry who had a normal uterus and were matched for age, BMI, stimulation protocol and the use of IVF or ICSI and for various infertility causes. The abortion/pregnancy rate was the main outcome measure. Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4 cm long yellow tip of the electric knife to the length of the resected septum.

Results

The abortion rate before hysteroscopic metroplasty was significantly higher, both in women with a small partial septum (78.9% before resection vs. 23.7% in the normal controls, OR 12.08) and a large septum (83.3% before resection vs. 16.7% in normal controls, OR 25.00) compared to women with a normal uterus. After the surgery, the abortion rate was comparable to the abortion rate in women with normal uterus: in both women with a small partial and women with a larger septum.

Conclusion(s)

Similar to a large uterine septum, a small partial uterine septum is an important and hysteroscopically preventable risk factor for spontaneous abortion in pregnancies after IVF and ICSI.     

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.     

Útero didelfo y hemivagina ciega. Una causa de dolor abdominal en la adolescencia

Objective

To evaluate didelphic uterus as a cause of abdominal pain.

Material and method

We reviewed 2 cases in adolescents managed by our service from 2002 to 2006.

Results

In both patients, we confirmed the existence of didelphic uterus and septate vagina associated with renal agenesis. Outcome was favorable in both patients after surgery.

Conclusions

The 2 cases described illustrate the need to include congenital abnormalities in the differential diagnosis of lower abdominal pain and vaginal mass in adolescents.     

Robotic-assisted laparoscopic surgery in uterine pathology

Objective

The feasibility and safety of robotic surgery have been demonstrated by numerous comparative studies. The aim of our study was to compare several parameters related to robotic surgical procedures in uterine pathology, and to analyse clinico-biological parameters that may influence the post-operative evolution of the patients.

Study design

Retrospective analysis of 100 patients with uterine pathology who had undergone robotic-assisted laparoscopic surgery at the Santa Chiara Hospital, Pisa, Italy, between 2008 and 2010.

Results

Duration of surgery, docking, hysterectomy, uterine suture, blood loss, and days of hospitalisation significantly improved in parallel with the increasing experience of the surgical team. Paradoxically, the length of myomectomy increased in the same time interval, probably due to operating on more complex clinical cases with this procedure as the surgical team's experience grew. None of the robotic surgeries was converted to laparotomy. No intra- or post-operative complications were noted.

Conclusion

Since robotic-assisted laparoscopic surgery is becoming the preferred surgical technique for uterine pathology treatment, more clinical studies and development of protocols are essential to increase the quality of surgical treatment.     

Small uterine septum is an important risk variable for preterm birth

Objective(s)

To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V).

Study design

Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3–1.5 cm.

Results

The preterm birth rate in Group A (n = 420) was 33.9% before and 7.2% after hysteroscopic resection (P < 0.001); the preterm birth rate in Group B (n = 406) was 36.5% before and 8.0% after hysteroscopic resection (P < 0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection (P < 0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection (P < 0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients.

Conclusion(s)

Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.     

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.     

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.