[Emergency embolization in gynaecological bleeding. Two case reports]. / Place de l'embolisation pelvienne en urgence dans les hémorragies d'origine gynécologique. A propos de deux cas.

Two patients with gynaecological hemorrhage underwent successfully trans-arterial embolization. The first womanhad an uncontrollable perineal hemorrhage following a delivery with forceps. Angiography showed extravasation of contrast from right and left vaginal artery. Hyperselective embolisation stopped the vaginal bleeding. The second woman had massive hemorrhage following radiotherapy for cervical cancer. Angiography demonstrated extravasation of contrast from both uterine arteries. The bleeding was controlled after hyperselective embolisation. Emergency arterial embolisation is a safe and effective means of control of irrepressible genital hemorrhage.

Pneumoperitoneum and an acute abdominal condition caused by spontaneous perforation of a pyometra in an elderly woman: a case report.

Pyometra, a collection of purulent material in the uterus, is an uncommon gynecologic entity. Spontaneous perforation of the uterus is an infrequent complication of pyometra, most often the result of malignant conditions in the uterus. We report the case of an elderly woman who had an acute abdominal condition and pneumoperitoneum due to a ruptured pyometra resulting from a degenerative and infected leiomyoma. Although uterine disease is a rare cause of an acute abdominal condition and pneumoperitoneum in the elderly, a perforated pyometra must be considered in the differential diagnosis.

Extrauterine pregnancy resulting from early uterine rupture.

BACKGROUND: Cesarean scar rupture of a gravid uterus in early gestation is rare. CASE: A 38-year-old woman, gravida 4, para 2-0-1-1, presented at 13 weeks' gestation with cramping and spotting. She had a history of two cesareans. Ultrasound and magnetic resonance imaging indicated probable uterine dehiscence and a viable extrauterine pregnancy. After embolization of the uterine arteries with subsequent fetal death, the subject had a hysterectomy. Intraoperatively, she had complete rupture of the lower uterine segment, but the pregnancy was enclosed within scar tissue between the uterus and bladder. Placenta percreta was found by histologic examination. CONCLUSION: Women with histories of cesareans might be at risk of early uterine rupture.

Rupture of low transverse cesarean scars during trial of labor.

We report eight cases of rupture of low transverse cesarean scars occurring during trials of labor. The cases occurred in five hospitals in the Denver metropolitan area during a 13-month period. The estimated incidence was 0.7% of planned trials of labor. Complications of rupture included one neonatal death, two cases of severe neonatal asphyxia, three maternal bladder lacerations, and one hysterectomy.

Spontaneous second trimester uterine rupture after classical cesarean.

BACKGROUND: Several cases of spontaneous second trimester uterine rupture have been reported, but none as early as 15 weeks' gestation after classical cesarean and with placenta percreta. CASE: A 23-year-old woman, gravida 5, para 3, at 15 37 weeks' gestation with a history of classical cesarean incision presented to the emergency department with abdominal pain, hypotension, and tachycardia. Ultrasound showed a normal intrauterine pregnancy. She developed worsening pain, abdominal rebound, and abdominal distention. On exploratory laparotomy, a large uterine rupture was found and hysterectomy was done. CONCLUSION: Spontaneous uterine rupture after classical cesarean can occur as early as 15 weeks' gestation. Uterine rupture must be considered in differential diagnoses of severe abdominal pain even in the early second trimester.

Uterine rupture as a cause of shoulder dystocia.

BACKGROUND: Shoulder dystocia and uterine rupture are complications that rarely are related. CASE: A 34-year-old white woman, gravida 4, para 2, therapeutic abortion 1, was admitted for labor induction. Fetal heart rate monitoring was normal until full dilation, when bradycardia developed and persisted. With the use of forceps, the vertex was delivered. Head retraction signaled the possibility of shoulder dystocia. Attempts at vaginal delivery failed, necessitating abdominal delivery. The fetal body was found anterior to the already contracted, anterolaterally ruptured uterus. An abdominally assisted vaginal delivery was accomplished. CONCLUSION: Uterine rupture may be an unsuspected cause of shoulder dystocia.

Postpartum hemorrhage and reevaluation of uterine packing.

Postpartum hemorrhage, occurring in 153 patients, is categorized according to etiology, predisposing conditions, and severity. Ruptured uterus is considered as a cause of postpartum hemorrhage, with an incidence of 7.1% overall and 11.9% in patients with severe hemorrhage. The effectiveness and complications of the uterine pack, used in 33 patients, are evaluated.

Ectopic endometrium in omentum. Uterine perforation by Lippes loop.

A case of ectopic endometrium in the omentum following perforation of the uterus by a Lippes Looptm is reported. Evidence is presented substantiating Sampson's theory of endometrial implantation.

PIP: This is a case report of a patient who had an IUD inserted the year following a spontaneous abortion. The next year she became pregnant and delivered a full-term infant. Another IUD was then inserted. After 2 years lower abdominal pain and vaginal bleeding of 2 months duration caused her to ask to have the IUD removed. The thread broke during the removal attempt so the patient was admitted to the hospital where a hysterogram revealed a Majzlin spring partially embedded in the uterine wall and a Lippes loop outside the uterine cavity. The Majzlin spring was removed through the vagina and curettage done. At laparotomy to remove the other IUD the Lippes loop was found embedded in a large mass of omentum. The loop and adherent omentum were removed. Histologic study revealed an area of well-preserved endometrium, an area of hemorrh agic endometrium with leukocytic infiltration, and dense fibrous tissue surrounding the endometriotic foci. These findings support the theory of endometrial transplantation rather than the theory of metaplasia.

Bladder injury associated with rupture of the uterus.

Rupture of the uterus is still a very common obstetric emergency in developing countries, and the urinary bladder is often injured in these patients. This fact is not fully documented in the literature. One hundred consecutive cases of rupture of the uterus in patients admitted during a 10-year period to the King George Hospital, Visakhapatnam, India, were analyzed. Bladder injury occurred in 22%. Thus, uterine rupture constitutes one of the important causes of bladder injury. In uterine rupture cases the most common clinical signs of concomitant bladder damage are hematuria and meconium-stained urine. Instillation of methylene blue solution into the bladder during surgery can help to identify small bladder rents. Routine postoperative drainage of the bladder by indwelling catheter in all cases of ruptured uterus with suspected bladder injury is an important aid to healing of the contused, devitalized bladder and can avert vesicovaginal fistula formation.

Successful pregnancy outcome following mid-gestational uterine rupture and repair using Gore-Tex soft tissue patch.

The first reported gestational use of the Gore-Tex soft tissue patch (expanded polytetrafluoroethylene) for uterine repair and support is presented in a pregnant woman whose partially dehisced, congenitally abnormal uterus was operated upon at 19 weeks' gestation. Use of the expanded polytetrafluoroethylene Gore-Tex soft tissue patch for assisted uterine integrity in combination with a program of uterine tocolysis and close maternal/fetal surveillance averted a pregnancy loss.

Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury.

Six patients with uncontrollable postpartum hemorrhage due to genital tract injury were treated with transcatheter arterial embolization. The causes of hemorrhage were laceration of the cervix and vagina in five cases and rupture of the uterus in one. Four cases included a large hematoma in the paravaginal and/or retroperitoneal space. Two women had a hysterectomy before arterial embolization. Angiography revealed extravasation in five cases. All six subjects had their hemorrhage arrested dramatically using transcatheter arterial embolization with gelatin sponge particles. No major complication was encountered in any case. Normal menstruation resumed in the women who did not undergo a hysterectomy. Transcatheter arterial embolization therapy seems to be the treatment of choice in patients with uncontrollable hemorrhage.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases.

OBJECTIVE: To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures. DESIGN: A retrospective clinical analysis of consequently operated 102 women. SETTING: Institutional. PATIENTS AND PARTICIPANTS: One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study. INTERVENTIONS: Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage. MAIN OUTCOME MEASURE: The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed. RESULTS: Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies. CONCLUSIONS: Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

Management of obstetric hemorrhage.

A reluctance to proceed with hysterectomy for obstetric hemorrhage may be a more likely cause of preventable death in obstetrics than a lack of surgical or medical skills. Every obstetric unit should have protocols available to deal with hemorrhage and, in addition, have specific guidelines for patients who object to blood transfusions for various reasons. Risk factors for hemorrhage should be identified antenatally, using all possible imaging modalities available, and utilizing multidisciplinary resources whenever possible. Novel strategies for prenatal diagnosis of abnormal placentation include advanced sonography and magnetic resonance imaging. Placement and utilization of arterial catheters for uterine artery embolization is becoming more widespread and new surgical technology such as the argon beam coagulator seems promising. When intra or postpartum hemorrhage is encountered, a familiar protocol for dealing with blood loss should be triggered. Timely hysterectomy should be performed for signs of refractory bleeding. Application of medical and surgical principles combined with recent technologic advances will help the obstetrician avoid disastrous outcomes for both mother and fetus.

Postpartum hemorrhage.

Early PPH remains a significant cause of maternal morbidity and mortality. Many cases occur in women with antecedent risk factors and can thus be anticipated, promptly diagnosed, and promptly treated. Postpartum hemorrhage is most commonly due to uterine atony and often responds to medical treatments such as ecbolic medications, uterine massage or bimanual compression, and blood and fluid replacement. Appropriate laboratory studies should be obtained promptly. Women with significant bleeding should receive blood product transfusions. Patients who do not promptly respond to these conservative measures should be considered and counseled for operative procedures. Surgical intervention, either to repair lacerations, transiently reduce pelvic pulse pressure, or remove the uterus, can be life-saving.

Vaginal birth after cesarean section: the demise of routine repeat abdominal delivery.

In light of the abundant very favorable data and considerable published patient experience regarding vaginal birth after cesarean for selected gravidas, the authors are moved to repeat with emphasis the question asked by Dr. Danforth in his recent treatise on cesarean delivery: "The question now is not whether the dictum of automatic repeat cesarean section is still valid, but rather why we continued to adhere to it for more than 60 years, as though it had been carved in stone." From recently published American data, it is obvious that more providers and more patients must be convinced of the safety, efficacy, and cost effectiveness of a selective program of trial of labor and vaginal delivery following previous cesarean birth if we are to effect a significant reduction in this nation's cesarean birth rate. The policy of "once a cesarean section, always a cesarean section" should be applied correctly only to its intended group of patients with previous uterine fundal or upper-segment incisions. As the advisability of insisting on a trial of labor for all parturients who have no contraindications becomes a signal part of the fabric of obstetric practice in the United States and the remainder of the world, we shall witness the demise of routine repeat abdominal delivery.

Rupture of the scarred uterus.

Although theoretically important, the bulk of obstetric literature indicates that scar separation following a lower transverse uterine incision is not a significant problem in clinical obstetrics. The need for emergency intervention for such scar separation is not increased over that in any laboring patient for a number of other causes. Ideally, the capability of emergency intervention should be available for any laboring patient. In reality, however, such a situation will not commonly be present in all hospitals in the United States. The absence of in-house anesthesia coverage does not appear to be a valid reason to exclude the carefully informed patient from a trial of labor following a previous low transverse uterine incision. Not only is scar separation infrequent, but maternal and perinatal morbidity should be negligible when such scar separation does occur. The use of oxytocin and epidural anesthesia appears to be appropriate. The latter does not mask signs or symptoms of scar separation. Because most scar separation will be heralded by the appearance of variable decelerations, extremely careful fetal heart-rate monitoring is mandatory for any patient laboring with a previous uterine incision. Finally, the detection of an asymptomatic scar separation after successful vaginal delivery in a nonbleeding patient does not appear to mandate repair. However, the uncertainties regarding the method of delivery for future pregnancies should be carefully explained to such patients if nonrepair is elected.

Hemorrhagic shock in obstetrics.

Hemorrhage during pregnancy is life threatening to both the mother and her fetus. Physiologic preparation for blood loss at parturition does take place but the wise clinician also prepares for this eventuality. The usual causes of hemorrhage are discussed in this article, as well as a useful clinical approach to priorities in the management steps for obstetric hemorrhage shock are also presented.

Extrusion of fetus into the abdominal cavity following complete rupture of uterus: a case report.

A gravida 10 para 9, after one Cesarean section (CS) followed by four vaginal deliveries was admitted at term without uterine contractions complaining of abdominal pain. The type of uterine scar was unknown. Severe bradycardia was observed at admission and an emergency Cesarean section was performed. A complete uterine rupture was revealed, the fetus in intact membranes and placenta were found in the abdominal cavity.

Rupture of pregnant noncommunicating uterine horn with fetal salvage.

A case is presented of pregnancy in an uncommunicating rudimentary uterine horn. The pregnancy proceeded to 31 gestational weeks, when the rudimentary horn ruptured. At laparotomy the surviving fetus was lying free in the peritoneal cavity, was delivered breech and subsequently did well. This is the fifth case reported of rupture of a pregnant rudimentary horn with neonatal and maternal survival.

Obstetrical problems in patients with Ehlers-Danlos syndrome type IV; a case report.

The Ehlers-Danlos syndrome type IV is a heritable connective-tissue disorder characterized by thin translucent skin, pronounced bruising and scarring, and extreme tissue fragility. Obstetrical complications include premature rupture of membranes, rupture of blood vessels and gravid uterus, tearing of perineum, vagina, urethra and bladder, requesting specific prophylactic and therapeutic measurements. Hereditary transmission is usually autosomal dominant with variable expression. Histological examination of skin biopsy and biochemical analysis of collagen proteins from skin fibroblast cultures confirm the clinical diagnosis. DNA studies offer the possibility of prenatal diagnosis in suitable families. The consecutive severe obstetrical complications of a woman with Ehlers-Danlos syndrome type IV are reported here. The patient died at age 33 years from renal artery rupture.