Successful delayed delivery of the second twin by evacuating the cord prolapsed first fetus and emergent cerclage: a report of 2 cases.

BACKGROUND: In twin pregnancies, the cord prolapse of either fetus during the pre-viable period leads to fetal death but can also cause an intrauterine infection, leading to death or prematu-re birth of the remaining fetus. However, there are no validated protocols to prolong the gestational period or decrease the morbidity and mortality of the remaining fetus. CASE PRESENTATION: The present cases were PPROM and cord prolapse very early during the second trimester (around 17 weeks in the first case and 19 weeks in the second case). The first fetus was evacuated, and cervical cerclage was performed at 23 and 20 weeks in the two cases, respectively. After maintaining the pregnancy, the second baby was born around 27 and 39 weeks in the first and second cases, respectively. The delivery interval between the first and second fetuses was 46 days in the first case and 126 days in the second case. CONCLUSION: If cord prolapse is identified at a pre-viable time in twin fetuses, evacuation and cerclage should be performed as soon as possible after the cord prolapse to reduce intrauterine infection and increase the survival chances of the remaining fetus.

Amniotic band syndrome in a monochorionic diamniotic twin pregnancy after rupture of the dividing membrane in the early second trimester: A case report.

BACKGROUND: Amniotic band syndrome is a rare phenomenon, but it can result in serious complications. We report herein our experience of amniotic band syndrome in a monochorionic diamniotic twin pregnancy where rupture of the dividing membrane occurred early in the second trimester. CASE PRESENTATION: A 29-year-old nulliparous woman was referred to us for management of her monochorionic diamniotic twin pregnancy at 10 weeks of gestation. When we were unable to identify a dividing membrane at 15 weeks of gestation using two-dimensional ultrasonography, we used three-dimensional ultrasonography to confirm its absence. Both modalities showed that the left arm of baby B was swollen and attached to a membranous structure originating from the placenta at 18 weeks of gestation. Tangled umbilical cords were noted on magnetic resonance imaging at 18 weeks of gestation. Emergency cesarean delivery was performed at 30 weeks of gestation because of the nonreassuring fetal status of baby A. The left arm of baby B had a constrictive ring with a skin defect. Both neonates had an uncomplicated postnatal course and were discharged around 2 months after delivery. CONCLUSIONS: Attention should be paid to the potential for amniotic band syndrome if rupture of the dividing membrane between twins is noted during early gestation.

The Association between Shirodkar Cerclage and Preterm Premature Rupture of Membranes in Singleton Pregnancies.

OBJECTIVE: The aim of this study was to estimate if preterm premature rupture of membranes in women with cerclage is due to the cerclage itself or rather the underlying risk factors for preterm birth in this population. STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies who underwent Shirodkar cerclage by a single maternal-fetal medicine practice between 2005 and 2019. The control group was an equal number of randomly selected women with a singleton gestation who had a prior preterm birth and were treated with 17-OH-progesterone but no cerclage. Patients with major uterine anomalies or fetal anomalies were excluded. The primary outcome was preterm premature rupture of membranes prior to 34 weeks. Chi-square and logistic regression were used. RESULTS: A total of 350 women with cerclage (154 [44%] history-indicated, 137 [39%] ultrasound-indicated, and 59 [17%] exam-indicated) and 350 controls were included. Preterm premature rupture of membranes prior to 34 weeks did not differ between the groups (8.9% in cerclage vs. 6.0% in controls, p = 0.149, adjusted odds ratio 0.62, 95% confidence interval: 0.24-1.64) nor between the different cerclage indications (9.1% of history-indicated, 7.3% of ultrasound-indicated, and 11.9% of exam-indicated, p = 0.582). This study had 80% power with an α error of 0.05 to detect an increase in preterm premature rupture of membranes prior to 34 weeks from 6.0% in the control group to 12.0% in the cerclage group. CONCLUSION: Cerclage does not increase the risk of preterm premature rupture of membranes prior to 34 weeks compared with other women at increased risk of preterm birth. The observed association between cerclage and preterm premature rupture of membranes is likely due to underlying risk factors and not the cerclage itself. The risk of preterm premature rupture of membranes prior to 34 weeks in women with cerclage is 10% or less and does not appear to differ based on cerclage indication. KEY POINTS: · Cerclage does not increase the risk of PPROM.. · Risk of PPROM with cerclage is approximately 10%.. · Risk does not appear to vary by indication..

Removal vs. retention of cervical cerclage in pregnancies complicated by preterm premature rupture of membranes: a retrospective study.

PURPOSE: To compare pregnancy outcomes in women with pPROM and a cervical cerclage in whom the cerclage was removed within 24 h and those in whom the cerclage was retained in situ. METHODS: A two-center retrospective cohort study of women with a singleton gestation with pPROM at < 340/7 weeks of gestation in the presence of cervical cerclage (January 1, 2012-July 30, 2016). Maternal and perinatal outcomes were compared between women in whom cerclage was removed within 24 h from pPROM and those in whom cerclage was retained until the onset of delivery. The primary outcome was time from pPROM to delivery. RESULTS: Seventy women met inclusion criteria. Cerclage was left in situ in 47 (67.1%) and removed in 23 (32.9%) women. Women in the cerclage retention group had a higher pPROM-to-delivery interval (7.0 ± 7.2 vs. 6.0 ± 10.9 days, p = 0.03), and were more likely to have a latency period > 48 h (87.2% vs. 65.2%, p = 0.03; aOR 3.9, 95% CI 3.1-4.9) or > 7 days (29.8% vs. 8.7%, p = 0.04; aOR 7.0, 95% CI 2.5-19.6) compared with women in whom cerclage was removed. Furthermore, chorioamnionitis rate was lower in the cerclage retention group compared to cerclage removal group (aOR 0.7, 95% CI 0.5-1.0). There were no differences between the groups in early neonatal sepsis, severe brain injury, or composite neonatal outcome. CONCLUSION: In women with pPROM and cervical cerclage, retention of cerclage may be associated with a longer latency period, and a lower chorioamnionitis rate, without an associated increase in the risk of neonatal infectious morbidity. Presentation information: The abstract of this study was presented as a poster at the 38th SMFM (Society of Maternal and Fetal Medicine) annual meeting, February 2018, Dallas, Texas, USA.

Perinatal Outcomes After Emergency Cervical Cerclage for Cervical Insufficiency with Prolapsed Membranes.

BACKGROUND To study the clinical effective of emergency cervical cerclage (ECC) in pregnant women who have cervical insufficiency with prolapsed membranes. MATERIAL AND METHODS This study was devised as a retrospective cohort in a single medical center, in which we collected clinical data from patient records. Inclusion criteria were: physical examination indicated ECC was performed at 15 to 25 gestational weeks at the Sixth Medical Center of the PLA General Hospital, and singleton pregnancy. The collected clinical data included: duration of pregnancy at delivery, interval between ECC and delivery, neonatal weight, neonatal mortality, neonatal morbidity, and Neonatal Intensive Care Unit (NICU) admission. RESULTS We included 50 women with singleton pregnancies. No surgical complications occurred in any patients. The gestational age at cerclage was 21.3±2.2 weeks. No patients had membrane damage due to surgery. No surgical complications were reported. Five (10%) patients underwent chorioamnionitis. The time interval between ECC and delivery was 11.2±7.1 weeks. The mean gestational age at delivery was 34.1 weeks. The rate of vaginal delivery was 96%. Ten patients had pregnancy lasting longer than 36 weeks. The mean neonate delivery weight was 2510.7 g. Twenty neonates were admitted to the Neonatal Intensive Care Unit (NICU), and the mean NICU stay was 21 days. CONCLUSIONS ECC has good perinatal results. Our results provide clinical evidence for the efficacy and risks of ECC.

Risk factors for Korean women to develop an isthmocele after a cesarean section.

BACKGROUND: The increase in number of cesarean section (CS) operations has resulted in an increase in cases of isthmocele development. The objective of this study is to determine the risk factors for isthmocele development after CS. METHODS: Isthmocele measurements were taken for 404 women with a history of at least one low transverse CS. The following potential risk factors were investigated: patient's age at CS, cause of CS, weeks of gestation at CS, premature rupture of membrane (PROM), phase of labor, type suture (single/double layer), operation time, uterine flexion (anteversion/retroversion), and blood transfusion during operation. A transvaginal ultrasound was carried out to examine the isthmocele in the uterus after CS, including the shape of the isthmocele, residual myometrial thickness, depth and width of isthmocele, cervical thickness, location of the isthmocele, and clinical characteristics. RESULTS: In our study population, the isthmocele had a prevalence of 73.8%. Most isthmocele had a triangular (65.4%) or semicircular shape (10.4%). The presence of an isthmocele was significantly associated with repeat CS, premature rupture of membrane (PROM), short operation time, and extent of cervix dilatation at CS. The risk of isthmocele was low in women who had placenta previa totalis (PPT), twin, a long operation time, or a transfusion during the operation. CONCLUSIONS: In our study, isthmocele development was significantly associated with repeat CS, PROM, a short operation time, and the extent of cervix dilatation at CS. Therefore, PROM prevention and a more careful uterine closure are needed to reduce the risk of developing an isthmocele after CS.

Successful preterm pregnancy in a rare variation of Herlyn-Werner-Wunderlich syndrome: a case report.

BACKGROUND: Herlyn-Werner-Wunderlich syndrome (HWWS) is an uncommon congenital anomaly of the female urogenital tract, characterised by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. We reported the difficult pregnancy course complicated by an extremely rare and unique case of this syndrome associated with ectrodactyly, a clinical combination never described in literature. CASE PRESENTATION: A 28- year-old nulliparous woman previously diagnosed for HWWS associated with ectrodactyly of the right foot and with a history of abdominal left hemi-hysterectomy, ipsilateral salpingectomy, vaginal reconstruction when she was an adolescent. She suffered from threats of abortion in the first trimester, recurrent urinary tract infections during all pregnancy. At 33 weeks + 5 days of gestational age, she was hospitalized for premature rupture of the membranes and uterine contractions and a caesarean section was performed because of breech presentation. Postpartum period was complicated by a pelvic abscess resolved with parental antibiotic therapies. CONCLUSIONS: Our literature review shows an unusual aspect in our case: HWWS is not classically associated with skeletal anomalies. Moreover, the most frequent urogenital side affected is the right, not left side as in this woman. Preterm spontaneous rupture of membranes and fetal abnormal presentation represent frequent complications and probably post-caesarean infections are related to pregnancies in the context of this syndrome.

Time to delivery: Transfers for threatened preterm labour and prelabour rupture of membranes in Western Australia.

OBJECTIVE: To describe the outcomes of patients transferred to King Edward Memorial Hospital (KEMH) with signs of labour at preterm gestations. DESIGN: A retrospective observational study of the 69 cases transferred to KEMH during 2015. SETTING: Patient transfers from all locations across Western Australia (WA) to the sole tertiary perinatal centre in Perth. PARTICIPANTS: Pregnant women within WA with threatened or actual preterm labour (PTL) or preterm prelabour rupture of membranes (PPROM) between 23 and 32 weeks gestation. MAIN OUTCOME MEASURES: The occurrence of delivery during the admission and time-to-delivery as well as length of admission and association between clinical factors and time-to-delivery. RESULTS: The percentage of the study population delivered during the admission following transfer was 72.5%. Eighty-six per cent of those who delivered did so within 72 hours of transfer. The median time from transfer to delivery was 1 day. Sixty-three per cent of those who did not deliver during the admission progressed to 36 weeks gestation. Patients transferred with PPROM were less likely to deliver during the admission compared to those with uterine activity (50% versus 19.6%, P = 0.007) and nulliparas were more likely to deliver (93.5% versus 55.3%, P < 0.001). CONCLUSION: The majority of women transferred with signs of PTL progress to delivery during the same admission with the highest risk of delivery being the first 72 hours following transfer. If the pregnancy is ongoing at 72 hours, there is a reasonable chance of progression to late preterm gestation supporting the return of woman to their place of origin for antenatal care following discharge.

Successful Closure of Small Iatrogenic Chorioamniotic Membranes Defect After Fetoscopy with Laser: A Case Report.

Background: Fetoscopic laser coagulation of the placental anastomoses is the standard treatment for twin-to-twin transfusion syndrome (TTTS). Despite certain improvements in fetoscopic technique, every fourth fetoscopic procedure is still complicated by preterm premature rupture of membranes, leading to ascending infection, fetal demise, and/or preterm delivery. re-TTTS occurs after fetoscopy in 2­14% of cases, impairing the outcome. Case: A 26-year-old woman underwent laser coagulation of placental anastomoses because of stage III TTTS at 21/6 weeks of gestation. A microinvasive fetoscopic technique with 1-mm optic was used. Three weeks later, during a second fetoscopy because of re-TTTS, a defect of the chorioamniotic membranes of about 3 mm2 in area was visualized. This was without any signs of wound healing. We decided to perform laser coagulation with Nd:YAG laser of 10­30 W energy, moving from the wound's edge to the center until complete closure of the defect could be achieved. The patient gave birth at 34/0 weeks to 2 healthy female infants weighing 2,013 g and 1,712 g. Microscopic evaluation of chorioamniotic membranes found dystrophic calcification within the treated membranes; this had been covered by amniotic epithelium. Conclusion: Small iatrogenic amniotic membrane defects could be successfully treated by laser technique.

Successful treatment of very PPROM caused by bipolar cord coagulation in acardiac twin.

The authors report management of a woman with an acardiac twin pregnancy complicated by preterm premature rupture of the membrane (PPROM) for more than two months after intrauterine treatment with bipolar cord coagulation at 24 weeks of gestation.

Vaginal Cerclage: Preoperative, Intraoperative, and Postoperative Management.

The role of the cerclage procedure has expanded from its initial application as treatment or prevention of cervical insufficiency to prevention of recurrent spontaneous preterm birth. Although recent prospective studies have clarified the indications for cerclage, additional prospective studies are needed to help define optimal perioperative management. Herein, we review the current data to provide the clinician with the most evidence-based approach to managing patients who require cerclage.

Predictors of Outcomes of Non-Elective Cervical Cerclages.

BACKGROUND: Non-elective cervical cerclages are associated with significant perinatal complications. There is scant available information about what the predictors of these outcomes are, thus making counselling difficult. OBJECTIVE: To identify which factors predict delivery at or beyond 28, 34, and 37 weeks' gestation in women with emergency/rescue cervical cerclage. METHODS: We conducted a retrospective cohort study of nonelective cerclages over 10 years in our centre. We included women with singleton pregnancies, morphologically normal fetuses, and a cervix dilated to at least 1 cm. Our primary outcome was delivery at or beyond 28 weeks' gestation, and secondary outcomes consisted of delivery at or beyond 34 and 37 weeks' gestation. Descriptive statistical and logistic regression analyses were performed. RESULTS: We identified a total of 69 cases, and 47 met the inclusion criteria; 44.6% of these women delivered at or beyond 28 weeks' gestation. Membranes seen in the vagina on ultrasound and postcerclage preterm premature rupture of membranes decreased the chance of delivery at or beyond 28 weeks by 81.7% (OR 0.183; 95% CI 0.048 to 0.703) and 95% (OR 0.050; 95% CI 0.006 to 0.429), respectively. The same factors were predictive of deliveries at or beyond 34 and 37 weeks' gestation. CONCLUSION: Membranes seen in the vagina on ultrasound and postcerclage pre-labour premature rupture of membranes were the strongest predictors of failure to reach 28 weeks' gestation. This information is of critical importance when counselling patients about non-elective cervical cerclage.

[Laparoscopic abdominal cerclage in a patient with recurrent miscarriages abortions - case report]. / Laparoskopická abdominální cerkláz u pacientky s habituálním potrácením - kazuistika.

OBJECTIVE: The use of laparoscopic abdominal cerclage in a patient with habitual miscarriage. DESIGN: Case report and literature review. SETTING: Department of Obstetrics and Gynecology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Department of Neonatology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Institute of Medical Genetics, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc. CASE REPORT: The patient is a 37 years old woman with a history of recurrent miscarriages. She had one labor at term and six pregnancies that were lost in the second trimester despite McDonald cerclages. Abdominal cerclages are necessary when the standard transvaginal cerclages fail or anatomical abnormalities preclude the vaginal placement. The disadvantage of the transabdominal approach is that it requires at least 2 laparotomies with significant morbidity and hospital stays. We discuss a case of abdominal cerclage performed laparoscopically. A 5 mm Mersilene tape was placed laparoscopically at the level of the internal os as an interval procedure. We feel it offers less morbidity and in the proper hands eliminates or significantly shortens hospital stays. Subsequent pregnancy was terminated at 28 weeks by caesarean section after premature rupture of membranes. CONCLUSION: Laparoscopic abdominal cerclage seems to be relatively effective option for the prevention of habitual abortion patients, which fail conventional surgical procedures in dealing with cervical incompetence. The success of subsequent full term pregnancy is given as 70%.

Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome.

OBJECTIVE: Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin-twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA. METHODS: Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and postoperative variables of 459 patients treated with FLA in three USA fetal centers. Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which were cross-validated using the k-fold method. Multivariate logistic regression was performed to identify risk factors for early compared with late preterm delivery based on median gestational age at delivery of 32 weeks. RESULTS: There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, multivariate analysis indicated that a lower maternal age at procedure, a history of previous prematurity, shortened cervical length, use of amnioinfusion, a cannula diameter of 12 French (Fr), lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery. CONCLUSIONS: Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.

Cornual placenta accreta managed by postpartum total laparoscopic hysterectomy.

The patient presented here delivered at 32 weeks' gestation after expectant management of spontaneous preterm membrane rupture. She had an unusually located placenta accreta at the left cornu that required a hysterectomy for treatment. The type of abnormal placentation and the laparoscopic approach to her surgery were unique features of her care.

[Comparative study between pregnancies induced for premature rupture of membranes and for prolonged pregnancy]. / Estudio comparativo entre gestaciones finalizadas electivamente por rotura prematura de membranas y por gestación cronológicamente prolongada.

BACKGROUND: To decrease maternal and fetal morbidity oftem is indicated the elective termination of pregnancy; when the cervix is unfavourable, it is possible to try to artificially reproduce these changes with exogenous prostaglandins. OBJECTIVES: Comparative evaluation of maternal and fetal results between patients in which cervical ripening is practiced with indication of premature rupture of membranes and those with prolonged pregnancy. MATERIAL AND METHOD: Historic cohorts study about pregnancies requiring cervical ripening, either for premature rupture of membranes or for gestational age > or = 41 weeks, in the "Miguel Servet" Hospital (Zaragoza, Spain), from 15/11/2005 to 15/05/2008. In all the cases dinoprostone (slow release vaginal system) was employed and the initial Bishop score was < 7. The main analysed outcomes were: intrapartum fetal heart monitoring characteristics, type of delivery, umbilical artery pH, Apgar score, hospitalization in neonatal unit requirement and time from cervical ripening start to delivery. RESULTS: Neonatal hospitalization was significantly more frequent in the ruptured membranes cohort (11.70% vs 2.33%); p = 0.001. This difference could be justified by gestational age (OR: 2,623. IC: 0.515-13.353. P = 0.246). It was observed more time cervical ripening - delivery in prolonged pregnancies cohort (25.96h vs 20.11h); p < 0.001. Umbilical cord medium pH was significantly superior in ruptured membranes group (7.25 vs 7.23); p = 0.017. No significant differences were observed in the rest of analyzed outcomes. CONCLUSIONS: Pregnancies electively ended for premature rupture of membranes are associated with a shorter time to delivery and a slightly superior umbilical cord pH than induced prolonged pregnancies. Neonatal hospitalization requirement is determined by gestational age but not by the rupture of the membranes. Cervical ripening in those patients has been demonstrated to be secure and effective.

Amniopatch treatment for spontaneous previable, preterm premature rupture of membranes associated or not with incompetent cervix.

OBJECTIVE: We reviewed women with previable spontaneous premature rupture of membranes (sPPROM) in whom an amniopatch was performed and compared their pregnancy outcomes with a conservative management group. METHODS: Amniopatch, an amnioinfusion of autologous platelet concentrate followed by cryoprecipitate, was performed in 7 women with sPPROM diagnosed at 17-23 weeks' gestation, including one twin pregnancy. Three patients had incompetent cervices and the other 4 patients had sPPROM without incompetent cervices. Pregnancy outcomes of the cases were compared with the controls who were managed conservatively (n = 22). RESULTS: Amniopatch treatment was successful in 1 of 7 cases (14.3%), in which the ruptured membranes were completely sealed and the patient delivered a healthy baby at 39 weeks' gestation. No procedure-related complications were observed. Overall, neonatal outcome was similar in the amniopatch and conservatively managed groups, although the incidences of early neonatal sepsis and respiratory distress syndrome were lower in the amniopatch group. CONCLUSION: The overall success rate of amniopatch among our small number of cases was low. However, if successful, amniopatch may prolong a pregnancy with previable sPPROM to term.

ANAESTHETIC CHALLENGES IN A HIGH RISK PARTURIENT WITH MYASTHENIA GRAVIS UNDERGOING CAESAREAN SECTION UNDER SPINAL ANAESTHESIA.

The prevalence of myasthenia gravis is low. The management implications of this disease in pregnant women are very challenging for anaesthetists. The objective is to highlight some of the challenges, the management and the lessons learnt during the management of this patient. This is a case report of a 31-year old parturient with diagnosed myasthenia gravis co-existing with hepatitis B infection that presented for caesarean section. Surgery was carried out under a single-shot spinal anaesthesia with bupivacaine. Intraoperative myasthenia crisis was managed with neostigmine infusion. She was managed in the Intensive Care Unit for a few days and discharged. Under spinal anaesthesia, she became very breathless and developed wide-spread musculo-skeletal weakness while having a stable haemodynamics intra-operatively. Surgery was carried out successfully. Both mother and child were discharged on the 71th day post-operative after baby was confirmed sero-negative of hepatitis B surface antigen. A better understanding of the pathophysiology and complications that accompany myasthenia gravis is needed to manage these patients under anaesthesia.

Aggressive intervention of previable preterm premature rupture of membranes.

OBJECTIVE: To assess the neonatal and maternal outcomes of pregnancy complicated by previable preterm premature rupture of membranes (PPROM). DESIGN: Retrospective study. SETTING: Tertiary referral hospital. Sample. Forty-five women having aggressive intervention with antibiotics, amnioinfusion, cerclage and tocolysis. METHODS: The hospital database between July 2001 and December 2009 was reviewed for women with singleton fetuses and PPROM before 23(+0) weeks of gestation. We analysed maternal and neonatal characteristics. MAIN OUTCOME MEASURES: Neonatal survival without major morbidity. RESULTS: Thirty-eight infants were delivered alive and seven were stillborn. Ten infants died in the neonatal intensive care unit and one in the labor ward. Twenty-seven live-born infants survived to discharge from hospital. The survival rate of pregnancies with aggressive management was 60% (27 of 45); that of live-born infants was 71.1% (27 of 38). The median gestational age at PPROM and at delivery were significantly lower in the non-surviving group than the surviving group. Thirty-seven women (82.2%) had an amniotic neutrophil elastase level >0.15 µg/mL. Only four women (8.9%) developed clinical chorioamnionitis. Overall, 90.7% of the women showed histological evidence of chorioamnionitis. Eighty-three per cent of the surviving children had bronchopulmonary dysplasia. Nine infants had serious sequelae at a corrected age of one and a half years. Maternal complications were uncommon. CONCLUSIONS: An aggressive treatment protocol for women with previable PPROM resulted in a high neonatal survival rate. Neonatal survival was associated with higher gestational age at delivery and with more frequent use of antenatal corticosteroids. The prognosis is still bad in PPROM before 22(+0) weeks of gestation.