Emergency peripartum hysterectomy.

OBJECTIVES: By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. STUDY DESIGN: From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. RESULTS: There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). CONCLUSIONS: The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred.

Placenta increta complicating a first-trimester abortion. A case report.

Placenta increta complicating pregnancy in the first trimester is rare. A patient with risk factors for placenta increta required a hysterectomy to control a hemorrhage after a first-trimester abortion. Pathologic study confirmed the preoperative diagnosis of placenta increta.

Bilateral postpartum vulvar edema associated with maternal death.

Reported is a maternal death associated with bilateral postpartum vulvar edema. Data are reviewed for this patient and four other patients who were previously reported to have had a syndrome of unilateral postpartum vulvar edema associated with maternal death. Overall, an 80% mortality rate has been observed.

Ultrasound guidance for selected dilatation and evacuation procedures.

Intraoperative ultrasound was used as an adjunct in difficult dilatation and evacuation (D&E) procedures for first-trimester abortions. This technique was useful in eight technically difficult D&Es in the presence of acute retroflexion, acute anteflexion, cervical stenosis and lower uterine segment fibroids.

The management of preterm labor with the calcium channel-blocking agent nifedipine combined with the beta-mimetic terbutaline.

We describe a successful, prolonged, inhibition of preterm labor using nifedipine combined with terbutaline in a patient undergoing complicated obstetrical problems. Delivery was delayed for two months and no significant ill effects were observed in the mother or her infant. This case reports the longest duration and the safe use of nifedipine for tocolysis, to date. A review of reports of the use of calcium channel-blockers in preterm labor is also presented.