Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study.

Background: The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders. Methods: A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons. Results: A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups. Conclusion: The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

Pelvic Packing for Intractable Obstetric Hemorrhage After Emergency Peripartum Hysterectomy: A Review.

IMPORTANCE: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Even after emergency peripartum hysterectomy (EPH), bleeding may occur in the setting of acquired coagulopathy. This type of bleeding resistant to clipping, ligating, or suturing could be successfully controlled with a pelvic packing. OBJECTIVE: This review provides an overview of the different pelvic packing techniques used after the failure of an EPH to control severe PPH. It aims to highlight the outcome of patients after packing, the morbidity and complications of packing, the timing and indications of packing, and finally the optimal duration of packing. EVIDENCE ACQUISITION: Literature relating to pelvic packing after EPH in a PPH setting was reviewed. RESULTS: Packing techniques can be divided into 2 types: pads or roller gauze and balloon pack. The overall success rate was as high as 78.8% with a mortality rate of 12.5%. No major morbidity related to the pelvic packing was documented. The optimal duration of packing is in the range of 36 to 72 hours. CONCLUSIONS: Pelvic packing should be part of the armamentarium available to the obstetrician whenever intractable pelvic hemorrhage is encountered. It is quite simple and quick to perform and requires no special medical materials, the rate of complications is very low, and the success rate is high. RELEVANCE: The pelvic packing should be particularly useful in developing countries where more advanced technologies such as selective arterial embolization are not always available. In developed countries, the pelvic packing may be a valuable temporary measure pending transport to a tertiary care facility.

Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy?

OBJECTIVES: To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN: All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS: A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S): The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting.

OBJECTIVES: To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN: From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fisher's exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS: Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION: The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.

Prenatal diagnosis of ectopia cordis: case report.

UNLABELLED: Ectopia cordis is a rare and impressive malformation presenting as an isolated lesion or as part of the Cantrell's pentology syndrom. It is defined as an anomaly in which the fetal heart lies outside the thoracic cavity. THE AIM of the study is to report the prenatal diagnostic features and management of ectopia cordis. CASE REPORT: We report a prenatal diagnosis case of ectopia cordis using two-dimensional ultrasound at 19 weeks of gestation. Multiple congenital anomalies were found. The most important one was the presence of a ventral thoracoabdominal wall defect with exstrophy of the heart, liver, stomach and intestines. Histopathological examination confirmed the ultrasound findings. Due to severity of the malformations, termination of pregnancy was made.

[Eclampsia: epidemiological aspects and management of 28 patients]. / Eclampsie: profil épidémiologique et prise en charge a propos de 28 cas.

AIM: To ascertain the characteristics, clinical features, and maternal fetal outcome in eclampsia in a tertiary referral center (Service A, CMNT). METHODS: 28 case notes were retrieved retrospectively and data was analyzed descriptively. RESULTS: Twenty eight pregnancies complicated by eclampsia were identified. 14.8% of the women were nulliparous and 50% were primiparous. The mean age was 32.5 years. Mean gestational age at the time of seizures was 33.4 weeks' gestation. Twenty-two women had antepartum seizures (78.57%); 8 of the 22 had seizures at home. 6 women had postpartum seizures (21.42%). Headache preceded seizures in 17 cases (60%) hyperreflexia preceded seizures in 16 cases. 50% of women presented with systolic blood pressure (SBP) > 160 mmHg and 42.85% presented with diastolic blood pressure (DBP) > 110 mmHg. One case of maternal mortality are noted. There were 12 perinatal deaths. Three patients had intrauterine fetal deaths. CONCLUSION: Eclampsia increased maternal and perinatal morbidity and mortality. She was not found to be a progression from severe preeclampsia. There is a need to develop new methods to identify this group of patients in an effort to further reduce the prevalence of this dangerous condition.

[Prenatal ultrasound aspects of arthrogryposis multiplex congenita]. / Aspects echographiques de l'arthrogrypose congenitale multiple.

AIM: To analyze the contribution of prenatal ultrasound in the diagnosis of arthrogryposis multiplex congenital according to its type and antenatal expression. METHODS: Retrospective study led between January 1993 and November 2007. We studied the cases of arthrogryposis suspected or diagnosed by antenatal ultrasound while analyzing the circumstances of discovery, the profile of the pregnant women and the abnormal scan findings. RESULTS: 16 observations have been collected. We recovered one multiple pterigium syndrome and five observations of severe fetal akinesia sequences diagnosed in the second trimester. The arthrogryposis was part of different syndromes in other cases. Four distal arthrogryposis had been diagnosed in the second trimester. All cases suspected during the third trimester were associated to an anomaly of the amniotic fluid, mainly to a polyhydramnios. The abnormal scan findings were less specific to this term. CONCLUSION: Arthrogryposis multiplex congenital is rare. It has several morphological aspects. Some ultrasound aspects are specific in the first and second trimesters. The diagnosis is more difficult at the third trimester.