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Cancer
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Elyce Cardonick, Charlotte Maggen, Puja Patel
When opting not to preserve pregnancy: The gestational age at diagnosis determines the management choices for the pregnant patient. For operable disease (IA2-IB2) a radical hysterectomy with fetus in utero, or after hysterotomy (late second trimester), can be performed [21]. For stages IB3 and higher diagnosed before 18 weeks, immediate chemoradiotherapy treatment is recommended with the fetus in situ. Often a spontaneous miscarriage will occur within a short time after radiotherapy. With advanced pregnancy, a pregnancy termination by hysterotomy is preferred, as it reduces the risk of obstetrical complications (bleeding, rupture of the cervix, DIC) and the psychological impact on the patient [21]. Prior to treatment, a feticide can be considered for ethical and psychological reasons.
Neoplasia in pregnancy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Frankly, invasive tumors of the cervix demand prompt treatment, although slight delay of up to 6–8 weeks has been shown not to alter prognosis (17,33). For stage IB1 and selected IIA tumors early in pregnancy, treatment options include radiation therapy and chemotherapy or radical hysterectomy with bilateral pelvic lymphadenectomy. Surgery does allow ovarian preservation, but the patient should be counseled prior that certain risk factors could lead to adjuvant radiation or chemotherapy. This option can be effective therapy with the fetus in situ up to 18–20 weeks (47); thereafter, hysterotomy and uterine evacuation should be performed. Radiation is equally efficacious, and no hysterotomy is necessary prior to 20 weeks of gestation with radiation therapy. In general, spontaneous abortion occurs rapidly after exposure to radiation in early pregnancy (48,49). Some authors now recommend using misoprostol to promote expulsion of the pregnancy if it does not occur within an expected time frame to avoid further complications. If the pregnancy is advanced, hysterotomy is required prior to intracavitary radiation. For IB and IIA tumors found in the third trimester, classical cesarean section can be followed by radical hysterectomy with pelvic and para-aortic lymph node dissection. If radiation is planned, lymph node dissection alone can be performed, which may guide subsequent therapy.
Antepartum Haemorrhage
Published in Sanjeewa Padumadasa, Malik Goonewardene, Obstetric Emergencies, 2021
Vaginal delivery may sometimes be the most reasonable option to deliver a fetus that is either dead or bearing a lethal abnormality even in the presence of placenta praevia. This is usually done before 24 weeks of gestation after embolisation of internal iliac arteries, foeticide and induction of labour with a high dose vaginal misoprostol regimen. This practice will bypass the need for a hysterotomy, an operation that carries significant maternal morbidity as far as future obstetric performance is concerned. However, hysterotomy may possibly be performed for maternal safety if there is unacceptable bleeding. In countries where fetocide is illegal, women with placenta praevia in the presence of a lethal fetal abnormality are managed similarly as the case of a live viable fetus.
Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases
Published in Fetal and Pediatric Pathology, 2023
Tess E. K. Cersonsky, Megan Lord, Halit Pinar
The patient was counseled on options for uterine evacuation. Pelvic examination confirmed the presence of a large uterine leiomyoma in the lower uterine segment, and it was unclear if the fetus would be able to pass through the pelvis. A hysterotomy for uterine evacuation would likely require incision into the contractile portion of the uterus. Given the size and location of the leiomyoma, there was also concern for uterine atony following hysterotomy, potentially resulting in hysterectomy. At the time of admission, attempted dilation and evacuation (D&E) in the operating room was not felt to be feasible given the patient’s advanced gestational age. Mildly elevated blood pressures were noted during induction on hospital day 2; serum creatinine and other end-organ laboratory values were normal at this time. The patient was mildly febrile and was started on gentamicin and clindamycin for possible intraamniotic infection.
A case of a contained uterine rupture
Published in Journal of Obstetrics and Gynaecology, 2019
Given the concern for continued bleeding with eventual hemodynamic instability, she was taken into the operating room for an abdominal exploration. A midline vertical incision was made. Upon entry into the abdomen, there was a 6 cm right broad ligament haematoma extending superiorly into the right paracolic gutter. The bladder densely adhered to the lower uterine segment and caesarean scar. The bladder was dissected off carefully and it revealed a rupture of the prior caesarean scar. The rupture was tamponaded by the bladder, giving the illusion of an intact scar on the prior vaginal exams. Once the bladder was adequately taken down, the hysterotomy was repaired in typical fashion. The right pelvic sidewall was opened and the haematoma was evacuated. After a copious irrigation, there was a good hemostasis and the patient’s abdomen was closed. She was discharged on the third postoperative day with a haematocrit of 26. On her postoperative office visits 5, 19 and 42 days later, she remained clinically well and afebrile.
Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity
Published in Journal of Obstetrics and Gynaecology, 2018
Lauren E. Giugale, Sara Sakamoto, Jonathan Yabes, Shannon L. Dunn, Elizabeth E. Krans
A hysterotomy extension was defined as any documentation of an extension by the surgeon in the operative note. The diagnosis of a hysterotomy extension was at the discretion of the operating physician. The estimated blood loss (EBL) in millilitres (ml) was extracted from the CD operative note. An intraoperative haemorrhage was defined as the 95th percentile for EBL (>1200 ml in our dataset). A change in the haemoglobin was the difference between the preoperative haemoglobin and the lowest postoperative haemoglobin value obtained during the hospitalisation. A clinically significant change in the postoperative haemoglobin was defined as ≥3.7 g/dL (95th percentile for this change). The need for a blood transfusion was defined as any transfusion of packed red blood cells intraoperatively or during the postoperative hospital course. The operative time was defined as the time in minutes from the skin incision to the skin closure. Because of the low frequency of cystotomy, an evaluation for lower urinary tract (LUT) injury was assessed as a composite outcome defined as the backfilling of the bladder, intraoperative cystoscopy or an actual cystotomy repair. Evaluation of the LUT was at the discretion of the surgeon.