Implementation of a breech program in a Belgian obstetric team

OBJECTIVE

To stimulate obstetric centers to start training in breech counseling and selection and performing vaginal breech deliveries.

METHODS

The different steps that were needed to roll out a breech program, are described: the "walking" epidural (PIEB protocol), the breech consultation with a structured counseling tool, and training of the whole team (gynecologists, midwives, anesthesiologists, and pediatricians). We describe below the results of 111 women who were counseled at the breech consultation, in the period May 2019 to August 2021.

RESULTS

In all, 86.5% of patients (n= 96) with a singleton term breech met the criteria for a vaginal breech delivery; 77% of this group (n= 74) accepted a planned vaginal breech delivery. Of this group, 54% (n=40) had a successful vaginal breech delivery, 27% (n=20) ended up in a secondary cesarean section, and 19% (n=14) had a planned cesarean section.

CONCLUSION

We were able to roll out a successful breech program, including vaginal breech delivery, in a safe way. The breech consultation is the most essential part of the process. Training of the whole team is mandatory. The results of the first 2 years are encouraging to continue this program.

Recurrent uterine artery pseudo-aneurysm requiring repeat embolization during pregnancy - A case report

Background

Uterine artery pseudo-aneurysms (UAP) mainly occur after traumatic delivery or traumatic pregnancy termination. A UAP can be either asymptomatic or present with symptoms such as vaginal bleeding, abdominal pain, hypovolemic shock, or fever when infected. We describe a patient diagnosed with a uterine artery pseudo-aneurysm in pregnancy that required repeat embolization. The patient had no risk factors in her recent medical history. She did, however, undergo in-vitro fertilization with oocyte retrieval performed under transvaginal ultrasonographic guidance. We suggest the hypothesis of formation of the pseudo-aneurysm secondary to vascular injury during oocyte retrieval.

Case Report

A 35-year-old primigravida, who conceived by in-vitro fertilization, presenting with severe abdominal pain at 19 2/7 weeks of gestation. Ultrasound examination with color doppler imaging revealed a hypo-echoic lesion with turbulent arterial flow pattern on the lower left side of the uterus. Selective catheterization and subtraction angiography permitted diagnosis of a large pseudo-aneurysm of the left uterine artery. A selective embolization was performed. Recanalization of the embolized artery was confirmed 11 weeks after initial presentation, requiring repeat embolization. A planned caesarean section was performed at 34 weeks of gestation and a healthy boy was born with a birth weight of 2065 g.

Conclusion

Uterine artery pseudo-aneurysm is a rare but potentially life-threatening condition. It can be diagnosed using (doppler) ultrasound, revealing a hypoechoic mass with swirling blood flow. Angiography is the standard reference in diagnosing UAP and may provide definitive treatment. Management with selective unilateral uterine artery embolization appears to be safe in hemodynamically stable patients. It does not compromise uteroplacental circulation and may help to prolong the pregnancy, reducing morbidity associated with preterm birth.

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Hypothesis of formation of pseudoaneurysm secondary to vascular injury during oocyte retrieval.

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A uterine artery pseudoaneurysm (UAP) should be considered in women with severe abdominal pain in pregnancy

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To our best knowledge, this is the first case report of UAP requiring repeat embolization during pregnancy