Louise Miner

The Role of Uterine Closure in the Risk of Uterine Rupture

To the Editor: I read with great interest the latest article on the role of single compared with double stitching on uterine closure.1 The article found that one of the 10 centers had no uterine ruptures during the 10year period. Perhaps future protocol might profit by looking at their apparently successful management. The study included 96 uterine ruptures after previous cesarean delivery, but only 74 of them had a known method of closure on the previous cesarean delivery, the variable being studied in this report. The 23% of cases in which the previous method of closure was unknown were irrelevant to the study. Despite this fact, these cases were found “matching controls” that occurred at the same time and place as the unknown closure cases, and the controls of the unknown cases were considered in all the analyses. This may reflect a desire to “prove” a predetermined outcome. In the study, to calculate how many controls were needed, it was assumed that 50% of uterine rupture would happen in women who had previous single-suture technique, whereas only 25% of controls would have previous singlesuture closure. Is it serendipitous that that the conclusions match the predetermined assumptions? It is exceeding logic that the more you stretch the skin near scar tissue, the more likely it is to rupture. Eight large studies found that trials of labor when the birth weight was more than 4,000 g was a significant factor for vaginal birth after cesarean failure and uterine rupture, and one found low rates of uterine rupture with birth weights of 2,500 g or less.2–10 Case–control studies are reliable when variables with important influence are matched for in the controls. Because birth weight is an already known and important factor for uterine rupture, birth weights needed to be matched in the control group with the cases. The authors write that it is impossible to control birth weight, thereby emphasizing a need to determine which closure rate is more effective. The literature already has shown that low glycemic diets with 50 g of protein intake per day after 12 weeks of gestation result in lower birth weights without increases in stillbirth or prematurity.11 A prospective multicenter study, controlling for the important factor of birth weight, surely is required before this question can be resolved.

Adhesion development and morbidity after repeat cesarean delivery.

OBJECTIVE The purpose of this study was to evaluate the development and implications of intraabdominal adhesions after repeat cesarean section delivery (CS). STUDY DESIGN We reviewed the charts of 1283 women who underwent repeat CS and 203 other women who underwent primary CS. Primary outcome measures were incidence and extent of adhesions, incision-to-delivery interval, and operating time. RESULTS No adhesions were found in primary CS. Compared with those women with a second CS (24.4%), significantly more women had adhesions after 3 CSs (42.8%; 95% confidence interval [CI], 0.84-0.99). Compared with a first CS (7.7 +/- 0.3 minutes), the delivery time was significantly longer at subsequent CSs (second CS, 9.4 +/- 0.1 minutes; 95% CI, 1-2; third CS, 10.6 +/- 0.3 minutes; 95% CI, 2-4; >or= 4 CSs, 10.4 +/- 0.1 minutes; 95% CI, 1-2). However, complication rates in those women with >or= 2 CSs were comparable with primary CS. CONCLUSION Increased adhesion development and a longer time to delivery were found with each subsequent CS.

Inherited thrombophilia and preeclampsia within a multicenter cohort: the Montreal Preeclampsia Study.

OBJECTIVE We sought to evaluate the association between inherited thrombophilia and preeclampsia. STUDY DESIGN From a multicenter cohort of 5337 pregnant women, we prospectively identified 113 women who developed preeclampsia and selected 443 control subjects who did not have preeclampsia or nonproteinuric gestational hypertension. Blood samples were tested for DNA polymorphisms affecting thrombophilia (factor V Leiden mutation, prothrombin G20210A mutation, methylenetetrahydrofolate reductase C677T polymorphism), homocysteine, and folate levels, and placentae underwent pathological evaluation. RESULTS Thrombophilia was present in 14% of patients and 21% of control subjects (adjusted logistic regression odds ratio, 0.6; 95% confidence interval, 0.3-1.3). Placental underperfusion was present in 63% of patients vs 46% of control subjects (P < .001) and was more frequent in women with folate levels in the lowest quartile (P = .04), but was not associated with thrombophilia. CONCLUSION We did not find evidence to support an association between inherited thrombophilia and increased risk of preeclampsia. Placental underperfusion is associated with preeclampsia, but this does not appear to be consequent to thrombophilia.

Prospective study of intraabdominal adhesions among women of different races with or without keloids

OBJECTIVE We sought to evaluate postsurgical adhesions in women of different races with or without keloids. STUDY DESIGN This was a prospective study evaluating postsurgical adhesions after a cesarean delivery in 429 women with or without keloids. The outcome measures were the prevalence and extent of adhesions in women of different races with or without keloids. RESULTS There was no difference in the prevalence of adhesions and adhesion score in various sites among women of different races. Compared with whites (0.5%), keloids were significantly more common in African Americans (7.1%; P = .007; odds ratio, 16.5) and in Asians (5.2%; P = .02; odds ratio, 11.9). Women with keloids were found to have more dense adhesions between the uterus and the bladder (P = .028; 95% confidence interval, 0-12) and between the uterus and the anterior abdominal wall (P < .0001; 95% confidence interval, 8-12). CONCLUSION The prevalence and degree of postsurgical adhesions in women of different races are comparable. Women with keloids on the cesarean scar have increased adhesions between the uterus and the bladder and between the uterus and the abdominal wall.

The effect of computer-assisted evaluation of labor on cesarean rates

&NA; Dystocia, or slow labor, is the leading cause of first‐time cesarean sections. Current diagnostic guidelines for dystocia are vague, and there is no clear postoperative confirmatory evidence to assess the correctness of this diagnosis. For several decades, various professional organizations have indicated that cesarean rates could be lowered safely and have recommended levels that are far below national averages. The three major factors, of roughly equal importance, associated with cesarean for slow labor are the babys weight, the mothers height, and the threshold at which the physician believes it is reasonable to intervene. The last is the only modifiable factor, and quality programs are a major part of changing medical behavior. By using two study designs, the effect of a mathematical method for evaluating labor progress on the rate of cesarean section was measured. In the prospective randomized clinical trial, the relative risk of cesarean in the experimental group was unchanged at 1.04. In the pretest‐posttest analysis, the rates fell from 19.54% to 17.04% at 6 months and 16.62% at 12 months.

Clinical relevance of intra-abdominal adhesions in cesarean delivery

The objective of this study was to evaluate the prevalence and extent of intra-abdominal adhesions at cesarean deliveries (CS) and their clinical relevance. We studied 490 cases of primary CS, 430 first repeat, and 106 cases of second or third repeat CS. Using a standard scoring system, the prevalence, extent, and consistency of adhesions were evaluated prospectively. We also examined the incision–delivery interval and the total operating time. At repeat CS, adhesions were found mainly between the uterus and the bladder or the abdominal wall. Dense adhesions to the bladder and to the abdominal wall were significantly more after ≥2 CSs (46.3% and 48.2%) than after one CS (29.8% and 25.6%). The adhesions on these areas were also more severe after ≥2 CSs than after one CS. There was a significant correlation between the adhesion score and the interval between the incision and delivery (r = 0.23, P < 0.0001) and the operating time (r = 0.26, P < 0.0001). CS leads to adhesion formation mainly between the uterus and the bladder and between the uterus and the anterior abdominal wall.

Spinal hamartoma with severe kyphoscoliosis--a rare case of spinal mass in a fetus.

Spinal hamartomas are rare lesions consisting of disorganized ecto- and mesodermal tissues of the spinal region. While postnatal identification of spinal hamartomas has been reported, a literature search did not reveal any published reports of prenatal identification of spinal hamartomas. Here we report a 46,XX fetus who presented at 20 weeks’ gestation with a lower thoracic and lumbar kyphoscoliosis, suspected spina bifida, and amniotic fluid α-fetoprotein (AFP) levels within the normal range. Interestingly, autopsy at 22 weeks revealed a lumbosacral spinal hamartoma with kyphoscoliosis. We discuss the differential diagnosis for such spinal masses which includes congenital tumors and spinal dysraphism. This case illustrates that spinal hamartomas should be considered as part of the prenatal differential diagnosis of spinal dysraphisms, especially in the presence of normal AFP levels.

IS SHOULDER DYSTOCIA WITH BRACHIAL PLEXUS INJURY PREVENTABLE

The sequelae of shoulder dystocia with persistent brachial plexus injury (BPI) are among the most serious of obstetrical complications. Shoulder dystocia with BPI generally places second or third in the list of the top causes of permanent birth-related neonatal injuries. Apart from the devastating medical and social consequences of lifelong impairment for the family, ensuing litigation with its allegations regarding poor care exacts a heavy toll on the medical profession.