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AJP Reports Jan 2024Heterotopic triplet pregnancy, cesarean scar ectopic pregnancy, and pregnancy following uterine ablation are all rare events that confer significant morbidity including...
Heterotopic triplet pregnancy, cesarean scar ectopic pregnancy, and pregnancy following uterine ablation are all rare events that confer significant morbidity including spontaneous abortion, intrauterine fetal demise, preterm labor, abnormal placentation, and uterine rupture. A woman in her 30s, G6P4014, with a history of uterine ablation presented with delayed menses and vaginal spotting with imaging showing two intrauterine pregnancies (one with cardiac activity) and one live pregnancy at the cesarean scar. The patient was extensively counseled on risk to her and to the pregnancies; treatment options were discussed including expectant management and termination of pregnancy. The patient underwent an uncomplicated dilation and curettage with bilateral salpingectomy and was discharged home the day of the procedure in stable condition. This case highlights the potential compound effect of comorbid conditions that can pose difficulty in counseling and management. Patients undergoing endometrial ablation should be carefully selected and counseled extensively on highly effective contraception.Suspected cesarean scar pregnancies should be carefully evaluated early in gestation. Management should include thorough counseling and may be indivisualized.Many conditions pose a significant threat to maternal health and warrant a discussion of termination, which should be widely availaible and safe for all who need and/or desire it.
PubMed: 38370332
DOI: 10.1055/s-0044-1779654 -
European Journal of Pediatric Surgery... Jan 2024We present a simple surgical technique aiming to improve urine outflow through the common urogenital sinus in cloaca and facilitate drainage of existing hydrocolpos. The...
We present a simple surgical technique aiming to improve urine outflow through the common urogenital sinus in cloaca and facilitate drainage of existing hydrocolpos. The study included three cases of cloaca with associated hydrocolpos that were operated during the period 2022 through 2023. The patient is placed in the prone position for a standard posterior sagittal anorectoplasty. The distal rectal fistula is severed flush with the vagina/sinus leaving an open defect in the posterior wall of the vagina/sinus. The defect is then widened distally via a vertical incision (∼1 cm) through the posterior wall of the common urogenital sinus toward but not reaching the perineum. This vertical defect is then closed horizontally displacing the posterior vaginal wall downwards toward the perineum (posterior sinuplasty). The postoperative recovery was uneventful in the three cases. Adequate drainage of hydrocolpos was confirmed by imaging at follow-up, as well as improvement of upper urinary tract dilatation. In selected cases of cloaca, posterior sinuplasty is a simple procedure that can be applied during anorectoplasty to provide effective drainage of associated hydrocolpos.
PubMed: 38351952
DOI: 10.1055/a-2204-8629 -
Orphanet Journal of Rare Diseases Feb 2024The European Reference Network for rare Inherited Congenital Anomalies, ERNICA, guidelines for gastroschisis cover perinatal period to help teams to improve care. (Review)
Review
BACKGROUND
The European Reference Network for rare Inherited Congenital Anomalies, ERNICA, guidelines for gastroschisis cover perinatal period to help teams to improve care.
METHOD
A systematic literature search including 136 publications was conducted. Research findings were assessed following the GRADE methodology. The evidence to decision framework was used to determine the strength and direction of recommendations.
RESULTS
The mode or timing of delivery do not impact neonatal mortality, risk of NEC or time on parenteral nutrition (PN). Intra or extra abdominal bowel dilatation predict complex gastroschisis and longer length of hospital stay but not increased perinatal mortality. Outcomes after Bianchi procedure and primary fascia closure under anesthesia are similar. Sutureless closure decreases the rate of surgical site infections and duration of ventilation compared to surgical closure. Silo-staged closure with or without intubation results in similar outcomes. Outcomes of complex gastroschisis (CG) undergoing early or delayed surgical repair are similar. Early enteral feeds starting within 14 days is associated with lower risk of surgical site infection.
RECOMMENDATIONS
The panel suggests vaginal birth between 37 and 39 w in cases of uncomplicated gastroschisis. Bianchi's approach is an option in simple gastroschisis. Sutureless closure is suggested when general anesthesia can be avoided, sutured closure. If anesthesia is required. Silo treatment without ventilation and general anesthesia can be considered. In CG with atresia primary intestinal repair can be attempted if the condition of patient and intestine allows. Enteral feeds for simple gastroschisis should start within 14 days.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Gastroschisis; Treatment Outcome; Retrospective Studies
PubMed: 38347519
DOI: 10.1186/s13023-024-03062-8 -
Cureus Jan 2024This paper will describe the case of a woman who presented with a rare condition called uterine arteriovenous malformation (AVM). A uterine AVM represents a connection...
This paper will describe the case of a woman who presented with a rare condition called uterine arteriovenous malformation (AVM). A uterine AVM represents a connection between veins and arteries in the uterus. Clinicians should always consider this condition for a woman of childbearing age who presents with unexplained vaginal bleeding. In this particular case, a woman had an AVM diagnosed two months following a miscarriage, and a dilation and curettage (D&C), for retained products of conception. This patient presented to the emergency department in apparent distress, although physical examination and initial laboratory values revealed no hemodynamic instability. Ultrasonographic study, followed by an MRI, confirmed the presence of a uterine AVM. Following a consultation with obstetrics and gynecology, she was ultimately referred to an interventional radiologist for a minimally invasive uterine artery embolization. On the day of the procedure, following vascular access, angiography revealed the AVM had spontaneously self-resolved in the interval. In this paper, we will further discuss the possible utility of a repeat ultrasonographic study to reconfirm AVM prior to any surgical procedure, as well as discuss some confounding factors including the use of medroxyprogesterone acetate injections for birth control prior to the formation of the AVM.
PubMed: 38344524
DOI: 10.7759/cureus.52098 -
European Journal of Obstetrics &... Mar 2024This study aims to compare the perinatal outcomes of emergency and elective cervical cerclages.
OBJECTIVE
This study aims to compare the perinatal outcomes of emergency and elective cervical cerclages.
MATERIAL AND METHODS
This retrospective study included a total of 247 patients, with a total of 142 emergency (with a history of mid-trimester miscarriage or vaginal delivery of < 34 weeks and cervical length < 25 mm) and 105 electives cerclage patients (with painless cervical dilation and cervical length <25 mm) who had cerclage with the vaginal cervical McDonald technique between 1.1.2017-1.10.2022. Pregnant women with normal screening tests at weeks 11-14, normal fetal morphology, and singleton pregnancies were included in the study. The study was conducted in a tertiary center providing NICU care for < 1500 g, less than 32 weeks of age, and on a mechanical ventilator. Obstetric and perinatal outcomes were reviewed.
RESULTS
There was no statistical difference between the two groups regarding maternal age or BMI. It was observed that the week of delivery was greater for elective cerclages than for emergency cerclages (mean 34.6 GW versus 30.8 GW). The week of cerclage application was statistically higher in emergency cerclage (19.2 GW versus 16.3 GW p < 0.000). In addition, when we evaluated perinatal complications: prenatal Ex (n34 vs. n8 p < 0.001), C-reactive protein which is a marker of neonatal infection (12.7 mg/L vs. 2.5 mg/L p < 0.022), antibiotic use in the NICU (n 35 vs. n23 p < 0.050), the number of days of antibiotic use in the NICU (mean 15.3 days vs. 10.4 days p < 0.024), rate of NICU intubation (n 27 vs. n 11 p < 0.003), and neonatal sequelae (n 16 vs. n 6 p < 0.016) were significantly higher in the emergency cerclage group than in the elective cerclage group. There was no found significant difference between the progesterone given and not given progesterone after the procedure in term of the weeks of delivery ( 0.810 emergency cervical cerclage; p < 0681 elective cervical cerclage).
CONCLUSION
Considering the available information, the results of elective cerclage seem to be more beneficial for the patient than those of emergency cerclage. Therefore, it would be more reasonable to perform elective cerclage in patients with mid-trimester or preterm miscarriage and concomitant cervical shortening before emergency cerclage is required. Furthermore, the benefit of progestin, in addition after surgical intervention, has not been established.
PubMed: 38323103
DOI: 10.1016/j.eurox.2023.100276 -
American Journal of Obstetrics &... Mar 2024A previous term (≥37 weeks' gestation), full-dilatation cesarean delivery is associated with an increased risk for a subsequent spontaneous preterm birth. The...
BACKGROUND
A previous term (≥37 weeks' gestation), full-dilatation cesarean delivery is associated with an increased risk for a subsequent spontaneous preterm birth. The mechanism is unknown. We hypothesized that the cesarean delivery scar characteristics and scar position relative to the internal cervical os may compromise cervical function, thereby leading to shortening of the cervical length and spontaneous preterm birth.
OBJECTIVE
This study aimed to determine the relationship of cesarean delivery scar characteristics and position, assessed by transvaginal ultrasound, in pregnant women with previous full-dilatation cesarean delivery with the risk of shortening cervical length and spontaneous preterm birth.
STUDY DESIGN
This was a single-center, prospective cohort study of singleton pregnant women (14 to 24 weeks' gestation) with a previous term full-dilatation cesarean delivery who attended a high-risk preterm birth surveillance clinic (2017-2021). Women underwent transvaginal ultrasound assessment of cervical length, cesarean delivery scar distance relative to the internal cervical os, and scar niche parameters using a reproducible transvaginal ultrasound technique. Spontaneous preterm birth prophylactic interventions (vaginal cervical cerclage or vaginal progesterone) were offered for short cervical length (≤25 mm) and to women with a history of spontaneous preterm birth or late miscarriage after full-dilatation cesarean delivery. The primary outcome was spontaneous preterm birth; secondary outcomes included short cervical length and a need for prophylactic interventions. A multivariable logistic regression analysis was used to develop multiparameter models that combined cesarean delivery scar parameters, cervical length, history of full-dilatation cesarean delivery, and maternal characteristics. The predictive performance of models was examined using the area under the receiver operating characteristics curve and the detection rate at various fixed false positive rates. The optimal cutoff for cesarean delivery scar distance to best predict a short cervical length and spontaneous preterm birth was analyzed.
RESULTS
Cesarean delivery scars were visualized in 90.5% (220/243) of the included women. The spontaneous preterm birth rate was 4.1% (10/243), and 12.8% (31/243) of women developed a short cervical length. A history- (n=4) or ultrasound-indicated (n=19) cervical cerclage was performed in 23 of 243 (9.5%) women; among those, 2 (8.7%) spontaneously delivered prematurely. A multiparameter model based on absolute scar distance from the internal os best predicted spontaneous preterm birth (area under the receiver operating characteristics curve, 0.73; 95% confidence interval, 0.57-0.89; detection rate of 60% for a fixed 25% false positive rate). Models based on the relative anatomic position of the cesarean delivery scar to the internal os and the cesarean delivery scar position with niche parameters (length, depth, and width) best predicted the development of a short cervical length (area under the receiver operating characteristics curve, 0.79 [95% confidence interval, 0.71-0.87]; and 0.81 [95% confidence interval, 0.73-0.89], respectively; detection rate of 73% at a fixed 25% false positive rate). Spontaneous preterm birth was significantly more likely when the cesarean delivery scar was <5.0 mm above or below the internal os (adjusted odds ratio, 6.87; 95% confidence interval, 1.34-58; P =.035).
CONCLUSION
In pregnancies following a full-dilatation cesarean delivery, cesarean delivery scar characteristics and distance from the internal os identified women who were at risk for spontaneous preterm birth and developing short cervical length. Overall, the spontaneous preterm birth rate was low, but it was significantly increased among women with a scar located <5.0 mm above or below the internal cervical os. Shortening of cervical length was strongly associated with a low scar position. Our novel findings indicate that a low cesarean delivery scar can compromise the functional integrity of the internal cervical os, leading to cervical shortening and/or spontaneous preterm birth. Assessment of the cesarean delivery scar characteristics and position seem to have use in preterm birth clinical surveillance among women with a previous, full-dilatation cesarean delivery and could better identify women who would benefit from prophylactic interventions.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Male; Premature Birth; Prospective Studies; Cicatrix; Dilatation; Cervical Length Measurement
PubMed: 38278178
DOI: 10.1016/j.ajogmf.2024.101298 -
Medicina (Kaunas, Lithuania) Jan 2024: Long and ineffective labor causes hardships for mothers and doctors and increases the rate of cesarean sections and medical comorbidities. Several factors contribute...
: Long and ineffective labor causes hardships for mothers and doctors and increases the rate of cesarean sections and medical comorbidities. Several factors contribute to effective and less painful labor, including maternal age, parity, fetal characteristics, and the medications or procedures that obstetricians use for labor. We aimed to study the factors that affect labor duration and identify those that make labor more effective. : This retrospective study included 141 patients who underwent normal vaginal deliveries at the Daegu Catholic University Medical Center between April 2013 and April 2022. Among the 141 patients, 44 received pethidine intravenously, 88 received oxytocin intravenously, and 64 received epidural anesthesia. The duration of the active phase and second stage of labor were recorded according to the findings of a manual examination of the cervix and continuous external electronic monitoring. We analyzed maternal and neonatal medical records and performed binomial logistic regression to identify the factors associated with a shorter active phase of labor. The clinical outcomes in mothers and neonates were also evaluated. : Among the various clinical factors, multiparity (odds ratio of parity 0.325) and the use of pethidine (odds ratio 2.906) were significantly associated with shortening the active phase of labor to less than 60 min. The use of epidural anesthesia or oxytocin was not significantly associated with reducing the active phase of labor. When patients were divided into two groups based on whether a pethidine injection had been used during labor, the duration of the active phase was shorter in the pethidine injection group than in the control group for both nulliparas and multiparas. No significant differences in the duration of the second stage of labor were observed between the pethidine injection and control groups. There were no significant differences in pregnancy outcomes, including the need for mechanical ventilation of neonates, Apgar scores, neonatal intensive care unit admissions, number of precipitous deliveries, maternal adverse side effects of drugs, or duration of maternal hospitalization between the two groups. : Pethidine can be safely administered to women during labor to help reduce the duration of the active phase by promoting dilatation of the cervix and preventing complications that may result from prolonged labor. Pethidine may be helpful, especially for those who cannot receive epidural anesthesia or who cannot afford it. However, large-scale randomized controlled studies are required to evaluate the efficacy and safety of this drug during labor. Furthermore, it would be helpful if various studies were conducted depending on the timing of administration and indications for delivery.
Topics: Pregnancy; Infant, Newborn; Humans; Female; Retrospective Studies; Labor, Obstetric; Drug-Related Side Effects and Adverse Reactions; Apgar Score; Cesarean Section
PubMed: 38256403
DOI: 10.3390/medicina60010143 -
Journal of Personalized Medicine Dec 2023We compare the outcomes of physical examination-indicated cerclage (PEIC) between singleton and twin pregnancies and analyze predictive factors for preterm birth < 28...
We compare the outcomes of physical examination-indicated cerclage (PEIC) between singleton and twin pregnancies and analyze predictive factors for preterm birth < 28 weeks of gestation. Patients who underwent PEIC at our center were reviewed. We compared perinatal outcomes between singleton and twin pregnancies. The primary outcome was delivery before 28 weeks of gestation. Also, we analyzed perioperative clinical, laboratory, and sonographic findings to determine the risk factors for predicting preterm birth < 28 weeks. The rate of preterm birth < 28 weeks was not significantly different. Also, neonatal outcomes were not different. Also, we compared the outcomes according to GA (gestational age) at delivery before (Group A) or after (Group B) 28 weeks, which is the primary outcome. In perioperative findings, group A was likely to have more advanced cervical dilatation, bulging membranes into the vagina, positive fFN or IGFBP-1, and shorter postoperative CL (cervical length) than group B. Also, positive fFN or IGFBP-1 and postoperative CL < 21.6 mm were independently associated with a higher risk of preterm birth < 28 weeks. These findings provide the effectiveness of PEIC with twin pregnancy as well as singleton pregnancy and helpful predictive methods that might effectively identify women at high risk of preterm birth < 28 weeks following PEIC.
PubMed: 38248739
DOI: 10.3390/jpm14010038 -
Fertility and Sterility Apr 2024To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The...
OBJECTIVE
To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery.
DESIGN
Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval.
SETTING
Teaching hospital.
PATIENT(S)
A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines.
INTERVENTION(S)
A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL.
MAIN OUTCOME MEASURE(S)
Not applicable.
RESULT(S)
The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy.
CONCLUSION(S)
Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.
Topics: Humans; Pregnancy; Female; Adult; Uterine Artery; Cesarean Section; Retroperitoneal Space; Laparoscopy; Uterine Hemorrhage; Hydatidiform Mole; Uterine Neoplasms; Hemostatics
PubMed: 38211762
DOI: 10.1016/j.fertnstert.2024.01.012