Uterine packing to control obstetrical hemorrhage has been generally discouraged over the past several decades. Intractable uterine hemorrhage postpartum or following an abortion is an extremely vexing management problem for the physician and continues to be a leading cause of maternal mortality. Uterine packing should be considered as a presurgical management tool after lacerations of the lower genital tract, uterine rupture, or retained products have been ruled out and when conventional therapy fails to control uterine hemorrhage. We describe two obstetrical patients with intractable uterine hemorrhage who were managed with uterine packing in combination with other methods of therapy. Causes of obstetrical hemorrhage and techniques of packing the uterus are discussed.

Abdominal pain during early pregnancy may be caused by leiomyoma of the uterus. Inconsistency of uterine size and gestational dates in a pregnant patient with acute abdominal pain may be the first sign of leiomyoma. This 31-year-old primigravida presented with progressively worsening lower abdominal pain at 12 weeks gestational age. Ultrasonography and magnetic resonance imaging demonstrated a large fundal heterogeneous mass and an intrauterine gestation compatible with her menstrual dates. Exploratory surgery and myomectomy confirmed a large leiomyoma showing benign degenerative changes. The operative procedure was successful, and the pregnancy progressed normally. An elective cesarean section was performed at 37 weeks gestation after confirming fetal maturity by amniocentesis and serial ultrasonography. Abdominal pain in a pregnant patient with leiomyoma uteri may be attributable to degenerative changes in the myoma. Surgical intervention during pregnancy is occasionally necessary in uncommon cases of intractable pain.

True knots of the umbilical cord are complications that can result in obstetric disasters, including fetal asphyxia and eventual fetal death. This study reports on 13 patients with a true knot of the umbilical cord in a delivery population of 967 deliveries during a 1-year period. In this group, there was one second-trimester fetal demise, four cases of fetal distress during labor necessitating cesarean delivery, and eight cases with a true knot found incidentally at delivery. No abnormal sequelae were found for the 12 viable newborns. True knots of the umbilical cord can be incidental findings; however, a tightened knot is reported to be associated with a fourfold increased risk of fetal death. Prenatal fetal surveillance, including targeted sonographic examination and Doppler studies, may identify true knots of the umbilical cord. Identification of high-risk patients and clinical expertise in the management of these patients have not been established.

A case of Couvelaire uterus with placenta accreta found during scheduled repeat low transverse Cesarean section will be discussed within this article. First described in the 1900s, Couvelaire syndrome, also known as uteroplacental apoplexy, is a rare form of nonfatal placenta abruption complication. The case involves a 30-year-old gravida 3 para 2 otherwise healthy female with an uncomplicated pregnancy and two previous cesarean deliveries without complication. She received routine prenatal care. During her pregnancy, she did not experience any symptoms such as vaginal bleeding or abdominal pain. After delivering a healthy female, there were several unsuccessful attempts to remove the placenta from the uterus. Upon inspection, the uterus was found have dark purple patches with ecchymosis and indurations, diagnostic of Couvelaire uterus. Furthermore, there was high clinical suspicion for placenta accreta as the 30-minute mark approached without placenta detachment. A telephonic emergency review with the wet desk radiologist of the 18-week ultrasound revealed high suspicion for placenta accreta. A Cesarean hysterectomy was performed for prevention of significant hemorrhage. This case report may be the first documented association of Couvelaire uterus with placenta accreta. Providers should be vigilant in monitoring for antenatal bleeding, timing of placenta separation, and postpartum hemorrhage.

Acute appendicitis is the most common nonobstetrical surgical condition of the abdomen complicating pregnancy. Appendectomy reportedly is performed during pregnancy once for every 1,500 deliveries. Although the incidence of appendicitis occurring in pregnant women is considered to be the same as in nonpregnant women, the signs and symptoms, and the laboratory findings usually associated with appendicitis in the nonpregnant condition, are frequently unreliable during pregnancy. Using the Computer Diagnostic Data System, we completed a retrospective analysis on all appendectomies performed at two Army Medical Activities (MEDDACs) during a 2-year period. With a representative large Army MEDDAC and a representative medium-sized Army MEDDAC studied, the incidence of appendectomy during pregnancy was the same frequency as in previous reports. The only consistent finding in all pregnant patients who underwent appendectomy was right lower quadrant abdominal pain. Presenting signs and symptoms, clinical evaluations, laboratory findings, and surgical management is discussed. No morbidity or mortality occurred during this study.