B-Lynch sutures for major primary postpartum haemorrhage at caesarean section.

This was a retrospective observational study of 11 consecutive patients of major primary postpartum haemorrhage (PPH) who had the B-Lynch suture at the time of caesarean section, performed between 1 March 2001 and 31 March 2004 at a teaching hospital in Scotland. Case-note review was performed in 123 patients, who had major primary PPH to identify patients who had B-Lynch sutures at the time of caesarean section. The patient's age, parity, gestation of pregnancy at which the B-Lynch suture was performed, the indication for caesarean section and the cause of primary major PPH were recorded. The operative details, intraoperative and immediate postoperative complications and the need for subsequent hysterectomy were noted. The patients were followed-up with clinic visits at 6 weeks and any further hospital referral for late postoperative complications and whether subsequent successful pregnancy was achieved, were documented. The incidence of major PPH in our centre was 0.5% of the total deliveries, of which 11 cases had the B-Lynch suture applied at the time of caesarean section. The patients were aged between 25 and 38 years old (mean 31 years). Parity ranged from 0 to 1 and the gestational age at which the procedure was performed ranged from 34 to 41 weeks (mean 38 weeks). Ten operations (91%) were performed by senior registrars supervised by the consultant on call and one (9%) case was performed by a consultant on call. All cases had the B-Lynch sutures performed for major primary PPH caused by uterine atony at the time of caesarean section. The weight of the babies delivered ranged between 2,110 - 4,820 g (mean 3,500 g). The total blood loss at surgery ranged from 2,000 - 10,000 ml (mean 3,500 ml). Only three patients (28%) required hysterectomy. All the patients made a good postoperative recovery. The hospital stay ranged from 4 - 24 days (mean 8 days). The patient who remained in hospital for 24 days did so because her baby was admitted into the neonatal unit. All the patients were reviewed 6 weeks postnatally. There was no significant morbidity. A subsequent successful pregnancy has been achieved in one patient.     

Is obstetric and neonatal outcome worse in fetuses who fail to reach their own growth potential?

OBJECTIVES: To determine the perinatal outcome of fetuses who had birthweights less than that expected from early third trimester ultrasound scanning. DESIGN: Retrospective estimation of centile fetal weight at early third trimester ultrasound scanning compared with actual centile birthweight corrected for gestational age, parity and sex. SETTING: Teaching Hospital Obstetric Unit, London. SUBJECTS: 197 unselected women with singleton cephalic pregnancies who were delivered at term in our unit between October 1989 and May 1990. MAIN OUTCOME MEASURES: CTG abnormality, need for fetal blood sampling in labour, meconium-staining of the amniotic fluid, mode of delivery, Apgar scores at 1 and 5 min, need for transfer of baby to neonatal unit, and need for neonatal intubation of the neonate at delivery. RESULTS: An actual birthweight greater than 5% less than the birthweight estimated from ultrasound scanning identified 44 babies (22%) with an increased risk of CTG abnormalities (chi 2 = 8.38, P less than 0.0025; Odds ratio (OR) = 2.54; 95% CI 1.36 to 4.78) and need for operative delivery (chi 2 = 5.81, P less than 0.0125; OR = 1.94; 95% CI 1.15 to 3.27), when compared with the remainder of the sample. Overall 14 (32%) of this group had birthweights above the 50th centile. A group of 44 babies selected as being the smallest for gestational age, without reference to growth pattern, had a similar excess morbidity. (All this group had birthweights below the 39th centile). CONCLUSIONS: This study supports the hypothesis that in-utero fetal growth pattern is as important for perinatal outcome as being small for gestational age per se.     

Bruton tyrosine kinase gene mutations in Argentina

The block in differentiation from pro-B to pre-B cells results in a selective defect in the humoral immune response characteristic of human X-linked agammaglobulinemia (XLA). Mutations of Bruton tyrosine kinase (BTK) gene have been identified as the cause of XLA. Mutation detection is the most reliable method for making a definitive diagnosis, except when clinical and laboratory findings are distinctive and coupled with history of X-linked inheritance. To provide a definitive diagnosis to 40 families incorporated in the Argentinian Primary Immunodeficiencies Registry we analysed the BTK gene by SSCP analysis as screening method for XLA, followed by direct sequencing. The molecular defect was localized in 45 patients from 34 unrelated families. From the 34 independent mutations identified, 16 were previously undescribed, 31 were unique mutations, 22 were exonic single nucleotide changes (16 missense and 6 nonsense) and four intronic mutations. Because five families had clinical, immunological and inheritance data sufficient for a definitive diagnosis, our study allowed 37 patients from 29 families previously categorized probable/ possible XLA, have now definitive diagnosis leading to appropriate genetic counseling.     

Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study

Objective  To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section.
Main outcome measures  The evolution of decision making, women's participation in decision making, and factors affecting decision making.
Design and methods  A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective.
Setting  An antenatal unit in a large teaching hospital in Scotland and participants' homes.
Sample  Twenty-six women who had previously had a caesarean section for a nonrecurrent cause.
Results  Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section.
Conclusion  Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.     

Severe alpha1-antitrypsin deficiency and pregnancy.

This case study describes a successful pregnancy in a 27-yr-old patient with severe emphysema, secondary to alpha1-antitrypsin deficiency, genotype PiZZ. Despite significant respiratory compromise, more severe than previously reported, no complications ensued. Maternal pulmonary function did not deteriorate significantly until the 32nd week of pregnancy, with an elective Caesarean section being performed during the 37th week. This experience suggests that even severe maternal airflow obstruction is, in itself, not an absolute contra-indication to pregnancy. Pre-pregnancy multidisciplinary counselling is likely to be helpful in these patients, including frank discussion on the risks of pregnancy, the prospects of successful completion and the mother's future prognosis in relation to caring for the child.