Pulmonary arterial and intracranial calcification in the recipient of a twin-twin transfusion

Pulmonary arterial and intracranial calcifications are rarely found in children. A female infant, the recipient of a twin-twin transfusion syndrome was found, by ultrasound and computed tomography, to have both pulmonary arterial and intracerebral calcification. A rare condition, termed idiopathic arterial calcification of infancy, is the likely cause. This condition carries a poor prognosis and is usually fatal.

Repeat cesarean section in a morbidly obese parturient: a new anesthetic option

Combined spinal epidural anesthesia (CSEA) has become an increasingly popular anesthetic technique for repeat cesarean section. However, the advantages of this technique have not routinely been available to morbidly obese patients because of the lack of an appropriately long needle. We present a case of a morbidly obese parturient who underwent repeat cesarean section under CSEA conducted with the recently introduced (and commercially available) CSEA needle set, specifically designed for morbidly obese patients.

Ripening of the uterine cervix in a post-cesarean parturient: prostaglandin E2 versus Foley catheter

OBJECTIVE

To compare the success and complication rates of prostaglandin E2 tablets (PGE2) and a Foley catheter for the ripening of the uterine cervix in post-Cesarean section parturients.

STUDY DESIGN

The study population in this retrospective cohort study consisted of parturients in their second pregnancy who had undergone Cesarean section in their previous delivery and who underwent ripening of the uterine cervix by using PGE2 (n = 55) or Foley catheter (n = 161) in the current pregnancy. The control group consisted of 1432 post-Cesarean section parturients without induction of labor. We compared the rates of placental abruption, non-reassuring fetal heart rate patterns, intrapartum fetal deaths (IPFD), uterine rupture, Apgar scores, labor dystocia, severe birth canal lacerations, vacuum deliveries and repeated Cesarean section rates in the three groups by using ANOVA, chi2 analysis and Fisher's exact test when appropriate.

RESULTS

A significant increase in the rates of labor dystocia during the first stage (30.4% vs. 11.6%, p < 0.01) and repeated Cesarean deliveries (49.1% vs. 35.2%, p < 0.01) were observed in women in whom the Foley catheter was used as compared to controls, respectively. No such changes were demonstrated in the PGE2 group as compared to the controls. No significant differences were found between the PGE2 group and Foley catheter group as compared to the controls in rates of placental abruption, IPFD, uterine rupture, fetal distress, birth canal lacerations, vacuum deliveries and Apgar scores.

CONCLUSIONS

PGE2 was found to be superior to the Foley catheter for ripening of the uterine cervix in a post-Cesarean parturient, as demonstrated by a lower repeated Cesarean delivery rate.

Prenatal and perinatal factors associated with isolated oral clefting

OBJECTIVE

To describe medical service utilization and maternal morbid conditions of women who carry offspring with oral clefts (OCs), to describe maternal and offspring complications during birth, and to evaluate postnatal characteristics of their newborns with isolated OCs.

METHODS

Two thousand four hundred thirty-seven patients with isolated OCs and 4871 unaffected matched controls meeting inclusion criteria were selected from the U.S. Natality database for 1997. Matching variables were mother's and father's race and child's race, sex, county of birth, and month of birth. Patients and controls were compared in terms of maternal demographic characteristics, gestational complications, physical characteristics of the newborns, maternal exposure to potential risk factors, and adequacy of prenatal care.

RESULTS

Although the quality of care was very good in both groups, low gestational age, low birth weight, and low 5-minute Apgar score are more frequent among newborns with OCs than in unaffected controls. Mothers of offspring with OCs are at increased risk, compared with mothers of controls, of having hydramnios or oligohydramnios, eclampsia, and abruptio placenta. Obstetric procedures, such as amniocentesis, electronic fetal monitoring, induction of labor, tocolysis, and ultrasound, and repeat cesarean deliveries are more frequent among mothers of patients than those of controls. At birth, newborns with isolated OCs are at risk of having hyaline membrane disease and of requiring assisted ventilation, independently of gestational age.

CONCLUSION

The results of this large population-based, case-control study suggest that the presence of an OC in the offspring is associated with increased risk for prenatal and perinatal complications in the mother.

[Estimate of expected cesarean section rate for maternal indications in a population of pregnant women in West Africa (MOMA survey)]

OBJECTIVES

There is still some debate about the optimal rate of cesarean section (CS) needed to achieve better outcome for both mothers and infants in developing countries. We examine here two aspects of the question: i) a simple method to estimate the expected rate of CS according to obstetrical risk; ii) a test of the method to estimate the appropriate rate for maternal indications in a general population of pregnant women in West Africa.

METHODS

This population-based study was conducted in a cohort of pregnant women in six West African countries (MOMA survey): Abidjan (Ivory Coast), Bamako (Mali), Niamey (Niger), Nouakchott (Islamic Republic of Mauritania), Ouagadougou (Burkina Faso), and in three areas of Senegal, two small towns (Fatick and Kafrine, Kaolack region), and one major city (Saint-Louis). 19,459 women with singleton pregnancies with expected breech presentation were followed to delivery and puerperium. Maternal indications for CS were defined as dystocia (prolonged labor over 12 hours), malpresentation, previous cesarean section, abruptio placentae, placenta paevia and eclampsia. A standardized method was used to calculate the number of expected CS in the MOMA population, according to the level of the obstetrical risk.

RESULTS

The minimal needs for Cs for maternal indications were estimated between 3.6 and 6.5 per 100 deliveries. However, we observed a rate of 1.3 CS per 100 deliveries.

DISCUSSION

These findings underline the lack of CS for maternal indications in urban West Africa. The method of standardization we propose could help policy makers, health planners and obstetricians to design programs to reach the appropriate level of CS and to monitor and follow-up these programs.

Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study

OBJECTIVE

To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries.

METHODS

Pregnant women admitted to our hospital from January 1999 to July 2000, for whom elective repeat cesareans were planned after 37 weeks gestation, were allocated randomly after their informed consent to spinal anesthesia or general anesthesia. Maternal age, gestational age, birth weight, Apgar's score, hospital stay duration, and duration of cesarean section time were all noted. The rate of the neonatal respiratory depression, perinatal asphyxia, and admittance to the neonatal intensive care unit of the infants were documented. We also studied arterial samples withdrawn from the cord for the pH, bicarbonate, PaO(2) (oxygen pressure, arterial), and PaCO(2) (carbon dioxide pressure, arterial). The serum levels of creatine kinase with myocardial-specific isoform, aspartate aminotransferase, alanine aminotransferase, and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia (and of myocardial damage). Statistical analyses was performed with the use of an unpaired Student's t-test, Chi-square test, and a power calculation was done.

RESULTS

From the randomly selected patients, we had 38 (45.2%) infants for general anesthesia and 46 (54.8%) for spinal anesthesia. None of our primary endpoints favored any of the study groups, and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia (P>0.05). The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress (P>0.05).

CONCLUSION

Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries. We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants.

[Seventh caesarean section with the same woman--case report]

Seventh caesarean section in the same pregnant woman was described. Pregnancy was terminated in 36 week of gestation cause of preterm uterine activity, after getting pulmonary maturation and estimating ultrasound fetal weight over three kilograms. The caesarean section and postoperative period were uncomplicated. There is little literature about multiple repeat caesarean sections. The authors discuss changes in outcomes and complications of multiple caesarean sections through last three decades.

[Is CV measurement relevant for the verdict "vaginal delivery prohibited"?]

INTRODUCTION

The clinical significance of conjugata vera (CV) values for estimating the possibility of vaginal delivery when caesarean section (CS) has earlier been performed is uncertain and therefore the prognostic value of this parameter was examined.

MATERIALS AND METHODS

We reviewed retrospectively the case notes of women who had had a CS or a vaginal delivery after a previous CS at the Department of Obstetrics and Gynaecology, County Hospital in Herlev, in 1998. For comparison of the results and statistical analysis, probability values (P) were calculated by logistic regression analysis.

RESULTS

The study comprised 246 women, whose CV was measured during the current or a previously performed CS. The probability of an emergency CS in the 106 women with a history of CS showed a clear decline with increasing CV values, (p = 0.006). No obvious difference was found in the distribution of CV values in the 179 women with CS deliveries in 1998, when we compared the indications, "asphyxia" and "others", but it was significantly lower for the indication, "cephalopelvic disproportion" (p = 0.001). Taking into account the CV values, no association was evident between the birth weight, the height of the mother, or the CS probabilities.

DISCUSSION

Our study demonstrated that CV values are considerably predictive of repeated CS; women with CV values < or = 11 cm have a probability of more than 50% for repeated CS and with CV values < or = 10 cm the probability rises to two thirds.

CONCLUSION

CV measurement has value as a parameter in itself and can help the obstetrician to estimate the route of delivery at subsequent births. There is an obvious correlation between low CV values and the probability of CS with "cephalopelvic disproportion" as the indication.

Mode of delivery for the morbidly obese with prior cesarean delivery: vaginal versus repeat cesarean section

OBJECTIVE

We sought to describe the peripartum outcome of women weighing >300 pounds (135 kg) who were candidates for trial of labor after a prior cesarean delivery.

STUDY DESIGN

All pregnant women who weighed in excess of 300 pounds and had a prior cesarean delivery were included in this prospective investigation. Student t test, chi(2) analysis, or Fisher exact tests were used. Odds ratios and 95% confidence intervals were calculated. P <.05 was considered significant.

RESULTS

During a 2-year period, 69 patients met the inclusion criteria; 39 (57%) underwent an elective repeat cesarean delivery, and 30 (43%) women attempted a vaginal delivery after prior cesarean delivery. The demographics of age, race, gravidity, maternal weight, and preexisting medical conditions were similar for the two groups. Vaginal birth after prior cesarean delivery occurred in 13% (4/30). Reasons for failure included a labor arrest disorder in 46%, fetal distress in 38%, and failed induction in 15%. The rates of endometritis and wound breakdown were higher in the women undergoing trial of labor (30% and 23%, respectively) than in those undergoing repeat elective cesarean delivery (20% and 8%). The combined infectious morbidity rate was significantly higher for women attempting trial of labor (53%) than those undergoing elective repeat cesarean delivery (28%; odds ratio 1.78, 95% confidence intervals 1.05, 3.02).

CONCLUSION

The success rate for a vaginal delivery in the morbidly obese woman with a prior cesarean delivery is less than 15%, and more than half of the patients undergoing a trial of labor have infectious morbidity.

Changes in the rate of tubal ligation done after cesarean section

OBJECTIVE

We studied tubal ligations done after cesarean section in a Spanish hospital during a 20-year period, in order to analyze changes in patient characteristics and indications for cesarean delivery.

STUDY DESIGN

We reviewed the clinical records, for the period from 1978 to 1997, of 1996 cases of cesarean section followed by tubal ligation in 108776 births in which the fetus weighed 1000 g or more.

RESULTS

During the 20-year period of study, the proportion of cesarean sections relative to vaginal deliveries increased, as did the frequency of cesarean section followed by tubal ligation relative to cesarean and vaginal deliveries. The proportion of women who underwent tubal ligation after a second cesarean section decreased from 60% during 1978-1982 to 5.6% during 1993-1997. The most frequent maternal pathology associated with gestation was previous cesarean section (60.5%), although 50% of the women had no underlying pathology.

CONCLUSIONS

In our setting, the rate of cesarean section followed by tubal ligation has been increasing steadily since the early 1980s. The proportion of women who requested tubal sterilization and who had only one living child, or who had had a previous cesarean birth, also increased.

Prenatal diagnosis and early in utero management of fetal dyshormonogenetic goiter

We present a case of a fetal dyshormonogenetic goiter diagnosed by ultrasound examination at 24 weeks of gestation, in a woman with no past history of thyroid disease or goitrogen treatment and with normal thyroid tests, including absence of auto-antibodies. In this situation, fetal goiter may only be associated with fetal hypothyroidism, therefore cord blood sampling was not performed but early treatment was initiated. Amniotic fluid instillation of thyroid hormone led to a rapid decrease in amniotic fluid volume and a clear reduction in thyroid goiter. However, fetal thyroid volume did not totally normalise, and cord blood analysis at birth showed elevated fetal TSH level. As prenatal treatment of fetal hypothyroidism remains controversial in euthyroid mothers, the main objective is to prevent obstetrical complications of large goiters. Therefore, in some selected cases with no maternal history of thyroid disease and normal thyroid function tests, cordocentesis is not necessary to confirm fetal thyroid status or to adjust fetal treatment.

Physical sequelae of caesarean section

The complications and recovery from caesarean section are dominated by the medical condition of the woman pre-operatively. Evidence regarding risks directly attributable to the caesarean section is scanty, and often derived from obstetric practice that differs from the current day. Mortality associated with the procedure is anything up to five times that for vaginal delivery, with emergency caesarean section associated with almost twice the risk of elective procedures. Data regarding placenta praevia and placenta praevia-accreta come from population series where antibiotics were not routinely used for caesarean section, but there is no doubt that previous caesarean section increases the risk of both. Antibiotic and thromboprophylaxis at the time of caesarean section decrease morbidity in the index pregnancy, but can also reasonably be expected to reduce future pregnancy complications.

Indications for caesarean section

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.

Vaginal birth following two previous cesarean sections

OBJECTIVE

To evaluate the management of vaginal delivery among women with two previous cesarean sections. The maternal and fetal morbidities of this attitude were studied.

SETTING

University hospital.

DESIGN

Retrospective study made over 6 years, from January 1st 1990 to December 31st 1995.

PATIENTS

Among 180 patients with two uterine scars, 96 patients with cephalic presentation and normal pelvic dimensions were allowed trial of labor.

RESULTS

The rate of vaginal birth following trial of labor was 65.6%. Three patients had an uterine scar dehiscence; among them, one hysterectomy was performed for haemorrhage with uterine atony. Neonatal issue was always favorable. Twenty-two newborns had superior birthweights compared to those born from the preceding cesarean section.

CONCLUSION

Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity.

[Recurrent abnormal motion of the lower legs during the recovery from spinal anesthesia]

A 33-yr-old pregnant woman developed recurrent motor-ataxia-like abnormal motion of the lower legs during the recovery from spinal anesthesia with hyperbaric tetracaine for repeated cesarean section. This symptom was thought to be due to the disturbance of coordination associated with the loss of positional sensation because deep sensory blockade seemed to be stronger and longer than motor blockade. The etiology of this abnormal motion could not be explained clearly, but her anatomical structure of the spine and her sensitivity to local anesthetic may have been related to this phenomenon.

[Delivery of large baby after cesarean section: role of trial of labor. Apropos of 355 cases]

OBJECTIVE

Our goal is to determine whether a trial of labor in women with suspected fetal macrosomia would be a valuable alternative to elective repeat cesarean.

MATERIAL

and methods: Based on retrospective analysis of 355 women with previous cesarean section who delivered macrosomic infants (> or =4,000g), we tried to determine the impact of fetal weight on a trial of labor. The outcomes of trial of labor with fetal macrosomia were compared on the one hand to those of elective repeat cesarean and on the other hand to those of trial of labor with normal birth weight (<4,000g).

RESULTS

The trial of labor was conducted in 297 cases (83,7%), and had led to vaginal birth in 189 cases (63,6%). There were 4 uterine ruptures (1,3%) and 8 uterine dehiscences (2,7%) among the women who underwent a trial of labor. In this group, there were 4 perinatal deaths (1,3%) related in one case to uterine rupture, and 2 brachial plexus injuries related to shoulder dystocia after vaginal birth. Perinatal and maternal outcomes of trial of labor were similar to those of elective repeat cesarean. A trial of labor was more associated with scar separations and lower success rate if the infant weighed 4,000g or more.

CONCLUSIONS

It appears that the use of trial of labor for delivery of large baby with prior cesarean section was associated with lower success rate and the maternal and fetal risks could be increased. However, carefully others controlled studies are necessary to establish the appropriate management in this setting.

[The overall and step-by-step duration of cesarean section]

The purpose of this study is to define the time for different steps of Caesarean section from the moment the women lays on the operating table to the last stitch on the skin. The study is prospective and include 82 elective and emergent CS. The traditional surgical technique is used without omitting any step. The mean stay of the women in the operating theater is 90 min. The preparation for the anesthesia/analgesia is 23 min (range 8-41). The proper time of the operation is 44.3 min. The laparotomy by Pannenstiel incision takes 3 min. The opening time of the uterus is 37 sec (10-190) and the closer on two layers is 17 min (10-35). The extraction of the foetus takes 53 sec (15-180). The exteriorization of the uterus doesn't affect the repair time. Leaving the visceral and parietal peritoneum unsutured can spare 5.5 min. The elective CS takes more time than the emergent one. The time from the beginning of the operation to the extraction of the foetus is longer in resection (7 min) than in first CS (5 min).

Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries

OBJECTIVE

We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries.

STUDY DESIGN

The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses.

RESULTS

Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2)

CONCLUSIONS

Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.

Extreme torsion of the pregnant uterus

Extreme uterine torsion of 180 degrees at term is a rare obstetric event and raises several critical management considerations. We report such a case detected at laparotomy for a repeat Caesarean section. The existing literature on uterine torsion is reviewed and a plan of management is suggested, based on previous reports and our own experience.

Uterine rupture after use of a prostaglandin E2 vaginal insert during vaginal birth after cesarean. A report of two cases

BACKGROUND

Prostaglandin E2, when used for cervical ripening, often initiates labor. Single dosing and ease of removal contribute to the common use of a commercially available prostaglandin E2 vaginal insert. We describe two cases of uterine rupture among 57 pregnancies undergoing attempted vaginal birth after cesarean section.

CASES

Two cases of women attempting vaginal birth after a single low transverse cesarean section were treated with the insert either at 41 weeks, 4 days, or 39 weeks, 3 days, for postdatism or preeclampsia. Signs of uterine rupture included persistent suprapubic pain and repetitive fetal heart rate variable decelerations followed by bradycardia. Infant outcomes were favorable, and tears along the prior low transverse uterine scar were repaired without additional morbidity.

CONCLUSION

This prostaglandin compound is not exempt from being associated directly or indirectly with uterine rupture and requires informed consent and continuous monitoring.

[2 or more cesarean sections--elective repeat cesarean or vaginal delivery?]

Cesarean section rates have been steadily increasing over the past two decades in most countries of the Western world. The review of the literature suggests that a trial of labor in patients with more than one previous cesarean delivery is appropriate, and that these women should be treated no differently from those who have had only one cesarean delivery. Obstetric management should be individualized after thorough patient counseling. If women are carefully selected for a trial of labor and supervised closely, the risk of serious complications can be minimized and a successful outcome achieved. Epidural anesthesia is safe, effective and justified. Similarly, if oxytocin administration is considered medically necessary either to augment or to induce labor, it should be given. It would appear from the present data, that the use of prostaglandins for priming and induction of labor is also safe and effective under consistent supervision. Rupture of the uterine scare is a rare but catastrophic complication (0-2.8%); fetal bradycardia may be the only diagnostic sign. Prompt intervention is necessary to minimize both maternal and neonatal complications. The maternal and fetal outcomes in women who have had multiple previous sections do not differ from those in women after ordinary cesarean section. At present there is no sufficiently predictive method to identify those women most likely to benefit from an elective repeat cesarean delivery.