Multiple repeated cesarean deliveries: operative complications in the fourth and fifth surgeries in urgent and elective cases.

OBJECTIVE: To evaluate the maternal and neonatal risk related with multiple repeated cesarean sections. MATERIALS AND METHODS: A case control study was conducted in a single tertiary maternity and children's center. The outcome of a study group including 122 pregnant women undergoing cesarean section for the fourth or fifth time was compared with a control group comprising 146 women sectioned for the second and third time. All multiple repeated cesarean sections were divided into urgent and elective groups to compare the outcome measures of demographic, neonatal, intra- and post-operative data. RESULTS: Compared with the control group, the study group had significantly lower birth weights (p=0.026), lower Apgar scores at 1 minute (p=0.0001) and 5 minutes (p=0.042), higher numbers of fetal death (p=0.03), higher rate of omentum adhesions (p =0.0001) and peritoneal adhesions (p=0.008), increased risk of cesarean hysterectomy (p = 0.014), increased need for transfusion (p = 0.018), and an increase in hospitalization days (p=0.005). Compared with the elective group, preterm birth incidence was higher (p = 0.01) and birth weight was lower (p=0.004) in the urgent group. The risk for myometrium herniation (p=0.018), need for drainage during operation (p=0.018), and post-operative fever (p =0.001) was also more common in the urgent group. CONCLUSION: Multiple repeated cesarean sections increase the risks for operative complications and poor perinatal outcomes. Patients must be informed about the related risks of multiple repeated cesarean sections and tubal ligation needs to be encouraged.

Termination of pregnancy and reasons for delayed decisions.

OBJECTIVE: To assess the indications and distribution of cases chosen for termination of pregnancy and reasons delaying until third trimester termination. METHODS: Retrospective study of cases between 2002 and 2006 in the hospital council. Cases were divided in two groups, as early termination (<23 weeks of gestation) and late termination (≥23 weeks of gestation). All pregnant women who underwent termination were classified according to related systemic pathology and chorionicity. Reasons for delaying until third trimester termination were evaluated in four groups. RESULTS: During this five year period 1.449 complicated pregnancies were counseled and in 713 cases termination was offered. Of 677 cases (94.95%) with termination, 412 cases (60.09%) had early and 265 cases (39.91%) late termination. The most frequent indications were central nervous system abnormalities (51.7%), chromosomal abnormalities (11.7%), and urogenital abnormalities (8.4%). The main reason for delaying termination was failure of screening by ultrasound (65.6%). CONCLUSION: Systematic screening for fetal anomalies is the main step for prevention of affected pregnancies. Information given to parents for TOP is important, but the decision for TOP is influenced by many factors.

Multidisciplinary approach in cystic hygroma: prenatal diagnosis, outcome, and postnatal follow up.

BACKGROUND: The aim of the present study was to determine prenatal follow up and clinical outcome in fetuses born with cystic hygroma. METHODS: A series of 64 cystic hygroma patients, who were diagnosed in the first and the second trimester of pregnancy, was enrolled. Associated structural abnormalities, karyotype analysis and pregnancy outcome were studied. Survivors were followed for their fetal outcome and prognosis. RESULTS: There were 64 new cases of cystic hygroma in 8524 subjects screened (0.75%). Thirty-nine (60.9%) were of non-septated and 25 (39.1%) were of septated cystic hygroma. Chromosomal abnormalities were present in 25 (39.1%). The most common abnormality in non-septated cystic hygroma was trisomy 21 (10, 27.8%), and that in septated cystic hygroma was Turner syndrome (5, 23.8%). Associated structural malformations are common in cystic hygroma and overall survival was poor. Nine of the present infants were live-born and were subsequently followed up. Two had cardiac pathology and died after cardiac operation, two others were diagnosed with axillary cystic hygroma, had an excellent prognosis and responded well to treatment, and another two had cranial findings with mild neurological sequel. Only three cases had, at birth and in the follow-up period, no complications. CONCLUSION: Cystic hygroma is highly correlated with adverse perinatal outcome. Prenatal diagnosis and invasive procedures are vital for counselling with close follow-up after delivery for appropriate medical support. A multidisciplinary approach is strictly recommended in live-born children.

Diagnosis and prognosis in double-outlet right ventricle.

The aim of this study was to examine prenatal diagnosis of double-outlet right ventricle (DORV)-associated anomalies and prognosis of each case. Medical records were reviewed of fetuses with DORV who had fetal echocardiography at our institution from 2002 to 2006. Pre- and postnatal diagnosis and outcome were compared and evaluated. Twenty-one fetuses were diagnosed with DORV. The pregnancy was terminated in seven cases. Three cases had chromosomal abnormalities; three cases, hypoplastic left ventricle; and one case, encephalocele. Accurate prenatal diagnosis of the ventricular septal defect, outflow obstruction, and great artery relationship was achieved in 14 of 16 cases (87.5%). Only 2 of 13 live-born cases survived beyond 6 months. The overall prognosis for fetuses with DORV is poor. DORV is found in fetuses with a huge spectrum of associated cardiac and extracardiac anomalies. Careful assessment by fetal echocardiography can determine important anatomic details with adequate correctness for precise counseling.

Re-laparotomy after cesarean section: operative complications in surgical delivery.

OBJECTIVE: To determine the risk factors causing re-laparotomy and the indications, management and outcomes of re-laparotomy after a cesarean section. METHODS: We had, during the study period of January 2002 to January 2007, 28,799 cesarean sections and 35 cases with re-laparotomy. We studied the patients' age, parity, indications for cesarean section and indications for re-laparotomy, time interval after cesarean section to reopening of the abdomen, type of surgery, need for blood transfusion and span of hospital stay. RESULTS: The incidence of re-laparotomy was 0.12%. Cases with placental abruption and previous cesarean > or =3 had a higher risk for re-laparotomy. Procedures that were performed at re-laparotomy were drainage and resuturing of hematomas (n = 8), resuturing of uterus and securing hemostasis with stitches (n = 10), bladder repair (n = 1), herniation repair (n = 1), total abdominal hysterectomy (n = 2), subtotal abdominal hysterectomy (n = 5), and draining and resuturing of broad ligament, parametrium, abdominal wound, and cutaneous and subcutaneous tissue due to infection and abscess formation (n = 8). Two cases required admission into the intensive care unit. We had one case with maternal mortality. Majority of the complications were revealed at an early period and these were hemorrhagic cases mostly. CONCLUSION: Although the rate of re-laparotomy after cesarean section is low, several actions must be undertaken to decrease the need for re-laparotomy. In particular, cases with placental abruption and previous cesarean > or =3 are with higher risk for re-laparotomy and have a 15-fold risk for re-laparotomy after cesarean section.

Cystic hygroma and lymphangioma: associated findings, perinatal outcome and prognostic factors in live-born infants.

OBJECTIVES: We aimed to determine associated ultrasonographic findings, chromosome abnormalities and the prognostic factors of cystic hygromas in live-born infants. METHODS: We reported a series of 57 cystic hygroma cases, who were diagnosed in the first and the second trimester of pregnancy by means of the ultrasonographic morphology of cystic hygroma, associated structural abnormalities, karyotype analysis and the autopsy findings. Survivors were followed for their fetal outcome and prognosis. RESULTS: There were 57 new cases of cystic hygroma among 8,155 screenings (0.7%). 35 of the cases (61.4%) were nonseptated and 22 of the cases (38.6%) were septated cystic hygroma. Chromosomal abnormalities were found in 23 of the cases (40.3%). The most common abnormality in nonseptated cystic hygroma was trisomy 21 (8 cases, 25%) and in septated cystic hygroma was Turner syndrome (4 cases, 21.1%). The most common associated structural malformations were cardiac abnormalities (in 7 cases, 20%) in nonseptated cystic hygroma cases and nonimmune hydrops (in 12 cases, 54.5%) in septated cystic hygroma cases. Overall survival was poor; only one case of septated cystic hygroma with axillary location and seven cases of nonseptated cystic hygroma, of whom two died in the neonatal period, were alive (10.5%). This study had 80% power to detect 0.03% difference in diagnosis cystic hygroma (alpha = 0.05, beta = 0.80). CONCLUSION: Fetuses with cystic hygroma are at high risk for adverse outcome. Prenatal diagnosis with invasive procedures should be done in order to inform the parents in detail. Axillary location of the hygroma and the depth of invasion had prognostic importance.