Trial of labor in patients with a previous lower uterine vertical cesarean section

OBJECTIVE: Our purpose was to determine the efficacy and safety of a trial of labor in patients previously delivered at least once by a lower uterine vertical cesarean section. STUDY DESIGN: A retrospective review was performed at a single tertiary perinatal center, The University of Florida Health Science Center, Jacksonville. The medical records of all patients with a previous low vertical cesarean section who underwent a trial of labor during a 72-month period from January 1988 until December 1993 were reviewed. The medical records of the next two patients who did not have a prior uterine incision admitted to labor and delivery after the index case served as the controls. The duration and outcome of labor, including mode of delivery, maternal and perinatal morbidity, and birth trauma were evaluated. RESULTS: Of 77 patients with a previous low vertical cesarean incision, 11 (14.3%) had a repeat operation compared with 14 of 154 patients (9.0%) in the no previous cesarean section group (not significant). No differences were noted in the incidences of operative vaginal deliveries or prolonged duration of the first or second stages of labor, or in the rate or maximum dose of oxytocin infusion between the two groups. One patient in the previous cesarean section group had uterine rupture. The incidence of umbilical artery pH < or = 7.20 was similar. No difference in the number of infants with 1- or 5-minute Apgar scores < or = 7 was noted. CONCLUSION: A trial of labor in women with previous low vertical cesarean sections results in an acceptable rate of vaginal delivery and appears safe for both mother and fetus.     

Late post-partum hemorrhage after cesarean section due to rupture of a false aneurysm of the uterine pedicle

We report a 14 year-old girl with a huge adenomatous goiter in the left lobe in the thyroid gland reaching the aortic arch with elevated thyroglobulin. The tumor grew rapidly for two years since the initial diagnosis as an euthyroid hemilateral goiter. Ultrasonography revealed multinodular tumors and magnetic resonance imaging made clear the lower expanding site of the tumor. We recommend careful follow up of hemilateral diffuse goiters by ultrasonography for earlier detection of nodular changes as seen in our case.     

External cephalic version after previous cesarean section--a clinical dilemma

It has been proposed that postsynaptic Ca2+ is required for induction of cerebellar long-term depression (LTD). However, whether a depolarization independent increase in Ca2+ is sufficient for LTD induction remains to be determined. We used nitr-5, a photolabile Ca2+ chelator, to address this issue. Photolysis of nitr-5 together with glutamate application, but neither photolysis of nitr-5 alone nor glutamate application alone induced LTD. When two independent glutamate pipettes were aimed at different dendrites of the same Purkinje neurone, LTD induction was confined to the site at which glutamate and photolysis of nitr-5 were applied. These results indicate that activation of glutamate receptors together with intracellular Ca2+ increase without depolarization is sufficient to induce LTD in cultured Purkinje neurones.     

Responses to vaginal birth after cesarean section

Recently, significant new insight has been obtained into the structure and catalytic mechanism of enzymes that convert environmental pollutants. Recent advances in protein engineering make it possible to use this information for improving the catalytic performance of such enzymes to achieve increased stability and expanded substrate range.     

Morbidity after cesarean section in obese women

The nucleotide sequences of the ribulose-1,5-bisphosphate carboxylase/oxygenase large subunit gene (rbcL) of Glycyrrhiza glabra, G. uralensis, G. inflata, G. echinata, and G. pallidiflora have been determined to construct the phylogenetic tree. In the phylogenetic tree based on the rbcL sequences, the five Glycyrrhiza species were divided into two groups: the three glycyrrhizin-producing species G. glabra, G. uralensis, and G. inflata; and the two glycyrrhizin-nonproducing species G. echinata and G. pallidiflora. Among the three glycyrrhizin-producing species, only two nucleotide substitutions were observed between the rbcL sequence of G. glabra and G. uralensis, and the sequence of G. uralensis was identical to that of G. inflata, indicating that the three glycyrrhizin-producing species are closely related.     

Vaginal birth after cesarean section in twin gestation

OBJECTIVE: We report a 10-year experience with vaginal birth after cesarean section in women with twins. STUDY DESIGN: Data were gathered from labor and delivery records and maternal and neonatal hospital charts. Women with a vertical uterine scar, a previous uterine rupture, an unrepaired dehiscence, or obstetric contraindications to labor were excluded from a trial of labor. Full-thickness uterine defects requiring intervention were classified as ruptures; all others were classified as dehiscences. RESULTS: Between Jan. 1, 1985, and Dec. 31, 1994, at Los Angeles County/University of Southern California Women's Hospital, 210 women with previous cesarean births were delivered of twins. One hundred eighteen (56%) underwent repeat cesarean delivery without a trial of labor. Ninety-two (44%) undertook a trial of labor with no uterine ruptures and no increase in maternal or perinatal morbidity or mortality. CONCLUSIONS: In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery.     

Fertility in anovulatory patients after primary cesarean section

We report a successful surgical treatment of an infective thoracic aortic aneurysm ruptured to the left lung. A 63-year-old man who had been suffering from fever and cough showed twice of hemoptysis. Chest CT revealed a descending thoracic aortic aneurysm ruptured to the left lung. A semiemergent operation was performed. At operation, aneurysm of descending thoracic aorta was found adherent to the left lung. Aneurysmectomy with left pneumonectomy was carried out. The postoperative course of the patient was uneventful. Conceivably, in order to avoid massive intraoperative bleeding during division of dense adhesion and postoperative graft infection, concomitant lung resection is necessary.     

Modifications to the technic of cesarean section after Stark

BACKGROUND: As the operating births (caesarean section) increase, many surgical equipes have been compelled to revise operating techniques in order to reduce fetus extraction times and the whole expense of operation without renouncing, at the same time to beauty advantages. With Stark technique, that we have modified, we have obtained all these aims, improving at the same time patients' postoperative course as well succeeding to extract the fetus in about five minutes. In the '70 Cohen explained the utility of a transiliac incision allowing the access to abdominal cavity with rectus muscles unsticking in an area in which these muscles should present a less adhesiveness. METHODS: Since 1988 Stark has used Cohen's technique changing however uterus closing times, peritoneal membranes and abdominal walls. Our technique is different since we performed the incision according to Pfannestiel. RESULTS: The times are considerably reduced to 4.8 minutes for fetus extraction and in postoperative time the complications are drastically reduced too (infection, pain, hematoma, adhesions). CONCLUSIONS: Therefore we can surely say that this kind of technique can be used with success in all gynaecological surgery, in extrauterine pregnancies and adnexial tumefactions (not malignant). Personal opinion is that spinal anesthesia is the best analgesic technique.     

Endometriosis in postoperative abdominal wall scar after cesarean section

Endometriosis in postoperative abdominal wall scar after cesarean section is rarely observed. In professional literature, only single cases are reported. The author presented 27 cases of this diseases. The women were treated in the Gynaecology and obstetrics Department of Medical School in Lód?, in 1985-1994. Because of the small response to pharmacological treatment, the treatment of choice was surgical of the lesion. In the article, the literature concerning the disease is presented.     

Parital cutaneous necrosis of the abdominal wall after cesarean section

OBJECTIVE: The assess the incidence of tardive dyskinesia (TD) in a sample of adolescents treated with neuroleptic medication and to identify the presence of any risk factors for TD within the affected group. METHOD: A retrospective chart review was conducted for 40 cases. The Abnormal Involuntary Movement Scale (AIMS) was used to measure side effects from medication at 6-month intervals over 2 years. Drug exposure was converted to chlorpromazine (CPZ) equivalent and the presence of risk factory for TD, such as a diagnosis of affective disorder, medication noncompliance, early age of illness onset, and concomitant antiparkinsonian medication, was also noted. RESULTS: Of the 40 cases reviewed, 2 patients (5%) met diagnostic criteria for TD, and another 5 patients (12.5%) showed symptoms of TD. CONCLUSIONS: TD is a serious risk at any age. Medication noncompliance, early age of illness onset, and concomitant use of antiparkinsonian medication may increase susceptibility to TD and should be carefully monitored.     

Complications for the mother in vaginal delivery after a prior cesarean section and in parturients with a planned repeat cesarean section

Over a period of 10 years (1980-1989) in the Clinic of Obstetrics and Gynaecology in Stara Zagora 740 women have delivered children after a previous caesarean operation. On the basis of this material the author has studied the vaginal delivery complications for the mother after a previous caesarean operation and in the cases of a second planned caesarean operation. The alternative and correlational analysis of the clinical data has shown that the complications for the mother in the latter group are 3 times more than those in the former group.     

Early diagnosis of breast carcinoma]

A case of 'benign tumor' of the liver (hepatocytic hamartoma), in a 24-year-old female is presented. The angiographic aspects are stressed and the radiological disgnosis is discussed in the light of similar observations reported in the recent medical literature.     

Early diagnosis of subacute free wall rupture complicating acute myocardial infarction

Of 2608 consecutive patients with acute myocardial infarction, 24 developed subacute free wall rupture (= 0.92%; 95% C.I. = 0.6-1.4). Clinical manifestations varied widely (shock on admission; 25% of cases; severe arrhythmias followed by shock: 17%; shock during hospital stay: 42%; symptoms suggestive of infarct extension without shock: 17%). The electrocardiograms were confusing rather than revealing: 56% of patients showed new ST segment elevations of 0.2 to 1 mV in the infarct-related leads, while autopsy or creatinine phosphokinase evidence of infarct extension was missing. In the first 21 cases, therefore, no definitive diagnosis was made before autopsy. Using 197 infarct patients in cardiogenic shock or with infarct extension during the acute stage, i.e. a patient group with comparable clinical manifestations, as control group, a logistic regression model was generated in which the variables age, lateral wall involvement and history of hypertension were used for estimating the probability of subacute rupture. In fact, probability may rise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min-6.5 weeks) following the onset of rupture symptoms, echocardiography must be performed urgently in all cases presenting symptoms of shock or infarct extension. Pretest probability which can be roughly estimated from our model as well as sensitivity and specificity of individual echocardiographic or clinical parameters are indispensable for correct therapeutic decisions. The routine application of this algorithm in our department contributed to a timely diagnosis in the last three consecutive cases of whom one patient survived.     

Early mortality after surgical repair of postinfarction ventricular septal rupture: importance of rupture location

BACKGROUND: The aim of this study was to identify factors influencing early outcome after surgical treatment of postinfarction ventricular septal rupture. We investigated the influence of proximal or distal rupture location. METHODS: Between 1980 and 1992 109 patients were treated surgically for ventricular septal rupture using a standardized technique. A division in time periods was made. The rupture was categorized according to its anterior or posterior site and proximal or distal location. RESULTS: The 30-day mortality rate was 27.5%. Multivariate logistic regression analysis identified preoperative shock (p = 0.0007) and right atrial oxygen saturation less than 60% (p = 0.021) as predictors for early death; the risk for early death declined over the time periods from 50% to 12.8% (p = 0.0007). Proximal ventricular septal rupture location (p = 0.0092) and interval between infarction and ventricular septal rupture less then 1 day (p = 0.034) were risk factors for the occurrence of preoperative shock. CONCLUSIONS: Proximal ventricular septal rupture location was the main determinant of preoperative cardiogenic shock, which in turn was the strongest predictor of early mortality. Over the time periods a decrease in early mortality was reached.