Uterine compression suture technique in the management of severe postpartum haemorrhage as an alternative to hysterectomy.

INTRODUCTION: One of the most dramatic conditions in obstetrics is definitely bleeding from the uterus which fails to compress. This condition is known as postpartum atony. When such a condition is diagnosed, the obstetrician has a choice of several conservative methods to stimulate the uterus to contract and several surgical methods to stop the bleeding. The most extreme measure used to save the patient's life and stop the bleeding is hysterectomy. This surgery is characterized by high morbidity, primarily by the loss of woman's fertility. In order to avoid hysterectomy, several authors have introduced the compressive uterine suture technique into gynaecological practice. OBJECTIVE: The aim of the paper is to demonstrate the technique of applying compressive uterine suture after delivery to stop excessive bleeding, and to present results obtained by this technique. METHODS: The paper explains the technique of applying compressive suture to the atonic uterus in cases when all other procedures to stop excessive bleeding after delivery fail. Since uterine atony is the main reason for excessive and uncontrollable bleeding after childbirth, the need to perform such surgery is rather common. Authors demonstrate the technique of applying four compressive sutures which prevent uterus dilation and thus stop the bleeding. RESULTS: Compressive suture technique was used by the authors eight times, seven of which during caesarean section and one after spontaneous delivery. All patients had normal postpartum period and normal involution of the uterus. CONCLUSION: Although this surgery requires a skillful and experienced obstetrician, the authors find it rather easy to perform and it is suggested to be applied in all cases of uterine atony when excessive bleeding cannot be stopped by other any other method except hysterectomy. This surgical procedure saves the uterus and facilitates quick and easy patient's recovery.

[Birth weight discordance and perinatal mortality among triplets].

INTRODUCTION: The incidence of multiple births has increased in the last decade. Perinatal mortality in triplets is significantly greater than in twin and singleton births. OBJECTIVE: The objective of this study was to describe the extent of birth weight discordance among triplets and to identify its association with an increased risk of perinatal mortality. METHOD: A retrospective analysis of triplet births, for the period 1993-2003, was conducted at the Gynaecological-Obstetric Clinic "Narodni Front" in Belgrade. Birth weight discordance was defined as the difference in birth weight between the largest and the smallest triplet's weight of more than 20%. RESULTS: The rate of triplets has increased by almost 75% between the first (7.7%) and the last (29.6%) 5-year period of the last decade. Triplets are becoming more common because of the frequent use of assisted reproductive technology as a treatment for infertility. In the period 1993-2003, there were a tota of 40 triplet live births (24 weeks and greater) with incidence of 0.06%. There was no clear association between maternal age, parity, method of conception, birth gestational age, and disorders complicating pregnancy with birth discordance more than 20%. Regarding birth weight groups, statistical significance occurred only in the < 999 grams group for discordant and in the 2000-2499 grams group for concordant triplets. Overall, the perinatal mortality rate in the group was 10.8%, the foetal mortality rate was 1.7% (2/120), and the neonatal (0-28 days) mortality rate was 9.1% (11/120). An odds ratio of 95% confidence interval shows 3 times greater risk for adverse perinatal outcome in the discordant group. However, the difference was not significant. CONCLUSION: Increasing birth weight discordance may increase the risk of adverse perinatal outcome. Triplet pregnancies, being high risk, require intensive antenatal care in order to prevent preterm delivery and ultrasound in order to diagnose foetal growth abnormality and discordance, which increase foetal surveillance, through the use of biophysical profiles, non stress tests, and Doppler velocimetry, thus assessing foetal well being and the appropriate moment for obstetric intervention.

[Twin transfusion syndrome--diagnosis and prognosis]. / Transfuzijski sindrom blizanaca--diagnoza i prognoza.

Twin-twin transfusion syndrome is a serious complication of monozygotic, monochorionic, diamniotic twins resulting from transplacental vascular communications. In this syndrome blood is thought to be shunted from one twin--donor, who develops anaemia, growth retardation and oligoamnios, to the other twin--recipient, who becomes plethoric, macrosomic and develops polyhydroamnios. The incidence of twin-twin transfusion syndrome ranges from 5-15% of all twin pregnancies. If this condition develops in the second trimester, it is usually associated with spontaneous abortion and death of one or both fetuses before viability. Developing the syndrome in the third trimester has better perinatal outcome. Mortality rates ranging from 56%-100%, depending on gestational age and severity of the syndrome. The ultrasound criterias for diagnosis, in this study, were the presence of twins of the same sex with discordant growth, with oligohydroamnios in one twin sac and polyhydroamnios in the other one, one placenta and thin membrane between twins. The present study shows clinical course of 14 cases and value of Doppler ultrasound to analyze the usefulness of umbilical artery blood flow velocimetry for predicting the risk of twin-twin transfusion syndrome. 14 twin pregnancies with twin-twin transfusion syndrome were diagnosed during the last four years period and prospectively followed. 9 cases were diagnosed before the completion od 28 weeks of gestation. The mean gestational age was 21.6 _+ 4.2 weeks at diagnosis and 23.2 +_ 3.6 weeks at delivery. 5 cases were diagnosed after 28 weeks of gestation. The mean gestational age in this group was 29.6 +_ 2.1 weeks at diagnosis and 33 +_ 3.3 weeks at delivery. The survival rate in this study was 29% (8/28). 9 cases ended in spontaneous abortion between 18th and 27th weeks of pregnancy (table 1) and 5 in premature labor (table 2). There were 7 intrauterine death (5 at admission and 2 few days after admission) and 13 neonatal deaths. Overall mortality rate was 71% (20/28). Up to 28th weeks mortality rate was 100% and after 28th weeks mortality rate was 20% (2/10). 9 cases had "stuck" twin phenomenon. The differences in the Doppler indexes from twin-twin transfusion syndrome cases significantly exceeded those without this syndrome. This difference seemed to predict the risk of twin-twin transfusion syndrome, but the number of cases is too small for general conclusions. Treatment regimens for twin-twin transfusion syndrome have included bed rest, tocolytic agents and serial amniocenthesis for decompression in some cases. Neither serial amniocenthesis nor tocolytic agents use were associated with an improved survival rate in our study. Twin-twin transfusion syndrome can be diagnosed early in second trimester of pregnancy, but the survival rate remains low with the current methods of treatment. Survival was related to gestational age at delivery and birth weight. Twin-twin transfusion syndrome diagnosed before 28th weeks of gestation represents one of the most lethal conditions in perinatal medicine today.