Delayed uterine rupture occurred 4 weeks after cesarean section following sexual intercourse: a case report and literature review

Maternal and Neonatal Outcomes After Ex-Utero Intrapartum Treatment for Congenital Diaphragmatic Hernia: A Case Series

INTRODUCTION

 Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition.

MATERIAL AND METHODS

 We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery.

RESULTS

 A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful.

CONCLUSIONS

 In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.

Secondary postpartum hemorrhage: Incidence, etiologies, and clinical courses in the setting of a high cesarean delivery rate

Objectives

To evaluate the incidence, etiologies, and clinical outcomes of secondary postpartum hemorrhage in a hospital with a high cesarean section rate and to compare the etiologies of secondary postpartum hemorrhage following cesarean delivery versus vaginal delivery.

Materials and methods

This retrospective study included 123 women with secondary postpartum hemorrhage who were treated at a tertiary-level hospital between January 2004 and June 2018. Descriptive statistics and the chi-square test were used for data analysis.

Results

The incidence of secondary postpartum hemorrhage was 0.21%. The median onset of bleeding was 12 days after delivery. Fifty-two percent of the deliveries were by cesarean section. The most common etiology of secondary postpartum hemorrhage was endometritis (67.5%), followed by retained placental tissue (21.1%). Women who delivered by cesarean section had a higher rate of endometritis (80.0% vs 53.4%) and a lower rate of retained placental tissue (10.8% vs. 32.8%) than those who delivered vaginally. Surgical intervention included uterine evacuation in 29.3% and hysterectomy in 8.1% of the patients. Five percent of women were treated by embolization.

Conclusions

Endometritis was the most common cause of secondary postpartum hemorrhage. Women who delivered by cesarean section were less likely to have retained placental tissue but were at higher risk for endometritis and uterine pseudoaneurysm than those who delivered vaginally.

Etiology of Cesarean Uterine Scar Defect (Niche): Detailed Critical Analysis of Hypotheses and Prevention Strategies and Peritoneal Closure Debate

There is an increasing incidence of cesarean scar (CS) defect/niche and its sequelae, probably not entirely explained by better diagnosis or rising cesarean rate. Discussion of possible etiological factors has received scant attention but would be important to formulate preventive strategies. Meaningful informative studies on long-term sequelae of cesarean section are very difficult and none are available for causation of CS defect. Hence, it is crucial to identify key areas in etiology of CS defect for focused research. This practical review proposes an "ischemia and mal-apposition hypothesis for CS niche", stating that the surgical technique of uterine incision closure is the most important determinant of CS defect formation. Other factors such as cervical location incision, adhesion formation and patient specific factors seem far less important in etiology. Rather than the headline theme of "single versus double-layer closure of uterus", the finer details of surgical technique which achieve good apposition without inducing tissue ischemia seem more important. Different techniques are discussed and it is proposed that continuous, non-locking absorbable sutures in two layers, without including much of decidua and without undue tight (constricting/devasculaizing) pulling of sutures are likely to result in good healing of uterine scar. Single-layer technique may be best reserved for thin myometrial edges especially during repeat cesareans. Adhesions between uterine isthmus and bladder/abdominal wall seem common associations but not causative for CS niche. It would be desirable to prove these surgical principles by good quality prospective randomized "quantitative" studies but the wait may be very long and this should not hinder the adoption of good surgical principles. Science is much cognitive and not just empirical. To consider a related example, the current recommendation of non-suturing of peritoneal layers during cesarean is mistakenly based on short-term irrelevant surrogate outcomes like analgesic requirements and time-saving, many of which have been already disproven. Evidence is presented recommending simple quick techniques of peritoneal closure to prevent adhesions. More analytical debate in surgical techniques is needed to inspire engaged, critical and insightful practitioners rather than unquestioning dependence on weak evidence/guidance.

Spontaneous postpartum rupture of an intact uterus: a case report

Rupture of uterus is an obstetrical complication characterized by a breach in the uterine wall and the overlying serosa. We report an unusual case of spontaneous rupture of an unscarred uterus in a 33-year-old woman, a day after her third successful vaginal delivery. A 33-year-old pregnant woman, gravid 3, para 3, was referred to our department at 39 gestational week because of rupture of membranes. Despite tocolysis administration, her pregnancy was delivered vaginally after 2 days, giving birth to a male neonate of 3,020 g with normal Apgar scores at first and fifth minute. Her uterus was intact and gynecological examination after delivery was normal without any potential signs or symptoms of pathology. However, the day following her labor, patient complained of left iliac fossa pain. Her blood tests revealed a CRP value at 27.6 mg/L, whereas the X-rays revealed an extensive impacted fecal mass in the colon. MRI revealed that the left lower myometrial part of the uterus was depicted abrupt, with simultaneous presence of hemorrhagic stuff. The decision of laparotomy was therefore made in order to further evaluate rupture of uterus and properly treat patient. And subtotal hysterectomy was performed. Postoperative follow-up period was not characterized by any complications and patient was finally discharged 4 days after hysterectomy.