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Introduction. La pratique de césariennes est en augmentation constante dans le monde, soulevant la problématique de la gestion des femmes enceintes ayant un utérus cicatriciel. L'objectif de notre travail était d'identifier les facteurs significativement associés au succès de l'épreuve utérine au sein de notre service, afin de réaliser une sélection rigoureuse des candidates à la tentative de voie basse. Méthodes. Nous avons mené une étude épidémiologique descriptive, rétrospective, mono centrique au niveau de l'EHS mère enfant Batna du 1er janvier 2018 au 31 décembre 2019 ayant intéressé les femmees porteuses d'un utérus cicatriciel d'origine obstétricale avec un âge de grossesse supérieur à 22 SA. Résultats. Au cours de notre étude nous avons recensé 3002 accouchements sur utérus cicatriciel. Le taux de tentatives de voie basse après césarienne était de 46,84 % avec un taux de succès de 89,19 %. Les principaux facteurs qui favorisent le succès de la tentative de voie basse après césarienne étaient : un antécédent d'accouchement par voie vaginale après la césarienne (p <0,001) la multiparité (p=0,0002), une césarienne précédente pour présentation podalique (p<0,001), un intervalle inter génésique de 12 mois et plus (p <0,001), des conditions locales favorables (dilatation du col supérieure à 4 cm ; p=0,02 et la p=0,02 et la rupture artificielle des membranes ; p =0,02 et la rupture artificielle des membranes ; p=0,03). Les facteurs qui défavorisent le succès de la TVBAC étaient : un antécédent de césarienne pour stagnation ou non-engagement à dilatation complète (p<0,001), un terme d'accouchement supérieur à 40 SA (p=0,002), un poids de naissance supérieur à 4000 g (p<0,001). Les facteurs qui ne semblent pas influencer l'issue de l'épreuve utérine étaient : l'âge maternel, l'âge de réalisation de la première césarienne, la présence de pathologies maternelles et la réalisation de radiopelvimétrie Conclusion. Les facteurs de succès et d'échec d'une TVBAC sur utérus cicatriciel sont importants à relever pour les décisions ultérieures de la voie d'accouchement, la situation obstétricale doit être soigneusement évaluée et en cas de doute, faire appel à une décision collégiale.
Sujets)
Humains , Femelle , Grossesse , Facteurs précipitants , Césarienne , Accouchement par voie vaginale après césarienne , Accouchement naturelRésumé
Objective To analyze the relationship between scar uterine stress and scar thickness/position by using finite element method, so as to study risk factors of scar uterus rupture. Methods Firstly, SolidWorks was used to establish a three-dimensional (3D) model of the uterus with variable scar thickness and position based on uterine size of the pregnant woman at 40th week of gestation, and then the intrauterine pressure was set in the ANSYS software with pressure range of 4.83-23.9 kPa to calculate the uterine stress. Results During the contraction process, the maximum stress was located in uterine scar, the maximum stress on the uterus with scar thickness smaller than 3 mm was greater than tensile strength of the uterus; 3 mm was used as thickness limit of the lower uterine body. If the thickness was smaller than 3 mm, cesarean section should be selected immediately. Otherwise, transvaginal delivery could be selected. When the scar thickness was 3.0 mm, the maximum stress experienced by the uterus decreased at first and then increased with the distance from the uterine floor increasing. The stress at the uterine scar was the smallest when the distance from the uterine floor was 295 mm; when the scar was 285-305 mm from the uterine floor, the ultimate stress on the scar was smaller than its tensile strength, and it was safer to choose a vaginal delivery. Conclusions Risk factors of scar uterine rupture were studied based on ANSYS finite element analysis. The analysis results were consistent with the clinical data, which provided analysis method and theoretical guidance for the choice of delivery method in clinic.
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Background: The iterative caesarean section, is a caesarean section that is performed on a uterus already healed, therefore for fear of maternal and perinatal risks, is recognized as one of the main causes of the inflation of caesarean section in the world. One in three caesarean sections is performed because of a scar uterus. Objective of this study was to analyse the epidemiological and clinical factors of iterative caesarean sections in the gynecology-obstetrics department at the Teaching Hospital of Cocody (Abidjan).Methods: This was a retrospective and descriptive study conducted from June 1st, 2018 to May 31st, 2019, including 349 iterative caesarean section cases.Results: The first iterative C-section accounted for 16.1% of the C-section indications during the study period. The average age of the patients was 30 years. Nearly half of the patients practiced in the informal sector 47.9%, were uneducated in 38.1% of cases and lived with a partner in 73.1% of cases. The majority of patients in this series 75.1% performed at least 4 ANCs. Patients were followed by prenatal visits in 61% of cases by midwives and in 8.6% of cases had an inter-reproductive space of less than 18 months. This study patients were evacuated in 46.4% of cases. Acute fetal distress was the first indication of first iterative caesarean section with 20.3% of cases. Emergency caesarean sections accounted for 84.4% of the cases in this series. Authors found maternal death 0.3% and 6.7% perinatal mortality.Conclusions: The iterative caesarean section is a caesarean section likely to cause difficulties and complications per- operative. Although in constant improvement the prognosis of the mother-child couple still remains a problem in this context, prenatal monitoring should be the prerogative of obstetrician gynecologists.
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From December 2016 to February 2018,5 patients with type Ⅲ or mass type cesarean scar pregnancy (CSP) were treated in Zhejiang Taizhou Hospital.The clinical features,imaging findings and disease outcome were retrospectively analyzed.There were 3 cases of type Ⅲ and 2 cases of mass type,which were diagnosed by transvaginal ultrasound.The CSPs were resected with combination of laparoscopy and hysteroscopy,the average intraoperative blood loss was 80 ml (50-100 ml) and there were not postoperative complications.The average length of hospital stay was 9.4 days (8-12 d).Postoperative serum β-hCG returned to normal in average 22 days (14-30 d),and the menstruation recovered in 22-39 days after operation.The data indicates that resection of type Ⅲ or mass type caesarean scar pregnancy with a combination of laparoscopy and hysteroscopy is an effective treatment.
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Objective To probe into the safety and feasibility of vaginal delivery of scar uterus in pregnancy. Methods 2048 cases of secondary pregnancy women in cesarean section in our hospital from Jan. 1 to Nov. 15, 2017, were selected, 1 case of women was randomly selected from each 15 cases as the sample in this study according to the inclusion criteria. A total of 136 cases were randomly allocated to 68 cases in the observation group and 68 cases in the control group. The observation group was treated with vaginal delivery again, while the control group was treated with cesarean section again. Then, the delivery situation, the amount of blood in the process of labor, the length of the hospitalization time, the Apgar score of the newborn and the puerperal infection of two groups of patients were observed, and the results of the indicators between the two groups were compared and analyzed. Results In the observation group, 63 cases of vaginal delivery were successful(92. 64％), and 5 cases (7. 36％) were failed. In the control group, 68 cases (100％) were successful in cesarean section again, and there was no significant difference between the two groups (P＞0. 05). There was a statistically significant difference in the amount of blood produced during labor, neonatal Apgar score and puerperal infection between the two groups(P＜0. 05). There was no significant difference in hospitalization days (P＞0. 05). Conclusion It is safe and feasible for the clinical scar uterus to be pregnant through vaginal delivery.
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Objective This experiment will discuss misoprostol combined with psychological intervention for scar uterus abortion effect, and concern for the use of security. Methods The experiment selected from June 2016 to December 2016 in our hospital for termination of gestation in 100 cases of patients with cicatricial uterus as the research object, were randomly divided into control group and observation group, control group using conventional treatment, which USES the local administration of lidocaine cervical to;While the observation group of patients with preoperative after flushing after 2 hours to gauge the vagina blue oxygen dome placing misoprostol tablets, 600 μg for treatment. Results Observation group of patients during surgery, intraoperative blood loss, pain degree, operation time and palace mouth sags were superior to control group, significant difference, the two groups have statistical significance (P<0.05). Conclusion Using misoprostol combined psychological intervention for scar uterus abortion has high security, and through psychological intervention can help patients relieve intraoperative pain degree, improve the coordination, is beneficial to reduce the occurrence of induced abortion syndrome, is worth popularizing in the process of clinical application.
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Objective To compare dexmedetomidine administered via different routes for epidural anesthesia during second cesarean section.Methods Sixty parturients who were at full term with a singleton fetus,of American Society of Anesthesiologists physical status Ⅰ or Ⅱ,aged 22-38 yr,weighing 58-84 kg,undergoing a second caesarean section under epidural anesthesia,were divided into 3 groups (n=20 each) using a random number table:Ⅳ infusion of dexmedetomidine conbined with epidural injection of ropivacaine group (VDER group),epidural injection of a mixture of ropivacaine and dexmedetomidine group (ERD group) and epidural injection of ropivacaine group (ER group).The epidural puncture was performed at L2,3.After identification of the epidural space and a negative aspiration test for blood or cerebrospinal fluid,the mixture of 0.75％ ropivacaine 15 ml and 0.9％ normal saline 2 ml was injected epidurally,and dexmedetomidine 1 μg/kg was intravenously infused for 10 min at the same time in VDER group;the mixture of 0.75％ ropivacaine 15 ml and 1 μg/kg dexmedetomidine 2 ml was injected epidurally in ERD group;the mixture of 0.75％ ropivacaine 15 ml and 0.9％ normal saline 2 ml was injected epidurally in ER group.The onset time of epidural block,maximum level ofepidural block,time to reach the maximum epidural block and time of sensory block were recorded.Ramsay sedation scores were assessed at 30 miu after the end of epidural administration,and intraoperative traction reaction was also assessed.The development of hypotension,bradycardia,respiratory depressim and shivering was observed.The number of patients in whom remifentanil was used before delivery and Apgar scores at 1 and 5 min after birth were recorded.Results Compared with VDER group and ER group,the onset time and time to reach the maximum epidural block were significantly shortened,and the time of sensory block was prolonged in ERD group (P＜0.05).Compared with ER group,the rate of satisfactory sedation was significantly increased,the number of patients in whom remifentanil was used before delivery was decreased,the degree of intraoperative traction reaclion was mitigated,and the incidence of respiratory depression and shivering was decreased (P＜0.05),and no significant change was found in Apgar scores at 1 and 5 min after birth in VDER and ERD groups (P＞0.05).Conclusion Both Ⅳ and epidural dexmedetomidine can enhance the efficacy of epidural anesthesia during second cesarean section,producing no adverse effects on neonates;epidural injection of a mixture of ropivacaine and dexmedetomidine provides faster onset and prolonged time of sensory block,which is helpful for postoperative analgesia.
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Objective To investigate the efficacy of oxytocin combined with hemabate in the prevention of postpartum hemorrhage and diverticulum in scarred uterus. Methods 88 patients with scar uterus, postpartum hemorrhage and diverticulum in Chang'an Hospital from May 2016 to May 2017 were divided into two groups by maternal numbering and randomization, with 44 patients in each group. The control group was treated with oxytocin, and the observation group was treated with oxytocin combined with hemabate. It must compare the amount of bleeding, the amount of 2 h bleeding, the amount of postpartum 24 h bleeding and the incidence of adverse reactions in the two groups after the treatment. Results Compared with the control group, the amount of bleeding, the amount of two hours' bleeding and the amount of postpartum 24 hours' bleeding in the observation group were significantly lower than that in the control group(P<0.05). The postpartum hemorrhage volume of the observation group was 6.81%, which was lower than that of the control group, and the rate of postpartum hemorrhage was 27.27% (P<0.05). The incidence of adverse reactions such as nausea, vomiting, heart rate and blood pressure in the observation group was significantly lower than that in the control group (4.54% vs. 18.18%), the difference was statistically significant(P<0.05). Conclusion In the scar uterus, postpartum hemorrhage and diverticulum, the use of oxytocin combined with hemabate treatment has obvious curative effect. It is an important measure to reduce the amount of bleeding and ensure safety.
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Objective To investigate the efficacy of oxytocin combined with hemabate in the prevention of postpartum hemorrhage and diverticulum in scarred uterus. Methods 88 patients with scar uterus, postpartum hemorrhage and diverticulum in Chang'an Hospital from May 2016 to May 2017 were divided into two groups by maternal numbering and randomization, with 44 patients in each group. The control group was treated with oxytocin, and the observation group was treated with oxytocin combined with hemabate. It must compare the amount of bleeding, the amount of 2 h bleeding, the amount of postpartum 24 h bleeding and the incidence of adverse reactions in the two groups after the treatment. Results Compared with the control group, the amount of bleeding, the amount of two hours' bleeding and the amount of postpartum 24 hours' bleeding in the observation group were significantly lower than that in the control group(P<0.05). The postpartum hemorrhage volume of the observation group was 6.81%, which was lower than that of the control group, and the rate of postpartum hemorrhage was 27.27% (P<0.05). The incidence of adverse reactions such as nausea, vomiting, heart rate and blood pressure in the observation group was significantly lower than that in the control group (4.54% vs. 18.18%), the difference was statistically significant(P<0.05). Conclusion In the scar uterus, postpartum hemorrhage and diverticulum, the use of oxytocin combined with hemabate treatment has obvious curative effect. It is an important measure to reduce the amount of bleeding and ensure safety.
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Objective To investigate delivery mode of uterine scar pregnancy and analyze the safety of vagi-nal delivery.Methods 210 delivery women with scar uterus after cesarean section and 85 delivery women with non -scar uterus vaginal delivery of maternal selection were collected.According to the different ways of delivery,the preg-nant women in the scar group were divided into A group (72 cases)and B group (138 cases).Delivery outcome, maternal complications and average hospitalization time between the two groups were compared.Results 72 cases of maternal vaginal delivery in scar A group was successful and smooth vaginal delivery in 64 cases,and success rate was 88.89%(64 /72).8 patients maternal modified cesarean section production,accounted for 11.11%(8 /72),including 3 cases of persistent occiput posterior position,2 cases of social factors give up vaginal delivery,2 cases fetal distress, 1 case for incomplete rupture of uterus.138 cases delivery women in scar B group successfully obtained the cesarean section.100 cases of delivery women in non scar group,91 cases successfully got vaginal delivery,and the success rate was 91.00% (91 /100).Another 9 cases of delivery women were replaced with caesarean birth[9.00%(9 /100)],of which 3 cases of fetal distress,2 cases for fetal macrosomia,2 cases of persistent occiput transverse position,2 cases as social factors give up of vaginal delivery.Scar in group A maternal average hospitalization time was significantly shor-ter than scar in group B,and mean postpartum hemorrhage was significantly increased than scar in group B,and the differences were statistically significant (t =15.87,26.32,all P 0.05). The maternal average hospitalization time,mean postpartum hemorrhage,postpartum hemorrhage and incidence rate of neonatal asphyxia between scar group A and non scar group had no significant differences (χ2 =0.88,1.30,1.03, 0.00,all P >0.05).Conclusion When choosing vaginal delivery in scar uterus again pregnancy,we should strictly grasp cesarean section pregnancy after vaginal delivery of the indications.Under strict monitoring,the safety of vaginal delivery was high.It was worth of clinical promotion.
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Objective To explore the complications and the treatments of repeated cesarean delivery in scar uterus pregnancy accompanied by the placenta praevia. Methods We performed a retrospective study in 6832 cases underwent first cesarean delivery,within which 201 cases were accompanied by the placenta praevia;and 337 cases underwent repeated cesarean deliver, within which 26 cases were accompanied by the placenta praevia. All subjects accepted cesarean delivery from January2006 toApril 2010 in our hospital. Results The occurrence rate of placenta previa was significantly higher in the repeated cesarean delivery than first-ever cesarean delivery (7. 72% vs 2. 94%, x2 = 22. 33, P ＜ 0. 01 ) , especially the occurrence of complete placenta previa (42. 30% vs 0. 00%, x2 = 80. 43, P ＜ 0. 01 ). The rates of uterus rupture, placenta accreta, postpartum hemorrhage and hysterectomy (r = 26. 92% ,23.08% ,26. 92% and 7. 69%, respectively) in repeated cesarean delivery in scar uterus pregnancy accompanied by the placenta praevia were significantly higher than those of the cases ( r = 2. 57% ,0. 32%, 1.29% and 0. 00%, respectively ) had repeated cesarean delivery in scar uterus pregnancy but no placenta previa ( x2 = 27.97,50. 41,42. 16,12. 79, respectively, Ps ＜ 0. 01 ). Conclusion The incidence of placenta previa increased in scar uterus pregnancy, especially the complete placental previa.Scar uterus pregnancy accompanied by the placenta praevia are more likely to occur uterus rupture,placenta accreta,postpartum hemorrhage and had hysterectomy. Obstetricians should give more effort to reduce the cesarean section rate,improve the quality of medical care.
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Objective To investigate the risks and anesthetic management of scar uterus undergoing cesarean section.MethodsOne hundred pregnant women(aged 24-43 years old)with scar uterus underwent cesarean section.Epidural anesthesia was used in 90 cases(group A)and general anesthesia in 10 cases(group B).The monitorings included ECG,BP,HR and SpO_2.CVP was measured in the high risk cases.The time from skin incision tO neonatal delivery(I-D).the time from uterine incision to delivery(U-D),and Apgar scores of neonates were recorded.Results Incomplete blockade was seen in 20 cases(22％).The I-D time was shorter in group B than that in group A[(7.5±2.0)min vs.(12.3±2.6)min](P<0.01).Intraoperative hypotension occurred in 32 cases (32％).Neonatal asphyxia happened in 21 cases(21%).Apgar scores of 11 neonatals werc less than 3,of whom 5 neonates died.Apgar scores were 4 to 7 in 10 cases,8 to 10 in 79 cases.Subtotal uterectomy was performed in 2 cases.Repair of injuried bladder had to be done in one case.Intraoperative huge bleeding took place in 15 cases.Conclusion The scar uterus undergoing cesarean section has a high risk for mothers and neonates.The incidence of incomplete epidural blockade is higher.Effectively preventing and managing the risk factors are the keys for reducing maternal and neonatal complications and mortality.