Regional centro-axial anaesthesia, primarily spinal block, is the preferred method of anaesthesia for elective caesarean section because it entails fewer risks for the mother and the foetus compared to general anaesthesia. The most common side effect associated with spinal block is hypotension due to sympatholysis, occurring in up to 75% of cases. Spinal block-induced sympatholysis leads to vasodilatation and consequently causes maternal hypotension, which may compromise uterine blood flow and foetal circulation, and thus cause foetal hypoxia, bradycardia and acidosis. The selection of the most efficient treatment strategy to achieve haemodynamic stability during spinal anaesthesia for caesarean section continues to be one of the main challenges in obstetric anaesthesiology. A number of measures for the prevention and treatment of spinal block-induced hypotension are used in clinical practice, such as preloading and coloading with crystalloid and/or colloid infusion, wrapping of lower limbs with compression stockings or bandages, administering an optimal dose of local anaesthetic and achieving an optimal spinal block level, left tilt positioning, and administering inotropes and vasopressors. Instead of administering vasopressors after a drop in blood pressure has already occurred, the latest algorithms recommend a prophylactic administration of vasopressor infusion. The preferred vasoconstrictor in this case is phenylephrine, which is associated with a lower incidence of foetal acidosis, and maternal nausea and vomiting compared to other vasoconstrictors.

Objective: The aim of the study was to present the incidence, indications, and operative morbidity and mortality in pregnant women undergoing emergency peripartum hysterectomy (EPH) at a tertiary obstetric institution. Methods: In this retrospective clinical study, performed during the period 1995–2003, 17 EPH procedures were recorded in a total of 21,659 deliveries carried out at Department of Gynecology and Obstetrics, Osijek Clinical Hospital in Osijek, Croatia. Data on the incidence of EPH in total number of deliveries, rate of EPH in vaginal delivery and cesarean section, indications for EPH, and maternal and fetal/early neonatal morbidity and mortality were derived from operative protocols and medical records of hospitalized patients. Results: During the 8-year study period, the incidence of EPH in total number of deliveries was 0.078%. Out of 17 EPH procedures, 5 (29.41%) were performed after vaginal delivery and 12 (70.59%) during cesarean section, elective in five and urgent in seven cases. The indications for EPH included severe peripartum hemorrhage with placenta previa in four, placenta previa percreta in four, various forms of invasive malplacentation (placenta accreta, increta, percreta) in five, uterine rupture in two cases, and atony along with massive retroperitoneal hematoma due to rupture of periuterine vascular bundle during cesarean section in one multipara. EPH was carried out in 12 multipara and five primipara. Lesions of urinary bladder occurred in three cases and were managed by suture. Twelve patients received blood transfusion, whereas development of hemorrhagic shock necessitated transfer to Intensive Care Unit in three patients. No late complications or maternal mortality were recorded. Sixteen total hysterectomies and one supracervical hysterectomy were performed. One case of intrauterine fetal death was caused by total abruptio placenta and uterine rupture during the patient’s transport from a primary obstetric institution. Conclusion: Invasive malplacentation is a major isolated risk factor for EPH, as shown in the present study. Other risk factors for EPH are massive hemorrhagy because placenta previa, uterine atony and uterine rupture associated with multiparity, and previous cesarean section. A great proportion of EPH procedures can be prevented by the introduction of compressive operative methods such as B-Lynch suture in the obstetric algorithms, which will certainly favorably reflect in future fertility and genital health of the female population.

Besides primary operative management of the wound, the patient should receive broad-spectrum antibiotic and antitetanic prophylaxis in cases of accidental and penetrating injuries (foreign object, cow's horn, kitchen knife). In case of suspect mechanism of infliction, VVI in a child require careful inspection because of the potential forensic implications (rape, abuse).

Objective: To determine the advantages of modified a Misgav Ladach method over conventional (Pfannenstiel-Dörffler) cesarean section. Study Design: From October 2002 to March 2005, 217 cesarean sections performed according to a modified Misgav Ladach method (without routine preoperative urinary catheterization, blunt separation of the fascia after a small incision, and unprepared plica vesicouterina) were prospectively compared with 153 randomly selected conventional cesarean sections. Maternal age, parity, gestational age, neonatal birth weight, procedure duration, operative complications and postoperative course were analyzed. Results: The incidence of postoperative fever was 2.30 and 4.57% (p = 0.001), wound seroma 0.46 and 1.96% (p = 0.01), local wound infection 0.92 and 1.96% (p = 0.01), wound dehiscence 0 and 0.65% (NS), anemia 3.68 and 7.84% (p = 0.001), and need of blood transfusion 1.38 and 1.96% (NS) in the modified Misgav Ladach and conventional group, respectively. The mean duration of the operation was 26.24 min with the Misgav Ladach versus 39.41 min with the conventional operation (p < 0.001). The postoperative use of antibiotics and analgesics/antipyretics was significantly lower in the modified Misgav Ladach group (p = 0.001). Conclusion: Study results demonstrated that the modified Misgav Ladach method of cesarean section is associated with faster postoperative recovery, lower morbidity and blood loss, shorter length of operative procedure, lower incidence of operative complications, lesser postoperative use of antibiotics and analgesics/antipyretics, and lower utilization of surgical material. The modified Misgav Ladach method of cesarean section is suitable for emergency and elective procedures, justifying its use in daily routine.

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