Uterine Incision Research Articles

Continuous local bupivacaine wound infusion with neuraxial morphine reduces opioid consumption after cesarean delivery

Background: As a part of a quality improvement program, maternal postoperative opioid use and pain scores were compared between those receiving continuous infusion of bupivacaine for local incisional pain control with multimodal pain management and neuraxial morphine versus multimodal pain management with neuraxial morphine alone.Objective: We compared postoperative opioid use and pain scores between the multimodal pain management group with neuraxial morphine and the group receiving multimodal pain management, neuraxial morphine, and continuous infusion of bupivacaine for local incisional pain control.Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of bupivacaine for local incisional pain control. For each postoperative day, the average daily opioid use, antiemetic use and pain scores were determined. Patients received 1–2 tablets oxycodone–acetaminophen (5–325 mg) every 4 h as needed with oxycodone 5–10 mg immediate release tablets every 4 h as needed for breakthrough pain in addition to acetaminophen and ibuprofen. Total dose of narcotic, antiemetic use, and pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of narcotic and pain scores from postoperative day 1 through day 4.Results: Patients in the standard multimodal group with neuraxial morphine used more opioids versus those receiving continuous wound infusion of bupivacaine in total postoperative dosing (122.79 ± 61.92 mg versus 89.88 ± 51.38 mg, p = .0063). There was a statistically significant difference between the standard group and local infusion of bupivacaine group on postoperative days 1 and 2 (32.79 ± 15.56 mg versus 22.13 ± 15.73 mg, p = .0011 and 40.25 ± 19.84 mg versus 29.13 ± 14.58 mg, p = .0018, respectively). There was no difference in narcotic use for postoperative days 3 and 4. There was a higher mean number of antiemetic doses in the standard group (0.31 ± 0.70 versus 0.10 ± 0.30, p = .0396). Pain scores did not differ between groups, although there was a correlation between opioid dosing and pain scores. The standard group received more IV ketorolac (87.72 ± 42.01 mg versus 64.50 ± 53.3 mg, p = .0165) and more IV acetaminophen (634.89 ± 706.42 mg versus 375.0 ± 490.29 mg, p = .0315) within the first 24 h postoperatively. In addition, the standard group received more oral acetaminophen (6969.67 ± 3230.14 mg versus 5248.75 ± 2711.71 mg, p = .0064). No difference was seen in regard to ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative opioid dosing, as well as differences in uterine incision type.Conclusion: We found a significant reduction in postoperative opioid use when continuous infusion of bupivacaine for local incisional pain control was added to our standard pain management with neuraxial morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal postoperative pain management strategy.

The effect of initiating intravenous oxytocin infusion before uterine incision on the blood loss during elective cesarean section: a randomized clinical trial

Objective: This study compares the effect of starting intravenous oxytocin infusion early before uterine incision versus late after umbilical cord clamping on the blood loss during elective cesarean section (CS).Methods: A single-blinded randomized clinical trial conducted on 200 pregnant women at term (>37 weeks) gestation scheduled for elective CS were assigned to either IV infusion of 30 IU of oxytocin started before uterine incision (Group I) or started immediately after clamping the umbilical cord (Group II). The primary outcome was the mean volume of blood loss during CS. The secondary outcomes included the mean volume of postoperative blood loss, the mean reduction in the hemoglobin and hematocrit levels, the need for additional uterotonics, blood transfusion and additional surgical procedures.Results: The baseline characteristics of both groups are quiet similar. No statistical significant difference between both groups as regard to pre- and postpartum hemoglobin levels (p = .06 and 0.24 respectively) and hematocrit values (p = .12 and .51 respectively). There was a significant reduction in the intraoperative blood loss in group I compared with group II (432.7 ± 90.6 versus 588.9 ± 96.3 mL respectively, p = .001). The need for additional uterotonics was more frequent in the group II (19 women) than in group I (seven women) with statistical significance (p = .002). No differences between both groups regarding the need for blood transfusion or additional surgical procedures.Conclusions: Initiating intravenous oxytocin infusion before uterine incision during elective CS could be associated with reduction in the intraoperative blood loss and the need for additional uterotonics.

Prior Cesarean Delivery Is a Challenge for Subsequent Birth Plans

Pregnant women with one or two prior cesarean deliveries with a low transverse uterine incision face the important decision of whether to attempt a

Outcomes of Women age 40 or More Undergoing Cesarean Delivery or Trial of Labor After Cesarean [19OP

INTRODUCTION: The purpose of this study was to evaluate United States maternal and neonatal outcomes in women age 40 or more undergoing cesarean delivery or trial of labor after cesarean delivery. METHODS: We conducted a secondary analysis using the MFMU Cesarean Registry database comparing women age 40 years or more at the time of delivery with those age less than 40 (control group). We excluded multiple gestations. Maternal and neonatal outcomes were compared and Poisson regression was used to adjust for confounders including race and type of delivery. RESULTS: A total of 67,389 women met inclusion criteria, of which 2,436 were age >40 year old and 65,403 were <40 at delivery. The >40 group had higher rate of PRBC transfusion (aRR 1.75; 95% CI 1.20–2.56), maternal ICU admission (aRR 2.02; 1.41–2.89), bowel injury (aRR 3.65; 1.43–9.31), placenta accreta (aRR 1.92; 1.09–3.38) and classical uterine incision (aRR 1.59; 1.43–9.31) compared to the control group. Maternal death rates were the same in both groups (P=.30). NICU admission and length of stay (LOS) was significantly higher in the >40 group compared to the control group (aRR 1.17; 1.09–1.25, LOS P=.005). Birth weight was significantly smaller in size of neonates born to women >40 group compared to the control group (3165 grams versus 3214 grams, P=.002). CONCLUSION: Women age 40 or more undergoing cesarean delivery or trial of labor after cesarean delivery are more likely to have maternal complications including intraoperative transfusion, maternal ICU admission, abnormal placentation and more complicated surgeries.

Influence of Blunt Versus Sharp Expansion of Uterine Incision on Degree of Intraoperative Blood Loss at Caesarean Section

Influence of Blunt Versus Sharp Expansion of Uterine Incision on Degree of Intraoperative Blood Loss at Caesarean Section

Evaluation of Patwardhan Technique in Second Stage Caesarean Section

Background: Caesarean sections done at full cervical dilatation with impacted fetal head are technically very difficult and are associated with increased incidence of maternal and fetal morbidities. The objective of this study was to compare the maternal and neonatal morbidities between the Patwardhan technique and the Push method for extraction of the fetus in second stage caesarean section. Methods: This is retrospective analysis of all caesarean sections done in the second stage at tertiary care centre at Dehradun, UK, India from 2014 to Dec 2016. Women with single fetus, with anterior vertex, at term with a deeply impacted fetal head into pelvis, in whom decision of caesarean section was already taken, were included in the study. Results: The patients were divided into two groups, Group 1 (study group) consists of all cases in which extraction of fetus was done by Patwardhan technique and group 2 (control) in whom extraction of fetus was done by push method and extracted as vertex. Complications like extension of the incision, injury to surrounding organs , PPH, need for blood transfusion and neonatal outcome in terms of weight , APGAR and NICU stay were compared in both groups Out of these 120 cases,56 belonged to group A .( Patwardhan) and 64 belonged to group B (push method ). Traumatic PPH and blood transfusions were significantly less in Patwardhan as compared to Push method (3%,16%,p=.0049). There were significantly less uterine incision extension seen in Patwardhan group as compared to Push method (5%, 22%, p=.0031).Baby outcome was almost similar in both the groups. While complications are inherent in both the techniques Patwardhan method has been shown to cover considerable advantage in prevention of maternal morbidities. Conclusions: Patwardhan is a useful manoeuvre in intra operative disengagement of fetal head in second stage CS and it should be learnt and practiced as the primary technique.

Effects of remifentanil and dexmedetomidine on the mother’s awareness and neonatal Apgar scores in caesarean section under general anaesthesia

ObjectiveThis study aimed to compare the effects of remifentanil and dexmedetomidine on awareness during the induction of general anaesthesia.Material and MethodsNinety patients scheduled for elective caesarean section under general anaesthesia were included and randomly divided into three anaesthesia groups: 2 mg/kg propofol (control group); 2 mg/kg propofol and 1 µg/kg dexmedetomidine (dexmedetomidine group); and 2 mg/kg propofol and 1 µg/kg remifentanil (remifentanil group). All patients received routine monitoring, and Apgar scores at 1 and 5 minutes were recorded. The bispectral index and the isolated forearm technique were used to determine the depth of anaesthesia.ResultsBispectral index values at skin and uterine incisions and at delivery were similar among the groups. The number of patients who responded positively to the isolated arm technique during the induction period was also similar. One-minute Apgar scores in the control group were significantly lower and 5-minute Apgar scores significantly higher than those in the other groups.ConclusionThe effects of remifentanil and dexmedetomidine added to propofol on maternal awareness, neonatal Apgar scores, and bispectral index values were similar compared with propofol alone. However, it was observed that remifentanil controlled the haemodynamic responses to sympathetic stimuli in a better manner than dexmedetomidine.

The Correlation between the Duration of Fetal Extraction during Cesarean Section and Development of Transient Tachypnea of the Newborn

AbstractBackground: Opted to assess the relation between each of the induction delivery time and the uterine incision delivery time during CD with the incidence of TTN.Study Design: A prospective cohort study.Patients and Methods: We included 100 pregnant women who were delivered by CS under spinal anesthesia, (completed 37 weeks), having singleton, non-anomalous fetus, at Kasr El-Aini Hospital, Cairo University, from May 2014 to Decem-ber 2014. Two time intervals (in seconds) were recorded: A) The induction delivery interval (from the start of induction of anesthesia till cord clamping=I-C interval), B) The uterine incision delivery interval (from the time of uterine incision till cord clamping=U-C interval). Neonatal parameters as regard; gender, weight, & 5 minute Apgar score were reportedas well as the development of TTN.Results: The reported I-C interval & U-C interval ranged between 335-999sec (mean ± SD; 696±129.7) & 23-66sec (mean ± SD; 48.7±14.32) respectively. The 5 minute Apgar score range was between 6 to 10 (median; 9) & the neonatal respiratory rate range was from 39/min to 66/min (median; 44). The 5 minute Apgar score did not show any correlation, neither with the different variables of the study, nor with the I-C & U-C intervals. Out of the 100 delivered neonates, 8 neonates (8%) developed TTN & were admitted to the NICU for further management. TTN development showed a signif-icant correlation with the Gestational Age (GA), otherwise, there had been no statistical correlation between the develop-ment of TTN and the duration of fetal extraction during CS.Conclusion: According to our finding TTN is not related to the length of the operative procedure till fetal delivery in cases under spinal anesthesia. We recommend the need of carrying on studies with larger populations, to offer the optimal time limit safe for fetal delivery and other possible risks for the development of TTN.

Cesarean Delivery in the Second Stage of Labor and the Risk of Subsequent Premature Birth

(Am J Obstet Gynecol. 2017;217(1):63.e1–63.e10) Cesarean delivery rates are on the rise in the United States, in part because of the increased use of cesarean delivery rather than forceps and vacuum deliveries for fetal distress and arrest disorders in the second stage of labor. However, cesarean delivery in the second stage of labor can be risky due to the difficulty of delivering a deeply impacted fetal head. Cohort studies have shown increased risk of extensions of the uterine incision, bladder injury, and postpartum hemorrhage in such deliveries. Surgical trauma to the cervix from other procedures has been demonstrated to significantly increase the risk of subsequent premature delivery. For these reasons, the authors hypothesized that second-stage cesarean deliveries may increase the rate of subsequent spontaneous preterm delivery.

Differences in outcomes between cesarean section in the second versus the first stages of labor

Objective: We aimed to compare maternal morbidity and mortality of cesarean sections (CS) in the second versus first stage of labor.Study design: Retrospective study of all CS at a single, university-affiliated medical center, between January 2010 and December 2014. Eligibility was limited to term, singleton pregnancies with cephalic presentation. Maternal outcomes of second-stage CS were compared to those of first-stage CS. The primary outcome was defined as estimated blood loss >1000 ml.Results: Overall, 1004 women met the inclusion criteria, of which 290 (29%) had a second-stage CS and 714 (71%) had a first-stage CS. Women in the second-stage CS group had a higher nulliparity and hypertensive disorders rates and a lower rate of previous CS. Second-stage CS was associated with more than double the rate of estimated blood loss >1000 ml (9.7% versus 3.8%, p<.001), and more prone to unintentional uterine incision extension, uterine atony, hemoglobin decrease >2 g/l and antibiotic treatment for suspected endometritis. In a multivariable logistic regression model, second-stage CS was found to be independently associated with unintentional uterine incision extension (OR 6.8, 95% CI 4.1–11.2), uterine atony (OR 3.3, 95% CI 1.4–8.0) and antibiotic treatment for suspected endometritis (OR 2.6, 95% CI 1.4–5.1), but not with excessive blood loss (OR 1.5, 95% CI 0.8–2.8). Additionally, failed assisted vaginal delivery prior to second-stage CS was not associated with a higher rate of complications.Conclusion: Second-stage CS is associated with higher rates of adverse maternal outcomes, mainly unintentional uterine incision extension, uterine atony, and suspected endometritis.

A randomized clinical trial of knotless barbed suture vs conventional suture for closure of the uterine incision at cesarean delivery

Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self-anchor, maintaining tissue approximation without the need for surgical knots. The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. This was a prospective, unblinded, randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included the number of additional hemostatic sutures needed and blood loss during incision closure. Patients were enrolled from August 2016 until March 2017. One hundred two women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesarean deliveries. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 minute 43 seconds (P < .001, 95% confidence interval, 67.69-138.47 seconds). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 vs 1, P < .001), and blood loss measured during incision closure was significantly lower (mean 221 mL vs 268 mL, P<.005). The use of a knotless barbed suture is a reasonable alternative to conventional sutures because it reduced the closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

Temporary Simultaneous 2 Arterial Occlusions during Laparoscopic Management for Cornual Ectopic Pregnancy

Study ObjectiveTo demonstrate a new technique of temporary simultaneous 2 arterial occlusions (TESTOs) of the uterine and ovarian (or utero-ovarian) artery to reduce operative blood loss during laparoscopic cornual resection for cornual ectopic pregnancy. DesignA step-by-step explanation of the surgical procedure using video (Canadian Task Force classification III). This study was approved by the institutional review board. SettingA university hospital. PatientsA 41-year-old woman presented with pelvic pain with 7 weeks of amenorrhea. A transvaginal sonogram and laboratory tests revealed left cornual pregnancy. She had a history of left salpingectomy caused by tubal pregnancy and wanted prompt surgical management without a surgical scar. InterventionsDuring the single-port laparoscopy, we found a 3-cm unruptured ectopic mass in the left uterine cornua. The retroperitoneum was opened using a harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) along the infundibulopelvic ligament. Then, both uterine arteries were temporarily occluded with a bulldog clamp (Aesculap, Tuttlingen, Germany) at the level where they originate from the internal iliac artery. The bulldog clamp, which is a spring-loaded crossover clamp with serrated blades that effectively occlude vessels without slippage or significant crush injury, is the laparoscopic instrument for minimizing blood loss during the surgical procedure. Each ovarian arterial vasculature was also transiently occluded at the utero-ovarian or ovarian pedicle by placing a bulldog clamp. Then, a uterine incision was made in the left cornua using a harmonic scalpel, the gestational conception was expressed through the incision, and corneal resection was completed. The uterine defect was closed using a V-Loc suture (Covidien, Mansfield, MA). In the final step, all vascular clamps were removed for reperfusion. Measurements and Main ResultsThe operative time was 45 minutes. The procedure time for TESTO and the occlusion time (defined as the time that the bilateral uterine and ovarian vessels were occluded by bulldog clamps) were 10 and 12 minutes, respectively. The estimated blood loss was 50 mL, and her postoperative hemoglobin was 11.9 g/dL from 13.0 g/dL preoperatively. No complications occurred in the postoperative course. Her menstruation resumed 2 months after surgery. ConclusionSurgical management of ectopic cornual pregnancy could be performed safely and efficiently under laparoscopy with the TESTO technique.

Complications and Outcomes of Pregnancy and Cesarean Delivery in Women With Neuropathic Bladder and Lower Urinary Tract Reconstruction

To determine the outcomes of pregnancy and cesarean delivery (CD) in women with neuropathic bladder (NB) and pediatric lower urinary tract reconstruction (LUTR) as these women often have normal fertility and may become pregnant. We reviewed consecutive patients with NB due to spinal dysraphism who underwent LUTR, became pregnant, and had a CD at our institution from July 2001 to June 2016. We collected data on demographics, hydronephrosis, symptomatic urinary tract infection, continence, and catheterization during pregnancy. CD data included gestational age, abdominal or uterine incisions, and complications. We identified 18 pregnancies in 11 women. Fifteen live newborns were delivered via CD (53.3% term births). Thirteen of 15 patients (86.7%) developed new (10) or worsening (3) hydronephrosis. Six of 13 patients (46.2%) underwent nephrostomy tube placement. Eight of 15 patients (53.3%) developed difficulty catheterizing (66.7% via native urethra, 44.4% via catheterizable channel); 50.0% of patients required an indwelling catheter. Five of 15 patients (33.3%) developed urinary incontinence during pregnancy. Ten of 15 patients (66.7%) had a urinary tract infection (30.0% febrile). A urologist was present for all CDs: 5 were scheduled, 10 occurred emergently. Complications occurred in 40.0% (5 cystotomies, 1 bowel deserosalization, 1 vaginal laceration). All cystotomies occurred during emergent CD. Three patients (20.0%) developed urinary fistulae after emergent CD. Women with NB and LUTR have high rates of complications during pregnancy and CD, despite routine involvement of urologists. Women with prolonged labor, previous CD, or those with a history of noncompliance developed the worst complications. Based on our experience, a urologist should always be present and participate in the CD.

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

Comparison of efficacy of different concentration of bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for postoperative pain relief in lower segment cesarean section

Large myomas as a complicating factor necessitating cesarean myomectomy followed by cesarean hysterectomy

Introduction. Although uterine myomas are becoming more common in pregnancies due to advanced maternal age, the literature lacks reports on complications, such as hysterectomy following cesarean myomectomy (CM). The aim of this work was to describe when CM is inevitable, complicated by severe intrapartum hemorrhage and requiring a hysterectomy. Case outline. A pregnant, with a term pregnancy and large multiple myomas, was referred for elective cesarean section (CS). During the CS, forced enucleation of a 100 mm anterior and left myoma previa (pre-fetal extraction) was necessary, and a 2,800 g neonate was delivered through the lower uterine segment incision. After the delivery and another CM, it was necessary to stop a massive hemorrhage from the myometrial myoma bed. Following provisory suturings of the hysterotomies, an urgent hysterectomy was performed with left salpingo-oophorectomy, due to a large hematoma in the left retroperitoneal space. The patient?s further recovery was uneventful and she was discharged with her baby on the sixth postoperative day. The histopathology report revealed a 135 ? 190 ? 150 mm uterus, weighing together with the enucleated myomas and left adnexa 5,000 g in total. The weight of the enucleated myomas was 1,670 g. The histopathological examination also showed 12 intramural and subserous myomas in the myometrium, ranging 30?190 mm. Conclusion. Large myomas, especially previa, may present a serious problem for fetal extraction during a CS. Therefore, the authors suggest an informed consent for CM, in patients who should undergo a CS. Additionally, such patients should be counseled about the possibility of an intrapartum hysterectomy.

32: Knotless barbed suture closure of the uterine incision at cesarean - a randomized controlled trial

Knotless barbed sutures are becoming increasingly available for surgical procedures in obstetrics and gynecology. Our purpose was to determine if the use of the knotless barbed suture reduces closure time of the uterine incision at cesarean delivery. This was a prospective randomized controlled trial. The primary outcome was closure time of the uterine incision. In order to show a decrease of 25% from 6 min to 4.5 min using the knotless barbed suture with a power of 0.9 and type 1 error of 5%, at least 34 women would be needed in each group. Women were randomized by sealed envelope to uterine closure with either a bidirectional knotless barbed suture or polyglactin 910 braided (conventional) suture. Secondary outcomes included blood loss during incision closure and the number of additional hemostatic sutures needed. Patients were enrolled from August 2016 until March 2017. 102 women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesareans. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 min 43 sec (P<0.000, 95% CI 67.69 - 138.47 sec). Blood loss estimated during incision closure was significantly lower (mean 221 ml versus 268 ml, P<0.005) and the use of hemostatic sutures was significantly less (median 0 versus 1, P<0.0001). The use of a knotless barbed suture significantly reduced closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

560: Uterine exteriorization versus intraperitoneal repair in primary and repeat cesarean section

Cesarean section is one of the most frequently performed surgical procedures, with increasing rate of recurrent operations worldwide. Different techniques have been practiced in order to reduce morbidity during and after caesarean section, among them the uterine incision repair. The aim of this study is to evaluate the effects of uterine exteriorization versus intraperitoneal repair, in first compared to recurrent caesarean section. A prospective randomized control single blinded trial conducted in a single tertiary center between January 2014 until march 2015, including 32 and 63 women in first and recurrent cesarean section, respectively. Inclusion criteria were elective operation and gestational age ≥37 weeks. Patients with abnormal placentation, chorioamnionitis, previous other abdominal surgery, past complication during first cesarean section on operation report, bleeding disorder, or urgent operation were excluded. Operative outcomes were compared between the groups including mean operative time, blood loss, hypotension, perioperative nausea and pain. Post operative outcomes were further compared, including post operative analgesia demand, first recognized bowel movement, nausea, length of hospital stay, fever, endometritis surgical site infection rate and total satisfaction. Sub-analysis was done in each group for the different techniques. 21(65.6%) and 48(76.2%) women matched the operation they were allocated in the first and recurrent cesarean section groups, respectively. Intraoperative nausea was found to be the only complication significantly higher in the recurrent cesarean section (n=17 ,40.4%) compared to first cesarean section (n=4 ,16.7%), in the uterine exteriorization group (p=0.046) .This difference was not demonstrated comparing uterine exteriorization to intraperitoneal repair in the recurrent cesarean section group (p=0.856). No other significant differences in either intraoperative or postoperative complications were demonstrated in and between the groups. Exteriorization of the uterus in recurrent cesarean section is associated with increased incidence of nausea. No other differences in operative and post operative complication rates were found between uterine exteriorization versus intraperitoneal repair comparing first to recurrent caesarean section.

Uterine Rupture Secondary to Placenta Percreta on Previa: A Case Report of Successful Management by Caesarian Hysterectomy

Background: Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall. Its incidence is growing due to the rising rate of cesarean sections and advanced maternal age on delivery. It is becoming the foremost cause of obstetric hemorrhage leading to significant maternal and fetal morbidity and even mortality. Rarely placenta accreta may lead to spontaneous uterine rupture in the second or third trimester. Case report: A 28-year-old woman gravida 4, para 3, was admitted at the maternity ward of Mendefera regional referral hospital, at a gestational age of 27 weeks due to vaginal bleeding. She had history of 3 time’s caesarian section. At admission her vital sign was stable and her complete blood count was normal, ultrasound showed anterior placentation with partial placenta previa. She was given Dexamethasone 6 gm. IM twice daily for 2 days to enhance lung maturity. At 36 weeks of gestation, she experienced massive vaginal bleeding. A decision was made to perform emergency cesarean section. The possibility of morbidly adherent placenta was considered. Intra-operatively, the placenta was found with engorged blood vessels under the rectus fascia with ruptured uterus and there was adhesion of rectus sheath with part of the uterus. A transverse uterine incision was made at the upper border of the placental attachment to uterus to deliver the fetus. After successful delivery of the fetus, the placenta was found to be densely adhered to the lower uterine segment, penetrating through it and adhered to the posterior wall of the urinary bladder. It was decided to do caesarian hysterectomy with the placenta left in situ. During discharge both the mother and the baby were in good condition. Conclusion: Placenta accreta is a potentially life-threatening obstetric condition that requires a meticulous approach to management. If a multiparous woman with a previous caesarian section is found to have placenta previa, the possibility of placenta accreta should be considered in the diagnosis of the patient. Grayscale ultrasonography is sufficient for the diagnosis of placenta accreta. The recommended management of placenta accreta is planned caesarian hysterectomy.

Laparoelytrotomy: An inadvertent complication of cesarean section in advanced labor

Laparoelytrotomy refers to the inadvertent delivery of the fetus through transverse incision over the vagina during a cesarean section. It is found to be associated with increased risk of maternal morbidity. Being an unintended, complication of cesarean section in advanced labor; it can be avoided by proper planning of the uterine incision. We report a case of inadvertent laparoelytrotomy during cesarean section for cephalopelvic disproportion in the second stage.

Pregnancy outcome in women presenting with obstructed labour at University Hospital of Sindh

Objective: To evaluate the frequency of early morbidity in women with obstructed labour and to analyze the factors leading to obstructed labour. Methodology: This hospital based retrospective study was conducted form 1st June 2014 to 30th November 2014 in the department of Gynecology & Obstetrics, Liaquat University Hospital, Jamshoro. All mothers who were admitted to the labour room during the period with obstructed labour were included in the study. Women with medical disorders, previous caesarean section and multiple pregnancies were excluded. The relevant information such as age, parity, antenatal care, causes, complications, treatment, maternal and neonatal outcome was collected. The statistical analysis was done in SPSS software version 17.0 Results: During the study period a total 1650 deliveries occurred at Liaquat University Hospital and 107(6.4%) presented with obstructed labour. Majority (91.7%) had taken trial of labour by some TBA or local doctor. Postpartum haemorrhage with atony of uterus occurred in 19(17.8%). The most common maternal morbidity was UTI 39(36.4%) followed by extension of uterine incision 27(25.2%), 17(15.9%) with ruptured uterus 7(6.5%) and with ruptured bladder Conclusion: Obstructed labour remains a major cause of maternal and prenatal morbidity and mortality in our part of world.