A. Fakokunde

Application of uterine compression suture in association with intrauterine balloon tamponade ('uterine sandwich') for postpartum hemorrhage.

We evaluated in a prospective observational study the use of a ‘uterine sandwich’ technique (uterine compression sutures in association with intrauterine tamponade) in women who had had unsuccessful medical treatment for postpartum hemorrhage. Ten of the 11 patients had cesarean sections (complicated by placenta previa and uterine atony) and one had a normal delivery. The median estimated blood loss and units of blood transfused were 1500ml (range 750–4000ml) and two units (range 0–9), respectively. B‐Lynch sutures were placed in two patients and Haymans modification was used in nine. Bakri balloon tamponade was in place for a median of 22hours (range 17–27hours), while the median volume infused in the balloon was 300ml (range 150–350ml). The combined technique was successful in avoiding hysterectomy in all cases, and there was no documented postpartum morbidity. This is a simple and quick surgical technique that can be used to treat atonic postpartum hemorrhage, particularly in conjunction with placenta previa.

Acute colonic pseudo-obstruction (Ogilvie's Syndrome) following caesarean section for triplets

A 22-year old primigravida booked for antenatal care at 12weeks gestation following a spontaneous conception of triplet pregnancy. She had no significant medical history. Antenatal course was uneventful until 28weeks gestation when she developed mild pre-eclampsia. Her blood pressure was well controlled with methyldopa and she remained asymptomatic, except for generalised abdominal discomfort attributed to gross abdominal distension associated with multiple pregnancy. Her pre-eclampsia gradually worsened, and was complicated by recurrent headaches and general feeling of unwell. In view of her worsening pre-eclampsia she was given a course of betamethasone to minimise the risk of neonatal respiratory distress syndrome and delivered by elective caesarean section at 32 weeks gestation. The procedure was complicated by uterine atony that required intramyometrial carboprost 250 microgram which was repeated after 15 minutes. She was also given 600 mg of rectal misoprostol as well as oxytocin (syntocinon) infusion 30 iu in 500 ml normal saline at a rate of 125 ml/hour to maintain uterine tone. She mobilised on the first post operation day, opened her bowel with no problems and tolerated oral feeds. However on the second day she developed gross abdominal distension, worsening colicky abdominal pain and loss of appetite. She opened her bowel that morning but her stool was loose and small in amount. Her temperature was 36.3, pulse 68, and blood pressure was 140/89. Abdominal tenderness and rigidity was prominent. Bowel sounds were tinkling. A working diagnosis of post-operation ileus, was made with Ogilvie’s syndrome as a differential diagnosis. Oral feeding was suspended and she was commenced on intravenous infusion and nasogastric suctioning. Her abdominal pain became progressively worse. She developed tachycardia with a pulse of 105/min and her blood pressure was160/105. Serum urea, creatinine and electrolytes were normal as was a full blood count, C-reactive protein and liver function test. Plain X-ray of the abdomen showed a gas filled distended colon with a colonic diameter of about 12 cm. Ogilvie’s syndrome was highly suspected and the General Surgical team reviewed. In view of her worsening pain and grossly distended colon, a laparotomy was performed. At laparotomy the colon was found to be grossly distended from the caecum to the rectum. No obvious cause for obstruction was found. The small intestine was normal. Intraoperative diagnosis of Ogilvie syndrome was confirmed. The colon was decompressed using a needle and a tube caecostomy was performed using a 20F Foleys catheter following appendicectomy. She made good post-operative recovery and the caecostomy tube was removed on post-op day 10. A stoma bag was placed over the fistula temporarily and the patient was discharged home six days later. She has since made full recovery and the fistula had healed completely. Discussion

Management of complicated second stage of labour in stillbirths: a review of the literature and lessons learnt from two cases in the UK.

Summary The stillbirth rate for singletons in the UK is approximately 5.3/1,000 births/year. Macrosomic babies are associated with obstructed labour and shoulder dystocia. Some 3.3% of stillborns weigh over 4 kg, when such problems are likely to be encountered. In developed countries, caesarean section is regarded as being more civilised than destructive operations for obstructed labour prior to full cervical dilatation in an interuterine death. However, when the cervix is fully dilated or severe shoulder dystocia is encountered, fetal destructive operations have half the maternal mortality rate of that associated with caesarean section, with fewer long-term sequelae. A significant obstacle in performing destructive operations in developed countries is the lack of skilled practitioners. It is difficult to acquire these skills in the UK, however simulated training can be provided with manikins. We feel mothers should be informed of the alternative of a destructive operation, potentially avoiding unnecessary caesarean section.

Fletcher factor deficiency in a woman requiring emergency caesarean section.

A 25 year-old black primigravida presented to the labour ward in spontaneous labour at term. She had an uneventful antenatal period. Her menstrual cycle was 5/28 days with no menorrhagia. She had had tooth extraction in the past with no excessive bleeding. A blood count, clotting screen, liver and renal function tests, and uric acid levels were done in view of mildly raised blood pressure in early labour. Results were normal except prolonged partial thromboplastin time (APTT) of 69.4 s (range 24–38) with a normal prothrombin time (PT) of 10.5 s (range 11–16). The prolonged APTT was confirmed on a repeat sample. She required emergency caesarean section (CS) for failure to progress in the first stage of labour. On advice from haematology team, she was transfused with 4 units of fresh frozen plasma (FFP) to correct the prolonged APTT. The CS was done under general anaesthesia, and uterine atony was prevented using syntocinon, Hemabate and misoprostol. She made an uneventful recovery and was discharged on the 5th day postpartum. Further test results on the pre-transfusion sample showed normal clotting factors and coagulation profile. Follow-up tests in the haematology clinic showed her to have a low kallikrein level of 51 U/dl (range 50–150) and high molecular weight kininogen of 110 U/dl (range 50–150). Her factors VIII, IX, XI, XII, thrombin and fibrinogen levels were normal. A diagnosis of Fletcher (contact) factor deficiency was made.

Torsion of a normal ovary and fallopian tube with an enlarged fibroid uterus

have described success with using this method to treat true interstitial ectopics (Moon et al. 2000), we proceeded to salpingotomy. Diathermy was used to open the superior border of the Fallopian tube at its most distended point. Hydro-dissection was used to separate the pregnancy tissue from the wall of the tube. Bleeding from the base of the tube was controlled with diathermy, and the superior border of the tube closed with interrupted Vicryl. The patient was discharged from hospital the following day and HCG levels rapidly fell below 2 mIU/ml.

Hip pain in pregnancy: An unusual case of venous thrombosis

Bartynski WS. 2008. Posterior reversible encephalopathy syndrome: fundamental imaging and clinical features. American Journal of Neuroradiology 29:1036–1049. Casey SO, Sampio RC, Michel E, et al. 2000. Posterior reversible encephalopathy syndrome: utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. American Journal of Neuroradiology 21:1199–1206. Covarrubias DJ, Luetner PH, Campeau NG. 2002. Posterior reversible encephalopathy syndrome: Prognostic utility of diffusionweighted images. American Journal of Neuroradiology 23:1038– 1048. Dittmar G. 1999. Neurological spectrum of pre-eclampsia and eclampsia. Nervenarzt 70:1098–1103. Doelken M, Lanz S, Rennert J, et al. 2007. Differentiation of cytotoxic and vasogenic edema in a patient with reversible posterior leukoencephalopathy syndrome using diffusion-weighted MRI. Diagnostic and Interventional Radiology 13:125–128. Donaldson JO. 1994. The brain in eclampsia. Hypertension in Pregnancy 13:115–133. Hinchey J, Chaves C, Appignani B, et al. 1996. A reversible posterior leukoencephalopathy syndrome. New England Journal of Medicine 334:494–500. Narbone MC, Musolino R, Granata F, et al. 2006. PRES: posterior or potentially reversible encephalopathy syndrome? Neurological Science 27:187–189. Powell ES, Goldman MJ. 2007. Posterior reversible encephalopathy syndrome (PRES) in a thirty-six-week gestation eclamptic. Journal of Emergency Medicine 33:377– 379. Stott VL, Hurrell MA, Anderson TJ. 2005. Reversible posterior leukoencephalopathy syndrome: a misnomer reviewed. Internal Medicine Journal 35:83–90. Striano P, Striano S, Tortora F, et al. 2005. Clinical spectrum and critical care management of posterior reversible encephalopathy syndrome (PRES). Medical Science Monitor 11:549– 553. Topuz S, Kalelioğlu I, Iyibozkurt AC, et al. 2008. Cranial imaging spectrum in hypertensive disease of pregnancy. Clinical and Experimental Obstetrics and Gynecology 35:194– 197.

Transcultural considerations in obstetrics and gynaecology: What the clinician needs to know

Summary Healthcare professionals working in the field of obstetrics and gynaecology may encounter patients from a variety of cultural backgrounds, particularly in our inner cities. These women may have similar cultural beliefs and values about aspects of care they experience compared with native women, but they may also have differing beliefs and may present with preconceptions about the care they expect to receive. In our experience, traditional medical training has limited core teaching on the existence of such cultural variations, and professionals often only experience them through working in the clinical setting. This review was, therefore, undertaken with the aim of increasing awareness of such variations, in order to promote more holistic management, and ultimately to enhance patient care.

The best way to determine the best way to undertake a hysterectomy

a relatively small sample size and the uncommon major morbidities assessed. We acknowledge that this is less robust than evaluating each complication separately. Nonetheless, it was the only reasonable approach given the relative rarity of placenta accreta in a single institution. We entirely agree with the authors that our study design does not permit us to conclude that ureteral stents are useful in cases of placenta accreta. In fact, we explicitly state this in the paper. Nonetheless, in our anecdotal experience they have been useful. In cases of suspected accreta, it is the practice of most of our colleagues to use preoperative ureteral stenting. The greatest blood loss in these cases occurs during dissection of the bladder from the lower uterine segment and ureteral stents allow for more rapid, continuous localisation of the ureters which may reduce operative time and blood loss while also reducing the likelihood of ureteral injury. Until appropriate randomised controlled clinical trials are conducted, such anecdotal case series are the best information available to practicing clinicians. The authors suggest that we drew conclusions regarding the utility of conservative management from only two cases in our cohort who were managed without hysterectomy. In fact, we avoided any specific comment on the utility of conservative management specifically because our dataset and study design was insufficient to assess this strategy. Conversely, there is considerable publication bias in papers reporting successful expectant management. Our statement in the manuscript and our response now are the same. We advise caution and extensive counseling of women who feel strongly about attempting uterine preservation based on significant maternal morbidity that can result. We agree that our cohort was subject to bias and we acknowledged this limitation in our manuscript. The only way to determine the best way to care for women with placenta accreta is through properly designed clinical trials. Until such data are available, case series such as ours can provide some guidance to clinicians regarding others experience with this morbid and increasingly common condition. It is our hope that obstetricians will continue to publish their institutional experiences so that the available evidence base for decision making can continue to grow. j