Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery

BACKGROUND

Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group.

METHODS

This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit.

RESULTS

Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality.

CONCLUSIONS

This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.

Predictors of successful trial of labor after cesarean section (TOLAC) in women with one prior transverse cesarean section at Tertiary Hospitals in northwest Ethiopia: a multicenter study

BACKGROUND

Trials of labor after cesarean section is the preferred strategy to decrease the cesarean delivery rate and reducing complications associated with multiple cesarean sections. The success rate of trials of labor after cesarean section and associated factors have not been well documented in Ethiopia. Hence, this study was aimed to determine the success rate and factors associated with the trial of labor after one cesarean section in five Comprehensive Specialized Hospitals located in northwest Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 437 women who came for the trial of labor from December 1, 2021, to March 30, 2022. All women who fulfilled the eligibility criteria were included to this study. Data was collected using structured and pre-tested questionnaire. Then, the data was entered into Epi Data 4.6 software and exported to SPSS version 26 for analysis. To identify the variables influencing the outcome variable, bivariable and multivariable logistic regression analyses were conducted. The model's fitness was checked using the Hosmer-Lemeshow goodness of fit test, and an adjusted odds ratio with a 95% confidence interval was used to declare the predictors that are significantly associated with TOLAC.

RESULTS

The success rate of the trial of labor after one cesarean section was 56.3% (95% CI, 51.3%, 61.2%). Maternal age ≥ 35 years (AOR: 3.3, 95% CI 1.2, 9.3), the fetal station at admission ≤ zero (AOR: 5. 6, 95% CI 3.3, 9.5), vaginal delivery before cesarean section (AOR: 1.9, 95% CI 1.2, 3.2), and successful vaginal birth after cesarean delivery (AOR 2.2, 95% CI 1.2, 4.1) were found to have a significant association with the success rate of trial of labor after cesarean section.

CONCLUSIONS

In this study, the success rate of the trial of labor after a cesarean section was low as compared to the ACOG guideline and other studies in different countries. Therefore, the clinicians ought to offer counsel during antenatal and intrapartum period, encourage the women to make informed decision on the mode of delivery, and the practitioners need to follow fetal and maternal conditions strictly to minimize adverse birth outcomes.

A jump into the deep end - Women's strategies on the way to VBAC in Poland

PROBLEM

In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low.

BACKGROUND

Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC.

AIM

This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC.

METHODS

The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth.

FINDING

Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC.

CONCLUSIONS

Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

The impact of a trial of labor after cesarean versus elective repeat cesarean delivery: A meta-analysis

BACKGROUND

The increasing global incidence of cesarean section has prompted efforts to reduce cesarean delivery rates. A trial of labor after cesarean (TOLAC) has emerged as an alternative to elective repeat cesarean delivery (ERCD) for women with a prior cesarean delivery. However, the available evidence on the comparative outcomes of these 2 options remains inconsistent, primarily due to varying advantages and risks associated with each. Our meta-analysis aims to compare the maternal-neonatal results in TOLAC and ERCD in women with prior cesarean deliveries.

METHODS

A comprehensive search was performed in PubMed, Embase, Cochrane library databases up to September,2022 to identity studies evaluating perinatal outcomes in women who underwent TOLAC compared to ERCD following a previous cesarean delivery. The included studies were subjected to meta-analysis using RevMan 5.3 software to assess the overall findings.

RESULTS

A total of 13 articles were included in this meta-analysis. Statistically significant differences were identified in the rate of uterine rupture (OR = 2.01,95%CI = 1.48-2.74, P < .00001) and APGAR score < 7 at 5 minutes (OR = 2.17,95%CI = 1.69-2.77, P < .00001) between the TOLAC and ERCD groups. However, no significant differences were observed in the rates of hysterectomy, maternal blood transfusion, postpartum infection, postpartum hemorrhage and neonatal intensive care unit (P ≥ .05) admission between the 2 groups.

CONCLUSIONS

Our analysis revealed that TOLAC is associated with a higher risk of uterine rupture and lower incidence APGAR score < 7 at 5 minutes compared to ERCD. It is vital to consider predictive factors when determining the appropriate mode of delivery in order to ensure optimal pregnancy outcomes. Efforts should be made to identify the underlying causes of adverse outcomes and implement safety precautions to select suitable participants and create safe environments for TOLAC.

Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania

BACKGROUND

Shared decision-making between clinicians and pregnant women with prior cesarean on the subsequent mode of delivery improves trial of labor rates, and reduces the number of repeat cesarean sections and their related complications. However, this practice is insufficient worldwide and the factors influencing it are still unknown. The study aimed at determining the proportion of pregnant women involved in shared decision-making and its associated factors in Dar es Salaam.

METHODS

A cross-sectional analytical study among 350 pregnant women with one prior cesarean section. Data was collected using a structured questionnaire and SPSS 23 was used for analysis. A score of 80 or higher on the nine-item Shared Decision-Making Questionnaire (SDM-Q9) was used to calculate the proportion of women, and the associated factors were obtained using a logistic regression model. P value of < 0.05 was considered significant.

RESULTS

The proportion of pregnant women involved in shared decision making was 38%. Factors that were significantly associated with sharing decision making were; having low level of education (AOR 0.55 95% CI 0.33-0.91), being married/having partner (AOR 2.58 95% CI 1.43-4.63), having a companion who had active participation (AOR 3.31 95% CI 1.03-10.6) and being familiar with the clinician (AOR 5.01 95% CI 1.30-19.2).

CONCLUSION

To promote practice of shared decision making in our setting, encouragement of socially vulnerable pregnant women's participation in decision-making by health care professionals, encouragement of companion participation during antenatal care and promotion of personal continuity of care to improve familiarity to clinicians are needed.

Frequency Of Vaginal Birth After Caesarean Section And Its Fetomaternal Outcome

BACKGROUND

Vaginal birth after caesarean section (VBAC) is associated with reduced blood loss and transfusions, fewer infections, and fewer thromboembolic events as compared to caesarean delivery. The current rate of repeat caesarean after one previous caesarean is above the WHO standard of 15%. We aimed to determine the occurrence of VBAC and to determine the occurrence of feto-maternal outcomes in successful VBAC cases so that trials of VBAC can be given to carefully selected patients to reduce the rate of repeat caesarean section.

METHODS

The Combined Military Hospital (CMH) Rawalpindi's Obstetrics and Gynaecology department conducted this cross-sectional study from March 20 to September 19, 2021. After obtaining ethical committee approval, data was collected using a non-probability, consecutive sampling technique from 150 patients on a self-developed structured proforma. Patients between the age range of 20-35 years with a history of previous lower segment caesarean section, having gestational age between 37-41 weeks and who presented in spontaneous labour were included in this study. After taking informed consent, all women were given a trial of labour and the outcome of the trial was noted. Women were followed for the feto-maternal outcomes. The gathered information was analysed using SPSS version 25.0. Post-stratification, a p-value of 0.05 or lower on the chi-square test was deemed statistically significant.

RESULTS

Following a C-section, 28.67% of patients experienced successful vaginal births. PPH was found in 2.32%, scar dehiscence in 0.0%, low birth weight babies in 16.28%, APGAR score <7 at 1 minute was 23.26% and NICU admission as 9.30% in women undergoing vaginal birth after caesarean section.

CONCLUSIONS

Appropriate selection of patients for the trial of VBAC can help reduce the higher rate of repeat caesarean section after a previous caesarean section and increase the chances of successful vaginal birth.

Preferred mode of delivery and its associated factors in pregnant women with a previous cesarean scar at a tertiary care hospital in Ethiopia: institutional-based cross-sectional study

BACKGROUND

Vaginal births after cesarean or elective repeat cesarean sections (CS) are the options for delivery after one cesarean scar. However, there is a lack of data regarding the preferred next mode of delivery in Ethiopia after a previous cesarean section. Thus, this study assessed the preferred mode of delivery and determinants after one previous CS in the antenatal clinic at the University of Gondar Comprehensive Specialized Hospital (UoGCSH).

METHODS

An institutional-based cross-sectional study was conducted among pregnant mothers with one previous CS at UoGCSH from March to August 2022. Structured questionnaires were used to collect the data. The collected data were entered, cleaned, and edited using Epi-data 4.6 and exported to SPSS version 26 for analysis. A binary logistic regression was performed to assess the determinants of the preferred mode of delivery. A p-value of < 0.05 at the 95% confidence level (CI) was considered statistically significant.

RESULTS

The majority, 71.5% (95% CI: 64.7, 77.1), of participants preferred the trial of labor after cesarean (TOLAC) as their mode of delivery. Mothers who were married (AOR = 4.47, 95% CI: 1.19-16.85), had a diploma educational level (AOR = 3.77, 95% CI: 1.84-12.36), had previous post-cesarean complications (AOR = 3.25, 95% CI: 1.08-9.74), and knew about the success of the trial of labor after cesarean (AOR = 13.56, 95% CI: 4.52-37.19) were found to prefer the trial of labor compared with their counterparts.

CONCLUSION

This study concluded that most pregnant mothers preferred labor trials after one CS, which is a bit lower but comparable with recommended practice guidelines. Providing adequate information and counseling mothers to make informed decisions about their preferred mode of delivery could be substantial.

Omental patch for lower uterine segment repair during caesarean section

Increasing rates of caesarean section have contributed to a higher number of complications such as vesicouterine fistula. A G6P5 woman in her early forties presented for her third elective repeat caesarean section. At the time of delivery, there was uterine dehiscence and the fetus was visible through a large 7×5 cm transparent window in the lower segment. After delivery of the baby, the uterus was unable to be repaired with sutures so an omental patch was fixed on the lower segment to facilitate healing. It is hypothesised that the angiogenic properties of the omentum may have promoted healing of the uterine defect and reduced the risk of vesicouterine fistula by providing a protective barrier. The patient recovered well and by 4 months post partum, her menstrual cycle had returned. Thereby, the use of an omental patch during uterine repair may reduce long-term complications associated with repeat caesarean section.

Repeat Cesarean Section among Pregnant Women in a Tertiary Center of Nepal: A Descriptive Cross-sectional Study

Introduction: Cesarean Section is the most common obstetrics surgery done for both maternal and fetal indications. There is a rising trend of cesarean section rates which is associated with increased maternal morbidities. This study aims to find out the prevalence of repeat Cesarean Section among women with previous cesarean sections done in a tertiary centre. Methods: This was a descriptive cross-sectional study conducted in a tertiary care hospital of Nepal from August 2020 to January 2021. Pregnant women with previous Cesarean Section status without other pelvic surgery and medical comorbidities were included and data were collected regarding intraoperative findings. Ethical approval was taken from the Institutional Review Committee (Reference Number: 14). A convenience sampling technique was used. Data were analysed using Statistical Package for the Social Sciences version 22. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. Results: Out of 1315 patients undergoing Cesarean Section, the prevalence of Repeat Cesarean Section was found to be 184 (13.99%) (12.11-15.86 at 95% Confidence Interval). Conclusions: The prevalence of Repeat Cesarean Cection from our study was similar to other studies done in similar settings. Repeat Cesarean Cection confers peri-operative morbidities which adversely affect postoperative recovery. Repeat Cesarean Cection continues to contribute to morbidity over subsequent pregnancies and serious maternal morbidity.

Preoperative sonographic prediction of intra-abdominal adhesions using sliding sign at repeat caesarean section at the University of Maiduguri Teaching Hospital, Nigeria: a prospective observational study

OBJECTIVE

To determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken to demonstrate this sign.

DESIGN

A prospective, observational, triple-blind study using tests of diagnostic accuracy.

SETTING

Single-centre tertiary health institution in north-east Nigeria.

PARTICIPANTS

67 women in the third trimester scheduled for repeat elective caesarean sections (CS) had transabdominal sonography to determine the absence or presence and degree of sliding sign. The time taken to make these decisions were noted. Surgeons blinded to the ultrasound findings graded adhesions intraoperatively and comparison between sonographic and intraoperative findings made. Women who were scheduled for emergency CS were excluded.

MAIN OUTCOME MEASURES

Accuracy of preoperative ultrasound to determine no/mild, moderate and severe adhesions. Secondary outcomes were interobserver correlations and time taken to determine sliding.

RESULTS

When classified as adhesion and no adhesion, the sliding sign demonstrated a sensitivity of 100.00% (CI₉₅ 85.18% to 100.00%), specificity of 100.00% (CI₉₅ 92.13% to 100.00%). In predicting presence of moderate intra-abdominal adhesions, a sensitivity of 65.0% (CI₉₅ 40.78% to 84.61%) and specificity of 82.98% (CI₉₅ 69.19% to 92.35%) was found. For predicting severe intra-abdominal adhesions, it had a sensitivity of 25.00% (CI₉₅ 0.63% to 80.59%) and specificity of 98.41 (CI₉₅ 91.47 to 99.96). Disease prevalence for mild, moderate and severe adhesions was 33.82% (CI₉₅ 22.79% to 46.32%), 29.85% (CI₉₅ 19.28% to 42.27%) and 5.97% (CI₉₅ 1.65% to 14.59%), respectively. Interobserver Cohen's kappa coefficient and PPA were 0.58 (CI₉₅ 0.39 to 0.76) and 58.82 (CI₉₅ 52.82 to 64.82), respectively. The mean duration to determine sliding sign was 7.56±2.86 s.

CONCLUSION

This study supports the role of transabdominal sliding sign in preoperative prediction of intra-abdominal adhesions in women with previous CS without significant increase in sonography duration. This information can encourage planning for CS by ensuring that surgeons of appropriate seniority are deployed to undertake anticipated complex operations.

Evaluating Shared Decision Making in Trial of Labor After Cesarean Counseling Using Objective Structured Clinical Examinations

INTRODUCTION

Although shared decision making (SDM) is optimal for trial of labor after cesarean (TOLAC) counseling, resources to assess residents' clinical competency and communication skills are lacking. We addressed this gap by developing and testing an objective structured clinical examination (OSCE) to evaluate whether learners were able to use SDM in TOLAC counseling.

METHODS

We created three simulation scenarios with increasing complexity to assess the skills of residents in their first, second, or third postgraduate year in using SDM in TOLAC counseling. All cases involved a standardized patient requesting a TOLAC consultation. Residents were provided with a medical history and instructed to counsel and develop a care plan. A 10-item scoring rubric was used, and each item was rated 0 (absent), 1 (partial), or 2 (complete). Three coders independently rated the encounters; discrepancies were resolved by consensus.

RESULTS

Over 3 years, 39 residents participated in 60 OSCE encounters. The majority provided complete discussions of the clinical issue (93%), chances of success (72%), and maternal and fetal risks (100% and 85%, respectively) but obtained partial assessments of understanding (78%). Discussions of benefits were typically absent, with the exception of the maternal benefits (47%). More than 40% of residents did not discuss the patient's goals, 53% lacked discussion of uncertainties related to TOLAC, and half failed to explore the patient's preference, with most deferring a decision to a future encounter.

DISCUSSION

Residents consistently discussed diagnosis, prognosis, and maternal risks yet infrequently addressed goals and preferences-two critical elements of SDM.

The effect of the use of a decision aid with individual risk estimation on the mode of delivery after a caesarean section: A prospective cohort study

Objective

After one previous caesarean section (CS), pregnant women can deliver by elective repeat CS or have a trial of labor which can end in a vaginal birth after caesarean (VBAC) or an unplanned CS. Despite guidelines describing women’s rights to make an informed choice, trial of labor and VBAC rates vary greatly worldwide. Many women are inadequately informed due to caregivers’ fear of an increase in CS rates in a high VBAC rate setting. We compared counseling with a decision aid (DA) including a prediction model on VBAC to care as usual. We hypothesize that counselling with the DA does not decrease VBAC rates. In addition, we aimed to study the effects on unplanned CS rate, patient involvement in decision-making and elective repeat CS rates.

Methods

We performed a prospective cohort study. From 2012 to 2014, 483 women in six hospitals, where the DA was used (intervention group), were compared with 441 women in six matched hospitals (control group). Women with one previous CS, pregnant of a singleton in cephalic presentation, delivering after 37 weeks 0 days were eligible for inclusion.

Results

There was no significant difference in VBAC rates between the intervention (45%) and control group (46%) (adjusted odds ratio 0,92 (95% Confidence interval 0.69–1.23)). In the intervention group more women (42%) chose an elective repeat CS compared to the control group (31%) (adjusted odds ratio 1.6 (95% Confidence interval 1.18–2.17)). Of women choosing trial of labor, in the intervention group 77% delivered vaginally compared to 67% in the control group, resulting in an unplanned CS adjusted odds ratio of 0,57 (0.40–0.82) in the intervention group. In the intervention group, more women reported to be involved in decision-making (98% vs. 68%, P< 0.001).

Conclusions

Implementing a decision aid with a prediction model for risk selection suggests unchanged VBAC rates, but 40% reduction in unplanned CS rates, increase in elective repeat CS and improved patient involvement in decision-making.

Rupture of multiple pseudoaneurysms as a rare complication of common iliac artery balloon occlusion in a patient with placenta accreta: A case report and review of literature

RATIONALE

Placenta accreta is the main cause of severe obstetric postpartum hemorrhage (PPH) and hysterectomy. Several hemostatic techniques have been performed in patients with placenta accreta to prevent PPH and reserve fertility. Abdominal aorta and pelvic arteries balloon occlusion are the only techniques which could be performed before cesarean section (CS) in patients who want to keep the fetus and reserve fertility. However, abdominal aorta and pelvic arteries balloon occlusion might lead to severe complications such as formation and rupture of pseudoaneurysm, angiorrhexis, etc.

PATIENT CONCERNS

We report a case diagnosed with pernicious placenta previa (PPP) combined with Rh(D) negative blood type, who was performed with bilateral common iliac arteries (CIA) balloon occlusion during CS. However, on the first day after CS, the patient caught sudden left-side lumbago and backache accompanied with palpitation and shortness of breath.

DIAGNOSES

Formation and rupture of multiple pseudoaneurysms in left CIA.

INTERVENTIONS

Covered stent was inserted into the proximal part of the left CIA and the ipsilateral internal iliac artery was embolized by coil to prevent endoleak.

OUTCOMES

The patient recovered and discharged from hospital in stable condition without other complications 9 days after CS.

LESSONS

It is of paramount importance that obstetricians and radiologists correctly estimate the appropriate occlusion volume and pressure of pelvic arteries before CS to avoid formation and rupture of a pseudoaneurysm. And if the rupture of a pseudoaneurysm occurred, it should be quickly identified and treated with endovascular intervention.

Limitations of Vaginal Birth After Cesarean Success Prediction

The Society for Maternal-Fetal Medicine endorses an algorithm for estimating the probability of successful vaginal birth for women undergoing trial of labor after cesarean (TOLAC). The algorithm is available online in the form of an easy-to-use calculator. This calculator has significant limitations that are easily overlooked by women and providers alike. The calculator has much greater positive than negative predictive power, and it cannot predict unsuccessful TOLAC or uterine rupture. Furthermore, the calculator cannot predict rare catastrophes, such as unplanned hysterectomy, permanent injury, or death. Predictions are heavily influenced by race and ethnicity, which are social and not biological constructs. Relevant variables, such as provider attitudes and institutional differences, are not accounted for. Providers should be mindful and transparent about calculator limitations when counseling women, particularly Latina and African American women. It may be appropriate to use the calculator to inform but not restrict women's options.

A history of repetitive cesarean section is a risk factor of anemia in healthy perimenopausal women: The Korea National Health and Nutrition Examination Survey 2010-2012

BACKGROUND AND OBJECTIVES

To determine whether the delivery method is associated with the rate of anemia in later life, using the data from the Korea National Health and Nutrition Examination Survey (KNHANES).

METHODS

This study used data from the KNHANES 2010-2012. Among 25,534 participants, 8,126 cases were included in this study after exclusion of males and other inappropriate data. The study population was divided into three groups according to the delivery modes: vaginal delivery (VD) only group, single cesarean delivery (SCD) group and repetitive cesarean delivery (RCD) group. The primary outcome was anemia and iron deficiency. Anemia was defined as hemoglobin <12 g/dl in accordance with the World Health Organization criteria. Iron deficiency was defined as low transferrin saturation (TSAT) or ferritin levels. Multivariate analysis was used for determination of association between the delivery modes and anemia.

RESULTS

The mean age was 53.4 years and the median time from the last delivery to the survey was 25 years. The VD only group was composed of 6,493 (79.9%) women, while 685 (8.4%) were classified as the SCD group and 948 (11.7%) were classified as a RCD group. The rates of anemia were 11.8%, 13.9%, and 19.7% in VD only group, SCD group, and RCD group, respectively. However, those groups were significantly different in many confounding factors. Therefore, to adjust those factors, multivariate analysis and subgroup analysis were followed. The odds of SCD for anemia and iron deficiency were not different from those of VD only. However, RCD was independently associated with anemia [Odds ratio(OR) 1.47, 95% Confidence interval (CI) 1.21-1.79, P <0.001] and iron deficiency (OR 1.42, 95% CI 1.21-1.67, P <0.001) compared to VD only. In the subgroup analysis, RCD was significantly associated with anemia in perimenopausal women, women with iron deficiency, those without any comorbidity and those without anemia-prone treatment.

CONCLUSION

Repetitive cesarean section may be a risk factor for future development of anemia in later life, especially in perimenopausal period. Therefore, evaluation and management of anemia in longer postpartum period should be considered for women who experience repetitive cesarean section.

Vaginal birth after two previous caesarean deliveries in a patient with uterus didelphys and an interuterine septal defect

Uterus didelphys is a congenital abnormality characterised by double uteri, double cervices and a double or single vagina that affects 0.3% to 11% of the general female population. A 23-year-old woman, gravida 3 para 3003, with uterus didelphys, acquired an iatrogenic interuterine septal defect during an otherwise routine primary caesarean delivery for fetal malpresentation. The defect was repaired but noted to have dehisced during her second pregnancy. A repeat caesarean section was performed due to fetal malpresentation after an unsuccessful external cephalic version. The dehisced defect was left unrepaired. During her third pregnancy, the placenta implanted in the right uterus, but the fetus migrated to the left uterus at approximately 28 weeks gestation. The umbilical cord traversed the interuterine septal defect. With the fetus in the vertex presentation at term gestation, the patient underwent a vaginal birth after two previous caesarean deliveries without any major perinatal complications.

Maternal obesity and major intraoperative complications during cesarean delivery

BACKGROUND

Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications.

OBJECTIVE

To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD).

METHODS

This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m², BMI 30 to 39.9 kg/m², BMI 40 to 49.9 kg/m², and BMI ≥ 50 kg/m². The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision.

RESULTS

A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m², 47% BMI 30 to 39.9 kg/m², 12% BMI 40 to 49.9 kg/m² and 3% BMI ≥ 50 kg/m². Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m², 3.2% BMI 30 to 39.9 kg/m², 2.6% BMI 40 to 49.9 kg/m² and 4.3% BMI ≥ 50 kg/m² (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m² had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m². Women with BMI 30 to 39.9 kg/m² (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication.

CONCLUSION

In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity.

Considerations of Epidural Analgesia in a Patient With Suspected Uterine Rupture

The practice of epidural analgesia in laboring women began to emerge in the 1970s. It is now a common method of pain relief for patients in labor and is used by 63% of women in the hospital setting. The patient who has had a previous cesarean delivery can benefit from having an epidural anesthetic placed early to expedite an emergency, such as a uterine rupture, if necessary. At one time there was a concern for placing an epidural anesthetic in laboring women who had a previous cesarean delivery. It was feared that the epidural anesthesia would mask abdominal pain that may present with a ruptured uterus and delay diagnosis. This worry was quickly dispelled with literature that strongly suggested that epidural analgesia did not disguise the signs or delay diagnosis of uterine rupture. The case presented is one in which pain of a uterine rupture was experienced with a functioning epidural catheter in situ, and successful anesthetic management.

Trial of labour after caesarean section and the risk of neonatal and infant death: a nationwide cohort study

BACKGROUND

Caesarean section (CS) rates are increasing worldwide and as a result repeat CS is common. The optimal mode of delivery in women with one previous CS is widely debated and the risks to the infant are understudied. The aim of the current study was to evaluate if women with a trial of labour after caesarean (TOLAC) had an increased odds of neonatal and infant death compared to women with an elective repeat CS (ERCS).

METHODS

A population register-based cohort study was conducted in Denmark between 1982 and 2010. All women with two deliveries [in which the first was a CS, and the second was an uncomplicated, term delivery (n = 61,626)] were included in the study. Logistic regression models were used to report adjusted odds ratios (AOR) and 95% confidence intervals (CI) of the odds of death according to mode of delivery. The main outcome measures were neonatal death (early and late) and infant death.

RESULTS

Women with a TOLAC had an increased odds of neonatal death (AOR 1 · 87, 95% CI 1 · 12 to 3 · 12) due to an increased risk of early neonatal death (AOR 2 · 06, 95% CI 1 · 19 to 3 · 56) and no effect on late neonatal death (AOR 0 · 97, 95% CI 0 · 22 to 4 · 32), or infant death (AOR 1 · 12, 95% CI 0 · 79 to 1 · 59) when compared to the reference group of women with an ERCS. There was evidence of a cohort effect as the increased odds of neonatal death (AOR 3 · 89, 95% CI 1 · 33 to 11 · 39) was most significant in the earlier years (1982-1991) and gradually disappeared (AOR 1 · 01, 95% CI 0 · 44 to 2 · 31) in the later years (2002-2010).

CONCLUSIONS

Although an increased risk of neonatal death was found in women with a TOLAC, there was evidence of a cohort effect, which showed this increased odds disappearing over time. Advances in modern healthcare including improved monitoring and earlier detection of underlying pregnancy complications may explain the findings.

Pregnancy and delivery after a cesarean section

One out of seven of all parturients and one out of five primigravid women deliver by caesarean section. Of four women having undergone caesarean section, three will give birth vaginally, provided that the indication for surgery has been temporary by nature. Spontaneous beginning of labor and a previous vaginal delivery improve the chances of succesful of vaginal delivery. Rupture of the uterus in subsequent pregnancies is the most feared sequel to a caesarean section, with an occurrence of 0.2 to 1.5%. Delivery by caesarean is indicated in case of previous rupture of the uterus, hysterotomy through vertical incision, and more than two previous caesarean sections.

Management of birth-associated subtrochanteric femur fractures

In daily clinical practice most orthopedic surgeons suffer from doubt about treatment of rare injuries. The aim of this study is to enlighten the management of birth related femoral subtrochanteric fractures of neonates. Four birth-related femoral subtrochanteric fractures of neonates were treated and followed up. Difficult caesarian breech delivery seems to be a risk factor. All patients were treated with Pavlik harness and union was achieved by the fourth week. None of the patients suffer any angulation or limb length discrepancy. Adequate management of this type of fractures lead to good results.

Short interpregnancy interval after B-Lynch uterine compression suture: a case report

PURPOSE

The influence of the B-Lynch suture technique on subsequent fertility and pregnancy outcomes is not clear. In the present report, the authors describe the case of a very short interpregnancy interval following the successful placement of a B-lynch suture and discuss the associated problems.

MATERIALS AND METHODS

A 33-year-old-woman underwent cesarean section after undergoing artificial induction of labor and subsequent atonic postpartum hemorrhage. Placement of a B-Lynch brace suture successfully stopped the bleeding and preserved the uterus. The patient became unexpectedly pregnant only four months later, making the present case the shortest reported interpregnancy interval after a surgery involving the B-Lynch suture.

CONCLUSION

In the present case, fertility was not affected, and obstetric complications (abortion, fetal growth restriction, preterm delivery, and placenta previa) were not observed. Adhesions between the abdominal wall and the surface of the uterus along the previous B-Lynch suture line were observed and irregular, large blood vessels were observed on the surface of the uterus. Further reports are expected to determine the influence of the B-Lynch brace suture technique on the subsequent pregnancy.

Surgical speed and risk for maternal operative morbidity in emergent repeat cesarean delivery

OBJECTIVE

The purpose of this study was to determine whether surgical speed is associated with maternal outcomes in women who have a history of previous cesarean delivery (CD) and who require emergent delivery.

STUDY DESIGN

This is a secondary analysis of a multicenter, prospective observational study of women with a history of previous CD. Women who attempted a vaginal birth after CD and required emergent CD were dichotomized into those with a skin incision-to-fetal delivery time of ≤2 min (I-D ≤2) or >2 min (I-D >2), based on the mode I-D. Rates of composite maternal complications and specific surgical complications were compared.

RESULTS

Seven hundred ninety-three women had an emergency repeat CD: 108 women (13.6%) had I-D ≤2, and 685 women (86.4%) had I-D >2. The composite of maternal morbidity occurred in 36% of women with I-D≤2 and 23% with I-D>2 (P < .01). Women with I-D ≤2 had higher odds of intraoperative transfusion, uterine artery ligation, and broad ligament hematoma. In a multivariable regression model, the only variable that remained associated with maternal outcome was I-D (relative risk, 1.66; 95% confidence interval, 1.23-2.23). There was no difference in the incidence of neonatal acidemia between groups.

CONCLUSION

Among women who underwent emergent repeat cesarean delivery, surgical speed was associated with an increased risk for maternal complications.

Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor?

OBJECTIVE

The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States.

STUDY DESIGN

We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors.

RESULTS

From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals.

CONCLUSION

Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.

Obstetric outcomes associated with induction of labor after 2 prior cesarean deliveries

OBJECTIVE

We sought to determine whether, in the setting of induction, obstetric outcomes differ based on the number of prior cesarean deliveries (CD) and to determine whether women with 2 cesareans undergoing induction face increased risks of adverse outcomes compared to women undergoing a repeat CD.

STUDY DESIGN

This is a secondary analysis of a 4-year multicenter prospective cohort. Women with 1 or 2 CD were included. Frequencies of vaginal birth after cesarean as well as maternal and neonatal complications were compared among women with 1 CD undergoing induction, women with 2 CD undergoing induction, and women undergoing repeat CD with 2 cesareans.

RESULTS

Of the 10,262 women included in this study, 4100 (40.0%) underwent an induction after 1 CD, 152 (1.5%) underwent an induction after 2 CD, and 6010 (58.6%) had a repeat CD after 2 CD. In women undergoing induction, the chance of vaginal birth after cesarean was no different in women with 2 compared to 1 prior CD (65% vs 69%, P = .28). Similarly, composite maternal (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 0.6-2.3) and neonatal (aOR, 1.1; 95% CI, 0.7-1.7) outcomes were not different between the 2 groups. In women who had 2 prior CD, undergoing an induction carried similar composite adverse maternal and neonatal outcomes compared to having a repeat CD (aOR, 0.7; 95% CI, 0.3-2.0; aOR, 1.1; 95% CI, 0.6-2.2).

CONCLUSION

Labor induction outcomes are similar regardless of whether women have had 1 or 2 CD. After 2 CD, undergoing an induction carries similar maternal and neonatal risks as having a repeat CD.

Timing the provision of a pregnancy decision-aid: temporal patterns of preference for mode of birth during pregnancy

OBJECTIVE

To help identify the optimal timing for provision of pregnancy decision-aids, this paper examines temporal patterns in women's preference for mode of birth after previous cesarean, prior to a decision-aid intervention.

METHODS

Pregnant women (n=212) with one prior cesarean responded to surveys regarding their preference for elective repeat cesarean delivery (ERCD) or trial of labor (TOL) at 12-18 weeks and again at 28 weeks gestation. Patterns of adherence or change in preference were examined.

RESULTS

Women's preferences for birth were not set in early pregnancy. There was evidence of increasing uncertainty about preferred mode of birth during the first two trimesters of pregnancy (McNemar value=4.41, p=0.04), decrease in preference for TOL (McNemar value=3.79, p=0.05) and stability in preference for ERCD (McNemar value=0.31, p=0.58). Adherence to early pregnancy choice was associated with previous birth experience, maternal country of birth, emotional state and hospital site.

CONCLUSION

Women's growing uncertainty about mode of birth prior to 28 weeks indicates potential readiness for a decision-aid earlier in pregnancy.

PRACTICE IMPLICATIONS

Pregnancy decision-aids affecting mode of birth could be provided early in pregnancy to increase women's opportunity to improve knowledge, clarify personal values and reduce decision uncertainty.

[Combined use of continuous epidural anesthesia nand transversus abdominis plane block for postoperative management of cesarean delivery in a patient whose previous cesarean deliveries were not properly controlled]

We report the successful combined use of continuous epidural anesthesia and transversus abdominis plane block for the management of postoperative pain following a cesarean delivery in a patient whose paralysis and pain were not well controlled after two previous cesarean deliveries. A 28-year-old female patient with no remarkable medical history was scheduled to undergo cesarean delivery at 38 weeks and 3 days of pregnancy. She had undergone cesarean deliveries twice previously, at 23 and 25 years of age. Both of these procedures were concluded using combined spinal-epidural anesthesia. However, in both procedures, the continuous epidural catheter could not be removed within 12 hours because of paralysis of the right leg and sharp pain. Therefore, during the third operation, the concentration of the continuous epidural anesthesia infusion was decreased to prevent complications, and a transversus abdominis plane block was added. The patient experienced no postoperative pain and fewer complications. We think that the combined use of these blocks provided good postoperative pain control with fewer complications.

Counseling women with a previous cesarean birth: toward a shared decision-making partnership

Pregnant women who had a previous cesarean birth must choose whether to have a repeat cesarean or to attempt a vaginal birth. Many of these women are candidates for a trial of labor. Current practice guidelines recommend that women should be thoroughly counseled during prenatal care about the benefits and harms of both a trial of labor after cesarean (TOLAC) and an elective repeat cesarean delivery and be offered the opportunity to make an informed decision about mode of birth in collaboration with their provider. The purpose of this article is to improve the process of counseling, decision making, and informed consent by increasing health care providers' knowledge about the essential elements of shared decision making. Factors that affect the decisions to be made and concepts that are critical for effective counseling are explored, including clinical considerations, women's perspectives, decision-making models, health literacy and numeracy, communicating risk, and the use of decision aids. Issues related to birth sites for TOLAC are also discussed, including access, safety, refusal of surgery, and clinical management.

Timing cervicovesical fistula repair with repeat cesarean section

We present a case in which there was optimal management of recurrent cervicovesical fistula. The patient sustained a fistula shortly after a cesarean for cephalopelvic disproportion in the second stage. She underwent an unsuccessful attempt at vaginal repair 3 months postpartum and continued experiencing intermittent urinary leakage through the vagina. She expressed a wish for further childbearing and was counseled to undergo fistula repair at the time of repeat cesarean section. Twenty-seven months after her first delivery, she had a second healthy pregnancy and the repair of her cervicovesical fistula was performed with collagen graft interposition at the time of her elective cesarean section. This case report highlights the importance of surgical timing and comments on various factors that possibly enhance the success of the fistula repair.

[Anaesthetic management of caesarean section in pregnancy with diabetes and hypertrophic myocardiopathy with restrictive diastolic dysfunction]

Haemodynamic changes that occur during pregnancy are maximal between 28 and 34 weeks. In the pregnant woman with several associated diseases, such as hypertensive myocardiopathy and pre-gestational diabetes, these changes can lead to a difficult control of pulmonary hypertension and acute pulmonary oedema. We report the case of a pregnant woman with long term type 1 diabetes mellitus who suffered pre-eclampsia in a previous pregnancy, and since then developed hypertensive cardiomyopathy. She was admitted at 30 week gestation for metabolic and blood pressure control, and developed congestive cardiac failure after the administration of betamethasone for foetal lung maturity. A transthoracic echocardiogram showed a non-dilated hypertrophic left ventricle with good systolic function, restrictive diastolic dysfunction and moderate pulmonary arterial hypertension. When her general condition improved, we performed a caesarean section under regional anaesthesia to prevent the complications of pulmonary and systemic hypertension. We present the anaesthetic management and resolution of complications after oxytocin administration.

[Ectopic pregnancy in cesarean scar]

The ectopic pregnancy within a cesarean scar, is defined as the implantation of the blastocyst outside the endometrium in the site where the histerotomy was made in the previous cesarean. We report a case of a 35-year-old patient, which arrives to the emergency room with 11.3 weeks of gestation. With the diagnostic, prognostic and pleased parity we decide to do block hysterectomy. We describe this case because of its low frequency, but catastrophic consequences that put on danger mothers life. Prevalence is calculated on 1:1800-1226 of all pregnancies (0.15%) and represents 6.15% of de ectopic pregnancies in women with at least one cesarean. They have been published a mayor number of cases during the last decade, probably because of the world increment of cesarean delivery or the earliest diagnostic. We recommend interruption of pregnancy at the moment of diagnosis, to avoid complications.

Exaggerated placental site reaction detected during caesarean delivery: a case report

Exaggerated placental site (EPS) reaction is an exuberant physiologic process in which intermediate trophoblasts infiltrate the underlying endometrium and myometrium at the implantation site. During a caesarean section, we noted a polypoid well shaped smooth lesion, about 3 cm in diameter on the anterior wall of the uterus apart from the placenta. The histopathologic examination revealed an exuberant proliferation of trophoblastic cells in the placental site, a low Ki-67 labelling index and the absence of mitotic activity. Distinguishing EPS reaction from the other intermediate trophoblastic tumours is critical, as the latter may likely involve surgical intervention and/or chemotherapy, although no specific treatment and follow-up is required for EPS reaction. It is necessary to be aware of this pathology and take biopsies from suspicious lesions in the placental site for pathologic examination.

Severe Asherman's syndrome complicated with placenta increta conceived by intracytoplasmic sperm injection following hysteroscopic surgery

Although severe Asherman's syndrome is a disease that may cause infertility, pregnancy and childbirth are possible by performing hysteroscopic surgery. However, the obstetrical outcome is not always satisfactory. We report a case where severe Asherman's syndrome occurred following a cesarean section. Hysteroscopic surgery was performed due to secondary infertility, and pregnancy was achieved through a subsequent intracytoplasmic sperm injection. At 23 weeks of gestation, the patient was hospitalized due to the threat of premature labor, and a cesarean section was performed at 29 weeks of gestation after pregnancy-induced hypertension occurred. It was determined to be abnormal adherent placentation such as placenta increta through intraoperative findings, and a cesarean hysterectomy was performed. The pathological diagnosis of the uterus was placenta increta. Due to the risk of complications from placenta increta in pregnancies following hysteroscopic surgery in patients with severe Asherman's syndrome, it is important to realize the high risk involved in such cases during the pregnancy course, and careful perinatal management should be required.

3D volume contrast imaging (VCI) for the visualization of placenta previa increta and uterine wall thickness in a dichorionic twin pregnancy

PURPOSE

Placenta increta is a rare event in pregnancy, but is associated with serious maternal morbidity and mortality due to life threatening hemorrhage. The incidence has increased due to high Cesarean rates. We describe a case of placenta previa increta in a dichorionic twin pregnancy, which was successfully treated conservatively, to discuss the role of ultrasound, especially 3D VCI and TUI, for diagnosis and conservative management in similar cases.

MATERIALS AND METHODS

A GE Voluson Expert 730 ultrasound system which provides both conventional 2D imaging and 3D volume acquisitions using VCI and TUI was used for diagnosis and management in a case of placenta increta in a dichorionic twin pregnancy in which the placenta previa increta of the first fetus was left in situ and the other placenta was removed.

RESULTS

The 3D VCI provided superior resolution of the anterior wall of the uterus, delineating the myometrial thickness in the area of the placental implantation site. With superior image quality, the 3D VCI technique facilitates the evaluation of the myometrial thickness and the depth of placental invasion due to significantly improved enhancement of the contrast and differentiation between various tissues compared to the 2D scan.

CONCLUSION

We describe for the first time the application of 3D VCI and TUI for the visualization of the depth of placental invasion in such a case. Preoperative ultrasound diagnosis allows appropriate preoperative preparations and the decision to leave the placenta untouched to avoid a probable fatal outcome for the patient.

[Cervical meningocele with filiform connection. Case report]

The meningocele is the least common form of spina bifida cystica and represents less than 10% of cases of this disorder. A case of a female patient aged 26 with a history of two pregnancies and two previous cesarean sections, present pregnancy unplanned, uncontrolled during the first trimester prenatal and without supplementation with folic acid. Family history of consanguinity with her husband (second cousins) and psychomotor reassessed in four maternal cousins. The first follow-up visit the patient was at 34 weeks of pregnancy. The ultrasonographic findings were: cervical meningocele posterior filiform connection between the first and second cervical vertebrae, lateral ventriculomegaly and third and fourth ventricles and hydrocephalus secondary. Cesarean section was performed at 37 weeks gestation and was a newborn male 3.000 g, 52 cm, head circumference of 36 cm, Apgar 8/9, Capurro 37 weeks of gestation. In the posterior cervical region tumor was located a soft 5 x 5 cm with intact skin, adhered to deep planes. Movement of all four extremities without neurological involvement. He referred to the department of neurosurgery for shunt placement and subsequently performed surgical excision of the meningocele.

[Case report. Post cesarean section laparoscopic cholecystectomy for hydrocholecystitis]

BACKGROUND

Acute cholecystitis is the second most common surgical emergency in pregnant women. Although laparoscopic cholecystectomy has been described previously in these cases, there is still controversy regarding the most appropriate moment in which to perform the procedure.

OBJECTIVE

To describe the clinical presentation and management of a female with 36.6 weeks of pregnancy and clinical signs of acute cholecystitis. Cesarean section to deliver a healthy newborn was immediately followed by laparoscopic cholecystectomy without complications. A 10 year literature review complements the analysis and discussion of the case.

CLINICAL CASE

A 33 year-old female with 36.6 weeks of gestation presented a history of 24 hours with right upper quadrant and epigastric abdominal pain, nausea and vomiting. Symptoms were precipitated by cholecystokinetics and did not subside after expectant and pharmacologic medical treatment. The medical group decided with the patient's consent to interrupt the pregnancy via Cesarean section immediately followed by laparoscopic cholecystectomy.

RESULTS

After Cesarean section through a Pfannenstiel incision, laparoscopic trocars were placed and cholecystectomy performed without complications. The postsurgical course was favorable and both patient and newborn were discharged on day four.

CONCLUSIONS

Laparoscopic surgery cholecystectomy during pregnancy and in the immediate puerperium is feasible and safe. These combined procedures: rapid pregnancy interruption followed by a minimal invasive approach gives the benefits of laparoscopic surgery in these patients.

[Caesarean section for ulcerative colitis]

We present a case of a 35-year-old patient with diagnosis of ulcerative colitis that presented failure and complications associated with medical treatment; with a report of a colonoscopy and biopsy of pancolitis with severe activity. The patient was submitted to laparoscopic restorative total proctocolectomy with ileal "J" pouch anal anastomosis. Two months later the ileostomy was reversed. The patient received progesterone at the same time she was receiving immunosuppressive drugs. This was suspended two months after the second colon surgery. The patient did not require treatment with ovulation induction to achieve pregnancy. At the fourth month of gestation, the patient developed a perianal abscess, which was successfully drained. After multidisciplinary assessment in week 38 of gestation, it was decided to perform cesarean birth as a way to not affect the ileal pouch and the anastomosis of the digestive tract. At present time, the patient has had no further complications.

Anesthetic management of a repeat cesarean section in a parturient with severe peripartum cardiomyopathy requiring ECMO in a previous pregnancy: a case report

The number of pregnant women with cardiac disease is increasing with improvements in technology. In addition, more people are part of the national health insurance plan. However, there are few reports concerning the best method for anesthesia and mode of delivery in these high-risk patients. We report a 29-year-old woman scheduled for a planned caesarean section, who had a history of severe peripartum cardiomyopathy requiring extracorporeal membrane oxygenation in a previous pregnancy. The patient had regular prenatal care in our obstetric clinic. At 29 weeks' gestation, she developed severe dyspnea. A chest radiograph revealed bilateral pulmonary edema and 2-dimensional echocardiography showed a global hypokinesis and severe valve regurgitation with left ventricular ejection fraction of 41.2%. She had an emergency caesarean section and a cardiovascular surgeon was consulted to stand-by. Anesthesia was induced by ketamine 25 mg, midazolam 2.5 mg and rocuronium 50 mg for rapid intubation. The patient tolerated the procedure well and was extubated on postoperative day 1. She was discharged one week after surgery. Postoperatively, the patient was followed in the obstetric and cardiovascular surgery outpatient departments and at 5 months after surgery she was in good condition without any complaints.

Substance P (SP) and vasoactive intestinal polypeptide (VIP) in the lower uterine segment in first and repeated cesarean sections

The authors studied the presence of substance P (SP) and vasoactive intestinal polypeptide (VIP) and their related fibers in the lower uterine segment (LUS) in 133 women undergoing cesarean sections (CS) during active labor. These were divided into 2 groups: women undergoing repeat or first CSs. Specimens were collected from the LUS and were evaluated by light microscopy and by immunohistochemistry, for the morphometrical quantification of the SP and VIP fibers in the LUS. The SP amount was higher in the post-CS scar, while the VIP amount decreased: nerve fibers contained an SP amount of up to 13 ± 2.6C.U., while nerve fibers contained a VIP amount of up to 7 ± 1.9 C.U. The SP amount counts 10 ± 1.5% of the total Bodian fibers, and the ratio of the VIP is 10 ± 1.8% of their total amount. In normal conditions only 6.61 C.U. of the Bodian surface is occupied by SP related nerve fibers in contrast to 6.63 C.U. of the total surface by VIP; the amount of SP increased up to 13 ± 2.6C.U., while it decreased in the LUS previous scars. The SP levels are higher in repeat CS, while the VIP levels are reduced in the LUS. The increase of SP is probably linked to the attempt to achieve cervical ripening in a post-CS LUS, with the possible consequences of dystocia during vaginal birth after CS. Nevertheless, the decrease of VIP probably affects the relaxation of the internal uterine orifice, compromising the LUS formation and cervical ripening.

[A case of post-spinal tinnitus which improved after undergoing epidural anesthesia]

A 34-year-old woman suffering from post-spinal tinnitus for 8 years was scheduled for a cesarean section under epidural anesthesia selected to prevent a deterioration of this condition due to a possible decrease in the cerebrospinal fluid level. Unexpectedly, the tinnitus disappeared completely after the epidural injection of 2% lidocaine 27 ml and following continuous epidural infusion. It is conceivable that moderate quantities of local anesthetics into the epidural space might have acted as an effective method similar to that of epidural physiologic saline injection in order to improve the cerebrospinal pressure.