[Prompt resuscitation by obstetric anesthesiologists saved a parturient with amniotic fluid embolism: a case report]

Amniotic fluid embolism (AFE) is a disorder with a high mortarity rate, because it often causes sudden respiratory failure, circulatory collapse and disseminated intravascular coagulation (DIC). We present a case of AFE in which an obstetric anesthesiologist promptly initiated resuscitation of a parturient and saved her without any sequelae. Her fetus was diagnosed as intrauterine fetal demise on 25th gestational week and vaginal delivery under epidural analgesia was planned. One hundred and five minutes after induction of labor with prostaglandine E1, sudden tetanic convulsion occurred with a loss of consciousness. An obstetric anesthesiologist immediately started to resuscitate her and her consciousness was restored. However, noncoagulable vaginal bleeding followed. As the hemorrhage persisted, AFE was suspected. Anesthesiologists gave effective massive transfusion therapy, and she recovered from coagulopathy. Total blood loss was 5,524 g. This case was diagnosed as AFE with high serum sialyl-Tn antigen and zinc-coproporphyrin. The obstetric anesthesiologists are one of the best groups of physicans for resuscitation because they have skills in managing obstetric emergencies such as AFE. In this case, the crucial points for successful resuscitation were prompt obstetric anesthesiologist involvement and good communications with obstetricians and midwives.

Vanishing twins in diamniotic dichorionic in vitro fertilization gestation in mid-second trimester

The authors report a diamniotic dichorionic twin pregnancy after in vitro fertilization (IVF) in mid-second trimester. The dead fetuses were delivered by cesarean section at the 20th week of gestation. The authors discuss management aspects and review of the literature.

Retrospective case study of fetal mummification in cows that did not respond to prostaglandin F2alpha treatment

Mummification of bovine fetuses is an uncommon condition, and cows do not always respond to treatment with prostaglandin F2alpha. The objective of the present retrospective and descriptive case study was to determine the conception rate and survival time of nonresponsive, prostaglandin F2alpha (PGF2alpha)-treated cows (n = 14), following hysterotomy or medical treatment and manual removal. Animal records from 1990 to 2005 from the Centre Hospitalier Universitaire Vétérinaire (CHUV) of the Université de Montréal were studied. Inclusion criteria were the nonexpulsion of the mummified fetus following PF2alpha treatment and absence of concomitant conditions upon physical examination. Of the animals included in the study, 36% (n = 5) became pregnant after extraction of the mummified fetus by hysterotomy and 0% conceived after medical treatment and manual extraction. In this study, hysterotomy represented an effective approach for extracting mummified fetuses from cows that did not respond to PF2alpha treatment.

An unusual case of acute hyperkalemia during pregnancy

We report a rare case of acute hyperkalemia in a patient with chronic kidney disease and intrauterine fetal demise. We propose that the hyperkalemia was due to a potassium load introduced into the maternal circulation as a result of intrauterine fetal demise and uterine rupture.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure

OBJECTIVE

To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure.

METHODS

This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database.

RESULTS

One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored "privacy," "avoiding going to sleep," and "previous experience" higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedure's discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01).

CONCLUSION

Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings.

LEVEL OF EVIDENCE

II-2.

Destructive operations in modern obstetrics

This is a retrospective study carried out over a period of 7 years at a tertiary care hospital to evaluate the indications, types and complications of destructive operations. During this period, 51 destructive operations were performed on women with obstructed labor and intrauterine fetal death. The most common operation performed was craniotomy (68.62%) followed by decapitation (19.60%), evisceration (7.84%) and cleidotomy (3.92%). The most common indication was cephalopelvic disproportion (31.25%). Out of 53 babies delivered (one triplet delivery), two were grossly malformed and 49.05% babies had birth weight between 3.0 kg and 4.0 kg and 9.43% were macrosomic. A total of 45.09% women had complications like atonic PPH, vaginal and perineal tears, puerperal sepsis and urinary tract infection. However, there was no maternal death. It is felt that for the women who belong to poor socio-economic status and have poor compliance and who present late in labor with features of obstruction, intrauterine sepsis and fetal death, destructive operation is still a good option.

[Surgical and conservative methods for removing mummified fetuses in cattle]

The purpose of this study was to describe the findings and therapy in 4 cows and 1 heifer with mummified fetus. All animals were admitted at the clinic after several unsuccessful therapies with prostaglandin F2alpha and local uterine infusions. All animals were in good condition. In case 1, diagnosis of mummified fetus could not be confirmed after manual rectal palpation and ultrasonography whereas cases 2, 4, 5 all had mummified fetus. In case 3, the fetus was in maceration. Initial therapy consisted of administration of prostaglandin F2alpha and prostaglandin E2 followed by repeated administration of prostaglandin E2. Mummies (length from apex to rump 13-32 cm) could be taken out within 3 to 6 days per vias naturales in cases 2, 4, 5 and in case 3, bones (maximal length 4 cm) could be unhinged. The structure in the uterus of case 1 could not be mobilised and was consequently removed under sight control using colpotomy followed by hysterotomy. Animals 2, 3, 4 and 5 were pregnant on the occasion of telephone inquiry. On the basis of our results, we recommend the conservative medical therapy with PGE2 for cases of mummified fetus. Colpotomy and hysterotomy are reserved as therapy feasible if the use of prostaglandin E2 is not successful.

Coexistence of a prolapsed, pedunculated cervical myoma and pregnancy complications: a case report

BACKGROUND

Different types of fibroids may affect reproductive outcome to a different extent, causing infertility and pregnancy wastage. Rectosigmoid compression, prolapse of a pedunculated submucous tumor through the cervix, venous stasis, polycythemia and ascites are infrequently associated with leiomyomas. Uterine leiomyomas arefound in approximately 2% of pregnant women; 1 in 10 causes complications during pregnancy.

CASE

A 37-year-old woman, gravida 3, para 2, abortion 0, at 18 weeks of pregnancy, arrived at our outpatient clinic with a complaint of leaking vaginal fluid. On examination, a prolapsed, pedunculated myoma, measuring 5 x 6 x 7 cm, and pooling of amniotic fluid in the vaginal fornix were detected. Antibiotics were started, but the amniotic fluid leak continued, and the fetal heart beat became undetectable after 12 hours of hospitalization. We tried to excise the myoma from the vagina but because it was very large, we could not reach the proximal point it originatedfrom. We dissected the posterior cervical channel, removed the myoma and performed a total abdominal hysterectomy.

CONCLUSION

Vaginal myomectomy is recommended as the initial treatment of choicefor a prolapsed, pedunculated submucous myoma except when other indications necessitate an abdominal approach. Use of Laminaria and hysteroscopic resection has been mentioned as other treatment choices. In our case a prolapsed, pedunculated cervical myoma was detected along with pregnancy complications, preterm premature rupture of membranes and fetal death. The cause-and-effect relationship between the prolapsed myoma and membrane rupture is unknown. We were unable to perform a vaginal or abdominal myomectomy because the myoma originated in the posterior cervical region, so we had to perform an abdominal hysterectomy.

Amniotic fluid embolism with second trimester pregnancy termination: a case report

PURPOSE

Describe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination.

CLINICAL FEATURES

A 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event.

CONCLUSIONS

It is now recognized that the pathophysiological features of AFE are similar to a type-1 hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.

[Coma caused by hypermagnesemia in a pregnant woman complicated with HELLP syndrome]

This case report describes a pregnant woman with acute renal failure, caused by aggravation of HELLP syndrome, who developed coma induced by overdose of continuous magnesium sulfate administration for eclampsia. Before examination of serum concentration of magnesium, coma was suspected to be the result of brain vascular problem or brain infarction. Patient was treated in ICU and hemodialysis was started, and she recovered fully from abnormal neurological symptoms. This case illustrate that hypermagnesemia should be considered in the pregnant woman with coma at ER and ICU. Furthermore, the accurate information about the continuous administration of magnesium by previous clinician helped us to make correct diagnosis and to treat the patient successfully.

The early sonographic appearance of placenta accreta

OBJECTIVE

To determine whether any sonographic findings in the first trimester predict placenta accreta.

METHODS

Patients who had a diagnosis of placenta accreta, increta, or percreta by clinical course or pathologic examination of the uterus and who had had a sonographic examination at 10 weeks or earlier were included in this study.

RESULTS

Seven patients met the study criteria. In 6 of these, who had had at least 1 previous cesarean delivery, the gestational sac was located in the lower uterine segment at the time of the early scan. Two of these pregnancies failed shortly after the early scan, and the patients underwent dilation and curettage, at which time severe bleeding necessitated a hysterectomy. The other 4 continued to term but had sonographic findings typical of placenta accreta during subsequent scans. In the seventh patient (who had had no previous cesarean deliveries), the gestational sac was located in the uterine fundus.

CONCLUSIONS

In a patient with a previous cesarean delivery, a sac lying in the lower uterine segment on a scan at 10 weeks or earlier suggests the possibility of placenta accreta.

Colored illustrations of obstetrics manipulations and instrumentation techniques of a Turkish surgeon Serafeddin Sabuncuoglu in the 15th century

Serafeddin Sabuncuoglu (1385-1470) was the author of the first illustrated surgical textbook Cerrahiyyet'ül Haniyye (Imperial Surgery) in the Turkish-Islamic literature. In the obstetric section he gave detailed descriptions of normal and abnormal presentation, surgical manipulation of intrauterine foetal death and retained placenta. He wrote about previously described procedures and the obstetric culture of his time. Some authors have claimed that he only translated Abu Kasim-al Zahrawa (Albucasis)'s Al-Tasrif (Textbook of Surgery) and added the illustrations of the surgical techniques. Even if this is accepted, the illustrations are enough to entitle this work as a milestone. In this paper, we describe the contributions of this pioneer in obstetrics and compare his recommendations with the current practice.

Expectant management versus surgical evacuation in first trimester miscarriage: health-related quality of life in randomized and non-randomized patients

BACKGROUND

Expectant management, although less effective, is an alternative treatment option for surgical evacuation in women with a miscarriage. We assessed health-related quality of life (HRQL) differences over time between expectant and surgical management in women with a miscarriage.

METHODS

Women with a miscarriage were randomized to either expectant (n = 64) or surgical (n = 58) management, and 305 eligible women who refused randomization because of a preference for either treatment option were managed according to their choice following the same clinical protocol (126 expectant, 179 surgical). The main outcome measures were score differences of HRQL during 12 weeks. Repeated measures analysis was applied.

RESULTS

Out of a total of 427 women, 198 were excluded in the questionnaire follow-up, leaving 229 women who participated. Mental health of women allocated to expectant management improved more and earlier (treatment effect) than of women allocated to surgical evacuation. Mental health scores were significantly better in women who chose, rather than women who were randomized, to curettage. The groups managed according to their own preference showed no differences in mental health scores.

CONCLUSION

Women with a miscarriage who chose their own treatment had the best HRQL over time, supporting the role of free choice from a clinical point of view. Women without a treatment preference should be encouraged to start with expectant management for psychological reasons.

Symphysiotomy and fetal destructive operations

Symphysiotomy and fetal destructive operations - while rarely, if ever, performed in developed countries - are an option in developing nations of the world. Problems endemic to developing countries not infrequently predispose to patients arriving at health care facilities in a moribund state with neglected labour. The health care provider then has to decide on the options available to him to deliver the mother by the safest route without incurring morbidity and mortality. Under the circumstances, the outcome for the baby will depend on factors prevalent at the time. If the fetus is alive, then the choice is between a Caesarean section and symphysiotomy, and if the fetus has died, a destructive procedure is an option to abdominal-route delivery which carries considerable risk to the mother. The following review outlines the role of symphysiotomy and fetal destructive operations and their role in modern obstetrics.

[Fetotomy in cattle with special reference to postoperative complications--an evaluation of 131 cases]

In the course of this retrospective study on fetotomy of cattle 131 operations were evaluated. The case studies put the cattle 2 to 96 hours into labour (average 13 hours). The cows that exhibited post-operative complications were on average 19.2 hours into labour prior to the operation. Those which had a normal puerperium however were only 8.4 hours, on average, in labour. 79% of the animals showed depressed general health on admission, 8% of which were unable to stand. The main cause of the dystocia was the incorrect position/orientation of the dead foetus (38.9%) as well as relative or absolutely too large calves (25.2%). In 14.5% of the cases the offspring were malformed causing the dystocia. 28 of the protracted births were due to both maternal as well as foetal causes. Mortality of the cows lay by 6.9%, irregularities in the puerperal period ran at 67.2%. The age of the mother did not seem to influence the post operative events. The most common complication was retained placenta (n = 49; 37.4%) followed by lochiometra (n = 21; 16%), vaginal wounds and pelvic phlegmons (each n = 16; 12.2%) and neurotripsy (n = 6; 12.2%). Of these puerperal complications the pelvic phlegmon required the longest post-operative care (14.3 days, retention secundinarum was cured in 13 days, lochiometra in 8.8, cows without complaint were treated for 3.8 days after the operation). The most important factors for the post-operative prognosis are the time in labour and any trauma of the soft birth canal which influence the forming of pelvic phlegmons.

Surgical resolution of an ectopic pregnancy in a captive gerenuk (Litocranius walleri walleri)

A full-term ectopic pregnancy was diagnosed in a multiparous, captive gerenuk (Litocranius walleri walleri) following prolonged gestation without parturition. Until 213 days of gestation, fetal viability was determined by transabdominal ultrasound of fetal heartbeat, physical palpation, and visual observations of fetal movements. Survey abdominal radiographs obtained at day 229 of gestation revealed a fully mineralized fetal skeleton in an inappropriate position for parturition. Surgical exploration revealed a full-term, nonviable, male calf contained within fetal membranes attached to the omentum. Histologic examination of the fetal membranes identified lesions compatible with placenta-cotyledon separation occurring prior to surgical removal. No congenital fetal abnormalities or infectious processes were identified. Visual observation of the reproductive tract at the time of surgery revealed no abnormalities or evidence of concurrent pregnancy.

Medical management of early fetal demise using a combination of mifepristone and misoprostol

BACKGROUND

This study aims to assess the efficacy of a combination of mifepristone and misoprostol in the management of missed miscarriage and anembryonic pregnancy.

METHODS

Data of 220 consecutive women with miscarriage, undergoing medical evacuation of the uterus were collected prospectively at an early pregnancy assessment unit in a tertiary referral hospital. Each woman received a single oral dose of mifepristone 200 mg and 36-48 h later vaginal misoprostol 800 microg. Three hours following the first dose, two further doses of misoprostol, 400 microg each, were administered vaginally or orally at 3 h intervals. Women who failed to pass products of conception were offered repeat medical regime with misoprostol. Success was defined as complete uterine evacuation within 3 days, without the need for surgical evacuation.

RESULTS

The overall success rate of medical management was 84.1%. Mifepristone alone induced natural expulsion of products of conception in 18.1% of women. The median dose of misoprostol required was 1600 microg and the median induction miscarriage interval after first prostaglandin administration was 8.04 h (range: 0.58-50.54 h). Of the 142 women who were symptomatic at presentation the medical regime failed in 30 (21.1%), compared with five (6.4%) failures of the 78 who were asymptomatic (P = 0.007). Of the 35 women who had surgical evacuation, eight required an emergency curettage for bleeding.

CONCLUSIONS

The combination of oral mifepristone 200 mg with vaginal or oral misoprostol is an alternative to surgical management of early fetal demise, although it is not as effective as surgery.

Calcified abdominal pregnancy with eighteen years of evolution: case report

CONTEXT

The lithopedion (calcified abdominal pregnancy) is a rare phenomenon and there are less than 300 cases reported in the medical literature.

CASE REPORT

In this case, a 40 year-old patient had had her only pregnancy 18 years earlier, without medical assistance since then. She came to our hospital with pain and tumoral mass of approximately 20 centimeters in diameter. Complementary examinations (abdominal X-ray, ultrasonography and computerized tomography) demonstrated an extra-uterine abdominal 31-week pregnancy with calcification areas. Exploratory laparotomy was performed, with extirpation of a well-conserved fetus with partially calcified ovular membranes.

[A rare differential diagnosis of a pregnancy gestosis]

HISTORY AND ADMISSION FINDINGS

After an unremarkable course of her pregnancy a 26-year-old woman was admitted in the 32nd week because of her poor general condition with nausea, vomiting and headache. Her blood pressure was 220/140 mmHg and the pulse irregular with a rate of about 90/min.

INVESTIGATIONS

The urine was markedly positive for glucose and protein, the cardiotachogram was unremarkable.

DIAGNOSIS, TREATMENT AND COURSE

Antihypertensive treatment was started because pre-eclampsia was suspected. At first the patient's condition improved, but a few hours after admission an emergency section had to be performed for maternal and fetal indications, but the eutrophic male child was dead. Postoperatively the electrocardiogram and increased creatine kinase activity were suspicious of an acute myocardial infarction. Chest radiogram and echocardiography showed signs of marked ventricular dysfunction. Coronary angiography excluded coronary artery disease. The concentrations of catecholamine and its metabolites in 24-hour urine were greatly elevated above normal. Ultrasound and computed tomography demonstrated a tumour in the region of the left adrenal suggesting phaeochromocytoma, a diagnosis that was confirmed when the tumour was resected.

CONCLUSIONS

Phaeochromocytoma is a rare cause of toxaemia of pregnancy and presents a high maternal and fetal risk. Its prognosis for both mother and child can be improved only if it is diagnosed and treated prenatally.

Uterine artery embolization--a successful treatment to control bleeding cervical pregnancy with a simultaneous intrauterine gestation

A case of a woman suffering from a bleeding heterotopic cervical pregnancy is described. The concurrent cervical pregnancy and intrauterine gestation were diagnosed by ultrasound and bleeding was initially controlled with selective fluoroscopic uterine artery embolization. A selective fetal reduction was done with ultrasound-guided intracardiac potassium chloride. Uterine artery embolization has been used successfully to control haemorrhage in cervical pregnancies when the main goal was to allow preservation of the uterus, thus maintaining potential fertility. This is the first report of arterial embolization used to control bleeding for maintaining a concurrent intrauterine heterotopic pregnancy in an in-vitro fertilization patient. Unfortunately, subsequent conservative measures led to undesired outcome. This procedure initially controlled the bleeding without disrupting the intrauterine fetal cardiac activity.

[A rare etiology of abdominal calcifications: lithopedion]

We report a case of a rare and particular cause of abdominal calcifications represented by the lithopedion. We describe different radiologic appearances observed by: abdominal plain film, echography and CT. It appeared to us that abdominal plain film alone is sufficient for diagnosis and undertaking surgery. Echography and CT are helpful, especially for complementary evaluation.

Primary term ovarian pregnancy superimposed by intrauterine pregnancy: a case report

A case of primary ovarian pregnancy proceeding upto term superimposed by another intrauterine pregnancy is presented. Compound extrauterine and intrauterine pregnancy is a rare obstetric phenomenon and still rarer is a primary ovarian pregnancy proceeding upto the term. The condition was diagnosed at laparotomy during the second trimester of current pregnancy. Diagnostic laparotomy was done because the ovarian pregnancy was mimicking an ovarian tumur. The ovarian pregnancy was successfully managed by surgery. Normal vaginal delivery of a term intrauterine pregnancy occurred in due time. The difficulty of diagnosing the heterotopic pregnancy is discussed and the clinico-pathological features of primary term ovarian pregnancy is emphasized, as it is a very rare condition.

[A case of abdominal pregnancy--a case report]

Rare anatomical variety, the ectopic abdominal gestation involve a high maternal and foetal risk. On report an abdominal gestation in the 2nd quarter of evolution at a 42 yrs. age of a female with multiple uterine leiomyomas, the diagnosis being establish by ultrasonography. The attitude in the same cases is decided by the foetal viability: if the foetus is in a life, the pregnant women is hospitalised and followed each day; if the foetus is dead, there are indication of surgery, the major problem being represented by the total or partial removed of the placenta.

Excitement in an elephant after intravenous administration of atropine

A 28-year-old Asian elephant (Elephas maximus) was anesthetized for cesarean section to remove a dead calf. The elephant was sedated with azaperone, and atropine was administered IV 90 minutes later in preparation for induction of anesthesia with etorphine HCl. Within 1 minute of injection of atropine, the elephant began swaying, kicking, and moving in an agitated manner around the stall. There is considerable variation among species in the toxicity of atropine, although development of toxicosis usually is associated with overdosage.

Fetal decapitation: the application and safety of the stout embryotomy scissors

Transverse lie with impacted shoulder and hand prolapse of the dead fetus was treated in 21 cases by decapitation of the fetus, performed with stout blunt-ended embryotomy scissors. Surgical complications were minimal and the procedure was simple, effective and safe.

Destructive operations still have a place in developing countries

OBJECTIVES

To determine the place of destructive operations in developing countries in patients arriving late in labor with a dead fetus and advanced infection, and to compare them with LSCS for patients with similar indications.

METHODS

A total of 56 cases of destructive operations were carried out on patients with obstructed labor and intrauterine fetal death (IUFD) from the labor wards of Smt. S.K. Hospital from January 1985 to December 1991. These were compared with 27 cases of LSCS done for similar indications during the years 1989 to 1990.

RESULTS

Patients treated with destructive operations had no maternal deaths, had very few complications and required a short hospital stay. Patients treated by LSCS, however, had one maternal death and complications such as post-partum hemorrhage, incidence of blood transfusion, post-operative shock, post-operative pyrexia and duration of hospital stay were more frequent.

CONCLUSIONS

It is felt that in some properly selected cases presenting late with obstructed labor, IUFD and intrauterine sepsis, destructive operations should be performed as first choice. Thus, destructive operations still have a limited place in developing countries and are safer than LSCS for these patients.

Midtrimester induction of abortion: comparison of extraovular prostaglandin E2 and intra-amniotic prostaglandin F2 alpha

The efficacy of extraovular prostaglandin E2 and intra-amniotic prostaglandin F2 alpha for pregnancy termination in midtrimester was compared. A retrospective review of pregnancy termination in midtrimester using intra-amniotic instillation of 40 mg of prostaglandin F2 alpha (n = 133) or extraovular instillation of prostaglandin E2 at a rate of 500 micrograms/hour (n = 81) was performed. Both groups had a similar mean induction-to-abortion interval (19.5 +/- 19.9 and 20.9 +/- 18.2 hours for extraovular PGE2 and intra-amniotic PGF2 alpha, respectively) and a similar success rate of abortion within the first 24 hours of initial treatment (84.0% for extraovular PGE2 and 76.7% for intra-amniotic PGF2 alpha). The two groups had a similar and low (9.8%) incidence of complications. It is concluded that either of the methods used in the study (i.e. extraovular PGE2 or intra-amniotic PGF2 alpha) can be used safely and effectively for pregnancy termination in midtrimester.

Evaluation of the role of craniotomy in developing countries

A review of 32 cases of craniotomy performed at the Jinnah Postgraduate Medical Centre Karachi, over a period of 6 years from January, 1984 to December, 1989 is presented. Total number of deliveries during this period were 37,682. Frequency of craniotomy was 0.08% i.e., 1 in 1177 deliveries. Of these 32 craniotomies, 28 were done on non-deformed dead fetus, 16 because of obstructed labour, 7 in cases of after coming head of breech and 5 in failure to progress in second stage of labour. Four cases were of live hydrocephalic fetus in whom cephalocentesis was done followed by craniotomy due to failure to progress in labour. Maternal morbidity was 12.5% with no maternal death. We conclude that it is safe and quicker than caesarean section in selected cases. Though unpleasant to perform, is of great relief to the patient and her family.

Caesarean sections in cattle attended by a practice in Cheshire

The results of 77 caesarean sections in cattle carried out in a seven-person practice over a period of 16 months are described and evaluated. The standardisation of the surgical technique, the speed of decision making in dealing with dystocia, and the education of the farmers contributed to the 84 per cent calf survival rate, and post surgical complications were few. There was only one fatality in a dam.

[Intrauterine death of one fetus in twin pregnancy]

A case of twin pregnancy complicated by intrauterine death of a foetus is reported. The most recent literature data on incidence, aetiology, diagnostic and monitoring difficulties (improved over the past few years thanks to echography) are discussed. Finally, prevention problems and the choice of therapy are examined, it being stressed that it is by now a widespread habit to close these pregnancies with Caesarean section as soon as the maturity of the surviving twin so permits.

Effects of dystocia on postpartum adrenocortical function in dairy cows

Postpartum adrenocortical responses to adrenocorticotropic hormone in cows after normal (n = 10) and difficult (n = 52) parturition were investigated. The post-partum adrenocortical function of cows was affected by type of parturition (spontaneous parturition, forced extraction of fetus, caesarean section calving with or without attempted forced extraction, and total fetotomy) and day after calving (d 1, 4, and 8; d 0 = day of parturition). Cows after normal calving did not show enhanced or depressed adrenocortical function postpartum. Adrenocortical function was enhanced, compared with cows calving normally, for cows with dystocia that had a caesarean section after forced extraction was attempted and in cows in which calves were already dead and total fetotomy was performed. Cows with dystocia assisted with forced extraction by one to two people and cows that had caesarean sections without forced extraction did not show higher plasma glucocorticoid concentrations before or after adrenocorticotropic hormone administration than did cows with normal calving. Results indicate that dystocia requiring caesarean section following unsuccessful extraction or total fetotomy enhanced postpartum adrenocortical function in cows.

Fetal hydrops and death from sacrococcygeal teratoma: rationale for fetal surgery

Most sacrococcygeal teratomas diagnosed before birth can be managed by planned delivery and postnatal surgery. However, large tumors early in gestation may result in placentomegaly, hydrops, and fetal death and a preeclampsia-like syndrome in the mother. This chain of events may result from high output cardiac failure in the fetus caused by arteriovenous shunting through the tumor. We recently encountered this situation in a fetus at 21 weeks' gestation and performed fetal surgery in an attempt to reverse the process. Excision of the teratoma resulted in reversal of hydrops, diminution of descending aortic flow on Doppler echocardiography, and decrease in placental thickness. Despite these changes, uterine irritability after hysterotomy resulted in labor and delivery of a nonviable premature infant. This case demonstrates that when fetal sacrococcygeal teratoma becomes very large early in gestation, high output cardiac failure can endanger both fetus and mother. In the future, use of Doppler echocardiography may allow appropriate selection of high-risk fetuses. Intervention to prevent arteriovenous shunting through the tumor may offer these fetuses an improved chance for survival.

[Abdominal pregnancy. An unusual case]

A general review is made about concept, incidence and clinical features of abdominal pregnancy. The early and accurate diagnosis of an abdominal pregnancy is very important in order to avoid catastrophic hemorrhage from placental separation. A case is reported of a young woman hospitalized at Morelia's General Hospital, SSA, with an abdominal pregnancy. The fetus died about 26th week and underwent mummification. Some time later the fetus spontaneously divided and the lower segment extruded through the intestines. The remain upper thoracic and cephalic segment was removed at laparotomy closing an intestine stoma; 60% of the placenta was also removed. The postoperative course was uneventful.

The microsurgical dissection of a stillborn fetal clubfoot

A microsurgical dissection was performed on a clubfoot of a seven-month-old stillborn fetus with camptomelic dysplasia. The most important anatomic alteration was marked rotation of the calcaneus beneath the talus. The calcaneus was rotated around a vertical axis. Its anterior aspect was rotated medially, while its posterior aspect was rotated laterally. A series of photographs obtained during the dissection shows the degree of realignment achieved by each stage of the progressive or stepwise surgical dissection. Dissection simulating a posteromedial release and plantar release failed to realign the hindfoot. A complete subtalar release was necessary to reposition the bones of the hindfoot completely. In this specimen, metatarsal capsulotomies were required to realign the forefoot, and the osteotomies of the tibia and tibula were required to straighten the angular deformities characteristic of camptomelic dysplasia, as well as the significant external torsion of these bones.

An abdominal mummified fetus in a Macaca assamensis

A case of an ectopic mummified fetus in a Macaca assamensis is described. The condition was detected on routine clinical examination of a newly acquired monkey, and the mummified fetus was surgically removed.