Broad ligament term pregnancy in an unscarred uterus: misdiagnosis and the challenges

A broad ligament pregnancy is a rare condition, but full term broad ligamnet pregnancy especially in an unscarred uterus is extremely rare. It is often misdiagnosed and usually finally diagnosed during surgery. Here is case of full term broad ligament pregnancy, which remained undiagnosed throughout her pregnancy, unfortunately had IUFD. Patient was referred to our hospital in view of failure of induction with increased BP records. No ultrasound was available on admission. On clinical assessment it appeared as transverse lie with IUFD. So cesarean was decided as a mode of delivery. Emergency ultrasound could just confirm IUFD with pelvic mass? Fibroid (actually deviated uterus). On laparotomy the broad ligament pseudosac had occupied entire abdomen. After delivery of baby, anatomy was found completely distorted. Highly vascular omental adhesions on fundus with difficulty in placental removal. Placenta could be traced reaching abdomen posteriorly. The first clinical impression was suspicion of placenta percreta. Uterus appeared non salvageable and hysterectomy was decided. Placenta was found lying in abdomen, adhered to bowel, omentum and fundus of uterus. The final diagnosis of broad ligament pregnancy could be made after the cut section of the uterus and anatomic evaluation. Patient required blood transfusions preoperatively .She remained stable and discharged on postoperative day nine. This case holds importance because may be outcome was different if it was a booked and investigated pregnancy. May be baby and uterus were salvageable with better outcome.

Histerectomía obstétrica en el Hospital San Bartolomé, Lima, 2003 - 2015 / Obstetrical hysterectomy at Hospital San Bartolome, Lima, Peru 2003 - 2015

Objetivos. Determinar la incidencia, factores asociados y repercusiones de la histerectomía obstétrica. Diseño. Estudio retrospectivo, descriptivo, analítico y transversal. Institución. Hospital Nacional Docente Madre Niño San Bartolomé, Lima, Perú. Material. Se analizaron las historias clínicas de 69 pacientes con histerectomía obstétrica (HO) realizadas del 01 de enero 2003 al 31 de diciembre 2015. Metodología. Se utilizó el odds ratio como medida de asociación. El análisis estadístico se realizó en los programas Excel 2013 y SPSS. Principales medidas de resultados. Tasa, factores asociados, indicaciones, complicaciones de la HO. Resultados. La tasa de histerectomía obstétrica fue 0,69/1 000. El 82,6% consistió en parto por cesárea (1,94/1 000), OR cesárea/parto vaginal 19,91. El 65,2% fue realizada en multípara de 35 años o menos de edad, 78,2% con control prenatal. Los diagnósticos principales fueron placenta previa (27,5%) y cesárea anterior (15,9%). Las principales indicaciones clínicas para realizar una HO fueron atonía uterina y acretismo placentario (ambas 39,1%). En 47,8% de los casos se practicó cesárea histerectomía, y la HO supracervical representó el 55%. Ingresó a la unidad de cuidados intensivos el 84%, necesitó transfusión sanguínea el 91,3%. Se reportó complicaciones durante el acto quirúrgico en 18,7%, siendo reintervenida el 15,9%. No hubo muerte materna. Conclusiones. La histerectomía obstétrica (HO), aunque de baja incidencia (0,69/1 000 eventos obstétricos), sigue siendo una circunstancia crítica y mutilante. La cesárea tuvo 19,9 veces más riesgo de histerectomía obstétrica que el parto vaginal (OR: 19,9; IC95%, 8,6 a 46,2). No hubo casos de muerte materna.

Objectives: To determine the incidence, associated factors and outcomes of obstetrical hysterectomy. Design: Retrospective, descriptive, analytical and cross-sectional study. Setting: Hospital Nacional Docente Madre Niño San Bartolome, Lima, Peru. Material: Clinical records of 69 patients who underwent obstetrical hysterectomy (OH) performed between January 1, 2003, and December 31, 2015. Methods: Odds ratio was applied as measure of association, and Excel 2013 and SPSS programs were used for statistical analysis. Main outcome measures: Incidence, associated factors and outcomes of obstetrical hysterectomy. Results: OH rate was 0.69/1 000; 82.6% followed cesarean section delivery (1.94/1 000), OR cesarean section/vaginal delivery was 19.91; 65.2% were multiparous women aged 35 or less, 78.2% with prenatal control. Main diagnoses were placenta previa (27.5%) and previous cesarean section (15.9%). Main indications for OH were uterine atony and placenta accreta (either 39.1%). In 47.8% of the cases, cesarean section-hysterectomy was performed, and supracervical OH represented 55%. Admission to ICU was necessary in 84% of cases, 91.3% needed blood transfusion. Complications during surgery occurred in 18.7%, and 15.9% needed reintervention. No maternal death was reported. Conclusions: In this study, obstetrical hysterectomy had a low incidence (0.69/1 000 obstetrical events), but remained a critical and mutilating circumstance. The risk of obstetrical hysterectomy was 19.9 times higher with cesarean section than with vaginal delivery (OR: 19.9; 95%CI, 8.6-46.2). There was no maternal death in this series.

The burden of severe maternal morbidity in contemporaneous Obstetrics / El lastre de la morbilidad materna severa en la Obstetricia contemporánea

Maternal health is deteriorating across the world due to multiple factors including increasing rates of obesity, chronic medical conditions such as chronic hypertension, type II diabetes, and cardiovascular disease, as well as advanced maternal age by the time of conception. These factors summed to the increasing cesarean delivery rate, lack of standardization of clinical practices, and inappropriate care during obstetrical urgencies are all major contributors to the rising rates of major obstetrical complications and maternal death. In recent years, national and international health care organizations have proposed new definitions of major maternal morbidity. The World Health Organization (WHO) defines "near maternal miss" (NMM) as the series of events leading from good health to a life-threatening complication associated with organ dysfunction or failure. Conversely, the Centers for Disease Control and Prevention (CDC) in United States classify "severe maternal morbidity" (SMM) if a pregnancy is complicated by one or more of twenty five ICD-9 clinical complications/procedures associated with a high maternal mortality risk. Although, each organization uses a different approach, existing data indicate that diagnostic criteria used for the CDC or the WHO accurately predicts pregnancies complicated with a "true" life-threatening maternal complication. These definitions are essential to better understand the burden of the disease. Each hospital providing maternal health care should adopt the definition that better fits its own health care system and is urged to incorporate initiatives that can reduce preventable major maternal complications. A fundamental step to address this issue is the establishment of a standardized review or audit process conducted by a multidisciplinary team that assesses systematically cases of severe maternal morbidity and mortality, evaluates deficiencies of health care at the provider, institution, and system levels, and adopts programs to improve quality of care. Maternal warning systems, composed by a set of abnormal physiological parameters that alert the provider about the deterioration of the patient's condition and prompt immediate bedside assessment, have shown to be effective in reducing maternal morbidity and mortality. Of importance, it has been recently demonstrated that linking these warning systems to standardized evidence-based clinical guidelines that address the most common obstetrical clinical pathways provides further benefits to the patient's care and improves outcomes. Despite the advances in the early detection and management of major maternal morbidity, there is a concise need of further research to standardize definitions at regional, national and international levels, validate the effectiveness of early warning systems in different clinical settings, improve long-term outcomes, and incorporate other preventive measures initiated even prior to conception to further decline the rates of serious maternal complications and death.

La salud materna se está deteriorando en el mundo debido a múltiples factores, entre los cuales se encuentran el incremento de las tasas de obesidad, las enfermedades crónicas como la hipertensión crónica, la diabetes mellitus tipo II y la enfermedad cardiovascular, así como la edad materna avanzada al momento de la concepción. Estos factores sumados a la mayor tasa de cesáreas, la falta de estandarización de la práctica clínica y la atención inapropiada de las urgencias obstétricas son las que contribuyen tremendamente al incremento de complicaciones obstétricas graves y muerte materna. En años recientes, las organizaciones de salud nacionales e internacionales han propuesto nuevas definiciones de la morbilidad materna severa. La Organización Mundial de la Salud (OMS) define 'morbilidad materna extrema' (MME) como una serie de ocurrencias que parten de la buena salud y se complican al punto de poner en riesgo de muerte por disfunción o falla orgánica. Al contrario, los Centros para el Control y Prevención de las Enfermedades (CDC) en los Estados Unidos clasifican como 'morbilidad materna grave' (MMS) si un embarazo se complica con una o más de las veinticinco complicaciones/procedimientos clínicos de la Clasificación Internacional de Enfermedades (ICD-9) asociados con un riesgo alto de mortalidad materna. Aunque cada organización emplea una aproximación diferente, la información existente indica que los criterios diagnósticos utilizados por el CDC o la OMS predicen con mucha precisión aquellas gestaciones complicadas con una 'verdadera' complicación materna que amenaza su vida. Estas definiciones son esenciales para comprender mejor la dimensión de la enfermedad. Cada hospital que provee atención de la salud materna deberá adoptar la definición que mejor se adapte a su propio sistema de salud y es urgido a incorporar iniciativas que puedan reducir las complicaciones maternas severas. Un paso fundamental para resolver este aspecto es establecer una revisión estandarizada o proceso de auditoría conducido por un equipo multidisciplinario que analice sistemáticamente los casos de morbilidad y mortalidad materna grave. Este equipo está encargado de evaluar las deficiencias de los proveedores de salud, de la institución y de los niveles del sistema. Además, tiene la obligación de implementar programas que mejoren la calidad de la atención. Los sistemas de alarma materna, compuestos por un grupo de parámetros fisiológicos anormales, han sido creados con el objetivo de alertar al proveedor sobre el deterioro de las condiciones de la paciente, exigiendo una pronta evaluación, reduciendo así la morbimortalidad materna. Recientemente se ha demostrado que al unir estos sistemas de alarma a las guías clínicas estandarizadas y basadas en la evidencia que están dirigidas a las complicaciones clínicas obstétricas más comunes permite mayores beneficios para el manejo de la paciente y mejora los resultados clínicos. A pesar de los avances en la detección y manejo temprano de la morbilidad materna severa, existe una necesidad de mayor investigación para estandarizar las definiciones a nivel regional, nacional e internacional y validar la efectividad de los sistemas de alarma temprana en diferentes escenarios clínicos. Además, es necesario implementar nuevas estrategias para mejorar los resultados maternos a largo plazo e incorporar otras medidas preventivas iniciadas aún antes de la concepción, de manera que se logre disminuir aún más las tasas de complicaciones graves y la muerte materna.

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES: The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria. METHODS: In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate's correction or Fisher's exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals. RESULTS: Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially lifethreatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths). CONCLUSIONS: Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.

The indications, effectiveness and complications of the selective arterial embolization in the management of obstetrical hemorrhage / 대한주산의학회잡지

PURPOSE:The objective of this study was to evaluate the indications, effectiveness and complications associated with uterine arterial embolization as an alternative treatment of obstetrical hemorrhage. METHODS:From January 2006 to December 2008, 25 patients who underwent angiographic embolization for the obstetrical hemorrhage that was not responsive to conventional treatments, like obstetric maneuvers and uterotonic drugs, were included in our study. All medical records were reviewed and detailed clinical data such as clinical status, underlying conditions, amount of transfusion, embolized arteries, hospital stay, the success rate and the complications were collected. RESULTS:We have experienced clinically successful embolization in 22 (88%) of 25 patients with obstetrical hemorrhage resulting from various causes. After embolization, the patients' vital signs were stabilized. The causes of hemorrhage were atony of uterus (n=10), myomectomy during cesarean section (n=6), abnormal placentation (n=5), arterio-venous malformation (n=3), and cervical pregnancy (n=1). The average amount of blood transfusion was 7.2 units (range; 0~39 units). The average length of the time for the procedure was 55 minutes (range: 25~96 minutes). The average duration of hospitalization was 5.5 days (range: 2~14 days). In 22 patients, menses resumed spontaneously after procedures. The main complications after embolization were numbness and pain on lower extremities (n=1), and hypomenorrhea (n=1). CONCLUSION:The atrerial embolization is one of the safe and effective procedures that offers patients an alternative to hysterectomy for the treatment of intractable postpartum hemorrhage.

Alarmingly High Maternal Mortality in 21st Century.

The study was conducted to determine the maternal mortality rate (MMR), various factors affecting it and possible prevention of maternal deaths in Christian Medical College & Hospital, a tertiary care institute during the past five years (2001- 2005). The individual record of maternal deaths was studied regarding their socio-demographic features, causes, modes of management and ultimate outcome. The Maternal Mortality rate was 1470 per lac live births. The major obstetrical complications accounted for more than three fourth of maternal deaths with hemorrhage (33%), sepsis (21.7%) and eclampsia (7.5%) playing an important role. Anemia (44.3%) and jaundice (16.0%) were two important indirect causes of maternal deaths. Un-booked cases accounted for majority of maternal deaths. Only two maternal mortality patients were showing regularly in our institute, rest all of the patients either had no antenatal check-up or were having ANC in private clinics and were referred as an emergency in critical condition. More than 90% of maternal deaths hailed from rural and urban slum areas. 61 (57.8%) cases received primary care from untrained birth attendants and 11 (10.4%) did not receive primary care in any form. There was delayed referral by the untrained personnel, 49 (46.2%) patients were referred after more than 48 hours of acute emergency, 51 (48.1%) died between 24 to 48 hours and 25 (23.6%) died within 24 hours of admission in spite of all resuscitative measures. It is concluded that providing good antenatal care, finding appropriate ways of preventing and dealing with the consequences of unwanted pregnancies, and improving the way society looks after pregnant women are three most important ways to reduce maternal mortality.

The indications, effectiveness and complications of the selective arterial embolization in the management of obstetrical hemorrhage / 대한산부인과학회지

OBJECTIVE: The object of this study was to evaluate the indications, effectiveness and complications associated with arterial embolization as a safe and effective alternative treatment of obstetrical hemorrhage. METHODS: From September 1998 to October 2005, 42 patients who had a pregnancy related hemorrhage which did not respond to treatment using obstetric maneuvers and uterotonic drugs were included in our study. The patients underwent angiographic embolization for the management of intractable obstetrical hemorrhage at Department of Obstetrics and Gynecology, Yonsei University Medical Center. All available medical records and telephone interviews were reviewed and detailed to collect adequate clinical data such as clinical status, underlying conditions, amount of transfusion, embolization sites, materials of embolization, hospital stay, the success rate and the complications. RESULTS: We have experienced clinically successful embolization in 40 (95.2%) of 42 patients of obstetrical hemorrhage resulting from various causes. After embolization, the patient's vital sign was stabilized. The causes of hemorrhage were atony of uterus (n=17), cervical pregnancy (n=5), abnormal placentation (n=5), laceration of uterine cervix and vagina (n=6). The average amount of blood transfusion was 10.3 unit (range; 0-63 unit). The average duration of hospitalization was 7.4 days (range; 4-18 days). We were able to follow up on 32 patients. The main complications after embolization were hypomenorrhea (n=6), numbness of lower extremities (n=3). In all cases menses resumed spontaneously after procedures. CONCLUSION: The arterial embolization is one of the safe and the effective procedures and offers patients a fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage.

Applicable Indications and Effectiveness of the Selective Arterial Embolization in the Management of Obstetrical Hemorrhage / 대한산부인과학회잡지

OBJECTIVE: To describe the angiographic embolization as a safe and an effective alternative treatment in the management of obstetrical hemorrhage and in preserving fertility. METHODS: Between March 1999 and May 2003, 43 patients at Asan Medical Center underwent angiographic embolization for the management of obstetrical hemorrhage. All cases received arterial embolization because of obstetrical hemorrhage unresponsive to conservative management or prophylaxis for massive obstetrical hemorrhage. Medical records were reviewed and detailed to collect adequate clinical data such as clinical status, underlying conditions, amount of transfusion, embolization sites, materials of embolization, duration of the procedure, complications associated with embolization, hospital stay, and the success rate. Patients were contacted by telephone to obtain long-term outcome for menstruation, desire for conception, and subsequent pregnancies. RESULTS: We have experienced the clinical successful embolization in 37 (86.0%) of 43 patients of obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was atony of uterus (n=17), followed by abnormal placentation (n=6), genital tract laceration (n=5). The average amount of blood transfusion was 7.0 units (range; 0-36 units). The average length of the time for the procedure was 68.2 minutes (range; 30-150 minutes). The average duration of hospitalization was 6.4 days (range; 3-20 days). The main complication after embolization was numbness and pain on right lower extremities in 5 cases and vessel dissection occurred in 1 case. But there was no major complication related to the procedure. We were able to follow up 28 patients. In all cases menses resumed spontaneously soon after the procedure. Seven cases of long-term follow-up became pregnant, and 3 cases of them completed gestations giving birth to healthy babies. CONCLUSION: The results suggest that angiographic embolization is a relatively noninvasive and highly effective method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.