Devendra Kanagalingam

Massive postpartum haemorrhage after uterus-conserving surgery in placenta percreta: the danger of the partial placenta percreta.

Placenta percreta is a rare but potentially life‐threatening condition associated with high maternal mortality and morbidity rates, usually arising from severe obstetric haemorrhage. Due to rising caesarean section rates, an increase in the incidence of morbidly adherent placentas (accreta, increta and percreta) has been observed. Various treatment strategies have been employed in different centres, ranging from performing a caesarean hysterectomy at the time of delivery to leaving the placenta in situ, with or without adjuvant internal iliac and uterine arterial embolisation and/or methotrexate therapy. In the case of placenta percreta, irrespective of the treatment method employed, women are still at high risk of life‐threatening haemorrhage and morbidity secondary to placental invasion beyond the confines of the uterine serosa into surrounding organs, most commonly the bladder. We describe an unusual case of a partially adherent placenta percreta in which partial separation of the normally implanted placenta led to torrential haemorrhage on the third postoperative day after the placenta was left in situ at the time of delivery. We therefore advise caution in following a conservative approach in the treatment of cases of placenta percreta in which the percreta feature is only partial and will discuss the merits and disadvantages of alternative options.

Obstetric outcomes in women with end-stage renal failure requiring renal dialysis

Objective: To study obstetric outcomes in women with end‐stage renal failure undergoing chronic renal dialysis. Methods: A retrospective review of the database from the High‐Risk Pregnancy Clinic at Singapore General Hospital, Singapore. Results: From 1995 to 2004, 7 women treated with chronic renal dialysis had a total of 11 pregnancies. There were 2 pregnancy losses at previable gestation ages and 9 live births. Median gestational age at delivery was 31 weeks, and mean birth weight was 1390 g. Seven newborns had a low birth weight and 5 required neonatal intensive care. Severe hypertension occurred in 4 women for a total of 7 pregnancies. Other complications included polyhydramnios (n = 2), preterm prelabor rupture of membranes (n = 2), obstetric cholestasis (n = 2), postpartum hemorrhage (n = 1), thrombosis of the arteriovenous fistula (n = 2), postpartum peritonitis (n = 1), and fetal anomaly (n = 1). There were no maternal deaths. Conclusion: Such pregnancies are high‐risk, particularly because of maternal hypertension and prematurity. They should be managed by multidisciplinary teams, and prepregnancy counseling should not be neglected.

Decision-to-delivery intervals and total duration of surgery for Caesarean sections in a tertiary general hospital.

INTRODUCTION This study aimed to determine the decision-to-delivery intervals (DDIs), total duration of surgery and factors influencing these for Caesarean sections (CSs). METHODS A retrospective study was conducted of all CSs performed from August 2013 to June 2014 at a single tertiary general hospital. Data collected included maternal demographics, indications for CS, category of urgency, DDI, total duration of surgery, grade of first surgeon and number of previous CSs. RESULTS In total, 488 CSs (Category 1: n = 28; Category 2: n = 137; Category 3: n = 184; Category 4: n = 139) were studied. Overall mean duration of surgery was 41.7 minutes. Mean DDI was 23.9 minutes and 64.5 minutes for Category 1 and Category 2 CSs, respectively. For Category 1 CSs, deliveries during office hours had a significantly shorter DDI than deliveries out of office hours (p < 0.05). For Category 2 CSs, deliveries during office hours had a significantly longer DDI (p < 0.05). Total duration of surgery for senior surgeons was significantly shorter than for trainee surgeons (p < 0.05). Women with no previous CSs had a significantly shorter duration of surgery than those who had one or more (p < 0.05). CONCLUSION The majority of the deliveries were within the recommended DDI corresponding to the degree of urgency of CS. The influence of time of day on DDI might be due to challenges of time taken to transfer patients to operating theatres. Total duration of surgery was influenced by surgical experience, history of previous CS and individual surgical styles and preferences.

Renal and obstetric outcomes in pregnancy after kidney transplantation: Twelve‐year experience in a Singapore transplant center

Renal and obstetric outcomes in pregnancy after kidney transplantation in Singapore were last studied in 2002. A review of these outcomes in Singapore is now timely following advances in transplant and obstetric medicine. The aim was to evaluate the renal and obstetric outcomes in pregnancy after kidney transplantation in a Singapore tertiary center.

A review of caesarean section techniques and postoperative thromboprophylaxis at a tertiary hospital.

INTRODUCTION Although Caesarean sections (CSs) are among the most commonly undertaken procedures in the world, there are wide variations in the surgical techniques used. This study aimed to: (a) review the surgical techniques used for CS by obstetricians working in a tertiary hospital in Singapore; (b) compare the techniques with those recommended in evidence-based guidelines; and (c) examine the relationship between the technique used and the level of seniority of the surgeons. METHODS Data on 490 CSs performed in Singapore General Hospital (SGH) between 1 August 2013 and 30 June 2014 was collected from the Delivery Suite database and reviewed. The surgical techniques studied were closure of the pelvic and parietal peritoneum, closure of the uterine layer, use of surgical drains and use of postoperative thromboprophylaxis. RESULTS A total of 486 CSs were analysed after four cases were excluded due to missing data. Most fetal head deliveries were manual. The majority of surgeons did not close the peritoneum; most of those who did were senior surgeons. Double-layer uterine closures were done for all cases and drain usage was rare. 2.0% of the patients received grossly inadequate thromboprophylaxis. CONCLUSION The surgical techniques currently practised in SGH are closely aligned with those of the evidence-based guidelines. Peritoneal closure appears to be associated with the surgeons early training, with a greater number of senior surgeons being less willing to abandon this step. Greater vigilance in implementing appropriate thromboprophylaxis is recommended.

Multiple pregnancy is the leading contributor to cesarean sections in in vitro fertilization pregnancies: An analysis using the Robson 10‐group classification system

In vitro fertilization (IVF) pregnancy is an important contributor to rising cesarean section (CS) rates. The profile of CS in this group is not well documented. This study sought to identify leading patient categories of the Robson 10‐Group Classification System (TGCS) contributing to the high IVF CS rate.

P15.11: Subsequent pregnancy outcome after embolisation of uterine arteriovenous malformation

Objective: To identify if ultrasound measurement of endometrial thickness is predictor of retained products of conception in women with clinical suspicion of incomplete miscarriage. Methods: This was a prospective study of 100 women with a diagnosis of incomplete miscarriage who were referred for surgical evacuation. All women had a positive pregnancy test and ultrasound findings suggestive of retained product of conception. The indication for intervention was heavy vaginal bleeding or the endometrial thickness above 15 mm on antero-posterior diameter. The final diagnosis of incomplete miscarriage was based on histopathologic evidence of chorionic villi in the surgical specimen. Results: 90 (90%) women with endometrial thickness above 15 mm had evidence of chorionic villi on histology and decidua was only found in the remaining 10 (10%) women. Conclusion: Considering 90% positive predictive value, the measurement of endometrial thickness is good predictor of retained product of conception.

Resolution of severe fetal distress following treatment of maternal diabetic ketoacidosis

Diabetic ketoacidosis (DKA) during pregnancy is a serious metabolic complication of diabetes with high mortality and morbidity if not detected and treated immediately. We report a case of a woman with type 1 diabetes mellitus who had poorly controlled diabetes in the first half of pregnancy and developed DKA at 29 weeks gestation. At presentation, she had a pathological fetal heart tracing but delivery was delayed for maternal stabilisation and reversal of acidosis. Once hyperglycaemia, acidosis and maternal stabilisation were achieved, fetal compromise resolved and delivery was no longer indicated. The patient was subsequently discharged home. She delivered vaginally a 2400 g baby at 34 weeks gestation after presenting with spontaneous rupture of membranes.

P33.02: Fetal clavicle length: an Asian nomogram

in about 15 minutes using 3D reconstructed volumes, but the evaluation time of volume data sets may be decreased significantly if the acquisition of volumes is standardized to minimize artefacts and produce uniform images. Evaluation of thoracic bones has been possible in all cases. The scapulae and clavicles can be easily visualized by multiplanar mode, but the relationships between the thoracic bones, especially with ribs, are better observed by rendering mode. Two fetuses affected by trisomy 21 have eleven ribs; one fetus with tetralogy of Fallot has also a spondylocostal dysostosis with hemivertebrae and four fused ribs; one fetus referred for ventriculomegaly had two thoracic hemivertebrae. In all cases ultrasound scans were confirmed after birth by radiological examinations. Conclusions: Three-dimensional ultrasound provides additional diagnostic information for the evaluation of fetal thoracic skeleton and it should be of value in the diagnosis of skeletal anomalies. Until now its use must be reserved in a research setting and offered to high-risk patients in order to understand which role 3D may play in the study of skeletal thoracic malformations as a screening or diagnostic tool.