Successful Cesarean Delivery Research Articles

Acute Sheehan syndrome following massive postpartum hemorrhage due to vulvar hematoma

Acute Sheehan syndrome appearing within 6 weeks postpartum is a rare form of hypopituitarism caused by postpartum hemorrhage. A 37-year-old Japanese woman experienced a vulvar hematoma after spontaneous labor at 40 weeks gestation, leading to massive postpartum hemorrhage (estimated total blood loss of 3,000 mL). Despite successful cesarean delivery and hematoma drainage, she presented 28 days postpartum with anorexia, fatigue, and hyponatremia after initial recovery. MRI revealed a swollen pituitary gland with subacute hemorrhage, confirming the diagnosis. Hormonal replacement therapy with levothyroxine, hydrocortisone, estrogen, and progesterone was initiated. This is the first reported case of acute Sheehan syndrome following a vulvar hematoma, a condition typically not considered a risk factor for this syndrome. The case highlights the importance of considering rare complications like acute Sheehan syndrome in patients with massive postpartum hemorrhage, even when the pathogenesis is clinically common, such as vulvar hematomas.

Rhesus alloimmunization in pregnancy. A Tertiary Care Center Experience in Kenya. A Case Report

Background: Rhesus alloimmunization is a significant cause of perinatal morbidity in sub-SaharanAfrica.Case presentation: A 28-year-old para 2+2 gravida 5, rhesus-negative mother with no living childpresented to the Kenyatta National Hospital (KNH) antenatal clinic at 20 weeks of gestation as a referralbecause of a bad obstetric history secondary to rhesus D alloimmunization following a positive indirectCoombs test. She was started on methylprednisolone, and serial middle cerebral artery peak systolicvelocity (MCA-PSV) monitoring was performed until 32 weeks of gestation when the fetus developedhemolytic disease of the newborn diagnosed via cordocentesis. She underwent two sessions ofintrauterine transfusion and had a successful cesarean delivery at 34 weeks and 1 day of gestation. Theneonate was admitted to the KNH neonatal intensive care unit where he was managed for hemolyticdisease of the newborn, 33 days after which he was successfully discharged home.Conclusion: The role of maternal-fetal specialists in the diagnosis, antenatal follow-up, and timelymanagement of rhesus D alloimmunization is key in the prevention of adverse perinatal outcomes.

Anesthetic management of an emergency cesarean section in a parturient with inoperable paraganglioma: A challenging case report

Paraganglioma is a neuroendocrine tumor characterized by small organs comprising neuroendocrine cells that can produce catecholamines. Because of the nature of such tumors, hemodynamic instability can pose a management challenge. This condition can influence the provision of medical care across different clinical settings. The aim of this case report is to highlight anesthesia management in parturient patients with abdominopelvic paraganglioma, particularly during an emergency cesarean section. At 34 weeks of gestation, the 33-year-old female patient with three pregnancies and two past deliveries had a known case of inoperable large pelvic and lower abdominal retroperitoneal paraganglioma and poor radiotherapy response. The 15.5 × 4.2 × 22 cm tumor encased the aorta, inferior vena cava, and bilateral iliac vessels, compressing the lumbar vertebrae. The patient had an uneventful and successful cesarean delivery with a multidisciplinary team effort. Paragangliomas are rarely reported in a parturient and its optimization course. Despite being interrupted by an emergency cesarean section, which was handled safely and effectively, both mother and fetus had a safe delivery and postoperative recovery without complications.

Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS)

PurposeTo limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH).PatientA 37-year-old woman with uterovaginal agenesis due to Mayer–Rokitansky–Küster–Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy.MethodsTransplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage.ResultsTLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized.ConclusionsTo our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.

Spontaneously Conceived Quadruplet with Three Viable Babies & A Papyraceous Fetus: A Case Report

Background: High order multiple gestations are an uncommon occurrence. The incidence of multiple gestation continues to decrease as the number of fetuses increase as calculated using Hellin’s rule: incidence = 1:80n-1 births, where n is the number of fetuses. Thus, the expected incidence of quadruplets is estimated at 1 in 512,000 births. All these have changed with the advent of reproductive technology. However, the occurrence of quadruplets as a natural process has remained rare globally. Objective: To report a case of a successful spontaneously conceived quadruplet with the death of one of the fetuses and delivery of 3 live fetuses and a twin papyraceous fetus at the 36th week of gestation. Methods: We report a case of a 28-year-old para-2 woman who had a spontaneous conception resulting in a quadruplet. She had an ultrasound diagnosis of death of one of the fetuses at 25 weeks of gestation. She was admitted twice in the course of the pregnancy and subsequently delivered at the 35th week of gestation. Results: A successful caesarean delivery of 2 fem ales and 1 male with a male papyraceous fetus.

Anesthetic Considerations for Cesarean Delivery in a Parturient With Severe Gitelman Syndrome

Gitelman syndrome is an autosomal recessive inherited disorder that impairs the function of thiazide-sensitive sodium-chloride cotransporters in the distal convoluted tubule of the nephron. During labor and delivery, avoidance of sympathetic overactivity, meticulous hemodynamic monitoring, and expedited repletion of potassium and magnesium are required to avoid adverse outcomes. We present a parturient with severe Gitelman syndrome, requiring continuous electrolyte and fluid infusions, who underwent successful cesarean delivery. Potential severe morbidity was avoided with multidisciplinary planning and management.

Splenic artery aneurysms and extrahepatic portal hypertension during pregnancy

Clinical case demonstrates successful treatment of a pregnant woman, who had multiple giant splenic artery aneurysms with a high risk of spontaneous rupture. Pregnancy proceeded along with hereditary thrombophilia, thrombosis and cavernous transformation of the vena cava, extrahepatic portal hypertension, esophageal and gastric varices II–III. The surgical and obstetric tactics, surgical intervention, appropriate salvage and multidisciplinary pregnancy follow-up ensured a successful Cesarean delivery at 38 weeks, saving the life of the child and mother.

First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery

Uterus transplantation is the only known potential treatment for absolute uterine factor infertility. It offers a unique setting for the investigation of immunologic adaptations of pregnancy in the context of the pharmacologic-induced tolerance of solid organ transplants, thus providing valuable insights into the early maternal-fetal interface. Until recently, all live births resulting from uterus transplantation involved living donors, with only 1 prior birth from a deceased donor. The Cleveland Clinic clinical trial of uterus transplantation opened in 2015. In 2017, a 35 year old woman with congenital absence of the uterus was matched to a 24 year old parous deceased brain-dead donor. Transplantation of the uterus was performed with vaginal anastomosis and vascular anastomoses bilaterally from internal iliac vessels of the donor to the external iliac vessels of the recipient. Induction and maintenance immunosuppression were achieved and subsequently modified in anticipation of pregnancy 6 months after transplant. Prior to planned embryo transfer, ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, with histology interpreted as grade 3 rejection suspicious for an antibody-mediated component. Aggressive immunosuppressive regimen targeting both cellular and humoral rejection was initiated. After 3 months of treatment, there was no histologic evidence of rejection, and after 3 months from complete clearance of rejection, an uneventful embryo transfer was performed and a pregnancy was established. At 21 weeks, central placenta previa with accreta was diagnosed. A healthy neonate was delivered by cesarean hysterectomy at 34 weeks' gestation. In summary, this paper highlights the first live birth in North America resulting from a deceased donor uterus transplant. This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate. This is the first delivery from our ongoing clinical trial in uterus transplantation, including the first reported incidence of severe mixed cellular/humoral rejection as well as the first reported placenta accreta.

Conservative Management of Single-twin Death at 22 Weeks’ Gestation at A Tertiary Hospital in North-central Nigeria: A Case Report and Review of Literature

Background: Single-twin intrauterine death in the second and third trimesters poses a great concern and psychological stress to both the parents and the obstetrician. A multidisciplinary approach to conservative management is associated with improved perinatal outcome for the surviving twin. Case: We present a 30-year-old gravida 2 para 1 (1 alive). She had an emergency caesarean section during her first delivery. Having been referred from a military hospital, she presented at 22 weeks with single-twin intrauterine death. She was admitted and discharged after one week. Subsequently, she was managed conservatively and had weekly antenatal follow-up visits. She kept a daily fetal kick chart, had fortnightly ultrasound scans for fetal growth and wellbeing and weekly maternal clotting profile. At 37 weeks of gestation, she had a successful repeat caesarean delivery of a live, male neonate with a birth weight of 3.9kg and Apgar scores of 9 at one minute and 10 at five minutes. The remains of the dead co-twin (fetus papyraceus) were seen attached to the placenta. Follow-up by the neonatologist showed that his developmental milestones were normal and comparable to those of his singleton peers. Conclusion: The management of single-twin intrauterine death after the second trimester is psychologically tasking, requiring adequate counselling for the couple. The multidisciplinary approach, adopted in this study, improved perinatal outcome for the surviving co-twin after 15 weeks of conservative management. Prolonged paediatric follow-up of the survivor was imperative.

SUN-LB060 Paraganglioma in Pregnancy: Challenges to Treatment

Background: Paragangliomas are rare neuroendocrine tumors that arise from extra-adrenal chromaffin cells derived from the embryonic neural crest. Sympathetic paragangliomas secrete catecholamines and present with episodic hypertension and tachycardia. Paragangliomas in pregnancy are extremely rare. Here we describe a complicated case of a paraganglioma in pregnancy that highlights the special considerations taken during this state. Case Presentation: A 17-year-old pregnant female presented with chest pain and dyspnea on exertion at 32 weeks of gestation secondary to hypertensive urgency. Further history revealed several paternal family members with tumors and resistant hypertension. A work-up for secondary causes of hypertension was performed. Pertinent studies included plasma normetanephrines >50 nmol/L (0-0.89 nmol/L) and normal plasma metanephrines. Plasma fractionated catecholamines revealed a norepinephrine level of 18,977 pg/mL (85-1250 pg/mL), a dopamine level of 83 pg/mL (0-20 pg/mL), and a normal epinephrine level. MRI revealed an 8.0 cm hyperintense left infrarenal mass consistent with a paraganglioma. The patient was started on increasing doses of phenoxybenzamine followed by metoprolol to reduce her blood pressure and heart rate, keeping placental perfusion in mind. At 35 weeks of gestation she underwent successful cesarean delivery immediately followed by surgical resection of the tumor. Pathology revealed a 9.1 cm mass with nests of tumor cells, prominent vascularity, and foci of necrosis. A periaortic lymph node infiltrated by tumor indicated malignancy. Immunostaining was positive for neuron specific enolase, chromogranin, and synaptophysin. The patient briefly required vasopressors post-operatively, but she and the neonate recovered well with intensive monitoring. Genetic testing revealed a mutation in the succinate dehydrogenase B gene, increasing her risk for recurrent malignant paragangliomas and necessitating genetic testing of her child. Conclusions: Paragangliomas discovered during pregnancy are extraordinarily rare and present several challenges to management. While alpha and beta blockade should be initiated to correct volume depletion and avoid hemodynamic lability, caution must be taken to avoid excessive reductions in blood pressure and heart rate that may precipitate uteroplacental insufficiency and intrauterine growth restriction. Cesarean delivery is preferred over vaginal delivery to reduce the risk of precipitating hypertensive crisis. Furthermore, phenoxybenzamine crosses the placenta and neonates should be monitored in the NICU for hypotension in the first few days of life. Lastly, as approximately one quarter of all paragangliomas are associated with a genetic mutation, it is imperative to discuss genetic testing with the patient and the implications of a positive result for both the patient and offspring. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Management of a Pregnant Woman with Idiopathic Interstitial Pneumonia Accompanied by Secondary Pulmonary Hypertension: Case Report and Literature Review

Idiopathic interstitial pneumonias (IIPs) typically occur in the fifth and sixth decades, and thus are uncommon in the child-bearing age group. We herein report an extremely rare case of a pregnant woman with IIP accompanied by secondary pulmonary hypertension that had a successful cesarean delivery. A 36-year-old primigravida woman was referred to our Obstetrics department at 6 weeks of gestation. Seven years ago, she had a dry cough and moderate dyspnea, and was diagnosed with non-specific interstitial pneumonia (NSIP), a subtype of IIP. At 11 weeks of gestation, spirometry showed a vital capacity of 1.89 L (60% of predicted). An arterial blood gas analysis showed PaO2 of 77.2 mmHg and oxygen saturation of 95% in breathing room air at rest. An echocardiogram revealed mild pulmonary hypertension; systolic pulmonary artery blood pressure (PABP) of 44 mmHg. Fetal growth and amniotic fluid volume were normal. Our management plan was to maintain oxygen saturation at more than 95% of oxygen saturation and systolic PABP at less than 50 mmHg. Oxygen therapy was initiated at 13 weeks of gestation because of dyspnea at rest. At 28 weeks of gestation, an echocardiogram showed severe pulmonary hypertension with systolic PABP of 64 mmHg. Therefore, we performed cesarean section at 30 weeks of gestation. The newborn was a male weighing 1.452 g with Apgar scores of 6 and 7 at 1 min and 5 min, respectively. Although the patient’s post-operative course was uneventful, she was discharged on a regimen of oxygen therapy. The effects of pregnancy on IIPs remain unclear because of its extreme rarity. In the management of pregnant women with IIPs accompanied by secondary pulmonary hypertension, the maintenance of systolic PABP of less than 50 mmHg on an echocardiogram may be effective.

Double Invasive Blood Pressure Monitoring for Cesarean Delivery in a Pregnant Woman With Aortic Coarctation.

Aortic coarctation is a discrete narrowing of the proximal thoracic aorta. It is poorly tolerated during pregnancy because of its association with hypertension, cerebrovascular accident, and aortic rupture. We report a case of severe uncorrected congenital aortic coarctation in a 31-year-old symptomatic pregnant woman at 29 weeks of gestation who underwent successful cesarean delivery with an epidural anesthetic technique. Transthoracic echocardiography showed a gradient of 75 mm Hg. To avoid undiagnosed arterial hypotension and inadequate uteroplacental flow distal to the coarctation, double (radial and femoral) invasive arterial blood pressure measurement was used to monitor both pre- and postcoarctation arterial blood pressure.

Large parasagittal meningioma in a pregnant woman

Large parasagittal meningioma is rare in pregnant women. In this paper, we report the successful treatment of a pregnant woman with a large parasagittal meningioma. A 35-year-old woman in her 37th week of pregnancy presented with acute consciousness disturbances after experiencing headache and nausea for 2 weeks. We performed a successful cesarean delivery under general anesthesia, and immediately after the delivery, brain computed tomography was performed. The scan revealed a large tumor (8.3 × 6.8 × 7.1 cm3) in the left frontal region, thickening of the adjacent skull base, and perifocal edema. Twenty-four hours after the delivery, the patient underwent imaging studies, namely, magnetic resonance imaging and angiography. The parasagittal meningioma was removed through craniotomy, and the surgical outcome was highly satisfactory. Although meningioma is benign, the tumor mass can expand rapidly during pregnancy. In our patient, an early cesarean section was first performed for a successful delivery, and imaging studies and transarterial embolization of the tumor blood supply were performed prior to the second operation for craniotomy and total tumor excision. A multidisciplinary team was critical for successfully treating this patient.

Successful cesarean delivery following prenatal diagnosis of giant sacrococcygeal teratoma in the fetus

Introduction: sacrococcygeal teratomas are the most common germ cell neoplasia in the newborn, which are seen on the frontal surface of coccyx and sacrum. As a result of ultrasonographic developments in recent years, sacrococcygeal teratoma can be easily diagnosed in the prenatal period. case report: We report a case of a 29 -year-old patient with a singleton pregnancy of 38 weeks, with a giant sacrococcygeal teratoma of 20x18 cm in the sacrococcygeal zone. the infant was successfully delivered by classical cesarean section. conclusion: It is quite important to diagnose sacrococcygeal teratomas in the early weeks of pregnancy and to monitor prenatal management and prenatal complications to be able to determine the mode and place of delivery. When planning delivery, the least traumatic method should be preferred.

Successful Salvage Delivery and Liver Transplantation for Fulminant Hepatic Failure in a 34-Week Pregnant Woman: A Case Report

We report the case of a 40-year-old multiparous woman with fulminant hepatic failure due to acute hepatitis B virus infection who underwent a successful cesarean delivery of a healthy male fetus at 34 weeks, gestation and a few hours thereafter successful salvage orthotopic liver transplantation (OLT). There were no obstetric complications; the neonatal outcome was excellent. At 27 months, follow-up, the patient is doing well, and the newborn exhibits normal development. OLT for acute liver failure during pregnancy is an uncommon occurrence with variable outcomes. This case illustrates the challenge of treating this rare condition and demonstrates that a salvage double surgical approach-emergency delivery and OLT-is a feasible therapeutic option for treatment of these patients.

Stenting for infantile adult aortic coarctation with successful conception of zygomatic twins at 4 years’ post-intervention

INTRODUCTIONAortic coarctation is a congenital defect which rarely presents in adulthood but results in significant morbidity and mortality. Endovascular techniques present novel therapeutic options for managing this anomaly with comparable results to traditional open surgical repair. PRESENTATION OF CASEWe convey a case of postductal aortic coarctation in a symptomatic 31-year-old woman, undetected, despite 27 years history of congenital bicuspid valve with aortic incompetence. We staged a successful endovascular repair following presentation with hypertension, abdominal pain, and worsening lower limb claudication. This lady recovered well, eventually giving birth to twins after a successful caesarean section delivery. The anatomical, clinical and technical features of the case are appraised. DISCUSSIONAortic coarctation is classified anatomically as preductal (infantile) or postductal (adult) and the morphological spectrum of abnormality ranges from a discrete stenosis distal to the left subclavian to a hypoplastic transverse arch and aortic isthmus presenting in infancy. Its incidence is 0.2–0.6 per 100 live births. Traditional open surgical repair of aortic coarctation is associated with high morbidity and mortality. Advances in endovascular techniques with their associated shorter hospital time and lower costs, reduced short term morbidity and mortality mean that they are likely to become mainstays of treatment. CONCLUSIONThe presentation of aortic coarctation for the first time in an adult is extremely unusual. Error and delayed diagnosis can never be fully exempted in the practice of medicine even with the most advanced diagnostic tools. Follow-up is mandatory by trans-oesophageal echo in all endovascular patients.

The “Nested Suture” Technique for Achieving Hemostasis After Cold-Knife Conization of the Cervix During Pregnancy

Background: Cold-knife cervical conization performed during pregnancy is technically challenging and may be accompanied by a greater risk of severe hemorrhage than conization performed in a nonpregnant patient. A handful of techniques for cervical conization during pregnancy have been described in the literature, but no direct comparative data exist. Case: A surgical approach (called the “nested suture” technique) for achieving hemostasis during cold-knife conization of the cervix is described. The technique involves placement of circumferential U-sutures prior to excision of the cone biopsy specimen; the sutures are placed immediately cephalad to the apex of the planned biopsy and are tied down prior to excising the specimen. Use of this technique in a woman at 13 weeks' gestation resulted in minimal blood loss with no immediate or delayed postoperative complications; the patient underwent successful cesarean delivery at term. Conclusions: The “nested suture” technique offers another surgical approach for securing hemostasis at the specimen excision site in women who require cold-knife conization during pregnancy. (J GYNECOL SURG 27:193)

Intrathecal sufentanil decreases the median effective dose (ED50) of intrathecal hyperbaric ropivacaine for caesarean delivery

The addition of opioid to local anaesthetics has become a well-accepted practice of spinal anaesthesia for caesarean delivery. Successful caesarean delivery anaesthesia has been reported with the use of a low dose of intrathecal hyperbaric ropivacaine coadministered with sufentanil. This prospective, double-blinded study determined the median effective dose (ED50) of intrathecal hyperbaric ropivacaine with and without sufentanil for caesarean delivery, to quantify the sparing effect of sufentanil on the ED50 of intrathecal hyperbaric ropivacaine. Sixty-four parturients undergoing elective caesarean delivery with combined spinal-epidural anaesthesia were randomized into two groups: Group R (ropivacaine) and Group RS (ropivacaine plus sufentanil 5 microg). The initial dose of ropivacaine was 13 mg in Group R and 10 mg in Group RS. The effective dose was defined as a T(6) level attained within 10 min and no supplemental epidural anaesthetic required during surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the dose of ropivacaine for the next patient using an up-down sequential allocation. The ED50 of intrathecal ropivacaine was 11.2 mg [confidence interval (CI) 95%: 11.0-11.6] in Group R vs. 8.1 mg (CI 95%: 7.8-8.3) in Group RS. Motor block was markedly more intense in Group R than in Group RS, and the incidence of shivering was lower in Group RS than in Group R. There were no differences in the onset time of sensory block or motor block, in the incidence of hypotension, nausea and vomiting. Intrathecal sufentanil 5 microg produced a 28% reduction of ED50 of intrathecal hyperbaric ropivacaine for caesarean delivery.

Acute liver failure at 26 weeks' gestation in a patient with sickle cell disease

Orthotopic liver transplantation (OLT) for acute liver failure (ALF) during pregnancy is an uncommon occurrence with variable outcomes. In pregnancy-related liver failure, prompt diagnosis and immediate delivery are essential for a reversal of the underlying process and for maternal and fetal survival. In rare cases, the reason for ALF during pregnancy is either unknown or irreversible, and thus OLT may be necessary. This case demonstrates the development of cryptogenic ALF during the 26th week of pregnancy in a woman with sickle cell disease. She underwent successful cesarean delivery of a healthy male fetus at 27 weeks with concurrent OLT. This report provides a literature review of OLT in pregnancy and examines the common causes of ALF in the pregnant patient. On the basis of the management and outcome of our case and the literature review, we present an algorithm for the suggested management of ALF in pregnancy.

Anaesthetic management of a craniopagus conjoined twin delivery

We report the successful caesarean delivery of craniopagus conjoined twins in a 21-year-old using a neuraxial technique. Early diagnosis at 19 +5 weeks of gestation enabled thorough multidisciplinary antepartum planning. The multidisciplinary approach aimed to reduce maternal and fetal morbidity. Teams involved in the delivery included the specialities of obstetrics, neonatology, anaesthesia, paediatric neurosurgery and radiology. The delivery was complicated by an anterior placenta. The obstetricians used a J-shaped incision avoiding the placenta and making space for the fetal heads at delivery. Regional anaesthesia was used successfully in this case; although plans had been made should the mother need general anaesthesia intra-operatively. At delivery there were 17 members of the multidisciplinary team present in the operating theatre. They were from five specialities from two separate hospitals. We discuss the anaesthetic considerations for the delivery of conjoined twins and the multidisciplinary approach used in this case.