Fertility after fetotomy: a clinical study focusing on heavy draft mares.

Although fetotomy is recommended for all mares when the fetus is dead and difficult to extract, little has been written about fetotomy and heavy draft mares. This lack includes indications for fetotomy in heavy draft mares, differences in treatment and prognosis of heavy mares kept by farmers of low socioeconomic status, and how this procedure affects the mare's further fertility. The literature on mares, in general, also differs on the survival rate of mares that undergo fetotomy, the prevalence of postpartum complications, and further fertility. To answer these questions, we reviewed the medical records of 102 mares that underwent fetotomy, mostly heavy draft mares (n=93). Head malposture (62.7 per cent) was the most common fetal maldisposition, which required fetotomy in all cases. The survival rate was 84.3 per cent (n=86). The most common postpartum complications were endometritis puerperalis (32.5 per cent) and retained placenta (27.9 per cent). 61 mares (70.9 per cent) both showed foal heat and cycled regularly in the first season after fetotomy. Out of 45 mares that were bred in the first season, 14 became pregnant (31.1 per cent). Survival rate and further fertility were reduced by delayed requests for veterinary assistance due to the difficult economic situation of the owners. Fetotomy is the method of choice for serious maldispositions, especially head malpostures, because in contrast with cesarean sections, it has a higher survival rate and allows the mare to return to breeding in the same season.

Perinatal pathologic examination of nonintact, second-trimester fetal demise specimens: the value of standardization.

CONTEXT: Management of second-trimester intrauterine fetal demise via dilation and evacuation results in nonintact specimens for pathologic examination. Surgical pathology examination is often mandated; however, evidence on expected findings and specimen evaluation guidelines are lacking. OBJECTIVES: To assess pathologic findings of nonintact, second-trimester fetal demise specimens, through comparison of anatomic abnormalities identified on standardized perinatal examination to individualized general pathology examinations. DESIGN: Single institution, retrospective chart review of 14- to 24-week gestational size fetal demise cases was conducted from May 2006 to October 2010. Suspected abnormalities, chromosomal and pathologic diagnoses were collected. A general surgical pathology examination occurred between May 2006 and October 2008, while a perinatal pathologist examined specimens between October 2008 and October 2010. Statistical analysis consisted of t tests and χ(2) tests by Stata/SE 12.1. RESULTS: One hundred eighteen specimens were included and mean gestational size was 16.0 weeks (standard deviation, 1.6 weeks). Perinatal pathologic evaluation diagnosed significantly more abnormalities than did general pathologic examination (77.3% [34 of 44] versus 9.5% [7 of 75], P < .001). Forty-eight abnormalities were identified: 77.0% (n = 37) were placental and 23.0% (n = 11) were fetal. Chromosomal analysis was done on 73.7% (n = 87 of 118) with 12.6% (n = 11 of 87) showing abnormalities. Among aneuploid specimens, the perinatal pathologist confirmed abnormalities in 66.7% (n = 4 of 6) of cases while general pathologists confirmed abnormalities in 0% (n = 0 of 5) (P = .02). CONCLUSIONS: Systematic surgical pathology examination of nonintact, second-trimester fetal demise specimens yields increased information on fetal or placental abnormalities, which may be clinically useful. Institutions with high-risk obstetrical practices and dilation and evacuation providers should consider integrating a standardized perinatal checklist into educational and practice guidelines.

Vanishing twins in diamniotic dichorionic in vitro fertilization gestation in mid-second trimester.

The authors report a diamniotic dichorionic twin pregnancy after in vitro fertilization (IVF) in mid-second trimester. The dead fetuses were delivered by cesarean section at the 20th week of gestation. The authors discuss management aspects and review of the literature.

Controversies in family planning: management of second-trimester losses in the setting of an abdominal cerclage.

For women who have a fetal demise with an abdominal cerclage in place, route of uterine evacuation is a clinical dilemma. We review a case of a second trimester loss in the setting of an abdominal cerclage in an HIV positive woman. We provide other clinician's experience and management strategies and provide a review of cases found in the literature.

[Prompt resuscitation by obstetric anesthesiologists saved a parturient with amniotic fluid embolism: a case report].

Amniotic fluid embolism (AFE) is a disorder with a high mortarity rate, because it often causes sudden respiratory failure, circulatory collapse and disseminated intravascular coagulation (DIC). We present a case of AFE in which an obstetric anesthesiologist promptly initiated resuscitation of a parturient and saved her without any sequelae. Her fetus was diagnosed as intrauterine fetal demise on 25th gestational week and vaginal delivery under epidural analgesia was planned. One hundred and five minutes after induction of labor with prostaglandine E1, sudden tetanic convulsion occurred with a loss of consciousness. An obstetric anesthesiologist immediately started to resuscitate her and her consciousness was restored. However, noncoagulable vaginal bleeding followed. As the hemorrhage persisted, AFE was suspected. Anesthesiologists gave effective massive transfusion therapy, and she recovered from coagulopathy. Total blood loss was 5,524 g. This case was diagnosed as AFE with high serum sialyl-Tn antigen and zinc-coproporphyrin. The obstetric anesthesiologists are one of the best groups of physicans for resuscitation because they have skills in managing obstetric emergencies such as AFE. In this case, the crucial points for successful resuscitation were prompt obstetric anesthesiologist involvement and good communications with obstetricians and midwives.

Coagulopathy associated with dilation and evacuation for second-trimester abortion.

OBJECTIVE: To characterize the clinical and laboratory features of coagulopathy following second-trimester surgical abortions. DESIGN. Retrospective study. SETTING: Gynecologic unit of a university-affiliated medical center. POPULATION: 1249 consecutive women underwent late second-trimester (16-24 weeks) surgical abortions between January 2002 and June 2010. Of those, 20 women (1.6%) were diagnosed with excessive bleeding accompanied by coagulopathy. METHODS: Women were divided into two groups based on whether the abortion was performed for fetal demise (n=14) or pregnancy termination (n=6). MAIN OUTCOME MEASURES: Gestational age, indication for abortion, blood clotting tests, number of blood products and coagulation factors administered. RESULTS: Women who had pregnancy termination began to bleed significantly earlier than those with fetal demise (p<0.05). A significantly higher number of women with fetal demise had a gradual deterioration of the clotting test, compared with women who had pregnancy termination (p<0.05). In women with fetal demise, early bleeding was associated with a more severe clinical presentation. CONCLUSIONS: Coagulopathy following surgical abortion manifests differentially in women who have fetal demise and those who have pregnancy termination, implying a different pathophysiology. Women with fetal demise suffering from excessive bleeding following surgical abortion accompanied with mild clotting test abnormalities should be carefully monitored to diagnose and treat an impending disseminated intravascular coagulation.

Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation.

OBJECTIVE: To compare the safety and effectiveness of dilation and evacuation (D&E) and labor-induction abortion performed for fetal anomalies or fetal death in the second trimester. METHODS: We performed a retrospective cohort study of second-trimester abortions performed for fetal indications. We compared the frequency of complications and effectiveness of abortions performed at 13-24 weeks for these indications. We calculated proportions of patients with complications for these two methods and controlled for confounding using a log binomial model. RESULTS: Labor-induction abortions had higher complication rates and lower effectiveness than did D&E. Thirty-two of 136 women undergoing labor induction (24%) experienced one or more complications, in contrast to 9 of 263 women (3%) undergoing D&E (unadjusted relative risk 6.9 [95% confidence interval 3.4-14.0]). When controlled for confounding, the adjusted risk ratio for labor induction was 8.5 (95% confidence interval 3.7-19.8) compared with D&E. CONCLUSION: Dilation and evacuation is significantly safer and more effective than labor induction for second-trimester abortion for fetal indications. Bias and chance are unlikely explanations for these large discrepancies. Women facing this difficult decision should be offered a choice of methods and be provided information about their comparative safety and effectiveness. LEVEL OF EVIDENCE: II.

Destructive operations--a vanishing art in modern obstetrics: 25 year experience at a tertiary care center in India.

BACKGROUND: Destructive operations have a limited role in modern day obstetrics. In the developed countries, obstetrics has become so advanced that these instruments have actually been put away. However, in developing countries like India, these procedures have a limited role where obstructed labor still continues to plague thousands of women every year and accounts for 8% of maternal deaths. This study was planned to define the changing role of destructive operations in obstetrics over the years as more number of abdominal deliveries are conducted in modern day obstetrics than these procedures. MATERIALS AND METHODS: A retrospective analysis of destructive operations performed at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, over a span of 25 years, between 1983 and 2007, was carried out. RESULTS: Of a total of 85,952 deliveries in PGIMER in these 25 years, there were 25,474 cesarean deliveries (29.63%), and 8,826 (10.26%) operative vaginal deliveries. The total number of destructive operations performed was 230 (0.26%). There were 202 craniotomies (87.8%), 13 decapitations (5.7%), 8 eviscerations (3.6%) and 7 cleidotomies (2.9%). CONCLUSION: There should be an individualized approach to each case of obstructed labor. The health care provider has to decide on the options available to him to deliver the mother by the safest route without causing morbidity and mortality. If the fetus is dead, a destructive procedure can be considered in place of abdominal-route delivery which carries considerable risk to the debilitated mother in neglected labor.

Purse-string suture technique to enable laparoscopic management of the interstitial gestation of a heterotopic pregnancy.

OBJECTIVE: To describe the laparoscopic management of an interstitial gestation of a heterotopic pregnancy. DESIGN: Case report and technique description. SETTING: Tertiary-level private practice. PATIENT(S): Woman with a 6-week gestation spontaneous heterotopic twin pregnancy: one twin intrauterine, one interstitial. INTERVENTION(S): A purse-string suture was applied to the proximal portion of the interstitial heterotopic pregnancy. MAIN OUTCOME MEASURE(S): To enable a cornual resection to be performed with minimal bleeding and without recourse to laparotomy. RESULT(S): At 8 weeks gestation an ultrasound scan confirmed a viable singleton intrauterine pregnancy, but a scan at 12 weeks showed a missed miscarriage. CONCLUSION(S): The embedding of the suture into the uterine serosa prevents slipping of the ligature that could occur with a pretied loop.

Failure of prostaglandin induction labor in a Müllerian abnormality.

Rudimentary-horn pregnancy (RHP) is a rare condition which is usually presented as a rupture of the pregnant horn during the second or third trimester, resulting in life-threatening bleeding. The authors report two cases of RHP which were diagnosed at the time of labor induction following fetal death diagnosis. Although the failure of prostaglandin induction to initiate labor could suggest that an additional obstructive Müllerian uterine anomaly is present, a directed investigation of such anomaly is more acceptable in cases of antepartum fetal death or atypical mid-trimester abdominal pain. Therefore, a high index of suspicion combined with clinical and imagiological findings are important to establish a correct diagnosis of pre-rupture RHP.

Internal podalic version for neglected shoulder presentation with fetal demise.

In modern obstetrics, the role of internal podalic version (IPV) is limited to delivery of the second twin. A retrospective study was conducted to assess the efficacy of IPV in singleton neglected shoulder presentation with fetal demise. Women with live fetuses, previous CS or contracted pelvis were excluded. The procedure involved repositioning the prolapsed hand under anaesthetic followed by breech extraction. 12 women were identified over a 19 month period and all underwent successful IPV. One woman had a postpartum haemorrhage. We conclude that, in singleton pregnancies with a transverse lie, IPV has a role to play in the delivery of dead fetuses.

Advanced pregnancy loss in the rudimentary horn of an undiagnosed unicornuate uterus.

A case of advanced pregnancy loss in the rudimentary horn of a unicornuate uterus is presented herein. The unknown uterine malformation and advanced pregnancy resulted in the condition being incorrectly diagnosed on ultrasound. After a failed attempt at dilatation and curettage, a correct diagnosis was made and proper treatment was given during salvage laparotomy performed for arising complications (coagulopathy).

Retrospective case study of fetal mummification in cows that did not respond to prostaglandin F2alpha treatment.

Mummification of bovine fetuses is an uncommon condition, and cows do not always respond to treatment with prostaglandin F2alpha. The objective of the present retrospective and descriptive case study was to determine the conception rate and survival time of nonresponsive, prostaglandin F2alpha (PGF2alpha)-treated cows (n = 14), following hysterotomy or medical treatment and manual removal. Animal records from 1990 to 2005 from the Centre Hospitalier Universitaire Vétérinaire (CHUV) of the Université de Montréal were studied. Inclusion criteria were the nonexpulsion of the mummified fetus following PF2alpha treatment and absence of concomitant conditions upon physical examination. Of the animals included in the study, 36% (n = 5) became pregnant after extraction of the mummified fetus by hysterotomy and 0% conceived after medical treatment and manual extraction. In this study, hysterotomy represented an effective approach for extracting mummified fetuses from cows that did not respond to PF2alpha treatment.

Two cases of reversal of twin-twin transfusion syndrome diagnosed by measuring hourly fetal urine production.

Reversal of twin-twin transfusion syndrome (TTTS) is a rare complication of monochorionic pregnancy. Diagnostic criteria and satisfactory therapeutic options have not been reported. We make a suggestion of diagnosis and therapy for reversal of TTTS. We report two cases of reversal of TTTS. Measurement of the fetal urine production rate was useful for management and better comprehension of the cases. In case 1, double intrauterine fetal demise occurred before the criteria for TTTS were fulfilled, in which each fetal urine production rate reversed prior to the change of amniotic fluid volume. In case 2, elevated urine production was noted prior to progressive polyhydroamnios and congestive heart failure in the new recipient and the fetoscopic laser photocoagulation of the placental communicating vessels was performed successfully before the criteria for TTTS were fulfilled. Both infants required intensive care, but developed normally and showed no neurologic complications at 2 years after birth. Hourly fetal urine production rate was useful for immediate diagnosis of reversal of TTTS, and laser photocoagulation of the placental communicating vessels is thus a method for the correction of the fetal blood flow imbalance in cases of reversal of the donor-recipient phenotype in TTTS.