Delayed second twin delivery: benefits and risks

Abdelazim equation: For 24-h urine protein from spot urine sample in preeclampsia

Measurement of 24-h urine protein (UP) is the standard method for detection of proteinuria in preeclampsia (PE). A 24-h urine sampling is time-consuming, inconvenient, and delays the diagnosis of PE. A 29-year-old woman, previous cesarean section (CS), pregnant 37 weeks'^{+2 days}, mild PE, and another 31-year-old woman, primipara, pregnant 34 weeks'^{+4 days}, severe PE, were admitted for control of blood pressure and termination of pregnancy. Studied women were subjected to fetal well-being assessment, routine antenatal, and laboratory investigations to exclude chronic renal diseases, and for 24-h urine sampling. A spot mid-stream urine sample was obtained shortly before the 24-h urine sampling to measure the protein/creatinine (P/C) ratio. The first studied woman had normal serum creatinine and blood urea, 688 mg protein/24-h urine, 86 mg/dL spot UP, 178 mg/dL spot urine creatinine, and 0.48 P/C ratio. The second studied woman had also normal serum creatinine and blood urea, 1199 mg protein/24-h urine, 147 mg/dL spot UP, 133 mg/dL spot urine creatinine, and 1.11 spot P/C ratio. The spot urine sample was suggested by the National Kidney Foundation to detect and monitor proteinuria in adults. Moreover, the 24-h UP can be calculated from the following equation: 24-h UP in g = P/C ratio × 0.81 + 0.3 (Abdelazim equation) without 24-h urine sampling. This report suggests the use of Abdelazim equation (24-h UP in g = P/C ratio × 0.81 + 0.3) for detection of 24-h UP from spot urine sample in PE without 24-h urine sampling.

Retrospective evaluation of attempted vaginal deliveries in dichorionic twin pregnancies

Purpose

Numbers of planned cesarean deliveries are increasing in twin pregnancies, despite the lack of evidence for this approach, and the second twin is thought to be at risk for a poorer outcome. The aim of this study was to examine whether twins have a poorer outcome if an attempted vaginal delivery is changed to a cesarean section or combined delivery.

Methods

This retrospective data analysis included all women with dichorionic twin pregnancies attempting vaginal delivery over a 10-year period. Outcome parameters for the first and second twins relative to their mode of birth were compared. A correlation model between the interdelivery time interval and Apgar scores was calculated. Subgroup analyses assessing the birth mode of the first and second twins were conducted.

Results

A total of 248 women were enrolled in the study. The second twins had significantly lower values for outcome parameters, such as umbilical artery cord pH and Apgar scores in comparison with the first twins (P < 0.01). The subgroup analysis of birth modes in first and second twins showed a significantly poorer outcome in the cesarean section and combined delivery group (P < 0.05). The interdelivery time interval was significantly longer in the second twin cesarean section group (P < 0.01). There was no significant correlation between the interdelivery time intervals and Apgar scores (P > 0.05).

Conclusion

Although outcome parameters were significantly lower in second twins and twins born via secondary cesarean section, the clinical relevance of this appears to be negligible.

The outcome of hypertensive disorders with pregnancy

BACKGROUND

Hypertensive disorders (HTDs) with pregnancy remain a major health problem because of the associated adverse maternal and perinatal adverse outcomes.

OBJECTIVES

To evaluate the outcomes of HTDs with pregnancy.

PATIENTS AND METHODS

Four hundred and five (405) hypertensive women included in this retrospective multicenter study. Data of the studied women including maternal age, parity, gestational age at delivery, pregnancy outcome [preterm delivery (PTD), birth weight (LBW), Apgar scores, neonatal intensive care unit admission (NICU), intrauterine fetal death (IUFD), intrapartum and/or early neonatal deaths] were collected. Collected data analyzed statistically to evaluate the outcome of HTDs with pregnancy.

RESULTS

Preeclampsia (PE)/superimposed PE group had significantly high relative risk (RR) and Odds ratio (OR) for PTD (RR 2.1; OR; 3.3; P = 0.0001 and P = 0.0001, respectively), LBW (RR 2.01; OR; 3.17; P = 0.0001 and P = 0.0001, respectively), and low Apgar score at 1st min (RR 1.7; OR 1.9; P = 0.01 and 0.01, respectively) and at 5th min (RR 2.2; OR; 2.36; P = 0.2 and 0.2; respectively). In addition, PE/superimposed PE group had significantly high RR and OR for NICU admission (RR 1.6; OR 2.2; P < 0.0002 and P < 0.0001, respectively) and IUFD (RR 2.9; OR 3.1; P = 0.01 and 0.01, respectively).

CONCLUSION

women with PE/superimposed PE have high RR and OR for PTD, LBW, and low Apgar score at 1st and 5th min, NICU, and IUFD compared to the gestational and chronic hypertension with pregnancy.

Abdelazim technique for repair of dehiscent previous cesarean section scars encountered during elective cesarean sections

The cesarean sections (CSs) rates increased worldwide (32.9% in the United States 2009). CS scar dehiscence (CSSD) is one of the complications encountered after cesarean delivery due to disruption of the scar tissue of the previous CS. CSSD is a risk factor of uterine rupture during trial of labor after previous CS. A 32-year-old woman, previous 3 CSs, admitted to the Obstetrics and Gynecology department of Ahmadi hospital, Kuwait, for elective CS. During the elective CS, the scars of previous CSs were complete dehiscent through its whole length with missing anterior uterine wall leaving visible fetal membranes underneath. This report represents a case of complete CSSD encountered during elective CS and the suggested I. Abdelazim technique for repair of dehiscent previous cesarean section scars encountered during elective CSs.

Prenatal Diagnosis and Immediate Successful Management of Isolated Fetal Epignathus

Epignathus or enigmatic teratoma is rare congenital tumor, arising from the sphenoid region of the palate or pharynx. A 30-year-old pregnant woman presented at 34 weeks + 2 days’ gestation with a well-defined solid mass measuring 6.47 cm × 5.7 cm arising from the fetal oral cavity. The color flow mapping showed that the mass was well vascularized, especially in its center, and its blood supply was originated from the fetal oral cavity. The newborn has no chromosomal abnormalities or other associated anomalies and/or intracranial extension immediately and successfully managed after delivery to highlight the importance of prenatal diagnosis and the importance of multidisciplinary team management.

Prenatal diagnosis of single umbilical artery complicated by intrauterine growth retardation and preterm labor: Case report

Fetuses with single umbilical artery (SUA) at great risk of intrauterine growth retardation (IUGR), intrauterine fetal death (IUFD) and prematurity. A 24-years-old woman, 28 weeks’ gestation, presented to the Ahmadi hospital, Kuwait, with history of preterm premature rupture of fetal membranes (PPROM). After exclusion of the PPROM, the ultrasound scan of the studied woman showed; asymmetrical IUGR with SUA. The diagnosis of SUA confirmed by the color flow Doppler. She delivered spontaneously at 36 weeks+2, and a cut section in the umbilical cord done to confirm the diagnosis of SUA. The congenital and chromosomal abnormalities of the studied neonate excluded after normal pelvi-abdominal, brain ultrasound and normal karyotyping (46, xx); respectively. The prenatal diagnosed SUA in the studied cases associated with IUGR, preterm labor (PTL) and small for gestational age (SGA). SUA can be considered a marker of diagnosable congenital fetal malformation (CFM) and aneuploidy.

Abdelazim and Shikanova suggested protocol of Ain Shams and West Kazakhstan Universities for management of delayed-interval delivery of the second twin: Case report

Background

The incidence of multiple gestations increased after the assisted reproductive techniques. Preterm labor and preterm premature rupture of fetal membranes are the most common complications of multiple gestations. Traditionally, if one fetus is delivered preterm in twin pregnancies, the situation is managed by delivery of the second fetus. Recently, there are reported cases of delayed-interval delivery (DID) of the second twin, with good outcome without established protocol for management of such cases. This report presents the protocol suggested by Abdelazim and Shikanova for the management of DID of the remaining second twin.

Conclusion

The birth weight and the survival rate increased after Abdelazim and Shikanova suggested protocol for management of DID of the remaining second twin without any maternal risks or complications. DID should be done in tertiary centers after informing the parents about the possible risks of keeping the live second twin in the hostile intrauterine environment.

Cesarean section scar dehiscence during pregnancy: Case reports

Background:

The incidence of cesarean section increased worldwide with subsequent increase in the risk of cesarean section scar dehiscence (CSSD). The clinical significance and the management of the CSSD are still unclear.

Case Reports:

Here, we report two cases of CSSD. A 35-year-old woman, gravida 2, previous CS, due to preterm premature rupture of membranes (PPROM) and breech presentation at 30 weeks, was admitted for elective CS at 38^+3d weeks’ gestation. During the second elective CS, it was seen that the site of the previous CS scar was very thin along its whole length and the anterior uterine wall was completely deficient, leaving visible bulging fetal membranes and moving baby underneath. A 32-year-old woman, previous three CSs, was admitted as unbooked case without any antenatal records at 29^+4d weeks’ gestation, triplet pregnancy with preterm labor. She received betamethasone and magnesium sulfate (MgSO₄) for fetal lung and fetal brain protection, respectively, followed by emergency CS. During the CS, the previous CSs scars were dehiscent over more than half of its length and the anterior uterine wall was missing leaving visible fetal membranes. The uterine incision of the studied women was repaired in two layers using vicryl 0 interrupted simple stitches for the first layer, followed by interrupted mattress stitches for the second layer. The studied women had uneventful postoperative recovery and were discharged from the hospital after counseling regarding intraoperative findings, uterine incisions repair, and future pregnancies.

Conclusion:

It is useful to assess the lower uterine segment of women with previous CS using the available ultrasound facilities. If the CSSD is diagnosed before the elective CS, the surgeon should prepare himself with the safest uterine incision with least possible complications and the best way of repair of the defective or dehiscent uterine wall.