Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation.

BACKGROUND: Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes. METHODS: This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes. RESULTS: Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001. CONCLUSIONS: Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review.

BACKGROUND: Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital. CASE PRESENTATION: A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications. CONCLUSIONS: The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.

Modified one-step conservative uterine surgery (MOSCUS) versus cesarean hysterectomy in the management of placenta accreta spectrum: A single-center retrospective analysis based on 619 Vietnamese pregnant women.

OBJECTIVES: To compare maternal outcome measures in surgical management of placenta accreta spectrum (PAS)-the modified one-step conservative uterine surgery (MOSCUS), a new approach at Tu Du Hospital in Vietnam, versus cesarean hysterectomy, and to identify factors that appear to contribute to the successful outcome of the MOSCUS. METHODS: This retrospective study was conducted at Tu Du Hospital in southern Vietnam between January 2019 and December 2020. The study enrolled all pregnant women at more than 28 weeks of pregnancy with a diagnosis of PAS who underwent either a cesarean hysterectomy or a uterus-preserving approach using the MOSCUS method. RESULTS: The prevalence of PAS at our single tertiary referral hospital was 0.4% (619 PAS cases/132 518 births) in 2 years. Among 296 patients, the surgical time duration, estimated blood loss, and red blood cell transfusion in the MOSCUS group (n = 217) were all significantly less than in the cesarean hysterectomy group (n = 79) (152.72 ± 42.23 vs 185.13 ± 58.22 min, 1000 vs 1500 mL, and 500 vs 710 mL, respectively). Intraoperatively, the rate of visceral injuries in the hysterectomy group was higher than that in the MOSCUS group (P < 0.001). However, the rate of postoperative infection was higher in the MOSCUS group than in the cesarean hysterectomy group (P = 0.012). Of a total of 217 cases managed using the MOSCUS management, 24 required a secondary hysterectomy; the success rate was 88.9% (95% confidence interval [CI] 84.3%-93.1%). Some of the primary factors associated with the success of MOSCUS included maternal age less than 35 years, planned surgery, severity of PAS, and estimated blood loss during surgery (odds ratio [OR] 5.16, 95% CI 1.96-13.59; OR 3.05, 95% CI 1.08-8.62; OR 3.62, 95% CI 1.19-10.98; and OR 49.66, 95% CI 11.16-221.02, respectively; P < 0.05). CONCLUSION: MOSCUS is an acceptable alternative to cesarean hysterectomy in many patients diagnosed with PAS. This new surgical management of PAS resulted in the preservation of the uterus, and a favorable outcome in nearly 9 out of 10 pregnant women. We believe that MOSCUS can be safely offered for the management of PAS in referral hospital settings.

Using dinoprostone slow release vaginal insert for cervical ripening in term-pregnancy with oligohydramnios.

AIMS: The study purposed to evaluate the success rate of cervical ripening using dinoprostone controlled-release vaginal insert and reveal some factors relating to successful cervical ripening. METHODS: This cross-sectional study was conducted at Tu Du Hospital in Vietnam from December 2021 to August 2022. The study enrolled 200 pregnant women with gestational age ≥37 weeks diagnosed with oligohydramnios. These candidates underwent dinoprostone cervical ripening (DCR) according to the local protocol. The Bishop score ≥7 after 24 h was determined for the successful cervical ripening (SCR). RESULTS: In total, the success rate of DCR achieved at 57.5% and the cesarean delivery rate was 46.5%. None of the severe side-effects and complications was present. Using multivariable logistic regression, the study found that the body mass index ≥25 kg/m2 and oxytocin infusion drip related to SCR with adjusted odds ratio (aOR): 3.67 (95% confidence intervals [CI]: 1.78-7.57) and aOR: 4.68 (95% CI: 1.84-11.93), p < 0.001. Using the Kaplan-Meier curve, the present study revealed a significant difference between Bishop <3 and ≥3 following the duration time of cervical ripening, with hazard ratio: 1.38 (95% CI: 1.19-1.59), p < 0.001. The time duration of cervical ripening was not significantly different following amniotic fluid index from 3 to 5 cm. CONCLUSIONS: Cervical ripening using a dinoprostone vaginal insert is a potentially acceptable method in term pregnancy accompanying with oligohydramnios. The probability of SCR can be predicted on a careful assessment of relative factors by obstetricians. Further studies are required to strengthen these findings.

Spontaneous hemoperitoneum in the second and third trimester of pregnancy: two uncommon case reports at Tu Du Hospital, in Vietnam and a literature review.

BACKGROUND: Spontaneous hemoperitoneum in pregnancy (SHiP) refers to fluid collection in the abdominal cavity with a vague presentation of clinical symptoms. Particularly, SHiP causes a life-threatening condition with the coexistence of intrauterine pregnancy, since this dangerous complication significantly increases the maternal and fetal mortality. Herein, we present two cases of nontraumatic SHiP in the second and third trimester of pregnancy, respectively. CASE PRESENTATION: The pregnant woman in case 1 was admitted to our hospital owing to severe paroxysmal shoulder pain along with abdominal pain. Her medical history was remarkably recorded with endometriosis and adenomyosis. At the emergency room, an ultrasound scan revealed a live fetus corresponding to 21 weeks and 3 days and free fluid in the abdominal cavity. She was subsequently diagnosed with SHiP and underwent immediate laparotomy for hemostatic procedures. During the postpartum course, the patient was uneventfully monitored. Unfortunately, the patient delivered on the 4th postoperative day in spite of the initial administration of tocolytic agents and close monitoring. The primigravid woman in case 2 complained of lower abdominal pain and vaginal bleeding. The patient's history was noted with ovarian tumor removal. At admission, the sonography scan revealed free fluid in the abdominal cavity, a fetus at 34 weeks and 3 days gestational age with bradycardia of 70 bpm, and a laboratory test showed a low hemoglobin level. Thus, exploratory laparotomy and hysterotomy were performed at the same time due to fetal distress. The postpartum course was uneventful. The patient was discharged 5 days later. CONCLUSIONS: In pregnant women with a history of endometriosis, adenomyosis, or ovarian tumor removal, acute abdominal pain combined with the presence of free fluid collection in the intraperitoneal cavity, and a decreased hemoglobin levels should be first assessed as SHiP originating from the spontaneous rupture of abnormal vascular proliferation. Proper management is strongly indicated for an emergent laparotomy to control the active bleeding point, thus increasing the survival rate for both mother and neonate.

Umbilical Cord Hematoma and Uterine Torsion: Rare Pregnancy Complications at Tu Du Hospital in Vietnam and Review of Literature.

Objective: Umbilical cord hematoma and uterine torsion are extremely rare complications in pregnancy. However, these should not be neglected in clinical practice in condition of abnormal fetal heart monitoring without others suspects. We hereby report rare case of umbilical cord hematoma and uterine torsion as well as review the literature. Through this report, we aim to mention on an available tool to investigate spontaneous umbilical cord hematoma on fetal well-being in such a case. Case report : A women aged 35 years old (G1P0) admitted to our hospital for term gestation with uncomplicated pregnancy, except large uterine fibroid accompanied with cervical pessary. Then, an uncommon complication of umbilical cord hematoma was revealed accidentally upon cesarean section. Particularly, this dramatic event was happened along with an asymptomatic uterine torsion noticed at the same time. Preoperative diagnosis of two rare complications was missed, hence, we extracted timely baby based on another modality of management, computerized cardiotocography. Conclusion: Umbilical cord hematoma along with uterine torsion is difficult to diagnosis due to its rarity. Moreover, no available tool could investigate umbilical cord hematoma prior to delivery. Surveillance on fetal heart rate monitoring may be helpful in this situation.

Placenta accreta spectrum on an unscarred uterus in the third-trimester pregnancy: two rare cases at Tu Du Hospital in Vietnam.

INTRODUCTION AND IMPORTANCE: Placenta accreta spectrum disorders (PASD) refer to an uncommon obstetrical conditions leading to significant life-threatening obstetrical issue for mothers and foetus during pregnancy. Rarely, this pathology can occur in the uterus without a history of uterine surgery, localize at unusual site of the uterus, and result in the spontaneous uterine rupture. We herein reported two unusual cases managed successfully in the third trimester of pregnancy at our tertiary referral hospital. CASE PRESENTATION: Two pregnant women were hospitalized at our maternity hospital for a dilemma diagnosis of PASD without history of previous caesarean scar. Following the suspected images of PASD on ultrasound combined with a hematoma anterior to the body of the uterus, especially a sudden onset of abdominal pain and intraperitoneal fluid without a clear etiology, we made the suspected diagnosis of uterine rupture associated with PASD. Moreover, a gradual reduction of hemoglobin concentration also supported this diagnosis. Both cases underwent immediately caesarean hysterectomy for saving the life of the mother and baby following suspicion. CLINICAL DISCUSSION: PASD associated with an unscarred uterus is an uncommon placentation during pregnancy. Although an extremely rare cases, PASD may be present without association with placenta praevia. Timely management by caesarean hysterectomy can avoid adverse maternal-foetal outcomes. CONCLUSION: PASD can be appeared on the uterus without a previous uterine scar, thus leading to unexpected complications during pregnancy. Closely strict monitoring helps avoiding the materno-foetal mortality. Further data is needed to summarize this rarely uncommon entity.