Case reportA 34 year old woman with an ultrasound diagnosis of a major placenta praevia was booked for an elective caesarean section at 38 weeks of gestation. As both of her previous deliveries had been by caesarean section, she was counselled regarding the possibility of an abnormally adherent placenta and the possible need for a hysterectomy at the time of delivery.The caesarean section was carried out on a consultant's elective operating list with a consultant anaesthetist; crossmatched blood was available. Anaesthesia was achieved by a combined spinal and epidural block. Two large bore venous cannulae and an arterial catheter were inserted. Her baby was delivered easily in good condition through a Pfannenstiel incision in the abdomen and a high transverse incision in the lower segment. At this stage, there had been minimal blood loss.Gentle attempts to identify a plane of separation of the placenta provoked torrential bleeding, and at this point, removal of the placenta was abandoned in favour of hysterectomy. The woman was, however, bleeding so heavily that manual aortic compression was necessary as a life-saving measure, and the 'major haemorrhage procedure' of the hospital was implemented. General anaesthesia was induced and assistance was requested. A second obstetric consultant, additional theatre nurses and a renal transplant surgeon gave their services. The haematology department sent a registrar to advise on transfusion and treatment of coagulopathy as the third request for 10 units of blood was received.Aortic compression controlled the bleeding to an extent that a closer inspection of the lower uterine segment was possible and during attempts to further reflect the bladder, placenta percreta involving the cervix and bladder was diagnosed.The incision was extended to the umbilicus in the midline and a subtotal hysterectomy was performed; however, despite this, every time the aorta was released from manual compression, bleeding restarted. At the suggestion of the consultant transplant surgeon (RHL), a cut-down onto the left femoral artery was performed and transluminal aortic occlusion was achieved just below the renal arteries using a 10 French aortic occlusion catheter (BVM Medical, Earl Shilton, Leicestershire). This enabled the remainder of the procedure to be carried out in a relatively bloodless field, with intermittent deflation of the balloon to check haemostasis and reperfuse the lower limbs.Invasion of the cervical stroma necessitated partial removal of the cervix, during which the bladder was opened and part of the bladder wall removed. A left ureteric stent and a suprapubic catheter were placed before closure of the bladder.When adequate haemostasis was achieved, the aortic balloon was deflated and the pelvis was packed with oxidised cellulose gauze ('Oxycel', Becton Dickinson, UK) and gauze soaked in warm saline, and the wound was closed in layers. Finally, the aortic balloon was removed and the femoral artery repaired.Four hours later, the woman was transferred to the intensive care uni...

No abstract

Case reportA 34 year old woman with an ultrasound diagnosis of a major placenta praevia was booked for an elective caesarean section at 38 weeks of gestation. As both of her previous deliveries had been by caesarean section, she was counselled regarding the possibility of an abnormally adherent placenta and the possible need for a hysterectomy at the time of delivery.The caesarean section was carried out on a consultant's elective operating list with a consultant anaesthetist; crossmatched blood was available. Anaesthesia was achieved by a combined spinal and epidural block. Two large bore venous cannulae and an arterial catheter were inserted. Her baby was delivered easily in good condition through a Pfannenstiel incision in the abdomen and a high transverse incision in the lower segment. At this stage, there had been minimal blood loss.Gentle attempts to identify a plane of separation of the placenta provoked torrential bleeding, and at this point, removal of the placenta was abandoned in favour of hysterectomy. The woman was, however, bleeding so heavily that manual aortic compression was necessary as a life-saving measure, and the 'major haemorrhage procedure' of the hospital was implemented. General anaesthesia was induced and assistance was requested. A second obstetric consultant, additional theatre nurses and a renal transplant surgeon gave their services. The haematology department sent a registrar to advise on transfusion and treatment of coagulopathy as the third request for 10 units of blood was received.Aortic compression controlled the bleeding to an extent that a closer inspection of the lower uterine segment was possible and during attempts to further reflect the bladder, placenta percreta involving the cervix and bladder was diagnosed.The incision was extended to the umbilicus in the midline and a subtotal hysterectomy was performed; however, despite this, every time the aorta was released from manual compression, bleeding restarted. At the suggestion of the consultant transplant surgeon (RHL), a cut-down onto the left femoral artery was performed and transluminal aortic occlusion was achieved just below the renal arteries using a 10 French aortic occlusion catheter (BVM Medical, Earl Shilton, Leicestershire). This enabled the remainder of the procedure to be carried out in a relatively bloodless field, with intermittent deflation of the balloon to check haemostasis and reperfuse the lower limbs.Invasion of the cervical stroma necessitated partial removal of the cervix, during which the bladder was opened and part of the bladder wall removed. A left ureteric stent and a suprapubic catheter were placed before closure of the bladder.When adequate haemostasis was achieved, the aortic balloon was deflated and the pelvis was packed with oxidised cellulose gauze ('Oxycel', Becton Dickinson, UK) and gauze soaked in warm saline, and the wound was closed in layers. Finally, the aortic balloon was removed and the femoral artery repaired.Four hours later, the woman was transferred to the intensive care uni...

No abstract

The aim of this study is to compare transperineal and endovaginal ultrasonography in the evaluation of the endometrium, assess for image quality and for a systematic difference in endometrial thickness measured by the two techniques. Methods: Transperineal and endovaginal ultrasonography evaluation of the endometrial thickness was performed on 58 women, in Dona Estefânia Hospital, between November 2005 and March 2007. Two physicians reviewed the images and rated the relative diagnostic value of the techniques for assessing the endometrial thickness. We identified two groups (G1-visualized; G2-not visualized). In G1 data were analyzed to determine if there is a correlation between the two approaches using the Spearman test, with a statistical significance of 5% (p < 0.05). In GI and G2 we concluded about the uterine position. Results: Fifty-eight women (average age 57.51) were divided in two groups (G1 n = 45; G2 n = 13). In G1 the Spearman test result was R = 0.933, which reveals a strong correlation between the two techniques. In this group 97.78% (44/45) of uterine position was anteversus or intermediary. In G2 the uterine positions were: anteversus 53.85% (7/13), intermediary 7.69% (1/13) and retroversus 38.46% (5/13). In the majority the transabdominal approach reveals worse quality images. Conclusions: Both transperineal and endovaginal ultrasonography can provide satisfactory images of the endometrium, but endovaginal images are frequently superior to transperineal images. With this study we can conclude that transperineal approach is correlated with endovaginal images for endometrial thickness evaluation, especially in anteversus and intermediary uterus. It had patient acceptance and tolerance, without the need for vaginal penetration, and could be a method of choice in virginal or in postmenopausal women with genital atrophy. This technique needs further study to validate its potential application.