Anomalías de inserción placentaria: diagnóstico y tratamiento oportuno / Placental insertion anomalies: timely diagnosis and treatment

Paciente de 34 años, gestante de 34 semanas. Doble cesáreada anterior con estudio ecográfico previo con informe de signos indirectos de ascetismo placentario, sin estudio de Resonancia Magnética Nuclear. Se realizó Operación Cesárea abdominal corporal, se dio nacimiento a recién nacido vivo. Se realizó instilación de 2 ampollas de 2 ml. de polidocanol al 3 % con sonda K33 en cordón umbilical para disminución del riesgo de sangrado, ligadura del mismo, introducción de cordón en cavidad uterina y cierre de Histerorrafia + Histerectomía subtotal El diagnóstico oportuno por medio de estudios de imagen, actuación médica criteriosa y el seguimiento de los protocolos establecidos nos llevara a la excelencia en la resolución de dichos casos.

34-year-old patient, 34 weeks pregnant. Previous double caesarean section with a previous ultrasound study with a report of indirect signs of placental asceticism, without a Nuclear Magnetic Resonance study. An abdominal cesarean section was performed, giving birth to a live newborn. Instillation of 2 ampoules of 2 ml was performed. of 3% polidocanol with a K33 probe in the umbilical cord to reduce the risk of bleeding, ligation of the cord, introduction of the cord into the uterine cavity and closure of hysterorrhaphy + subtotal hysterectomy Timely diagnosis through imaging studies, judicious medical action and following established protocols will lead us to excellence in the resolution of these cases.

A propósito de un caso: presentación atípica de rotura uterina / A case report: unusual presentation of uterine rupture

RESUMEN La rotura del útero gestante se define como una solución de continuidad patológica de la pared uterina, situada con mayor frecuencia en el segmento inferior. La rotura de un útero intacto es muy rara, su incidencia está estimada entre 1/5700 y 1/20000 embarazos. Su prevalencia ha aumentado dado el incremento de parto vaginal con cesárea anterior. Actualmente oscila entre el 0.3 y el 1 %, siendo mayor en mujeres en las que tiene lugar un intento de parto vaginal tras cesárea (0,78%) que en aquellas en las que se lleva a cabo una cesárea electiva (0,22%). En cuanto a su diagnóstico, suele ser precoz, dada la clínica de gravedad con la que debutan. En este caso se presenta una evolución atípica de rotura uterina, donde la paciente se mantiene asintomática hasta que acude a urgencias cinco días después del parto con fiebre y dolor abdominal; gracias a la ecografía abdominal y trans-vaginal se pudo establecer rápidamente el diagnóstico y así proceder a su inmediata reparación quirúrgica.

ABSTRACT Rupture of the pregnant uterus is defined as a solution of pathological continuity of the uterine wall, most often located in the lower segment. The rupture of an intact uterus is very rare, its incidence is estimated between 1/5700 and 1/20000 pregnancies. Its prevalence has increased given the increase in vaginal delivery with previous caesarean section. Currently, it ranges between 0.3 and 1%, being higher in women with a vaginal delivery after caesarean section (0.78%) than in those who undergo an elective caesarean section (0.22%). Their diagnosis is usually early given by the severity of the debut. In this case, there is an atypical evolution of uterine rupture where the patient remains asymptomatic until she goes to the emergency room five days after delivery with fever and abdominal pain; Because of the abdominal and transvaginal ultrasound, the diagnosis could be quickly established and thus proceed to immediate surgical repair.

Outcome of pregnancy in previous caesarean section: an observational study

Background: Presently, good obstetrics means an uncomplicated antenatal period, labour and puerperium for the mother and birth of a healthy body. Post caesarean section pregnancy has now become one of the most common high-risk cases tackled at any hospital. In this paper an attempt has been made to assess the outcomes of pregnancy in previous caesarean section.Methods: This study was conducted among patients in the department of gynecology and obstetrics at Al-Ameen Hospital from June 2016 to December 2018. For that purpose, a sample size of 100 was considered. Data were analyzed using SPSS software v. 23.0. and Microsoft office 2007.Results: The incidence of caesarean section was 10.25%. Anaemia, pregnancy-induced hypertension and diabetes mellitus found in this study is more coincidental. Placenta previa cases were also present. Cephalopelvic disproportion was the commonest indication of the previous section in this study. 20% of the cases have had their previous section due to cephalopelvic disproportion. 18% of the cases had delivered vaginally, 15 cases were delivered by forceps (72.2%) and 3 cases were delivered normally (27.8%). Maternal morbidity was found to be low and there was no maternal death.Conclusions: The patient whose primary section was done due to cephalopelvic disproportion should be assessed thoroughly in her current pregnancy before placing her to elective repeat section. As there is always the possibility of scar rupture in a case of post caesarean section pregnancy one must think twice before doing the primary section. More research is required to evaluate optimum time of management.

A study of high-risk factors in ante-natal women at a tertiary care centre

Background: High-risk pregnancy refers to any condition in pregnancy that increases risk for morbidity or mortality in mother, fetus and neonate. Globally, nearly 5,29,000 women die due to pregnancy related complications. In India, 20-30% of the pregnant patients contribute to high risk group. This study was conducted to determine different high-risk factors prevalent in antenatal women in Haryana. Objective of this study was to find out prevalence of different high-risk factors in antenatal women.Methods: Data of all antenatal high-risk patients attending OPD during one year was taken from hospital record registers. Maternal characteristics such as age, gravida/parity, gestational age, and gestational age at the time of first visit were noted. High risk factors identified were noted.Results: The records of total 10073 antenatal women were analyzed, 1283 were included in the high-risk group. Most prevalent high-risk factors found were previous cesarean section (31.04%), anaemia (31.02%), malpresentation (12.93%) and thyroid disorders (13.09%).Conclusions: Antenatal surveillance for the high-risk factors complicating pregnancy may prevent or treat most of the complications. Authors should develop strategies for early screening of high-risk pregnancy cases to prevent maternal and perinatal mortality and to improve the maternal and perinatal outcome.

A study on pattern of placentation in post caesarean pregnancy

Background: It appears that the rate of caesarean delivery has been increasing over the past two decades. Various western studies have shown that with previous caesarean section, increased risk of placenta previa, adherent placenta, and greater incidence of antepartum haemorrhage. Nonetheless, the extent to which previous caesarean delivery predisposes women to the development of placenta previa is unclear from earlier studies. Also, there are not many Indian studies regarding the association of placenta previa and previous caesarean section. This study aims to find the association between prior caesarean delivery and subsequent development of placenta previa and adherent placenta.Methods: A descriptive study was conducted on 600 antenatal women with post cesarean pregnancy in a tertiary care centre. Similar number of women with previous normal delivery was included in comparison group and placental location was studied. Those patients with previous caesarean were further divided into those with placenta previa and without previa to study the determinants of previa in those with previous caesarean section.Results: Placenta previa was found in 2.8% of the study group compared to 1.2% of comparison group. Adherent placenta was found only in post caesarean group. In the post caesarean group, the incidence of anterior previa was 41.2% compared to posterior previa (29.3%). In those with post cesarean pregnancy, determinants of placenta previa found were multiparity (35.3%), previous history of abortions (35%), multiple previous caesarean sections (29.4%), interpregnancy interval <2 years (35.29%).Conclusions: In post cesarean pregnancy, the risk of placenta previa is 2 times compared to those with a previous normal delivery. Anterior previa occurred with sufficient frequency in post-caesarean pregnancy to warrant ultrasonic placentography prior to surgical entry into lower segment. When the combination of previous caesarean and placenta previa occurs the risk of adherent placenta is 17.6%.

Study of caesarean section at tertiary care centre: a retrospective study

Background: Caesarean section (C-section) is one of the most widely performed surgical procedure in obstetrics worldwide. The WHO guidelines revised in 1994 states that the proportion of C-section birth should range between 5-15% but both in developed and developing countries C-section rate is on the rise. This study was conducted to analyse the frequency and indications for C-section and associated maternal morbidity and mortality.Methods: This retrospective study was conducted over a period from January 2018 to May 2019 at the department of obstetrics and gynecology, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Hingna, Nagpur, Maharashtra, India. Data of patients who delivered by C-section in our hospital during the defined study period were studied and statistically analysed according to various parameters namely, the frequency of caesarean section, its indications, age, parity and gestational age of the patient.Results: The total number of women delivered over the study period were 2811. Out of which C-sections were done in 1461 women (51.97%). Previous C-section was the leading indication in 35.72% women followed by fetal distress 14.09%, failure of induction 12.93%, arrest of labour 7.93%, PIH 7.18%, oligo/IUGR 6.50%, breech 4.44%, refusal of vaginal birth 4.24%, CPD 1.71%, bad obstetrics history (BOH) 1.43%, malpresentation 1.30%, prematurity 1.23%,  and multifetal gestation in 1.09% women. Two women had classical C-section 0.07. 14.09% women had various complications. There was no maternal mortality.Conclusions: A high rate of caesarean deliveries was observed. Individualization of the indication and careful evaluation, following standardized guidelines can help us to limit C-section. Audit and feedback are the best way to judge clinical practice and to reduce the frequency of caesarean section in any tertiary setup.

Embarazo ectópico en cicatriz de cesárea previa, enfoque terapéutico y revisión de la literatura / Ectopic Pregnancy in Previous Cesarean Section Scar Therapeutic Approach and Literature Review

RESUMEN Introducción: El embarazo ectópico en cicatriz de cesárea previa es una forma novedosa y potencialmente mortal de implantación anormal de un saco gestacional dentro del miometrio y el tejido fibroso de la cicatriz. Se desconoce la historia natural de esta condición para lo cual no existe consenso en su manejo. Presentación de caso: Se presenta un caso que se manejó quirúrgicamente de forma conservadora por minilaparotomía, evacuación del tejido trofoblástico, lográndose preservar el útero. Con edad gestacional de 10 semanas, se aplicó metrotexate localmente e intramuscular. La paciente evolucionó satisfactoriamente hacia la mejoría siendo dada de alta. Métodos: Se realiza una revisión bibliográfica en bases de datos Pub Med y Science Direct con las palabras claves obtenidas del MeSH: "Scar ectopic pregnancy" durante los años 2000 y 2018. Se presentan las alternativas de manejo, tanto médico como quirúrgico, sin embargo, ello estará sujeto a las condiciones de la paciente y a la experiencia del médico tratante(AU)

ABSTRACT Introduction: Ectopic pregnancy in a previous caesarean section is a novel and life-threatening form of abnormal implantation of a gestational sac within the myometrium and the fibrous tissue of the scar. The natural history of this condition is unknown, thus there is no consensus in its management. Case report: We report a case that was surgically managed in conservative way by minilaparotomy, trophoblastic tissue evacuation. The uterus was preserved. The gestational age was 10 weeks. Metrotexate was applied locally and intramuscularly. The patient evolved satisfactorily towards improvement and discharge. Methods: A literature review during the years 2000 and 2018 was carried out in Pub Med and Science Direct databases. The keywords from MeSH used were "Scar ectopic pregnancy". Both medical and surgical management alternatives are presented, however the patient condition and the experience of the attending physician will contribute as well(AU)

Elective versus emergency caesarean section: differences in maternal outcome

Background: Caesarean section is a life-saving surgical procedure when certain complications arise during pregnancy or labour. The use of CS worldwide has increased worldwide unprecedented levels although the gap between higher- and lower-resource settings remains. The present study evaluates the difference in maternal outcome in elective versus emergency caesarean sections in our institute.Methods: The study included first 65 cases of emergency caesarean section (group A) and during the study period, first 65 elective caesarean section (group B) if they fulfilled the inclusion criteria. Various intra operative and postoperative events were recorded which included intra operative complications, postpartum haemorrhage and transfusion indices.Results: The most common indication of caesarean section in group A was fetal distress (27.7%). In group B most caesarean sections were classified under 5 followed by class 6, the most common indication being previous caesarean section (27.6%). It was observed that pre-operative mean haemoglobin in group A was 10.6 g/dl and in group B was 11.2g/dl. A drop of 1.36 g/dl in group A and 1.10 g/dl in group B was observed in the post-op period. Cross match / transfusion ratio 1.5 in group A and  2 in group B, transfusion probability ratio was 60 % in group A and  66.7%  in group B and transfusion index was 1 in group A and  group B. There was significantly higher contraception acceptance in group B compared to group A.Conclusions: Elective caesarean section has more favourable maternal outcome as compared to emergency caesarean section as the former is done under controlled and planned circumstances.  However, there should be stringent audit to scrutinise indication of caesarean section, outcome of caesarean and blood transfusion practices.

Utilidad y eficacia de la clasificación de Robson para disminuir la tasa de cesáreas / Utility and efficacy of Robson's classification to reduce the rate of cesareas

Resumen Objetivo: Evaluar la eficacia y utilidad de la clasificación de Robson en la reducción de la práctica de cesáreas. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo y de corte transversal efectuado en pacientes de nivel socioeconómico medio y bajo atendidas entre enero y diciembre de 2016 en un hospital de segundo nivel. Para clasificar a las pacientes, según sus características obstétricas, se aplicó el modelo de Robson. Resultados: Se estudiaron 374 pacientes embarazadas; de ellas 91 (24.3%) terminaron la gestación mediante cesárea. Los grupos de Robson con mayor contribución al porcentaje de cesáreas fueron: grupo 1 con 50.5%, grupo 2 con 29.8% y grupo 10 con 8.7%. El grupo 5 reportó que 62.7% de los embarazos terminaron mediante parto. El 89.8% de las pacientes ingresó con trabajo de parto espontáneo. Las principales indicaciones de cesárea fueron, en el grupo 1, trabajo de parto estacionario; en el grupo 2, cesárea iterativa y en el grupo 10, feto pretérmino. Conclusiones: La aplicación del modelo de clasificación de Robson es útil y práctica para identificar los grupos de pacientes en los que es posible disminuir el porcentaje de cesáreas.

Abstract Objective: Evaluate the effectiveness and usefulness of the Robson classification to reduce the practice of cesarean sections. Materials and methods: Observational, descriptive, retrospective and cross section was made in patients of medium and low socioeconomic status attended between January and December 2016 in a second level hospital. For classify the patients, according to their obstetric characteristics, the model of Robson was applied. Results: 374 pregnant patients were studied; in 91 (24.3%) the pregnancy ended by caesarean section. The Robson groups with the greatest percentage contribution of caesarean sections were: group 1 with 50.5%, group 2 with 29.8% and group 10 with 8.7%. Group 5 reported that 62.7% of pregnancies ended by delivery; 89.8% of the patients was admitted with spontaneous labor. The main Cesarean indications were, in group 1, stationary labor; at group 2, iterative caesarean section and group 10, preterm fetus. Conclusions: The application of the Robson classification model is useful and practice to identify groups of patients in who it is possible to decrease the percentage of cesareans.

Fatores associados à via de parto atual em mulheres com cesariana prévia / Factors associated with mode of delivery in present pregnancy in women with previous caesarean section

O aumento alarmante e crescente das taxas de cesariana é realidade mundial, representando problema de saúde pública, por se associar a maior morbidade materna e fetal além de elevados custos hospitalares. Uma das principais estratégias para diminuir esses índices é submeter a paciente com uma cesariana anterior à prova de trabalho de parto. O objetivo deste estudo foi descrever o desfecho neonatal e via de parto de pacientes com história de cesariana em gestação anterior e compará-los a primíparas. Foram avaliadas 188 mulheres, 94 em cada grupo, no período de janeiro a abril de 2010. A taxa global de cesariana foi de 42%. Nas primíparas 38,2%, e nas pacientes com uma cesariana anterior 77,6%. Apenas 46,8% das pacientes com uma cesariana anterior foram submetidas à prova de trabalho de parto, neste grupo a frequência de parto normal foi de 44,19%. Não houve diferença no desfecho neonatal ou obstétrico entre os grupos. Conclusão: Uma cesariana anterior aumenta em 5,6 vezes a chance de uma nova cesariana na gestação atual se comparadas à primíparas.

The alarming increase and rising rates of caesarean section is a worldwide reality, representing a public health problem, associated with increased maternal and fetal morbidity and higher hospital costs. A strategy to reduce these rates is to submit a patient with a previous cesarean to a trial of labour (VBAC). The objective of this study was to describe neonatal outcome and mode of delivery in patients with a cesarean section in previous pregnancy compared with primiparous. We evaluated 188 women, 94 in each group during the period from January to April 2010. The epidemiological profile of patients who had vaginal delivery or cesarean section were similar. The overall rate of cesarean section was 42%. In primiparous 38.2% and 77,6 % in patients with a previous cesarean section. Only 46.8% of patients with a previous cesarean section were submitted a trial of labor after c-section, in this group the frequency of vaginal delivery was 44.19%. There was no difference in neonatal outcome between groups. Conclusion: a previous caesarean section increases by 5.6 times the chance of a new caesarean section in the current pregnancy compared to primiparous women.

Ruptured Rudimentary Horn in Pregnancy at 20 Weeks with Previous Caesserian Section: A Case Report.

Pregnancy in a non communicating rudimentary horn is extremely rare and usually terminates in rupture during first or second trimester of pregnancy . Diagnosis of rudimentary horn and its rupture in a woman with previous caesarean section is difficult . It can be missed on routine ultrasound scan and is usually diagnosed after rupture. We report a case of rupture of rudimentary horn in a patient with previous caesarean section at 20 wks of gestation. Timely laprotomy revealed rupture of left rudimentary horn with massive haemoperitoneum. Excision of horn and blood transfusion saved the patient in a young female with pregnancy is reported for its unusual presentation.