RETERM BIRTH IS THE MOST COMmon cause of neonatal morbidity and mortality worldwide.Almost 75% of perinatal deaths occur in infants born before 37 weeks' gestation. 1Consequently, pre-term birth is associated with a large burden of disease, high costs for medical care, special education, and institutionalized care for disabled infants. 2 In threatened preterm labor before 34 weeks, delay of delivery for 48 hours allows antenatal corticosteroid treatment to improve fetal maturity and transfer of the pregnant woman to a center with a neonatal intensive care unit. 3For initial tocolysis, nifedipine is comparable with magnesium sulfate 4 and superior to ritodrine 5 and atosiban. 6Because perinatal morbidity and
On a global scale, cases of placenta accreta spectrum are often just identified during cesarean delivery because they are missed during antenatal care screening. Routine operating teams not trained in the management of placenta accreta spectrum are faced with difficult surgical situations and have to make decisions that may define the clinical outcomes. Although there are general recommendations for the intraoperative management of placenta accreta spectrum, no studies have described the clinical reality of unexpected placenta accreta spectrum cases in resource-poor settings. This study aimed to describe the maternal outcomes of previously undiagnosed placenta accreta spectrum managed in resource-poor settings in Colombia and Indonesia. This was a retrospective case series of women with histologically confirmed placenta accreta spectrum treated in 2 placenta accreta spectrum centers after referral from remote resource-poor hospitals. Clinical outcomes were analyzed according to the initial type of management: (1) no cesarean delivery; (2) placenta left in situ after cesarean delivery; (3) partial removal of the placenta after cesarean delivery; and (4) post–cesarean hysterectomy. In addition, we evaluated the use of telemedicine by comparing the outcomes of women in hospitals that used the support of the placenta accreta spectrum center during the initial surgery. A total of 29 women who were initially managed in Colombia (n=2) and Indonesia (n=27) were included. The lowest volume of blood loss and the lowest frequency of complications were in women who underwent deferred cesarean delivery (n=5; 17.2%) and in those who had a delayed placental delivery (n=5; 20.7%). Five maternal deaths (14%) occurred in the group that did not receive telehelp, and 4 women died of irreversible shock because of uncontrolled bleeding. Previously undiagnosed placenta accreta spectrum in resource-poor hospitals was associated with a high risk of maternal mortality. Open–close abdominal surgery or leaving the placenta in situ seem to be the best choices for unexpected placenta accreta spectrum management in resource-poor settings. Telemedicine with a placenta accreta spectrum center may improve prognosis.
Abstract Background: The presence of differences between the clinical and histological classification of PAS hinders an accurate depiction of the extent of the maternal condition. None of the existing histological classification criteria are based on and correlate with surgical difficulty, morbidity risk, or maternal outcome. Methods: We conducted a case-control study of data of all PAS cases between January 2017 and December 2021 at Dr. Soetomo General Hospital, Surabaya, Indonesia. Uterine dehiscence and any cases with incomplete data were excluded from the study. After surgery, the area of abnormal adherence was marked using small pins for histological analysis. The histopathology specimens were immersed in using Hematoxylin Eosin (HE). PAS cases were divided into three groups depending on the depth of villi: accreta, increta and percreta. Primary outcome was the vesicouterine adherence. Secondary outcomes were intraoperative topography, and surgical outcome. Results: Three hundred sixty-three cases were included for analyses. Our cohort comprised of 99 accreta cases, 246 increta cases and 18 percreta cases. Estimated blood loss was significantly higher in the high-grade PAS (increta and percreta) groups than in the low-grade PAS (accreta) group (2851.0 + 2437.7 mL vs 1970.8 + 1315.8 mL; p < 0.001). Sixty-five (17.9%) cases of vesicouterine adherence were observed. This was associated with higher odds of caesarean hysterectomy (adjusted odds ratio [Adj OR] 30.77 (95% CI 12.52–75.62; p < 0.001) and bladder injury (Adj OR 7.19; 95% CI 1.94–26.64; p = 0.003) but not estimated blood loss (> 2500 mL) (Adj OR 1.06; 95% CI 0.52–2.16; p = 0.87). Cases with bladder injury had a higher estimated blood loss (p = 0.012) and concomitant caesarean hysterectomy (p < 0.001) compared to those without bladder injury. The depth of villi implantation was associated with higher blood loss (> 2500 mL) (p = 0.046) but not bladder injury (p = 0.442) and vesicouterine adherence (p = 0.503). Conclusions: Vesicouterine adherence is not associated with the depth of villi implantation, but rather with the presence of fibrosis between the bladder and uterus. These adhesions also correlated to iatrogenic bladder injuries.
It is routine to give a uterotonic drug following delivery of the neonate during caesarean section. However, there is much heterogeneity in the relevant research, which has largely been performed in low-risk elective cases or women with uncomplicated labour. This is reflected in considerable variation in clinical practice. There are significant differences between dose requirements during elective and intrapartum caesarean section. Standard recommended doses are higher than required, with the potential for acute cardiovascular adverse effects. We recommend a small initial bolus dose of oxytocin, followed by a titrated infusion. The recommended doses of oxytocin may have to be increased in women with risk factors for uterine atony. Carbetocin at equipotent doses to oxytocin has similar actions, while avoiding the requirement for a continuous infusion after the initial dose and reducing the need for additional uterotonics. As with oxytocin, carbetocin dose requirements are higher for intrapartum caesarean sections. A second-line agent should be considered early if oxytocin/carbetocin fails to produce good uterine tone. Women with cardiac disease may be very sensitive to the adverse effects of oxytocin and other uterotonics, and their management needs to be individualised.
15% of multiple pregnancies ends in a preterm delivery, which can lead to mortality and severe long term neonatal morbidity. At present, no generally accepted strategy for the prevention of preterm birth in multiple pregnancies exists. Prophylactic administration of 17-alpha hydroxyprogesterone caproate (17OHPC) has proven to be effective in the prevention of preterm birth in women with singleton pregnancies with a previous preterm delivery. At present, there are no data on the effectiveness of progesterone in the prevention of preterm birth in multiple pregnancies. We aim to investigate the hypothesis that 17OHPC will reduce the incidence of the composite neonatal morbidity of neonates by reducing the early preterm birth rate in multiple pregnancies. Women with a multiple pregnancy at a gestational age between 15 and 20 weeks of gestation will be entered in a placebo-controlled, double blinded randomised study comparing weekly 250 mg 17OHPC intramuscular injections from 16–20 weeks up to 36 weeks of gestation versus placebo. At study entry, cervical length will be measured. The primary outcome is composite bad neonatal condition (perinatal death or severe morbidity). Secondary outcome measures are time to delivery, preterm birth rate before 32 and 37 weeks, days of admission in neonatal intensive care unit, maternal morbidity, maternal admission days for preterm labour and costs. We need to include 660 women to indicate a reduction in bad neonatal outcome from 15% to 8%. Analysis will be by intention to treat. We will also analyse whether the treatment effect is dependent on cervical length. This trial will provide evidence as to whether or not 17OHPC-treatment is an effective means of preventing bad neonatal outcome due to preterm birth in multiple pregnancies. Current Controlled Trials ISRCTN40512715
Objective To investigate whether vaginal Group B Streptococcus ( GBS ) colonisation or other baseline characteristics of women with preterm premature rupture of membranes ( PPROM ) can help in identifying subgroups of women who would benefit from immediate delivery. Design Secondary analysis of the PPROMEXIL trials. Setting Sixty hospitals in the Netherlands. Population Women with PPROM between 34 and 37 weeks of gestation. Methods Random assignment of 723 women to immediate delivery or expectant management. Main outcome measures Early onset neonatal sepsis. Results Vaginal GBS colonisation status was the only marker which was significantly associated with the benefit of immediate delivery ( P for interaction: 0.04). GBS colonisation was observed in 14% of women. The risk of early onset neonatal sepsis in GBS ‐positive women was high (15.2%) when they were managed expectantly but this risk was reduced to 1.8% with immediate delivery. The early onset neonatal sepsis risk was much lower in neonates of GBS ‐negative women: 2.6% after expectant management and 2.9% with immediate delivery. We estimated that by inducing labour only in GBS ‐positive women, there would be a 10.4% increase in term delivery rate, while keeping neonatal sepsis and caesarean delivery rates comparable to a strategy of labour induction for all. Conclusions Our post hoc findings suggest that women with PROM between 34 and 37 weeks might benefit from immediate delivery if they have GBS vaginal colonisation, while in GBS ‐negative women labour induction could be delayed until 37 weeks.
In Brief BACKGROUND: Cisplatin is considered safe to use during the second and third trimesters of pregnancy in patients with cancer. CASE: A 34-year-old pregnant woman was diagnosed with cervical cancer. She received five weekly dosages of cisplatin and paclitaxel, starting at 26 5/7 weeks of gestation. An elective cesarean delivery was performed at 34 4/7 weeks of gestation. After birth, the neonate was diagnosed with severe bilateral perceptive hearing loss. CONCLUSION: Cisplatin during the second and third trimesters of pregnancy may lead to fetal ototoxicity. Cisplatin use during the second and third trimesters of pregnancy may cause fetal ototoxicity.
