Andrée Sansregret

The effect of gestational age on trial of labor after Cesarean section

Objectives: To evaluate the effect of gestational age on the rate of successful vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior Cesarean delivery.Study design: This was a cohort study including patients with a live singleton fetus undergoing a TOL after a previous low transverse Cesarean delivery between 1988 and 2002. Patients were divided into three groups according to gestational age: 24–36 weeks 6 days, 37–40 weeks 6 days and ≥41 weeks. Obstetric outcomes, including the rates of successful vaginal delivery and symptomatic uterine rupture, were compared between the groups. Multivariate logistic regression analysis was performed to adjust for potential confounding factors.Results: There were 253, 1911 and 329 patients in each group, respectively. In patients with advanced gestational age (≥41 weeks) the rate of uterine rupture was significantly higher (0% vs. 1.0% vs. 2.7%, p=0.006) and the rate of successful vaginal deliveries was significantly lower (83% vs. 76.9% vs. 62.6%, p<0.001). After adjusting for confounding variables, advanced gestational age was associated with a lower rate of successful vaginal delivery (odds ratio 0.68, 95% CI 0.51–0.89), and a higher rate of uterine rupture (odds ratio 2.85, 95% CI 1.27–6.42) when compared to 37–40 weeks 6 days.Conclusion: Advanced gestational age is associated with higher rates of failed TOL and uterine rupture.

Twin Delivery After a Previous Caesarean: A Twelve-Year Experience

OBJECTIVES To compare maternal and neonatal morbidities between trial of labour (TOL) and elective Caesarean section in women with twin pregnancies who have had a prior Caesarean. METHODS An observational study was conducted of women with a prior Caesarean who delivered twins at 28 weeks gestation or greater in Ste-Justine Hospital between 1988 and 2001. Maternal and neonatal outcomes were compared between women who had a TOL (group 1) and those who had an elective Caesarean delivery (group 2). RESULTS Twenty-six women and 52 fetuses were included in group 1 and compared to the 71 women and 142 fetuses in group 2. Maternal age, gestational age, and birth weight were comparable in both groups. In group 1, 22 (85%) out of 26 women delivered twin A vaginally and 19 (73%) delivered both vaginally. There was no significant difference in the umbilical artery cord pH, Apgar score, ventilatory support, and admission to the neonatal intensive care unit between the 2 groups. There was also no significant difference in the rate of postpartum maternal fever or decrease of serum hemoglobin between the 2 groups, but the median hospital stay was higher in the group with elective Caesarean (5.0 vs. 3.0 days, p <0.001). There were no uterine ruptures or other major complications in either group. CONCLUSION There were no significant differences in maternal and neonatal morbidity outcomes between births by trial of labour and by elective Caesarean, in twin pregnancies after a prior Caesarean section. A trial of labour is associated with a shorter hospital stay.

Assessment of correlation between p16INK4a staining, specific subtype of human papillomavirus, and progression of LSIL/CIN1 lesions: first comparative study.

OBJECTIVES To study and compare the effectiveness of p16(INK4a) staining and specific human papillomavirus (HPV) subtypes as a prognostic marker in cervical intraepithelial neoplasia grade 1 (CIN1; low-grade squamous intraepithelial lesions). METHODS Sixty-four cervical samples diagnosed as CIN1 and stained with p16(INK4a), with HPV status assessed by polymerase chain reaction-direct sequencing. RESULTS Of the 34 p16(INK4a)-negative biopsy specimens, 26 regressed, seven persisted, and one progressed. Of the 20 p16(INK4a) diffusely positive biopsy specimens, seven regressed, eight persisted, and five progressed. Ten biopsy specimens stained positive only in the lower one-third of the sample, of which seven regressed and three persisted. p16(INK4a) diffusely positive CIN1 lesions were associated with only high-risk HPV subtypes, with the exception of one HPV-negative biopsy specimen. Three different high-risk HPV subtypes and one low-risk HPV subtype (HPV66) were identified in the six CIN1 lesions that progressed. CONCLUSIONS There is a significant relationship between p16(INK4a) immunostaining and follow-up (P = .002). p16(INK4a)-negative specimens or positivity in the lower one-third of CIN1 lesions seldom progress to a CIN2-3 lesion.

Choosing the right physical laparoscopic simulator? comparison of LTS2000-ISM60 with MISTELS: validation, correlation, and user satisfaction

BACKGROUND The LTS 2000-ISM60 (LTS; Realsim Systems, Alburquerque, NM, USA) is a computer enhanced video-laparoscopic training system. Our purpose was to validate the LTS and to correlate its scoring performance with that of the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), a widely used and well-validated physical simulator. METHODS Participants (n = 124) included medical students, residents, fellows, and attending surgeons from general surgery, gynecology, and urology in 3 Canadian universities. They were classified in groups based on laparoscopic experience: novice, intermediate, competent, and expert. Participants (n = 124) were tested on the LTS, and 74 were tested on both the LTS and the MISTELS. A user satisfaction questionnaire was completed after each performance. RESULTS LTS metrics showed a progressive improvement in total scores according to academic level as well as level of laparoscopic experience (P < .001). Good correlation was found between the LTS and the MISTELS (r = .79). Level of user satisfaction was highest with LTS. CONCLUSIONS Based on laparoscopic experience and academic level, the LTS has a comparable discriminating capability for level of performance with that of the MISTELS. The higher degree of user satisfaction attributed to the LTS could justify its use as a training and assessment tool for surgical specialties.

Early versus late amniotomy for labour induction: a randomized controlled trial

Objective: To evaluate the impact of early vs. late amniotomy on delivery mode in women undergoing induction of labor. Study design: 143 women admitted for induction were randomized to early amniotomy (EA, concomitant with the beginning of oxytocin infusion; n = 71) or to late amniotomy (LA, four hours after the beginning of oxytocin; n = 72). Randomization was stratified by parity. The primary outcome was the rate of cesarean. Secondary outcomes were duration of labor and intrapartum fever. Results: The cesarean rate was similar between groups (18% vs. 17% among nulliparous; and 3% vs. 0% among parous women, in EA and LA group, respectively). However, EA was associated with shorter oxytocin-to-delivery interval (12 vs. 15 h) and a non-significant decrease in intrapartum fever (3% vs. 25%) than LA in nulliparous women (p = 0.05). Conclusion: For women undergoing oxytocin induction, early amniotomy is associated with shorter labor in nulliparous women with no effect on the risk of cesarean section in both nulliparous and multiparous women.

Early Versus Delayed Postoperative Feeding After Major Gynaecological Surgery and its Effects on Clinical Outcomes, Patient Satisfaction, and Length of Stay: A Randomized Controlled Trial

OBJECTIVE To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction. METHODS We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus. RESULTS A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4 ± 21.0 hours in the early feeding group vs. 85.6 ± 26.2 hours in the delayed feeding group; P > 0.05). No significant difference was noted in patient satisfaction (P > 0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement. CONCLUSION The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.

Immediate closure of uterine wall following spontaneous rupture at 23 weeks' gestation, allowing prolongation of pregnancy

Uterine rupture is a dramatic complication of pregnancy associated with increased fetal morbidity and mortality. It occurs frequently during a vaginal birth in women with a previous Cesarean section1. Corporeal rupture has also been reported and usually occurs after previous laparoscopic myomectomy2. More recently, other conditions have been associated with uterine rupture, such as after mid-gestational open maternal fetal surgery3, after laparoscopic salpingectomy4 and even in a previously unscarred uterus5. We report a case of recurrent uterine rupture in a pregnant woman following a previous vaginal delivery with retention and manual removal of the placenta. A 35-year-old woman presented to the emergency room at 23 + 6 weeks’ gestation with acute abdominal pain located on the left side of the uterus. Her obstetric history was significant, with her first pregnancy delivering vaginally at term with manual removal of the placenta which was located in the left cornual region, close to the tubal ostium. In a second pregnancy, spontaneous uterine rupture near the left cornual region of the unscarred uterus occurred at 35 weeks and resulted in fetal demise. The third and fourth pregnancies were twin and singleton pregnancies, respectively, both of which miscarried. The latter was treated with dilation and curettage. Before allowing this current pregnancy, the integrity of the uterine wall was ascertained with ultrasound and hysteroscopy. In the current pregnancy, a diagnosis of uterine rupture was confirmed as a fetal foot and amniotic sac could be seen protruding through the uterine wall scar. An emergency laparotomy was performed under combined epidural and intrathecal analgesia. The site of the rupture was again close to the left ostium. The decision to perform immediate closure of the uterine wall was based on the following: (1) fetal wellbeing and prematurity status; (2) presence of posterior placenta; and (3) absence of intraperitoneal hemorrhage. The patient wanted the best outcome for her baby and consented to this approach. For closure of the uterine wall, a 6-cm single-layer suture with vicryl-0 was performed (Figure 1). Perfusion of nitroglycerine was given for uterine relaxation and phenylephrine perfusion was also needed to counteract the nitroglycerine actions. On completion of surgery, iatrogenic preterm prelabor rupture of membranes (PPROM) occurred. In the Figure 1 Uterine wall defect at laparotomy (a) and its immediate closure (b) in a case of recurrent uterine rupture at 23 weeks’ gestation.

Spontaneous uterine rupture at 23 weeks’ gestation with immediate closure of the uterine wall allowed prolongation of pregnancy

Uterine rupture is a dramatic complication of pregnancy associated with increased fetal morbidity and mortality. It occurs frequently during a vaginal birth in women with a previous Cesarean section1. Corporeal rupture has also been reported and usually occurs after previous laparoscopic myomectomy2. More recently, other conditions have been associated with uterine rupture, such as after mid-gestational open maternal fetal surgery3, after laparoscopic salpingectomy4 and even in a previously unscarred uterus5. We report a case of recurrent uterine rupture in a pregnant woman following a previous vaginal delivery with retention and manual removal of the placenta. A 35-year-old woman presented to the emergency room at 23 + 6 weeks’ gestation with acute abdominal pain located on the left side of the uterus. Her obstetric history was significant, with her first pregnancy delivering vaginally at term with manual removal of the placenta which was located in the left cornual region, close to the tubal ostium. In a second pregnancy, spontaneous uterine rupture near the left cornual region of the unscarred uterus occurred at 35 weeks and resulted in fetal demise. The third and fourth pregnancies were twin and singleton pregnancies, respectively, both of which miscarried. The latter was treated with dilation and curettage. Before allowing this current pregnancy, the integrity of the uterine wall was ascertained with ultrasound and hysteroscopy. In the current pregnancy, a diagnosis of uterine rupture was confirmed as a fetal foot and amniotic sac could be seen protruding through the uterine wall scar. An emergency laparotomy was performed under combined epidural and intrathecal analgesia. The site of the rupture was again close to the left ostium. The decision to perform immediate closure of the uterine wall was based on the following: (1) fetal wellbeing and prematurity status; (2) presence of posterior placenta; and (3) absence of intraperitoneal hemorrhage. The patient wanted the best outcome for her baby and consented to this approach. For closure of the uterine wall, a 6-cm single-layer suture with vicryl-0 was performed (Figure 1). Perfusion of nitroglycerine was given for uterine relaxation and phenylephrine perfusion was also needed to counteract the nitroglycerine actions. On completion of surgery, iatrogenic preterm prelabor rupture of membranes (PPROM) occurred. In the Figure 1 Uterine wall defect at laparotomy (a) and its immediate closure (b) in a case of recurrent uterine rupture at 23 weeks’ gestation.