This study evaluates the use of inverting the cervix as a natural tamponade to control bleeding in cases of placenta previa and accreta. The study included 35 patients who underwent cesarean section where the cervix was inverted and sutured over the placental bed. This technique successfully controlled bleeding in 33 of 35 patients (94%). Only 2 patients required a hysterectomy. The mean blood loss was 1572.5 mL. At 3 month follow up, most cervices (29/31) appeared normal on speculum exam. This simple technique utilizes the cervix as a natural tamponade and appears to be an effective way to control bleeding and preserve the uterus in cases of placenta
Simon Leeson - Colposcopic treatment standardstriumphbenelux
This document discusses standards for colposcopic treatment of precancerous cervical lesions. It summarizes current European standards agreed through a Delphi process, including that 85% of excisional treatments should contain CIN2+, 100% of cases should have a pre-treatment colposcopy, 80% of excised lesions should have clear margins, and documentation of the squamocolumnar junction. The document evaluates data on factors like excision length, margin status, and HPV testing after treatment. It discusses modifying standards based on discussions, including recording excision length, margin involvement, and HPV/cytology outcomes post-treatment. The conclusions are that additional treatment standards may be needed despite existing Delphi standards, and
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...Premier Publishers
To analyse complications in patients who underwent pelvic exenteration procedures performed in our, between January 2013 – December 2018. A retrospective analysis of the baseline characteristics, surgical outcomes, complication rates of 51 patients who had undergone pelvic exenteration procedures between January 2013 and December 2018 was made. The results analysed using chi-square test. Of the 51 patients, 38 were operated for primary malignancy and 13 underwent exenteration for recurrences. Seventeen patients were operated by laparoscopy whereas the rest underwent open procedures. The diagnosis for which exenteration had been done included cancers of cervix (37), urinary bladder (5), rectum (4), urethra (1), vagina (3), and ovary (1). Bleeding was the most common complication encountered. Hypokalaemia, surgical site infections, urine leak and sepsis were seen in early post-operative period. The morbidity rate (major) was 33.3% and the mortality rate was 5.8% in our centre. The late outcome was inadequately evaluated as most patients lost follow-up. Pelvic exenteration is the only surgical option available for advanced pelvic malignancies and the morbidity pattern differs based on diagnosis, extent of resection and the type of diversion procedure. In a high-volume centre, the morbidity and mortality rates are acceptable compared with international standards.
The Diagnostic value of saline infusion sonohysterography and hysteroscopy in...Ahmed Mowafy
Hysteroscopy is more sensitive and has a higher negative predictive value than saline infusion sonohysterography (SIS) in detecting intracavitary abnormalities, according to a study comparing the two techniques. The study of 80 women found hysteroscopy had a sensitivity of 96.3% versus 89.3% for SIS. Hysteroscopy also had a higher negative predictive value of 92.3% compared to 76.9% for SIS. However, SIS has advantages of being non-invasive, cheaper, faster, and less discomfortable for patients. Both techniques had few complications, with bleeding being most common for SIS. The study concludes hysteroscopy is superior for diagnosis but S
This randomized controlled trial studied three surgical techniques used in caesarean sections to determine their effects on maternal infectious morbidity: 1) Single vs double layer closure of the uterine incision, 2) Closure vs non-closure of the pelvic peritoneum, and 3) Liberal vs restricted use of a subrectus sheath drain. The trial recruited 3033 women undergoing their first caesarean section. It found no significant differences in maternal infectious morbidity between any of the surgical technique pairs studied. The results have implications for changing current guidance on peritoneum closure.
Sonographic assessment of myometrial thickness as a predictor 2Tamer Essam
This document describes a study that aimed to measure myometrial thickness by ultrasound in patients with preterm premature rupture of membranes (PPROM) as a predictor of latency interval. The study involved measuring myometrial thickness at different sites in 100 pregnant women divided into three groups: those with PPROM, preterm non-labor controls, and term non-labor controls. Results showed significantly thicker myometrial thickness at all sites in the PPROM group compared to controls. Regression analysis found a direct correlation between latency interval and fundal myometrial thickness in PPROM patients. The study concluded that thickening of the uterine fundal wall follows PPROM, and a thick myometrium in non-
This document discusses fetal endoscopic surgery, including the indications and anesthetic management. It describes several fetal conditions that may benefit from fetoscopic intervention, including twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion sequence (TRAP), and bladder outlet obstruction from conditions like posterior urethral valves. For TTTS and TRAP sequence, fetoscopic techniques like selective fetoscopic laser photocoagulation of placental vessels and umbilical cord ligation are discussed as alternatives to open fetal surgery or other treatments. The document also reviews maternal and fetal considerations for anesthesia during these procedures.
The document discusses new trends in the treatment of placenta accreta. It begins by defining placenta accreta and discussing the increasing incidence. Risk is highly associated with the number of prior cesarean deliveries and the presence of placenta previa. Ultrasound is usually sufficient for diagnosis but MRI can provide additional information. Prenatal care involves frequent ultrasound exams and potential adjuvant therapies. Cesarean hysterectomy is the definitive treatment, ideally without attempting placenta removal. A conservative approach may be attempted in select cases for women wishing to preserve fertility, but outcomes are unpredictable and further intervention is often needed. Management of hemorrhage, including techniques such as hemostatic resuscitation,
Hysterectomy for benign conditions in a university hospital inTariq Mohammed
This document summarizes a study examining hysterectomies performed at a university hospital in Saudi Arabia between 1990-2002. A total of 251 hysterectomies were reviewed. The most common indications were uterine fibroids (42%) and dysfunctional uterine bleeding (27%). Abdominal hysterectomy accounted for 79% of cases and vaginal hysterectomy 21%. Overall complication rates were 33.5% for abdominal, 15.4% for vaginal, and 30.4% for both. The most common complications were blood transfusion (7.2%) and postoperative infection (18.7%). Rates of complications were similar to other international studies.
Simon Leeson - Colposcopic treatment standardstriumphbenelux
This document discusses standards for colposcopic treatment of precancerous cervical lesions. It summarizes current European standards agreed through a Delphi process, including that 85% of excisional treatments should contain CIN2+, 100% of cases should have a pre-treatment colposcopy, 80% of excised lesions should have clear margins, and documentation of the squamocolumnar junction. The document evaluates data on factors like excision length, margin status, and HPV testing after treatment. It discusses modifying standards based on discussions, including recording excision length, margin involvement, and HPV/cytology outcomes post-treatment. The conclusions are that additional treatment standards may be needed despite existing Delphi standards, and
A Retrospective Analysis of Complications of Pelvic Exenteration - A Single I...Premier Publishers
To analyse complications in patients who underwent pelvic exenteration procedures performed in our, between January 2013 – December 2018. A retrospective analysis of the baseline characteristics, surgical outcomes, complication rates of 51 patients who had undergone pelvic exenteration procedures between January 2013 and December 2018 was made. The results analysed using chi-square test. Of the 51 patients, 38 were operated for primary malignancy and 13 underwent exenteration for recurrences. Seventeen patients were operated by laparoscopy whereas the rest underwent open procedures. The diagnosis for which exenteration had been done included cancers of cervix (37), urinary bladder (5), rectum (4), urethra (1), vagina (3), and ovary (1). Bleeding was the most common complication encountered. Hypokalaemia, surgical site infections, urine leak and sepsis were seen in early post-operative period. The morbidity rate (major) was 33.3% and the mortality rate was 5.8% in our centre. The late outcome was inadequately evaluated as most patients lost follow-up. Pelvic exenteration is the only surgical option available for advanced pelvic malignancies and the morbidity pattern differs based on diagnosis, extent of resection and the type of diversion procedure. In a high-volume centre, the morbidity and mortality rates are acceptable compared with international standards.
The Diagnostic value of saline infusion sonohysterography and hysteroscopy in...Ahmed Mowafy
Hysteroscopy is more sensitive and has a higher negative predictive value than saline infusion sonohysterography (SIS) in detecting intracavitary abnormalities, according to a study comparing the two techniques. The study of 80 women found hysteroscopy had a sensitivity of 96.3% versus 89.3% for SIS. Hysteroscopy also had a higher negative predictive value of 92.3% compared to 76.9% for SIS. However, SIS has advantages of being non-invasive, cheaper, faster, and less discomfortable for patients. Both techniques had few complications, with bleeding being most common for SIS. The study concludes hysteroscopy is superior for diagnosis but S
This randomized controlled trial studied three surgical techniques used in caesarean sections to determine their effects on maternal infectious morbidity: 1) Single vs double layer closure of the uterine incision, 2) Closure vs non-closure of the pelvic peritoneum, and 3) Liberal vs restricted use of a subrectus sheath drain. The trial recruited 3033 women undergoing their first caesarean section. It found no significant differences in maternal infectious morbidity between any of the surgical technique pairs studied. The results have implications for changing current guidance on peritoneum closure.
Sonographic assessment of myometrial thickness as a predictor 2Tamer Essam
This document describes a study that aimed to measure myometrial thickness by ultrasound in patients with preterm premature rupture of membranes (PPROM) as a predictor of latency interval. The study involved measuring myometrial thickness at different sites in 100 pregnant women divided into three groups: those with PPROM, preterm non-labor controls, and term non-labor controls. Results showed significantly thicker myometrial thickness at all sites in the PPROM group compared to controls. Regression analysis found a direct correlation between latency interval and fundal myometrial thickness in PPROM patients. The study concluded that thickening of the uterine fundal wall follows PPROM, and a thick myometrium in non-
This document discusses fetal endoscopic surgery, including the indications and anesthetic management. It describes several fetal conditions that may benefit from fetoscopic intervention, including twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion sequence (TRAP), and bladder outlet obstruction from conditions like posterior urethral valves. For TTTS and TRAP sequence, fetoscopic techniques like selective fetoscopic laser photocoagulation of placental vessels and umbilical cord ligation are discussed as alternatives to open fetal surgery or other treatments. The document also reviews maternal and fetal considerations for anesthesia during these procedures.
The document discusses new trends in the treatment of placenta accreta. It begins by defining placenta accreta and discussing the increasing incidence. Risk is highly associated with the number of prior cesarean deliveries and the presence of placenta previa. Ultrasound is usually sufficient for diagnosis but MRI can provide additional information. Prenatal care involves frequent ultrasound exams and potential adjuvant therapies. Cesarean hysterectomy is the definitive treatment, ideally without attempting placenta removal. A conservative approach may be attempted in select cases for women wishing to preserve fertility, but outcomes are unpredictable and further intervention is often needed. Management of hemorrhage, including techniques such as hemostatic resuscitation,
Hysterectomy for benign conditions in a university hospital inTariq Mohammed
This document summarizes a study examining hysterectomies performed at a university hospital in Saudi Arabia between 1990-2002. A total of 251 hysterectomies were reviewed. The most common indications were uterine fibroids (42%) and dysfunctional uterine bleeding (27%). Abdominal hysterectomy accounted for 79% of cases and vaginal hysterectomy 21%. Overall complication rates were 33.5% for abdominal, 15.4% for vaginal, and 30.4% for both. The most common complications were blood transfusion (7.2%) and postoperative infection (18.7%). Rates of complications were similar to other international studies.
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
The document discusses the anatomy and histology of the endometrium, the lining of the uterus. It then covers endometrial cancer, including risk factors, common presentations, workup involving endometrial biopsy and imaging, and staging. Treatment is discussed for each stage, with surgery being primary treatment and adjuvant therapy depending on grade, myometrial invasion, and other pathological factors. Sentinel lymph node biopsy and recent advances are also mentioned.
Endometrioma and how it affects IVF outcome : modified procedure with encoura...Mohamed Walaa El Deeb
1) Endometriomas are common in women with endometriosis and infertility, affecting up to 50% of subfertile women. Surgical removal carries risks of reducing ovarian reserve.
2) A meta-analysis found no significant difference in ovarian response or pregnancy rates between surgery vs no treatment prior to IVF. However, large endometriomas over 4cm may interfere with oocyte retrieval.
3) The authors propose a modified aspiration technique for large, recurrent endometriomas as an alternative to repeated surgery. Preliminary results show encouraging pregnancy rates without complications. Larger studies are still needed.
Vaginal cuff closure in laparoscopic hysterectomy (TLH) was compared between polyglactin 910 suture and unidirectional barbed suture. In a study of 68 patients, vaginal cuff complications, postoperative vaginal bleeding, long term complications, and closure duration were estimated. Patients were divided into two groups - Group 1 used polyglactin 910 suture (n=44) and Group 2 used unidirectional barbed suture (n=24). Postoperative vaginal bleeding occurred in 32.5% of Group 1 and 18.8% of Group 2, showing a significant reduction with barbed suture. No other short or long term complications showed a significant difference between
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
This document discusses sacrococcygeal teratoma (SCT), a rare congenital tumor. SCT arises from embryonic cells and can be benign or malignant. It presents prenatally via ultrasound in most cases. Risk of malignancy increases with age of diagnosis. Treatment involves complete surgical excision, with early surgery associated with better outcomes. Large or rapidly growing tumors may require intervention like chemotherapy or early delivery to prevent complications of high output cardiac failure. Complete resection remains the main treatment for benign SCT to prevent malignant transformation.
- The document discusses fertility outcomes after ectopic pregnancy and various treatment options.
- Fertility rates after ectopic pregnancy are around 60% for subsequent intrauterine pregnancy and 28% risk of recurrent ectopic pregnancy, regardless of treatment.
- Expectant management, methotrexate treatment, and surgery all have comparable fertility outcomes, with subsequent intrauterine pregnancy rates around 60-70% within 2 years. The risk of recurrent ectopic pregnancy is also similar between treatments.
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
This document discusses anesthesia considerations for obstetric hemorrhage. It provides statistics on causes of maternal mortality, including that obstetric hemorrhage accounts for 67.4% of maternal deaths in Vietnam. Common causes of obstetric hemorrhage are uterine atony, retained placenta, abnormal placentation. Risk factors include previous cesarean sections, placenta previa, and placenta accreta. Treatment involves medical uterotonics, blood transfusion, and in severe cases, hysterectomy. Anesthesia management includes anticipating blood loss and having blood products available.
Free nipple grafting is proposed as an alternative for patients ineligible for nipple-sparing mastectomy due to anatomical limitations. A retrospective review was conducted of 36 breasts that underwent nipple-sparing mastectomy with immediate reconstruction using free nipple grafting. Average graft take was 93.6% with no complete graft losses. Four nipples lost all projection and 4 experienced hypopigmentation requiring tattooing. For patients ineligible for nipple-sparing mastectomy due to anatomical factors, free nipple grafting in a single stage is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties.
effectiveness of operative hysteroscopy in primary infertility on pregnancy rateDr-Alaa Hassanin
This study evaluated 50 women with primary infertility who underwent hysteroscopic surgery to treat intrauterine abnormalities. The most common abnormalities were polyps (42%) and fibroids (20%). The majority of women presented with abnormal uterine bleeding (70%) and dysmenorrhea (52%). Hysteroscopic resection successfully treated the abnormalities and resulted in high pregnancy rates, with 85% of women conceiving within 8.5 months on average. The study demonstrates hysteroscopic surgery is an effective treatment for intrauterine lesions associated with infertility.
Role of tranexamic acid in cesarean sectionAhmad Farouk
Tranexamic acid reduces blood loss during cesarean sections. A study of 220 women undergoing elective c-sections compared intravenous tranexamic acid (1g) administered 10 minutes before incision (study group, 110 women) to intravenous saline (control group, 110 women). The tranexamic acid group had significantly less estimated blood loss, higher post-operative hematocrit levels, and fewer cases of blood loss over 1000mL compared to the control group. No increase in thromboembolic events was observed with tranexamic acid use. The study concludes that tranexamic acid effectively and safely reduces blood loss during cesarean sections.
This research article evaluated the efficacy and safety of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation for treating rectal cancer. 211 patients underwent either laparoscopic (131 patients) or open (80 patients) surgery. Results showed that both surgeries were successfully completed with no differences in lymph nodes removed or post-op complications. The laparoscopic group had shorter time to pass gas, get out of bed, and hospital stay. No differences were found in recurrence, mortality, or urinary/sexual dysfunction between groups. The study concludes that laparoscopic D3 lymphadenectomy combined with nerve preservation is a feasible and safe treatment for rectal cancer.
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
This document summarizes a study that evaluated the effectiveness of hysteroscopic transcervical resection of uterine septum (HTCRS) in improving reproductive outcomes for women with infertility or recurrent miscarriages. The study included 210 women in Libya who underwent HTCRS. Results found that after the procedure, 57.3% of patients who were trying to get pregnant achieved pregnancy within one year. Miscarriage rates and preterm birth rates were reduced compared to before the procedure. The procedure was concluded to be safe and effective in managing infertility and recurrent miscarriage by increasing pregnancy rates and live birth rates while decreasing miscarriage risks.
Primary postpartum hemorrhage is a leading cause of maternal mortality. This presentation defines PPH as blood loss exceeding 500mL after vaginal delivery or 1000mL after c-section within 24 hours of delivery. The main causes are uterine atony, retained placenta or clots, genital tract trauma, and coagulopathy. Risk factors include previous c-sections, multiple gestation, and medical disorders. Prevention focuses on active management of the third stage of labor and treatment involves addressing the underlying cause, fluid resuscitation, blood transfusion, and potentially hysterectomy for uncontrolled bleeding.
This document summarizes pre-clinical and clinical data on the Colon Ring for circular anastomosis. A porcine study showed the Colon Ring had higher burst pressure and preserved natural lumen size compared to stapling. Over 1050 human procedures showed an overall leak rate of approximately 2%. Planned clinical studies include a 300-patient prospective study of the Colon Ring for rectal anastomosis starting in 2009, and a 150-patient comparison study of the Colon Ring versus stapling.
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
The Jada System is a new device for treating postpartum hemorrhage (PPH). A clinical study of 107 women found that the Jada System was 94% effective in controlling PPH within 3 minutes of use, without need for further intervention. The study also found a very low rate of device-related adverse events, demonstrating the Jada System's excellent safety profile. Investigators reported that the Jada System was easy to use, with 98% finding it simple to insert and remove. The study provides strong evidence that the Jada System is a fast, definitive, and physiologic option for resolving PPH in a safe and effective manner.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Postoperative chylothorax after cardiothoracicgisa_legal
This study examines the incidence, risk factors, and outcomes of postoperative chylothorax in children undergoing cardiothoracic surgery. The researchers found that the incidence of chylothorax was 3.8% and was significantly higher after heart transplantation, Fontan procedures, and tetralogy of Fallot repairs. Patients with chylothorax had significantly longer hospital stays compared to those without chylothorax. Nutritional management including low fat diets and octreotide were used to treat chylothorax, but surgical interventions provided limited benefit when reserved for severe or prolonged cases. Early diagnosis may reduce the duration of chylothorax.
The document discusses the anatomy and histology of the endometrium, the lining of the uterus. It then covers endometrial cancer, including risk factors, common presentations, workup involving endometrial biopsy and imaging, and staging. Treatment is discussed for each stage, with surgery being primary treatment and adjuvant therapy depending on grade, myometrial invasion, and other pathological factors. Sentinel lymph node biopsy and recent advances are also mentioned.
Endometrioma and how it affects IVF outcome : modified procedure with encoura...Mohamed Walaa El Deeb
1) Endometriomas are common in women with endometriosis and infertility, affecting up to 50% of subfertile women. Surgical removal carries risks of reducing ovarian reserve.
2) A meta-analysis found no significant difference in ovarian response or pregnancy rates between surgery vs no treatment prior to IVF. However, large endometriomas over 4cm may interfere with oocyte retrieval.
3) The authors propose a modified aspiration technique for large, recurrent endometriomas as an alternative to repeated surgery. Preliminary results show encouraging pregnancy rates without complications. Larger studies are still needed.
Vaginal cuff closure in laparoscopic hysterectomy (TLH) was compared between polyglactin 910 suture and unidirectional barbed suture. In a study of 68 patients, vaginal cuff complications, postoperative vaginal bleeding, long term complications, and closure duration were estimated. Patients were divided into two groups - Group 1 used polyglactin 910 suture (n=44) and Group 2 used unidirectional barbed suture (n=24). Postoperative vaginal bleeding occurred in 32.5% of Group 1 and 18.8% of Group 2, showing a significant reduction with barbed suture. No other short or long term complications showed a significant difference between
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
This document discusses sacrococcygeal teratoma (SCT), a rare congenital tumor. SCT arises from embryonic cells and can be benign or malignant. It presents prenatally via ultrasound in most cases. Risk of malignancy increases with age of diagnosis. Treatment involves complete surgical excision, with early surgery associated with better outcomes. Large or rapidly growing tumors may require intervention like chemotherapy or early delivery to prevent complications of high output cardiac failure. Complete resection remains the main treatment for benign SCT to prevent malignant transformation.
- The document discusses fertility outcomes after ectopic pregnancy and various treatment options.
- Fertility rates after ectopic pregnancy are around 60% for subsequent intrauterine pregnancy and 28% risk of recurrent ectopic pregnancy, regardless of treatment.
- Expectant management, methotrexate treatment, and surgery all have comparable fertility outcomes, with subsequent intrauterine pregnancy rates around 60-70% within 2 years. The risk of recurrent ectopic pregnancy is also similar between treatments.
PREVENTIONandTreatment of Sleeve Gastrectomy Leaks
Dr Rutledge
Where does it occur?
ONE PLACE!
This is “Tiger Country” – remember that!
Managing ComplicationsFIRST Prevent Complications
Managing LeaksFirst Prevent Leaks!!
Examples of ComplacencySleeve Gastrectomy Leak
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
This document discusses anesthesia considerations for obstetric hemorrhage. It provides statistics on causes of maternal mortality, including that obstetric hemorrhage accounts for 67.4% of maternal deaths in Vietnam. Common causes of obstetric hemorrhage are uterine atony, retained placenta, abnormal placentation. Risk factors include previous cesarean sections, placenta previa, and placenta accreta. Treatment involves medical uterotonics, blood transfusion, and in severe cases, hysterectomy. Anesthesia management includes anticipating blood loss and having blood products available.
Free nipple grafting is proposed as an alternative for patients ineligible for nipple-sparing mastectomy due to anatomical limitations. A retrospective review was conducted of 36 breasts that underwent nipple-sparing mastectomy with immediate reconstruction using free nipple grafting. Average graft take was 93.6% with no complete graft losses. Four nipples lost all projection and 4 experienced hypopigmentation requiring tattooing. For patients ineligible for nipple-sparing mastectomy due to anatomical factors, free nipple grafting in a single stage is an option with acceptable complication rates similar to free nipple grafting in reduction mammaplasties.
effectiveness of operative hysteroscopy in primary infertility on pregnancy rateDr-Alaa Hassanin
This study evaluated 50 women with primary infertility who underwent hysteroscopic surgery to treat intrauterine abnormalities. The most common abnormalities were polyps (42%) and fibroids (20%). The majority of women presented with abnormal uterine bleeding (70%) and dysmenorrhea (52%). Hysteroscopic resection successfully treated the abnormalities and resulted in high pregnancy rates, with 85% of women conceiving within 8.5 months on average. The study demonstrates hysteroscopic surgery is an effective treatment for intrauterine lesions associated with infertility.
Role of tranexamic acid in cesarean sectionAhmad Farouk
Tranexamic acid reduces blood loss during cesarean sections. A study of 220 women undergoing elective c-sections compared intravenous tranexamic acid (1g) administered 10 minutes before incision (study group, 110 women) to intravenous saline (control group, 110 women). The tranexamic acid group had significantly less estimated blood loss, higher post-operative hematocrit levels, and fewer cases of blood loss over 1000mL compared to the control group. No increase in thromboembolic events was observed with tranexamic acid use. The study concludes that tranexamic acid effectively and safely reduces blood loss during cesarean sections.
This research article evaluated the efficacy and safety of laparoscopic D3 lymphadenectomy combined with pelvic autonomic nerve preservation for treating rectal cancer. 211 patients underwent either laparoscopic (131 patients) or open (80 patients) surgery. Results showed that both surgeries were successfully completed with no differences in lymph nodes removed or post-op complications. The laparoscopic group had shorter time to pass gas, get out of bed, and hospital stay. No differences were found in recurrence, mortality, or urinary/sexual dysfunction between groups. The study concludes that laparoscopic D3 lymphadenectomy combined with nerve preservation is a feasible and safe treatment for rectal cancer.
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
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weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
This document summarizes a study that evaluated the effectiveness of hysteroscopic transcervical resection of uterine septum (HTCRS) in improving reproductive outcomes for women with infertility or recurrent miscarriages. The study included 210 women in Libya who underwent HTCRS. Results found that after the procedure, 57.3% of patients who were trying to get pregnant achieved pregnancy within one year. Miscarriage rates and preterm birth rates were reduced compared to before the procedure. The procedure was concluded to be safe and effective in managing infertility and recurrent miscarriage by increasing pregnancy rates and live birth rates while decreasing miscarriage risks.
Primary postpartum hemorrhage is a leading cause of maternal mortality. This presentation defines PPH as blood loss exceeding 500mL after vaginal delivery or 1000mL after c-section within 24 hours of delivery. The main causes are uterine atony, retained placenta or clots, genital tract trauma, and coagulopathy. Risk factors include previous c-sections, multiple gestation, and medical disorders. Prevention focuses on active management of the third stage of labor and treatment involves addressing the underlying cause, fluid resuscitation, blood transfusion, and potentially hysterectomy for uncontrolled bleeding.
This document summarizes pre-clinical and clinical data on the Colon Ring for circular anastomosis. A porcine study showed the Colon Ring had higher burst pressure and preserved natural lumen size compared to stapling. Over 1050 human procedures showed an overall leak rate of approximately 2%. Planned clinical studies include a 300-patient prospective study of the Colon Ring for rectal anastomosis starting in 2009, and a 150-patient comparison study of the Colon Ring versus stapling.
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
The Jada System is a new device for treating postpartum hemorrhage (PPH). A clinical study of 107 women found that the Jada System was 94% effective in controlling PPH within 3 minutes of use, without need for further intervention. The study also found a very low rate of device-related adverse events, demonstrating the Jada System's excellent safety profile. Investigators reported that the Jada System was easy to use, with 98% finding it simple to insert and remove. The study provides strong evidence that the Jada System is a fast, definitive, and physiologic option for resolving PPH in a safe and effective manner.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
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NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
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Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
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3. Presented by :-
Dr. Wedad Alfithoure
Supervised by :-
Dr . Abdullah Abudaber
Consultant Obstetrician &Gynecologist Libya, Assistant professor, Faculty of Medicine,
University of Tripoli
This dissertation is submitted in partial fulfillment for certification by the master degree
in Obstetrics and Gynecology, Tripoli- Libya, Dec 2018.
4. Subject Page
Study protocol 6
Abstract 11
Introduction 12
Aim of study 17
Materials and methods 19
Result 24
Discussion 27
Conclusion 33
Limitation of the study 34
References 42
Arabic summary 48
Table of content:
6. Background:-
• A nationwide review of the peripartum hysterectomies by the UK
Obstetric Surveillance System (UKOSS) found that morbidly
adherent placenta was the cause in 38% of cases.
7. • Women undergoing attempts of removal of the placenta before
hysterectomy have an increased incidence of maternal morbidity
(admission to the ICU for >24 hours, transfusion of ≥4 units of
packed red blood cells, coagulopathy, ureteric injury, or early
re‐operation) when compared with those undergoing cesarean
hysterectomy with the placenta left in situ.
8. • Currently, there is dramatic increase in the incidence of placenta
previa and placenta accreta due to the increasing rate of cesarean
delivery combined with increasing maternal age
9. • The maternal mortality in women with PA may reach as high as 7–
10 %.
10. • Manual removal of the placenta would lead to increased risk of
hysterectomy, hemorrhage, and blood transfusion.
11. • Several techniques have been described in the literature for
controlling massive bleeding associated with placenta previa
cesarean sections, including uterine packing with gauze, balloon
tamponades, the B-Lynch suture, insertion of parallel vertical
compression sutures, a square suturing technique, and
embolization or ligation of the uterine and internal iliac arteries ,
but there is a wide variation in the success rate of these
maneuvers.
12. • Internal iliac artery ligation or embolization is associated with
significant risks of failure especially in cases of placenta previa
and accreta as the lower uterine segment has additional arterial
supply by the cervical, inferior vesical and vaginal arteries.
13. • An alternative method to leaving the placenta in situ involves
resection of the invaded myometrium together with the placenta
and suturing the myometrial defect. Reconstruction is possible if
there is non‐invaded segment of the uterus below the placental
invasion, so that the lower uterine segment can be sutured to the
upper segment after resecting the invaded myometrial segment.
14. • In a case report, Dawlatly et al. described a simple technique of
suturing an inverted lip of the cervix over the bleeding placental
bed that was successful in controlling the bleeding, and preserving
fertility.
15. Here
• We present our experience with the use of this Dawlatly stitch in
35 cases of placenta previa and/or placenta previa accreta.
17. Objective
• Evaluate the efficacy and safety of the use of the cervix as a
natural tamponade in controlling intrapartum hemorrhage caused
by placenta previa and accretta .
18. Material and Methods
Study design: prospective study
Study setting : Alkhadra hospital obstetrics and
gynaecology department ,Tripoli ,Libya
Study period : January 2017 and December 2017
19. Study population
• All participating women had one or more previous cesarean
deliveries and were diagnosed with placenta previa and/ or
placenta previa accreta by ultrasound.
All women meeting inclusion criteria were selected which
included 35 patients who had received the decided type of the
modified cervical inversion stitch.
20. • All participating women desired to preserve their fertility. They
were counseled properly and were given clear information about
the diagnosis, the risk of severe postpartum hemorrhage and the
methods that can be used to control this massive hemorrhage,
including conservative methods and radical method (emergency
hysterectomy).
21. • Patients were informed that cesarean hysterectomy is the
first option in case of placenta percreta, diffuse placenta accreta
or increta and in the presence of uncontrollable hemorrhage and
these were considered as exclusion criteria for conservative
management. The conservative methods used were explained to
the patients and included the suture technique described in this
study, uterine and/or internal iliac artery ligation.
22. Primary Outcome measures:-
• The amount of intra-operative blood loss.
• The change in pre and post-partum hemoglobin .
• The need for further surgical intervention to control bleeding.
• The bleeding control with the primary technique
• The need for blood transfusion.
• The operative time.
24. Statistical analysis
• Statistical analysis was performed using the Statistical Package for
Social Science (SPSS Inc., NY) version 21 for Microsoft Windows.
Data was described in terms of mean ± SD (standard deviation) for
continuous variables and frequencies (number of cases) and
percentages for categorical data.
25. • Independent Student’s t-test was used to compare quantitative
variables and Chi square test was used to compare categorical
data. A p value < 0.05% was considered significant.T-test was
performed to compare the mean pre-operative hemoglobin and
the mean post-operative hemoglobin.
26. Results
• Tables one and two ,and figure one, two, and three show the
demographic and the intraoperative clinical data of the studied
group.
The mean age was 29.2 ± 2.7 years. Regarding parity, one patient
(2.85 %) was para 1 , 5 patients (14.28 %) were para 2 , 9 patients
para 3 (25.73 %) , and 20 ( 57.14 % ) patients were para 4 .
27. Table 1: Demographic Data of the patients.
Characteristics Mean _+SD Range Number %
Total 35
Age 29.2 + -2.7 25 -36
Parity :- P1- 4
P1 1 (2.85%)
P2 5 (14.28 %)
P3 9 (25.73 %)
P4 20 (57.14
%)
Number of Living children :- 0 - 4
No alive 3 ( 8.6 % )
1 1 ( 2.8 % )
2 5 ( 14.2 % )
3 10 ( 28.6 % )
4 16 ( 45.8 % )
Previous Cesarean section : -
P1cs 5 ( 14.2 % )
P2cs 7 ( 20 % )
P3cs 7 ( 20 % )
P4cs 16 ( 45.8%
)
Gestational age in weeks 5.9+-1.1 33_ 37
SD – Standard Deviation ,P – Para.
28. Table 2: Intraoperative clinical data of the
participants
Characteristics Number (%)
(Total 35)
Mean + -
SD
P value
Type of placenta previa:
P. previa accreta 27 (77.1 % )
P. previa major anterior 5 ( 14.3 % )
P.previa major posterior 3 (8.6 % )
Cervical Lip Inverted:-
Both cervical lips 8 ( 22.8 % )
Anterior cervical lip 25 ( 71.5 % )
Posterior cervical lip 2 (5.7 % )
Time required to apply the stitch(minutes) 5.4+-0(4.3-
7.1)
Intraoperative blood loss( ml) 1572.2+-
390.2
Hysterectomy 2 (5.7 % )
Haemoglobine :-
Preoperative 10.8 +-0.23 <0.000
1
Postoperative 10.3 +-.22
SD Standard Deviation,
29. Figure1: parity of patients
2.85%
14.28%
25.73%
57.14%
Parity of patients
para 1
Para 2
Para 3
Para 4
30. Figure2: number of previous C/S
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Previous on C/S Previous two C/S Previous three C/S Previous four C/S
14.20%
20%
20%
45.80%
Number of previous C/S
Number of previous C/S
31. Figure 3: types of placenta previa
77.10%
14.30%
8.60%
Types of palcenta previa
P. previa accreta
P. previa major anterior
P.previa major posterior
32. • . The number of living children, three patients (8.6 %) have no
children and 1 patient (2.8 %) has one child and 5 patients (14.2
%) have two children, 10 patients ( 28.6 %) have three living
children , and 16 ( 45.8 % )patients have four living children
which are considered small family size in our communities.
33. • Intra-operatively, we identified twenty seven cases of placenta
accreta, five cases of placenta previa major anterior and three
cases of placenta previa major posterior.
34. • To control bleeding from the placental bed, both the anterior and
posterior cervical lips were used in eigth cases, the anterior lip
only was used in twenty five cases and the posterior lip in two
cases.
35. • The technique of cervical inversion described above was
successful in stopping the bleeding in 33 out of 35 patients;
yielding a success rate of 95 %.
36. • We resorted to hysterectomy in only two cases (5.7 % ).
Histopathological examination of the uterus in these two cases
showed placenta percreta.
37. • The mean intra-operative blood loss was 1572.5 mL, and the mean
number of blood units transfused was 3.1. The difference between
the mean pre-operative hemoglobin (10.8 ± 0.23 gm/dl) and the
mean post-operative hemoglobin (9.3 ± 0.22 gm/dl) was
statistically significant (p value < .0001).
38. • Table 3 showed that placenta accreta cases were more in those
who had previous 4 cesarean sections .
39. Table 3: Type of previa & Relation to
number of C.S
Type of placenta previa Previous
1 C.S
Previous 2
C.S
Previou
s 3 C.S
Previou
s 4C.S
Total Nu. 35
Placenta previa accreta 3 5 5 14 27
Placenta previa major
anterior
2 1 1 1 5
Placenta previa major
posterior
0 1 1 1 3
Total Nu. 5 7 7 16 35
C.S Cesarean Section
40. • Table 4 showed the postoperative data and the complications
encountered were as follows: bladder injury in the two patients
who underwent hysterectomy and wound infection in one patient.
Postoperative fever that responded to antibiotics occurred in one
patient. The mean duration of the postoperative hospital stay was
3.5 days.
41. Table 4
Postoperative clinical data
Characteristics Number(%)(Total
35)
Mean +-
SD P
value
Postoperative hospital stay ( Days ) 3.5 +-0.6
Blood Transfusion ( units ) 3.1 +-0.6
Urinary bladder injury 2 (5.7 % )
Wound infection 1 (2.8 % )
Postoperative fever 1 (2.8 )
Speculum.examination (at 3 months)
Normal cervix 2931 (93.6%
)
Distorted cervix 231 ( 6.4%
)
SD Standard Deviation
42. • 33 patients were given follow-up appointments 3 and 6 months
following delivery as two patients had hysterectomy done and
were excluded from followup .
43. • At the 3 months follow up appointment, speculum examination
was performed in only 31 cases (93.9 % ), as the other two cases
(6.1 % ) failed to keep their appointment. Speculum examination
revealed normal position and normal morphology of the cervix in
29 cases.
44. • In two patients, the cervix was displaced upwards. Examination of
the cervix in the two patients showed unremarkable findings. In
the same sitting, office hysteroscopy was done and the cavity was
normal with no evidence of intrauterine synechiae in these two
patients.
45. • Twenty five patients ( 80 % ) attended their 6 months follow-up
appointment. Menstruation was resumed in 21 ( 84 % ) patients.
The other four patients (16 %) were amenorrheic and were
lactating .
46. Discussion
• The management options in PPH associated with placenta previa
and placenta accreta include either (1) a radical approach
(Hysterectomy and resection of the involved tissues e.g., partial
cystectomy if the bladder is involved) or (2) a conservative
approach including the adjuvant measures to conserve the uterus.
47. • Although cesarean hysterectomy is still the recommended
treatment for placenta accreta, when placenta percreta involves
adjacent structures, the bleeding might be severe, and surgery is
very risky, with the possibility of damage to these structures due
to the morbidly adherent placenta.
48. • Clearly, this radical approach is unacceptable to women with low
parity who desire uterine preservation.
(3) In some cultures as in our community, many people consider
women who have had a hysterectomy as having lost the most
important aspect of their feminine character. This could have a
major impact on the psychological state of these women, their
quality of life and selfesteem
49. • Conservative management does not mean “no surgery,” because it
often requires emergent delayed hysterectomy (which is
frequently performed without a multidisciplinary team approach).
50. • A very dangerous but unavoidable surgery and the patient’s
insufficient understanding place a great burden on the attending
doctor, pushing him/her into a tight corner, and conservative
management exaggerates this further.
51. • In the presence of hemorrhage, shock, and coagulopathy, it has
been proposed to abandon conservative management and resort to
delayed hysterectomy.
52. • Conservative treatment requires a prolonged period of postpartum
follow-up and patient compliance and adherence to treatment as
well as consideration of the risk for severe morbidity and possibly
mortality for weeks or even months after delivery.
53. • In this study, we present a suture technique which was 1st
described by Dawlatly in a case report in 2007.We used a modified
type of this suturing technique in our department in cases of
cesarean section when the lower uterine flap during the surgery is
extremely thin that can not be salvaged to repaire the uterotomy
incision or in cases of lower segment uterine rupture for the same
reasone
54. • Grasping the cervical lip(s) and suturing it into the paper-thin
lower uterine segment seen in such cases can help to control the
massive bleeding and create a good flap that can be used in
closing the uterine incision even in paper thin lower flaps in none
previa cases. With this technique, the cervix can be used as a
natural tamponade replacing the artificial tamponades that are
frequently used for stopping PPH in cases of placenta previa and
placenta previa accreta.
55. • The cervical canal remains patent, and an absorbable suture
material is used to help return the cervix to its original position.
There is no risk of injury to the ureters or uterine vessels as the
stitches are inserted in the substance of the cervix and the lower
uterine segment.
56. • When compared to artificial tamponades like Bakri balloon,
cervical inversion is a natural method, affordable with no cost and
in the same time appears to be safe, potentially effective and
more useful in controlling bleeding from the placental bed in the
lower uterine segment.
57. • the long term implications of cervical inversion are still unclear
the short term results in our study were satisfactory.
58. • Our patients were of young age and low parity with a small
number of living children. This reflects the importance of using
conservative technique(s) to preserve the uterus and fertility of
women in the studied group. This technique was introduced in our
department and is now widely adopted by our staff. In addition, it
can be used in cases of repeated cesarean deliveries with very
thin lower uterine segment to help close the uterine incision.
59. • Our study is supported by a recent study done by Sakhavar et al.
who reported that cervical inversion exerts pressure on the lower
segment arteries thus reducing the vascular blood flow leading to
relative hemostasis.
60. • Preventive devascularization can be achieved by surgical or
interventional radiology procedures also used in the management
of severe postpartum hemorrhage, such as stepwise uterine
surgical devascularization, bilateral uterine or hypogastric artery
surgical ligation, iliac artery embolization, or balloon occlusion.
Embolization before performing hysterectomy may reduce the risk
of intraoperative blood loss and prophylactic devascularization
may prevent the occurrence of secondary hemorrhage and could
also accelerate placental resorption. Overall, these
uterine‐sparing procedures seem to be less effective in cases of
PAS disorders.
61. • A systematic review including 177 cases of PAS disorders reported
success rates of 90% for arterial embolization, with secondary
hysterectomy necessary in only 11.3%.39 In the remaining 85
women, subsequent menstruation occurred in 87% and three
women had a subsequent pregnancy. The indications for
embolization and the depth of villous invasion are not accurately
reported by the authors, limiting the interpretation of the data.
This technique is also associated with significant maternal
morbidity.
62. • The value of prophylactic placement of balloon catheters in the
iliac arteries in cases of PAS disorders is even more controversial,
mainly owing to the higher risks of complications than with
embolization. In particular, there are two case reports, one of a
popliteal and one of an external iliac arterial thrombus, a case of
iliac artery rupture and a case of ischemic nerve injury
attributable to iliac artery thrombosis complicating common iliac
balloon catheterization at cesarean hysterectomy.
63. • A recent single‐institution observational cohort series of 45 cases
of PAS disorders reported the use of prophylactic lower abdominal
aorta balloon occlusion and found a reduced need for blood
transfusion. One of the cases was complicated by lower extremity
arterial thrombosis and another by ischemic injury to the femoral
nerve.
64. Conclusion
• Based on these preliminary data of this study, we conclude that
this technique of using the cervix as a natural tamponade is
apparently safe, simple, time-saving and potentially effective in
controlling the severe bleeding associated with cases of placenta
previa accreta. This technique deserves to be one of the tools in
the hands of obstetricians who face the life-threatening
hemorrhage of cases of placenta accreta.
65. • Further studies are needed with extended follow-up of the
patients to explore the long-term implications of this
technique.This study is still on going to increase the sample size
and to test the long term results.
66. • Now we are training our junior surgeon with less experience and
skill in emergency conditions so they can apply this technique . It
can be used in hospitals with limited techniques and equipment.
67. Limitation of the Study:-
• The technique is not used in presence of diffuse placenta
accreta, increta and percreta with severe post-partum
hemorrhage diagnosed intraoperatively, as no time for cervical
inversion (these cases excluded from our study) and we proceed to
emergency hysterectomy. The first limitation in interpreting the
results of our study is that it is not a randomized trial.
68. • So this technique might be effective and could gain widespread
acceptance in controlling hemorrhage in placenta previa cases as
we have a good experience with this technique in thin cesarean
section scars .
69. • Another limitation is the difficulty of inversion of the cervix in
some cases as their cervices were not suitable and not partially
dilated and we used a modified technique of partial inversion or
we proceeded to other options of conservative management such
as transverse B Lunch, internal iliac artery ligation, balloon
tamponade and vertical compression sutures.
70. • The last limitation is the uncertainty of the effect of the cervical
inversion technique on the anatomical and functional capacity of
the cervix and its impact on future pregnancy and delivery.
However, these worries could be minimized by the promising
results of the short term follow-up of these patients .