History Of Previous Cesarean Section Research Articles

Prophylactic bilateral internal iliac artery ligation for management of low-lying placenta accreta: a prospective study

Background Morbidly adherent placenta is one of the most feared complications causing high morbidity and mortality in obstetrics. Cesarean hysterectomy is still the main procedure in the current management of patients diagnosed with morbidly adherent placenta. Objective To evaluate the efficacy of prophylactic bilateral hypogastric arteries ligation on maternal outcome in diagnosed cases of morbidly adherent placenta. Design Prospective study. Setting Obstetrics and Gynecology Department, Mansoura University Hospital, Egypt. Methods This was a prospective cohort study of 51 pregnant women with a history of previous cesarean sections and diagnosed with low-lying abnormally adherent placenta. All patients underwent prophylactic internal iliac artery ligation after fetal delivery and before extraction of the placenta, the placenta was removed manually in a piecemeal manner and any remaining bleeding points from the placental site were then controlled by hemostatic sutures. Results Bilateral internal iliac artery ligation was performed in patients with invasive placenta (accreta and increta) (46/51 = 90.1%) and satisfactory hemostasis was achieved in 38 patients (38/46 = 82.6%). In five patients with placenta previa increta (5/17 = 29.4%), there was uncontrolled blood loss; thus, we proceeded to cesarean hysterectomy. The mean intraoperative blood loss was 1255 ± 589 ml. Blood transfusion was necessary in 35 patients (35/46 = 76%) during the operations. The mean hemoglobin and hematocrit 1 day after the operation were 9.8 ± 1.3 and 31.4 ± 2.3, respectively. Conclusion Prophylactic bilateral internal iliac artery ligation before extraction of placenta accrete seemed to be an effective technique to decrease cesarean complications and avoid emergent peripartum hysterectomy.

Assessing the Relative Contribution of Causes Leading toCesarean Section Among Women Who had Referred toShahidMadani Clinic in Marand City

Int J Women’s Health Reproduction Sci Vol. 2, No. 1, Winter 2014 ISSN 2330-4456 Assessing the Relative Contribution of Causes Leading to Cesarean Section Among Women Who had Referred to ShahidMadani Clinic in Marand City Zahra Ghanbari1, Rana Shokouhmand2, HakimehKhatoon Asadi2, Shirin Naghizadeh2, Fatemeh Chupani3 Abstract Objectives: Cesarean section is a surgical procedure and it is performed when the normal vaginal delivery is not available or vaginal delivery is dangerous for mother or fetus. In other words, there are some special indications for cesarean section. In the past decade the rate of cesarean delivery in the absence of clear indications has increased. This subject suggests an intensive research and attention. This study has compared the causes of cesarean delivery among women. Material and methods: 100 women who had referred to Shahid Madani Clinic in Marand city, were asked based on questionnaire that included information about patients and a list of causes that could lead women to a cesarean deli ery.Thereafter,the contribution of each cause was assessed. Results: Fear of labor pain is the most common cause of cesarean delivery (35%) while having history of previous caesarean section, fear of disturbing the anatomy of external genitalia , medical indication for caesarean section and cultural beliefescaused with lower rate in comparsion to fear of labor pain. were placed in lower classes. Conclusion: This study showed that, several factors may lead women to caesarean delivery; The fear of labor pain is the most common factor that could be reduced by proper training and holding childbirth preparation classes for pregnant women. 1-Faculty of Medical Sciences, Islamc Azad University Tabriz Branch, Iran. 2-Marand Health Network System, Tabriz University of Medical Sciences, Iran. 3-Faculty of Medicine, Department of Midwifery, Tabriz University of Medical Sciences, Iran. Article History: Received September 2013 Accepted October 2013 Available online January 2014 Corresponding Author: Zahra Ghanbari, General Physician, Islamic Azad University Tabriz Branch, Iran Tel: +989143057376 Email: dr_zahra2009@yahoo.com

Risk Factors Associated with Gestational Diabetes among Pregnant Women in Owerri Municipal Council, Southeastern Nigeria

Background Gestational diabetes is emerging as a serious public health problem in Nigeria where the largest number of people with diabetes in Africa occurs. Current studies in Nigeria give an overall prevalence of gestational diabetes as 13.4% among pregnant women with unidentified risk factors. Aims and Objectives This study aimed at investigating the risk factors associated with gestational diabetes. Materials and Methods A cross-section analytical study design was adopted for this research and comprising a total of 100 pregnant women receiving ante-natal health care service at the Federal Medical Center, Owerri. A structured questionnaire including a set of detailed pre-determined questions was administered on the subjects. Data collected were analyzed statistically, using chi-square and T test. Results The results obtained suggest that there is a significant relationship (p<0.05) between previous macrosomic baby, parity, previous history of caesarean section, family history of diabetes and occurrence of gestational diabetes, respectively. However, there is no significant relationship (p>0.05) between history of miscarriages and stillbirth, socioeconomic status and occurrence of gestational diabetes. A family history of diabetes is independently and significantly associated with the development of gestational diabetes itself even after adjusting for other risk factors. Conclusion This study will be a working tool to guide obstetricians and midwives in counseling and advising women of their risk of developing GDM. DOI: http://dx.doi.org/10.3126/ajms.v5i1.8302 Asian Journal of Medical Science Vol.5(1) 2014 pp.39-46

Hysterosalpingography (HSG) in secondary infertility or prior to assisted conception in women with a history of previous caesarian section: pictorial review and assessment of the significance of detected abnormalities

Purpose: To assess the frequency and demonstrate the range of potentially clinically significant abnormalities in women with a history of Caesarian section (C-section) undergoing HSG for investigation of secondary infertility or prior to assisted conception.

İkinci Trimester Gebelik Sonlandırmalarında Misoprostolün Etkinliğinin, Güvenilirliğinin ve Maliyetinin Değerlendirilmesi

Objective: The aim of the study was to evaluate the efficacy, safety, cost analysis and complications of the misoprostol protocol of our clinic (using intravaginal misoprostol after using oral misoprostol) in the second trimester termination of pregnancy. Methods: The study was designed in Gynecology & Obstetrics Clinic of Suleymaniye Maternity Training and Research Hospital, Istanbul between January 2010 and July 2011. Eighty patients, of whose pregnancies were terminated at 14-28 weeks of gestation, were retrospectively analyzed. The patients were separated into two groups as with and without a history of previous cesarean section. 200 mcg misoprostol was applied vaginally to the group without a history of previous cesarean section, and then 4 doses of 400 mcg misoprostol was applied orally every 4 hours. Patients with a prior cesarean delivery were administered 200 mcg misoprostol vaginally, and 200 mcg misoprostol was applied every 4 hours orally. Findings of the cases at 24th and 48th hours were recorded. The method was considered to fail in cases that birth does not happen after 48 hours. Results: Delivery/abortion was carried out in 85%of patients (68 cases) during the first 48 hours. The number of patients, who gave birth in the first 24 hours, was 43. The success rate in the first 24 hours was 53.75%. Ten out of 13 patients with a history of previous cesarean section had abortion in the first 48 hours. The success rate in the first 48 hours was 76.9%. Only 3 cases (3.75%) had fever and one case (1.25%) had cervical laceration. Conclusion: Our study shows that our misoprostol protocol which we used in the second trimester termination of pregnancy is safe, effective and acceptable in terms of cost. However, there is no consensus yet about the dose and the most effective application method of misoprostol.

Büyük Bir Fibroidin Kırmızı Dejenerasyonu İle İlişkili Uterus Rüptürü: Bir Olgu Sunumu

Introduction: The purpose of this case report is presentation of a ruptured fibroid with red degeneration during pregnancy. Case: A woman at 33 weeks of gestation was admitted to our clinic with the complaint of severe abdominal pain. The ultrasound examination revealed a large hypodense mass adjacent to the uterus. She had a history of previous cesarean section. Due to the presence of regular contractions and cervical dilatation, a cesarean section was performed. When the abdomen was explored; the placenta protruding from ruptured uterine fibroid was found. Peripartum hysterectomy was performed because of severe bleeding. Conclusion: Uterine fibroid rupture is a rare condition during pregnancy with high insidence of fetal and maternal morbidity.

Uterine Rupture - Experience of 30 Cases at Faridpur Medical College Hospital

Rupture uterus is a rare and often catastrophic condition. It is associated with a high incidence of fetal and maternal mortality and morbidity. Our objective in this study is to determine incidence, etiology, trend, management, maternal and fetal outcome of uterine rupture in Faridpur Medical College Hospital. This is a prospective cross-sectional study of patients with ruptured uterus from the period of January 2011 to December 2011 admitted at Faridpur Medical College Hospital. All the cases of ruptured uterus who were either admitted with uterine rupture or who developed it in hospital were included in the study. Patients having ruptured uterus due to congenital anomaly were excluded from the study. Patients were initially assessed in labour ward, relevant sociodemographic data, previous antenatal and surgical history recorded. Ways of management, maternal and fetal outcome were taken for analysis. There were 30 cases of ruptured uterus out of total 3606 deliveries (including 1809 caesarian sections) over a one year time period, with a prevalence of 0.83%. The most common age group was 21-30 years. A majority of patients 16(53.3%) were cases of unscarred uterus presenting with rupture; the common cause of rupture in scarred uterus was injudicious use of oxytocin (13,43.33%). Proper antenatal care, appropriate counseling of patients with history of previous caesarian section for hospital delivery, training of skilled birth attendant can reduce mortality and morbidity due to rupture uterus. DOI: http://dx.doi.org/10.3329/fmcj.v7i2.13504 Faridpur Med. Coll. J. 2012;7(2):79-81

Huge desmoid tumor of the anterior abdominal wall mimicking an intraabdominal mass in a postpartum woman: a case report

Desmoid tumors are benign neoplasms that most often arise from muscle aponeurosis and have been associated with both trauma and pregnancy. The etiology of desmoids has not been determined. We report the case of anterior abdominal wall desmoid tumor in a female patient with previous history of cesarean section. Preoperative ultrasound and computed tomography demonstrated a large mass mimicking a large hematoma or an intraabdominal mass. The tumor was removed by wide excision with safe margins. The abdominal wall defect was reconstructed with polypropylene mesh. Subsequent histology revealed a desmoid tumor. Desmoid tumors in females are often associated with pregnancy or occur post-partum. The reasons behind this association are unclear. The most common sites are in the abdominal muscles.

Cavernous lymphangiomas involving bilateral labia major after caesarian section

Sir, Cavernous lymphangioma is an extremely rare benign mass in the vulva. In this study, we report a case of cavernous lymphangiomas involving the bilateral labia major after caesarian section. A 31-year-old woman with a history of previous caesarian section, G2 L2 that was delivered by caesarian section seven months before, referred to Shahid Beheshti Hospital in 2011 with symmetrical vulvar lesion that was onset form five months ago. The lesion was a small red papule similar in appearance to nevus or angium in the bilateral labia major [Figure 1]. It was removed by punched biopsy. Physical examination was normal. She did not have any particular disease in the past, and no history of radiation therapy or any other pathology. Laboratory data was normal; histological diagnoses showed cavernous lymphangioma [Figure 2]. The management of these lesions depends on type, size, and anatomical location. Two cases of cavernous lymphangioma involving the unilateral labium majora in a young woman[1] and involving the bilateral labia minor were reported.[2] In previous studies, it was discussed that increase in estrogen and progesterone levels may play a role in cavernous lymphangioma; however, in this case it was seen that after caesarian section, estrogen and progesterone levels were decreased. Hence, it can be concluded that there are other factors that might affect this lesion. Further studies with more cases are required to make a fair conclusion. Figure 1 Histological examination of cavernous lymphangioma of labia majora. This section reveals cavernous vessels in the dermis that contain only lymph without any red blood cells Figure 2 Gross picture of bilateral cavernous lymphangioma of thein labia majora

Maternal Outcome in Emergency Peripartum Hysterectomy: Minimizing the Risks

ABSTRACT Objective To study the incidence, causes and maternal outcome in emergency peripartum hysterectomy. Materials and methods Retrospective, descriptive study of emergency peripartum hysterectomy by analyzing the labor records of patients undergoing the procedure in the past 5 years. Results There were 57 emergency hysterectomies among the 28940 deliveries, over the past 5 years. The incidence of EPH was 1.97 per 1000 deliveries. The mean age of the patients was 35.03 ± 5.9 (range: 21-47) years. Mean parity was 4.8 ± 2.8 (range: 0-13). Of 57 patients, 50 (87.7%) patients had previous history of cesarean section (CS). The main indications for hysterectomy were placental abnormalities 63.1% (OR = 1.54; 95% CI = 9.5-13.34, p-value <0.001) and uterine atony 24.5% (OR = 1.42; 95% CI = 7.43-15.43, p-value <0.001). Subtotal hysterectomy was performed in majority 50 (87.7%) of the cases. Bladder injury was the significant intraoperative complication in 17 (30%) cases (OR = 1.87; 95% CI = 9.45- 18.97, p-value <0.001) with no residual damage. Infections were the commonest complication seen in 15 (26%) patients postoperatively. The maternal mortality occurred in 2 (3.5%) patients. Conclusion Emergency peripartum hysterectomy, though uncommon, remains a challenging but life saving procedure in obstetrics. Its indications in modern obstetrics are changing and still emerging. Abnormal placentation, previous CS, multiparity are important risk factors. Antenatal diagnosis of low lying and adherent placenta, minimizing the CS rate, proper and timely management of third stage of labor and emergency preparedness are imperative to minimize the chances of emergency peripartum hysterectomy and improving the outcome. How to cite this article Zia S, Rafique M, Rizwan A, Khan T, Al-Shamrani A. Maternal Outcome in Emergency Peripartum Hysterectomy: Minimizing the Risks. J South Asian Feder Obst Gynae 2013;5(3):91-95.

Frequency of Smooth Muscle Tumors and Adenomyosis in Patient with Previous History of Cesarean Section and the Fate of the Cesarean Section Scar: A Long Term Follow-Up Study

Leiomyoma and adenomyosis are two common pathologic entities encountered in hysterectomy specimens. It is often speculated, but not confirmed, that repeated injury to uterine wall may initiate smooth muscle proliferation resulting in a smooth muscletumor. Similarly injury to the wall may lead to entrapment of endometrium in muscle layer leading to adenomyosis. To evaluate the above questions and assess the long term morphologic appearance of the C-section scar, 55 consecutive hysterectomies with previous history of C-section and 45 control cases were studied to evaluate the frequency of leiomyoma and adenomyosis. Our findings show no significant statistical difference in the frequency of such lesions between study and control groups in this series. Besides the scar formation, only rare instances of cystic change, osseous metaplasia and abnormal vasculature were noted at the site of C-section incision in the uterus.

162: Evaluation of the efficacy of the intrauterine balloon tamponade as a second-line procedure in the management of severe postpartum hemorrhage within a perinatal network

tamponade as a second-line procedure in the management of severe postpartum hemorrhage within a perinatal network Thomas Popowski, Pierre Raynal, Patrick Rozenberg Poissy Saint-Germain Hospital, Versailles Saint-Quentin-en-Yvelines University, research unit EA 7285, Department of Obstetrics and Gynecology, Poissy, France, Mignot Hospital, Department of Obstetrics and Gynecology, Le Chesnay, France OBJECTIVE: To evaluate the efficacy of the intrauterine balloon tamponade (IUBT) as the initial second-line procedure when medical management fails in the management of severe postpartum hemorrhage (PPH). STUDY DESIGN: We carried out a prospective cohort study within a perinatal network comprising 10 perinatal units managing around 20,000 deliveries per annum. The protocol for management of PPH followed the French national guidelines. In April 2008, the IUBT using Bakri balloon was introduce in the tertiary referral university hospital and the protocol was modified to require that an IUBT test be used before any invasive procedure in PPH unresponsive to prostaglandin. The modified protocol was progressively extended to the 9 other maternities. The tamponade test was considered successful if control was achieved following inflation of the balloon. RESULTS: Between April 2008 and June 2012, 166 IUBT tests were performed. The mean maternal age was 30.4 (SD 5.2) years, the mean gestational age 39.1 (SD 2.5) WG, and the mean parity 1.1 (SD 1.2). Nineteen (11.5%) patients had a previous history of cesarean section (CS), 25 (15.1%) a previous history of PPH, 14 (8.4%) were multiple pregnancies, and 8 (4.8%) presented a placenta previa. Among the 166 patients, the mean blood loss was 1484 (SD 602) mL, 105 (63.3%) patients had blood transfusion with a mean of 3.9 (SD 2.8) units of packed red blood cells. Among the 122 patients delivered vaginally, the IUBT failed in 17 (13.9%) patients leading to 11 embolizations, 2 conservative surgical procedures, and 4 hysterectomies. Among the 44 patients delivered by CS, the IUBT failed in 10 (22.7%) patients leading to 5 embolizations, 3 conservative surgical procedures, and 2 hysterectomies. The global success rate of the IUBT was 83.7%. CONCLUSION: In the setting of PPH unresponsive to medical management, IUBT should be used as the initial second-line procedure.

P30.11: Ultrasound assessment of cervical length in labour induction: prediction of maternal and perinatal outcome

To evaluate the usefulness of sonographic assessment of cervical length in the prediction of maternal and perinatal outcome at the beginning of labour induction. We performed a prospective cohort study of 165 inductions of labor. Indications of labor induction were prolonged pregnancy (53.9%), pre-eclampsia (13.3%), fetal growth restriction (10.9%), gestational diabetes (9.7%), and others (12.2%). When the Bishop score was below 6 at admission, cervical ripening with prostaglandins was performed. Membrane rupture and intravenous oxytocin was used in all cases. Maternal and perinatal variables were collected prospectively. Analisys was performed by logistic regression analysis and ROC curves. The rate of cesarean delivery after induction was 23.6%, 46.7% of patients were nulliparous, and 16.7% of patients had a history of previous cesarean section. Mean gestational age at the inclusion was 39.7(1.6) weeks. Ultrasound cervical length areas under the ROC curve for prediction of Cesarean section were 75% (95% CI 62–83%; P = 0.04), and for the prediction of severe maternal complication 83% (95% CI 74–92%; P = 0.007). Cervical length of 20 mm was the best cut-off for the prediction of cesarean after labor induction (92% sensitivity and 68% specificity). Patients with a cervical length < 20 mm at the beginning of labour induction had a lower rate of cesarean sections (10.7% vs. 33.7%; P = 0.018) (OR 0.19 (CI 95% 0.05–0.76; P = 0.02)) and cesarean section for failed induction (7.1% vs. 24.7%; P = 0.045) (OR 0.16 (CI 95% 0.03–0.75; P = 0.03)) and a trend to reduced neonatal admission rate (3.6% vs. 15.1%; P = 0.101), umbilical artery pH below 7.20 (7.4% vs. 17.4%; P = 0.184) and severe maternal complications (0% vs. 7%; P = 0.151). Ultrasonographic measurement of cervical length at labour induction admission predicts maternal and perinatal outcome and the risk of Cesarean section.

Rare coexistence of placenta previa accreta and peritoneal adhesion: three-decade clinical observation

Peritoneal adhesion makes abdominal surgery difficult. The recent increase in cesarean section (CS) is considered a main culprit for increase of placenta previa accreta (PPA) (accreta, increata, or percreta), which usually requires cesarean hysterectomy (CH). A recent article in this journal demonstrated that of 247 patients with placenta previa, 12 (4.9 %) required hysterectomy; 11 out of 12 had histologically confirmed placenta accreta [1]. We have devised some measures for CH [2, 3], which I have also described in this journal [2]. Briefly, we avoid administering uterotonic agents after infant delivery [2] and we employ ‘‘double distal edge pickup’’ mass ligation to ligate the medial side of the incised uterus [2]. If the placenta invades the bladder, we, without separating the bladder, intentionally cut the bladder wall and remove the uterus with the posterior bladder wall kept adhering to the uterus [3]. Even with these techniques, CH for PPA is always challenging. If peritoneal adhesion exists, it will make this difficult surgery more difficult. Laparotomy including CS sometimes leads to peritoneal adhesion, which makes next CS difficult. Since PPA usually occurs in patients with previous CS, it is likely that peritoneal adhesion and PPA tend to coexist. This is contrary to my observation derived from my three-decade tertiary obstetric center practice. My observation is that PPA does not, or at least rarely, accompanies peritoneal adhesion. Fortunately, no patients had severe adhesion requiring its adhesiolysis. This is in stark contrast to both previous data and our own data. Previous reports indicated that adhesion requiring surgical intervention such as adhesiolysis occurred in approximately one quarter (21-27 %) [4, 5] in repeat CS. I have performed approximately 40 CH for PPA during three decades, with almost all having a previous history of CS. Although the detailed surgical data have been missing during three decades and adhesion was not scored, the uterus could be easily exteriorized without adhesiolysis in all patients. This indicated that no PPA patients had adhesion of more than stage 3, with stage 4 being the full mark, according to the Myers and Bennett adhesion staging system [4]. Usually stage 3 and 4 adhesion are referred to as ‘‘clinically significant’’ adhesion [4]. Thus, whereas approximately one quarter of repeat CS patients had significant adhesion [4, 5], no PPA patients had it even though almost all had a previous CS history. I examined the surgical records of patients who underwent repeat CS without current PPA from July to December 2011 in this institute. Excluding the patients with the abdominal surgery history other than CS and those under steroid administration, 64 patients received repeat CS. Although its degree was not staged [4], peritoneal adhesion was present in 47 % (30/64), with 13 % (8/64) requiring surgical intervention. The mechanism for this observation is unclear; however, decreased wound healing may, at least partly, account for this phenomenon. Not well-healed CS scar leads to insufficient decidualization, which results in trophoblasts invading the uterine muscle layers, causing PPA [6]. Thus, decreased wound healing is considered to be a possible culprit for PPA. Wound healing consists of several steps: inflammatory cell mobilization to the site, fibroblast mobilization, and finally proliferation and regeneration of the corresponding tissue. Peritoneal adhesion formation S. Matsubara (&) Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

Treatment of unilateral fetal pleural effusion by intrauterine thoracocentesis

Fetal pleural effusion refers to an accumulation of fluid in the pleural space. It is most commonly attributed postnatally to chylothorax, a primary lymphatic abnormality. Following the diagnosis of pleural effusion, detailed investigation is essential to exclude other conditions (secondary pleural effusion). The natural history of the lesion is variable. The effusion may resolve spontaneously, remain stable or progress to hydrops and fetal or neonatal demise [1]. The treatment modalities include thoracocentesis, pleuro-amniotic shunting and pleurodesis. The optimal antenatal management is controversial [2,3]. We report a case of isolated pleural effusion diagnosed at 32 weeks of gestation that we successfully treated with thoracocentesis, resulting in a good outcome. The patient was a 30-year-old woman, G2P1A0, referred to our hospital for further management of fetal right pleural effusion at 32 weeks’ gestation. According to the referral information, the pregnancy had been unremarkable until 32 weeks’ gestation. She had not had any illness or recent infectious disease, had not been exposed to teratogenic agents during the pregnancy, and did not have a family history of congenital anomalies. The Down syndrome screen during her second trimester was negative. She had a history of previous cesarean section as a result of preeclampsia and fetal distress. Sonography demonstrated fetal right pleural effusion (Fig. 1). The right lung was compressed and displaced slightly to the midline. There was no evidence of pericardial effusion or gross cardiac defect. There was no other fetal anomaly detectable during the detailed ultrasound examination. One week after the initial visit to our hospital, an increase in the volume of the fetal right pleural effusion occurred. Transabdominal fetal thoracocentesis at 33 2/7 weeks’ gestation was suggested and the patient consented to undergo the procedure. Using a 22-gauge needle and sonographic guidance, 70 mL yellow fluid was removed from the right fetal

Factors associated with complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy

To identify risk factors for complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy (LAVH). Retrospective study. Tertiary referral hospital. All 2012 consecutive women who underwent LAVH for non-malignant diseases in a single institution. Retrospective study. Operative complications and conversion to laparotomy. Most of the LAVHs were successful, but conversion to laparotomy was required in 97 women (4.8%) because of pelvic adhesion (n= 71), large uterine size (n= 18) or bowel injury (n= 8). There were 45 women (2.2%) with complications (bladder injury, 26; bowel injury, 9; vascular injury, 9; and ureteral injury, 1). A history of previous cesarean section (twice or more) was a significant risk factor for complications [odds ratio (OR) 3.38]. A body mass index ≥30 kg/m(2) (OR 2.98), history of previous myomectomy (OR 6.19) and uterine weight ≥500 g (OR 3.24) independently influenced the risk of conversion to laparotomy. Risk factors identified in this study include a history of previous cesarean section (twice or more) and myomectomy, body mass index ≥30 kg/m(2) and uterine weight ≥500 g. The findings may be useful in counseling women preoperatively about the potential complications of LAVH.

Trial of vaginal delivery after caesarean section, the present and the future after adoption of the new nice guidelines

Introductiontrial of vaginal birth after caesarean section (VBAC) offers women with history of previous caesarean section the chance of a vaginal delivery with its associated lower risk of morbidity. Recently...

Placenta accreta: Pathogenesis of a 20th century iatrogenic uterine disease

Placenta accreta refers to different grades of abnormal placental attachment to the uterine wall, which are characterised by invasion of trophoblast into the myometrium. Placenta accreta has only been described and studied by pathologists for less than a century. The fact that the first detailed description of a placenta accreta happened within a couple of decades of major changes in the caesarean surgical techniques is highly suggestive of a direct relationship between prior uterine surgery and abnormal placenta adherence. Several concepts have been proposed to explain the abnormal placentation in placenta accreta including a primary defect of the trophoblast function, a secondary basalis defect due to a failure of normal decidualization and more recently an abnormal vascularisation and tissue oxygenation of the scar area. The vast majority of placenta accreta are found in women presenting with a previous history of caesarean section and a placenta praevia. Recent epidemiological studies have also found that the strongest risk factor for placenta praevia is a prior caesarean section suggesting that a failure of decidualization in the area of a previous uterine scar can have an impact on both implantation and placentation. Ultrasound studies of uterine caesarean section scar have shown that large and deep myometrial defects are often associated with absence of re-epithelialisation of the scar area. These findings support the concept of a primary deciduo-myometrium defect in placenta accreta, exposing the myometrium and its vasculature below the junctional zone to the migrating trophoblast. The loss of this normal plane of cleavage and the excessive vascular remodelling of the radial and arcuate arteries can explain the in-vivo findings and the clinical consequence of placenta accreta. Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.

Obstetrics and Gynaecology: Conservative Management of Cervical Pregnancy: A Case Report

Cervical pregnancy is a rare form of ectopic pregnancy, which accounts for less than 1% of all ectopic pregnancies. This case has been reported because of its rarity and successful treatment by methotrexate injection alone, in early viable pregnancy. A 25 year old G3P1L1E1 with history of previous caesarean section and previous abdominal pregnancy, presented with complaints of bleeding per vaginum for 10 days, after 7weeks of amenorrhoea. Transvaginal sonogram showed – single live intrauterine gestational sac with live fetal pole of CRL7.2mm in the cervical stroma, with surrounding increased vascularity. Her Beta-HCG was 53,280mIU/ml. Inj. Methotrexate 70mg i.m was given on Day1,3,5,7 and Inj. Folinic acid 7mg on Day2,4,6,8. Transvaginal ultrasound after 5days showed decrease in vascularity . Ultrasound after 1 week of treatment showed normal uterus and cervix. Beta HCG was 2300mIU/ml. Patient was on follow up with weekly serum beta-HCG. After seven weeks her Beta HCG became normal. Though studies have shown unsatisfactory results using methotrexate for Beta-HCG more than 10,000mIU/ml and cardiac activity is present, in our case we considered methotrexate, because vascularity will be reduced and bleeding will be less when we add other adjuvant conservative procedures. There are also studies showing treatment with methotrexate in viable cervical pregnancy less than12 weeks gestation carrying a high success rate. As with increasing caesarean section and artificial reproductive technique, there is increase in cervical pregnancy, a life threatening event. Early diagnosis allows early intervention and increases the likelihood of successful conservative treatment,there by preserving patient’s fertility. Methotrexate multidose regime as a conservative treatment is found out to be highly successful in viable cervical pregnancy.

Induction of labour audit – barnsley district general hospital

Induction of labour is a common procedure in the UK. Induction has a significant impact on the birth experience of women. It also places a strain on labour wards hence...