Cephalad-caudad versus transverse blunt expansion of the low transverse hysterotomy during cesarean delivery decreases maternal morbidity: a meta-analysis.

OBJECTIVE: Cesarean delivery is the most prevalent surgical procedure worldwide, reaching approximately 29.7 million cases in 2015. It is directly associated with an increased risk of maternal and neonatal morbidity rates in the absence of malpresentation. Several techniques have been investigated, and there is evidence that cephalad-caudad expansion of the uterine incision might be associated with improved maternal outcomes compared with traditional transverse blunt expansion. The purpose of this meta-analysis was to evaluate the impact of cephalad-caudad expansion on adverse maternal outcomes, including intraoperative blood loss, risk of uterine vessel injury, and tearing of the lower uterine segment. DATA SOURCES: We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials, Google Scholar, and Clinicaltrials.gov databases from inception to January 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that assessed the impact of the cephalad-caudad blunt expansion of the low transverse uterine incision during cesarean delivery rather than those of transverse blunt expansion were selected for inclusion. METHODS: Effect sizes were calculated with the Hartung-Knapp-Sidik-Jonkman random-effects model in R. Trial sequential analysis was performed to evaluate the adequacy of sample sizes. RESULTS: Cephalad-caudad blunt expansion of the uterine incision was associated with a lower prevalence of unintended incision extension (relative risk, 0.62; 95% confidence interval, 0.45-0.86) and uterine vessel injury (relative risk, 0.55; 95% confidence interval 0.41-0.73). However, these complications were not accompanied by the increased need for additional suture placement (relative risk, 0.62; 95% confidence interval, 0.31-4.12) or transfusion rates (relative risk, 0.75; 95% confidence interval, 0.28-2.03). Similarly, the intraoperative duration was comparable with cases treated with transverse blunt expansion (mean difference = -0.45 minutes; 95% confidence interval -2.12 to 1.21) and the risk of intentional incision extension in the form of an inverted T (relative risk, 0.38; 95% confidence interval, 0.09-1.52). Trial sequential analysis revealed that the required sample size was reached in the unintended incision extension and uterine vessel injury outcomes. CONCLUSION: The findings of our study suggested that cephalad-caudad blunt expansion of the uterine incision is superior to transverse expansion in terms of reducing unintended incision extension and uterine vessel injury.

Laparoscopic Cervical Cerclage: Do Not Catch the Wrong Needle, or What to Do Next if It Happens!

STUDY OBJECTIVE: To present a technique to correct the misplacement of tape during laparoscopic cervical cerclage. Catching and introducing the wrong needle resulted in a knot formed around the right adnexa. DESIGN: Step-by-step demonstration of the mistake and the technique to correct it. SETTING: A patient para 0+V (V corresponds to 5) with cervical insufficiency was managed with laparoscopic interval cerclage [1-3]. The patient's 2 most recent pregnancies had been managed with emergency transvaginal cerclage, which failed to prolong her gestation beyond 24 weeks. INTERVENTIONS: Before the cerclage procedure a 2.0 × 0.8-cm deep endometriotic nodule was excised. Both curved needles were straightened extracorporeally, and the tape was dropped inside the peritoneal cavity. The first needle was introduced successfully through the right side. After insertion of-what was believed to be-the same needle through the left side following the opposite direction, it was discovered that a tight knot had been formed around the right adnexa (Fig. 1). To avoid complete removal, the needleless tape was pulled back completely from the right side (Supplemental Fig. 1), and this end was stitched to a straight needle 2-0 polyglactin suture. The much thinner needle passed easily through the already created path, along with the tape (Supplemental Fig. 2), and the procedure was completed as planned (Supplemental Fig. 3). CONCLUSION: When performing laparoscopic cervical cerclage with the tape and needles inside the abdomen, it is important to keep both under constant view. In the event of misplacement, no need to completely remove the tape. The tape's cut end can still be reintroduced successfully, stitched to a straight needle suture.

Acute pancreatitis in pregnancy: an overview.

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

A case of sebaceous carcinoma arising within a benign ovarian cystic teratoma.

BACKGROUND: Mature cystic teratoma, also known as dermoid cyst, is the most common germ cell tumor of the ovary. Malignant change in a component of a mature ovarian teratoma is rare, occurring in less than 2% of cases, with squamous cell carcinoma corresponding to 80% of such neoplasms. Pure sebaceous carcinoma is exceedingly rare, with only 6 reported cases thus far. CASE REPORT: A 74-year-old woman presented with lower abdominal pain due to a palpable mass in the right abdomen. Abdominal and pelvic ultrasound as well as computed tomography demonstrated a heterogenic tumor of the right ovary. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histological examination of the tumor showed features of a well-differentiated sebaceous carcinoma arising within a mature cystic teratoma. CONCLUSIONS: This is an extremely rare ovarian malignancy of which the clinical behavior and optimal management are not well established. Differential diagnosis with other malignant neoplasms arising in mature cystic teratomas is exceedingly important for treatment and prognosis.