Type II and III selective fetal growth restriction: perinatal outcomes of expectant management and laser ablation of placental vessels

OBJECTIVES: To describe the perinatal outcomes of type II and III selective fetal growth restriction (sFGR) in monochorionic-diamniotic (MCDA) twin pregnancies treated with expectant management or laser ablation of placental vessels (LAPV). METHODS: Retrospective analysis of cases of sFGR that received expectant management (type II, n=6; type III, n=22) or LAPV (type II, n=30; type III, n=9). The main outcomes were gestational age at delivery and survival rate. RESULTS: The smaller fetus presented an absent/reversed "a" wave in the ductus venosus (arAWDV) in all LAPV cases, while none of the expectant management cases presented arAWDV. The median gestational age at delivery was within the 32nd week for expectant management (type II and III) and for type II LAPV, and the 30th week for type III LAPV. The rate of at least one twin alive at hospital discharge was 83.3% and 90.9% for expectant management type II and III, respectively, and 90% and 77.8% for LAPV type II and III, respectively. CONCLUSION: LAPV in type II and III sFGR twins with arAWDV in the smaller fetus seems to yield outcomes similar to those of less severe cases that received expectant management.

Ablação dos vasos placentários com laser para tratamento da síndrome de transfusão feto-fetal grave: experiência de um centro universitário no Brasil / Laser ablation of placental vessels for treatment of severe twin-twin transfusion syndrome: experience from an university center in Brazil

OBJETIVO: descrever os resultados do tratamento da síndrome de transfusão feto-fetal grave com a ablação vascular placentária a laser em um centro universitário do Brasil. MÉTODOS: estudo observacional retrospectivo que incluiu pacientes tratadas na Universidade Estadual de Campinas entre 2007 e 2009. A ablação vascular placentária foi realizada em casos de transfusão feto-fetal grave (estágios II, III e IV de Quintero) diagnosticados até a 26ª semana de gravidez. As principais variáveis avaliadas foram a idade gestacional no parto, a sobrevida (alta do berçário) de pelo menos um gêmeo e o comprometimento neurológico nos sobreviventes. Regressão logística foi utilizada para investigar a influência do comprimento do colo uterino, da idade gestacional e do estágio da doença (antes da cirurgia) sobre o parto/abortamento e o óbito fetal após a intervenção, sobre o parto pré-termo extremo e a sobrevida. RESULTADOS: em toda a amostra, pelo menos uma criança sobreviveu em 63,3 por cento dos casos (19/30). Entre as gestantes que não tiveram parto/abortamento após à cirurgia, a sobrevida de pelo menos um gêmeo foi 82,6 por cento (19/23). Nesse subgrupo (n=23), a idade gestacional média no parto foi 31,9 semanas e o comprometimento neurológico ocorreu em um neonato (1/31; 3,2 por cento). O comprimento do colo uterino influenciou na ocorrência de parto/abortamento após a cirurgia (valor de p=0,008). Entre sete pacientes (7/30; 23,3 por cento) que apresentaram essa complicação, cinco (5/7; 71,4 por cento) tinham medidas do colo uterino menores do que 15 mm. Entre as 23 gestantes que não tiveram parto/abortamento após a cirurgia, os estágios mais avançados da doença (III e IV) aumentaram o risco de parto antes de 32 semanas (valor de p=0,025) e diminuíram a chance de sobrevida de ambas as crianças (valor de p=0,026). CONCLUSÕES: os resultados são semelhantes aos descritos na literatura. Na presente amostra, os principais fatores associados a piores resultados foram o colo uterino curto (menor do que 15 mm) e os estágios mais avançados da doença (III e IV) no momento em que o tratamento foi realizado.

PURPOSE: to describe the results of laser ablation of placental vessels for the treatment of severe twin-to-twin transfusion syndrome in an university center in Brazil. METHODS: retrospective observational study of patients treated at UNICAMP from 2007 to 2009. Laser ablation of placental vessels was performed in cases of severe twin-twin transfusion syndrome (Quintero stages II, III and IV) diagnosed before 26 complete weeks of gestation. The main variables evaluated in this series were gestational age at delivery, survival (discharge from the nursery) of at least one twin and neurological damage in survivors. Logistic regression was used to investigate the influence of cervical length, gestational age and stage of the disease (before the surgery) on the occurrence of delivery/abortion and fetal death after the intervention, and the influence on severe preterm birth and survival. RESULTS: in the whole series, at least one twin survived in 63.3 percent of cases (19/30). Among patients who did not have delivery/abortion after surgery, the survival of at least one twin was 82.6 percent (19/23). In this subgroup (n=23), mean gestational age in delivery was 31.9 weeks and neurological damage was identified in one neonate (1/31; 3.2 percent). Cervix length influenced the occurrence of delivery/abortion after surgery (p-value=0.008). Among seven patients (7/30; 23.3 percent) who carried this complication, five (5/7; 71.4 percent) had cervix length lower than 15 mm. Among the 23 patients who did not have delivery/abortion as a result of the surgery, the highest stages of the disease (III and IV) increased the risk of delivery prior to 32 complete weeks of gestation (p-value=0.025) and decreased the chance of survival of both twins (p-value=0.026). CONCLUSIONS: the results are similar to those available in the literature. In our series, the main factors associated with poorer results were short cervix (lower than 15 mm) and the highest stages of the disease (III and IV) at the time of the treatment.

comparison of placental removal methods on operative blood loss

On an average 1 litre of blood is lost during Caesarean Section. Many variable techniques have been tried to reduce this blood loss. Many study trials have shown the spontaneous delivery of placenta method to be superior over manual method because of reduced intra operative blood loss and reduced incidence of post operative endometritis. The main objective of our study was to compare the risk of blood loss associated with spontaneous and manual removal of the placenta during caesarean section. Quasi Experimental. September 2004 to September 2005, a 13 months study at Islamic International Medical Complex Islamabad. This study was conducted at Department of Obstetrics and Gynaecology, Islamic International Medical Complex, Islamabad from September 2004 to September 2005. All Women undergoing elective or emergency caesarean section were included in the study. Exclusion criteria were pregnancy below 37 weeks, severe maternal anemia, and prolonged rupture of the membranes with fever, placenta praevia, placenta accreta and clotting disorders. Patients were allocated to the two groups randomly. Group A comprised of women in whom the obstetrician waited a maximum of 5 minutes till the placenta delivered spontaneously. In group B the obstetrician manually cleaved out the placenta as soon as the infant was delivered. The primary outcome measures noted were difference in haemoglobin of >2 gm/dl [preoperatively and postoperatively], time interval between delivery of baby and placenta, significant blood loss [>1000 cc], additional use of oxytocics, total operating time and blood transfusions. Data was analysed by SPSS. Statistical tests used for specific comparison were chi 2-test and Student's t-test. One hundred and forty-five patients were allocated to two groups randomly. Seventy-eight patients were allocated to group A and 67 patients allocated to group B. Mean maternal age, birth weight, and total operating time were the same in two groups, but blood loss as measured by a difference in haemoglobin of greater then 2 grams/dl was statistically significant. Significant blood loss [>1000 cc] and time interval between delivery of infant and placenta were also statistically significant between the two groups. Spontaneous delivery of placenta has significant reduction of blood loss as compared to manual removal at caesarean section

Assessment of blood loss during cesarean section under general anesthesia and epidural analgesia using different methods

Obstetric blood loss is usually a big issue when dealing with obstetric morbidity and mortality. Blood loss during cesarean section [CS] is usually underestimated; therefore this study addressed that problem by comparing 3 different methods for assessment of blood loss during CS under general anesthesia and epidural analgesia. The study included 100 informed and consented full-term pregnant women undergoing elective CS fulfilling the inclusion criteria. Intraoperatively, for each patient blood loss was assessed by: subjectively by visual estimation by the attending staff [obstetrician, anesthetist and the scrub nurse], by weighing of blood-soaked surgical swabs and by calculation using the formula described by Bourke and Smith [15]. The results showed that visual estimation of blood loss gave the lowest estimated value while the calculation gave the highest estimate of blood loss. Anesthetists gave more accurate visual estimation of blood loss than obstetricians, while scrub nurses gave the lowest estimation. Past history of CS, breech presentation, placenta previa and manual separation of the placenta were associated with more blood loss during CS. Neither the type of anesthesia nor the patients' parity had a positive correlation with blood loss while, the weight of the patient had a positive correlation with blood loss. Conclusively, the present study pointed out that calculation of intraoperative blood loss during CS was overestimated by the formula used and was underestimated visually by the obstetricians and scrub nurses involved. Reliably, anesthetists gave a close estimation to that obtained by weighing of swabs method. The study recommended spontaneous removal of the placenta to reduce intraoperative blood loss during elective CS

El uso de la placenta en el entrenamiento microquirúrgico / The use of the placenta in the microsurgical training

Objetivo: Evaluar el empleo de la placenta como un modelo de instrucción no animal en microcirugía. Diseño: Estudio experimental, transversal. Sede: Departamento de Cirugía Experimental de la Facultad de Medicina de León, de la Universidad de Guanajuato. Material y métodos: Se valoró la utilidad de 50 placentas como un modelo de instrucción no animal dada su disponibilidad y características vasculares. De cada placenta se recabaron las siguientes varibles. Tipo de inserción del cordón umbilical (central o periférico), tipo de vasos (número de arterias y venas), diámetro de las placentas, longitud de los vasos de la placenta y su diámetro. Se valoró como útil una placenta si se puede realizar en ella los siguientes procedimientos microquirúrgicos: anastomosis término-terminales y láteroterminales, cierre de arteriotomía y transposición de colgajo venoso. Resultados: Se encontraron en promedio 14 arterias por placenta (rango de 10 a 19) y 14 venas (rango de 10 a 16). La longitud total de los vasos fue de 110.80 cm (rango de 36.0 a 191.0 cm). El diámetro promedio de los vasos fue de 2.10 mm (rango de 1.40 a 3.70 mm). Residentes y estudiantes del área quirúrgica pudieron realizar en las placentas los siguientes procedimientos: Anastomosis término-terminales y láteominales, cierre de arteriotomía y transposición de colgajo venoso con material de sutura 8,9 y 10 ceros. Colocando la cara fetal hacia abajo se logró hacer los procedimientos con sentido de profundidad. Conclusión: En cada placenta se dispone en promedio de 110 cm de vasos sanguíneos de consistencia y dimensiones milimétricas similares a las encontradas en modelos vivos

Repair of vesicovaginal fistula using fresh placental membranes

Simple vesicovaginal fistulas are usually due to local trauma. The commonest cause, worldwide, is tissue necrosis following prolonged obstructed labor. The causes of recurrence are unhealthy tissue and under-tension of the sutures. Five women suffering vesicovaginal fistulas were operated upon. Three cases were complex and 2 cases were simple with an average age 27.9 years. The sites of the fistulas of the 3 complex cases were in the upper part of the trigone and that of the 2 simple cases were above the left ureteric orifice. Placental membranes amnion and chorion were sutured to the urinary bladder wall defect, leaving the mucosa unsutured. Urethral catheter was adopted for 14 days. The follow up was excellent. Clinical examination and ascending cystogram revealed no recurrence. Mucosal and detrusal regeneration along the placental patch was evident by pathological examination

Hallazgos histopatologicos en el aborto incompleto / Histopatolologic findings in the incomplete abortion

Se estudia 246 resultados histopatologicos de otras tantas mujeres en las que se efectuo el diagnòstico clinico de aborto incompleto. Se propone una clasificaciòn de los reportes histologicos en : 1) Aspectos que sugieren aborto, 2) Aspectos certeros de aborto con, a) Vellosidad conservadas, b) Vellocidades degeneradas y c) Vellosidad infectadas. Se discute en detalle cada uno de estos topicos