Emergency cesarean section of a patient with refractory status epilepticus: A case report of challenges during anesthesia.

INTRODUCTION: Maternal epilepsy is a critical condition that can significantly affect mothers and fetuses. Notably, the admission of a laboring mother with uncontrolled refractory status epilepticus (RSE) to the operating room presents a challenging scenario for anesthesiologists. THE MAIN SYMPTOMS OF THE PATIENT AND THE IMPORTANT CLINICAL FINDINGS: A 30-year-old primigravida was transferred to the operating room for an emergency cesarean section. Cesarean section was performed after a provisional diagnosis of preeclampsia was made. THE MAIN DIAGNOSES, THERAPEUTIC INTERVENTIONS, AND OUTCOMES: Cesarean section was performed under general anesthesia. During the postoperative period, the patient exhibited no seizure activity in the brain; however, she experienced mild cognitive dysfunction for up to 6 months postdelivery. The neonate were discharged without any complications. CONCLUSION: Inducing anesthesia in pregnant women with ongoing seizure activity are challenging; however, anesthesiologists provide judgment based on the balance between the safety of the mother and fetus and the balance between patient monitoring and the progression of anesthesia. This challenge can be addressed through multidisciplinary collaboration.

Cauda equina syndrome with surgical intervention in pregnancy during the periviable period.

INTRODUCTION: Cauda equina syndrome (CES) following lumbar disc herniation is exceedingly rare in pregnancy and there is limited literature outlining management of CES in pregnancy. There is further limited data addressing the management of periviable pregnancies complicated by CES. CASE PRESENTATION: A 38-year-old female at 22 weeks gestation presented with worsening lower back pain radiating to the right posterior lower extremity. She was initially managed with conservative therapy, but re-presented with worsening neurologic symptoms, including fasciculations and perineal numbness. Magnetic resonance imaging showed a large herniated disc at L4-5, and given concern for CES, she underwent emergent decompression surgery, which was complicated by a superficial wound dehiscence. She ultimately carried her pregnancy to term and had a cesarean delivery. The patient's residual neurologic symptoms continued to improve with physical therapy throughout the postpartum period. DISCUSSION: Cauda equina syndrome is a rare spinal condition with potentially devastating outcomes if not managed promptly. Diagnosis and management of CES in pregnancy is the same as in non-pregnant patients, however, standardization of patient positioning for surgery, surgical approach, anesthetic use, and fetal considerations is lacking. A multidisciplinary approach is critical, especially at periviable gestational ages of pregnancy. Our case and review of the literature demonstrates that patients in the second trimester can be managed surgically with prone positioning, intermittent fetal monitoring, and continued management of the pregnancy remains unchanged. Given the rarity of these cases, there is a need for a consensus on management and continued care in pregnant patients with CES.

Recognizing uterine torsion as a differential diagnosis in pregnant cats with severe anemia to provide appropriate and timely care in the absence of a definitive presurgical diagnosis.

A pregnant female domestic longhair cat ~8 mo of age was referred to the Western College of Veterinary Medicine (Saskatoon, Saskatchewan) for a diagnostic evaluation of severe anemia (PCV: 10.8%) after a 2-day period of lethargy. A CBC, serum biochemistry profile, FeLV/FIV testing, and abdominal radiographs were completed and did not determine a cause for the anemia. Abdominal ultrasonography identified 1 viable and 6 nonviable and fetuses, anechoic fluid in the uterus, and a mild volume of peritoneal effusion. A whole-blood transfusion and C-section with ovariohysterectomy were performed even though a definitive presurgical diagnosis for the anemia had not yet been established. Exploratory surgery revealed a left uterine horn torsion with a necrotic base, severe congestion, and 7 nonviable fetuses. Following surgery, the queen made a full clinical recovery. Key clinical message: Uterine torsion can be easily overlooked as a cause of severe anemia due to the relative infrequency of this condition in cats and the low sensitivity of ultrasonography to provide a definitive presurgical diagnosis. Client communication must emphasize the need for a prompt surgical intervention to establish the diagnosis and to save the cat, despite poor rates of neonatal survival. Once the animal is stabilized after surgery, further diagnostic tests and procedures are indicated if the cause of anemia has not yet been identified.

Reconnaître la torsion utérine comme un diagnostic différentiel chez les chattes gestantes souffrant d'anémie sévère afin de fournir des soins appropriés et opportuns en l'absence d'un diagnostic pré-chirurgical définitif. Une chatte domestique à poils longs, âgée d'environ 8 mois, a été référée au Western College of Veterinary Medicine (Saskatoon, Saskatchewan) pour une évaluation diagnostique d'anémie sévère (hématocrite : 10,8 %) après une période de léthargie de 2 jours. Une formule sanguine complète, un profil biochimique sérique, des tests FeLV/FIV et des radiographies abdominales ont été réalisés et n'ont pas permis de déterminer la cause de l'anémie. L'échographie abdominale a identifié 1 foetus viable et 6 non viables, du liquide anéchoïque dans l'utérus et un léger volume d'épanchement péritonéal. Une transfusion de sang total et une césarienne avec ovariohystérectomie ont été réalisées même si le diagnostic pré-chirurgical définitif de l'anémie n'avait pas encore été établi. La chirurgie exploratoire a révélé une torsion de la corne utérine gauche avec une base nécrotique, une congestion sévère et 7 foetus non viables. Après l'opération, la chatte s'est complètement rétablie cliniquement.Message clinique clé:La torsion utérine peut facilement être négligée comme cause d'anémie sévère en raison de la rareté relative de cette affection chez le chat et de la faible sensibilité de l'échographie pour fournir un diagnostic pré-chirurgical définitif. La communication avec le client doit souligner la nécessité d'une intervention chirurgicale rapide pour établir le diagnostic et sauver le chat, malgré de faibles taux de survie néonatale. Une fois l'animal stabilisé après la chirurgie, d'autres tests et procédures de diagnostic sont indiqués si la cause de l'anémie n'a pas encore été identifiée.(Traduit par Dr Serge Messier).

Factors predicting the need for surgical intervention for hydronephrosis during pregnancy: a systematic review of the literature.

PURPOSE: Symptomatic hydronephrosis in pregnancy can cause both maternal and obstetric complications. In various studies, factors predicting the need for surgical intervention have been evaluated, however these factors have not been systematically assessed yet. This systematic review analyzes published studies about hydronephrosis during pregnancy and determines the predictive factors for the need for surgical intervention for hydronephrosis during pregnancy. MATERIALS AND METHODS: A systematic review was conducted in January 2023 using the Medline, Web of Science and ScienceDirect/Scopus databases according to PRISMA guidelines. We searched these databases with the following search strategy: (intervention OR nephrostomy OR stent insertion) AND (pregnancy hydronephrosis). RESULTS: The literature review revealed 2461 potentially eligible studies. After the screening, six studies were enrolled in this review. High neutrophil-to-lymphocyte ratio, high C-reactive protein level, high white blood cell count, high creatinine levels, fever, persistent pain for more than 4 days, presence of ureteral stones more than 8 mm, high grade hydronephrosis, high fetal body weight and high delta resistive index were reported to be related with the need for surgical intervention. CONCLUSION: The rate of symptomatic hydronephrosis and requirement for surgical intervention is low during pregnancy. However, as symptomatic hydronephrosis may cause serious obstetric complications, it is important to know the parameters that can predict patients who may need surgical intervention. These results will assist gynecologists and urologists to stratify pregnant women for surgical intervention.

Pregnancy complicated by massive incisional hernia: challenges in management and review of literature.

Pregnancy complicated by incisional hernia is rare but can become an obstetric challenge if the gravid uterus becomes displaced or incarcerated into the hernial sac or if there is ulceration of the overlying dermis as a result of increased intra-abdominal pressure being transmitted to the skin. We report a case of a pregnant woman presenting with a large incisional hernia at 19 weeks of gestation and discuss how problems encountered with progressing pregnancy were managed conservatively by adopting a multidisciplinary team approach (which included surgeons and radiologists). She underwent a caesarean section at 35 weeks of gestation due to active bleeding from the ulcerated skin and foetal growth restriction with subsequent staged secondary hernia repair at a tertiary centre. Close surveillance is mandatory, and a decision on the mode and timing of delivery as well as when to perform the surgical repair of the fascial defect should be team based.

General Surgery During Pregnancy and Gynecologic Emergencies.

Nonobstetrical surgical emergencies can occur throughout pregnancy but are often difficult to diagnose due to the physiologic and anatomical changes that occur during pregnancy. Medical providers should have insight into these changes and be familiar with options for the diagnosis and management of common nonobstetrical surgical emergencies, such as appendicitis, cholecystitis, and small bowel obstruction. Surgeons should also be aware of obstetrical emergencies, such as ectopic pregnancy and severe vaginal bleeding, which may be life threatening to mother and the fetus. Intraoperatively, surgeons should be familiar with minimally invasive approaches for surgical diseases and special anesthetic considerations for pregnant patients.

Non-obstetric Acute Abdomen in Pregnancy: a Review of Literature.

Background: Acute abdomen in pregnancy (AAP) is defined as intensive abdominal pain lasting less than 24 hours that may require urgent surgery. It is a challenging situation to diagnose and manage, as it is associated with pain due to the normal anatomical and physiological changes that occur during pregnancy. Objective: Therefore, understanding these changes and their effect on almost every system, will help us appreciate the upcoming causes of AAP, mainly the non-obstetric surgical emergencies (e.g., appendicitis, cholecystitis). Methods: This article highlights the importance of the well-rounded care that should be offered to every pregnant patient presenting to any center with a Non-obstetric Acute Abdomen. The causes are discussed separately (for surgical pearls), laparoscopic approach and radiologic modality decision-making in pregnancy, which is an academic and a practice-based helpful summary. Results and Discussion: This article highlights the importance of the well-rounded care that should be offered to every pregnant patient presenting to any center with a Non-obstetric Acute Abdomen. The causes are discussed separately (for surgical pearls), laparoscopic approach and radiologic modality decision-making in pregnancy, which is an academic and a practice-based helpful summary. Results and Discussion: In addition, the sequence of ideas and language used in the article was based to help the reader understand the topic, rather than inform them about it. In addition, the utility of laparoscopy in pregnancy remains a concern due to the possible risk of injury to the fetus and fetal acidosis. Although, trials showed that laparoscopy was associated with less blood loss and a shorter hospital stay. Moreover, in some cases radiographic imaging is necessary, posing a diagnostic dilemma. Conclusion: AAP is a major concern that requires early interventions to pinpoint the cause and manage the patient, properly.

[Diagnosis and management of primary hyperparathyroidism during pregnancy: A systematic review and a longitudinal case study]. / Diagnostic et prise en charge d'hyperparathyroïdie primaire pendant la grossesse : revue de la littérature autour d'un cas.

OBJECTIVE: There is no specific recommendation for management in pregnant women: the aim of this review, based on a clinical case study, is to clarify its development, complications, risk factor and treatment. METHODS: A review of the literature was performed by consulting the Pubmed, Cochrane Library, and Science Direct databases. RESULTS: Primary hyperparathyroidism is defined as excessive production of parathyroid hormone resulting in hypercalcemia. The prevalence of primary hyperparathyroidism during pregnancy is not known. Indeed, the symptomatology, related to hypercalcemia, is not very specific and easily confused with the clinical manifestations of pregnancy. The physiological changes specific to the pregnant state frequently lead to a slight hypocalcemia which may complicate the diagnosis of primary hyperparathyroidism. Primary hyperparathyroidism results from a parathyroid adenoma in the majority of cases and is detected by ultrasound during pregnancy. Primary hyperparathyroidism in pregnancy causes significant risks to both mother and fetus. The maternal complication rate is 14-67%, however, the most serious complication is hypercalcemic crisis, which requires increased surveillance in the postpartum period. Obstetrical complications are also induced by primary hyperparathyroidism, such as acute polyhydramnios, or intrauterine growth retardation. The fetal complication rate can reach 45-80% of cases with neonatal hypocalcemia as the main complication. If medical treatment is based on hyperhydration, only surgical treatment is curative. CONCLUSION: Surgery should be proposed to symptomatic patients or those with high blood calcium levels, discussed in interdisciplinary committee and should be organized ideally in the second trimester to avoid maternal and fetal complications.

Hysteroscopic morcellation vs. curettage for removal of retained products of conception: a multicenter randomized controlled trial.

OBJECTIVE: To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications. DESIGN: A randomized controlled, nonblinded trial. SETTING: Three teaching hospitals and one university hospital from April 2015 to June 2022. PATIENTS: A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration. INTERVENTION: Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8- or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible. MAIN OUTCOME MEASURES: In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs. RESULTS: Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspiration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspiration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively). CONCLUSION: In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments. CLINICAL TRIAL REGISTRATION NUMBER: NTR4923 (https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923). Date of registration: November 23, 2014, date of initial participant enrollment: January 1, 2015.

Periumbilical giant abscess and intestinal leakage in late pregnancy: A rare case report and literature review.

BACKGROUND: Complicated Periumbilical abscess in late pregnancy is rare in clinical practice. Pubmed searches for articles published from January 1980 to September 2021. Such related reports did not retrieve article about "pregnancy" and "periumbilical abscess." CASE PRESENTATION: We reported on a 34-year-old female patient who was admitted to the hospital with periumbilical pain for 3 days at 34 + 1 weeks of pregnancy. The result of imaging examination showed that there was an inflammatory mass in the middle and lower abdominal wall in the third trimester of pregnancy. The periumbilical abscess was punctured and drained first, and then the pregnant woman was assisted to give birth to a baby girl through vagina after the condition was stable.Subsequently, laparotomy + abdominal abscess resection and drainage + partial small bowel resection + ileostomy were performed. Pathology showed inflammatory mass. CONCLUSIONS: Periumbilical abscess in the third trimester of pregnancy is rare clinically. For some pregnant women with previous trauma and surgical history, obstetric examination should not be restricted. For example, pregnant women with a history of abdominal surgery should expand the range of abdominal color Doppler ultrasound during the prenatal examination. When necessary, combine with computed tomography for diagnosis and treatment, avoid missed diagnosis, which will make the treatment more difficult and increase the risk. If the pregnant women has corresponding symptoms in the third trimester, vaginal delivery can be performed to terminate the pregnancy, and then the periumbilical abscess can be removed. At the same time, closely monitor the vital signs of newborn and mothers.

Office intrauterine morcellation for retained products of conception.

OBJECTIVE: Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs). DESIGN: Prospective analysis. SETTING: A teaching and university hospital. PATIENTS: Women with RPOC. INTERVENTIONS: Office -HM with 'Truclear 5 C'. MATERIAL AND METHODS: Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed. RESULTS: Mean procedure time was six minutes (SD ± 5). Tissue samples had a mean collection size 2.5 cm3+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any de novo IUAs in any of the enrolled patients. CONCLUSIONS: In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.

Maternal Malnutrition During Pregnancy Among Women with Metabolic and Bariatric Surgery.

INTRODUCTION: As the utilization of metabolic and bariatric surgery (MBS) continues to rise, it is important to address the nutritional needs of women who had MBS who become pregnant. Not meeting those nutritional needs could lead to complications associated with malnutrition. To better understand the relationship between MBS, pregnancy, and malnutrition, this study sought to determine whether differences exist in the presence of malnutrition during pregnancy in women with a history of MBS compared to women without a history of MBS. METHODS: This cross-sectional study used the National Inpatient Sample (NIS) from 2012 to 2017, which samples 20% of hospital discharges in the USA. Multivariate logistic regression models were fitted, and odds rations and 95% confidence intervals were calculated with obesity and MBS as the independent variables and malnutrition during pregnancy as the dependent variable. Covariates included in the multivariate model were age, primary payer, hypertension, hyperlipidemia, and depression. RESULTS: Compared to women who did not have MBS, women who had MBS had higher odds of malnutrition during pregnancy (aOR = 8.33, 95% CI 7.30-9.50), this result was moderated by racial category (aORBlack = 6.35, 95% CI 4.97-8.13; aORwhite = 8.25, 95% CI 7.00-9.73; aORLatina = 10.93, 95% CI 8.38-14.25). Women with obesity also had higher odds of malnutrition during pregnancy. CONCLUSIONS: The increased odds of malnutrition among women with MBS suggests that it is important to consider tailoring nutrition recommendations to address the different nutritional needs of pregnant women who had MBS and may be at risk for malnutrition.

A case of moyamoya disease diagnosed as cerebral infarction in the early postpregnancy period and surgically treated by bilateral revascularization after term delivery.

We treated a 37-year-old Japanese woman with moyamoya disease who developed cerebral infarction in the early period after pregnancy and had undergone infertility treatment. After being adequately informed, including regarding the risk of stroke in the perinatal period and the option to prioritize the treatment of moyamoya disease even if the pregnancy was interrupted, the patient decided to continue the pregnancy and underwent surgical treatment after a full-term delivery by caesarean section. No new stroke was observed throughout the perinatal period or postoperative course. Since serious stroke during the perinatal period has also been reported in moyamoya disease, it is important to plan "tailored" treatment by sufficiently informing patients considering individual backgrounds and for multiple medical departments, including obstetrics, neurology, and neurosurgery departments, to carry out close outpatient follow-up in the perinatal period and carefully careful medication usage and radiological examinations.

Post-cesarean section laparoscopic cholecystectomy: a case report.

BACKGROUND: Laparoscopic cholecystectomy at the time of cesarean section is novel in medicine. It is safe, feasible, and cost-effective. CASE PRESENTATION: A 29-year-old G3P2 + 0 woman had two previous cesarean sections. She was pregnant at 32 weeks. The fetus had anencephaly. She had acute cholecystitis. Laparoscopic cholecystectomy done at the time of termination of pregnancy by cesarean section. CONCLUSIONS: In a critical period, such as acute cholecystitis, the combination of laparoscopic cholecystectomy immediately post cesarean section is effective if the surgeon is highly qualified and experienced.

Rotation of the uterus to obtain a lower transverse incision in the posterior wall in a cesarean section: a case report and literature review.

OBJECTIVE: To demonstrate that cesarean section with a transverse incision at the lower posterior wall of the uterus is suitable for some special obstetric cases. CASE REPORT: A 35-year-old primigravida with a previous surgical history of laparoscopic myomectomy underwent elective cesarean section at 39 weeks and 2 days of gestation. During surgery, there were severe pelvic adhesions and engorged vessels on the anterior wall. Considering safety, we rotated the uterus 180 degrees and made a lower transverse incision on the posterior wall. The infant was healthy and the patient had no complications. CONCLUSIONS: A low transverse incision in the posterior uterine wall is safe and effective when the incision of the anterior wall encounters a dilemma, especially in patients with severe pelvic adhesions. We recommended this approach should be done in selected cases.