Transabdominal Cerclage

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To follow along, we suggest reading SMFM Consult Series #65: Transabdominal Cerclage 

  • What is the background to cerclages? 

    • Preterm birth is still the leading cause of neonatal morbidity and mortality 

    • Cervical insufficiency (inability of cervix to retain a pregnancy, characterized by painless cervical dilation usually in middle of second trimester) is an important cause of preterm birth 

    • Diagnosis of cervical insufficiency: 

      • History of one or more second-trimester losses after painless cervical dilation in absence of labor or abruption 

    • Cervical cerclages are indicated for those with cervical insufficiency – most are done transvaginally 

      • McDonald or Shirodkar method 

      • Other indications = history of PTB <34 weeks, cervical length <25 mm before 24 weeks 

      • Advanced cervical dilation before 24 weeks 

    • Transabdominal cerclage (TAC) are also an option - first described by Benson and Durfee in 1965 

      • Advantages: can be placed higher, in the cervicoisthmic junction, so may provide greater structural support  

        • Avoids presence of foreign body in vagina, so may decrease risk of PPROM or IAI 

      • Disadvantages: more morbid and more complicated surgery because need abdominal access and dissection, necessitates cesarean delivery 

  • So when is a TAC indicated? 

    • TACs are usually not offered as first line treatment for cervical insufficiency 

      • Due to increased morbidity of placement and need for CS 

      • Exception is for those where transvaginal cerclage would be very difficult to place 

        • Ie. Those with history of multiple LEEPs or trachelectomy 

    • More often, TAC is used for patients with unsuccessful transvaginal cerclage 

      • Previous unsuccessful TV cerclage = spontaneous delivery before 28 weeks of gestation 

      • TAC reduced risk of recurrent preterm birth compared with repeat transvaginal cerclage in patient with a previous delivery <33-34 weeks gestation 

    • Multicentre Abdominal vs. Vaginal Randomized Intervention of Cerclage (MAVRIC) study 

      • Randomized controlled trial 

      • Compared use of a TAC, high vaginal cerclage, and low vaginal cerclage among patients with previous miscarriage or preterm birth between 14-28 weeks of gestation with transvaginal cerclage in situ in previous pregnancy 

        • TACs were performed as an open procedure either before pregnancy or up to 14 weeks 

        • Vaginal cerclages done between 10-16 weeks gestation 

      • Findings: preterm birth rates <32 weeks were significantly lower with TAC compared with both low vaginal cerclage (8% vs. 33%%, RR 0.23, 95% CI 0.07-0.76), and high vaginal cerclage (8% vs. 38%, RR 0.2, 95% CI 0.06-0.64) 

      • NNT to prevent 1 preterm birth when TAC was compared with low vaginal cerclage was 3.9, and compared with high vaginal cerclage was 3.2 

  • How is a TAC placed?

    • We won’t go into full detail, since that’s a little beyond the scope of a podcast! 

    • Open technique 

      • Typically done via spinal or regional anesthesia 

      • Pfannenstiel incision 

      • Uterus is exteriorized and surgeon identifies and palpates the uterine vessels bilaterally 

      • Uterine vessels are retracted laterally → create an avascular space between the uterus and the vessels in the broad ligament at the level of the internal os of the cervix 

      • Non-absorbable thick braided 5mm suture (ie. Mersilene tape) guided through space with right-angle clamp 

      • Suture is tied anteriorly or posteriorly and left in place 

    • Minimally invasive technique 

      • Many different techniques have been described, using both traditional laparoscopy and robotic surgery

      • Most will use 3-port laparoscopic approach, some with fourth suprapubic assistant port 

      • Some will use a uterine manipulator (usually done prior to pregnancy) 

      • Can dissect the uterovesical and paravesical spaces and make a window in the broad ligament through which the suture is placed 

      • Suture used can be same nonabsorbable thick braided 5-mm suture (Mersilene tape), and some places have described using mono-filament, non-braided polypropylene suture 

      • Suture is tied anteriorly or posterior and left in-situ 

  • Is laparoscopic or open better? 

    • Studies show that laparoscopic TACs are associated with less risk of blood loss and shorter hospital stays 

    • However, laparoscopic procedures take longer 

    • Other studies show no difference in blood loss, operative time, or hospital stay between the two 

    • Overall, similar rates of pregnancy and miscarriage rates after laparoscopic and open TAC placement 

    • Many studies have also shown similar preterm birth rates <34 weeks with both approaches, but overall, no RCTs as of yet 

    • Therefore, both laparoscopic and open TAC are acceptable 

  • Should I tocolyze? 

    • No evidence to suggest that tocolysis is helpful 

  • Ideal time for placement 

    • Can be placed before pregnancy or in the first trimester 

    • However, if there is an indication for TAC after first trimester, placement up to 22 weeks can be considered 

  • Management of a pregnancy after TAC? 

  • Management antepartum 

    • MFM consultation should be obtained before TAC placement is done 

    • Can continue with MFM consultation if questions arise 

    • Should we continue to measure transvaginal cervical lengths? 

      • Several studies show that although cervical shortening after cerclage may increase the risk of preterm birth, cervical length does not directly correlate with outcomes 

      • Rescue cerclage does not improve outcomes in the setting of a short cervix after cerclage 

      • Therefore, SMFM does NOT recommend routine transvaginal cervical length screening for patients with TACs 

    • Should we use progesterone? 

      • In the MAVRIC trial, 27% of patients used progesterone (17% in TAC, 28% in high vaginal cerclage and 48% in low vaginal cerclage) 

      • However, since this trial, the FDA has withdrawn approval of IM progesterone 

      • Benefit of adding vaginal progesterone to treatment regimen of patients with cerclage is unknown

      • SMFM recommend having a risk-benefit discussion of supplemental vaginal progesterone be undertaken and shared decision making take place

        • What we did at Penn: If they were already on progesterone, we didn’t take it away. If they weren’t on progesterone already, we don’t recommend 

        • What did they do in UW? - same

  • What to do in setting of pregnancy loss 

    • If needed, D&E can be done with a TAC in situ 

    • Large retrospective study of 142 patients with TAC found that 14 patients underwent 19 D&E procedures, with 15 of those occurring at <12 weeks 

    • Osmotic dilators and standard surgical techniques were used 

    • No major complications noted 

    • SMFM recommends that pregnancy loss be managed with D&C or D&E with TAC in situ or with obstetrical management after laparoscopic removal of TAC depending on gestational age 

  • Timing of delivery 

    • Cesarean delivery is recommended, as TACs are not removed 

    • There have been case reports of uterine dehiscence or uterine rupture when patients with TAC labor 

    • Therefore, recommendation is delivery timing similar to previous myomectomy (37w0d-39w0d) 

    • Leave TAC in situ for future pregnancies 


The CLASP Trial

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CLASP: A randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women 

Background: 

  • Who did the study and who published it? 

    • CLASP: Collaborative Low-dose Aspirin Study in Pregnancy Collaborative Group 

      • Coordinating center in Oxford, UK but multiple centers in the UK participated 

      • Published in the Lancet in 1994.

  • Why was the study done? 

    • Preeclampsia is a serious condition that can lead to both maternal and fetal morbidity and mortality 

    • Specifically, it can cause fetal growth restriction and neonatal demise due to prematurity

    • Those that did the study hypothesized that preeclampsia is due to structure and occlusive changes in the spiral arteries that can affect uteroplacental circulation

      • Thought that this contributed to FGR as well 

    • Therefore, if there is some way to prevent preeclampsia, it might also prevent some cases of FGR without preeclampsia 

    • PEC associated with deficient intravascular production of prostacyclin and excessive production of thromboxane → aspirin can modify these pathways, so low-dose aspirin might help by blocking thromboxane 

  • What was the research question?

    • Can use of low-dose aspirin in pregnancy decrease fetal/neonatal morbidity and mortality in those at high risk of developing severe preeclampsia or fetal growth restriction? 

Methods: 

  • Who participated in the study? 

    • Conducted in 213 centers in 16 countries over 5 years (from January 1988 to December 1992) 

    • Inclusion criteria 

      • Between 12-32 weeks of gestation 

      • If there was sufficient risk of preeclampsia or IUGR as deemed by the opinion of the responsible clinician, but no clear indication for or against low-dose aspirin otherwise. Divided into two groups  

        • Prophylactic entry - women with history of PEC or IUGR in previous pregnancy, chronic hypertension, renal disease, or other risk factors (maternal age, family history, multiple pregnancy) 

        • Therapeutic entry - women with signs or symptoms of preeclampsia or IUGR in current pregnancy 

    • Exclusion criteria 

      • Increased risk of bleeding 

      • Asthma 

      • Allergy to aspirin 

      • High likelihood of imminent delivery 

  • How was the study done? 

    • Randomized controlled trial 

    • Staff would call a central 24-hour service at Clinical Trial Service Unit at Oxford —> randomized by computer to get a specific trial treatment pack containing aspirin or placebo tablets 

      • Minimization algorithm was used to limit differences between treatment groups for certain prognostic baseline variables 

    • Treatment was either 60 mg aspirin daily or matching placebo tablet 

      • Sign of the times: currently, we use 81 mg here in the US and the current low dose aspirin in the EU is 150 mg 

    • Follow-up 

      • Single page follow-up form completed after hospital discharge of both mother and baby (or 6 weeks postpartum if either had not been discharged) 

      • Compliance with study treatment 

      • Use of antihypertensives or anticonvulsant drugs (remember this was before magnesium!) 

      • Major events that occurred after randomization (esp. Preeclampsia, fetal loss, maternal or neonatal bleeding) 

      • Birthweight, vital status of baby, and neonatal complications 

  • What outcomes were they looking for? 

    • Main outcomes: 

      • Development of proteinuric pre-eclampsia 

      • Estimated duration of pregnancy 

      • Crude birthweight, birthweight <3rd%ile for sex and gestational age 

      • Stillbirth/neonatal death due to preeclampsia or maternal hypertension or associated with IUGR, or ascribed to maternal or neonatal bleeding 

      • Death of baby at any time attributed to preeclampsia, maternal hypertension, or IUGR 

    • A word on definitions 

      • This was 1994, so the definition of preeclampsia was very different 

      • Defined proteinuric preeclampsia as:  

        • For those with baseline diastolic pressure <90 mmHg, hypertension defined as rise of at least 25 mmHg to 90 mmHg or higher 

        • For those with initial diastolic pressure of 90mmHg or higher, increment of at least 15 mmHg was required 

        • Proteinuria was defined as appearance after randomization of at least 1+ on protein stick-testing during pregnancy w/o UTI evidence 

      • Defined IUGR as: 

        • Birthweight <3rd%ile for sex and estimated gestational maturity 

      • Preterm delivery: before 37 weeks 

    • Other outcomes 

      • Also looked at comparisons regarding parity, prophylactic use according to time of entry (<20 weeks or >20 weeks), and therapeutic use according to time of entry (<28 weeks or > 28 weeks) 

    • Statistics 

      • Wanted to be able to detect a decrease of a quarter in incidence of proteinuric preeclampsia, increase of 100g in mean birthweight, and increase of 1 day of mean duration of gestation 

      • Initially wanted 4000 women, but because this size could not detect differences in rate of stillbirth and neonatal death ascribed to preeclampsia, ultimately decided to include 10,000 women 

Results:

  • Who did they recruit? 

    • 9364 women randomized (4683 in aspirin arm and 4681 in placebo arm) 

      • 74% in prophylaxis for preeclampsia, 12% for prophylaxis of IUGR alone 

      • 11% for treatment of preeclampsia, 3% for treatment of IUGR alone 

    • Some other interesting characteristics: 

      • 62% of women were enrolled at 20 weeks gestation or earlier 

      • 2% had already developed preeclampsia 

      • 28% were primigravidas 

    • Post delivery follow up forms were obtained for 9309 patients (99.4%) 

    • Compliance 

      • Of the 8915 randomized patience where compliance information as gathered, 96% started the medication, 66% continued treatment for 95% of the time, and 88% continued for 80% of the time between randomization and delivery 

  • Outcomes - note, there are a TON of findings in the results section, but for time purposes, here are the main ones 

    • Preeclampsia 

      • 6.7% of women on aspirin had preeclampsia compared to 7.6% of those with placebo 

        • 12% reduction, but not statistically significant 

        • No difference when looking specifically at women who entered for prophylaxis vs. therapeutic reasons 

      • Effect was greater among women who entered for prophylaxis at 20 weeks gestation or earlier (22% reduction) p =0.02) 

      • Interestingly, when looking at those that delivered earlier, there was a progressively greater reduction in preeclampsia with aspirin use 

  • Duration of pregnancy 

    • Average duration of pregnancy was 1 day longer among aspirin allocated patients than placebo allocated women (38.15 vs. 37.99 weeks), p=0.05 

    • Aspirin did reduce likelihood of delivery before 37 weeks 

      • 19.7% vs. 22.2%, p=0.003 

    • Seemed to be in prophylactic group 2 fewer preterm deliveries/100 women allocated to aspirin 

    • In therapeutic group, benefit was about 5 fewer preterm deliveries/100 women allocated to aspirin  

  • Birthweight 

    • Aspirin group had babies that were on average 32 g greater (p=0.05) 

    • Slightly smaller proportion of babies with IUGR, but not statistically significantly different 

    • Interestingly, among women entered for therapeutic reasons, aspirin seemed to have discrepant effects, with increased incidence of IUGR among those entered at 28 weeks or earlier and decreased incidence among those entered later 

  • Stillbirth

    • 129 (2.7%) stillbirths/neonatal deaths in the aspirin group vs. 136 (2.8%) in the placebo group 

    • Not statistically significantly different 

  • Safety 

    • Intraventricular hemorrhage rates were not different in the two groups 

    • No significant differences in fetal or neonatal deaths attributed to hemorrhage 

Impact 

  • Conclusions from this study: 

    • Impact of aspirin on preeclampsia and fetal sequelae were smaller than previously thought 

    • POtentially important effect of aspirin could be discerned on prevention or delay of delivery with early-onset preeclampsia 

  • How do we practice now and why? 

    • So… why are we using aspirin for everything nowadays? 

      • It’s important to realize that this study, while groundbreaking, was almost 30 years ago 

    • Aspirin does have a good mechanism to potentially decrease preeclampsia development, but may need to be used earlier in pregnancy 

      • Hypothesis as stated before is that preeclampsia might be associated wit vascular disturbances and coagulation defects resulting from an imbalance in prostacyclin and TXA2 

    • Until recently, this has not borne out in the data 

    • Another study in 2017 - Aspirin for Evidence-Based Preeclampsia Prevention Trial 

      • Randomized 1776 women and was based on first trimester screening algorithms 

      • Used 150 mg aspirin vs. placebo 

      • Found significant decrease rate of preterm preeclampsia (4.3% vs. 1.6%, OR 0.38, 95% CI 0.2-0.74) 

    • Meta Analysis in 2014 from the USPSTF guideline pooled data from 15 high-quality RCTs, and showed a 24% reduction in preeclampsia (RR0.76, CI 0.62-0.95) with low dose aspirin prophylaxis (60 - 150 mg/day) 

  • So what are the actual recommendations, and what are the lingering questions? 

    • Basically, based on the data from the USPSTF guidelines, in low risk groups (where disease prevalence is 2%), the number needed to treat to prevent preeclampsia is 500

      • Compared to those in a high risk group with disease prevalence of 20%, the number needed to treat is only 50 

      • USPSTF guideline recommends giving low-dose aspirin after 12 weeks of gestation to women with absolute risk of preeclampsia of at least 8% (optimally before 16 weeks) 

      • ACOG has a list of guidelines regarding who meets criteria for aspirin prophylaxis  - can post on website

    • Lingering questions 

      • What is the best dose? 

        • Is it 60? 81? 150? - we don’t know as there hasn’t been a head to head comparison between these doses 

      • What about other things like stillbirth and fetal growth restriction?

        • Insufficient evidence, as few studies have solely looked only at stillbirth or only at FGR  

      • Preterm birth? 

        • Maybe! 

        • There is some good data coming out, so stay tuned 

Diabetes V: Intrapartum and Postpartum Glucose Management

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Great! Your patient is here in labor or for induction… now what?

  • Glycemic goals - why do we have them and what are they? 

    • Why do we have them? 

      • It is a good idea to avoid hyperglycemia in labor due to risk of fetal hypoxemia and neonatal hypoglycemia 

      • Fetal hypoxemia 

        • Some evidence that fetal hypoxia can result from diabetes with uncontrolled blood sugars 

        • Also increased blood sugars that lead to ketoacidosis can increase fetal acidosis and hypoxia 

      • Neonatal hypoglycemia 

        • Increased maternal blood sugars increases fetal production of insulin 

        • High levels of insulin after delivery with no exposure to maternal blood sugar → hypoglycemia and NICU admission 

    • What are they? 

      • Initially, there was recommendation by ACOG that blood sugar be between 60 -100 mg/dL

      • However, there was a study that showed that tight control maternal control did not results in better initial neonatal glucose concentrations compared to a more liberalized management strategy 

      • Hamel H et al 2019, Obstet Gynecol: https://pubmed.ncbi.nlm.nih.gov/31135731/

      • The goals can be different depending on your institution, but based on the above study, the goal is to be between 60 - 120 mg/dL 

      • Based on ACOG’s Practice Bulletin, goal should be <110 mg/dL 

  • How often should we monitor blood sugar? 

    • ACOG recommends checking blood sugar levels q1 hour in active labor 

    • If not on an insulin drip and during labor, please follow the protocol at your hospital, as certain hospitals have adopted a more liberalized form of glucose management 

    • One example of protocol: 

      • If not in active labor, can check blood sugar every 4 hours 

      • In active labor, can check every 2 hours, but if needs treatment → recheck in 1 hour after treatment 

    • If we follow Hamel et al’s protocol, the plan is to check every 4 hours, but to check more frequently if treatment is needed 

Example protocol - acog practice bulletin, pregestational diabetes mellitus

Treating Hyperglycemia

  • Use insulin! 

      • Coming in for scheduled induction/cesarean: we usually ask patients to take half the dose of long acting insulin.

        • Example: patient is on 20 NPH during the day and 40 NPH at night. They are coming in for a 7 am induction and will not be eating much during labor 

        • Patient should be instructed to take 40 NPH the night prior (to help with fasting), and can be given or should take 10 u NPH that morning, as patient likely will not be eating much during the day they are being induced 

        • Do not take short acting insulin the day of if patient is not eating 

    • In patients who come in laboring:

      • Ask patients what insulin they have taken that day 

      • If still in labor and time for long acting insulin, if patient is not eating, can plan for half of the long acting insulin 

    Ok, so that takes care of long acting insulin, but what if the patient is having elevated blood sugars during labor? 

    • Short acting insulin 

      • If a patient is having elevated blood sugars above protocol, they can be given short acting insulin to bring down their blood sugars 

      • How much to give: 

        • This will come down to the patient, but this is a good time to remember the rules we taught you before! 

        • Type 1s: use the rule of 1800: 1800 / TDD insulin (units) = expected ICF

        • Type 2/GDM: use the rule of 1500: 1500 / TDD insulin (units) = expected ICF

          1. So if I’m taking 50 units total of insulin per day, as a T2DM/GDM I would have a correction factor of 30 - meaning 1u of insulin would bring my blood sugar down about 30 mg/dL

          2. This is helpful for the floor - if you need to cover someone, knowing their total daily insulin dose (or approximating using their weight) can help you provide more reliable amounts of insulin. 

        • You may also have protocols within your hospital with certain types of sliding scales 

    • Insulin drip 

      • Who needs an insulin drip? 

        • Patients whose blood sugars are difficult to control 

          1. Very high blood sugars (>200 mg/dL) 

          2. Those who require multiple treatments with short acting insulin (> 2 times, usually)

          3. Those who have an insulin pump that cannot be used in the hospital 

      • How do I manage an insulin drip? 

        • Most of the time, insulin drips should be co-managed either with endocrinology or with MFM - so ask for help! 

        • We cover this in our episode for diabetic ketoacidosis!

        • As a brief overview: the insulin in a drip is usually regular or rapid-acting insulin 

          1. Most of the time, if the blood sugar is <200mg/dL, there is a protocol in the hospital to follow for labor 

          2. Can usually start at 1-1.5u/hr, but if patient is in DKA or has very high blood sugars, can also start at 0.1u/kg/hr or even first start with a bolus of 0.1u/kg 

        • Blood sugar should be checked every hour and insulin drip can be adjusted up and down by 1u/hr depending on blood sugar control 

  • Hypoglycemia - Low blood sugars 

    • If patient is not eating or patients with T1DM, they will need to placed on some form of dextrose so that they do not go into DKA; pregnant patients are also more likely to be in euglycemic DKA 

    • Again, there is usually a protocol in the hospital, but these patients should be placed on D5NS if not eating and in active labor or if blood sugar drops <70 mg/dL 

    • These can follow the usual maintenance fluid calculations, using the 4-2-1 formula for how much fluid is needed per hour 

      • 4 mL/kg/hr for the first 10 kg 

      • 2 ml/kg/hr for the second 10 kg 

      • 1 ml/kg/hr for the remainder 

      • Example 

        • For a patient who weighs 70kg: 

          1. 40 ml/hr (4*10) + 20 ml/hr (2*10) + 50 ml/hr (1*50) = 110 ml/hr 

    • Another method to calculate is 2.5mg of dextrose/kg/min 

    • For everyone who is getting insulin, you should order an as needed D50 injection or D25 injection depending on what your hospital has 

      • This is in the event of acute hypoglycemia or who may be unresponsive and not able to take PO 

    • If someone is able to take PO, you should follow the 15/15 rule: basically, consume 15g of glucose and check blood sugar in 15 minutes 

      • Usually 3 glucose tablets 

      • Approximately 4 oz of regular juice or soda

Let’s say we get our patient through labor and birth … what about the postpartum period? 


  • Insulin requirements postpartum 

    • Insulin requirements go down significantly postpartum, especially if the patient is breastfeeding 

    • If the patient was on insulin prior to pregnancy, they should return to their prepregnancy insulin regimen 

    • If patients were not on insulin, but were diagnosed with T2DM during their pregnancy, then during recovery in the hospital, our general recommendation depends on pre-pregnancy or early pregnancy A1C 

      • For T2DM, patients with A1C > 9.0%, they should generally stay on insulin 

      • If <9.0%, then can have discussion with endocrinology and MFM to try oral medications, and would need to be safe during breastfeeding if patient desires to breastfeed 

        • Hopefully this plan was made as an outpatient! 

      • General consensus for continuing insulin is to half their long acting insulin and then put them on a sliding scale 

      • After approximately 24 hours, calculate how much sliding scale they needed, and this can be turned into short acting insulin if needed 

      • Consult endocrinology and MFM for guidance, and also make sure patient has endocrinology or PCP follow up 

Espresso: Cord Prolapse

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What is cord prolapse? 

  • Definition 

    • When the cord moves out of the cervix in front of the fetal presenting part; can usually only happen when rupture of membranes has occurred 

      • Otherwise, it is called funic presentation (cord presenting with intact membranes)

    • Uncommon: 1.4-6.2/1000 

    • Majority of them happen in singleton gestation, but there is an increased risk in twin pregnancies of the second twin 

  • Risk Factors

    • PPROM - especially if the fetus is not in the cephalic position 

    • Multifetal gestation 

    • Polyhydramnios 

    • Fetal growth restriction 

    • Preterm labor 

    • AROM when fetal head is not well engaged 

      • Nearly half of cases are attributed to iatrogenic causes 

      • 57% occur within 5 minutes of membrane rupture, and 67% occur within 1 hour of rupture 

  • Why do we care? 

    • Compression of the cord → vasoconstriction and → fetal hypoxia 

    • Can lead to fetal death or brain damage if not rapidly diagnosed and managed 

How can I recognize cord prolapse? 

  • Exam 

    • Palpation of a pulsatile mass in the vaginal vault or at the cervix 

    • No need for radiographic or laboratory confirmation 

  • Fetal heart tracing 

    • Usually can see recurrent variable decelerations or fetal bradycardia 

  • Differential diagnosis 

    • Another mass in the vagina could be fetal malpresentation 

    • Other causes of fetal bradycardia/decelerations should also be considered 

How do I manage cord prolapse if it is found? 

  • Reduction of the cord – if possible 

    • This is usually not possible if there is large amount of cord in the vagina, and not recommended 

    • However, if there is small amount of cord at the internal cervical os, at times, it is possible to reduce it back beyond the present part 

    • However, if there is recurrent prolapse … 

  • Expedient delivery

    • Usually via cesarean delivery 

    • Prior to getting to the operating room, the goal should be decompression of the umbilical cord 

      • Elevate the fetal presenting part as interval to umbilical cord decompression can be associated with worse outcomes than interval to delivery 

        • Decompression can be done manually: place finger or hand in the vagina and gently elevate the head or presenting part off of the umbilical cord 

        • Do not put additional pressure on the cord → can lead to vasospasm 

      • Another way of decompression 

        • Place pregnant patient into steep Trendelenburg or knee-chest position 

        • Usually if there is not a provider who is able to do manual decompression or if there is prolonged interval to delivery (ie. transfer to hospital) 

      • If there is visible cord protruding from the introitus, try to place a warm, moist sponge or towel over the cord to prevent vasospasm

        • Or can replace into vagina 

What are the outcomes, and how do I prevent prolapse? 

  • Prognosis 

    • Fetal mortality is <10% now that we are able to complete cesarean sections in a timely manner 

    • In earlier studies, the range was 32-47% 

    • Gestational age and location of prolapse (in or out of hospital) can significantly determine outcomes 

      • Cord prolapse outside of hospital carries 18x increased risk of fetal mortality 

  • Prevention 

    • For patients who are at increased risk of cord prolapse (ie. PPROM, malpresentation), they should be encouraged to deliver at a hospital 

    • Early recognition training by both patient and providers

      • SIM! 

    • ACOG recommend against routine amniotomy in normally progressing labor unless needed for fetal monitoring 

      • AROM - if needed, make sure that there is engagement of the fetal head 

      • If AROM is needed, but there is polyhydramnios or high fetal station, can use a fetal scalp electrode to rupture the amniotic sac to slowly release fluid 

Espresso: Uterine Rupture

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What is uterine rupture? 

  • Definition

    • Spontaneous tearing of the uterine muscles which can lead to expulsion of the fetus into the peritoneal cavity

    • In the literature, uterine rupture can also incorporate less catastrophic phenomena, like uterine window or asymptomatic scar dehiscence without expulsion of the fetus

    • Focus today: intrapartum uterine rupture.

    • The true incidence of uterine rupture across all populations in pregnancy is likely very low.

      • With no history of surgery, the risk is 1/8000-17,000 deliveries 

    • With one prior low transverse cesarean, the incidence has been reported to be between 0.2-1.5%, though usually quoted as <1% 

    • With two prior low transverse cesareans, the incidence is reported to be between 0.8-3.9%, usually quoted as just over 1% 

    • However, there are things that can modify this risk: 

      • History of prior successful VBAC → reduce the risk of rupture from 1.1% to 0.2% 

    • In other types of incisions such as T-incisions and classical incisions, the rate of rupture can be as high as 4-9%

  • What are some other risk factors? 

    • By far, the biggest one is previous uterine surgery,

    • Other risk factors: 

      • Uterine scar presence

      • Uterine anomalies

      • Prior invasive molar pregnancy

      • History of placenta accreta spectrum

      • Malpresentation

      • Fetal anomaly

      • Obstructed labor

      • Induction of labor with use of prostaglandins

        • These other risk factors are much less significant than prior uterine surgery/presence of scar  

How do I recognize uterine rupture?

  • Again — only be discussing uterine rupture in labor 

    • There are a few studies looking at thinning of the myometrium on ultrasound, but this is controversial.

    • It is much more likely that you will encounter uterine rupture at time of labor and birth than during other times 

  • Diagnosis

    • High index of suspicion - know your patient’s risk factors and be on the lookout for uterine rupture given how catastrophic it can be for both maternal and fetal wellbeing 

    • Some of the classical signs: 

      • Sudden, tearing uterine pain

      • Vaginal hemorrhage

      • Cessation of contractions 

      • Destationing of the fetal head 

    • However, these classical signs are actually not necessarily reliable and not always present! 

    • The most reliable presenting clinical symptom is actually fetal distress 

      • One study of 99 patients with uterine rupture showed: 

        • Only 13 patients reported pain and 11 had vaginal bleeding 

        • However, bradycardia or signs of fetal distress (decelerations) were present in the majority.

    • Ultrasound examination 

      • Not necessarily reliable and if you are truly suspicious of uterine rupture, this should prompt immediate delivery 

  • Why do we need to diagnose uterine rupture promptly? 

    • Maternal complications

      • Maternal circulatory system delivers 500 cc of blood to the uterus every minute 

      • Uterine rupture increases the risk of hemorrhage, with studies showing that about 50% of cases result in EBL of 2000cc or greater 

      • This can lead to need for blood transfusion, and in more dire circumstances, hysterectomy  

    • Fetal complications 

      • Depends on how quickly the neonate is delivered after recognition of uterine rupture 

      • One study showed a neonatal mortality rate of 2.6%, and increases to 6% if uterine rupture occurs outside of the hospital

        • Older literature report rates as high as 13%  

      • Many neonates will require resuscitation and admission to the NICU 

Management

  • The best form of management is prevention or setting expectations - ie. counseling 

    • All patients who desires a trial of labor after cesarean section should be counseled about the risks and benefits of TOLAC 

    • Patients should deliver at a location where labor and delivery staff, anesthesia staff, and neonatal staff are available 24 hours in order to facilitate prompt delivery if needed. 

    • Patients who are at high risk of uterine rupture (ie. classical cesarean, T-incision, prior uterine rupture, >2 cesarean sections, history of prior fundal surgery) should be counseled against TOLAC 

    • We did a whole episode on TOLAC counseling back in 2019, so check it out here: https://creogsovercoffee.com/notes/2019/9/22/trial-of-labor

      • Note that the VBAC calculator we included in those notes is outdated! 

    • There is a new VBAC calculator available that does not include race as a predictor: https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator

  • What if it happens? The answer is prompt delivery via cesarean delivery 

    • Urgent delivery - as quickly as possible, but within 30 minutes generally 

    • Patient can be under general anesthesia or if they already have working regional anesthesia, this can also be used 

    • Cesarean delivery should be performed, and if there is a uterine rupture, the neonate can often be delivered via the area of rupture without creating a new hysterotomy 

      • However, if there is just a uterine window, a hysterotomy may be needed 

    • Once the neonate is delivered, pediatrics should be there immediately to facilitate resuscitation 

    • If uterine rupture is confirmed, a full exam of the uterus should be done to assess for other injury 

      • Ie. bladder injury, broad ligament hematoma 

    • If possible, the area of rupture should be repaired 

    • However, if it is not possible to repair the rupture due to significant damage, patient is not stable, or significant hemorrhage, then the next step should be hysterectomy 

  • Follow-up 

    • Debriefing - this should occur with the team who was present for uterine rupture 

    • But also, should discuss with your patient when they are at a place when they can discuss what happened 

    • Counsel patient that if they desire future pregnancy, TOLAC should not be attempted due to increased risk of repeat rupture