Third and Fourth Degree Perineal Tear in Four-Year Period at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

OBJECTIVES:

Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman.

MATERIAL AND METHODS:

We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012.

RESULTS:

We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05).

CONCLUSION:

Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.

Abdominal Wall Endometriosis Eleven Years After Cesarean Section: Case Report

Endometriosis is a common chronic disease characterized by growth of the endometrial gland and stroma outside the uterus. Symptoms affect physical, mental and social well-being. Extrapelvic location of endometriosis is very rare. Abdominal wall endometriosis occurs in 0.03%-2% of women with a previous cesarean section or other abdominopelvic operation. The leading symptoms are abdominal nodular mass, pain and cyclic symptomatology. The number of cesarean sections is increasing and so is the incidence of abdominal wall endometriosis as a potential complication of the procedure. There are cases of malignant transformation of abdominal wall endometriosis. Therefore, it is important to recognize this condition and treat it surgically. We report a case of a 37-year-old woman with abdominal wall endometriosis 11 years after cesarean section. She had low abdominal pain related to menstrual cycle, which intensified at the end of menstrual bleeding. A nodule painful to palpation was found in the medial part of previous Pfannenstiel incision. Ultrasound guided biopsy was performed and the diagnosis of endometriosis confirmed. Surgery is the treatment of choice for abdominal wall endometriosis. Excision with histologically proven free surgical margins of 1 cm is mandatory to prevent recurrence. A wide spectrum of mimicking conditions is the main reason for late diagnosis and treatment of abdominal wall endometriosis. In our case, the symptoms lasted for eight years and had intensified in the last six months prior to surgery.

THE RISK OF HYPERCOAGULABILITY IN OVARIAN HYPERSTIMULATION SYNDROME

Ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication of infertility treatment occurring during either the luteal phase or early pregnancy. An increasing number of thromboembolic complications associated with the increased use of assisted reproductive techniques have been reported in the literature. Identification of the risk factors is crucial for prevention of thromboembolic events in OHSS patients. Alterations in the hemostatic system cause hypercoagulability in women affected by severe OHSS. Coexistence of inherited hypercoagulable conditions increases the risk of thromboembolism. The role of clinical parameters that can help predict development of thrombosis is controversial. Patients with a personal or family history of thrombosis undergoing infertility treatment should be considered for thrombophilia screening, while routine examination of inherited thrombophilic mutations is not indicated in infertile patients. Antithrombotic primary prevention is not indicated in healthy women undergoing assisted reproductive procedures or in women with thrombophilia. Anticoagulant therapy is indicted if there is clinical evidence of thrombosis or laboratory evidence of hypercoagulability. In this review, the risks of hypercoagulability in the OHSS are discussed.