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Archives of Gynecology and Obstetrics Apr 2024The incidence, diagnosis, management and outcome of face presentation at term were analysed.
OBJECTIVES
The incidence, diagnosis, management and outcome of face presentation at term were analysed.
METHODS
A retrospective, gestational age-matched case-control study including 27 singletons with face presentation at term was conducted between April 2006 and February 2021. For each case, four women who had the same gestational age and delivered in the same month with vertex position and singletons were selected as the controls (control group, n = 108). Conditional logistic regression was used to assess the risk factors of face presentation. The maternal and neonatal outcomes of the face presentation group were followed up.
RESULTS
The incidence of face presentation at term was 0.14‰. After conditional logistic regression, the two factors associated with face presentation were high parity (adjusted odds ratio [aOR] 2.76, 95% CI 1.19-6.39)] and amniotic fluid index > 18 cm (aOR 2.60, 95% CI 1.08-6.27). Among the 27 cases, the diagnosis was made before the onset of labor, during the latent phase of labor, during the active phase of labor, and during the cesarean section in 3.7% (1/27), 40.7% (11/27), 11.1% (3/27) and 44.4% (12/27) of cases, respectively. In one case of cervical dilation with a diameter of 5 cm, we innovatively used a vaginal speculum for rapid diagnosis of face presentation. The rate of cesarean section and postpartum haemorrhage ≥ 500 ml in the face presentation group was higher than that of the control group (88.9% vs. 13.9%, P < 0.001, and 14.8% vs. 2.8%, P = 0.024), but the Apgar scores were similar in both sets of newborns. Among the 27 cases of face presentation, there were three cases of adverse maternal and neonatal outcomes, including one case of neonatal right brachial plexus injury and two cases of severe laceration of the lower segment of the uterus with postpartum haemorrhage ≥ 1000 ml.
CONCLUSIONS
Face presentation was rare. Early diagnosis is difficult, and thus easily neglected. High parity and amniotic fluid index > 18 cm are risk factors for face presentation. An early diagnosis and proper management of face presentation could lead to good maternal and neonatal outcomes.
PubMed: 38594406
DOI: 10.1007/s00404-024-07406-4 -
American Journal of Perinatology May 2024This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.
OBJECTIVE
This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.
STUDY DESIGN
We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes.
RESULTS
Among 495 birthing people (PRE, = 293; POST, = 202), IOL length was shorter POST (22.0 vs. 18.3 h, = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, = 0.009), vaginal misoprostol (34.5 vs. 68.3%, < 0.001), and early amniotomy (19.1 vs. 31.7%, = 0.001) increased POST.
CONCLUSION
Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.
KEY POINTS
· Implementation of an IOL guideline is associated with faster time to delivery.. · Evidence-based induction practices were used more often after guideline implementation.. · Adoption of evidence-based induction practices is variable even with a guideline..
PubMed: 38593985
DOI: 10.1055/a-2302-7334 -
Annals of Medicine and Surgery (2012) Apr 2024Uterine arteriovenous malformations (AVMs) are a rare cause of obstetrical hemorrhage. It can be congenital due to a defect during embryogenesis or acquired. Uterine...
INTRODUCTION
Uterine arteriovenous malformations (AVMs) are a rare cause of obstetrical hemorrhage. It can be congenital due to a defect during embryogenesis or acquired. Uterine AVMs can cause life threatening postpartum hemorrhage, and is most frequently misdiagnosed. This case highlights the diagnostic challenges posed by uterine arteriovenous malformation, a rare vascular anomaly that poses significant challenges in diagnosis and management.
CASE PRESENTATION
This case report details the clinical presentation, diagnostic challenges, and treatment approach for a 39-year-old woman. In the absence of a medical history indicative of pre-existing ailments, the individual in question has undergone two emergency cesarean sections as documented in her surgical history, in addition to two previous dilation and curettage D&C operations. The patient presented with heavy vaginal bleeding 6 months after a cesarean section. The patient's clinical presentation, imaging findings, and intraoperative observations collectively substantiate the diagnosis of uterine AVMs.
DISCUSSION
Women who have had uterine instrumentatio surgery, such as a cesarean section or dilatation and curettage (D&C) are more likely to develop acquired uterine AVMs. The absence of uterine artery embolism options compelled the use of alternative diagnostic methods, including contrast MRI, which successfully detected abnormal vascular lesions. The choice for hysterectomy was influenced by the patient's completion of childbearing and the presence of large vessels in proximity to critical regions.
CONCLUSION
This case emphasizes the significance of adapting treatment plans based on local resource constraints and the need for ongoing efforts to enhance diagnostic capabilities in undeserved regions.
PubMed: 38576934
DOI: 10.1097/MS9.0000000000001832 -
Journal of the College of Physicians... Apr 2024To determine the frequency of successful trials of vaginal birth after Caesarean section (VBAC) using the Flamm and Geiger model. (Observational Study)
Observational Study
OBJECTIVE
To determine the frequency of successful trials of vaginal birth after Caesarean section (VBAC) using the Flamm and Geiger model.
STUDY DESIGN
Observational study. Place and Duration of the Study: Obstetrics and Gynaecology Unit II of Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan, from August 2022 to January 2023.
METHODOLOGY
Women with singleton pregnancy having cephalic presentation, previous one lower segment caesarean section (LSCS), and without any contraindication for vaginal delivery were included. Women bearing foetus having estimated weight >3.5kg, morbid obesity, multiple pregnancies, non-cephalic presentation, placenta praevia, abruptio placentae, uncontrolled maternal comorbidities, or had previous two or more Caesarean sections were excluded. Flamm and Geiger score was applied to record observations of successful and unsuccessful trials. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the score were calculated by ROC curve, along with its area under the curve (AUC) and Youden's index curve, with 95% confidence interval.
RESULTS
This study included 258 participants. Successful vaginal delivery was possible in 125 (48.4%) participants, whereas 133 (51.6%) underwent emergency Caesarean section. Cervical dilatation and effacement were the main factors assessing the success. The Flamm and Geiger score of >5 had an area under the curve of 0.813 (0.762-0.864). The score's sensitivity was 75% (67-82%), specificity 76% (68-82%), and PPV of 75% with an accuracy of 76%.
CONCLUSION
The Flamm and Geiger score of >5 demonstrated high sensitivity, specificity, PPV, and accuracy in predicting later successful vaginal birth. It is recommended as a promising and valuable tool for assessing VBAC's success in low-resource countries.
KEY WORDS
Vaginal birth after caesarean, Flamm and Geiger Model, Indication of caesarean, trial of labour after caesarean, VBAC risk scoring criteria.
Topics: Female; Humans; Pregnancy; Cesarean Section; Delivery, Obstetric; Labor, Obstetric; Pakistan; Vaginal Birth after Cesarean
PubMed: 38576287
DOI: 10.29271/jcpsp.2024.04.440 -
Gynecologic and Obstetric Investigation Apr 2024To evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies.
OBJECTIVES
To evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies.
DESIGN
Retrospective cross-sectional study (ClinicalTrial iD: NCT06184139), including only late-term pregnancies in healthy nulliparous women and single cephalic fetus with normal birthweight. Specify the type of study (randomized, prospective cohort, case-control, other) and include the number of study subjects (cases/controls), treatment type and duration, sampling procedures if applicable.
PARTICIPANTS/MATERIALS, SETTING, METHODS
One-hundred-and-four pregnant women underwent induction of labor with oral misoprostol for late-term pregnancy on the 290th day of gestation. Study population was divided in two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). Statistical analysis was performed using SPSS V.21.0 (IBM Corporation, Armonk, NY). The inclusion of 51 women from each of the two arms achieved 80% power with an alpha error of 0.05. Continuous variables were expressed as the mean and standard deviation (SD). Categorical variables are expressed as frequencies and percentages. Results No statistically significant differences were recorded between younger and older women. Obese women reported a longer time between the last dose of misoprostol and cervical dilation of 6 cm (p=0.01), a longer time between the last dose of misoprostol and delivery (p=0.04), and a higher rate of grade II vaginal lacerations (p=0.02). Limitations While this study contributes novel insights into cervical ripening and labor induction using oral misoprostol for late-term pregnancies, its scope is limited by the retrospective study design, inherently carrying biases compared to prospective approaches, and the limited sample size within the study cohort. Conclusions Maternal BMI is a factor negatively influencing the efficacy of oral misoprostol for induction of labor in late-term pregnancy.
PubMed: 38565086
DOI: 10.1159/000538374 -
Fertility and Sterility Mar 2024Müllerian agenesis, known as Mayer-Rokitansky-Küster-Hauser syndrome, is characterized by the absence of the uterus, cervix, and two thirds of the proximal vagina. To...
BACKGROUND
Müllerian agenesis, known as Mayer-Rokitansky-Küster-Hauser syndrome, is characterized by the absence of the uterus, cervix, and two thirds of the proximal vagina. To allow sexual intercourse, dilatator-based conservative approaches and Vecchietti vaginoplasty generate progressive traction on the vaginal stump until adequate vaginal size is achieved. Other approaches create the neovagina using mucous/cutaneous, peritoneal, or ileal/sigmoid grafts or cutaneous flaps from the genitalia to fulfill a newly developed space between the bladder and rectum. The drawback of the first approach is the long time required, whereas stenosis, dehiscence, poor esthetic results, or absence of vaginal sensitivity limit the latter.
OBJECTIVE
To present a new surgical technique on the basis of an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of the external genitalia.
DESIGN
Video demonstration of the surgical steps.
PATIENT(S)
An 18-year-old woman with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counseling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve the external genitalia with the chance to have a sensitive vagina guided the choice.
INTERVENTION(S)
The cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm-long canal bounded anteriorly by the bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying the vascular-from the pudendal artery-and nervous pedicles. A tunnel between the flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching the vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. The inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. During the postoperative period, no special positioning or ambulation restrictions were used.
MAIN OUTCOME MEASURE(S)
Compliance and sensitivity of the neovagina, esthetic result, and perioperative and long-term complications.
RESULT(S)
The postoperative course was uneventful, with early mobilization. The length of hospital stay was 16 days to allow proper vaginal dilator use; initial daily followed by intermittent use was planned. At a 2-year follow-up, the neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and esthetic result.
CONCLUSION(S)
The new surgical technique was feasible and effective, preserving the external genitalia and avoiding graft healing and bowel secretion drawbacks without an intra-abdominal surgical step and related risks. However, more cases-2 cases performed to date with similar results-and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and the connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.
PubMed: 38554765
DOI: 10.1016/j.fertnstert.2024.03.022 -
International Journal of Gynaecology... Mar 2024To determine the reliability of the Carousel simulator in medical education for obstetric examinations. Cervical dilation examination training in pregnant women exposes...
OBJECTIVE
To determine the reliability of the Carousel simulator in medical education for obstetric examinations. Cervical dilation examination training in pregnant women exposes patients to additional uncomfortable and health-risk procedures, a gold standard, and does not objectively evaluate the medical student's competence.
METHOD
We studied the reliability of training internship medical students in obstetrics. Participating students were assigned to take the examination of digital assessment of the cervical dilation on the simulator. Classes performed 12 consecutive randomly blind predetermined cervical dilation examinations using the Carousel simulator. The exact answer and the answer with certainty within ±1 cm were registered and analyzed. Incorrect or outlier answers were considered with a cutoff of ≥2 cm from the dilation. A dispersion graph for each centimeter of dilation simulation was constructed.
RESULTS
Sixty-six medical obstetricians took part, performing 396 examinations. Thus, we observed 49 outliers (12.37%) in simulated assessments. According to the analysis, we did not observe outliers from dilation 1 to 4 cm; dilation 7 to 9 cm had a higher index of outlier measurements. We did not consider any dilation simulation dispersion graphic as a null correlation. A strong correlation was seen in the dilation 1 to 6 cm and the dilation 10 cm. The dilations 7, 8, and 9 cm showed a weak correlation.
CONCLUSION
The Carousel simulator model is a reliable method for student learning. The simulator is an essential study tool capable of reducing the embarrassment and possible harm caused by the excessive and repetitive number of in vivo digital vaginal examinations. Novel studies are proposed to improve the simulator device and method, mainly to estimate the adequate repetitions and training needed before in vivo practice.
PubMed: 38554012
DOI: 10.1002/ijgo.15508 -
Medicine Mar 2024Puerperal sepsis is a life-threatening condition caused by infection that can rapidly progress to multisystem infection and toxin-mediated shock. Symmetrical peripheral...
RATIONALE
Puerperal sepsis is a life-threatening condition caused by infection that can rapidly progress to multisystem infection and toxin-mediated shock. Symmetrical peripheral gangrene is defined as symmetrical distal ischemic damage in two or more sites in the absence of major vascular occlusive disease. The syndrome is devastating and rare. In this study, we introduce a case of puerperal septicemia complicated by symmetrical peripheral gangrene.
PATIENT CONCERNS
A 23-year-old woman delivered a live female infant vaginally after cervical balloon dilatation at 39 weeks of gestation. Persistent hyperthermia developed on the first postpartum day. After experiencing ventricular fibrillation, acute liver failure, and acute pulmonary edema, she developed blackened extremities on the 5th postpartum day.
DIAGNOSES
Puerperal septicemia complicated by symmetrical peripheral gangrene.
INTERVENTIONS
Upon transfer to our hospital, the patient was enrolled in the intensive care unit and underwent anti-infective and amputation surgery.
OUTCOMES
After the surgery, the patient recovered well and was successfully discharged from the hospital.
LESSONS
Early detection and timely treatment is the best way to reduce the mortality and sequelae of puerperal sepsis. Physicians should be alert to the possibility of comorbid symmetrical peripheral gangrene when sepsis patients present with hepatic impairment.
Topics: Humans; Female; Young Adult; Adult; Gangrene; Shock, Septic; Extremities; Amputation, Surgical; Postpartum Period
PubMed: 38552074
DOI: 10.1097/MD.0000000000037571 -
American Journal of Obstetrics &... Apr 2024Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than...
BACKGROUND
Trial of labor after cesarean after 2 cesarean deliveries is linked to a lower success rate of vaginal delivery and higher rates of adverse obstetrical outcomes than trial of labor after cesarean after 1 previous cesarean delivery.
OBJECTIVE
This study aimed to investigate the factors associated with failed trial of labor after cesarean among women with 2 previous cesarean deliveries.
STUDY DESIGN
This was a multicenter retrospective cohort study, which included all women with singleton pregnancies attempting trial of labor after cesarean after 2 previous cesarean deliveries between 2003 and 2021. This study compared labor, maternal, and neonatal characteristics between women with failed trial of labor after cesarean and those with successful trial of labor after cesarean. Univariate analysis was initially performed, followed by multivariable analysis (adjusted odds ratios with 95% confidence intervals).
RESULTS
The study included a total of 1181 women attempting trial of labor after cesarean after 2 previous cesarean deliveries. Among these cases, vaginal birth after cesarean was achieved in 973 women (82.4%). Women with failed trial of labor after cesarean had higher rates of maternal and neonatal morbidities. Several factors were found to be associated with failed trial of labor after cesarean, including longer interpregnancy and interdelivery intervals, lower gravidity and parity, lower rates of previous successful vaginal delivery, smoking, earlier gestational age at delivery (38.3±2.1 vs 39.5±1.3 weeks), late preterm delivery (34-37 weeks of gestation), lower cervical dilation on admission, no use of epidural, and smaller neonatal birthweight. Our multivariable model revealed that late preterm delivery (adjusted odds ratio, 3.79; 95% confidence interval, 1.37-10.47) and cervical dilation on admission for labor <3 cm (adjusted odds ratio, 2.58; 95% confidence interval, 1.47-4.54) were associated with higher odds of failed trial of labor after cesarean.
CONCLUSION
In the investigated population of women with 2 previous cesarean deliveries undergoing trial of labor after cesarean, admission at the late preterm period with a cervical dilation of <3 cm, which reflects the latent phase, may elevate the risk of failed trial of labor after cesarean and a repeated intrapartum cesarean delivery.
Topics: Humans; Female; Pregnancy; Trial of Labor; Retrospective Studies; Adult; Vaginal Birth after Cesarean; Infant, Newborn; Parity; Cesarean Section, Repeat; Risk Factors; Gestational Age; Cesarean Section
PubMed: 38536661
DOI: 10.1016/j.ajogmf.2023.101209 -
PloS One 2024This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as...
OBJECTIVES
This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation.
METHODS
A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies.
RESULTS AND IMPLICATIONS FOR RESEARCH
Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle-income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness.
Topics: Pregnancy; Female; Humans; Labor Stage, First; Retrospective Studies; Labor, Obstetric
PubMed: 38517902
DOI: 10.1371/journal.pone.0298046