Uterine-sparing surgical management of postpartum hemorrhage: is it always effective?

Purpose  

To further study the efficacy of uterine-sparing procedures based on triple uterine artery ligation (TUAL) possibly complemented with hemostatic multiple square suturing (HMSS) for the management of post-partum hemorrhage (PPH).     

Umbilical vein oxytocin in the management of retained placenta: an alternative to manual removal of placenta?

Purpose  

Retained placenta is potentially life threatening due to possible complications associated with manual removal. Our aim was to determine whether umbilical vein injection of oxytocin in saline reduces the need for manual removal of placenta.     

Prenatal vitamin K1 administration in epileptic women to prevent neonatal hemorrhage: is it effective?

OBJECTIVE: To summarize current knowledge on whether prenatal prophylactic vitamin K1 administration to epileptic women receiving enzyme-inducing antiepileptic drugs (AEDs) to prevent neonatal hemorrhage is effective. STUDY DESIGN: A computerized MEDLINE search was conducted using the terms antiepileptic drug, hemorrhagic disease of the newborn, pregnancy and vitamin K since 1966 to July 2004, limited only to human studies. English-language publications were selected based on their relevance to the clinical effectiveness of administration of oral vitamin K to epileptic women exposed to enzyme-inducing AEDs for prevention of hemorrhagic disease of the newborn (HDN). RESULTS: No randomized, controlled trial testing prenatal vitamin K1 administration for reducing the incidence or severity of neonatal hemorrhage was identified. This review summarizes the data from published observational studies. CONCLUSION: There is inadequate evidence to recommend the routine administration of prenatal vitamin K to epileptic women exposed to enzyme-inducing AED therapy in order to prevent HDN.     

Does manual removal of the placenta affect operative blood loss during cesarean section?

OBJECTIVE: To investigate whether manual removal of the placenta is associated with significantly more blood loss compared to spontaneous separation of the placenta during cesarean section. STUDY DESIGN: This was a randomised study of 200 women with normal pregnancies undergoing cesarean section. Patients were randomly assigned to the study group, manual removal (n=100) or the control group, spontaneous separation (n=100). Operative blood loss was measured using a volume and gravimetric method. Patients postoperative complications were recorded and hemoglobin levels measured at 24 and 48 h. RESULTS: The amount of blood loss associated with spontaneous and manual removal of the placenta was 626+/-253 ml and 589+/-272 ml, respectively. This difference was not significant. There was a decrease in the postoperative hemoglobin levels in both groups which was not significantly different. The incidence of endometritis, wound infection, and the need for blood transfusion was similar in the two groups. CONCLUSION: Manual delivery of the placenta is not associated with a significantly greater risk of operative blood loss, decreased postoperative hemoglobin levels or increased incidence of endometritis compared with spontaneous placental separation.     

Laparoscopic treatment of polycystic ovaries: is it time to relinquish the procedure?

OBJECTIVE: To evaluate the role of laparoscopic ovarian drilling and treatment with metformin in the management of the polycystic ovary syndrome (PCOS). DESIGN: A literature search was conducted using the keywords laparoscopy, laparoscopic ovarian drilling, laparoscopic ovarian diathermy, PCOS, metformin, and ovulation. The MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews were searched. RESULTS: No randomized comparisons have been done between laparoscopic ovarian drilling and metformin therapy. However, the ovulation and pregnancy rates appear to be similar for both techniques. Both treatments decrease the incidence of ovarian hyperstimulation and the cancellation rate of IVF cycles. However, unlike laparoscopic ovarian drilling, metformin may decrease the incidence of type 2 diabetes and coronary heart disease. CONCLUSION(S): Given the similar magnitude of the results without the potential risks and complication of surgery, we propose that laparoscopic ovarian drilling should be used sparingly in favor of less invasive treatment with metformin.     

Oocyte cryopreservation: is it time to remove its experimental label?

As more reproductive-age women survive cancer at the expense of gonadotoxic therapy, the need for viable fertility preservation options has become paramount. Embryo cryopreservation, often using donor sperm, has been the standard offered these women over the past 20 years. Preservation of unfertilized oocytes now represents an acceptable and often equally viable alternative, particularly for single women, due to technologic advances made in the past decade. Given such, oocyte cryopreservation’s experimental designation and need for IRB approval should thus be revisited.     

Freeze-all policy: is it time for that?

Purpose

This publication will evaluate the available evidence in the literature comparing fresh embryo transfer (ET) and elective frozen-thawed embryo transfer (FET) regarding the possible interference of controlled ovarian stimulation (COS) in implantation and endometrial receptivity, IVF safety, and obstetric and perinatal outcomes.

Methods

We performed a review in the literature of the available evidence comparing fresh to elective FET (freeze-all policy).

Results

The improvements made in cryopreservation techniques have led to few or no detrimental effects to the embryo and have resulted in no consequences to the offspring when compared to fresh embryos; this has allowed reproductive practitioners to create the freeze-all policy (when all viable embryos are electively cryopreserved in the fresh cycle and transferred in a posterior cycle). There are increasing concerns about the adverse effects associated with COS over the endometrial and uterine environments, as well as with the safety of COS in pregnancies that have originated from fresh ET during in vitro fertilization (IVF) treatments. COS may contribute to modifications in the endometrium, which might be related to poorer outcomes when fresh ET is performed. It has been suggested that obstetric and perinatal outcomes in pregnancies resulting from fresh ET are poorer when compared with those that occur after FET. In cycles with fresh ET, there is still a risk of ovarian hyperstimulation syndrome (OHSS).

Conclusion

There is growing evidence in the literature suggesting better IVF outcomes, and decreased obstetric and perinatal morbidity when adopting the freeze-all policy instead of fresh ET.     

Zygosity of twins: is it time for a new terminology?

The term zygosity reflects the origin of twins--when twins are monozygotic, they are derived from a single fertilized ovum; when twins are dizygotic--the come from two fertilized ova. Zygosity assessment seemed straightforward 50 years ago. Currently, as more information and more technology becomes available, zygosity testing becomes a real problem. It is important to realize the importance of correct zygosity testing not only in the antepartum care of the pregnant mother, but more importantly--during the whole lifetime of twin individuals. This paper discusses revolving around zygosity, methods of assessment, their limitations and proposes new terminology which incorporates the recent knowledge about early human development.     

Uterine compression sutures for postpartum hemorrhage: is routine postoperative cavity evaluation needed?

Postpartum hemorrhage due to uterine atony continues to be one of the major causes of maternal morbidity and mortality. Several uterine compression suture techniques have been described and are increasingly being used worldwide as a conservative approach. However, little is known about the long-term effects on the uterine cavity, as well as fertility and pregnancy outcomes. We reviewed the reported complications and uterine findings after the use of compression sutures, both in examinations to evaluate the cavity (hysteroscopy, hysterosalpingography or sonohysterography) and at cesarean section, in order to assess the possible usefulness of routine postoperative cavity evaluation. Overall, the use of uterine compression sutures is effective and safe; however, some severe and potentially life-threatening complications have been reported and could possibly have been prevented if uterine cavity evaluation had been performed. Routine follow-up, both by hysteroscopy and an imaging technique, seems worthwhile.     

Infertility treatment: When is it time to give up? An internet-based survey

A 42-year-old female patient with history of secondary infertility was referred to our assisted conception unit for in vitro fertilization (IVF). Before her referral, she had two cycles of IVF at another centre; the first was unsuccessful and, after conceiving at the second attempt, the pregnancy was terminated at 14 weeks' gestation following a positive nuchal translucency scan and a diagnosis of trisomy 21 (Down syndrome) by a chorionic villous biopsy performed in the first trimester. The screening tests for trisomy 21 were offered to the patient in view of her advanced age. Subsequent karyotyping revealed that both partners had a normal chromosomal complement. Following genetic counselling, the couple were offered IVF treatment along with preimplantation genetic screening for trisomy 21. Four of the five embryos were suitable for biopsy, and one blastomere from each embryo was analyzed using fluorescent in situ hybridization for chromosome 21. The analysis revealed that two embryos had trisomy 21, one had monosomy 21, and only one embryo was diploid for chromosome 21. The single diploid embryo was transferred to the uterus on day 3, and resulted in an uneventful pregnancy and delivery of a healthy live-born male.     

Tranfusion risk: is “two-step” vaginal delivery a risk for postpartum hemorrhage?

Objective: In the active management strategy of third stage of labor, the optimal timing for clamping the umbilical cord after birth has been a subject of controversy. We want to evaluate if “two-step” delivery is a risk factor for postpartum hemorrhage (PPH), defined as need of transfusion, comparing to operative delivery, elective caesarean delivery and emergency caesarean delivery.

Methods: This is a retrospective cohort study conducted in division of Perinatal Medicine, Policlinico Abano Terme. We evaluated the need of transfusion in all cases of PPH verified in all single deliveries between January 2011 and December 2012. The main outcome measure was blood loss and red blood cell transfusion.

Results: We found 17 cases of PPH (0.88%). The distribution of PPH in relation to mode of delivery was 0.71%, 2.46% and 1.98% respectively for two-step vaginal delivery (RR?=?0.81 (0.56–1.22)), emergency cesarean section (RR?=?2.88 (1.27–7.77)) and operative vaginal delivery (RR?=?2.88 (0.59–5.66)). In labor induction there is a stronger relative risk association between PPH and as emergency cesarean delivery (p?<?0.05) as operative vaginal delivery (p?<?0.05).

Conclusion: “Two-step” delivery approach did not increase the risk of PPH with respect to operative delivery, elective caesarean section and emergency caesarean section.