Tomislav Kulaš

Successful of the B-Lynch compression suture in the management of massive postpartum hemorrhage: case reports and review

The authors describe three patients who developed massive primary postpartum hemorrhage and review the case reports. In two patients, primary postpartum hemorrhage was due to uterine atony, and in one patient it was due to atony and thrombophilia. In all three patients, excellent effect was achieved with hemorrhage reduction by a compression B-Lynch suture alone, with bimanual compression following medicamentous uterotonic therapy. B-Lynch suture is an efficient, safe, and simple method for the treatment of primary postpartum hemorrhage during cesarean section, which successfully reduces the number of urgent postpartum hysterectomies, also preserving subsequent fertility. In our opinion, the method should be included in the algorithm of primary postpartum hemorrhage management at all obstetric departments.

Nonobstetrics vulvovaginal injuries: mechanism and outcome.

ObjectiveThe aim of this study is the evaluation of mechanisms and outcome of nonobstetrics vulvovaginal injuries (VVI).Study designMedical documentation on 17 VVI recorded during the 1998–2005 period was analysed. The analysis included age, mode of injury infliction (accidental, intracoital, rape), treatment, and VVI outcome. Pregnant women and obstetrics peripartal and postpartal VVI were excluded from this study, and there was no sexual assault VVI in children and young girls in this period.ResultsThere were five young girls, all of them raped by the straddle mechanism, five adolescents (aged <25), and five postmenopausal women. Two postmenopausal women were raped by young men. Straddle accident due to fall from bicycle was recorded in three, fall onto a metal object in two, and athletic injury by a foreign object, cow’s horn, and kitchen knife in one patient each. Intracoital injuries, mostly rupture of the posterior fornix, were recorded in six patients. Revision and primary suture of the wound were performed in 16 patients, whereas 1 patient underwent laparotomy and revision of the vaginal stump due to intestinal prolapse after vaginal rupture.ConclusionsBesides primary operative management of the wound, the patient should receive broad-spectrum antibiotic and antitetanic prophylaxis in cases of accidental and penetrating injuries (foreign object, cow’s horn, kitchen knife). In case of suspect mechanism of infliction, VVI in a child require careful inspection because of the potential forensic implications (rape, abuse).

New Views on Cesarean Section, its Possible Complications and Long-Term Consequences for Children’s Health

Historical developments and advancements in cesarean section techniques and logistics have reduced the maternal and neonatal risks associated with the procedure, while increasing the number of operatively completed pregnancies for medically unjustifiable reasons. The uncritical attitude towards cesarean section and the fast emergence of ‘modern’ diseases such as obesity at a young age, asthma, type 1 diabetes mellitus and various forms of dermatitis have stimulated researches associating cesarean section with these diseases. Intestinal flora of the children born by cesarean section contains less bifidobacteria, i.e. their intestinal flora is similar to the intestinal flora in diabetic individuals. In children born by cesarean section, the ‘good’ maternal bacterial that are normally found in the maternal birth canal and rectum are lacking, while the ‘bad’ bacteria that may endanger the child’s immune system are frequently present. In children born by vaginal delivery, the ‘good’ maternal bacteria stimulate the newborn’s white blood cells and other components of the immune system, which has been taken as a basis for the hypotheses explaining the evident association of the above morbidities and delivery by cesarean section.

Modified Misgav Ladach Method for Cesarean Section: Clinical Experience

Objective: To determine the advantages of modified a Misgav Ladach method over conventional (Pfannenstiel-Dörffler) cesarean section. Study Design: From October 2002 to March 2005, 217 cesarean sections performed according to a modified Misgav Ladach method (without routine preoperative urinary catheterization, blunt separation of the fascia after a small incision, and unprepared plica vesicouterina) were prospectively compared with 153 randomly selected conventional cesarean sections. Maternal age, parity, gestational age, neonatal birth weight, procedure duration, operative complications and postoperative course were analyzed. Results: The incidence of postoperative fever was 2.30 and 4.57% (p = 0.001), wound seroma 0.46 and 1.96% (p = 0.01), local wound infection 0.92 and 1.96% (p = 0.01), wound dehiscence 0 and 0.65% (NS), anemia 3.68 and 7.84% (p = 0.001), and need of blood transfusion 1.38 and 1.96% (NS) in the modified Misgav Ladach and conventional group, respectively. The mean duration of the operation was 26.24 min with the Misgav Ladach versus 39.41 min with the conventional operation (p < 0.001). The postoperative use of antibiotics and analgesics/antipyretics was significantly lower in the modified Misgav Ladach group (p = 0.001). Conclusion: Study results demonstrated that the modified Misgav Ladach method of cesarean section is associated with faster postoperative recovery, lower morbidity and blood loss, shorter length of operative procedure, lower incidence of operative complications, lesser postoperative use of antibiotics and analgesics/antipyretics, and lower utilization of surgical material. The modified Misgav Ladach method of cesarean section is suitable for emergency and elective procedures, justifying its use in daily routine.

A Case of Intra-Amniotic Maternal Hemorrhage in Term Pregnancy

Introduction: Intra-amniotic maternal hemorrhage is a rare condition, hard to differentiate from some other conditions in pregnancy. We report an unusual case of intra-amniotic maternal hemorrhage in term pregnancy ending in urgent cesarean section, identified on ultrasound examination. Case Report: A 24-year-old female (gravida 3, para 2, abortion 0) was admitted to hospital at 40 weeks’ gestation for collapse and general weakness. Her blood pressure was 90/60 mm Hg, pulse 112 bpm, temperature 36°C. The fetal heart race tracings were stable and reactive. The cervix was opened 3 cm. Further examination revealed no vaginal bleeding and normal amnioscopic findings. An ultrasound examination confirmed singleton, head-presenting gestation without any visible congenital anomalies, amniotic fluid index was at the 50th percentile, anterior placenta without evidence of previa, abruption or retroplacental hematoma. An inhomogeneous echogenic mass, measuring 12 × 8 cm, was noted within the amniotic cavity, there was no evidence of pathological flow through the mass on color Doppler. After admittance to the hospital, the patient complained of regular pains, weakness and collapsed with signs of hemorrhagic shock. Repeated ultrasound evaluation showed no change in acoustic texture and size, but the amniotic fluid now had a hyperechoic appearance which revealed increasing intra-amniotic hemorrhage. Because of clinical signs of maternal hemorrhagic shock confirmed by laboratory findings of decreasing red blood parameters, an urgent cesarean section was performed. A female infant weighing 3,070 g, Apgar score 5/7, was delivered. After removal of the placenta there was no sign of abruption, which was confirmed at histopathology. Hemoglobin A was detected in the amniotic fluid by Abt’s test. The patient had an uncomplicated postoperative course. The infant developed normally. Conclusion: When there are signs of fetal distress or maternal hemorrhagic shock, an urgent cesarean section should be performed.

3D-Ultrasound Detection of Fetal Grasping of the Umbilical Cord and Fetal Outcome

A case of persistent fetal palmar grasping of the umbilical cord in a 23-year-old primigravida is described. Palmar grasping was detected with three-dimensional ultrasound examination after cardiotocographically recorded fetal bradyarrhythmia. Because of acute fetal hypoxia, urgent Misgav-Ladach cesarean section was performed to deliver a hypotrophic female newborn, 2,120 g/43 cm, Apgar score 4/7, pH 7.29. No other pathology was found during the procedure. The postoperative course proceeded uneventfully and the early neonatal neurological status and neurosonographic findings were normal.

Uteroplacental apoplexy (Couvelaire syndrome)

A 40-year-old woman in the 41st week of gestation with previously inadequately controlled hypertension was admitted to the obstetric emergency unit in a state of shock (blood pressure 90/60, heart rate 110/min), pale, with nausea, uterine hypertonia, no vaginal hemorrhage. Fetal heartbeat could not be detected by cardiotocography, whereas ultrasonography verified total abruptio placentae and marked fetal bradycardia. Urgent cesarean section was performed to deliver a severely asphyxial male newborn (Apgar score 0/4). The neonate underwent primary resuscitation and died on the second day of life. An abundance of fresh coagula (> 1 L) and the placenta with total central rupture were evacuated from the uterine cavity. The posterior uterine wall showed blood imibibition to the serosa expanding to the broad ligament and lateral parametrium corresponding to uteroplacental apoplexy (Fig. 1). Uteroplacental apoplexy (Couvelaire Syndrome) is a rare but nonfatal complication of severe forms of placental abruption. It occurs when vascular damage within the placenta causes hemorrhaging that progresses to and infiltrates the wall of the uterus. It is a syndrome that can only be diagnosed by direct visualization, biopsy or both. For this reason, its occurrence is perhaps underreported and underestimated in the literature. Considering the patient’s multiparity, massive abruptio placentae and the extent of apoplectic lesions it was decided to perform total hysterectomy without adnexa, with abdominal and subfascial drainage. Postoperatively, the patient was transferred to the intensive care unit and eight days later could be discharged from the hospital.

Infective puerperal endocarditis caused by Escherichia coli.

Abstract Presentation is made of a rare case of infective puerperal endocarditis involving the native mitral valve in a young puerpera after cesarean section, without a history of pre-existing heart disease, inflammation focus or intravenous drug abuse.

Refractory shoulder dystocia in term macrosomic newborn with verified complete meningoencephalomyelocele

The authors presented the birth course, in a primiparous woman with complicated, refractory, high shoulder dystocia, of a macrosomic term-born malformed child (4400/54) with complete occipital meningoencephalomyelocele and microcephaly. After head delivery, high shoulder dystocia occurred that could not be resolved with neither the McRoberts or Resnik maneuver nor with the Woods and Barnum maneuvers, despite recurred tries. Only on third attempt with the Barnum maneuver was the posterior arm released with hand traction, followed by the whole body of the macrosomic baby. The child was transferred to the Neurosurgery department where operative correction was performed, and after the intervention the child died because of respiratory insufficiency. Due to the strict parental decision on pregnancy continuation and prohibition of any obstetric interventions during delivery, unborn child and parturient, as well as the obstetric team, were put into high professional, forensic and ethical risk.