Anesthesia for Maternal-Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network.

Maternal-fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal-fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal-fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network. This consensus statement describes the comprehensive preoperative evaluation, intraoperative anesthetic management, and postoperative care for the different types of maternal-fetal interventions.

Risk factors for spontaneous miscarriage above 12 weeks or premature delivery in patients undergoing cervical polypectomy during pregnancy.

BACKGROUND: It currently remains unknown whether the resection of cervical polyps during pregnancy leads to miscarriage and/or preterm birth. This study evaluated the risk of spontaneous PTB below 34 or 37 weeks and miscarriage above 12 weeks in patients undergoing cervical polypectomy during pregnancy. METHODS: This was a retrospective monocentric cohort study of patients undergoing cervical polypectomy for clinical indication. Seventy-three pregnant women who underwent polypectomy were selected, and risk factors associated with miscarriage above 12 weeks or premature delivery below 34 or 37 weeks were investigated. A multivariable regression looking for predictors of spontaneous miscarriage > 12 weeks and PTB < 34 or 37 weeks were performed. RESULTS: Sixteen patients (21.9%, 16/73) had spontaneous delivery at < 34 weeks or miscarriage above 12 weeks. A univariate analysis showed that bleeding before polypectomy [odds ratio (OR) 7.7, 95% confidence interval (CI) 1.6-37.3, p = 0.004], polyp width ≥ 12 mm (OR 4.0, 95% CI 1.2-13.1, p = 0.005), the proportion of decidual polyps (OR 8.1, 95% CI 1.00-65.9, p = 0.024), and polypectomy at ≤10 weeks (OR 5.2, 95% CI 1.3-20.3, p = 0.01) were significantly higher in delivery at < 34 weeks than at ≥34 weeks. A logistic regression analysis identified polyp width ≥ 12 mm (OR 11.8, 95% CI 2.8-77.5, p = 0.001), genital bleeding before polypectomy (OR 6.5, 95% CI 1.2-55.7, p = 0.025), and polypectomy at ≤10 weeks (OR 5.9, 95% CI 1.2-45.0, p = 0.028) as independent risk factors for predicting delivery at < 34 weeks. Polyp width ≥ 12 mm and bleeding before polypectomy are risk factors for PTB < 37 wks. CONCLUSIONS: Our cohort of patients undergoing polypectomy in pregnancy have high risks of miscarriage or spontaneous premature delivery. It is unclear whether these risks are given by the underlying disease, by surgical treatment or both. This study establishes clinically relevant predictors of PTB are polyp size> 12 mm, bleeding and first trimester polypectomy. PTB risks should be exposed to patients and extensively discussed with balancing against the benefits of intervention in pregnancy.

Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey).

BACKGROUND: The aim of this study was to explore the personal views of female gynecologists regarding the management of POP with a particular focus on the issue of uterine sparing surgery. METHODS: A questionnaire based survey of practicing female gynecologists in the Czech Republic, Slovenia and Slovakia. RESULTS: A total of 140 female gynecologists from 81 units responded to our questionnaire. The majority of respondents stated they would rely on a urogynecologist to aid them with their choice of POP management options. The most preferred options for POP management were sacrocolpopexy and physiotherapy. Almost 2/3 of respondents opted for a hysterectomy together with POP surgery, if they were menopausal, even if the anatomical outcome was similar to uterine sparing POP surgery. Moreover, 81.4% of respondents, who initially opted for a uterine sparing procedure, changed their mind if the anatomical success of POP surgery with concomitant hysterectomy was superior. Discussing uterine cancer risk in relation to other organs had a less significant impact on their choices. CONCLUSIONS: The majority of female gynecologists in our study opted for hysterectomy if they were postmenopausal at the time of POP surgery. However, variation in information provision had an impact on their choice.

MOMS Plus: Single-Institution Review of Outcomes for Extended BMI Criteria for Open Fetal Repair of Myelomeningocele.

BACKGROUND: In utero repair has become an accepted therapy to decrease the rate of ventriculoperitoneal shunting and improve neurologic function in select cases of myelomeningocele. The Management of Myelomeningocele Study (MOMS) trial excluded patients with a BMI >35 due to concerns for increased maternal complications and preterm delivery, limiting the population that may benefit from this intervention. OBJECTIVES: The aim of this study was to evaluate outcomes associated with extending the maternal BMI criteria to 40 in open fetal repair of myelomeningocele. METHOD: Retrospective review of fetal closure of myelomeningocele at a quaternary referral center between 2013 and 2016 with maternal BMI ranging from 35 to 40. RESULTS: Eleven patients with a BMI >35 were identified. The average BMI was 37. The average maternal age at the time of evaluation was 27 years. The average gestational age at fetal surgery was 24 weeks. Gestational age at birth was an average of 32 weeks. There was one perinatal death immediately following the fetal intervention. The shunt rate at 1 year was 45% (5/11 patients). CONCLUSIONS: In this single-institution review of expanded BMI criteria for fetal repair of myelomeningocele, we did not observe any adverse maternal outcomes associated with maternal obesity; however, the gestational age at delivery was 2 weeks earlier compared to the MOMS trial.

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair.

OBJECTIVE: This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre. STUDY DESIGN: Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application. RESULTS: The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%). CONCLUSION: Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.

Influence of Resident Involvement in Obstetrics and Gynaecology Surgery on Surgical Outcomes: Systematic Review and Meta-Analysis.

OBJECTIVE: The effect of resident involvement during obstetrics and gynaecology (OB/GYN) surgery on surgical outcomes is unclear. This study sought to review the evidence systematically for the influence of resident participation in OB/GYN surgery on (1) operative time, (2) estimated blood loss, and (3) perioperative complications. METHOD: Published studies were identified via searches of PubMed, Embase, Cochrane Central Register, Web of Science, and ClinicalTrials.gov databases. The study included randomized or observational studies that compared outcomes for OB/GYN surgery performed by attending surgeons alone or with residents. Risk ratios or mean differences were extracted from the studies. A random effect model was performed for each outcome, with subgroup analysis by type of surgery and study quality. RESULTS: A total of 13 studies were included in the meta-analysis, comprising 40 968 patients in seven countries. Surgical procedures performed only by attending surgeons had shorter operative times (mean difference 18.20 minutes; 95% CI 13.58-22.82), whereas surgical procedures with resident involvement were associated with an increased risk of blood transfusion (risk ratio 1.23; 95% CI 1.08-1.41). There were no observable differences in risk of estimated blood loss, wound infection, urologic injury, viscus injury, or return to the operating room. Significant heterogeneity (I2 >50%) was present in one of seven outcomes. CONCLUSION: Resident participation in OB/GYN surgery is associated with longer operative times and increased risk of blood transfusion; however, other perioperative complications are not increased.

Predictors of postoperative hospitalisation in women who underwent the Triple-P Procedure for abnormal invasion of the placenta.

The 'Triple-P Procedure' is a conservative surgical alternative to peri-partum hysterectomy; it involves Peri-operative placental localisation and delivery of the foetus above the placenta, Pelvic devascularisation, and Placental non-separation with myometrial excision and uterine wall reconstruction. Our aim was to determine the factors influencing the duration of post-operative hospitalisation in women undergoing the procedure. A retrospective analysis of 24 patients was performed. The results were; 4 had additional measures (compression sutures and intrauterine balloon tamponade), 2 had co-morbidities, 3 undergoing intra and post-operative complications. We concluded that in those who had the procedure alone, the mean of hospitalisation was 4.2 days, compared to 5.5 days for those who had the complications mentioned above (p < .001). Regarding placental position, 19 had anterior, 4 had posterior and 1 had cornual placenta. The resulting blood loss mean was 3, 1.3 and 1.1 L, respectively, which explains that the blood loss is greater with anterior placenta compared to posterior and cornual invasion. Impact statement What we already know: Abnormal invasion of the placenta is associated with a maternal mortality rate of 7-10% worldwide. The conventional management options are surgical peri-partum hysterectomy and conservative intentional retention of placenta, which are associated with post-operative morbidity and mortality. Therefore, the need for a new approach is mandatory. What the results of this study add: The Triple-P Procedure is a conservative surgical technique associated with a low incidence of complications, as reflected by the short period of post-operative hospitalization. The implications of the findings for practice and/or further research: This research emphasis that more attention needs to be paid to pregnant women with co-morbidities and anterior abnormal invasion of placenta: as they are at great risk for bleeding. post-operative complications and prolonged hospital stay.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.

Rational selection of antibacterial drugs and postoperative nursing for gynecologic and obstetric surgery patients.

Infection after gynecologic surgery is very common and frequent. If the control is not good, it will lead to serious consequences. Therefore, it is necessary to use antibiotics in the period of obstetrics and gynecology. This study will explore the use of antimicrobial agents in gynecologic and obstetric surgery, thus standardizing the use of antibiotics in the process of obstetrics and gynecology. Through the analysis of the use of antibacterials, we can see that the highest utilization rate of 5 kinds of antibacterial drugs followed by Cefaclor Sustained Release Tablets (65.7%), metronidazole (32.5%), cefathiamidine (26.8%), enoxacin (22.5%) and cefoperazone tazobactam sodium (11.8%). At the same time, the hospital should improve the consciousness of rational drug use and strengthen the administration of antibacterials in the operative period of obstetrics and gynecology. The application of antibiotics in the operative period of the department of obstetrics and gynecology can improve the current situation of its irrational use. Nursing work must take strict aseptic operation to prevent cross infection. At the same time, we should strengthen the observation of the effect of medication, monitor the body temperature and blood pressure, and identify the side effects of drugs.

Injured bodies, damaged lives: experiences and narratives of Kenyan women with obstetric fistula and Female Genital Mutilation/Cutting.

BACKGROUND: It is well acknowledged that Female Genital Mutilation/Cutting (FGM/C/C) leads to medical, psychological and sociocultural sequels. Over 200 million cases of FGM/C exist globally, and in Kenya alone, a total of 12,418,000 (28%) of women have undergone FGM/C, making the practice not only a significant national, but also a global health catastrophe. FGM/C is rooted in patriarchal and traditional cultures as a communal experience signifying a transition from girlhood to womanhood. The conversations surrounding FGM/C have been complicated by the involvement of women themselves in perpetuating the practice. METHODS: A qualitative inquiry employing face-to-face, one-on-one, in-depth semi-structured interviews was used in a study that included 30 women living with obstetric fistulas in Kenya. Using the Social Network Framework and a feminist analysis we present stories of Kenyan women who had developed obstetric fistulas following prolonged and obstructed childbirth. RESULTS: Of the 30 participants, three women reported that health care workers informed them that FGM/C was one of the contributing factors to their prolonged and obstructed childbirth. They reported serious obstetric complications including: the development of obstetric fistulas, lowered libido, poor quality of life and maternal and child health outcomes, including death. Fistula and subsequent loss of bodily functionalities such as uncontrollable leakage of body wastes, was reported by the women to result in rejection by spouses, families, friends and communities. Rejection further led to depression, loss of work, increased sense of apathy, lowered self-esteem and image, as well as loss of identity and communal sociocultural cohesion. CONCLUSION: FGM/C is practised in traditional, patriarchal communities across Africa. Although the practice aims to bind community members and to celebrate a rite of passage; it may lead to harmful health and social consequences. Some women with fistula report their fistula was caused by FGM/C. Concerted efforts which embrace feminist understandings of society, as well as multi-sectoral, multidisciplinary and community development approaches need to be employed to address FGM/C, and to possibly reduce cases of obstetric fistulas in Kenya and beyond. Both government and non-government organisations need to be involved in making legislative, gender sensitive policies that protect women from FGM/C. In addition, the policy makers need to be in the front line to improve the lives of women who endured the consequences of FGM/C.

Long-term outcomes for women after obstetric fistula repair in Lilongwe, Malawi: a qualitative study.

BACKGROUND: Obstetric fistula affects a woman's life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman's quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula. METHODS: In-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis. RESULTS: About half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women's concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities. CONCLUSIONS: Nearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

OBJECTIVE: To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery PATIENTS AND METHODS: A retrospective review of all patients from four different high-volume institutions between 2002 and 2013 that had a robot-assisted (RA) repair by a urologist after an OBGYN genitourinary injury. RESULTS: Of the 43 OBGYN operations, 34 were hysterectomies: 10 open, 10 RA, nine vaginally, and five pure laparoscopic. Nine patients had alternative OBGYN operations: three caesarean sections, three oophorectomies (one open, two laparoscopic), one RA colpopexy, one open pelvic cervical cerclage with mesh and one RA removal of an invasive endometrioma. In all, 49 genitourinary (GU) injuries were sustained: ureteric ligation (26), ureterovaginal fistula (10), ureterocutaneous fistula (one), vesicovaginal fistula (VVF; 10) and cystotomy alone (two). In all, 10 patients (23.3%) underwent immediate urological repair at the time of their OBGYN RA surgery. The mean (range) time between OBGYN injury and definitive delayed repair was 23.5 (1-297) months. Four patients had undergone prior failed repair: two open VVF repairs and two balloon ureteric dilatations with stent placement. In all, 22 ureteric re-implants (11 with ipsilateral psoas hitch) and 15 uretero-ureterostomies were performed. Stents were placed in all ureteric cases for a mean (range) of 32 (1-63) days. In all, 10 VVF repairs and two primary cystotomy closures were performed. Drains were placed in 28 cases (57.1%) for a mean (range) of 4.1 (1-26) days. No case required open conversion. Two patients (4.1%) developed ureteric obstruction after RA repair requiring dilatation and stenting. The mean (range) follow-up of the entire cohort was 16.6 (1-63) months. CONCLUSIONS: RA repair of GU injuries during OBGYN surgery is associated with good outcomes, appears safe and feasible, and can be used successfully immediately after injury recognition or as a salvage procedure after prior attempted repair. RA techniques may improve convalescence in a patient population where quick recovery is paramount.

Characterising women with obstetric fistula and urogenital tract injuries in Tanzania.

INTRODUCTION AND HYPOTHESIS: World Health Organisation (WHO) data suggest that more than two million women and girls live with fistula and that an additional 50-100,000 are newly affected each year. In Tanzania, it has been estimated that there are between 1,200 and 3,000 new cases of obstetric fistula annually. METHODS: To characterize women undergoing surgery in 2011 for obstetric fistula repair at a disability hospital associated with Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), we identified routinely collected data and input into an Access database. RESULTS: Women affected by obstetric fistulae in Tanzania are frequently young, poorly educated, primiparous, subsistence farmers or housewives and have experienced obstructed labour as a result of delays occurring at home and/or after reaching a health facility. The majority experienced stillbirth, particularly in cases of assisted or operative delivery. Success rates for fistula closure were high, at 91 %, but residual incontinence on discharge from hospital was seen in 39 %. CONCLUSIONS: Longer-term follow-up is required to determine rates of disabling residual incontinence and to examine demographics in greater depth, including variation between regions and in urban, periurban and rural settings in Tanzania.

Retained placental tissue as an emerging cause for malpractice claims.

BACKGROUND: Removal of retained placental tissue postpartum and retained products of conception (RPOC) abortion is done by uterine curettage or hysteroscopy. Trauma to the endometrium from surgical procedures, primarily curettage, can cause intrauterine adhesions (Asherman's syndrome) and subsequent infertility. The incidence of malpractice claims relating to intrauterine adhesions is rising, justifying reevaluation of the optimal way of handling these complications. OBJECTIVES: To review malpractice claims regarding intrauterine adhesions, and to explore the clinical approach that might reduce those claims or improve their medical and legal outcomes. METHODS: We examined 42 Asherman's syndrome claims handled by MCI, the largest professional liability insurer in Israel. The clinical chart of each case was reviewed and analyzed by the event preceding the adhesion formations, timing and mode of diagnosis, and outcome. We also assessed whether the adverse outcome was caused by substandard care and it it could have been avoided by different clinical practice. The legal outcome was also evaluated. RESULTS: Forty-seven percent of the cases occurred following vaginal delivery, 19% followed cesarean section, 28% were RPOC following a first-trimester pregnancy termination, and 2% followed a second-trimester pregnancy termination. CONCLUSIONS: It is apparent that due to the lack of an accepted management protocol for cases of RPOC, it is difficult to legally defend those cases when the complication of Asherman syndrome develops.

Patient characteristics, surgery outcomes, presumed aetiology and other characteristics of fistula surgeries and related procedures supported by Fistula Foundation from 2019 to 2021: a multicentre, retrospective observational study.

OBJECTIVES: Obstetric fistula is a devastating childbirth injury primarily caused by prolonged, obstructed labour. It leaves women incontinent, severely stigmatised and isolated. Fistula repair surgery can restore a woman's health and well-being. Fistula Foundation, a non-profit organisation, works in partnership with local hospitals and community organisations in Africa and Asia to address key barriers to treatment and to increase the number of women receiving surgical care. This paper presents data on fistula and fistula repair surgery across a large global network of hospitals supported by Fistula Foundation. The data were collected between 2019 and 2021. DESIGN: Multicentre, retrospective, observational, descriptive study. SETTING AND PARTICIPANTS: The study analysed deidentified data from 24 568 surgical repairs supported by Fistula Foundation to treat women with obstetric fistula at 110 hospitals in 27 countries. RESULTS: The data highlight patient characteristics and key trends and outcomes from obstetric fistula repair surgeries and related procedures. Of those surgeries, 87% resulted in a successful outcome (fistula dry and closed) at the time of discharge, highlighting the effectiveness of fistula repair in restoring continence and improving quality of life. Over the period studied, the number of supported surgeries increased by 14%, but there remains an urgent need to strengthen local surgical capacity and improve access to treatment. Women suffered an average of 5.7 years before they received surgery and only 4% of women sought care independently. This underscores the importance of enhancing community awareness and strengthening referral networks. CONCLUSIONS: This research provides essential insight from a vast, global network of hospitals providing highly effective fistula repair surgery. Further investment is needed to strengthen surgical capacity, increase awareness of fistula and remove financial barriers to treatment if stakeholders are to make significant progress towards the United Nations' ambitious vision of ending fistula by 2030.

Chronic pain after childbirth.

PURPOSE OF REVIEW: Although childbirth is considered a natural event, some deliveries may necessitate instrumentation or surgical intervention. In contrast with trauma or surgery, persistent pain after delivery has received little attention until recently, despite the large number of individuals potentially at risk. RECENT FINDINGS: Excluding pre-existing pain or pain that developed during pregnancy, prospective studies show a surprisingly low prevalence of persistent pain after childbirth, much lower than the prevalence reported in retrospective studies and that of persistent postsurgical pain in a general population for similar procedures. The nature of persistent pain itself remains poorly characterized; the chronic pain following caesarean delivery appears to be predominantly neuropathic, but the intensity is generally lower than usually reported for other types of chronic neuropathic pain. Finally, the type of delivery and the degree of tissue trauma do not seem to impact the risk of developing persistent pain. It is unclear whether individual factors place specific women at a risk for persistent pain. Experimental study suggests that protective mechanisms against the development of neuropathic pain may be active during the puerperium, but whether these mechanisms exist following human childbirth remains unknown. SUMMARY: Some recent findings on the development of persistent pain after childbirth are intriguing and might open the way to interesting perspectives for the treatment of persistent pain caused by trauma or surgery.

The diagnosis and treatment of iatrogenic ureteral and bladder injury caused by traditional gynaecology and obstetrics operation.

OBJECTIVE: To explore the etiologic factors and treatments of iatrogenic ureteral and bladder injury during obstetric and gynecologic operations. METHODS: Forty-one patients who underwent traditional obstetric and gynecologic operations were found with iatrogenic ureteral and bladder injury, and recruited into our study. The etiologic factors and treatment for iatrogenic ureteral and bladder injury were analyzed retrospectively. RESULTS: Four cases of iatrogenic ureteral injury and five cases of iatrogenic bladder injury occurred in hysterectomy. Seven cases of iatrogenic ureteral injury and four cases of iatrogenic bladder injury occurred in subtotal hysterectomy for precancerous lesion. Five cases of iatrogenic ureteral injury and seven cases of iatrogenic bladder injury occurred in radical hysterectomy. One case of iatrogenic ureteral injury and eight cases of iatrogenic bladder injury occurred in cesarean section. Intra-operative ureteral injury in 11 patients was repaired by end-to-end anastomosis, and intra-operative bladder injuries in 19 patients were repaired during operation. In six patients the ureteral injury was found after operation, including three cases of ureterovaginal fistula, and the injury was repaired after resection of fistulas. These six cases all received ureteroesical anastomosis at early stage. Bladder injury was found in five cases after operation, and the injuries were repaired by closure of fistulas of bladder 3 months later. All cases recovered with no relapse during the follow-up period of 5 months to 1 year. CONCLUSIONS: Iatrogenic injury occurs during gynecologic surgery should be prevented first. Early discovery and effective treatments could bring good therapeutic effects.

Antibiotic prophylaxis in obstetric and gynaecological procedures: a review.

Surgical site infections are a common complication of obstetric and gynaecological surgeries; up to 10% of gynaecological patients undergoing an operative procedure will develop a surgical site infection. In surgeries with high rates of post-operative infection, antibiotic prophylaxis (using an antibiotic with an appropriate microbiological spectrum and administered in a timely manner) can play a major role in improving outcomes. This review examines the medical literature to assess the indications and appropriate antibiotic choices for prophylaxis to prevent surgical site infection in obstetric and gynaecological surgery. For some procedures, such as caesarean section, surgical termination of pregnancy and hysterectomy, antibiotic prophylaxis is clearly indicated. For other procedures, such as insertion of an intrauterine device, medical termination of pregnancy and laparoscopy, antibiotic prophylaxis is usually not required. For several other procedures where the evidence for antibiotic prophylaxis is unclear or inadequate, we discuss the current evidence for and against prophylaxis. Guidelines for infective endocarditic prophylaxis with surgery are also discussed.

Uterine damage induces placenta accreta and immune imbalance at the maternal-fetal interface in the mouse.

INTRODUCTION: Placenta accreta spectrum (PAS) disorder is one of the major complications resulting in maternal death and serious adverse pregnancy outcomes. Uterine damage - principally that associated with cesarean section - is the leading risk factor for the development of PAS. However, the underlying pathogenesis of PAS related to uterine damage remains unclear. METHODS: For this study, we constructed a mouse PAS model using hysterotomy to simulate a cesarean section in humans. Pregnant mice were sacrificed on embryonic days 12.5 (E12.5) and E17.5. Trophoblast invasion and placental vascularization were analyzed using Hematoxylin-Eosin (H&E) staining and immunohistochemistry (IHC), and the proportions of immune cells at the maternal-fetal interface were analyzed using flow cytometry. We analyzed the expressions of genes in the decidua and placenta using RNA sequencing and subsequent validation by QPCR, and measured serum angiogenic factors by ELISA. RESULTS: Uterine damage led to increased trophoblast invasion and placental vascularization, with extensive changes to the immune-cell profiles at the maternal-fetal interface. The proportions of T and NK cells in the deciduas diminished significantly, with the decidual NK cells and M - 2 macrophages showing the greatest decline. The expression of TNF-α and IL4 was upregulated in the deciduas, while that of IFN-γ and IL10 was downregulated significantly. The expression of Mmp2, Mmp9, Mmp3, and Dock4 was significantly elevated in the placenta, and the serum levels of anti-angiogenic factors were significantly attenuated. DISCUSSION: Uterine damage can cause immune imbalance at the maternal-fetal interface, which may contribute to abnormal trophoblast invasion and enhanced vascularization of the mouse placenta.