Trial of labor after two cesarean sections: A retrospective case-control study.

AIM: The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. METHODS: This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. RESULTS: A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N = 82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N = 1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. CONCLUSIONS: There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

Metastatic Ovarian Clear Cell Carcinoma in the Context of In Vitro Fertilization Pregnancy.

Adnexal masses are routinely encountered in the clinical practice. However, adnexal masses during pregnancy are incidental findings and usually resolve spontaneously or can be managed conservatively during pregnancy due to their benign nature. Ovarian malignancy is a rare event to occur during pregnancy. Only a few cases of ovarian clear cell carcinoma (OCCC), a subtype of epithelial ovarian cancers, have been reported in pregnancy and all of which have undergone cystectomy or pregnancy termination prior to the last trimester of pregnancy. We present a unique case of OCCC in a pregnant 38-year old female of Asian ethnicity with endometriosis and an in vitro fertilization (IVF) pregnancy. The OCCC, initially suspected to be of benign nature, was removed via emergency cesarean section during delivery in the late preterm period. The Positron Emission Tomography scan performed a few weeks after delivery confirmed metastatic lesions. Our case study not only emphasizes the need for definitive treatment option for endometriosis but also a close surveillance of all masses diagnosed during pregnancy, in particular with a background of other risk factors such as endometriosis and Asian ethnicity. In addition, our study advocates the need for the guidelines for management of such rare cases.

Over the hill and falling down: Can the NEXUS criteria be applied to the elderly?

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) criteria have been criticized due to the presumed unreliability of the clinical exam in elderly patients. The objective of this study was to determine if the NEXUS criteria can be safely applied to this vulnerable group of patients. METHODS: 596 trauma patients over the age of 65 were enrolled in a prospectively designed study between April 1, 2015 and October 1, 2016. The study was designed to encourage the use of the NEXUS criteria for all trauma patients including the elderly. NEXUS-negative patients (n = 226) were defined as individuals fulfilling none of the low risk criteria. The specificity and sensitivity of the NEXUS criteria were calculated based on any cervical spine injuries which were missed in NEXUS-positive patients (n = 129) who met one or more criteria. RESULTS: Out of the 596 included elderly patients, 355 patients underwent computed tomography (CT) of the cervical spine. 129 patients were NEXUS-positive and in this group ten nonoperative cervical spine injuries were detected. There were no NEXUS-positive patients who did not undergo CT scans of the cervical spine. No cervical spine injuries were detected in the 226 NEXUS-negative patients. In elderly patients, the NEXUS criteria had a sensitivity of 100% and specificity of 100%. CONCLUSION: The NEXUS criteria have been criticized in prior literature as less sensitive in elderly patients. Based on the current study, the use of the NEXUS criteria may lead to decreased radiation exposure and healthcare costs allowing for better allocation of resources for patients who warrant imaging of the cervical spine.