The RPOC long axis is a simple indicator for predicting the need of invasive strategies for secondary postpartum hemorrhage in either post-abortion or post-partum women: a retrospective case control study.

BACKGROUND: The retained products of conception (RPOC) and related conditions (RPOC-ARC) are the main cause of secondary postpartum hemorrhage (sPPH), but there is no clear consensus for their management. The purpose of this study was to characterize those RPOC-ARC that require invasive treatment and those that could be managed more conservatively. METHODS: We retrospectively analyzed 96 cases of RPOC-ARC that occurred after miscarriage, abortion, or delivery at a gestational age between 12 and 42 completed weeks, that were managed within our institution from May 2015 to August 2020. We reviewed the associations between the occurrence of sPPH requiring invasive treatment with clinical factors such as the maternal background and the characteristics of the lesions. RESULTS: The range of gestational age at delivery in our study was 12-21 weeks in 61 cases, 22-36 in 5, and 37 or later in 30. Among them, nine cases required invasive procedures for treatment. The onset of sPPH was within one month of delivery in all but two cases, with a median of 24 days (range 9-47). We found significant differences between requirements for invasive versus non-invasive strategies according to gestational age at delivery, assisted reproductive technology (ART) pregnancy, amount of blood loss at delivery, and the long axis of the RPOC-ARC lesion (p = 0.028, p = 0.009, p = 0.004, and p = 0.002, respectively). Multivariate analysis showed that only the long axis of the lesion showed a significant difference (p = 0.029). The Receiver Operating Characteristic (ROC) curve for predicting the need for invasive strategies using the long axis of the lesion showed that with a cutoff of 4.4 cm, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was 87.5, 90.0, 43.8, and 98.7%, respectively. CONCLUSION: The long axis of the RPOC-ARC is a simple indicator for predicting which sPPH will require invasive procedures, which use is rare in cases with lesions less than 4.4 cm or those occurring after the first postpartum month. Conservative management should be considered in such cases.

Case report: difficulty in diagnosis of delayed spinal epidural hematoma in puerperal women after combined spinal epidural anaesthesia.

BACKGROUND: Spinal epidural hematoma is a rare but serious complication of epidural anaesthesia and neurological impairment. Epidural hematoma usually becomes evident within a few hours of the procedure. Delayed clinical presentation of spinal epidural hematoma is even rarer and insidious. CASE PRESENTATION: We reported a case of a 44-year-old woman who underwent a caesarean section for a twin pregnancy during which a delayed dorsal spinal epidural hematoma occurred. Symptoms were reported 5 days after surgery and 72 h after removal of the epidural catheter. An MRI scan showed a dorsal epidural hematoma. The patient was moved to the Neurosurgical Department and underwent decompression surgery. CONCLUSION: The possibility of the delayed onset of a spinal epidural hematoma in a pregnant woman who undergoes epidural anaesthesia in labour must always be taken into consideration. In order to achieve the best clinical result, we stress the importance of a timely diagnosis and prompt surgical treatment.

Spontaneous coronary artery dissection in a postpartum e-cigarette smoker.

Spontaneous coronary artery dissection (SCAD) is a rare but lethal cause of acute coronary syndrome that occurs in young women during the peripartum/postpartum periods. We present a case of a 41-year-old woman with no significant medical history, but was a habitual e-cigarette smoker who presented with atypical chest pain 2 weeks after an uncomplicated delivery while breast feeding. The patient was found to have elevated cardiac enzymes and ST segment elevations in the anterior leads. An urgent cardiac catheterisation was performed, which revealed dissection and occlusion of the left anterior descending artery, and a drug-eluting stent was placed that resulted in the resolution of chest pain. Physiological changes during the postpartum period may be linked to an increased risk of developing SCAD.1 In addition, e-cigarette smoking is associated with increased oxidative stress and sympathetic activity, which may predispose patients to an increased risk of acute coronary syndrome.

Surgical Repair of Rectovaginal Fistula Using the Modified Martius Procedure: A Step-by-Step Guide.

STUDY OBJECTIVE: To demonstrate the surgical repair of a rectovaginal fistula (RVF) using the modified Martius procedure. DESIGN: A step-by-step presentation of the procedure using video (Canadian Task Force classification III). SETTING: RVF is abnormal epithelialized connections between the vagina and rectum. Causes of RVF include obstetric trauma, Crohn disease, pelvic irradiation, and postsurgical complications. Many surgical interventions have been developed, from the laparoscopic technique to muscle transposition and even rectal resection. However, the treatment of RVF is a great challenge to gynecologic surgeons because the incidence of RVF is low and there is no high evidence for the best surgical approach to this disease. When RVF is persistent or recurrent, the surrounding tissue is always scarred or damaged, so the interposition of a healthy and well-perfused tissue is an appropriate approach to fistula management. The modified Martius procedure using adipose tissue from the labia major places well-vascularized pedicle in the place of the RVF. Limited studies involving the procedure present favorable successful rates. PATIENT: Consent was obtained from the patient. The study was approved by the local ethics committee. INTERVENTION: The surgical repair of rectovaginal fistula by the modified Martius procedure is described as follows: The patient is placed in the high lithotomy position. A temporary transurethral urinary catheter is placed preoperatively to keep the operative site clean. The rectovaginal fistula is identified by a fistula probe. A 4-cm incision is made vertically over the left labium majus from the level of the mons pubis to the bottom of the labium to harvest pedicle. It is imperative to ensure adequate length on the flap before transection. Blood supply to the fat-muscle flap is provided superiorly by the external pudendal artery, posteriorly by the internal posterior and laterally by the obturator artery. The fat-muscle flap is dissected in a lateral-to-medial direction and divided in the upper section by two clamps, preserving its posterior aspect intact to maintain its blood supply. After that the fistula is circumcised with a scalpel through the vaginal wall with a margin of healthy tissue. During the process, the rectovaginal septum is opened and wide mobilized so that a multilayer closure can be performed without any tension. Then a subcutaneous tunnel is made from the labium majus to the fistula with a forcep. It is also important to make the tunnel wide enough to easily accommodate the flap. The fat-muscle flap is pulled through the tunnel gently, ensuring proper orientation without kinking the blood supply. The rectal mucosa is sutured in one layer with 3-0 Vicryl in interrupted fashion. The flap is then sutured down to the rectal wall with four single sutures in interrupted fashion. So the rectal and vaginal walls are separated with a healthy, well-vascularized pedicle. In addition, the flap fills in the dead space and enhances granulation tissue. The vaginal mucosa is then closed over the pedicle with 1-0 Vicryl in interrupted suture without tension. The labial incision is closed in layers with absorbable suture. Neither incision is drained. MEASUREMENTS AND MAIN RESULTS: In this video, we describe the modified Martius procedure for the management of RVF. We present a 26-year-old woman who suffered from RVF caused by obstetric trauma. She complained of passing flatus and feces through the vagina 1 week after vaginal delivery. Clinical examination performed in the local hospital confirmed RVF 1 cm in diameter located in the lower third of the vagina. The fistula was present for about 6 months, which brought psychosocial dysfunction to the patient. She was transferred to our clinic. After examination, the anal sphincter was intact. After mechanical bowel preparation with polyethylene glycol solution, the patient was presented for surgery. The operating time was about 40 minutes. No recurrence or complications were observed at the 4-month follow-up. A protective ileostomy or colostomy was avoided. The patient reestablished intestinal continuity. The functional and cosmetic results were excellent with high patient satisfaction and greatly improved quality of life. CONCLUSION: The Martius flap is easy to harvest with minimal external disfigurement and a minimal recovery time. The modified Martius procedure is a feasible adjuvant technique for RVF with excellent postoperative outcomes.

Iatrogenic propagation of coronary dissection during diagnostic coronary angiography: an uncommon but important procedural consideration.

Spontaneous coronary artery dissection is an uncommon cause of acute myocardial infarction in the general population but is relatively more common in the peripartum period. Regardless of clinical setting, the management strategy is individualised, ranging from conservative to invasive. We report a case of peripartum myocardial infarction due to spontaneous coronary dissection that propagated during diagnostic angiography and ultimately required emergent bypass surgery.

Puerperal Complications of a Retroplacental Uterine Leiomyoma.

Leiomyoma can be found concomitant with pregnancy and can cause complications during labor, delivery, and postpartum management. In the present case, a 26-year-old nulliparous patient at 39.4 weeks gestational age with a 12×9-cm retroplacental leiomyoma underwent a spontaneous vaginal delivery. Nine weeks after delivery, the patient presented with acute pain and vaginal bleeding. Immediate manual removal of the bulk of the leiomyoma tissue via vaginal approach was performed. Four weeks later, the patient returned for removal of the remaining tissue via hysteroscopic excision. This case demonstrates that a large retroplacental leiomyoma can be associated with both immediate and delayed postpartum complications, and it can be managed in a minimally invasive way.

Bilateral Subcapital Femoral Neck Fracture in a 28 Year Old Postpartum Woman.

INTRODUCTION: Subcapital femoral neck fractures are associated with high morbidity and mortality. These fractures mostly occur as a result of a high-force impact from traffic accidents and a fall from a great height, though non-traumatic forms are described in transient osteoporosis during the second half of pregnancy, in convulsions during electric shock, eclampsia, hypocalcemia, osteomalacia, renal osteodystrophy and myeloma. CASE REPORT: In this report we present a bilateral subcapital femoral neck fracture in a woman sustained two days after delivery. The right hip fracture was treated with fixation using three spongious screws without capsular decompression, while for the left hip a capsular decompression by open reduction and fixation was performed. Physical treatment based on active and passive movements was immediately initiated. The patient was able to rest upon her right leg within seven and upon the left leg within eight months. X-Rays showed the accurate position of fragments and implants throughout the recovery period. Twelve years later, the patient made a full recovery and the x-rays showed that both femoral heads are vital and fully recovered. CONCLUSION: Early anatomical reconstruction followed by internal fixation is crucial in the prevention of long-term complications. Complications of internal fixations include non-union (10-30%), avascular necrosis (15-33%), deep vein thrombosis and pulmonary embolism.

Rare complication of fibroids in pregnancy: Spontaneous fibroid rupture.

Uterine fibroids in pregnancy present with numerous complications. However, spontaneous rupture is a rare and potentially life-threatening event. We report a case of a 43-year-old multiparous woman who presented with hypovolemic shock secondary to a ruptured uterine fibroid 2 days after a spontaneous vaginal delivery. Emergency laparotomy confirmed massive intra-abdominal hemorrhage from the ruptured capsule of a 10-cm subserosal fibroid. A myomectomy was performed. Her postoperative recovery period was uneventful. This case is very rare, with fewer than 30 cases of hemoperitoneum secondary to rupture of fibroids having been reported in published works. It demonstrates how a benign and common condition, such as fibroids, can lead to an obstetric emergency that mimics a surgical abdomen requiring swift diagnosis and surgical intervention.

[Adrenocortical oncocytoma presenting as Cushing´s syndrome in pregnancy with spontaneous postpartum uterine rupture]. / Adrenokortikální onkocytom jako raritní prícina Cushingova syndromu v gravidite a následná delozní ruptura po porodu.

OBJECTIVE: The description of rare case of the Cushings syndrome in pregnancy resulting in the spontaneous rupture of uterus. DESIGNS: A case report. SETTING: Department of Gynecology and Obstetrics, 1st Medical Faculty of Charles University and Hospital Na Bulovce. CASE REPORT: The authors report the case of a 33 year old woman, who was admitted to the clinic in 30th week of pregnancy for elevated blood pressure and hypokalemia. Arterial hypertension was corrected with the combination of Vasocardin and Dopegyt. In 36th week of pregnancy the patient was admitted to the hospital with premature rupture of membranes. In less than sixteen hours the patient spontaneously gave birth to a healthy girl. Subsequently the patient suffered from abdominal pain. CT scan showed haemoperitoneum and a right adrenal mass and the surgical revision was performed. During the surgery uterine rupture was identified and the patient uderwent abdominal hysterectomy. Based on the endocrinological examination the diagnosis of Cushings syndrome was made. Three months after the delivery she underwent laparoscopic right adrenalectomy. Histological examination revealed adrenocortical oncocytoma. CONCLUSION: Cushings syndrome is rare in pregnancy and misdiagnosis is common. Symptoms mimic pregnancy complications. The disease is often diagnosed with delay even after delivery. The sonography and magnetic resonance are dominant imaging methods. Laboratory diagnosis is difficult due to pregnancy related changes. In spite of rarity of Cushings syndrome in pregnancy we should think about it in terms of the differential diagnosis of hypertension, diabetes, dysbalance of mineralogram and typical cushingoid habitus.

[Ureterovaginal fistula after caesarean: Diagnosis and management in a resource-constrained hospital in Togo]. / La fistule urétérovaginale après césariennes : diagnostic et traitement dans un hôpital à ressources limitées au Togo.

The purpose of this study is to describe a simple, non-expensive, accessible and effective technique of ureterovaginal fistula diagnosis, and to assess the results of surgical management in a resource-constrained hospital. During a campaign of obstetric fistulas repair, we diagnosed ureterovaginal fistulas by vaginal exam with the blue methylene test associated to abdominal ultrasonography, two simple and non-expensive explorations which permitted to identify ureterovaginal fistula and to do differential diagnosis with vesicovaginal fistula. The management was surgery, by ureterovesical reimplantation. Four ureterovaginal fistulas have been diagnosed in 32 women presented with obstetrical fistula. The mean age of those fistulas was 4.85 years; it was located on the left ureter in three cases, on the right in one case. The ureteral lesion was consecutive to a caesarean section in all patients and sited on the pelvic segment of ureter. In three patients, diagnosis was performed by the negativity of the blue test and unilateral dilation of ureter and kidney while the discovery was done during the treatment of vesicovaginal and rectovaginal fistulas associated in the last patient. After effects of surgery were simple, characterized by disappearance of urine leakage and dilation of ureter kidney. In resources-constrained context, techniques such as blue test and ultrasonography are enough to perform diagnosis of ureterovaginal fistula. Ureterovesical reimplantation is an effective therapeutic method for diagnosing ureterovaginal fistula.

A Case of Spontaneous Postpartum Thyroid Hemorrhage Leading to Upper Airway Obstruction.

BACKGROUND: Spontaneous goiter hemorrhage is a rare entity that can lead to life-threatening respiratory compromise. Goiter hemorrhages are usually due to effects of anticoagulation or neoplastic processes. The hormonal effects of pregnancy may also lead to such life-threatening goiter hemorrhages in the immediate postpartum period. CASE REPORT: We report the case of a 36-year-old woman who complained of progressive neck swelling as well as eventual shortness of breath in the immediate postpartum period. Computed tomography scans and ultrasound of the neck revealed an enlarged and heterogeneous thyroid with airway compression. The patient underwent an emergent subtotal thyroidectomy to alleviate the mass effect on the airway. Upon resection, the thyroid was noted to contain a goiter hemorrhage with no signs of neoplastic degeneration on pathology. CONCLUSIONS: Pregnancy is a known hormonal stressor that routinely increases the size of the thyroid and also predisposes patients to goiter formation. In rare cases, thyroid goiters may be predisposed to hemorrhage, causing airway obstruction and necessitating urgent surgical intervention.

[Intestinal occlusion secondary to a retained surgical item]. / Oclusión intestinal secundaria a oblito quirúrgico.

BACKGROUND: Retained surgical items after a surgical procedure is a real, existing, and preventable problem that affects the safety of the surgical patient. Its incidence is not exactly known due to under-reporting of occurrence, due to the potential risk of lawsuits. CLINICAL CASE: A 31 year-old women that had an elective caesarean, apparently without complications. In the immediate post-operative period, clinical features appeared that were compatible with intestinal obstruction, such as inability to channel gas, bloating, abdominal pain and vigorous peristalsis. The diagnosis is made by the recent history of abdominal-pelvic surgery and the finding of a foreign body on a simple x-ray of the abdomen. The patient was operated upon, with a satisfactory outcome, and was discharged 5 days later. CONCLUSION: A retained surgical instrument is an under-reported event that represents a medical-legal problem, leading to various complications, including death if it is not diagnosed and treated early. It is important to know the risk factors and adopt a culture of prevention through perioperative monitoring of equipment and instruments used during the surgical act.

Is the cold loop hysteroscopic technique a myometrial sparing treatment for placenta accreta residuals in a puerperal uterus?

Placenta accreta is a life-threatening obstetric pathology characterized by an abnormal invasion of chorionic villi into the uterine wall. The management represents a challenge for the gynecologist, especially in patients desiring to preserve their fertility. Several methods have been proposed to avoid hysterectomy. A case of a hysteroscopic conservative management with the cold loop technique in a puerpera with a large mass of placenta accreta residuals is described. The chorionic tissue was safely detached and it was subsequently removed by an electric cutting loop. Even in the absence of a clear cleavage plane, the thermal damage of surrounding healthy myometrium and dreadful complications as uterine perforation due to the electric cutting loop were avoided. The cold-loop hysteroscopic resection seems to be a safe and effective choice for the treatment of retained placenta accreta in patients desiring to preserve fertility. Moreover, it can also be proposed to patients who need to be treated immediately after delivery.