Non-descent vaginal hysterectomy: should all hysterectomies for benign conditions be performed vaginally?

The vaginal approach is the natural route of excellence, also known as “natural orifice hysterectomy” or “no scar hysterectomy”. It seems to be the current trend in minimally invasive context for urogynecological procedure, which follows all criteria of minimally invasive surgery. Vaginal hysterectomy (VH) is a longpracticed procedure since the fourteenth century (Berengario de Carpi, 1470–1550). Non-descent vaginal hysterectomy (NDVH) was introduced later in 1934, pioneered by Haeney. In the United States, the trend is now more towards NDVH, especially with the presence of new tools (vessels sealing device), new techniques and changes in contraindications of the procedure

Placenta Cretas: Early Diagnosis is Needed

Incidence of placenta cretas increased in women who had previous caesarean or previous procedures for termination of pregnancy. The diagnosis of this emergency situation is often made at time of caesarean which could lead to increase maternal morbidity or even mortality. Placenta cretas had been reported to cause uterine rupture in early pregnancy. The availability of conventional 2D grayscale, color Doppler or the 3D power Doppler has changed the trend of time of the diagnosis made ie from at time of caesarean to as early as first trimester. These would give the advantage in anticipating and preventing complications. We demonstrate two cases of placenta increta one diagnosed at autopsy whereby presented as acute abdomen at 15 weeks of pregnancy and the other was diagnosed at 14 weeks by all the above ultrasound techniques. First case: A 35 year old G6 with previous one caesarean for her first pregnancy and two dilatation and curettage (D&C) procedures during her fourth and fifth pregnancies. At 15 weeks of pregnancy, she was brought to the emergency department for an acute abdomen following sexual intercourse. However her condition deteriorated to asystole. At autopsy there was a ruptured uterus over the uterine lateral-fundal measured 8 x 4.5 cm exposing sac of fetus. The histopathology was reported as placenta increta. Second case: A 33 year old G4 with two normal vaginal deliveries and a D&C for missed miscarriage during the third pregnancy. She first presented at 14 weeks for routine antenatal visit. 3D Power Doppler showed increased periplacental vascularity highly suggestive of morbidly adherent placenta. She was followed and had caesarean hysterectomy at 36 weeks with histopathology of placenta increta. Conclusion: Placenta cretas may lead to ruptured uterus and maternal mortality even in early pregnancy. In early pregnancy, prenatal diagnosis by ultrasound techniques is possible. Women with risk factors of placenta cretas need further ultrasound evaluation at the earliest stage of pregnancy

Induction of labour using foley catheter: traction versus non traction technique, a randomized prospective study.

Background: Cervical ripening of an unfavourable cervix can be achieved by placement of a transcervical Foley catheter. Objective: To assess the effectiveness of 750 ml traction on Foley catheter compared to no traction for labour induction. Study design: A randomized controlled trial performed on pregnant women at 37-41 week who were admitted for induction of labour with unfavourable cervix. They were randomly assigned into two groups, Foley’s with 750 ml traction and and without traction. The primary outcomes were improvement in Bishop Score, number of favourable cervix following induction and the mode of delivery. The secondary outcomes were maternal pain score, neonatal outcome, and maternal infection. Results: A total of 160 women were randomized into traction group (n=80) and non-traction group (n=80). The mean change in Bishop Score was similar in both groups. Traction group had significantly (p=0.006) higher number of vaginal delivery (70%) compared to non-traction group. The rate of successful VBAC was also significantly (p= 0.001) higher in the traction group. Participants were comfortable using both methods with low pain score. There was no difference in neonatal outcomes and risk of maternal infections in both groups. Conclusion: application of traction did result in more vaginal delivery and successful VBAC without risk of maternal and neonatal infection

Maternal outcome of prenatally diagnosed lethal fetal anomalies: a year review

Objectives: To determine maternal morbidities in relation to prenatal diagnosis of lethal fetal anomalies and termination of pregnancy (TOP). Materials: Twenty five patients with prenatal diagnosis of lethal fetal anomalies in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. Methods: This was a retrospective review in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia in the year of 2011. All patients diagnosed prenatally to carry lethal fetal anomalies was reviewed. Data regarding maternal morbidities and outcome was collected from patients’ case note in the hospital record office. Analysis was done by using SPSS version 17.0. Results: Twenty five pregnant patients were diagnosed with lethal fetal anomalies via ultrasound with or without genetic study. The patients’ mean age was 29.9±6.3 years old. The mean gestational age at diagnosis of lethal fetal anomalies and at TOP or delivery were 26.5±7.4 and 28.7±7.8 weeks respectively. The lethal fetal anomalies included fetuses with multiple structural abnormalities (40%), anencephaly or severe encephalocele (32%), non-immune hydrops fetalis (16%) and syndromic fetuses (12%) i.e. Pentalogy of Cantrell and Edward’s syndrome. Seven (28%) patients had early counseling and TOP at the gestation of <22 weeks. Beyond 22 weeks gestation, 8 (32%) patients had TOP and 10 (40%) patients had spontaneous delivery. Twenty (80%) patients delivered or aborted vaginally, 3 (12%) patients with assisted breech delivery, and 2 (8%) patients with abdominal delivery. The abdominal deliveries were for transverse lie in labour and emergency hysterotomy for failed induction complicated by hysterectomy due to intraoperative finding of ruptured uterus. Overall, the associated adverse events included abnormal lie during delivery (16%), symptomatic polyhydramnios requiring amnioreduction (16%), post-partum haemorrhage (12%), retained placenta (12%), blood transfusion (8%), uterine rupture (4%) and endometritis (4%). Mean duration of hospital stay was 6.6±3.7 days. Conclusions: Prenatal diagnosis and TOP at an early gestation may reduce maternal morbidities and improve the outcom

Maternal outcome of prenatally diagnosed lethal fetal anomalies: a year review

This was a retrospective review in Hospital Tengku Ampuan Afzan, Kuantan, Malaysia In the year of 2011. All patients diagnosed prenatally to carry lethal fetal anomalies was Reviewed. The outcome of the pregnancy including type of labour, mode of induction and delivery, and associated morbidities during antenatal, intrapartum, and postpartum period was analyse

Bladder scan vs urethral cathetarization for measurement of immediate post partum bladder volume

Introduction: Bladder scan is a well known non invasive and cost effective tool for the measurement of post void residual urine(PVR) however with some limitation. Literature on the efficacy of bladder scan on big uterus is limited and not promising. Study Objective: To determine the validity of bladder scan BV13000 in detection of bladder volume in immediate postpartum women. Methodology: A prospective cross sectional study conducted in Hospital Tengku Ampuan Afzan, Pahang from 1st September to 30 November 2010, A total of 193 women who had undergone Caesarean section were recruited on postpartum day 1. Prior to removal of Foley’s catheter, their bladder volumes were first estimated by bladder scan BV13000. Immediately the bladder was then catheterized for the true bladder volume followed by 2D ultrasound bladder scanning to ensure that it was completely emptied. The data was analyzed using SPSS software version 18(SPSS Inc. Chigaco, Illinois). P value of less than 0.05 is considered as statistically significant. Resul : There were a total of 193 women recruited with the mean age of 28.84 years (SD 5.516) with mean BMI of 29.69( SD 5.69) kg/m2 and fundal height of 16cm (SD 2.382 ). The mean for time interval between bladder scan and catheterization was 3 min(range between 1-8 min). There is a linear relationship between the bladder scan-estimated and catheter bladder volumes (r2=082). The patient’s body weight also is significantly (p=0.01) correlated with the bladder scan-estimated volume with r2 of-0.25. The size of the uterus however does not correlate with the bladder-scan volume Conclusion : Bladder scan is comparable to urethral catheterization in the measurement of postpartum bladder volume

A six years review of placenta Accreta Spectrum Disorder in a tertiary referral Hospital

A Six Years Review of Placenta Accreta Spectrum Disorder in a Tertiary Referral Hospital Izzni Adilah Dzulkifli1, Hamizah Ismail1, Zalina Nusee1, Noraihan Mohd Nordin2 1 Department of Obstetrics and Gynaecology, International Islamic University Malaysia, Kuantan, Pahang 2Department of Obstetrics and Gynaecology, Hospital Tuanku Azizah Kuala Lumpur Introduction: Placenta Accreta Spectrum results from the rising caesarean sections, hence impacting maternal morbidity and mortality. This research is a review of women with PAS at a single tertiary center from 2015 till 2020.Materials and method: Data from medical records were collected in which women with PAS were categorized according to their primary surgical approach. SPSS version 25.0 was used for descriptive analysis. Results: There were 65 PAS cases with an overall incidence of 1 per 1000 deliveries. Four cases were excluded due to missing records. PAS affected women of age 35.8+/-4.8(36), 85% were multiparous, 96% of the women had previous caesarean delivery in whom 88% had placenta praevia. Thirty-eight had a primary caesarean hysterectomy, 23 had uterine conserving surgery. Fourteen women required delayed hysterectomy due to complications. Prenatal imaging (US/MRI) had a significant association with the intraoperative findings and histopathological confirmation of PAS (p<0.01).Adjunct procedure (internal iliac artery balloon occlusion, uterine artery embolization, uterine artery ligation) on both groups showed no significant effect on the blood loss (p=0.64).Caesarean hysterectomy were associated with higher blood loss, blood transfusions and bladder injury (p<0.05).There was no maternal death in this study. No pregnancy reported in the uterine conserved group. Conclusion: Previous caesarean delivery is the leading risk factor for PAS. Primary caesarean hysterectomy carries higher morbidity. Conservative approach is possible in selected cases through perioperative planning in an established well-equipped center. KEYWORDS: placenta accreta spectrum, caesarean hysterectomy, conservative surgery, maternal morbidit