Oxytocin Induced Second Trimester Uterine Rupture

A case of oxytocin induced rupture of an unscarred uterus during the second trimester is presented. While rupture of the uterus by oxytocic agents in the second trimester has previously been documented, this case is unusual in that fetal parts were palpable through the cervical os, delaying diagnosis and definitive management. Digital palpation of fetal parts through the cervix does not preclude the diagnosis of fetal extrusion secondary to uterine rupture.     

Second Trimester Abortion

This article details the adaptation of Lamaze techniques for use by patients undergoing second trimester abortions and covers the program of counseling the abortion patients on family planning in the short time available before and after saline instillation and during post-abortal examinations. Specific Lamaze techniques taught were slow, rhythmic chest breathing, relaxation, effleurage, and back massage. To evaluate pain relief, 43 of the 416 patients taught by the author were interviewed at random following their labors. Of the 43 patients interviewed, 26 used the techniques, and 21 of these stated that they were to some degree helpful. Abortion patients were found to be difficult to teach, probably because of their high level of anxiety.     

Spontaneous Uterine Rupture in the Second Trimester in a Patient With Previous Pelvic Radiotherapy in Childhood: A Case Report

BackgroundPelvic irradiation in childhood may result in abnormal uterine function. Poor obstetric outcomes have been reported in these patients.CaseA 30-year-old woman with a previous midtrimester miscarriage, G2, P0, presented at 23⁴ weeks gestation with acute abdominal pain and signs of hemodynamic instability. The patient was treated in childhood for Ewing sarcoma of the pelvis. Spontaneous uterine rupture was diagnosed. A supracervical hysterectomy with intrauterine fetus was performed.ConclusionA high index of suspicion is needed in primigravidas with risk factors for uterine rupture. Pelvic radiotherapy in childhood may be a risk factor.     

Routine Measurement of Nuchal Thickness in the Second Trimester

Nuchal thickness was measured prospectively in all fetuses of 15 0/7 to 20 6/7 weeks scanned from January 1, 1988, to October 31, 1990. The most frequent indication for scan was gestational age. Of the 7,106 scans performed, 30 fetuses had an abnormal thickness of 6 mm or more. Twelve of the 30 had an abnormal karyotype: 9 with trisomy 21, 1 with triploidy and tetrasomy 12, 1 with partial trisomy 9, and 1 with trisomy 13 plus a 3,9 translocation. Two fetuses with normal karyotypes had another reason for nuchal thickening—Noonan's syndrome in one and achondrogenesis in the other. Seven of the 18 fetuses who had a normal karyotype had an abnormal thickness measured at the upper end of the gestational age range between 20 0/7 and 20 6/7 weeks. Increased nuchal thickness is infrequently (0.4%) detected in the early second trimester and is associated with abnormal karyotypes (40%) and other anatomic findings. A nuchal thickness measurement should be part of every scan performed between 15 0/7 and 19 6/7 weeks, inclusive. When thickness is abnormal, a detailed scan is indicated and karyotype analysis should be offered.     

Spontaneous Resolution of Second Trimester Fetal Pleural Effusion

A case of pleural effusion, diagnosed by ultrasound in the second trimester, underwent spontaneous resolution without adverse effect on lung development. Optimal management has not been defined; because the natural history of fetal pleural effusion is unknown, observation with serial ultrasound is an alternative to in utero therapy.     

Pregnancy Loss Rates Following Second Trimester Genetic Amniocentesis

Data from 3,953 consecutive second trimester genetic amniocenteses were analysed to determine pregnancy loss rates up to 6 weeks after the procedure. Information was prospectively collected on a cohort of 3,685 women in 3,896 singleton and 50 twin pregnancies, from 2 operating sites in Perth, Western Australia, using 9 operators over the 6-year period, 1989 to 1995. Complete information regarding pregnancy outcome was obtained for 3,643 of the 3,685 women (98.9%). There were 27 identified singletons and 1 set of twins lost within 6 weeks following amniocentesis. The overall pregnancy loss rate in this cohort was 29 of 3,911 (0.74%). The pregnancy loss rate associated with genetic amniocentesis is not excessive in comparison to the calculated background pregnancy loss rate of 1%, and it is suggested that each prenatal diagnostic team should determine their own complication rates for the purpose of counselling prior to amniocentesis.     

Neck Circumference Measurements in Second Trimester Fetuses with Down's Syndrome

Ultrasound examinations were performed on 132 normal fetuses between 12 and 25 weeks of gestation to measure the fetal neck circumference (NC), biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). The relationships between the fetal neck circumference and gestational age, as well as between the fetal neck circumference and fetal biometric parameters (BPD, HC, AC, FL) were linear. Nomograms between the fetal neck circumference and all other parameters were established including the 5th, 50th, and 95th percentile lines. Only one of nine fetuses with Down's syndrome was found to have abnormally increased fetal neck circumference (above the 95th percentile), whereas the remaining eight cases were equally distributed above and below the 50th percentile of these nomograms. The positive predictive value of an abnormally increased fetal neck circumference was 1.6% in our tested population, where the prevalence of Down's syndrome was 1 in 132. Our observations suggest that the use of fetal neck circumference in second trimester fetuses does not add in the prenatal diagnosis of Down's syndrome.     

Minimally Invasive Management of Second Trimester Placenta Percreta

Study ObjectiveTo describe the diagnostic and surgical challenges in the management of second trimester placenta percreta.DesignStepwise demonstration of the surgical technique with the use of an educational video.SettingSecond trimester placenta percreta is a rare entity, with very few case reports in the literature. Our video demonstrates the challenges of a minimally invasive approach toward definitive surgical management with hysterectomy.A 39-year-old G7P3 (3 previous cesarean deliveries) female at 17 weeks and 2 days gestation presented with acute abdominal pain to a community hospital. This was a spontaneously conceived pregnancy. Her hemoglobin level on admission was 92 g/L. An ultrasound showed a normal uterus, and the appendix was not visualized. One unit of packed red blood cells was transfused, and she underwent exploratory laparoscopy for a possible retrocecal hematoma/mass seen on computerized tomography. In the operating room, acute hemoperitoneum was visualized with placenta-like tissue invading through the anterior lower uterine segment (Figures 2 & 3). A hemostatic agent (Floseal, Baxter) was placed over the bleeding, and she was then transferred to a tertiary academic center for further management.InterventionsMagnetic resonance imaging was performed on the following day after transfer to our facility, which confirmed placenta percreta at the level of the bladder (Figure 1). Following counseling with a multidisciplinary team and given that there was ongoing bleeding from the invading placental tissue, pregnancy continuation and uterine conservation were not possible. The patient was offered preprocedure termination of pregnancy with intra-cardiac injection of potassium chloride and 350 cc of amniotic fluid was drained at that time. This was done to facilitate visualization for a minimally invasive approach. We describe 5 main challenges of minimally invasive hysterectomy for placental percreta and provide a stepwise approach to mitigating them: visibility, vascular control, bladder dissection, colpotomy, and specimen retrieval. We adapted the previously described laparotomy techniques of progressive uterine devascularization and approach to bladder dissection and colpotomy to laparoscopy 1, 2. In addition, we performed dilatation and evacuation to allow for vaginal specimen removal. The patient's postoperative course was uncomplicated, and she was discharged home in a stable condition.ConclusionMidtrimester placenta percreta poses significant challenges in diagnosis and surgical management. Total laparoscopic hysterectomy for this condition poses unique challenges but is feasible and safe.     

Pre-induction with Mifepristone for Second Trimester Termination of Pregnancy

Objective

To study the efficacy and safety of combining mifepristone before misoprostol use in second trimester to considerably reduce the induction–abortion interval with the lowest possible dose and adverse reaction.

Material and methods

A prospective study was conducted which included 60 patients visiting the antenatal OPD for elective abortions between 13 and 20 weeks of gestation as per the MTP act. They were randomly divided into two groups of 30 each—the study group received mifepristone 200 mg orally before misoprostol, whereas the control group was induced with misoprostol alone. The results were analyzed.

Observation

Statistical analysis of the study was done using χ² test. The induction–abortion interval was significantly shorter in the study group, thereby decreasing the side-effects of the drug as well as duration of hospital stay.

Conclusion

This study, like many others, offers a reliable, safe, and cost-effective option by combining mifepristone before misoprostol to decrease the induction–abortion interval.     

Pathological Uterine Perfusion in the Second Trimester Is Not Associated with Neutrophil Activation

Objective: Preeclampsia and intrauterine growth retardation (IUGR) are associated with elevated concentrations of myeloperoxidase (MPO) and polymorphonuclear (PMN) elastase, which indicate maternal neutrophil activation. The aim of the study was to measure maternal MPO and PMN elastase plasma concentrations in second trimester pregnancies with pathological uterine perfusion that are a high risk group for preeclampsia and IUGR, and compare them to normal controls. Methods: The study includes 25 pregnancies with normal and 25 pregnancies with pathological uterine perfusion. In both groups, doppler‐sonographic measurement of uterine perfusion was performed in the twenty‐first week of gestation. Maternal plasma concentrations of MPO and PMN elastase were measured using a specific ELISA for both enzymes. Results: The plasma MPO concentration of pregnant women with normal perfusion did not differ significantly from that of the group with pathological perfusion (27.4 ± 3.3 vs. 23.7 ± 2.0 ng/mL). Likewise, the plasma PMN elastase‐concentration also did not show a significant difference between the groups (5.7 ± 0.5 ng/mL normal vs. 8.0 ± 1.0 ng/mL pathological). Patients with pathological perfusion that later developed preeclampsia or IUGR (9/25) showed unchanged MPO and PMN elastase values in the second trimenon compared to those with pathological perfusion and normal outcome. Conclusions: Pathological uterine perfusion in the second trimester was not associated with maternal neutrophil activation. The measurement of the MPO and PMN elastase concentration suggested that neutrophil activation in preeclampsia or IUGR is a secondary effect of the disease rather than a primary pathophysiological factor.     

Circulating Angiogenic Factors and Abnormal Uterine Artery Doppler Velocimetry in the Second Trimester

Objective: Circulating angiogenic growth factors (such as vascular endothelial growth factor [VEGF] and placental growth factor [PlGF]) and their interaction may be associated with vascular remodeling of spiral arteries in normal pregnancy. Soluble Flt-1, an antagonist of both VEGF and PlGF, has been shown to be increased, while PlGF is decreased in women prior to the onset of preeclampsia. The purpose of this study was to compare maternal soluble Flt-1 and PlGF levels in the second trimester with a marker of abnormal placentation, abnormal uterine artery Doppler (UAD). Method: A prospective cohort of women, 16 to 24 weeks estimated gestational age (EGA), with singleton pregnancies, underwent UAD and phlebotomy. Maternal soluble Flt-1 and free PlGF were measured by ELISA in samples from women with abnormal UAD with a group, controlled for EGA, with normal UAD. Mann-Whitney Rank-Sum test was used to compare maternal serum levels of both soluble Flt-1 and PlGF between women with abnormal uterine artery Doppler versus women with normal uterine artery Doppler. Results: Of the 222 study subjects enrolled, 34 (15%) had abnormal UAD. The mean EGA at enrollment of subjects in each group was 18 weeks. There was no difference in PlGF between subjects with abnormal UAD (median, 191 pg/mL; range, 187 to 337 pg/mL) versus controls (median, 171 pg/mL; range, 169 to 289 pg/mL) (p = 0.59) or soluble Flt-1 (median, 780 pg/mL; range, 280 to 3200 pg/mL) or between subjects with abnormal UAD versus controls (median, 720 pg/mL; range, 220 to 1980 pg/mL) (p = 0.36). Conclusion: Concentrations of maternal soluble Flt-1 and free PlGF in the second trimester do not appear to be altered in women with abnormal UAD. This suggests that these biochemical markers are independent of the increased placental resistance seen with abnormal uterine artery Doppler.     

Misoprostol Vs Mifepristone and Misoprostol in Second Trimester Termination of Pregnancy

Objective

The present study was conducted with the aim to assess and comparatively evaluate the safety and efficacy of misoprostol alone and mifepristone with misoprostol for second trimester termination of pregnancy.

Methods and Materials

The study was conducted on 200 selected cases, divided in two groups of 100 cases each. In the study group mifepristone was given 200 mg 12 h before intravaginal insertion of 600 μg of misoprostol followed by 400 μg every 3 h up to a maximum of 5 doses or until the abortion occurs, whichever occurs early. In the control group only misoprostol was inserted in the same dose regime. The results were analyzed.

Results

The success rate in both regimens was 100%. Mean induction abortion interval from the insertion of the first misoprostol tablet was significantly shorter in the mifepristone pretreated group 6.72 ± 2.26 h as compared to 12.93 ± 3.4 h in the misoprostol alone group (P < 0.001). The mean blood loss was slightly higher in the control group. The mean dose of the misoprostol required was significantly less in the study group 1,186 ± 291.64 μg as against 1,736 ± 320.20 μg (P < 0.001). The side effects observed in both the groups were similar mainly nausea vomiting, fever, abdominal cramps.

Conclusion

Pretreatment with mifepristone 12 h before intravaginal misoprostol significantly improves the induction abortion interval.     

Correlation Between Fasting Glucose in the First Trimester and Glucose Challenge Test in the Second

Objective: To determine if there is a statistically significant correlation between the plasma glucose level obtained following a glucose challenge test at 24–28 weeks’ gestation and the fasting plasma glucose level in the first trimester.Methods: The study population included 621 healthy women with singleton pregnancies followed in the antenatal clinic of the Hadassah Medical Center, with a fasting plasma glucose level performed during the first trimester. Nine women had fasting blood glucose levels above 105 mg/dL and were excluded from the study. Of the remaining 612 women, 425 (69%) had 50-g glucose challenge tests at 24–28 weeks’ gestation.Results: The mean (± standard deviation [SD]) first-trimester fasting glucose level was 77.8 ± 9.7 mg/dL and the mean (±SD) glucose level 1 hour after the second-trimester glucose challenge test was 109.1 ± 29.8 mg/dL. The fasting plasma glucose level and the glucose level following the glucose challenge correlated significantly but not strongly (r = .26, P < .001). However, using a linear regression model in which fasting plasma glucose level and maternal weight were explanatory variables and glucose level following the glucose challenge test was the dependent variable resulted in a very low r² (.10).Conclusion: The correlation between the plasma glucose level obtained following a glucose challenge test and the fasting plasma glucose level in the first trimester is low, indicating that fasting glucose measurement early in pregnancy has no clinical benefits.     

米索前列醇引产在早期重度妊高征中的应用

目的观察米索前列醇用于早期发生的重度妊高征终止妊娠的安全性和可行性.方法选择伴有各种严重并发症且发病较早,需要终止妊娠的重度妊高征8例(孕周26～32+5),同期正常足月需引产者13例为对照组.米索前列醇50μg阴道给药,依据宫缩情况3～4h重复给药.监测血压、心率、体温、诱发宫缩时间、用药至临产时间及产程.结果两组用药前后血压、心率、体温变化均无统计学差异(P＞0.05),两组均荻引产成功,妊高征组用药总量及给药次数明显高于对照组(P＜0.001),但临床经过平稳,无副反应.结论米索前列醇用于早期重度妊高征的终止妊娠,尤其是对不期待活产的病例,具有一定的安全性和可行性.     

不同作用时间二氧化碳气腹对妊娠中期大鼠胎盘组织的影响

目的:探讨不同作用时间的二氧化碳(CO2)气腹对妊娠中期大鼠胎盘组织中血管性血友病因子(vWF)水平的影响;并且在透射电镜下观察妊娠中期CO2气腹后大鼠胎盘超微结构的变化,判断CO2气腹对胎盘功能的影响。方法:建立妊娠中期CO2气腹的大鼠模型,接受CO2气腹1小时(处理组1)、CO2气腹2小时(处理组2)和未接受CO2气腹(对照组)大鼠的胎盘组织行固相夹心法酶联免疫吸附实验(ELISA),检测vWF含量变化。透射电镜观察妊娠中期CO2气腹后大鼠胎盘近期超微结构的变化。结果:处理组2 vWF的OD值(0.1175±0.0237)高于对照组(0.0732±0.0096)和处理组1(0.0864±0.0103),差异均有统计学意义(P<0.05);对照组和处理组1胎盘的合体滋养细胞超微结构均为正常表现,处理组2有早期缺氧的表现。结论:妊娠中期大鼠胎盘组织中vWF含量在相同气腹压力下随气腹作用时间延长而增加,长时间CO2气腹后其胎盘透射电镜下出现早期缺氧的改变。     

Multiple Dose Extraamniotic Prostaglandin Gel for Second Trimester Termination of Pregnancy

Summary: Multiple doses of PGF_2α gel were administered into the extraamniotic space in 30 patients to induce mid-trimester termination of pregnancy. In 18 of these patients, repeat doses of gel were given only in the absence of uterine contractions and in 12 patients the gel was administered every 4 hours, irrespective of uterine activity. The mean time to abortion in all patients was 13.9 hours; no benefit seemed to accrue from using routine 4-hourly doses and it is recommended that repeat doses are given only when contractions are absent. The latter technique compares favourably with the use of other natural prostaglandins and prostaglandin analogues.     

Second Trimester Placental Growth Factor Levels and Placental Histopathology in Low-Risk Nulliparous Pregnancies

ObjectivePlacental growth factor (PlGF) levels are lower at delivery in pregnancies with preeclampsia or fetuses small for gestational age (SGA). These obstetrical complications are typically mediated by placental dysfunction, most commonly related to the specific placental phenotype termed placental maternal vascular malperfusion (MVM). The objective of this study was to determine the relationship between PlGF levels in the second trimester and the development of placental diseases that underlie adverse perinatal outcomes.MethodsWe performed a secondary analysis of the prospective Placental Health Study in unselected healthy nulliparous women (n = 773). Maternal demographic data, Doppler ultrasound measurements, and plasma PlGF levels at 15 to 18 weeks gestation were analyzed for association with pregnancy outcomes and placental pathology following delivery.ResultsLow PlGF levels in the second trimester (<10th percentile; <72 pg/mL) was associated with preterm delivery (<37 weeks; 26% vs. 6%, P < 0.001; unadjusted odds ratio (OR) 5.75, 95% CI 3.2–10.5), reduced mean birth weight (2998 vs. 3320 g, P < 0.001), SGA deliveries (25% vs. 11%, P = 0.001; OR 2.6, 95% CI 1.5–4.6), and preeclampsia (7% vs. 2%, P = 0.02; OR 4.3, 95% CI 1.5-12.8) relative to normal PlGF levels (≥10th percentile; ≥72 pg/mL). Low PlGF was associated with lower mean placental weight (447 vs. 471 g, P = 0.01), aberrant cord insertion (25% vs. 12%, P = 0.001) and a pathologic diagnosis of MVM (18% vs. 11%, P = 0.04; OR 1.9, 95% CI 1.01–3.55) but not with other placental pathologies.ConclusionMVM placental pathology and related adverse perinatal outcomes are associated with low PlGF in the early second trimester for healthy nulliparous women.     

Second Trimester Maternal Serum Alpha-fetoprotein as an Indicator of Fetal Risk

Serum alpha-fetoprotein levels were raised to 2.0 or more times the median for gestation in 30 of 507 singleton pregnancies after excluding pregnancies complicated by fetal neural tube defects. The serum alpha-fetoprotein levels were significantly more often elevated in pregnancies complicated by prematurity, fetal heart rate abnormalities, delivery of a small for dates infant, a perinatal death and admission of the baby to the neonatal unit. While the predictive value of an elevated serum alpha-fetoprotein was 76% for abnormal outcomes in general it ranged between only 16% and 46% for specific abnormalities. The usefulness of this assay relates only to its ability to predict an abnormal outcome when performed during the second trimester.