La ruptura vesical durante el parto. Reporte de caso / Bladder rupture during labor: a case report

La ruptura de la vejiga durante el parto es una complicación rara. Puede ser primaria o secundaria, complicando un traumatismo obstétrico. Presentamos un caso infrecuente en una mujer de 34 años que presentó una ruptura uterina complicada con una ruptura vesical a través de la cual se describen los aspectos diagnósticos, pronósticos y terapéuticos de la ruptura vesical durante el parto (AU)

Rupture of the bladder during labor is a rare complication that can be primary or secondary, complicating an obstetric trauma. We report an unusual case in a 34-year-oldwoman who presented with a uterine rupture complicated with bladder rupture. We describe the diagnosis, prognosis and treatment of bladder rupture during labor (AU)

Uncommon cause of acute pelvic pain: isolated torsion of hydrosalpinx.

Isolated torsion of hydrosalpinx is a rare cause of acute pelvic pain. Pre-operative diagnosis is very difficult because of non specific clinical presentation. Definitive diagnosis is always made at surgical exploration performed for suspected adnexal torsion and salpingectomy is performed in the majority of cases. A 34-year-old woman was admitted for acute pelvic pain with nausea and vomiting. Vaginal examination revealed a right adnexal tender mass and ultrasound revealed a well circumscribed right adnexal cystic mass. Surgical exploration has revealed torsion of a right hydrosalpinx and right salpingectomy was performed. Differential diagnosis between adnexal and tubal torsion is very difficult, however both should be managed by rapid surgical exploration which an allow precocious diagnosis and conservative treatment.

[Vesico-uterine fistula of obstetrical origin. Report of 3 cases]. / Les fistules vésico-utérines d'origine obstétricale. A propos de 3 cas.

Vesico-uterine fistulae (VUF) lead to an abnormal breech between the bladder and the womb. They are responsible for urinary incontinence and/or cyclic hematuria. They are rare and, in most cases, lead to complications following caesarean deliveries. We report observations of 3 vesico-uterine fistulae treated over a 5 years period at university maternity based at Casablanca, Morocco; they all occurred following caesarean deliveries. These patients were consulted for urinary leakage occurring few weeks up to many years following surgical traumatism. Diagnosis was evoked clinically in all cases and confirmed by intravenous urography and/or hysterography. These VUF were successfully treated by simple breech suture at laparotomy. Treatment is very simple and efficient when the diagnosis is made early and fistula simple. Surgery is recommended after medical treatment failure aiming at fistula drainage.

[Current profile of obstetrical vesicovaginal fistulas at the maternity unit of the University of Casablanca]. / Profil actuel des fistules vésicovaginales obstétricales à la maternité universitaire de Casablanca.

Obstetrical vesicovaginal fistulas are secondary to dystocia. Late and inappropriate treatment are still a health public problem in under development countries. In five years (1993-1997), twelve vesicovaginal fistulas were repertored in the department of obstetrics and gynaecology of Casablanca (Morocco) with a frequency of 0.33@1000 deliveries and 2.4 new cases a year. 80% of the cases occurred after a long labour without efficient obstetrical care. Most of the cases (75%) were simple with an easy surgical treatment. All the fistulas were resolved after one or two surgical procedures realised by vaginal route in eight cases (2/3). During these last decades, with the efforts in obstetrical care in our country, we are assisting in a diminution of the frequency of this pathology and specially the number of complicated fistulas.

[Delivery of large baby after cesarean section: role of trial of labor. Apropos of 355 cases]. / Accouchement du gros bébé sur utérus cicatriciel : la place de l'épreuve utérine.

OBJECTIVE: Our goal is to determine whether a trial of labor in women with suspected fetal macrosomia would be a valuable alternative to elective repeat cesarean. MATERIAL: and methods: Based on retrospective analysis of 355 women with previous cesarean section who delivered macrosomic infants (> or =4,000g), we tried to determine the impact of fetal weight on a trial of labor. The outcomes of trial of labor with fetal macrosomia were compared on the one hand to those of elective repeat cesarean and on the other hand to those of trial of labor with normal birth weight (<4,000g). RESULTS: The trial of labor was conducted in 297 cases (83,7%), and had led to vaginal birth in 189 cases (63,6%). There were 4 uterine ruptures (1,3%) and 8 uterine dehiscences (2,7%) among the women who underwent a trial of labor. In this group, there were 4 perinatal deaths (1,3%) related in one case to uterine rupture, and 2 brachial plexus injuries related to shoulder dystocia after vaginal birth. Perinatal and maternal outcomes of trial of labor were similar to those of elective repeat cesarean. A trial of labor was more associated with scar separations and lower success rate if the infant weighed 4,000g or more. CONCLUSIONS: It appears that the use of trial of labor for delivery of large baby with prior cesarean section was associated with lower success rate and the maternal and fetal risks could be increased. However, carefully others controlled studies are necessary to establish the appropriate management in this setting.

[Maternal complications of cesarean section: retrospective analysis of 3,231 interventions at the Casablanca University Hospital, Morocco]. / Complications maternelles des césariennes: analyse rétrospective de 3,231 interventions à la maternité universitaire de Casablanca, Maroc.

We carried out a retrospective analysis of 3,231 cases of cesarean section between 1994 and 1997, to assess the maternal mortality and morbidity associated with this intervention. The frequency of cesarean delivery was 12.4%. The indications for cesarean section were of three types: elective indications (627 cases, 19.4%), emergency indications (454 cases, 14.1%), failure of normal labor (2,150 cases, 66.5%). Nine maternal deaths were noted (2.8 per thousand), one of which was directly linked to surgery. The peroperative complications were primarily major hemorrhagia (39 cases, 1.2%), visceral lesions such as bladder rupture (3 cases, 0.1%) and intestinal lesions (3 cases, 0.1%). Postoperative morbidity was predominated by infectious complications, particularly endometritis (5.1%). Thromboembolism was reported in 7 cases (0.2%). Cesarean section is used to preserve the life of both the mother and the child. However, maternal morbidity and mortality rates are higher with cesarean section than with vaginal delivery and therefore its indications must be justified.

[Twin delivery after cesarean section: is a trial of labor warranted?]. / Accouchement gémellaire sur utérus cicatriciel: peut-on autoriser l'épreuve utérine?

OBJECTIVE: To determine whether a trial of labor in twin pregnancy is a valuable alternative to routine repeat cesarean section. MATERIAL AND METHODS: Based on retrospective analysis of 31 cases of twin gestation with previous cesarean section, we tried to assess the outcomes of 25 cases of trial of labor. The outcomes of trial of labor in twin pregnancy were compared to those of trial of labor in singleton pregnancy. RESULTS: The trial of labor was successful in 21 cases (84%). There was one case of scar dehiscence among the women who underwent a trial of labor, that occurred in the parturient with two previous cesarean sections after complete breech extraction. There were no significant differences in perinatal outcomes in any comparison of trial of labor versus no trial of labor. The outcomes of trial of labor in the twin pregnancy were similar to singleton pregnancy. CONCLUSIONS: Routine repeat cesarean section in the twin pregnancy is not necessarily warranted; a controlled trial of labor in selected cases would be a valuable alternative.

[Induction of labor by misoprostol, an analog of PGE1. A prospective study of 200 cases]. / Induction du travail par misoprostol, analogue de PGE1. Etude prospective à propos de 200 cas.

We carried out a prospective study of 200 pregnant women who required induction of labor at full term, at the Lalla Meryem maternity unit of the Ibn Rochd University Hospital, Casablanca, between January 1st 1996 and June 30th 1997. The aim of this study was to evaluate the efficacy, tolerance and acceptance of misoprostol (Cytotec) as a drug for inducing labor in unfavorable conditions (Bishop < 5). Misoprostol (a PGE1 analog) was administered to the women via the vagina, with a dose of 1/4 tb (50 mg) given every 6 hours, and a maximum of 3 doses (150 mg). If labor had not begun 18 h after the start of the protocol, misoprostol induction was considered to have failed. We found that misoprostol failed to induce labor in 5% of cases, Syntocinon was required in 40% of cases and the interval between misoprostol insertion and vaginal delivery was 13.3 + 11.1 h. The rate of delivery by cesarean section was 22% and the mean amount of misoprostol required was 1.3 doses (66 mg). The mean cost of labor induction was 0.6 FF, the frequency of uterine hyperstimulation was 3.5% and maternal, fetal and neonatal tolerance was good. Our results confirm that intravaginal misoprostol is very effective and well tolerated for the induction of labor in pregnant women at full term, in unfavorable obstetric conditions.

[Vaginal birth after cesarean delivery: can the trial of labor be extended]. / Accouchement des utérus cicatriciels: peut-on élargir l'épreuve utérine?

Based on a retrospective analysis of 1000 cases of scared uteri following cesarean section(s) (one cesarean, n = 857, 85.7%); two n = 129, 12.9%; three n = 14, 1.4%), we tried to answer two questions. Is trial of labor in case of low segment uterine-scar (excepting pelvic abnormalities, corporeal scar and more than two scars) free of risk for the mother and child? Can trial of labor be extended to cases of breech presentation, two previous cesarean sections, twin pregnancy and suspected macrosomia? In this series, the cesarean was indicated before labor in 138 cases (13.8%). Trial of labor was conducted in 862 cases (86.2%), and led to vaginal birth in 728 (84.5%). Successful trial of labor was observed in 75% of twin pregnancies, in 100% of breech presentations and in 69.6% of macrosomic infants. Uterine rupture occurred in 23 cases (2.7%), especially in cases with unknown corporeal scars (15 cases). No case of perinatal death related to uterine rupture was observed in this series.

[Trial of labor after 2 cesarean sections. Prospective study of 130 cases]. / Epreuve du travail sur utérus bicicatriciel. Etude prospective à propos de 130 cas.

The mode of delivery in the parturient women with two prior cesarean is controversial. Based on a prospective analysis of 130 cases, we tried to assess the outcome of trial of labor after two cesarean sections. Among 167 patients with two uterine scars, 130 (77.8%) were selected for a trial of labor that was successful in 65 cases (50%). The overall rate of vaginal birth and cesarean section was 39% and 61%, respectively. There were 4 scar dehiscences and 2 uterine ruptures among the women who underwent trial of labor, but no case of perinatal death or morbidity related to these complications was observed. In the majority of the cases, these scar separations were due to poor obstetrical conditions. Trial of vaginal delivery after two prior cesarean sections seems to us a reasonable attitude if it is well indicated and supervised correctly.