Repair of the myometrial scar defect at repeat caesarean section: a modified surgical technique.

BACKGROUND: To investigate whether the existing surgical technique for uterine closure at repeat lower segment Caesarean section (LSCS) can be modified to achieve adequate residual myometrial thickness (RMT) to ensure scar integrity and reduce complications in future pregnancy. METHODS: Women with a significant scar defect at repeat LSCS had the anterior uterine wall closed by a single experienced obstetrician with a technique focused on recognition, mobilisation and apposition of the retracted myometrial edges at the boundary of the defect. This was aimed at anatomical restoration of the lower segment. The RMT at the scar area was assessed by postnatal pelvic ultrasound scan at three months. RESULTS: Thirty women with a history of at least one previous CS, incidentally found to have a large defect at operation underwent the technique with prior consent. A postnatal scan showed a mean residual myometrial thickness of 8.4 mm (SD ±1.3 mm; range 5.6-11.0 mm). The average operating time was 91 mins and the average blood loss 728 ml. Two women who underwent the repair have gone on to have a further uneventful CS. CONCLUSION: This modified technique resulted in scan evidence of an RMT indicative of uterine wall stability postnatally and offers the potential for reducing the risk of rupture and placenta accreta spectrum (PAS) in future pregnancy.

Caution with bilateral salpingectomy and consideration of tubal stump ectopic in IVF.

We report a 35-year-old female patient with a history of bilateral salpingectomy from ectopic pregnancies presenting with a positive serum beta-human chorionic gonadotropin (bhCG) result following in vitro fertilisation (IVF) treatment. Apart from per vaginal spotting, she remained asymptomatic. Initial ultrasound showed an empty uterus with a cystic mass on the right side of the uterus. Serum beta-hCG was trended. A follow-up pelvic ultrasound 1 week later showed a live pregnancy in the right adnexa. A diagnostic laparoscopy was performed, which revealed an unruptured right stump ectopic pregnancy that was successfully removed. As a stump ectopic pregnancy can be a potentially life-threatening occurrence, we emphasise caution with salpingectomy and the consideration of tubal stump ectopic pregnancies following IVF treatment.

An Unusual Case of a Filshie Clip Presenting as a Bladder Wall Abscess 12 Years After Sterilization.

BACKGROUND There is growing evidence suggesting that Filshie clip migration is a rare but significant late complication following tubal sterilization. Although most women are asymptomatic, clip migration can result in serious morbidity such as abscess formation and be a source of sepsis years later. CASE REPORT A 51-year-old woman presented with 2-week history of worsening right flank pain with fever and chills, unresponsive to oral antibiotics. CT imaging showed a 4-cm anterior bladder wall mass with a tubal ligation clip within, initially suspicious for a tumor, with secondary infection. Cystoscopy was unremarkable and tumor markers were negative. A subsequent CT urography confirmed the finding of right adnexal abscess with ligation clip within, suggesting a diagnosis of pelvic inflammatory disease. Due to failure of conservative management, she underwent a diagnostic laparoscopy, which was then converted to an exploratory laparotomy due to dense omental adhesions. A Filshie clip was found within the bladder wall abscess and removed. An inadvertent bladder dome perforation was repaired. Pain and fever resolved after the operation and she was discharged home on post-op day 4 with an indwelling catheter. A micturating cystogram a month later showed no extravasation of contrast and the catheter was removed. CONCLUSIONS This case report highlights the importance of considering Filshie clip migration as a differential diagnosis vs. pelvic inflammatory disease in women without other risk factors and who had previously undergone tubal ligation. Women should be made aware of this potential, rare late complication and its serious morbidity, which may occur years later.

Comparing Different Diagnostic Guidelines for Gestational Diabetes Mellitus in Relation to Birthweight in Sri Lankan Women.

Introduction: While the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria is widely adopted in many countries, clinicians have questioned the applicability of these diagnostic thresholds for different races/ethnicities. We first compared the prevalence of gestational diabetes mellitus (GDM) diagnosed with different criteria including IADPSG, World Health Organization (WHO) 1999 and Sri Lankan national guidelines, and subsequently related individual guidelines-specific GDM prevalence to offspring birthweight in Sri Lanka. Materials and Methods: We retrospectively collected data on singleton pregnancies (n = 795) from two tertiary hospitals in Sri Lanka. We applied three diagnostic guidelines to define GDM, namely IADPSG criteria, the Sri Lankan national and WHO 1999 guidelines. We calculated the age- and first booking BMI-adjusted prevalence rates of GDM and assessed the association of GDM (using each guideline) with birthweight. Results: The age- and first booking BMI-adjusted GDM prevalence rates were 31.2, 28.0, and 13.1% for IADPSG criteria, Sri Lankan national and WHO 1999 guidelines, respectively. The IADPSG criteria identified 90 distinctive GDM cases at a lower cut-off of fasting glucose (from 5.1 to 5.5 mmol/L) while Sri Lankan national guideline identified 15 distinctive GDM cases at a lower cut-off for 2-h glucose (from 7.8 to 8.4 mmol/L). After adjusting for age, GDM diagnosed by IADPSG criteria was associated with higher birthweight [90.8 g, 95% CI: 10.8, 170.9], while the associations for GDM diagnosed either by Sri Lankan national or WHO 1999 guidelines were not significant. Conclusion: Adopting the IADPSG criteria for diagnosing GDM may be important in Sri Lankan pregnant population.