Postoperative dystocia of the gastric bursa after LRYGB: A case report.

RATIONALE: Laparoscopic Roux-en-Y gastric diversion is one of the most widely used surgical procedures for weight reduction and metabolic surgery, which is a hybrid approach to restrict intake and reduce absorption. Despite the successful completion of laparoscopic Roux-en-Y gastric diversion, 10% to 20% of patients still experience regained body mass or other complications. PATIENT CONCERNS: The patient had regained weight after all the RYGB surgeries, and after diet and exercise control, the results were not good, so she came to our department for treatment. DIAGNOSES: Dilatation of the gastric pouch was observed on iodinated water imaging of the upper gastrointestinal tract and on abdominal CT. INTERVENTIONS: We report 2 patients with dilated gastric bursa after RYGB, both female, who underwent gastric diversion revision. OUTCOMES: Both patients in this case underwent laparoscopic gastric diversion correction to improve weight rebound. Their quality of life improved significantly after treatment. There were no grade 3/4 treatment-related adverse events during the treatment period. LESSONS: The above cases suggest that patients who regain weight after RYGB should routinely undergo preoperative upper gastrointestinal endoscopy and upper gastrointestinal iodine hydrography in order to observe the muscle tone of the patient's gastric bursa and the degree of dilatation of the gastrointestinal anastomosis and consider whether to correct the dilated gastric bursa intraoperatively before converting to LSG.

Dysfunctional labor and hemoperitoneum secondary to an incidentally discovered dysgerminoma: a case report.

BACKGROUND: Ovarian dysgerminoma, a subtype of malignant germ cell tumor (GCT), is a rare ovarian neoplasm that is infrequently found in the gravid patient. When dysgerminomas do occur in pregnancy, the rapidly growing tumors can have a heterogeneous presentation and lead to peripartum complications and morbidity. Due to the rarity of this condition, diagnostic and therapeutic strategies are not well described in the literature. CASE PRESENTATION: A healthy multigravida with an uncomplicated antenatal history presented for elective induction of labor. She had a protracted labor course, persistently abnormal cervical examinations, and eventually developed a worsening Category II tracing that prompted cesarean birth. Intraoperatively, a 26 cm pelvic mass later identified as a Stage IA dysgerminoma was discovered along with a massive hemoperitoneum. The mass was successfully resected, and the patient remains without recurrence 6 months postoperatively. CONCLUSION: Although rare and generally indolent, dysgerminomas can grow rapidly and cause mechanical obstruction of labor and other complications in pregnancy. Pelvic masses, including malignant neoplasms, should be included in as part of a broad differential diagnosis when evaluating even routine intrapartum complications such as abnormal labor progression. Additionally, we demonstrate that adnexal masses can be a source of life-threatening intraabdominal hemorrhage.

Müllerian-Inhibiting Substance/Anti-Müllerian Hormone as a Predictor of Preterm Birth in Polycystic Ovary Syndrome.

Context: There is increasing evidence for Müllerian-inhibiting substance (MIS)/anti-Müllerian hormone (AMH) physiologic activity in the human uterus, so it is relevant to study how MIS/AMH levels impact pregnancy. Objective: To investigate the association of MIS/AMH levels with the risk of adverse obstetric outcomes. Design: Retrospective cohort study. Setting: Academic fertility center. Patients: Women who became pregnant through in vitro fertilization between January 2012 and October 2016. Exclusion criteria were: oocyte donation, gestational carrier, multiple gestations, miscarriage before 20 weeks, or medically indicated preterm deliveries. Interventions: None. Main Outcome Measures: There were two primary outcomes, preterm birth and cesarean delivery for arrest of labor. Because MIS/AMH level is highly skewed by certain infertility diagnoses, the preterm birth analysis was stratified by polycystic ovary syndrome (PCOS) diagnosis, and the cesarean delivery for arrest of labor analysis was stratified by diminished ovarian reserve diagnosis. χ2, Mann-Whitney, and t tests were used as appropriate. A P value of <0.05 was considered statistically significant. Results: Among women with PCOS, those who delivered prematurely had substantially higher MIS/AMH levels (18 vs 6.4 ng/mL, P = 0.003) than did those who delivered at term. At the highest MIS/AMH values, preterm deliveries predominated; above the 90th percentile in women with PCOS, all deliveries were premature. No effect of MIS/AMH level was observed in women without PCOS. We found no association between MIS/AMH values and cesarean delivery for labor arrest. Conclusion: In women with PCOS, substantially elevated MIS/AMH levels are significantly associated with preterm birth, suggesting closer follow-up and further studies to elucidate the underlying mechanisms.

Morbidity Associated with Fetal Macrosomia among Women with Diabetes Mellitus.

OBJECTIVE: This article aims to compare the composite maternal and neonatal morbidities (CMM and CNM, respectively) between macrosomic (≥4,000 g) and nonmacrosomic (<4,000 g) newborns among women with diabetes mellitus (DM). METHODS: Maternal demographic and peripartum outcome data (N = 1,260) were collected from a retrospective cohort. CMM included chorioamnionitis/endometritis, wound infection, shoulder dystocia, eclampsia, pulmonary edema, admission for hypoglycemia, 3rd/4th degree perineal laceration, and death. CNM included 5-minute Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score of <4, neonatal intensive care unit (NICU) admission, respiratory distress syndrome, mechanical ventilation, intraventricular hemorrhage grade III/IV, necrotizing enterocolitis stage II/III, hypoglycemia, hypocalcemia, bronchopulmonary dysplasia, sepsis, seizures, hyperbilirubinemia, and death. Multivariable Poisson regression models with robust error variance were used to calculate adjusted relative risk (aRR) and 95% confidence interval (CI). RESULTS: The study population consisted of 967 subjects, including 854 (88.3%) nonmacrosomic and 113 (11.7%) macrosomic infants. After adjustment, the risk of CMM was higher among macrosomic deliveries (aRR = 4.08, 95% CI = 2.45-6.80). The risk of CNM was also higher among macrosomic deliveries (aRR = 1.77, 95% CI = 1.39-2.24). Macrosomia was associated with an increased risk in NICU admission, hypoglycemia, and hyperbilirubinemia. CONCLUSION: Among DM deliveries, macrosomia was associated with a fourfold higher risk of CMM and almost twofold higher risk of CNM.

Risk of labor dystocia increases with maternal age irrespective of parity: a population-based register study.

INTRODUCTION: Advanced maternal age is associated with labor dystocia (LD) in nulliparous women. This study investigates the age-related risk of LD in first, second and third births. MATERIAL AND METHODS: All live singleton cephalic births at term (≥ 37 gestational weeks) recorded in the Swedish Medical Birth Register from 1999 to 2011, except elective cesarean sections and fourth births and more, in total 998 675 pregnancies, were included in the study. LD was defined by International Classification of Diseases, version 10 codes (O620, O621, O622, O629, O630, O631 and O639). In each parity group risks of LD at age 25-29 years, 30-34 years, 35-39 years and ≥ 40 years compared with age < 25 years were investigated by logistic regression analyses. Analyses were adjusted for year of delivery, education, country/region of birth, smoking in early pregnancy, maternal height, body mass index, week of gestation, fetal presentation and infant birthweight. RESULTS: Rates of LD were 22.5%, 6.1% and 4% in first, second and third births, respectively. Adjusted odd ratios (OR) for LD increased progressively from the youngest to the oldest age group, irrespective of parity. At age 35-39 years the adjusted OR (95% CI) was approximately doubled compared with age 25 and younger: 2.13 (2.06-2.20) in first birth; 2.05 (1.91-2.19) in second births; and 1.81 (1.49-2.21) in third births. CONCLUSIONS: Maternal age is an independent risk factor for LD in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to LD due to the higher rate.

Clinical indicators of blood gas disturbances, elevated L-lactate concentration and other abnormal blood parameters in newborn beef calves.

Blood gas disturbances, commonly resulting from dystocia, are associated with failed transfer of passive immunity, morbidity and mortality in newborn calves. Modified APGAR scores intended to identify compromised calves are not widely adopted due to lack of practicality and inconsistent associations with blood parameters. The objective of this study was to determine clinical indicators of acidemia in newborn beef calves. Blood parameters at 10 min and 24 h after birth were compared to at-birth clinical examination parameters and calving characteristics in 77 commercial beef calves. There were no associations between heart rate or respiratory rate and blood pH or blood L-lactate concentration (LAC; r < 0.25); however, LAC was highly correlated with blood pH (r, -0.86). Abnormal mucous membrane color (red, white or blue) was associated with increased LAC (P = 0.002) but not decreased blood pH (P = 0.07). Abnormal results for tests of muscle tonicity and reflexes, namely inability to completely withdraw the tongue when pinched and a weak suckle reflex, were associated with decreased blood pH and increased LAC (P <0.05). Calves born to primiparous dams or from an assisted calving also had decreased blood pH and increased LAC (P <0.05). Differences in blood pH between at-birth categories resolved for all parameters by 24 h after birth, except for tongue withdrawal (P= 0.04). In conclusion, traditional APGAR parameters, heart rate, respiratory rate and mucous membrane color were not useful for the identification of acidemic calves; however, tongue withdrawal, calving ease, and parity should be included in such an assessment. Utilizing hand-held LAC meters may be a practical method to quickly identify compromised calves with acidemia in a field setting.

Fetal Ascites Mimicking Maternal Ovarian Tumor: A Rare Cause of Obstructed Labour.

Fetal ascites has been diagnosed more frequently these days because of routine ultrasound scanning in pregnancy. However as a cause of dystocia in labour, it is very rare. Twenty four years second gravida of 28 weeks 6 days of gestation presented to labour room with preterm obstructed labour. Abdominal examination revealed less readily palpable fetal parts and distantly localized fetal heart sounds. An urgent ultrasound showed huge maternal ovarian cyst. She then underwent emergency cesarean section; delivered a male baby with grossly distended abdomen. However, the ovaries were normal looking. Routine antenatal ultrasounds help in identifying maternal and congenital fetal anomalies. They also guide in planning the most appropriate management. Whenever fetal ascites is diagnosed antenatally, possibility of dystocia in labour should be kept in mind.

Fetus papyraceus causing dystocia in a rural setting: a case report.

INTRODUCTION: Fetus papyraceus is a rare condition which describes a mummified fetus in a multiple gestation pregnancy in which one fetus dies and becomes flattened between the membranes of the other fetus and uterine wall. We report a case of fetus papyraceus diagnosed during labor as a result of arrested descent. CASE PRESENTATION: A 23-year-old Sukuma woman, gravida 2, para 1 presented to an maternity emergency unit of Sengerema Designated District hospital at a gestation age of 35(+5) weeks as a referral from a rural health center due to arrested descent despite being in active labor for the past 8 hours. On vaginal examination, her cervix was 6cm dilated; fully effaced, presenting part was at station -3. A sharp and solid object-like thing was felt on the right side of her cervix. Due to uncertainty of the presenting part together with arrested descent, a decision was reached to deliver her by caesarean section. A twin gestation was identified during caesarean section: one being a male baby in cephalic presentation, weighing 1.9kg with Apgar score 8 in first minute and 9 in fifth minute with its own normal placenta and membranes. There was another atrophied placenta with calcifications without a cord and with mummified fetal bones on the anterior to the lower segment at the level of the internal orifice of the uterus. The atrophied placenta and mummified fetal bones weighed 200gms. One unit of blood was transfused intraoperatively due to severe anemia prior to surgery. Both the mother and the baby were discharged home in good condition. CONCLUSIONS: The primary concern for fetus papyraceus is its effect on the surviving fetus and on the mother. To avoid possible complications, the intrauterine diagnosis of fetus papyraceus by serial ultrasound examinations and routine placental examination to search for fetus papyraceus is mandatory.

Prolonged second stage of labor is associated with low Apgar score.

There is no consensus on the effects of a prolonged second stage of labor on neonatal outcomes. In this large Swedish population-based cohort study, our objective was to investigate prolonged second stage and risk of low Apgar score at 5 min. All nulliparous women (n = 32,796) delivering a live born singleton infant in cephalic presentation at ≥37 completed weeks after spontaneous onset of labor between 2008 and 2012 in the counties of Stockholm and Gotland were included. Data were obtained from computerized records. Exposure was time from fully retracted cervix until delivery. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Adjustments were made for maternal age, height, BMI, smoking, sex, gestational age, sex-specific birth weight for gestational age and head circumference. Epidural analgesia was included in a second model. The primary outcome measure was Apgar score at 5 min <7 and <4. We found that the overall rates of 5 min Apgar score <7 and <4 were 7.0 and 1.3 per 1000 births, respectively. Compared to women with <1 h from retracted cervix to birth, adjusted ORs of Apgar score <7 at 5 min generally increased with length of second stage of labor: 1 to <2 h: OR 1.78 (95% CI 1.19-2.66); 2 to <3 h: OR 1.66 (1.05-2.62); 3 to <4 h: OR 2.08 (1.29-3.35); and ≥4 h: OR 2.71 (1.67-4.40). We conclude that prolonged second stage of labor is associated with an increased risk of low 5 min Apgar score.

A cow-level association of ruminal pH on body condition score, serum beta-hydroxybutyrate and postpartum disorders in Thai dairy cattle.

Subacute ruminal acidosis in dairy cows occurs when ruminal pH is below about 5.5. However, the exact threshold level of ruminal pH affecting cow health is still in debate. This investigation was carried out in 505 cows within 31 farms. The postpartum disorders, including dystocia, retained placenta, anestrus, cystic ovary, metritis, clinical mastitis and lameness, were analyzed. Ruminal pH, serum beta-hydroxy butyrate (SBHB), serum urea nitrogen and body condition score (BCS) were measured once during the 3 to 6 weeks postpartum, while BCS was determined once more at 1 week before calving. Ruminal pH was determined by ruminocentesis technique. The ruminal pH was evaluated to study the association with BCS, SBHB and postpartum disorders using linear regression in a generalized linear mixed model with farm as a random effect. The results show that low ruminal pH was associated with dystocia, metritis and lameness. Moreover, a low ruminal pH can be found in cows with a high loss of BCS after calving and also in cows with low SBHB postpartum. These findings confirmed the feasibility of the ruminocentesis technique and the association of low ruminal pH on various postpartum disorders at the individual cow level. However, the consequences of low ruminal pH on dairy cow health still needs more exploration for a better understanding of the physiological mechanisms.

A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.

OBJECTIVE: To compare the outcomes of operative cephalic births by Kielland forceps (KF), rotational ventouse (RV), or primary emergency caesarean section (pEMCS) for malposition in the second stage of labour in modern practise. DESIGN: Retrospective observational study. POPULATION: Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS. METHODS: Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS). MAIN OUTCOME MEASURES: Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage-blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded. RESULTS: Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54-14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition. CONCLUSIONS: Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour.

Vaginal leiomyoma in pregnancy presenting as a prolapsed vaginal mass.

Vaginal leiomyomas are rare benign solid tumours of the vagina. They can cause mechanical dystocia, which is a common problem in obstetrics leading to serious maternal and perinatal complications. Here we describe a patient with a vaginal leiomyoma diagnosed during the mid-trimester that could have caused dystocia. This 22-year-old woman presented with a vaginal mass and leaking vaginal fluid during pregnancy. On examination, a prolapsed, pedunculated mass, measuring 5 × 3 × 4 cm was detected in the anterior vaginal wall. Via a midline incision, the mass was easily enucleated and removed. Transvaginal surgical enucleation of the vaginal leiomyoma is usually curative and recommended as the initial treatment of choice to prevent for dystocia. Such treatment is indicated when the tumour is a potential obstacle to normal labour.

Undiagnosed rectal tumour--a rare cause of obstructed labour in the second stage.

Colorectal cancer presenting in pregnancy is extremely rare. Here the authors present the case of a 25-year-old woman who was diagnosed with second-stage obstructed labour secondary to a large rectal tumour. Decision for emergency caesarean section was made for labour dystocia. Histology later confirmed villous adenocarcinoma of the rectum. The patient died from metastatic rectal cancer within 2 years of diagnosis.

Woman abuse and pregnancy outcome among women in Khoram Abad, Islamic Republic of Iran.

We carried out a descriptive analysis on the pregnancy outcome in 313 pregnant women abused, 160 non-abused). Abuse was statistically significantly correlated with mean weight gain during pregnancy, mean frequency of the prenatal care, prolonged labour (dystocia), premature rupture of membrane, low mean birth weight and mean gestational age at birth. Given the high likelihood that a woman will access health care services during her pregnancy, physicians providing prenatal care are in a strategic position to screen for partner abuse.