Successful Cesarean Section Research Articles

Successful post-term pregnancy in scared bicornuate uterus: case report

Pregnancies in the bicornuate uterus are usually considered high-risk because of their association with poor reproductive outcomes such as recurrent pregnancy loss, cervical insufficiency, low birthweight, preterm birth, malpresentation, cesarean delivery, and uterine rupture. The objective of the report was to show that patients with a scared bicornuate uterus at post-term could have successful pregnancy outcomes. We are presenting a 28-year-old gravida III para II lady with a bicornuate scared uterus at post-term. She has a history of early third-trimester pregnancy loss, and her second pregnancy was delivered via cesarean section. In her first pregnancy, the patient's uterus was not identified as bicornuate. However, an ultrasound during her second pregnancy revealed that she had a bicornuate uterus, which led to the diagnosis. At term, the lady had a successful cesarean section. Lastly, for the current post-term pregnancy she had no prenatal check-up. Even though this, she was coming at the latent first stage of labor and an emergency cesarean section was done.Conclusion Successful outcomes could be achieved in patients with the bicornuate uterus at post-term gestation.

Neurosurgical emergencies during pregnancy - Management dilemmas.

Neurosurgical emergencies in the obstetric setting pose considerable challenges. Decision-making involves deliberations on the gestational age, critical nature of the illness, timing of surgery, maternal positioning during neurosurgery, anesthesiologic strategies, monitoring of the pregnancy during surgery, and the mode of delivery. The present study discusses the management and ethical dilemmas encountered during the management of six obstetric patients with neurosurgical emergencies. A retrospective review of all neurosurgical operations performed between January 2016 and December 2022 were included in the study. This study includes a series of six pregnant women who presented with neurosurgical emergencies, secondary to freshly diagnosed pathologies in the period 2016-2022. The mean maternal age was 31.33 years. Four of the six patients were in the third semester and two were in the second trimester. The underlying etiologies were as follows: spontaneous intracerebral hypertensive hemorrhage (1), obstructive hydrocephalus due to shunt malfunction (1), brain tumor (02), and compressive spinal cord myelopathy due to tumors (02). Three patients who were near term underwent lower cesarean section followed by emergency neurosurgical procedure in the same sitting. Two second trimester patients continued their pregnancy after the emergency neurosurgical operation. In one patient, in whom a brain tumor was diagnosed near term, underwent neurosurgery 1 week after successful cesarean section. All the six mothers and fetus recovered well, ex3cept two patients who have persisting residual deficits. Treatment of neurosurgical emergencies during pregnancy needs to be customized depending on the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. With careful planning, timely intervention, consultative decision making and it is possible to achieve the ultimate goal - which is to protect and safeguard the mother and preserve and deliver a viable fetus.

PS-BPR01-1: SUCCESSFUL TREATMENT WITH ESAXERENONE IN A PREGNANT WOMAN WITH PRIMARY ALDOSTERONISM AND SUPERIMPOSED PREECLAMPSIA

Background: During pregnancy, there is no established treatment for idiopathic hyperaldosteronism (IHA), the most common form of primary aldosteronism (PA) due to bilateral adrenal hyperplasia. Here, we report the case of a pregnant patient with IHA who was successfully treated with esaxerenone, a non-steroidal mineralocorticoid receptor (MR) antagonist. Case: A 39-year-old woman was referred to our outpatient clinic for hypertension with high plasma aldosterone concentration (PAC). Her PAC was 204 pg/mL (radioimmunoassay) and plasma renin activity was 1.2 ng/mL/h at the time of referral. She was diagnosed with PA since the saline-loading test for PA was positive. She had no hypokalemia and computed tomography scans showed no adrenal tumors. Adrenal vein sampling indicated overproduction of aldosterone in both adrenal glands leading to the diagnosis of IHA. She was commenced on nifedipine controlled release (CR) 20 mg daily because she desired to be pregnant. After one year, she became pregnant. Her blood pressure was well controlled until 34 weeks of gestation when her home blood pressure became elevated up to 140/90 mmHg. Although the dose of nifedipine CR was increased to 80 mg daily, her blood pressure increased to 151/97 mmHg and urinary test showed proteinuria of 2 + in 35 weeks of gestation. She was diagnosed with superimposed preeclampsia (SPE) and additionally treated with esaxerenone. Her blood pressure decreased to 120–140/98–100 mmHg and the proteinuria improved to +/-. A successful cesarean section at 37 weeks resulted in the delivery of a healthy baby boy. Esaxerenone was discontinued 2 weeks after delivery, because she was eager to breast-feed the baby and no safety data of esaxerenone in breast-feeding woman was available. Her blood pressure has been well controlled by nifedipine CR 80 mg daily even after 100 days of postpartum. Conclusions: This is the first case of a pregnant woman who was successfully treated with esaxerenone despite being an elderly pregnant woman who had been diagnosed with IHA and developed SPE. Further studies are needed to investigate the efficacy and safety of non-steroidal selective MR antagonist in similar pregnant patients with IHA, to establish better treatment strategy for these patients.

Staged treatment of abdominal sepsis in a puerpera with COVID-19 and pancreatonecrosis after cesarean section: case report

The aim of the study. Description of the medical history and discussion of treatment tactics in a puerperal woman after a caesarean section against the background of pancreatic necrosis, panmetritis, abdominal sepsis, COVID-19.Material and methods. A 30-year-old pregnant woman (30–31 weeks) was hospitalized in a perinatal center 5 days after the onset of girdle pain in the abdomen and uncontrollable vomiting, which did not bring relief. She had a history of caesarean sections 10 and 5 years ago. Sterile pancreatic necrosis was diagnosed. Successful caesarean section was performed. During the revision of the abdominal cavity, multiple plaques of fatty necrosis, omentobursitis were found in the upper abdomen. The treatment included pancreatic abdominization, cholecystostomy, abdominal drainage. Clinical roentgenologic examination and PCR-test verified COVID-19.Infected pancreatonecrosis developed, complicated with necrotic omentitis, abscess of the omental bursa (Enterococcus faccilis 107 CFU, Acinobacter baumani 106 CFU), abdominal sepsis, successfully treated. During vaginal examination, hemorrhagic discharge appeared (Klebsiella pneumoniae 105 CFU, Pseudomonas aeruginosa 105 CFU). Extirpation of the uterus revealed the defect of the anterior wall, thrombosis of the uterine arteries and veins, peripheral vessels. The patient recovered. The body build index was 26.03 kg/m2 at admission, 18.22 kg/m2 – at discharge, 23.61 kg/ m2 – 3 months later.Conclusion. 1. During the COVID-19 pandemic, pregnant women are often targeted by SARS-CoV-2. Prevention, diagnosis and treatment of coronavirus infection should be carried out according to the recommendations approved by the authorized health organ. 2. In the presented case report, the pathogenesis of complicated sterile pancreatonecrosis, cesarean section, abdominal sepsis were significantly influenced by changes due to organ ischemia in the result of peripheral vessels thrombosis. 3. The severity of the patient’s condition was certainly determined by the miscellaneous microbial profile – association of four agents of aggressive in-hospital infection in high concentration.

Use of a Combined Anaesthetic Technique and Minimally Invasive Hemodynamic Monitoring in a Primigravid with Uncorrected Tetralogy of Fallot for Caesarean Section

Tetralogy of Fallot (TOF) in pregnancy is a rare occurrence which poses a high risk for detrimental effects on bothmother and fetus. This paper reports a 21-year-old primigravid diagnosed with uncorrected TOF who had a successful caesarean section at 32 weeks of gestation. To address the hemodynamic challenges, the anaesthetic management involved the use of a minimally invasive hemodynamic monitor, controlled mechanical ventilation and a combined technique of intravenous anaesthesia using remifentanil and lumbar epidural anaesthesia using levobupivacaine.

Successful Pregnancy with HeartMate 3 (Abbott) Left Ventricular Assist Device

<h3>Introduction</h3> Left ventricular assist devices (LVADs) are an evolving therapy for patients with end-stage heart failure (HF). Due to high maternal and fetal risk from hemodynamic variation and need for anticoagulation, LVADs are a relative contraindication to pregnancy. Successful pregnancies have been observed with axial-flow LVADs as well as the continuous-flow HeartWareTM (Medtronic) LVAD, but the safety of the continuous-flow HeartMate 3TM (HM3) LVAD (Abbott) with pregnancy is unknown. Herein we present a case of a successful delivery in a patient with a HM3 LVAD. <h3>Case Report</h3> A 39-year-old female with peripartum cardiomyopathy underwent HM3 implantation as destination therapy due to severely elevated panel-reactive antibodies. She followed routinely with HF clinic. Two years after implantation, she presented to HF clinic at 15 weeks gestation despite oral birth control. She received counseling on the risk of pregnancy but opted against termination. Spironolactone was discontinued; all other medications (carvedilol, torsemide) were continued. She was anticoagulated with enoxaparin until imaging confirmed that she was no longer in the first trimester and then subsequently resumed warfarin. She underwent transthoracic echocardiogram-guided speed optimization at 20 weeks after her clinical exam demonstrated volume overload. LVAD speed was increased from 5500 to 5700 revolutions per minute. Serial obstetric sonography demonstrated normal fetal anatomy. Fetal echocardiogram and genetic screening were unremarkable. Maternal fetal medicine, anesthesia, and HF cardiology agreed on scheduled cesarean section with bilateral salpingectomy at 34 weeks gestation. At 33 weeks gestation, she switched back to enoxaparin from warfarin with her last dose timed for 24 hours prior to delivery. The patient underwent successful cesarean section with neuraxial anesthesia. During delivery, she was supported with low-dose phenylephrine with return-to-flows in the 80s. A healthy boy was delivered. <h3>Summary</h3> This case supports the notion that HM3 LVADs may provide adequate hemodynamic support during pregnancy and delivery. As previously shown, successful care of patients with LVADs during pregnancy requires a multidisciplinary approach to optimize the health and safety of mother and baby.

Outcomes of women with congenital heart disease admitted to acute-care hospitals for delivery in Japan: a retrospective cohort study using nationwide Japanese diagnosis procedure combination database

BackgroundThe number of women with congenital heart disease (CHD) who are of childbearing age is increasing due to advancements in medical management. Nonetheless, data on the outcomes of delivery in women with CHD remain limited. Therefore, we conducted a retrospective cohort study using a nationwide database of deliveries by women with CHD.MethodsDeliveries by women with CHD discharged from acute-care hospitals between April 2017 and March 2018 were identified based on the Diagnosis Procedure Combination database which covers almost all acute-care hospitals in Japan. By using this database, we tried to include relatively high-risk deliveries by women with CHD. Subjects were divided into three groups according to the underlying disease complexity: simple, moderate, and great complexity. The clinical characteristics and incidence of peripartum cardiovascular events were compared among the three groups.ResultsA total of 249 deliveries from 107 hospitals were included. The largest facility had 29 deliveries per year. Given the uncertainty of underlying cardiac anomalies, 48 women were excluded, and the remaining 201 women (median age, 32 years) were analyzed. In-hospital maternal death, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, pacemaker, and direct current cardioversion were not observed. Nine patients (4.5%) required intravenous diuretic administration. However, the difference in the frequency of diuretic use was not significant among the three groups (simple, 1.9%; moderate, 7.2%; great, 6.9%; P = 0.204). One participant required valve replacement surgery at 22 days after a successful cesarean section. As the disease complexity increased, deliveries occurred more frequently at university hospitals (simple, 41.7%; moderate, 52.2%; great, 72.4%; P = 0.013) and the length of hospitalization was significantly longer, with median durations of 9.0 (interquartile range [IQR] 7.0–11.0) days, 10.0 (IQR 8.0–24.0) days, and 11.0 (IQR 8.0–36.0) days in the simple, moderate, and great complexity groups, respectively (P = 0.002).ConclusionsAppropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.

Spontaneous Rupture of Spleen in a Pregnant Armenian Woman with Favourable Pregnancy Outcome: Case Report

Background: Spontaneous or traumatic rupture of spleen in pregnancy is a rare event with catastrophic consequences. This report presents a case of spontaneous splenic rupture of a pregnant woman with thrombophilia in complicated somatic history and successful cesarean section with maternal and infant survival. Case: A 28-year-old Armenian woman at 35 weeks of gestation presented to the Emergency Department at “Erebouni” medical center in Yerevan, Armenia with sharp pain in the epigastric region, general weakness and worsening condition. The patient was immediately transferred to the operating room. All clinical-laboratory examinations were urgently carried out, the fetus condition began to be assessed under the control of the CT. She was in obvious distress with blood pressure of 90/50 mm Hg and a pulse rate of 80 - 70 beats per minute. Abdominal ultrasound confirmed free fluid in the peritoneal cavity. Cesarean section was performed on the lower segment of the uterus. A live premature female infant was born weighing 2580 g, height 48 cm, and with an Apgar score of 7 - 8 points. Then the integrity of the uterus was restored. Abdominal rehabilitation was performed, there were about 1000 ml of blood loss and continuous internal bleeding. Doctors found splenic ruptures around the perineum. Lower middle laparotomy, splenectomy, abdominal rehabilitation, drainage were performed. Conclusion: This case illustrates the need to consider ruptured spleen as part of differential diagnosis of hemoperitoneum in pregnant women. Immediate surgical intervention is needed to ensure survival of mother and fetus.

Successful pregnancy and delivery in a woman with achondroplasia

Achondroplasia is a common form of dwarfism occurring in one out of 25,000 of live births. These patients present many problems during pregnancy and at the time of the delivery. The anaesthetist may also face several difficulties for both general and regional anaesthesia. The aim of this case report is to discuss various obstetric and anaesthetic considerations in such patients and ways to manage the difficulties. A 29-year-old woman expecting her first child, with achondroplasia -height of just 3'2'' (98 centimetres) - at 31 weeks of gestation, presented to our OPD for antenatal visit on May 15, 2018. Her successful elective lower segment caesarean section was performed on June 25, 2018 at 37 weeks in view of contracted pelvis under general anaesthesia. A live male baby was delivered, with no complications, good Apgar score and birth weight of 2.7kg. This shows that a woman with a genetic disorder like achondroplasia can become pregnant and deliver a healthy child at term.

Graves Disease: Successful Cesarean Section and Salpingectomy

Graves Disease: Successful Cesarean Section and Salpingectomy

Sudden cardiac arrest as a result of anterior and lateral myocardial infarction at 16 weeks of gestation - case report

Sudden cardiac arrest (SCA) is defined as a significant impairment of the mechanical function of the heart muscle, characterized by the patient's lack of response to stimuli, no perceptible pulse and apnea or agonal breathing, most often caused by acute coronary syndrome (ACS). ACS during pregnancy is a rare phenomenon and its incidence increases with the age of giving birth.The most common cause of ACS in pregnancy are typical changes in the etiology of atherosclerosis or coronary artery thrombosis. Other factors increasing the risk of a heart attack are arterial hypertension, diabetes, obesity and lipid disorders. To describe a rare clinical case and demonstrate the importance of maintaining cardiac vigilance in pregnant patients. A 32-year-old patient, at 16 weeks of gestation, hospitalized due to an anterior and lateral ST Elevation Myocardial Infarction (STEMI), complicated by SCA due to the mechanism of ventricular fibrillation. The patient was qualified for invasive reperfusion treatment which included left anterior descending (LAD) coronary artery surgery with drug eluting stent (DES) implantation and ballooning of the diagonal first coronary artery. Echocardiography done after treatment revealed apical hypokinesia and left ventricular ejection fraction of 70%. Subsequently the patient was kept under obstetrical and cardiological care. At 37 weeks of gestation, the pregnancy was finished by a successful caesarean section. Pregnancy is a state of hypercoagulability and decreased activity of the fibrinolytic system.The clinical management in this case does not differ from the clinical procedure adopted for non-pregnant women. It is important to make a diagnosis quickly and implement a life-saving procedure as soon as possible.

High dose and low dose oxytocin regimens as determinants of successful labor induction: a multicenter comparative study

BackgroundInduction of labor by Oxytocin is a routine obstetric procedure. However, little is known regarding the optimal dose of oxytocin so as to bring successful induction. This study was aimed at comparing the effects of high dose versus low dose oxytocin regimens on success of labor induction.MethodsHospital-based comparative cross-sectional study was conducted in four selected hospitals in Ethiopia prospectively from October 1, 2017 to May 30, 2018. A total of 216 pregnant women who undergo induction of labor at gestational age of 37 weeks and above were included. Data were entered into Epi-data version 3.1 and then exported to SPSS version 20 for cleaning and analysis. Chi-square test and logistic regression were done to look for determinants of successful induction. The result was presented using 95% confidence interval of crude and adjusted odds ratios. P-value < 0.05 was used to declare statistical significance.ResultThe mean “Induction to delivery time” was 5.9 h and 6.3 h for participants who received high dose Oxytocin and low dose Oxytocin respectively. Higher successful induction (72.2% versus 61.1%) and lower Cesarean Section rate (27.8% vs. 38.9) were observed among participants who received low dose Oxytocin compared to high dose. Favourable bishop score [AOR 4.0 95% CI 1.9, 8.5], elective induction [AOR 0.2 95% CI 0.1, 0.4], performing artificial rupture of membrane [AOR 10.1 95% CI 3.2, 32.2], neonatal birth weight of <4Kg [AOR 4.3, 95% CI 1.6, 11.6] and being parous [AOR 2.1 95% CI 1.1, 4.0] were significantly associated with success of induction.ConclusionsIn this study, Different oxytocin regimens didn’t show significant association with success of induction. But, high dose oxytocin regimen was significantly associated with slightly shorter induction to delivery time. Favourable bishop score, emergency induction, performing artificial rupture of membrane and delivery to non-macrosomic fetuses were positive determinants of successful induction. We recommend researchers to conduct multicenter research on a large number of patients that controls confounders to see the real effects of different oxytocin regimens on success of labor induction.

First reported caesarean section performed under light anaesthesia in a lowland tapir (Tapirus terrestris)

This is a case report describing a caesarean section in a lowland tapir (Tapirus terrestris), under field conditions, at a UK zoological collection. The procedure was performed through a left...

A Case of Successful Pregnancy in a Complete Bicornuate Uterus

Background & aim: Complete bicornuate uterus is a type of Mullerian duct deformity, resulting from abnormal duct fusion. Similar to other Mullerian anomalies, bicornuate uterus is associated with specific complications during possible pregnancies. While various studied have reported successful deliveries in a bicornuate uterus, it might be accompanied with various complications, ranging from preterm labor to more catastrophic outcomes such as uterine rupture. Case report: One of the current approaches to diagnosis this abnormality is ultrasound monitoring. In the present report, we presented a 25-years-old multiparous women with a history of abortion. The patient was not diagnosed with a complete bicornuate uterus in her first unsuccessful pregnancy. However, she was suspected with a complete bicornuate uterus based on the findings of ultrasound in the present pregnancy. A successful cesarean section was performed on the subject in the 39th week of gestation. Conclusion: According to the results, successful delivery could be achieved in patients with bicornuate uterous. Considering factors such as recurrent miscarriage, suspicious findings, and unreliable results of ultrasound, other diagnostic evaluations, including magnetic resonance imaging and hysterosalpingography, are recommended.

Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta

To determine the efficacy and safety of caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation (UAE) for the treatment of patients with placenta accreta. This retrospective study involved 42 patients with placenta accreta. All patients underwent caesarean section combined with temporary aortic balloon occlusion followed by UAE through the right femoral approach. All patients were confirmed to have placenta praevia and accreta, including five patients with placenta percreta, at the time of delivery. The technical success rate of the combined treatment was 97.6% (41/42). Forty-one patients underwent successful caesarean section with conservation of the uterus. Hysterectomy was required in one (3.1%) patient. The amount of blood loss and blood transfusion, and the operation time were was 586±355ml, 422±83ml and 65.5±10.6 minutes, respectively. The mean postoperative hospital stay, occlusion time and fetal radiation dose were 5.5±2.6 days, 22.4±7.2 minutes and 4.2±2.9mGy, respectively. There were no significant changes before and 7 days after the endovascular procedure in creatinine levels (56.8±13.8μmol/l versus 63.4±16.7μmol/l, p=0.09) or urea nitrogen (6.3±2.5μmol/l versus 7.4±3.8μmol/l, p=0.17). There were no access-site complications after the endovascular procedure and no complications related to the intervention during follow-up. Temporary aortic balloon occlusion followed by UAE can effectively control postpartum haemorrhage during placental dissection, and reduce transfusion requirements, hysterectomy rate, and operation time in patients with placenta accreta.

Use of intra-arterial nitroglycerin during uterine artery embolization for severe postpartum hemorrhage with uterine artery vasospasm

ObjectiveUterine artery embolization (UAE) is a standard method for treating postpartum hemorrhage (PPH), although uterine artery vasospasm during UAE may lead to failure of hemostasis. Here, we report our experience with a case of PPH in which the bleeding was successfully controlled by intra-arterial administration of nitroglycerin during the second UAE. Case reportA 30-year-old woman experienced PPH following a successful cesarean section, and a UAE was performed. However, 6 hours later, vaginal bleeding restarted; the reason for unsuccessful embolization during the first UAE was vasoconstriction due to hypovolemic shock. We performed a second UAE, but uterine bleeding continued. After intra-arterial administration of nitroglycerin, hemostasis was confirmed, and there was no reperfusion of the uterine artery. After these two UAE procedures, no recurrence of bleeding was observed. ConclusionThus, use of intra-arterial nitroglycerin was effective for controlling uterine artery vasospasm during UAE. However, larger studies are required to confirm these findings.

Can Sonographic Evaluation of Lower Uterine Segment Predict Women at Risk of Uterine Rupture / Dehiscence?

Introduction : Ultrasonography has been used to examine the scarred uterus in women who have had previous caesarean sections in an attempt to assess the risk of rupture of the scar during subsequent labour. This study aims to evaluate the usefulness of sonographic measurement of the lower uterine segment before labour in predicting the risk of intrapartum uterine rupture. Methods : This is a prospective cohort study. Eligible parturients were those with one previous caesarean section who meet the inclusion criteria and were booked for delivery at Irrua Specialist Teaching Hospital. 153 patients underwent transvaginal ultrasound examination at 35-37 weeks' gestation, and were allocated to four groups (≤2.5mm, 2.6-3.5mm, 3.6-4.5mm and ≥4.6mm) according to the thickness of the lower uterine segment. A systematic random sampling technique was used for patient selection. All labor was actively managed. Inclusion criteria included women with 1 previous transverse lower uterine segment caesarean section scar presenting in spontaneous labor, singleton fetus with vertex presentation, non-recurrent indications for previous caesarean section e.g. malpresentation such as breech presentation, fetal distress and an estimated fetal weight (EFW) of less than or equal to 3.8 kg. The exclusion criteria included Women with a previous history of uterine rupture, women with fetal macrosomia, placenta previa, multiple gestation as well as abnormalities in amniotic fluid volumes such as polyhydramnious or oligohydramnious, women with co-existing medical conditions like hypertensive disease in pregnancy, uncontrolled diabetes mellitus in pregnancy, and women whose previous caesarean section was complicated by wound sepsis or wound breakdown. Main Outcome Measure(s) : The primary outcome in this study was the association between echographic measurements of the LUS and the risk of intrapartum uterine rupture. The secondary outcomes were trial of labor outcome (successful VBAC versus repeat Cesarean section), and determination of clinical (obstetric) factors that could serve as predictors for uterine rupture or dehiscence. Results : The overall frequency of defective scar was 3.9% (2 ruptures, 4 dehiscences). The frequency of defects rose as the thickness of the lower uterine segment decreased: there were no defects among 49 women with measurements greater than 4.5 mm, 1 (1.4%) among 70 women with values of 3.6-4.5 mm, 2 (10%) among 20 women with values of 2.6-3.5 mm, and 3 (21.4%) among 14 women with values of 2.5 mm and below. With a cut-off value of 3.5 mm, the sensitivity of ultrasonographic measurement was 83.3%, the specificity was 80.3%, positive predictive value was 14.7%, and negative predictive value was 99.2% with an accuracy of 80.4%. Conclusion : The results from this study showed that the risk of a defective scar is directly related to the degree of thinning of the lower uterine segment at around 37 weeks of pregnancy. The high negative predictive value of the study may encourage obstetricians to offer a trial of labour to patients with a thickness value of 3.5 mm or greater.

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.

Anesthesia for a Cesarean Section in a Patient with a Congenital Heart Disease and Complete Placenta Previa

Pregnant patients with Congenital heart disease (CHD) make for a unique challenge to the obstetrician and anesthesiologist, when the patient has to undergo emergency cesarean section. Managing high-risk parturient requires a thorough understanding of the hemodynamic changes of pregnancy, its effect on the patient and physiology of the abnormal heart. Beyond this, our patient presented with placenta previa and vaginal bleeding. This combination of factors makes this case a worst-case scenario for any anesthesiologist. There is limited data in the literature on these combination factors. CHD is becoming the most common source of cardiac problems in pregnant patients but non-corrected cardiac defect patient are rare cases in the obstetric department. In adult population, chronic non-palliated congenital heart lesions present new difficult situations for the anesthesiologist working with high-risk obstetric anesthesia. This case report makes a successful cesarean section in a CHD patient in emergency condition. A 27 year old female from Rio de Janeiro, Brazil; Gravida 1, Para 0, at 30 weeks gestation age was admitted to Pedro Ernesto University Hospital (HUPE) high risk maternity ward in Rio de Janeiro, she had a history of endocarditis in 2005. The patient was diagnosed with a complete placenta previa and was admitted to have a scheduled cesarean section. At 31 weeks of gestation the patient presented vaginal bleeding, the probable diagnosis was of placenta previa bleeding and emergency cesarean section was indicated. The anesthesia technique was general anesthesia with inhaled and intravenous anesthetic agents in rapid sequence induction. The newborn was delivered quickly with APGAR score 8 after 5 minutes. Postoperatively, the patient was admitted to the intensive care unit (ICU) for close monitoring of vital signs and post-operative care. The case report will include details in pre-operative, peri-operative and post-operative outcome of the patient.

Use of left ventricle assist device in a pregnant woman with acute aortic and coronary dissections

We report the case of a 31-year-old female in her 32nd week of pregnancy, who experienced an acute type A aortic dissection resulting in severe aortic insufficiency, dissection of the left anterior descending coronary artery, and left ventricular infarct with ejection fraction of 20%. After a successful cesarean section, she underwent a Bentall operation and three-vessel coronary artery bypass grafting. Despite maximal inotropic support, her cardiovascular indices deteriorated postoperatively. On the first postoperative day she was started on mechanical circulatory support with the Levitronix CentriMag left ventricular assist device. Her myocardial function improved and she was successfully weaned from this mechanical support on post-implant day 14. She remains alive and well to date.