Search

Background: Conjoined twins (CT), which used to be historically defined as "monstrous human" and previously so-called Siamese twins in the early eighteenth century, are one of the very rare congenital malformations with an uncertain etiology and complex yet remain inconclusively debatable regarding its pathophysiological mechanisms of fusion and fission theories. Among all types of CT, parasitic CT, especially the pygopagus sub-type, is exceedingly rarer. To the best of the authors' knowledge, no parasitic CT had been reported in Papua, and this is the first finding in South Papua. Case Report: Herein, a 30-year-old multigravida female with 37th-week gestation, previous twice spontaneous miscarriage, and non-adequate antenatal care history is presented with a chief complaint of painful construction and greenish fluid leakage from the vagina, with an examination that showed a cephalic presentation with a "peculiar" big mass at the upper uterus and complete cervical dilation toward second-stage inpartu. Vaginal delivery was performed with a complication of obstructed labor due to uncommon dystocia with a suspected "big mass" below the fetal buttocks and intrapartum dead. Intrapartum transabdominal ultrasound demonstrates a gross anatomically like an organ inside a fluid-filled mass with unidentified parts, leading to a suspected type of congenital malformation at the baby's sacral region. Emergency C-section was done with findings of parasitic pygopagus CT, showing an attachment of a large irregular fluid-filled mass-like incomplete twin (parasite) with palpable soft tissue and bony structure inside to the buttocks of a male autosite twin, and an additional third leg which happened to be an under-developed lower extremity with a sacrum-like structure. Conclusions: An obstetrician's routine ANC and critical radiological evaluation will increase the odds of identifying CT or other congenital malformations to provide better delivery planning or further management. Increasing maternal health knowledge in society, improving medical skills and knowledge levels for health providers, and advancing supporting facilities and specialists are future strategies for managing and preventing such cases in low-middle-income countries. [ABSTRACT FROM AUTHOR]

Background: In Egypt, as elsewhere around the world, there are more medical malpractice claims and lawsuits being brought against doctors and hospitals. The present study attempts to identify the medico-legal aspects of medical malpractice cases, determine the most frequent causes of medical errors, and the most medical specialities facing this problem and their qualifications. Find out the positive cases from the negative ones, and determine the causes of their death. Methods: This study is a retrospective descriptive observational study of medical malpractice dead cases in Cairo and Giza governorates from the available records and reports of the Forensic Medical Authority from the 1st of January 2014- to the 1st of January 2015 which included 112 cases with alleged medical malpractice dead cases. The outcomes of forensic autopsies were used to distinguish between positive and negative cases. Results: According to the socio-demographic data of the claimed cases, the female cases (53.6%) dominated the male cases (46.4%). The majority of accusations of medical errors were submitted due to negligence (73.68%), followed by complications within surgical therapy (15.79%). In the study, claims against obstetricians were the highest (24.1%), followed by those against anesthesiologists (20.5%), and general surgeons (17%). university hospitals have the highest percentage of positive cases (75%), followed by insurance hospitals (25%), private hospitals (15.6%), and public hospitals (11.1%). Conclusions: The majority of the studied cases were female. Obstetricians had the most accusations in the study and the most positive cases. The most frequent medical error in the study is negligence. All of the study's cases of obstructed labour are positive, but none of the cardiac arrhythmia or heart failure cases are. The majority of cases at university hospitals were positive and the majority of cases at public hospitals were negative. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure.Methods: The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as “easy,” “of intermediate complexity,” or “difficult” based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression.Results: The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success (“closed and dry”) was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for “easy” cases, 68% for “intermediate” cases, and 57% success for “difficult” cases. Success decreased with increasing numbers of previous attempts at surgical repair.Conclusions: These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: We tested the null hypothesis that there were no differences between patients with obstetric fistula and parous controls without fistula. Methods: A unmatched case-control study was carried out comparing 75 women with a history of obstetric fistula with 150 parous controls with no history of fistula. Height and weight were measured for each participant, along with basic socio-demographic and obstetric information. Descriptive statistics were calculated and differences between the groups were analyzed using Student's t test, Mann-Whitney U test where appropriate, and Chi-squared or Fisher's exact test, along with backward stepwise logistic regression analyses to detect predictors of obstetric fistula. Associations with a p value <0.05 were considered significant. Results: Patients with fistulas married earlier and delivered their first pregnancies earlier than controls. They had significantly less education, a higher prevalence of divorce/separation, and lived in more impoverished circumstances than controls. Fistula patients had worse reproductive histories, with greater numbers of stillbirths/abortions and higher rates of assisted vaginal delivery and cesarean section. The final logistic regression model found four significant risk factors for developing an obstetric fistula: age at marriage (OR 1.23), history of assisted vaginal delivery (OR 3.44), lack of adequate antenatal care (OR 4.43), and a labor lasting longer than 1 day (OR 14.84). Conclusions: Our data indicate that obstetric fistula results from the lack of access to effective obstetrical services when labor is prolonged. Rural poverty and lack of adequate transportation infrastructure are probably important co-factors in inhibiting access to needed care. [ABSTRACT FROM AUTHOR]

Introduction: Uterine rupture is a catastrophic obstetrical emergency associated with a significant feto-maternal morbidity and mortality. Many risk factors for uterine rupture, as well as a wide range of clinical presentations, have been identified. Objectives: To analyze the frequency, predisposing factors, and maternal and fetal outcomes of uterine rupture. Methods: A retrospective analysis of cases of unscarred uterine rupture was conducted at the Department of Obstetrics and Gynecology, RIMS, Imphal from June 1, 2010 to June 30, 2012. Results: Our analysis comprised 13 cases. Of these, 30.8 % were booked cases. Most of the cases (46.2 %) were Para 2. Uterine rupture occurred at term in 10 cases. The rupture occurred due to mismanaged labor (30.8 %), the use of oxytocin (23 %), instrumental delivery (15.4 %), obstructed labor (15.4 %), induction by prostaglandin gel (7.7 %), and placenta percreta (7.7 %). Maternal deaths and perinatal deaths were 30.8 and 53.8 %, respectively. Sub-total hysterectomy was done in 8 cases and in 1 patient laparotomy with repair was performed. Conclusion: Ruptured uterus causes a high risk in patients. An unscarred uterus can undergo rupture even without etiological or risk factors. The patients with mismanaged labor, grand multiparas, and obstructed prolonged labor must be managed by properly trained personnel at a tertiary care center in order to avoid the morbidity or mortality. [ABSTRACT FROM AUTHOR]

Background: Destructive operations have a limited role in modern day obstetrics. In the developed countries, obstetrics has become so advanced that these instruments have actually been put away. However, in developing countries like India, these procedures have a limited role where obstructed labor still continues to plague thousands of women every year and accounts for 8% of maternal deaths. This study was planned to define the changing role of destructive operations in obstetrics over the years as more number of abdominal deliveries are conducted in modern day obstetrics than these procedures. Materials and methods: A retrospective analysis of destructive operations performed at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, over a span of 25 years, between 1983 and 2007, was carried out. Results: Of a total of 85,952 deliveries in PGIMER in these 25 years, there were 25,474 cesarean deliveries (29.63%), and 8,826 (10.26%) operative vaginal deliveries. The total number of destructive operations performed was 230 (0.26%). There were 202 craniotomies (87.8%), 13 decapitations (5.7%), 8 eviscerations (3.6%) and 7 cleidotomies (2.9%). Conclusion: There should be an individualized approach to each case of obstructed labor. The health care provider has to decide on the options available to him to deliver the mother by the safest route without causing morbidity and mortality. If the fetus is dead, a destructive procedure can be considered in place of abdominal-route delivery which carries considerable risk to the debilitated mother in neglected labor. [ABSTRACT FROM AUTHOR]

Background: Uterine rupture during pregnancy is a rare occurrence that frequently results in high incidence of maternal and fetal morbidity and mortality. Aim: To study the incidence, risk factors, maternal and fetal outcome of uterine rupture. Study design: A retrospective study. Methods: A retrospective study was carried out in the Department of Obstetrics and Gynecology in a tertiary health care center. The cases of uterine rupture whether booked or unbooked that were received and managed in the hospital over a period of 5 years from January 2002 to December 2006, were included in the study. Results: The total number of uterine rupture cases was 57 out of 33,394 deliveries. The incidence of uterine rupture was 0.17%. Majority of the patients belonged to age group 30-34 years and were multiparas. Most of the cases were due to obstructed and neglected labor (52.63%), 35.08% due to scar rupture and 8.77% were due to uterine trauma. The bladder injuries were found in 8.77%. Repair of the uterine rent was possible in 70.18% (40/57) cases. Hysterectomy was done in 29.82% cases. Stillbirths were observed in 94.74% of women with uterine rupture. There was no maternal mortality. Conclusions: The leading cause of uterine rupture was found to be neglected and obstructed labor due to mismanagement by local untrained birth attendants. Timely recognition and referral to higher centers can reduce the maternal and fetal morbidity and mortality due to uterine rupture. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The objectives of this study are to analyze the surgical outcomes of women undergoing obstetric fistula repair operations at the ECWA Evangel VVF Center, Jos, Nigeria, and to identify factors associated with postoperative urinary continence. Methods: Sociodemographic and clinical data were abstracted retrospectively from the Center's database for patients who underwent vesicovaginal fistula (VVF) repair operations. These data were compared with clinical outcome ('wet' or 'dry') at the time of hospital discharge. Results: From August 1998 to April 2004, 1,084 fistula repair operations were performed on 926 patients. A vaginal approach was used in 90.1% of cases, and postsurgical continence was achieved in 70.5% of patients. Continence was more likely in patients with an intact urethra, an upper or midvaginal fistula, and less fibrosis than in those patients who remained wet. Conclusions: Two thirds of patients with obstetric fistulas can be cured, with complete restoration of continence and low surgical morbidity, using a transvaginal surgical approach. [ABSTRACT FROM AUTHOR]

Background: Pelvic angiomatosis is a very rare cause of obstructive labor. Materials and methods: A 26-year-old P2 L2 had two cesarean sections for recurrent obstructed labor due to a large pelvic mass. Investigations after the first cesarean section suggested a benign nature of the mass for which she was advised surgical resection, but she refused due to social reasons. Tumor had pelvic and extrapelvic part extending through obturator foramen into the right thigh. Resection of the pelvic part by abdominoperineal approach led to a profusely bleeding bed which was managed by ligation of bilateral internal iliac artery. Resection of extrapelvic part was attempted but it was abandoned due to hemodynamic instability of the patient. Results: Patient is asymptomatic and is having a relatively static residual extrapelvic part of pelvic tumor for last 2 years. Conclusion: Pelvic angiomatosis is a very rare condition but should be considered and ruled out in case of a pelvic mass of uncertain origin. MRI plays an important role in the initial diagnosis, in surgical planning and in the follow-up in order to detect recurrences. Surgical resection should be as conservative as possible, balancing the need for complete surgical extirpation with the morbidity of the procedure. [ABSTRACT FROM AUTHOR]

Creation of the bladder flap, i.e., dissecting the urinary bladder from the lower segment of the uterus is a standard part of cesarean section (CS). However, it is yet to be established whether the formation of bladder flap is advantageous. Pelosi and Ortega in 1994 introduced a new minimally invasive technique of CS, which included the omission of bladder dissection together with other modifications. Omission of the bladder flap provides short-term benefits such as reduction of operating time and incision-delivery interval, wound infection, reduced blood loss and analgesic requirement. In addition, it is associated with good long-term outcomes with regards to adhesion formation. Further large-scale controlled randomized clinical trials are needed to investigate the safety of this technique with respect to in deeply engaged head, preterm, subsequent pregnancies and trial of labor and also to determine the future role of this technique that will contribute to advancement and popularity of this technique amongst obstetricians. [ABSTRACT FROM AUTHOR]

Metastatic retroperitoneal adenocarcinoma presenting as obstructed labor is extremely rare. An unbooked 35-year-old multipara came to our casualty in obstructed labor at 38 weeks of pregnancy. A palpable retroperitoneal mass was found behind the gravid uterus and cervix after delivery of a live baby during emergency cesarean section. Needle biopsy was taken from the mass and abdomen was closed due to nonavailability of frozen section facility at night. Post cesarean section CT scan confirmed the pelvic mass, which was subjected to open biopsy. A diagnosis of retroperitoneal adenocarcinoma with an unknown primary was made based on histopathology and a negative workup for the possible primary sites. Patient was treated successfully with chemotherapy and did not show recurrence for last 2 years of follow-up. Surgeons should be aware of this extremely rare entity and it highlights the importance of proper antenatal care to pick up such pathology at an early stage by careful examination and ultrasound to minimize the morbidity and mortality. We also suggest frozen biopsy in a suspected pelvic mass during surgery and early cesarean section to avoid the complications of obstructed labor in such advanced stages of malignant tumor. [ABSTRACT FROM AUTHOR]

This is a retrospective study carried out over a period of 7 years at a tertiary care hospital to evaluate the indications, types and complications of destructive operations. During this period, 51 destructive operations were performed on women with obstructed labor and intrauterine fetal death. The most common operation performed was craniotomy (68.62%) followed by decapitation (19.60%), evisceration (7.84%) and cleidotomy (3.92%). The most common indication was cephalopelvic disproportion (31.25%). Out of 53 babies delivered (one triplet delivery), two were grossly malformed and 49.05% babies had birth weight between 3.0 kg and 4.0 kg and 9.43% were macrosomic. A total of 45.09% women had complications like atonic PPH, vaginal and perineal tears, puerperal sepsis and urinary tract infection. However, there was no maternal death. It is felt that for the women who belong to poor socio-economic status and have poor compliance and who present late in labor with features of obstruction, intrauterine sepsis and fetal death, destructive operation is still a good option. [ABSTRACT FROM AUTHOR]

Vesicovaginal fistulas that result from the trauma of obstructed labor cause a massive problem worldwide in developing countries. An assessment of the problem and a call for action are presented in this paper. [ABSTRACT FROM AUTHOR]

An unusual case of anuria due to the obstruction caused by blood clot following repair of ruptured uterus is presented. Although the blood clot usually dissolves, the awareness of this complication is important to avoid the unnecessary procedures. [ABSTRACT FROM AUTHOR]