Stepwise Devascularization Research Articles

Non-pneumatic anti-shock garment (NASG) and balloon tamponade decrease maternal mortality and morbidity from Obstetrics Haemorrhage: A prospective observational study

Obstetric haemorrhage is the leading cause of maternal mortality and morbidity worldwide. A prospective observational study was conducted among 132 women admitted, booked/referred, at tertiary care centre with Obstetric Haemorrhage for 2 years period. Of these 71 patients had received Non-pneumatic antishock garment and / or Uterine Balloon Tamponade (Group 1) and 61 didn’t receive any (Group 2). Both groups were observed for its outcome. The socio-demographic parameters and obstetric characteristics among both groups were comparable. However, there were differences in their outcomes and complications. Surgical interventions were more among group 2 as compared to group 1, B-lynch/Modified B-lynch (8.4% vs. 1.6%), Stepwise devascularisation (2.8% vs. 1.6%) and Obstetric hysterectomy (7.0% vs. 3.2%). There was significantly more blood loss in Group 2 than group 1. Duration of hospital stay was significantly shorter (9.8±2.7 days) in Group 1 as compared to Group 2 (12.7±3.6). The shock index after intervention was significantly smaller (0.7±0.1) in Group 1 in comparison to Group 2 (0.8±0.1) and Group 1 required significantly less number of blood and blood products as compared to group 2. 19.7% required ICU admission in group 1 and 24.6% in Group 2. There was no mortality in group 1 and 3 patients died in group 2. NASG and UBT is both life-saving and cost effective and can become the first defence against Obstetric Haemorrhage.

Caesarean Myomectomy: Safety and Feasibility of The Procedure

Introduction: Frequency of uterine myomas has increased these days with factors like delayed child bearing and IVF conception in elderly pregnant women. The vascularity of uterus increased and thus myomectomy during caesarean was considered a risk. With advanced surgical techniques the risk has become minimal these days. Case Report: 42 year G4P3L3 presented with 36 weeks gestation with USG s/o 3 large uterine fibroid, 2 subserosal fibroids with largest of size 7.1 x 6.3 x 7.2 cms, and 1 intramural fibroid. Emergency LSCS was done for her due to fetal indication. Due to emergency nature of surgery the option of preoperative uterine artery embolisation was not feasible and hence decision of stepwise de-vascularisation was taken. The de-vascularisation was done at the level of B/L uterine arteries, utero ovarian anastomosis bilaterally followed by removal of the three myomas. Discussion: Majority of myomas do not require surgical intervention during pregnancy or delivery. It has been repeatedly stated in the literature that routine myomectomy during cesarean section should be avoided and should only be carried out in carefully selected patients. In our case, stepwise devascularisation was required to control the bleeding. Proper devascularization and experienced obstetricians can reduce the incidence of haemorrhage and hysterectomy. The approximate blood loss was only 400 ml signifying the importance of this approach to myomectomy during caesarean section.

Stepwise Devascularization and Resection of the Placenta with Adherent Uterine Wall. A New Effective Applicable Technique to Preserve the Uterus in Morbidly Adherent Placenta: Case Series

Abstract Background: Morbidly adherent placenta is considered one of the most life-threatening obstetric complications and may cause severe intra operative bleeding requiring massive blood transfusion. The challenge is how to preserve the uterus with less complications? Aim of Study: This study aimed to present an alternative applicable surgical technique to save the uterus in cases with MAP by application of stepwise devascularization and resection of the placenta with adherent uterine wall. Material and Methods: It is a retrospective study in which 75 patients with morbidly adherent placenta, who delivered by cesarean section, were selected. Bilateral uterine artery ligation was done after downward dissection of the bladder, followed by upper uterine segment incision, downward step-wise clamping and resection of the whole lower uterine segment with adherent placenta till the cervix by vertical and transverse clamps. Finally reconstruction of the uterus was done. The amount of blood loss, operative time, post-operative hospital stay and operative complications were analyzed. Results: In all cases the placenta was adherent to the lower uterine segment and involving the posterior wall of the bladder in four cases. In all cases the mean estimated blood loss was 1156.3±403.2mL, the mean operative time was 76.3 ±24.5min, and the mean post-operative hospital stay was 3.8± 1.6 days. The four cases, in which the placenta was invading the bladder wall, underwent bladder repair due to bladder injury during dissection. In all cases, the uterus had been preserved. No other intra operative complications were reported. Conclusion: Stepwise devascularization and resection of the placenta with adherent uterine wall is an effective and applicable technique to preserve the uterus in patients with morbidly adherent placenta with excellent operative results, less blood loss, blood transfusion was needed in limited cases.

Emergency Peripartum Hysterectomy: Indications and Outcome in a Tertiary Care Setting.

Emergency Peripartum Hysterectomy (EPH) is an important lifesaving procedure, mostly reserved for conditions deemed to be serious and life threatening, and not amenable to conservative methods. In the present scenario, the advent of newer medical and conservative surgical methods for controlling obstetric haemorrhage has influenced the incidence, trend and the outcomes of the procedure. To evaluate the demographic profile, indications, operative details, maternal morbidity and mortality and neonatal outcomes of women undergoing EPH. A descriptive analysis of case records of women who underwent EPH between September 2006 to July 2014, at Guru Teg Bahadur Hospital Delhi, India was done. Data were collected from the medical records department. A total of 194 cases (n) were identified among 1,00712 deliveries, an incidence of 1.92 per 1000 deliveries. Majority of the women were unbooked i.e., they did not receive any form of antenatal care and were gravida 3 and above. The indications were atonic PPH in 89 (45.87%), rupture of unscarred uterus in 36 (18.56%), morbidly adhered placenta in 30 (15.46%), scar rupture in 20 (10.31%) and gangrenous uterus 19 (9.79%). The mean blood loss was around 1.6±0.45 litres. Approximately 14% cases underwent stepwise devascularisation prior to hysterectomy and in only 2% women, B-Lynch suture was applied. Thirteen (6.7%) cases had bladder injury and 22 (11.34%) needed re-laparotomy for hysterectomy. Around 76 (39%) women were shifted for ICU care. Nineteen (9.79%) women developed Disseminated Intravascular Coagulation (DIC). The case fatality rate was 7.2% and perinatal mortality was 30%. Atonic PPH remains the leading cause of EPH in our analysis. Surprisingly rupture of unscarred uterus was more common compared to scar rupture. Creating awareness among women to seek health services in time with facilities for early referral, teaching younger obstetricians with conservative surgical procedures like stepwise devascularisation steps and compressive sutures should be of utmost priority.

Uterine artery embolization versus surgical management in primary atonic postpartum hemorrhage: A randomized clinical trial

BackgroundPostpartum hemorrhage is the leading cause of severe maternal morbidity and death. A prompt management of uterine atony is life saving. Surgery can be needed in many cases. Uterine artery embolization (UAE) is a safe procedure and can be tried to be alternative to surgical approach. ObjectiveTo evaluate the clinical effectiveness and safety of uterine artery embolization (UAE) in comparison with stepwise devascularization and compression sutures in the treatment of postpartum hemorrhage (PPH). MethodsRandomized controlled parallel-group trial included twenty-three women with postpartum hemorrhage who were treated with either selective embolization of the uterine arteries or stepwise devascularization and compression sutures after failure of conservative measures. ResultsTechnical success was achieved in 9 patients (81.8%) of cases with complete cessation of the bleeding, while 2 cases (18.2%) suffered DIC and needed hysterectomy in the UAE group, while the other group (12 patients) had stepwise devascularization and compression sutures done after failure of the conservative measures, with 3 cases who needed hysterectomy after failure of these methods. ConclusionsUterine artery embolization is a safe, minimally invasive and effective method for treatment of postpartum hemorrhage and is alternative to surgical management.

Comparative Study of Cesarean Myomectomy with Abdominal Myomectomy in Terms of Blood Loss in Single Fibroid.

In this study, we evaluate the safety and feasibility of cesarean myomectomy and compare this procedure with abdominal myomectomy in single fibroid, in terms of blood loss and postoperative complications. Thirty-three patients who underwent cesarean myomectomy from June 2006 to 2012 in Amrita Institute of Medical Sciences, were included in the study. Almost an equal number of patients who underwent abdominal myomectomy (32) in the same period were included. Women are divided into two groups: group 1-cesarean myomectomy, group 2-abdominal myomectomy. Mean age of the women was comparable; mean gestational age in group 1 was 37.97+/-1.57weeks; and 60% were primiparous. Hemoglobin (Hb) drop postoperatively was compared between the groups, and there was no significant difference. Though there was statistically significant difference among the groups regarding the size of fibroids, the main outcome measure of the study, the Hb drop was comparable between group 1 and 2. There is statistically significant difference in the Hb difference with increasing mean diameter of the fibroids. As the size increases, Hb drop also increases indicating the increasing blood loss. The measures used to reduce blood loss such as vasopressin instillation and stepwise devascularization influence the blood loss, and P value shows borderline significance. There was no difference in Hb drop among the groups according to the type of fibroids. But more subserous fibroids were removed in group 1, whereas more intramural fibroids were removed in group 2. Cesarean myomectomy can be safely done in single fibroids and is comparable to abdominal myomectomy in terms of blood loss.

Uterine Necrosis following B-Lynch and Gunasheela's Global Stitch Sutures for Primary Postpartum Hemorrhage

ABSTRACTUterine atony causing postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Here by reporting a case of 22-year-old woman who underwent full-term vaginal delivery followed by atonic PPH, for which emergency laparotomy was done and stepwise devascularization along with B-Lynch and Gunasheela's global brace sutures over the uterus. On postoperative day 9, she developed features suggesting sepsis and magnetic resonance imaging (MRI) showed area of avascularity and features of abscess formation in the uterine wall. She underwent subtotal hysterectomy and histopathology showed uterine necrosis.How to cite this articlePunya BS, Sailakshmi MPA, Akash S, Nagarathnamma R. Uterine Necrosis following B-Lynch and Gunasheela's Global Stitch Sutures for Primary Postpartum Hemorrhage. J Med Sci 2015;1(2):38-40.

Caesarean Myomectomy : Feasibility and Safety = عملية إستئصال ورم الرحم العضلي أثناء إجراء العملية القيصرية : إمكانية إجراء العملية و السلامة

Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity. We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed. The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1-1.5 litres, 2 lost 1.5-2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients. In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons.