Low Vertical Incision Research Articles

Conservative Management of Placenta Accreta Using Helium Plasma Focused Radio Frequency Energy [11N

INTRODUCTION: Abnormal placentation, including placenta accreta, have been occurring at a higher incidence than before due to the increase in cesarean sections. The gold-standard treatment if uncontrolled bleeding occurs is peripartum hysterectomy, depriving woman of future fertility. The purpose of this case was to apply a conservative management by using a helium plasma device to fulgurate the placenta accreta at the uterine site. METHODS: Patient informed consent was obtained for submission of a case report. Cesarean delivery with low-vertical incision and manual extraction of the placenta was performed. The uterus was exteriorized and the helium plasma radio frequency (RF) device (J-Plasma system) was used to fulgurate the retained placental tissue, confirming hemostasis with a radius of 3 cm from the site. Hemabate was given to the site to maintain uterine contraction. RESULTS: The helium plasma device provided adequate hemostasis to the 12.76 cc of retained placenta accreta at 40% power 4 L/min gas flow, reducing lateral and depth damage of normal endometrial tissue. Quantitative blood loss was 560 cc. Obstetric hemorrhage and peripartum hysterectomy were avoided, allowing for future fertility. CONCLUSION: The helium plasma RF device provided a high-precision and efficient operative time in conservatively managing placenta accreta. This adds a safer alternative form of managing abnormal placentation and avoiding radical treatment. More research and trials should be done on larger placenta accreta and on other morbidly adherent placentas. It will be able to allow woman of high-risk to maintain their ability of reproducing in the future since a peripartum hysterectomy could be avoided.

Cirques in the Sierra de Guadarrama and7 Somosierra Mountains (Iberian Central System): Shape, size and controlling factors

The Guadarrama and Somosierra mountain ranges form the eastern sector of the Iberian Central System and hosted numerous glaciers during the Late Pleistocene (MIS2). Glaciation was of low intensity with glaciers of small sizes, strongly controlled by the climatic context and the topography. This study analyses the shape, size, distribution and location of 96 cirques existing in these mountain ranges. In addition to the standard morphometric parameters and controlling factors (altitude, aspect and lithology) used in most studies, additional factors were considered here in relation to the pre-glacial relief and fracture network. The data were obtained and processed using ArcGIS 10.4 and relations between the parameters and controlling factors were evaluated using statistical methods. The results indicate that most are simple cirques, tending to isometry, with low vertical incision capacity, considerable variation in size and predominantly east-facing. In the context of the Iberian Peninsula and other European mountains, these cirques are among the most isometric, the lowest in height and present the least overdeepening. The development of these cirques has generally been the result of random combination of various factors. Thus: (i) the largest cirques are located at intermediate altitudes, with the headwall located on the main divides, at former torrential valley heads or at the headwalls of fracture corridor valleys, and are north-facing; (ii) the longest cirques are located at former torrential valley heads, on metamorphic bedrock (i.e. schists, slates) and on uniform slopes. Finally, the prevailing eastern aspects are explained by topoclimatic factors and are in agreement with previous studies, which have proposed a Circulation Weather Type (CWT) model throughout the Iberian Peninsula during the Last Glacial Period, similar to its current configuration.

Classical Cesarean: What Are the Maternal and Infant Risks Compared With Low Transverse Cesarean in Preterm Birth, and Subsequent Uterine Rupture? A Systematic Review and Meta-analysis.

Classical cesarean section may be associated with increased short- and long-term risks. The objectives of this study were to review the following systematically: first, the short-term maternal and infant risks with preterm classical compared with low transverse cesarean sections; and second, the risk of spontaneous or early-labour uterine rupture. Medline, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from January 1980 to July 2018. A total of 772 studies were independently screened by two reviewers, and 91 full texts were reviewed. The review included nine studies comparing outcomes after preterm classical versus low transverse cesarean section and 15 studies addressing subsequent pregnancy outcomes. Our primary short-term outcomes were maternal death and intensive care unit (ICU) admission. For subsequent pregnancies, our primary outcome was the risk of spontaneous or early-labour uterine rupture. The data were synthesized using random effects, and odds ratios (ORs) and 95% confidence intervals (CIs) were generated. There were no significant differences between preterm classical and low transverse cesarean sections in the odds of maternal death (OR 2.38; 95% CI 0.15-38.07) or ICU admission (adjusted OR 2.38; 95% CI 0.42-13.35). A subgroup from 28 to 31 weeks gestation had increased risks of endometritis, transfusion, and ICU admission with the classical incision. The low vertical incision was associated with a lower odds of organ injury than was the low transverse incision. The incidence of uterine rupture following the classical incision without a trial of labour was 1%. Preterm classical cesarean section is not associated with significantly increased risks, but data are scarce. Subsequent uterine rupture risk when not planning a trial of labour is 1%.

Numerical simulations of bedrock valley evolution by meandering rivers with variable bank material

AbstractBedrock river valleys are fundamental components of many landscapes, and their morphologies—from slot canyons with incised meanders to wide valleys with strath terraces—may record environmental history. Several formation mechanisms for particular valley types have been proposed that involve changes in climatic and tectonic forcing, but the uniqueness of valley evolution pathways and the long‐term stability of valley morphology under constant forcing are unknown and are not predicted in existing numerical models for vertically incising rivers. Because rivers often migrate more rapidly through alluvium than through bedrock, we explore the hypothesis that the distribution of bank materials strongly influences river meandering kinematics and can explain the diversity of bedrock river valley morphology. Simulations using a numerical model of river meandering with vector‐based bank‐material tracking indicate that channel lateral erosion rate in sediment and bedrock, vertical erosion rate, and initial alluvial‐belt width explain first‐order differences in bedrock valley type; that bedrock‐bound channels can evolve under steady forcing from alluvial states; and that weak bedrock and low vertical incision rates favor wide, shallow valleys, while resistant bedrock and high vertical incision rates favor narrow, deep valleys. During vertical incision, sustained planation of the valley floor is favored when bedrock boundaries restrict channel migration to a zone of thin sediment fill. The inherent unsteadiness of river meandering in space and time is enhanced by evolving spatial contrasts in bank strength between sediment and bedrock and can account for several valley features—including strath terraces and underfit valleys—commonly ascribed to external drivers.

Uterine incision-to-delivery interval and perinatal outcomes in transverse versus vertical incisions in preterm cesarean deliveries

Objective: To compare the uterine incision-to-delivery interval and neonatal and maternal complications in vertical versus transverse uterine incisions in preterm cesarean births.Methods: This is a retrospective cohort study of singleton cesarean deliveries from 2002 to 2009 between 23 and 34 weeks of gestation. Statistical analysis utilized Wilcoxon rank-sum test and multivariable logistic regression.Results: Of the 773 singleton cesarean deliveries, 586 (75.8%) had a transverse uterine incision and 187 (24.2%) had vertical uterine incision (classical = 134 and low vertical incision = 53). After adjusting for confounders, there was no significant difference in incision-to-delivery interval between the two types of incisions. The risk for maternal transfusion was higher among those with a vertical incision (odds ratio: 2.17; 95% confidence interval: 1.00, 4.67) than those with a transverse incision. Incision type was not associated with any neonatal outcomes studied, including intraventricular hemorrhage, Apgar scores and neonatal mortality.Conclusion: We observed no difference in Uterine Incision-to-Delivery interval and neonatal complications between vertical and transverse incision. Performance of a vertical uterine incision for the sole reason of facilitating a more rapid delivery is not justified. Development of methods to better determine transverse incision feasibility may facilitate a decrease in vertical uterine incisions.

Sediment supply, base level, braiding, and bedrock river terrace formation: Arroyo Seco, California, USA

In many settings, rivers alternate between carving wide valley bottoms (straths) and cutting narrow gorges over time, thereby creating longitudinally continuous paired bedrock strath terraces along valleys. Strath terraces are used ubiquitously in geomorphology and tectonics; however, how and why they form remain poorly understood. Here, we focus on Arroyo Seco in the central California Coast Ranges, where we test hypotheses for strath planation and subsequent strath terrace formation. Several lines of evidence indicate that strath planation is triggered by braiding in bedrock channels. In particular, hydraulic modeling reveals that the width of Arroyo Seco’s most recently formed terrace is comparable to the width of currently braided channel reaches. Additionally, a comparison of currently braided reaches to abandoned bedrock meander cutoffs shows that braided channels have valleys that are several times wider than single-thread meandering bedrock channel reaches. Lastly, in locations where the modern channel is currently braided, terraces are poorly preserved, suggesting that evidence for past episodes of braiding, in the form of paired strath terraces, is apparently largely destroyed by subsequent episodes of braiding. Field observations combined with mapping of terrace levels using an objective light detection and ranging (LiDAR)–based terrace identification algorithm reveal that temporal variation in tectonic uplift rate, sea level, and/or alluvial cover along the river cannot explain strath planation and subsequent terrace formation in Arroyo Seco. Rather, our results provide evidence that aggradation and degradation of alluvial sediments downstream of the Reliz Canyon fault result in impulsive base-level forcing of Arroyo Seco’s bedrock channel. Strath abandonment and terrace formation apparently occur as incision into downstream alluvial sediments propagates upstream into bedrock. Braiding and planation of straths, in contrast, occur during intervals of low vertical incision rate associated with downstream aggradation or immediately following pulses of vertical lowering triggered by downstream incision of alluvial sediments.

Maternal and Perinatal Outcomes Associated With a Trial of Labor After Prior Cesarean Delivery

Fewer women today are attempting vaginal delivery after a previous cesarean delivery, mostly because of concern about its safety. This prospective cohort study, carried out at 19 academic medical centers, compared outcomes in 17,898 women with a history of cesarean section who attempted vaginal delivery and 15,801 others who had elective repeat cesarean section without labor. Women having a trial of labor were more likely than those having elective repeat cesarean delivery to be less than 30 years of age, black, unmarried, and nonobese. They also were likelier to have both preterm and delayed delivery. Vaginal delivery succeeded in 73.4% of women. The rate of symptomatic uterine rupture in women having a trial of labor was 0.7%. It was the same for those having a previous low transverse incision and 2.0% in those with a previous low vertical incision. Uterine rupture was associated with augmentation of labor using oxytocin and also with induction of labor by any method. Both endometritis and maternal blood transfusion were significantly more frequent with a trial of labor. Hysterectomy was performed in 88 women, in 41 after a trial of labor. The odds ratio for maternal adverse events in women having a trial of labor was 1.96 (95% confidence interval, 1.73–2.22) after adjusting for demographic differences and maternal diseases. Hypoxic–ischemic encephalopathy was significantly more frequent when women had a trial of labor at term than in the infants of women having elective repeat cesarean delivery. Both stillbirths and neonatal deaths were more frequent in the trial of labor group. There were no intrapartum fetal deaths. Adverse perinatal outcomes are more frequent when women with a history of cesarean delivery who undergo a trial of labor. Maternal adverse events also are increased. Although the degree of risk is small, it is important that both pregnant women and the healthcare providers who advise them be aware of the possible consequences.

Cesarean Breech Extraction For Impacted Fetal Head In Deep Pelvis After A Prolonged Obstructed Labour: A Cesarean Technique Variation

Objective: To evaluate the efficiency and safety of novel cesarean delivery technique for infants with a wedged fetal head in a deep pelvis. Methods: Cesarean delivery of infants with a wedged fetal head in the deep pelvis was performed on three women who had a trial of failed instrumental vaginal delivery. Cesarean section was carried out in a standard fashion up to uterine incision. Subsequently, a low-vertical was preferred and delivery of the infant with a fetal head impacted in the deep pelvis was conducted in a similar fashion that is employed for delivery of infants with breech presentation. Result: Three infants weighed 4600, 4700, 4200g were delivered in a good condition as reflected by operative delivery time and Apgar scores. Lower segment tears or unintended extension was not documented in any case and incisions were limited to the lower uterine segment in all three cases. Conclusion: Cesarean delivery of infants with a wedged fetal head in the deep pelvis may be readily achieved thorough the lowvertical incision in a similar way that is employed for cesarean delivery of infants with breech presentation

Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions

Objective: To determine whether gravidas with prior low vertical uterine incision(s) are at a higher risk for uterine rupture during a trial of labor after cesarean delivery than women with prior low transverse uterine incision(s). Methods: The medical records of women undergoing a trial of labor after prior cesarean delivery over a 12-year period (July 1984–June 1996) at a tertiary-care hospital were reviewed. Maternal and perinatal outcomes for women with prior low transverse and low vertical incision were compared. Women whose low vertical incision was noted to extend into the corpus of the uterus were excluded. All uterine scar disruptions, which included both symptomatic ruptures and detected asymptomatic dehiscences, were analyzed together, and ruptures were examined separately. Results: The outcomes of 2912 patients undergoing trial of labor for the low transverse group and 377 patients undergoing trial of labor for the low vertical group were compared. Overall, there were 38 (1.3%) scar disruptions in the low transverse group and six (1.6%) in the low vertical group, P = .6. There were 28 (1.0%) symptomatic ruptures in the low transverse group and 3 (0.8%) in the low vertical group, P > .999. The study had a power of 80% to detect an increase in the low vertical rupture rate from 1% (as noted for low transverse incisions) to 3%. Conclusion: Gravidas with a prior low vertical uterine incision are not at increased risk for uterine rupture during a trial of labor compared with women with a prior low transverse uterine incision.

Unknown uterine scar and trial of labor

A review of 393 patients undergoing trial of labor after one or more previous cesarean sections was performed. Three hundred patients had an unknown uterine scar, 88 patients had a documented low cervical transverse incision, and five patients had a prior low vertical incision. The rate of vaginal delivery and maternal and fetal morbidity was no different in those patients with an unknown prior uterine incision compared with those having a known prior low cervical transverse incision. In 66 of the patients with a documented low cervical transverse incision, the original operative record was reviewed in regard to single-layer closure of the uterine incision versus double-layer closure or imbricating technique. No patient with a double-layer uterine closure had a subsequent dehiscence, whereas three patients with a prior single-layer closure exhibited scar separation. These data suggest that neither an unknown scar nor a single-layer uterine closure places the mother or fetus at greater risk.

Low vertical uterine incision in caesarean section.

Eleven of the 3,420 Caesarean sections performed in Westmead Hospital, Sydney during a 6-year period from 1979 to 1985 were by a low vertical uterine incision. All the others were the standard transverse lower segment operation except for 1 which was a postmortem classical Caesarean section. There are indications when the preferred lower segment Caesarean section with a transverse incision should be avoided in the interest of the mother and baby. A low vertical incision has more advantages and less dangers than a classical fundal incision. It is prudent to defer the decision regarding the type of incision until the uterus is inspected intraoperatively. If access to the lower uterine segment is limited by prematurity, an obstructing lesion, a transverse lie, or if the presenting part is high and difficulty in delivering the baby is anticipated, a low vertical incision should be considered.

EVALUATION OF LEUCOTOMY RESULTS

Investigations of discharged cases after successful leucotomy resulted in the following findings: 1. The likelihood of a patient being discharged after leucotomy is greater if he is less than middle-aged; it does not depend on the preoperative duration of illness if the personality is preserved. 2. Discharge is also significantly higher when leucotomy is performed as a low vertical incision. 3. It is demonstrated that personality modifications can be better achieved by the orbital than by the other types of operative incisions. These personality changes are attributable to structural damages of the lower quadrants of the frontal lobes. 4. These postoperative personality changes are superimposed on the pre-existing symptomatology, and it was found that patients showing introversion, lack of initiative, shallowness of affects, etc., are more likely to respond favourably to the low vertical cut. 5. The reintegration between the pre- and postoperative symptomatology is a function of the total personality. Deteriorated patients are incapable of readjustment, and only cases with well-preserved personalities should be operated upon.