[Epidural anesthesia for cesarean section in a patient with von Hippel-Lindau disease]

Von Hippel-Lindau disease is a dominant autosomal genetic condition with variable penetrance and expressivity. It is characterized by hemangioblastomas in multiple organs but mainly in the retina and cerebellum. There is a predisposition to carcinoma. We report a cesarean section in a 28-year-old woman with von Hippel-Lindau disease. She had no neurologic symptoms at the time of the operation but a history of ocular and cerebellar involvement and several procedures to remove cerebellar hemangioblastomas. Epidural anesthesia was chosen given that there was no nervous system involvement at the time of surgery.

The frequency and complication rates of hysterectomy accompanying cesarean delivery

OBJECTIVE

To estimate the frequency, indications, and complications of cesarean hysterectomy.

METHODS

This was a prospective, 2-year observational study at 13 academic medical centers conducted between January 1, 1999, and December 31, 2000, on all women who underwent a hysterectomy at the time of cesarean delivery. Data were abstracted from the medical record by study nurses. The outcomes included procedure frequency, indications, and complications.

RESULTS

A total of 186 cesarean hysterectomies (0.5%) were performed from a cohort of 39,244 women who underwent cesarean delivery. The leading indications for hysterectomy were placenta accreta (38%) and uterine atony (34%). Of the hysterectomy cases with a diagnosis recorded as accreta, 18% accompanied a primary cesarean delivery, and 82% had a prior procedure (P<.001). Of the hysterectomy cases with atony recorded as a diagnosis, 59% complicated primary cesarean delivery, whereas 41% had a prior cesarean (P<.001). Major maternal complications of cesarean hysterectomy included transfusion of red blood cells (84%) and other blood products (34%), fever (11%), subsequent laparotomy (4%), ureteral injury (3%), and death (1.6%). Accreta hysterectomy cases were more likely than atony hysterectomy cases to require ureteral stents (14% compared with 3%, P=.03) and to instill sterile milk into the bladder (23% compared with 8%, P=.02).

CONCLUSION

The rate of cesarean hysterectomy has declined modestly in the past decade. Despite the use of effective therapies and procedures to control hemorrhage at cesarean delivery, a small proportion of women continue to require hysterectomy to control hemorrhage from both uterine atony and placenta accreta.

LEVEL OF EVIDENCE

II.

Posterior uterine rupture in a woman with a previous Cesarean delivery

A 33-year-old primipara with a previous low transverse Cesarean delivery underwent labor induction at 41 weeks' gestation with a 10-mg dinoprostone vaginal insert. Eleven hours later, with the cervix fully dilated, an emergency Cesarean delivery was performed because of repetitive variable decelerations followed by fetal bradycardia. A posterior uterine wall rupture extending from the fundus to the vagina was repaired in layers. The neonate had an Apgar score of 2 and 4 and expired on the 7th day of life.

Pregnancy termination using vaginal misoprostol in women with more than one caesarean section

We set out to evaluate the safety and efficacy of the proposed misoprostol regimen in women with previous multiple caesarean sections. This was a retrospective cohort study of 21 women with more than one caesarean section who underwent termination of pregnancy (TOP) with 400 mug of vaginal misoprostol followed by 200 mug/6 h (max 800 mug). The complete abortion rate was 12/21 (57.14%) and six (28.57%) women had an incomplete abortion. Three TOPs (14.29%) failed. In the first trimester group, only 3/9 (33.34%) aborted completely, while (9/12) 75% second trimester patients aborted completely. There were no major complications. The proposed regimen is considered safe and reasonably effective in second trimester TOPs in women with previous multiple caesarean sections. In first trimester patients, the possibility of manual vacuum aspiration (MVA) should be discussed during counselling, or a higher dose should be used as the effectiveness is low.

Sudden cardiac arrest during cesarean section -- a possible case of amniotic fluid embolism

Amniotic Fluid Embolism (AFE) is a rare obstetric catastrophe that occurs in approximately 1/50,000 pregnancies and has a mortality rate in excess of 80%. AFE is a condition that is poorly understood and often difficult to diagnose. We report a case of a healthy 27-yr-old gravid two, 35 wk gestation parturient with a previous Cesarean section two years previously, and presently admitted for emergent Cesarean section due to premature uterine contractions. Induction of general anesthesias was performed with no problem and a male preterm infant with Apgar 8 at 1 min was delivered. Amniotic fluid was bloody and 40% placental abruption existed. Following delivery of the placenta, patient suddenly became plethoric and O2 saturation began to decrease and no pulse could be palpated! Immediate CPR was successful but she was hemodynamically unstable and signs of right heart strain was obvious. Right jugular venous catheterization was performed, vasopressors were administered. After a two hours period of relatively stable vital signs, patient's reflexes returned to normal, however, profound coagulopathy on lab data was reported and she was treated with 10 unit Packed Red Blood Cells (PRBCs), 10 unit FFP and 8 unit platelets, Sodium bicarbonate, oxytocin and Methergine. The patient remained hemodynamically unstable while laparotomy-hysterectomy was performed to stop the bleeding. Unfortunately attempts were unsuccessful and patient died four hours later in ICU. Post-mortem findings showed signs of Disseminated Intravascular Coagulation (DIC), no fetal squamous cells in pulmonary vasculature were found and special staining of Cytokeratin marker shows no positive cells in lumen of vessels. The post-mortem diagnosis of AFE is challenging to forensic investigators and pathologists and can be confirmed by histological confirmation of amniotic fluid contents in the pulmonary vasculature, although they may be difficult to identify. In recent years it has been suggested that AFE is an anaphylactoid reaction to fetal antigens and an elevated serum tryptase level is increasingly being used to support the diagnosis. Sudden onset of cardiovascular collapse and early signs of right heart strain and fulminant DIC supports the diagnosis of AFE in this case, although no fetal debri could be find in pathologic staining.

Neonatal outcomes after elective cesarean delivery

OBJECTIVE

To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC.

METHODS

We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity.

RESULTS

Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use).

CONCLUSION

In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.

LEVEL OF EVIDENCE

II.

Elective primary cesarean section: weighing the risks and benefits

The increasing understanding of the nature and extent of pelvic floor injury during childbirth, coupled with an increasing medico-legal demand to present a flawless baby at the completion of the birth process, has helped fuel the rising cesarean section rate. As more women become educated in the controversies surrounding the protective benefits of cesarean, they may increasingly elect to undergo cesarean delivery primarily. Evidence concerning maternal, fetal, and ethical considerations in this decision is presented.

Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?

OBJECTIVE

The objective of the study was to determine whether a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL).

STUDY DESIGN

Using a previously published prediction model, we categorized women with 1 prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach.

RESULTS

Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P < .001) but not elective repeat cesarean section (ERCS) (P > .05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (relative risk [RR], 2.2; 95% confidence interval [CI], 1.5-3.1) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the 2 groups (RR, 0.8; 95% CI, 0.5-1.2). The results were similar for neonatal morbidity.

CONCLUSION

A prediction model for VBAC provides information regarding the chance of TOL-related morbidity and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.

Severe transfusion-related acute lung injury managed with extracorporeal membrane oxygenation (ECMO) in an obstetric patient

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortality in the United States. Management is usually supportive, including supplemental oxygen, intravenous fluids, and mechanical ventilation if necessary. Most patients recover within 72 hours. We present a nearly fatal case of TRALI in an obstetric patient, which was successfully managed with extracorporeal membrane oxygenation (ECMO).

[Vaginal birth after one previous cesarean section]

OBJECTIVE

To evaluate the frequency of different modes of delivery after one previous cesarean section and those factors which may influence mode of delivery.

MATERIAL AND METHODS

During the study period (1.1.2001-31.12.2005) 925 women with a previous cesarean section and a following singleton pregnancy were identified and included. Information regarding mode of delivery, induction of labor, instrumental delivery, the urgency and indications for first and second cesarean section, birth weight and Apgar scores were collected retrospectively.

RESULTS

Trial of labor (TOL) was initiated for 564 women of which 61% were successful while 39% delivered by an emergent cesarean section. In total, 346 women delivered vaginally (37%), 341 women (37%) delivered with an elective cesarean section and 238 (26%) underwent an emergency cesarean section. The VBAC rate increased during the study period, from 35% to 46%. Women who underwent an elective cesarean section due to fetal malpresentation (most often breech) in their first pregnancy were significantly more likely to have a successful VBAC in their second pregnancy (53%) compared with women who had an elective cesarean section for any other indication (21%) (p<0.0001). Uterine rupture occurred in six women (1%) during TOL, five underwent an emergency cesarean section and had healthy infants while there was one intrapartum fetal death. No correlation was found between birth mode and Apgar scores at five minutes. Perinatal mortality rate was 5,4 per thousand. Trial of labor was less likely to succeed if the infant's birth weight was >4000 grams compared with <4000 grams (p<0.01).

CONCLUSION

The results of this study indicate that VBAC is a safe option for women with a history of one previous cesarean section while in the hospital setting where there are resources for an immediate cesarean section.

KEYWORDS

Vaginal birth after cesarean section (VBAC), uterine rupture, perinatal mortality rate. Correspondence: Hildur Hardardóttir, hhard@landspitali.is.

[Anesthetic management of two cases with placenta percreta that caused massive hemorrhage during cesarean section]

We report the anesthetic management of two cases with placenta percreta that caused massive hemorrhage during cesarean section. These pregnant women, with a past history of cesarean section underwent elective operation after being diagnosed with total placenta previa and suspected adhesion of the placenta. The placenta percreta became evident after laparotomy and the patients underwent total hysterectomy after infant expulsion. They went into serious hemorrhagic shock, and recovered after the application of intensive cardiovascular support and blood transfusion. In recent years, the incidence of adhesion of the placenta has increased, but definitive, preoperative diagnosis is difficult; especially for the severe type: placenta percreta. Therefore, intensive management is necessary for the anesthesia of pregnant women with suspected adhesion of the placenta, including adequate preparation of transfused blood, since it might be difficult to save the mother's life after the onset of massive hemorrhage.

Decision support for women choosing mode of delivery after a previous caesarean section: a developmental study

OBJECTIVE

To examine the impact of a decision support intervention designed for women choosing mode of delivery after one previous caesarean section.

METHODS

A decision support intervention was developed comprising of an informational DVD/video and a home visit by a midwife. 16 women received standard clinical care and 16 women additionally received the intervention. Pilot questionnaire data was collected at 12, 28 and 37 weeks gestation from all participants. 18 of the 32 participants also participated in semi-structured interviews after they had decided mode of delivery at 37 weeks gestation.

RESULTS

Four themes were identified in the qualitative data relating to decision-making: informational support, emotional support, participation and involvement in decision-making, and the way in which decision support was used.

CONCLUSION

The difficulties experienced by women in this decision-making scenario were confirmed. The intervention was welcomed by the participants and both qualitative and quantitative findings suggest the intervention improved decision-making experiences.

PRACTICE IMPLICATIONS

This intervention offers an accessible method of decision support which effectively targets the needs of women choosing mode of delivery after a previous caesarean delivery. Using easily reproducible informational materials, and the pre-existing skills of midwives, it would be relatively straightforward to introduce this intervention into current clinical practice.

Evaluation of pregnant women with scarred uterus in a low resource setting

AIM

Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided.

METHODS

An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted.

RESULTS

A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively).

CONCLUSIONS

Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple.

Hemolytic Transfusion Reaction After Preoperative Prophylactic Blood Transfusion for Sickle Cell Disease in Pregnancy

BACKGROUND

Preoperative transfusions are frequently given to prevent morbidity in nonpregnant patients with sickle cell disease. We describe a case of a life-threatening delayed hemolytic transfusion reaction with hyperhemolysis syndrome in pregnancy.

CASE

A multigravida with sickle cell disease underwent prophylactic blood transfusion before repeat cesarean delivery. Her immediate postpartum course was uneventful, but on postoperative day number 6 she presented in grave condition with what was thought initially to be an infection versus crisis. Delayed hemolytic transfusion reaction with hyperhemolysis was ultimately diagnosed.

CONCLUSION

In the gravida with sickle cell disease and known multiple red cell antibodies, blood transfusion may incur a higher risk for delayed transfusion reaction, hyperhemolysis syndrome, and possible death. Blood transfusion should be used cautiously in these patients.

Vaginal birth after cesarean delivery in the West African setting

OBJECTIVE

To determine the fetal weight beyond which women with one previous cesarean delivery (CD) are most likely to have a repeat CD.

METHODS

A retrospective cohort study of 586 women who had one previous CD and were undergoing trial of labor was conducted in Accra, Ghana. Following delivery, the women were allocated to one of three groups according to whether they had a successful vaginal delivery, underwent a CD for cephalopelvic disproportion, or underwent a CD for another indication. The groups were then compared using analysis of variance or Kruskal-Wallis tests. Multiple logistic regression was used to assess the effect of fetal weight on the odds of having a repeat CD.

RESULTS

A fetal weight greater than 3.45 kg tripled the odds of having a repeat CD, and the probability of having a repeat CD were 50% for a fetal weight of 3.70 kg.

CONCLUSION

In settings similar to those in Ghana, women who have undergone a previous CD whose fetuses weigh more than 3.70 kg are likely to have less than a 50% chance of having a successful vaginal delivery.

Uterine Compression Sutures for Postpartum Hemorrhage

OBJECTIVE

To review the efficacy, morbidity, and subsequent pregnancy outcome after uterine compression sutures for severe postpartum hemorrhage.

METHODS

A 7-year review (2000-2006) of all uterine compression sutures for postpartum hemorrhage at one tertiary obstetric hospital.

RESULTS

During the 7 years, 28 uterine compression sutures were performed in 31,519 deliveries (1 per 1,126). All were done at the time of cesarean delivery: 22 in 4,870 cesarean deliveries in labor (1 in 221) and 6 in 3,819 elective cesarean deliveries (1 in 637). The indications for suture were atonic postpartum hemorrhage in 25 of 28 (89%), placenta previa in 2 of 28 (7%), and partial placenta accreta in 1 of 28 (4%). Hysterectomy was avoided in 23 of 28 women (82%). Blood transfusion was needed in 13 of 28 (46%), and intensive care in 5 of 28 (18%). Seven women had subsequent uncomplicated term pregnancies, all delivered by elective repeat caesarean delivery.

CONCLUSION

Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy.

Once a cesarean always a cesarean? A computer-assisted decision analysis

OBJECTIVE

A previous decision analysis models for two strategic choices for trial of labor or repeated cesarean after prior cesarean concluded that the degree of wish for an additional future pregnancy appeared to be a major determinant for choice between the two strategic options. We had extended the analysis model to stillbirth and hypoxic-ischemic encephalopathy in addition to placental complications while updating most of the outcomes in the decision tree.

STUDY DESIGN

A model was formulated using a decision tree based on reported probabilities for various outcomes and estimated utilities. The question asked was should trial of labor or repeated cesarean be performed after a prior cesarean, with a varying desire for an additional pregnancy. The highest expected outcome determines the preference of our model.

RESULTS

Our model favors repeated elective cesarean (0.9947) over trial of labor (0.9917) after a previous cesarean and is the preferred approach. This approach was preferable irrespective of the probability of additional pregnancy.

CONCLUSION

In contrary to previous models, when taking into account the occurrence of a live infant birth, birth of an infant with hypoxic-ischemic encephalopathy stillbirth, neonatal death, abnormal placental implantation, hysterectomy and maternal death the preferred approach for women with previous cesarean is an elective repeated cesarean rather than trial of vaginal delivery.

Incidence of adhesions at repeat cesarean delivery

OBJECTIVE

To compare the incidence and severity of adhesions at repeat cesarean delivery based on the closure at primary section.

STUDY DESIGN

A retrospective chart review was conducted for 62 cases of repeat cesarean sections. A score was assigned based on the severity of adhesions. The primary operative report was reviewed, and the closure type recorded. Statistical analysis was performed with a t test, chi2, and ANOVA.

RESULTS

Forty-nine and eight-tenths percent of cases had extensive adhesions. Closure of the peritoneal or rectus abdominis muscle resulted in significantly fewer extensive adhesions than nonclosure (31.2% vs 70.0%; P = .013). The mean adhesion score for the nonclosure group was 2.67, compared with 1.91 for the parietal peritoneal closure group (P = .044) and 1.73 for the rectus muscle group (P = .009), where 1 is no adhesions and 4 is the most severe).

CONCLUSION

Closure of the rectus muscle or the parietal peritoneum at primary section resulted in significantly fewer adhesions at repeat cesarean delivery.