Placenta accreta and the developing world--a review.

BACKGROUND: The rising Caesarean section rate in the developing world implies that the incidence of placenta accreta might be on the increase and this might worsen the maternal mortality burden. OBJECTIVE: To draw the attention of Obstetricians and other relevant professionals to this emerging but challenging trend. DATA SOURCES: Original research findings and reviews published in the English literature. Additional information was obtained from texts and electronic books such as CD ROMS. DATA EXTRACTION: Online searches of electronic database (Medline, Pubmed and Embase), requests for reprints from corresponding authors and institutional/private subscriptions. DATA SYNTHESIS: Information obtained was categorised accordingly. CONCLUSION: Optimal treatment of women with placenta accreta requires recognition of the clinical risk factors, accurate pre-operative diagnosis and meticulous planning to ensure safety at the time of delivery. In view of the rising incidence of this condition, and the absence of a highly reliable antenatal diagnostic method especially in developing countries, a high index of suspicion and advanced preparation is required to reduce its associated maternal morbidity and mortality.

Salvage autotransfusion versus homologous blood transfusion for ruptured ectopic pregnancy.

OBJECTIVE: To compare the clinical outcomes of simple salvage autotransfusion and homologous blood transfusion in the management of ruptured ectopic pregnancies. METHODS: Standard statistical analysis was done and relative risk (RR) and 95% confidence interval (CI) were calculated for 112 women randomized to salvage autotransfusion or donor blood transfusion following ruptured ectopic pregnancy. RESULTS: More women in the autologous group received more than 1000 mL of blood (RR, 6.41; 95% CI, 2.75-15.24) and had a hematocrit greater than 0.27 at discharge (RR, 3.62; 95% CI, 1.41-6.67). There were no significant differences in the incidence of postoperative fever (RR, 0.95; 95% CI, 0.43-2.01), postoperative wound infection (RR, 0.73; 95% CI, 0.17-3.19) or duration of hospital stay longer than 7 days (RR, 1.3; 95% CI, 0.44-4.31). CONCLUSION: In resource-poor countries, women with a ruptured ectopic pregnancy receive more blood with salvage autotransfusion.

External cephalic version (ECV): experience in a sub-Saharan African hospital.

External cephalic version (ECV) is not a popular procedure in developing countries such as Nigeria. Over a 3-year period, we prospectively studied women who had ECV in a Nigerian University Teaching hospital. Comparative analysis was made between the successful ECV and the unsuccessful ECV groups. Following adequate counselling, Nigerian women were willing to accept an ECV for the singleton term breech. The ECV success rate was 67%. Favourable factors for success were multiparity (Relative Risk, RR 3.8; 95% confidence interval, CI 1.14 - 12.1), flexed breech (RR 2.4; 95% CI 1.02 - 5.7), unengaged breech (RR 4.8; 95% CI 1.3 - 17.2), normal liquor volume (RR 4.8; 95% CI 1.3 - 17.1) and a posterior placenta (RR 6.8; 95% CI 2.8 - 16). Once turned, 97% of the babies remained cephalic until delivery. The caesarean section rate in each group was higher than the unit rate of 12.7%. There was one fetal death from cord prolapse in the vaginal breech delivery group.

Management of cervical incompetence in Aba, south-eastern Nigeria.

BACKGROUND: There have been relatively few reports on the outcome of cervical cerclage performed in non-tertiary centres. The aim of this study was to determine the pregnancy complications and outcome in patients following cervical cerclage. METHODS: Seventy-one patients who had 103 pregnancies and underwent cervical cerclage at Women's Hospital, Aba over a ten-year period were reviewed. The diagnosis of cervical incompetence was made from the history in 90.6% of cases and also in some cases by hysterosalpingography and ultrasonography. RESULTS: The Shirodkar (65%) and McDonald (35%) techniques were employed and 10.7% of cases were done as emergency procedures. The more common post-insertion complications were urinary tract infection (50.4%), preterm rupture of membranes (20.4%) and vulvovaginitis (14.6%). Common labour associated complications were antepartum haemorrhage, perineal/cervical tears and malpresentations. The preterm birth rate was 32%. Term births accounted for 68% of the deliveries. The overall fetal salvage rate was 92.2%. Antepartum haemorrhge was a significant indication for caesarean section delivery. The perinatal mortality was 63.2 per 1000 and there was no maternal death. CONCLUSION: The high fetal salvage rate of 92.2% justifies the procedure of cervical cerclage.

Case Report - Heterotopic Pregnancy with Spontaneous Vaginal Delivery at 36 Weeks and Laparotomy at Term - A Case Report

Heterotopic pregnancy; although rare; is occurring more frequently because of an increase in genital infection and the escalating use of new reproductive technologies in infertility patients. The case of a 30-year-old para 2+1 prophetess is presented. She had a spontaneous vaginal delivery at term. Persistent abdominal pain and distension led to suspicion of heterotopic pregnancy. This was confirmed by ultrasonography. Laparotomy revealed a macerated fetus in the peritoneal cavity. The purpose of this report is to sensitise practitioners about the reality and existence of the condition

An audit of five years' experience of pregnancy in spinal cord damaged women. A regional unit's experience and a review of the literature.

In a retrospective review of pregnancy and delivery in 8 spinal cord damaged women managed at Hexham General Hospital Spinal and Maternity Units between 1986 and 1991, antenatal complications included urinary tract infection, anaemia, constipation, suspected deep venous thrombosis and pressure sores. Five of the 8 patients had adductor spasms. Autonomic hyperreflexia occurred in 2 patients in the antenatal period, and in one patient in the postpartum period. Four patients were delivered by caesarean section, and 4 of the 8 patients had breech presentation of the foetus at delivery. The perinatal outcome was good.

Outcome of cesarean section in twin pregnancy.

In an 8-year period (January 1978 to December, 1985), the 17,379 deliveries at the University of Benin Teaching Hospital (UBTH) consisted of 2089 cesarean sections (12.0%), 56 of which were associated with twin pregnancy. The main indications for cesarean section on the twin pregnancies were antepartum hemorrhage (placenta previa), malpresentation, cervical dystocia and previous cesarean section. The maternal mortality rate was 2% for all twin mothers delivered by cesarean section. There was no statistical difference in perinatal mortality rates (PMR) for all twin deliveries, vaginal twin deliveries and deliveries by cesareans section which were 111,113 and 100 per 1000 births, respectively. In the case of a retained second twin, however, recorded PMR was significantly higher (133 per 1000 births). Consideration of more liberal recourse to cesarean section in all cases of twins may reduce these unacceptably high perinatal death rates in twin pregnancy.