Obstetrics injuries during shoulder dystocia in a tertiary perinatal center.

OBJECTIVES: This study will present our results in management of fetal shoulder dystocia with special consideration of maternal and neonatal outcome. STUDY DESIGN: A retrospective study was performed at a university tertiary perinatal center. The study included data of singleton vaginal term deliveries in the period of 15 years (2006-2020). Analized informations include: obstetrics maternal and neonatal data and outcomes. RESULTS: This period included 45,687 deliveries with diagnosed shoulder dystocia in 254 (0.7 %) cases in vaginal deliveries. Most of the deliveries were spontaneous births 69.7 %, induced deliveries 30.3 %, 47.2 % primiparas and preexisting or gestational diabetes in 21.7 %. The delivery was managed by vacuum extraction in 13.8 %, mediolateral episiotomy in 48.0 % of births, most of the shoulder dystocia were unilateral anterior, while only two cases were diagnosed as more difficult bilateral and 5 cases were recurrent. 87.4 % cases were resolved by McRobert's maneuver, 7.8 % by Barnum's 3.9 % by Wood's maneuver and one case was managed by Menticoglou and by Bourgoise-Siegemundin maneuver. 4.3 % injuries were classified as OASIS of III/IV degree, early postpartum hemorrhage due in 1.6 %. 54.3 % of newborns were male sex, 61.0 % of newborns had birth weight of above 4000 g (mean 4071 g). Maximal Apgar scores were atributed to 92.5 % in first and to 97.2 % in fifth minute, one case that requaired resuscitation. Clavicle fracture was found in 9.5 %, humerus fracture in 0.4 %, transient form of Duchenne Erb obstetrics brachial palsy was diagnosed in only in 7.5 % newborns, while we have not found any case of permanent brachial palsy. CONCLUSIONS: Our results confirmed that strategy of prompt identification of shoulder dystocia accompanied by cessation of axial fetal head traction decrease the risk of brachial plexus strain, injury or tear, while performance of exact obstetrical maneuvers resulted in decanceration of fetal shoulders without permanent obstetrics brachial palsy or cerebral morbidity. We think that our good results corelate with our opinion that the performance of external obstetrical manoeuvres should be done without one minute postpone since efforts should be put in sooner shoulder liberation decreasing the time of fetal hypoxia.

Transvaginally surgically treatment of early postpartum hemorrhage caused by lower uterine segment atony.

OBJECTIVES: Prove the success of transvaginal hemostatic procedures in treatment of the early postpartum hemorrhage caused by lower uterine segment atony. METHODS: We have conducted a retrospective, clinical study during a 10-year period (2010-2019) in our institution that is tertiary perinatal university center. RESULTS: This particular study enrolled total number of 29,543 deliveries with 215 cases of early postpartum hemorrhage (0.72%). Lower uterine segment atony was diagnosed in 44 cases (29.93%) in all uterine atony cases of early postpartum hemorrhage. Hemostatic ligation procedures according to authors: Losickaja in two cases, Hebisch-Huch in 13 cases, Habek in seven cases, Hebisch-Huch + Losickaja in 10 cases. According to our results, hemostatic ligation procedures alone (32 cases; 72.72%) or combined with gauze or ballon tamponade (five cases, 11.36%), have shown to be highly effective in 37 cases (84.09%). CONCLUSIONS: Lower uterine segment atony should definitely be identified and understood as a clinical entity. Transvaginal hemostatic approach for surgical treatment of lower uterine segment atony is accessible, minimally invasive, feasible, successful and lifesaving. All of the above-mentioned methods are of great importance in the prevention and treatment of obstetric shock, multiorgan failure, postpartum hysterectomy and finally vital for fertility preservation.

Effects of lateral episiotomy on the emergence of urinary incontinence during the first postpartum year in primiparas: prospective cohort study.

AIM OF THE STUDY: Lateral episiotomy is a widely used procedure, although it is rarely mentioned in the literature and its effects on the pelvic floor are largely unexplored. The purpose of this study is to evaluate the impact of lateral episiotomy on the incidence of urinary incontinence (UI) after vaginal delivery in primiparas. MATERIAL AND METHODS: The study design is a prospective cohort study. The primiparas were divided into two groups. The first group consisted of women who gave birth with lateral episiotomy, while the second group included women who gave birth with an intact perineum or with perineal tears of first and second degree. Assessments of UI were performed at 5 and 8 months after childbirth using the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) questionnaire followed by the stress test. RESULTS: The results revealed no significant differences (p > 0.05) in emergence of stress urinary incontinence (SUI) between the groups at the two time points. There were no statistically significant differences in overall rate of UI, urge urinary incontinence (UUI), or mixed urinary incontinence according to the ICIQ-SF questionnaire. The overall incontinence rate on the first examination was 24% in the episiotomy group and 36% in the perineal laceration group, although the difference was not statistically significant (p = 0.064). On the second examination, rates were similar and without a statistically significant difference. CONCLUSIONS: Lateral episiotomy has a neutral effect on the onset of UI in primiparous women in the first year after delivery.

Acute Abdomen Syndrome Due To Spontaneous Intraperitoneal Bladder Rupture Following Vaginal Delivery.

We report a rare case of spontaneous intraperitoneal bladder rupture following normal vaginal delivery without concomitant uterine rupture. Key diagnostic clinical features were acute renal failure, new-onset ascites and bowel ileus with urosepsis. Laparotomy and bladder repair with omentum patch were performed with no adverse outcome reported.

Potential beneficial role of sevelamer hydrochloride in diabetic retinopathy.

Patients with chronic kidney disease (CKD) experience co-morbid illnesses, including cardiovascular disease and retinopathy. Sevelamer hydrochloride (Renagel®); a non-calcium phosphate binder reduces coronary artery and aortic calcification as compared to calcium containing phosphate binders and additionally effects inflammatory biomarkers such as C-reactive protein (CRP), and lowers LDL cholesterol in patients with CKD. Since retinopathy is proven to be associated with increased coronary calcification, shared pathophysiological processes may contribute to both microvascular and macrovascular disease. We here suggest three different mechanisms of possible sevelamer's influence on the retinopathy: (1) by direct effect on the microvasculature through lowering CRP and LDL, involved in endothelial dysfunction and atherogenesis, (2) indirectly by attenuation of vascular calcification of aorta and carotid internal artery, it reduces ischaemia and improves circulation in the opthalmic artery and hence postponing retinopathy, (3) through hypertension by reducing atherosclerosis and calcification of carotid arteries, sevelamer decreases stiffness and intima-media wall thickness, therefore lowering blood pressure, which is well known to increase progression of diabetic retinopathy. So far no studies have yet been published on the direct influence of sevelamer on the retinopathy which we believe has good theoretical background. With its combined macrovascular and microvascular effect, sevelamer could potentially postpone and/or decrease retinopathy in diabetic patients with hypertension, and that are on hemodialysis or even predialysis patients.

The antimetastatic effect of macrophages restored by indomethacin: concomitant tumor immunity model.

The role of macrophages acting as immunologic antitumor effectors and promoters of tumor growth are poorly understood as yet. We investigated the role of macrophage in model of concomitant immunity (CI), a phenomenon of secondary tumor rejection during the primary tumor growth. It has been shown that the period of CI weakening can coincide with appearance of tumor metastases. We used mammary carcinoma (MC) artificial lung metastases to evaluate the influence of macrophages from various period of CI on the development of metastases in mice. Our results indicated that macrophages are responsible for the late period of CI weakening and suppression. To investigate weather prostaglandins can mediate suppressive effect of macrophages we used experiments with indomethacin and we found that inhibition of prostaglandin E2 synthesis by indomethacin restored antimetastatic effect of concomitant immune macrophages.

Is hyperthyroidism underestimated in pregnancy and misdiagnosed as hyperemesis gravidarum?

Thyroid changes are considered to be normal events that happen as a large maternal multiorganic adjustment to pregnancy. However, hyperthyroidism occurs in pregnancy with clinical presentation similar to hyperemesis gravidarum (HG) and pregnancy itself. Moreover, 10% of women with HG will continue to have symptoms throughout the pregnancy suggesting that the underlying cause might not be elevation of human chorionic gonadotropin in the first trimester. Variable frequency of both hyperthyroidism and HG worldwide might suggest the puzzlement of inclusion criteria for both diagnoses enhanced by the alternation of thyroid hormone levels assessed in normal pregnancy. Increased number of hyperthyroidism among women population without the expected rise in gestational hyperthyroidism encouraged us for creating the hypotheses that hyperthyroidism could be underestimated in normal pregnancy and even misdiagnosed as HG. This hypothesis, if confirmed, might have beneficial clinical implications, such as better detection of hyperthyroidism in pregnancies, application of therapy when needed with the reduction of maternal or fetal consequences.

Pattern and prenatal diagnosis of skeletal dysplasias in Qatar population.

OBJECTIVE: To determine the pattern of skeletal dysplasias in Qatar population and to assess the accuracy of prenatal diagnosis and prognosis. METHODS: This was a retrospective descriptive study of 30 women with high risk for skeletal dysplasias. The recruited women were submitted to clinical assessment, ultrasound scanning using 2-dimensional, 3-dimensional/4-dimensional and colour Doppler technique with possible molecular diagnosis. The findings were compared with the postnatal or postmortem assessments. Final diagnosis was based on clinical examination, skeletal survey, autopsy and molecular testing as deemed necessary. RESULTS: Thirty cases of skeletal dysplasia were antenatally diagnosed over 4-year period with family history in few cases. Among many entities thanatophoric dysplasia showed largest prevalence [7(23%)]. Prenatal diagnosis was accurate in 76% of foetuses while the first indicator of abnormality was a suspected anomaly found during routine ultrasound assessment in most cases [17(56%)]. Prediction of lethality based on ultrasound findings was 100% accurate. CONCLUSIONS: This study confirmed the possibility of good prenatal diagnosis of skeletal dysplasias present among Qatar population. Diagnosis based on ultrasound assessment will improve by adding molecular techniques with positive impact on prenatal care.