Fetal Head Entrapment Research Articles

The risk of fetal head entrapment at 22-25 weeks

The risk of fetal head entrapment at 22-25 weeks

Benefits of the «en caul» technique for extremely preterm breech vaginal delivery

IntroductionThe “en caul” technique, i.e. delivery with intact membranes, may reduce the risk of obstetric trauma in vaginal breech delivery of extreme preterm infants. We aimed at comparing perinatal mortality and morbidity among extremely preterm breech vaginal deliveries between infants delivered “en caul” and those with “ruptured membranes”. Material and methodsWe performed a fourteen-year retrospective study in a tertiary university center. All vaginal deliveries of singleton breech live infants with an antenatal decision of active resuscitation between 24 weeks and 27+6 weeks were included. Perinatal outcomes were compared between the “en caul” group, with intact membranes at the onset of pushing efforts and the “ruptured membranes” group, with ruptured membranes at the onset of pushing efforts. The primary outcome was perinatal mortality defined by intrapartum or neonatal death. The secondary outcomes were fetal extraction difficulties, arterial pH and 5 min Apgar score. ResultsWe included 52 infants in the “en caul” group and 71 in the “ruptured membranes” group. The perinatal mortality rate did not differ between the two groups (19.2% in the “en caul” group versus 28.2% in the “ruptured membranes” group, p = 0.25). The mean arterial pH at birth was higher in the « en caul » group (7.32 ± 0.1 vs 7.24 ± 0.1, p = 0.001). There were no differences between the groups for fetal extraction difficulties, especially fetal head entrapment (9.6% versus 9.9%). ConclusionEven though the “en caul” technique does not seem to decrease the perinatal mortality rate, it remains a simple technique, which could improve neonatal morbidity.

501 Risk of fetal head entrapment at 22-25 weeks

To determine the rate of fetal head entrapment in periviable infants (22w0d and 25w6d); to assess the differences in outcomes between vertex and non-vertex neonates delivering vaginally A retrospective cohort study of periviable deliveries (22w0d-25w6d) from 2013-19 at a single institution was conducted. After IRB approval, charts of vaginal deliveries of vertex and non-vertex neonates were reviewed to abstract maternal, obstetric, and neonatal information. Charts were excluded if neonatal resuscitation was not desired or offered. The primary outcome was the rate of fetal head entrapment at the time of vaginal delivery for non-vertex infants. Secondary outcomes for cephalic vs non-cephalic vaginal births included neonatal survival to discharge, a composite of neonatal morbidity and mortality (death, grades 3/4 IVH, chronic lung disease, and stage 3-5 ROP), and a composite of maternal morbidity (ICU admission, wound infection, unplanned operation, sepsis). Logistic regression was used to account for variation between cohorts. After exclusion, 71 vaginal deliveries of periviable neonates were included in the cohort (54 cephalic, 17 non-cephalic). Baseline maternal characteristics for the vertex and non-vertex cohorts are in Table 1. For the primary outcome, the rate of fetal head entrapment was 2/17 (11.8%). Survival to discharge was higher among cephalic infants (40/54 74.1% vs 7/17 41.2%, p-value 0.01, OR 0.2 95%CI 0.1-0.8). After adjustment for birthweight, there was no significant difference in survival to discharge between cohorts (aOR 0.4 95%CI 0.1-1.4). None of the neonates with head entrapment were discharged alive. When non-vertex IUFD deliveries were included in the cohort the rate of head entrapment decreased to 2/58 (3.4%). A composite of maternal morbidity, EBL, and LOS were similar between the groups. In this small cohort of non-vertex vaginal deliveries of neonates delivered from 22w0d-25w6d the risk of head entrapment was approximately 12% with similar neonatal and maternal outcomes. These risks should be included in shared decision making.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fetal head entrapment within the lower uterine segment

Abstract Fetal head entrapment by a uterine scar or adhesion is a rare obstetric complication. We present a case of a uterine constriction diagnosed in pregnancy that resulted in confinement of the fetal head to the lower uterine segment. The developing fetus ultimately suffered growth restriction of the head and was delivered after the mother experienced preterm premature rupture of membranes (PROM). Severe adhesions of the lower uterine segment were confirmed during the patient’s classical cesarean section.

A transient finding of fetal head entrapment caught in a uterine synechium or amniotic band

Abstract Background Uterine synechia are bands of fibrous tissue that when seen on prenatal ultrasound are not felt to pose significant risk to a fetus outside of early pregnancy loss. On the contrary, amniotic bands are diagnosed when bands of amniotic tissue are found to entrap and possible amputate involved fetal parts. Case presentation Ultrasound imaging demonstrated a twin pregnancy affected by entrapment of twin B’s head in a uterine synechium versus an amniotic band at 11 weeks + 0 days. The entrapment persisted until the second trimester. After a review of still images and video clips with a fetal surgeon, the patient was scheduled for possible fetal surgery. Upon arrival at 16 weeks + 0 days, the entrapment was observed to have spontaneously resolved. The patient experienced preterm premature rupture of membranes at 17 weeks + 6 days, and developed chorioamnionitis at 18 weeks + 5 days. Shortly after diagnosis with chorioamnionitis, she delivered spontaneously at 18 weeks + 5 days. Postnatal hysteroscopy demonstrated uterine synechium at the uterine fundus, which was resected. Conclusions This is the first case of fetal head entrapment by a uterine synechium.

A review of abnormal birth positions and complications in Uyo, Akwa Ibom State

Introduction: Abnormal birth positions persisting to term have been associated with serious complications such as uterine rupture, umbilical cord prolapse, cervical spine injury, nuchal arms, and fetal head entrapment. Aim: The purpose of this study was to find out the most common abnormal birth position, mode of delivery, and associated complications at birth. Materials and Methods: This study covered the period of 5 years from 2005 to 2009 in three major hospitals in Uyo Local Government Area of Akwa Ibom State. The hospitals are St. Luke Hospital established in 1937, Mainland Hospital (a private hospital) established in 1975, and University of Uyo Teaching hospital established 1996. Totally, 1100 term singleton fetuses in abnormal birth positions were considered in this study. Results: Six different types of abnormal birth positions were recorded viz.: Breech 70.00% (the most common fetal malposition), transverse lie 14.73%, occiput posterior 8.45%, face presentation 3.27%, shoulder 1.91%, and compound 1.64%. Associated complications observed were umbilical cord prolapse (the most common complication) 6.27%, ruptured uterus 1.64%, and shoulder dislocation 0.54%. The rate of cesarean delivery for these fetuses was high (68.36%) compared to vaginal delivery (31.64%). Conclusion: Pregnant women are hereby encouraged to make childbirth a medically-centered hospital event to avoid unnecessary loss of their lives and/or that of their babies to complications of pregnancy and childbirth.

P17.05: Fetal head entrapment between the maternal pelvic bone and a pelvic mass

P17.05: Fetal head entrapment between the maternal pelvic bone and a pelvic mass

Prehospital Breech Delivery with Fetal Head Entrapment –A Case Report and Review

We present a case in which an emergency medical services (EMS) crew was called for a precipitous breech delivery with fetal head entrapment that was unrelieved following standard prehospital interventions and eventually resulted in neonatal cardiac arrest and death. Although this is a rare occurrence, EMS responders must have adequate training and guidelines on how to assist with vaginal delivery of breech presentation and how to appropriately manage fetal head entrapment in the field. There is little literature to provide guidance but it appears that standard EMS teaching does not represent current best obstetrical practice. We review the available literature, make expert recommendations, and provide a sample new treatment guideline for basic life support, advanced life support, and EMS physician response. Key words: prehospital; fetal head entrapment; breech delivery

Fetal head entrapment through a spontaneous chorionic septostomy in a first trimester dichorionic diamniotic twin pregnancy: a case report

What's already known about this topic? Spontaneous septostomy of the chorionic membrane in dichorionic diamniotic (DCDA) twin pregnancy is an extremely rare event with only a two reported cases, so far none with associated increased NT.What does this study add? This case reports a spontaneous septostomy of the chorionic membrane associated with increased NT in the first trimester with favorable pregnancy outcome. Along with an overview on the previous cases, possible etiologies and the role of genetic counseling and invasive karyotyping are discussed.

Intravenous nitroglycerin: a potent uterine relaxant for internal podalic version: case

Dear Editor, The uterine-muscle relaxation required for complicated obstetric situations traditionally has been achieved by use of a potent inhalation anesthetic. However, this procedure exposes the obstetric patient with full stomach to unnecessary general anesthesia, with the attendant risk and potentially lethal complications. Emergent uterine relaxation may be required for conditions such as retained placenta, uterine inversion, internal podalic version (IPV), and breech extraction. EVective on smooth muscle tissue and a venodilator, nitroglycerin is a short-acting and a potent uterine relaxant [1, 2]. Safety, predictability, and ease of intravenous (IV) administration of this drug have been established, and it has attracted the attention of obstetricians. Nitroglycerin is primarily indicated for the treatment or prevention of angina pectoris. Nitroglycerin has been used during manual extraction of retained placenta without clinically signiWcant hemodynamic eVects [1] and during replacement of a contracted, completely prolapsed uterus [1, 2]. Its use as a tocolytic has been reported in cesarean delivery of twins performed under spinal anesthesia: two cases of intrapartum external cephalic version, internal intrapartum podalic version of the second twin, and for the fetal head entrapment during vaginal breech delivery [1]. We report a case of IPV of intrauterine fetal demise (IUFD) in which relaxation of the uterus was accomplished quickly and safely with the use of IV nitroglycerin. A 30-year-old gravida 4 para 3 at 38 weeks gestation presented in active labor with antepartum hemorrhage since 2 h. Ultrasound conWrmed transverse lie, abruption placentae and IUFD; and examination revealed 4 cm dilated cervix. Her vitals were stable, hematocrit was 28% and coagulation proWle was normal. She made good progress, reaching 8 cm cervical dilatation over the next 4 h after which she started having hematuria so the decision was taken immediately to deliver the fetus by IPV. Uterine relaxation was achieved by direct IV nitroglycerin bolus 50 mcg along with ketamine hydrochloride 30 mg IV for sedation. Infusion of nitroglycerin at the rate of 50 mcg/min was started after 1 min of loading dose. When the uterus was relaxed (conWrmed with manual palpation), approximately 45 s after bolus, the obstetrician performed IPV and breech extraction. The procedure was completed in 4 min and 30 s. The total dose of nitroglycerin was 250 mcg. The placenta delivered spontaneously with no unusual cord traction. Transabdominal massage of the uterus and oxytocin infusion improved uterine tone. The hematocrit had decreased from 28 to 22%. One unit blood transfusion was given and she remained stable in the postpartum period. Hematuria was cleared in 2 h postpartum. Monitoring consisted of electrocardiogram, SpO2 and non-invasive blood pressure measurement. Hypotension occurred 1 min after nitroglycerin injection, which was normalized within 50 s with rapid infusion of crystalloids. The heart rate increased at the same time to 130 bpm. Side M. N. Gandhi · H. R. Iyer Department of Anaesthesiology, B. Y. L. Nair Charitable Hospital, T. N. Medical College, Dr. A. L. Nair road, Bombay 400008, Maharashtra, India

Intrauterine Head Entrapment of a Second Twin by a Uterine Synechia

In Brief BACKGROUND Fetal head entrapment during delivery is a rare occurrence in modern obstetrics. We present a case of intrauterine head entrapment of a second twin by a uterine synechia diagnosed by ultrasound and subsequent complications that occurred. CASE A woman with a twin intrauterine pregnancy presented at 19 weeks for evaluation of a shortened cervix. Ultrasound examination demonstrated fetal head entrapment of twin B by a uterine synechia, as well as intrauterine growth restriction (IUGR). The patient experienced pre-term premature rupture of membranes at 24 weeks' gestation and underwent a cesarean delivery for a nonreassuring fetal heart rate tracing of twin B, with findings of a constricting band of fibrous tissue around the neck of twin B. CONCLUSION Uterine synechia might cause intrauterine head entrapment and IUGR. Uterine synechia might cause intrauterine head entrapment and intrauterine growth restriction and can be diagnosed by antenatal ultrasound.

The use of intravenous nitroglycerin for cervico-uterine relaxation: a review of the literature.

The safety, predictability, and ease of intravenous administration of nitroglycerin (NTG) have been firmly documented. In recent years, intravenous NTG has come to the attention of the obstetrician as a potent uterine relaxant. Intravenous nitroglycerin has been used to relax the uterus during manual extraction of retained placenta and to permit replacement of a contracted, completely prolapsed, inverted uterus. The use of this agent as a tocolytic has previously been reported in cesarean delivery of twins, in cases of intra partum external cephalic version, and for internal intrapartum podalic version of the second twin. This new procedure was also used for fetal head entrapment after vaginal breech delivery. The authors report a review of the literature about this subject.

Nitroglycerin for Fetal Head Entrapment During Vaginal Breech Delivery?

In Response: We appreciate the comments of Drs. Mercier and Benhamou about our case report. They correctly point out that in the discussion of possible uses of intravenous nitroglycerin the references for head entrapment were both reports of head entrapment with cesarean section. We regret this error. In the case of vaginal delivery, we are aware of at least one case in which intravenous nitroglycerin was used successfully (L. Kirz, Providence Hospital, Anchorage, AK, personal communication, 1992). In addition, we agree that smooth muscle is not the most important tissue of the cervix, and hence direct cervical relaxation with nitroglycerin is unlikely. On the other hand, we speculate that intravenous nitroglycerin may still be helpful in the case of vaginal head entrapment, because nitroglycerin relaxes the uterine wall and may relieve some pressure from the head entrapment. In addition, uterine relaxation may cause a change in the cervical architecture and thus indirectly dilate the cervix. Amr Abouleish, MD Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555-0591 Stephen Corn, MD Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Nitroglycerin for Fetal Head Entrapment During Vaginal Breech Delivery?

Nitroglycerin for Fetal Head Entrapment During Vaginal Breech Delivery?

Nitroglycerin for Fetal Head Entrapment During Vaginal Breech Delivery?

Nitroglycerin for Fetal Head Entrapment During Vaginal Breech Delivery?