Spontaneous pneumomediastinum: A report of two cases at a district general hospital.

Spontaneous pneumomediastinum is a rare condition thought to be caused by excessive Valsalva manoeuvre during the second stage of labour. Women with pneumomediastinum typically presents with chest pain or tightness, dyspnoea, and a tearing sensation around the neck. It is commonly diagnosed with a chest radiograph but further imaging may be necessary to exclude more sinister conditions with similar clinical features. We describe two cases of pneumomediastinum and the different management approaches with different multi-disciplinary input. It is often a self-limiting condition. We propose a management algorithm for women suspected to have pneumomediastinum during the intrapartum and postpartum period.

COVID-19 and maternity care in South East London: shared working and learning initiative.

The SARS-CoV-2 COVID-19 pandemic has had an immediate and profound impact on how healthcare systems organise and deliver services and specifically, there is a disproportionate negative impact on Black, Asian and Minority Ethnic groups and other risk factors. This has required clinical leaders to respond at pace to meet patient's care needs, while supporting staff working in a volatile, uncertain, complex and ambiguous environment. During the initial wave and then the later waves within our South East London sector, there were new challenges as everyone faced a novel disease necessitating real-time learning and reflection. Through informal conversations and networks, the clinicians highlighted in the first wave the need for a forum for clinical discussion. Using our existing South East London Local Maternity System and the evolving Maternal Medicine Networks alliance, we initiated a sharing and learning platform to support clinical decision-making for all maternity health professionals during the pandemic. Fortnightly, multidisciplinary virtual huddles were established allowing obstetric physicians, obstetricians, midwives and obstetric anaesthetists to share their clinical experience, operational and service challenges. This approach fostered and developed cross-site team working and shared learning across traditional, organisational boundaries. In South East London, prior to the introduction of universal testing in the first surge, we had a total of 65 confirmed positive cases of which 5 women were delivered due to COVID-19, 5 women required high dependency or intensive care and 3 women were intubated and ventilated. During the second and third waves, the COVID-19 Local Maternity System huddles provided monthly learning opportunities to share clinical practice, guidelines, vaccination updates and challenges with workforce. The huddles have proven to be a sustainable platform, which have built trust across the sector, facilitating effective teamwork and providing invaluable support for clinical decision-making. We describe the evolution of this structure and share our experience of working within this new clinical network during the first wave and how this established way of working facilitated collaboration during the second and third waves as staff and the system became more fatigued. The huddles have developed to become multi-professional, multisite collaborations with the whole group taking joint ownership to develop shared learning and are providing a forum for discussions for the emerging South East London's Maternal Medicine Network.

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy.

BACKGROUND/AIMS: Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity. METHODS: A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status. RESULTS: There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP. CONCLUSION: Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

Ectopic pregnancy with Implanon® as a method of contraception in a woman with a previous ectopic pregnancy - case report.

OBJECTIVES: To present a rare case of tubal ectopic pregnancy in a woman using Implanon® after a previous contralateral ectopic pregnancy that had occurred without contraceptive use. CASE: A 26-year-old woman presented with an ectopic pregnancy conceived whilst having an etonogestrel implant (Implanon®) in situ. A laparoscopic salpingectomy was performed and the implant was removed. Two years previously she had been treated for a contralateral ectopic pregnancy following which the implant was inserted. CONCLUSION: Implanon®, being a highly effective long-acting reversible method of contraception, has been advocated in women with previous ectopic pregnancy. However, as demonstrated by this case, ectopic pregnancy may exceptionally supervene even in the absence of identified risk factors for contraceptive failure.

Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy.

STUDY OBJECTIVE: To determine the safety and sustainability of operative laparoscopy in hemodynamically unstable women with ectopic pregnancy according to the effect of operator experience on success rates, whether the volume of hemoperitoneum affects the operative method used, and requirements for admission to the intensive care unit (ICU) and administration of blood transfusion. DESIGN: Prospective cohort study (Canadian Task Force classification II-A). SETTING: University hospital. PATIENTS: Between January 2003 and February 2010, 505 women with ectopic pregnancy (55 tubal, 4 ovarian, 7 cornual, and 1 in the cesarean scar) were seen, including 124 women with hemoperitoneum greater than 500 mL, of whom 67 were hemodynamically unstable. INTERVENTIONS: Operative laparoscopy. MEASUREMENTS AND MAIN RESULTS: The greater the volume of hemoperitoneum, the greater the likelihood of hemodynamic instability. The odds of hemodynamic instability were greater in nontubal ectopic pregnancies. The overall operative laparoscopy rate in hemodynamically unstable patients was 85%, compared with 95% in hemodynamically stable women. The volume of hemoperitoneum did not affect the operative method used. Experienced operators had a 100% success rate at operative laparoscopy in hemodynamically unstable women, compared with a 72% success rate with confident operators. A small number of women required admission to the ICU. Although the laparoscopy group required more blood transfusions, they had a shorter length of hospital stay compared with the laparotomy group. CONCLUSION: Operative laparoscopy is safe and sustainable in most women with hemodynamic instability. Women who undergo operative laparoscopy do no worse than those who undergo laparotomy, and even those who require ICU admission still benefit from the advantages of operative laparoscopy.

Laparoscopic management of a 16-week ruptured rudimentary horn pregnancy: a case and literature review.

INTRODUCTION: Pregnancy in a rudimentary horn is although rare, but is associated with the risk of rupture and life threatening hemorrhage. With the use of ultrasound the diagnosis can be made before symptoms occur. Management usually consists of excision of the rudimentary horn along with the pregnancy and the ipsilateral tube, traditionally by laparotomy. MATERIALS AND METHODS: We present a case of a 16-week ruptured rudimentary horn pregnancy diagnosed intraoperatively and managed laparoscopically in the presence of massive haemoperitoneum, which is first of its kind along with literature review. CONCLUSION: This case demonstrates that laparoscopy is a feasible approach and can provide rapid diagnosis and control of bleeding in such cases provided there is availability of efficient multi-disciplinary teamwork, optimal anesthesia, advanced cardiovascular monitoring, laparoscopic expertise and ability to convert rapidly to laparotomy if required.