Intrapartum hemorrhage secondary to circumferential ectopic cervical deciduosis: A case report.

INTRODUCTION: Intrapartum hemorrhage constitutes a life-threatening obstetric complication and can have multiple etiologies. Some rare causes of intrapartum bleeding warrant consideration when assessing these patients. This case study represents one such instance where cervical deciduosis presented with bleeding relatively early in labor and explores the management that followed. CASE: A review was requested for a woman undergoing induction of labor due to intrapartum hemorrhage. On vaginal examination, a mass was palpated attached to the cervix which extended from 3 o'clock to 9 o'clock. During emergency caesarean section, a circumferential, sessile, polypoidal mass was attached to the superior margin of the internal cervical os. Histopathology revealed cervical deciduosis. CONCLUSION: With regard to this patient, it is unknown if this episode of cervical deciduosis (and the associated intrapartum hemorrhage) was the sole cause of fetal distress or if it was an incidental finding. It is worth remembering that although placental causes of intrapartum hemorrhage are foremost in our minds, there can be other structures and causes that lead to intrapartum bleeding. This shows the complexity that may be associated with intrapartum care.

Work-related musculoskeletal injuries among obstetricians and gynaecologists: A cross-sectional survey of Fellows of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).

BACKGROUND: Obstetricians and gynaecologists (O&Gs) are at a risk of work-related musculoskeletal injuries (WRMI) on a daily basis. AIMS: To describe the prevalence of WRMI among O&Gs in Australia and New Zealand, explore risk factors for such injuries, and evaluate their impact. METHODS: An online survey of Fellows of Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted in July 2016. It comprised questions on personal attributes, type of work, site and cause of WRMI, if any and treatment required. RESULTS: We received responses from 765 O&Gs giving a response rate of 38.3% (765/1997). Four hundred and ten specialists (53.6%) reported suffering a WRMI at some point, including 252 (32.9%) who reported multiple injuries. In multivariable analysis, females had increased risk of WRMI (odds ratio (OR): 2.12; 95% CI: 1.54-2.91) and among generalists and subspecialists, gynaecological oncologists had highest risk for WRMI (OR: 3.13; 95% CI: 1.21-8.14). Commonest sites of injury were back (218/633, 34.4%) and shoulder (131/633, 20.7%). Laparoscopic surgery (117/633, 18.5%) was the commonest cause of injury. Treatment was required for 88.6% of injuries (561/633) including 8.4% (53/633) of cases which required surgery. Ongoing symptoms post-injury were reported for 52.1% of injuries (330/633) and in 25.8% (163/633) of instances the practitioner needed to modify their scope of work. CONCLUSION: This survey among a large cohort of O&Gs shows a high prevalence of WRMI with a profound negative impact on the practitioner and profession. There is a pressing need to advocate for improved ergonomics in their workplaces.

Sacrospinous hysteropexy: review and meta-analysis of outcomes.

INTRODUCTION: Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery. METHODS: Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration's Review Manager software to perform meta-analysis of randomized controlled studies and observational studies. RESULTS: Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n = 651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76-5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41-2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy. CONCLUSION: Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.

Is the third trimester repeat ultrasound scan for placental localisation needed if the placenta is low lying but clear of the os at the mid-trimester morphology scan?

INTRODUCTION: It is unclear whether women with a low-lying placenta (not overlapping the internal cervical os) at the mid-trimester scan need follow-up. The aim of the study was to determine the rate of placenta praevia, vasa praevia and cord prolapse in the third trimester in this cohort of women. METHODS: A retrospective cohort study of women with a documented low-lying placenta (<30 mm from the internal cervical os) at the mid-trimester morphology ultrasound scan was done. A composite outcome of rate of placenta praevia, vasa praevia or cord prolapse at term was evaluated. Multivariate analysis was performed to investigate the variables influencing the composite outcome. In addition, a meta-analysis of methodologically similar studies was performed to investigate the effect of the placenta to os distance at the mid-trimester scan on the rate of placenta praevia at term. RESULTS: One hundred and eighty-one women with a low-lying placenta not overlapping the os at mid-trimester scan were identified. The composite outcome was documented in 20 (11.0%) women, including placenta praevia in 15 (8.3%). Based on multivariate analysis, multiparity, distance from os < 10 mm and antenatal bleeding were independently associated with the composite outcome. Meta-analysis demonstrated significant reduction in rate of placenta praevia for every 10-mm increase in placenta-os distance at mid-trimester. CONCLUSION: Our study supports the recommendation to follow up all women with a placenta lying <20 mm from the cervical os at mid-trimester.