Eric Verspyck

Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions. METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage. RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization. CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates. LEVEL OF EVIDENCE: III

B‐Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization

Objective. To estimate the effectiveness and safety of the B‐Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. Design. Cohort study. Setting. University‐affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B‐Lynch suture for persistent PPH despite vessel ligation. Methods. Data were retrieved from medical files and telephone interviews. Main outcome measure(s). Hysterectomy, infection, hysteroscopy, future menstruations. Results. In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B‐Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. Conclusions. B‐Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Fetal death in a patient with intrahepatic cholestasis of pregnancy.

BACKGROUND: Treatment with ursodeoxycholic acid in intrahepatic cholestasis of pregnancy reduces concentration of transaminases and bile acids in maternal serum, and is thought to reduce fetal death. We report a case of fetal death in a patient with intrahepatic cholestasis of pregnancy who had responded well to ursodeoxycholic acid, demonstrated by a low bile level. CASE: A young nulliparous woman presented with intrahepatic cholestasis of pregnancy at 28 weeks of gestation. Transaminases and bile acids decreased after ursodeoxycholic acid administration. The patient was discharged from the hospital until delivery and received biochemical markers and conventional fetal monitoring twice weekly. Due to low bile acid values (< 13 UI/L) and unfavorable cervix, the patient was followed up expectantly. Fetal death occurred at 39 weeks and 3 days, although cardiotocograph testing results were normal the day before. CONCLUSION: When lung maturity is achieved for patients with intrahepatic cholestasis of pregnancy, delivery should be considered.

Obstetric and neonatal outcomes in grand multiparity

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among grand multiparas with age-matched multiparas. METHODS: Six hundred twenty-one grand multiparas (para more than 4) women were prospectively compared with 621 age-matched multiparous (para 2–4) controls. RESULTS: Grand multiparity was associated with low socioeconomic status and education (odds ratio [OR]6.4; 95% confidence interval [CI] 4.5, 9.0), poorer prenatal care (OR 3.1; 95% CI 1.5, 6.1), smoking (OR 2.2; 95% CI 1.5, 3.2), and alcohol consumption (OR 9.0; 95% CI 2.1, 39.3). Grand multiparas had a higher body mass index (OR 1.5; 95% CI 1.2, 1.9) and rate of insulin-dependent gestational diabetes (OR 1.7; 95% CI 1.02, 3.1). They had more previous intrauterine (OR 4.2; 95% CI 1.5, 11.3) and perinatal deaths (OR 3.2; 95% CI 2.0, 5.0). They had fewer intrapartum complications (arrests of cervical dilatation [OR 0.19; 95% CI 0.06, 0.66], instrumental deliveries [OR 0.31; 95% CI 0.16, 0.59], and fever during labor [OR 0.47; 95% CI 0.26, 0.86]). Conditional logistic regression models found that grand multiparity was the most closely correlated factor to a previous history of fetal death (OR 4.3; 95% CI 1.6, 11.6), but it was not an independent predictor of insulin-dependent gestational diabetes mellitus (OR 1.3; 95% CI 0.75, 2.2). CONCLUSION: Grand multiparas, when compared with same-age multiparous controls, appear to have fewer intrapartum complications. However, they present several prenatal risk factors that require special antenatal care. LEVEL OF EVIDENCE: II-3

Attempted vaginal versus planned cesarean delivery in 195 breech first twin pregnancies

Background. To compare neonatal and maternal outcomes for breech first twins according to whether vaginal or cesarean delivery was planned and to verify that in appropriate selected cases, attempted vaginal delivery is a reasonable choice. Methods. A retrospective study of all twin pregnancies with the first twin in breech position and gestational age at least 35 weeks at birth at two French university hospital centers from January 1994 through December 2000. The primary outcome was a combined indicator of neonatal mortality and severe morbidity, as defined by one or more of the following: death before discharge, admission to neonatal intensive care unit, 5‐minute Apgar score <7, cord blood pH <7.10, or birth trauma. Results. Cesarean delivery was planned for 71 (36.4%) patients, and attempted vaginal delivery for 124 (63.6%), 59 (47.6%) of whom were delivered vaginally and 65 (52.4%) by cesarean during labor. Neither the combined negative outcome indicator nor neonatal mortality differed significantly for either twin or either group. There were no significant differences in maternal mortality or morbidity between the two groups. The frequency of deep vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy was significantly higher in the planned cesarean group [3/71 (4.2%) versus 0/124; p = 0.047]. Conclusion. When appropriate criteria are used to decide mode of delivery, a careful intrapartum protocol is followed, and an experienced obstetrician, midwife, and anesthesiologist are in attendance, attempted vaginal delivery is a reasonable option for first twins in breech position.

Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium

Case reportA 35 year old primiparous woman attended the emer-gency department at 17 weeks of gestation for acute rightiliac fossa pain with guarding. Rebound pelvic examinationwas painful. The patient’s temperature was 38.6jC andlaboratory tests showed no leucoytosis. Ultrasound re-vealed a single intrauterine viable pregnancy equivalentto dates and additionally a uterine mass in the left lateralwall of the uterus, 5 cm in length. Due to a suspectedadnexal torsion, a laparoscopy was performed, whichrevealed a degenerating pedunculated uterine leiomyomawithout torsion of the pedicle. It was situated on theanterior surface of the uterus below the right uterine cornu.Because the woman was so symptomatic, myomectomywas performed by resection of the myoma using monopolarcutting diathermy via a hook electrode with a 40 W poweroutput. Despite the insertion of an endoloop constrictingthe pedicle prior to electroresection, the top of the pediclewas slightly electrocoagulated to ensure perfect hae-mostasis. The uterine cavity was not opened. The myomawas extracted via a transumbilical approach, by morcella-tion. Histological examination confirmed the diagnostic ofaseptic degeneration of uterine leiomyoma. Abdominalpain occurred six days post-operatively, with associatedileus and pus at the umbilical incision but with no fever.The umbilicus was irrigated with Betadine and penicillin Vwas started. Clinical improvement occurred and she wasdischarged from hospital. She returned two weeks laterwith an intestinal obstruction mass in the right iliac fossaand a recurrence of umbilical infection. Ultrasound exam-ination showed collection of 10 cm diameter, comparedwith the area of myomectomy extending to the neighbour-ing myometrium. Laparotomy was performed via an umbil-ical median incision and revealed an abscess on the anteriorsurface of the uterus. It was situated on the scar of thepedicle of the resected myoma. Following peritoneal lavage,a full thickness of myometrium was lost due to uterinenecrosis. An area approximately 7 2 cm of the amnioticsac was clearly visible (Fig. 1). The edges of the defectwere brought together with three slow absorption stitches.The remainder of the abdominopelvic cavity was normal.The right iliac fossa was drained using a natural rubbercorrugated drain (Peters Laboratories, France). Parenteralantibiotics were initiated with piperacilline and tazobactam,gardenerella vaginalis, peptostreptococcus and anaerobicnegative gram bacillus were obtained on bacteriology. Oralmedication (amoxicilline and clavulanic acid) was contin-ued for three weeks. Tocolysis was achieved using indo-methacin following laparatomy. The remainder of thepregnancy was normal. The woman was readmitted at ges-tation for 37 weeks to elective caesarean section. The babyweighed 3530 g with an Apgar score of 10 at 5 minutes oflife. During the caesarean section, adhesions were identifiedin the right iliac fossa and were divided. There was noobvious defect in the uterine wall. There was a placentaaccreta and removal of placenta was distinct. The area ofaccreta was adjacent to the previous myomectomy. Due toprofuse arterial bleeding from this area, the uterine pedicles,

Thrombophilia and immunological disorders in pregnancies as risk factors for small for gestational age infants

Objectives To determine if inherited thrombophilia and immunological disorders represent risk factors for small for gestational age infants, and to assess their relationship with neonatal status.

Newborn shoulder width: a prospective study of 2222 consecutive measurements.

Objectives To relate maternal and infant characteristics to newborn shoulder width and to evaluate the predictive value of newborn shoulder width measurement in cases of shoulder dystocia.

Surgical uterine devascularization for placenta accreta: immediate and long-term follow-up

Background.  To report immediate and long‐term outcome in patients with surgical  uterine devascularization for placenta accreta.

Ineffectiveness of associating a suburethral tape to a transobturator mesh for cystocele correction on concomitant stress urinary incontinence.

OBJECTIVES To evaluate the effect of a transobturator subvesical mesh for cystocele on concomitant stress urinary incontinence (SUI). Genital and urinary prolapse surgery presents difficulties, particularly regarding cure of SUI. Advances in vaginal prosthetic surgery could correct these difficulties. METHODS Between July 2003 and October 2007, a total of 74 patients with a minimum stage 2 anterior prolapse with concomitant SUI were operated on, using a porcine collagen-coated large-pore-size monofilament polypropylene mesh with 2 transobturator expansions, but without an additional procedure for SUI. All patients had a physical examination and a subjective symptoms assessment using a questionnaire in the preoperative period and again 6 weeks, 6 months, and then each year after surgery. The pelvic organ prolapse quantification system was used for anatomic results. For SUI, Ingelman-Sundberg classification and cough test were used. Loss of urine was measured by a 1-hour pad test. Functional results were evaluated by visual analog scale, pelvic floor distress inventory, and pelvic floor impact questionnaire. RESULTS Median follow-up was 36 months (range 12-51). Seventy-two women (97%) were cured of their prolapse. A total of 53 women (72%) were cured of their SUI and 11 (15%) were improved. Pad test, visual analog scale, pelvic floor distress inventory, and pelvic floor impact questionnaire all showed improvement (P <.05). Prolonged bladder catheterization was not required. Complications consisted of 1 hematoma requiring blood transfusion and 5 vaginal extrusions (6%). CONCLUSIONS Transvaginal mono prosthesis for the simultaneous correction of prolapse and SUI represents an effective treatment without the risk of prolonged urinary retention.