OB-GYN-L Messages for October, 2005: Re: Cesarean hysterectomy

Re: Cesarean hysterectomy
From: Terrence.Jones@kp.org
Fri Oct 14 17:20:51 2005

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Think UFE is more likely to have success in submucosal predominant symptoms. The area of greater morbidity from UFE (ie: having to call Art's 'Dr. Who' for complications) would be subserous myomas when adherent to cecum/sigmoid - when these infarct, postembolization, they may cause serosal migration of coliforms from nearby bowel, adherent from prior laptmy X 3. Ultimately She decides, but factors particular to this case are Your experience, myoma location and symptoms, need for future surgery ('fourth' laparotomy), and permanent nature of C-Hyst WRT age (15 more years of estrogen - mediated stimulation to myometrial cells left in situ by any technique that preserves uterus). Can She autodonate 1/2 unit q week starting at 34 weeks? Ask Anesthesia if they might contribute: after the baby is out - they can phlebotomize 500-750 cc and leave clamped and hanging, followed with isovolemic hemodilution. Then, all the EBL from that point on is with a volume containing a lower HCT (acute normovolemic hemodilution). They can return (unclamp) the phlebotomized blood when You've got good hemostasis. Cell-saver can help, but this requires alot of prep and, in the past, occasional arm-twisting/education of the tech due to resistance from supervisory personnel surrounding concerns of amniotic fluid contamination. Would IR (radiology) place stents in pre-C/S to allow any problems accessing the uterines due to the lower segment nature of the myomas? After upper pedicles - can inflate to occlude until morcellating access to uterines. To go full circle (back to Richard and HIFUS) it's interesting to note the widescale application of focused ultrasound - as the French are embarked on animal studies directing the thermal coagulative effects of focused sono to the uterine artery(-ies) in a postpartum hemorrhage model (Nizard 3/2004, Ultrasound Obstet Gynecol. 23:262-6). If interventional rad can't help - maybe have Her sign for provisional procedure, then wait and see what the vascularity and access to the uterines is like at the time of c/s? If exposure and mobility is a problem, and the mesosalpingeal veins are the size of Your thumbs, then puerperal involution and a few months lupron may be the better course. At least with an elective repeat not in labor, You won't have the problem of identifying the cervix. Oh - She's not O neg (blood type)? If so, be sure Your blood bank is well stocked with products before clamping the rounds - just had an accreta on one of these and the blood bank wouldn't give rH pos platelets 'cause it might affect future pregnancy! The resident had to explain to the tech that this issue (ie: pregnancy) would not be a future concern. Platelets can make the difference between a pack and a T - tube... /tj
rmodugno@aol.com Sent by: ob-gyn-l@obgyn.net 10/14/2005 10:47 AM Please respond to ob-gyn-l
To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> cc: Subject: Re: Cesarean hysterectomy
She has pain with her fibroids requiring narcotics during her pregnancy and has been symptomatic in-between pregnancies. Doing a TAH 6 months postpartum will be her 4th laparotomy.
Robert Modugno MD MBA FACOG Marietta, GA
-----Original Message----- From: Dr Eberhard W Lisse <el@lisse.NA> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> Sent: Fri, 14 Oct 2005 08:42:10 -0500 Subject: Re: Cesarean hysterectomy
In message <8C79ED27C74594F-156C-1E226@MBLK-M13.sysops.aol.com>, rmodugno@aol.c om writes:
> Patient 35 years old. 2 previous cesareans. Symptomatic fibroids,
> multiple wi th last pregnancy and this. Last cesarean section: multiple
> fibroids in upper portion of lower uterine segment. Largest 6 cms.
> Would any of you contemplat e a Cesarean hysterectomy on this patient?

No! Why? She gets a Parkland's though.
> Or should we send her for UAE if f ibroids continue to be symptomatic
> after this pregnancy?

Well, we don't have UAE here so I would do the TAH after she stopped breastfeeding or after six months, whatever is later.
greetings, el
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         Think UFE is more likely to have success in submucosal predominant symptoms. The area of greater morbidity from UFE (ie: having to call Art's 'Dr. Who' for complications) would be subserous myomas when adherent to cecum/sigmoid - when these infarct, postembolization, they may cause serosal migration of coliforms from nearby bowel, adherent from prior laptmy X 3. Ultimately She decides, but factors particular to this case are Your experience, myoma location and symptoms, need for future surgery ('fourth' laparotomy), and permanent nature of C-Hyst WRT age (15 more years of estrogen - mediated stimulation to myometrial cells left in situ by any technique that preserves uterus). Can She autodonate 1/2 unit q week starting at 34 weeks? Ask Anesthesia if they might contribute: after the baby is out - they can phlebotomize 500-750 cc and leave clamped and hanging,  followed with isovolemic hemodilution. Then, all ! the EBL from that point on is with a volume containing a lower HCT (acute normovolemic hemodilution). They can return (unclamp) the phlebotomized blood when You've got good hemostasis.  Cell-saver can help, but this requires alot of prep and, in the past,  occasional arm-twisting/education of the tech due to resistance from supervisory personnel surrounding concerns of amniotic fluid contamination. Would IR (radiology) place stents in pre-C/S to allow any problems accessing the uterines due to the lower segment nature of the myomas? After upper pedicles - can inflate to occlude until morcellating access to uterines. To go full circle (back to Richard and HIFUS) it's interesting to note the widescale application of focused ultrasound - as the French are embarked on animal studies directing the thermal coagulative effects of focused sono to the uterine artery(-ies) in a postpartum hemorrhage model (Nizard 3/2004, Ultrasound Obstet Gynecol. 23:262-6). If inter! ventional rad can't help - maybe have Her sign for provisional procedu re, then wait and see what the vascularity and access to the uterines is like at the time of c/s? If exposure and mobility is a problem, and the mesosalpingeal veins are the size of Your thumbs, then puerperal involution and a few months lupron may be the better course. At least with an elective repeat not in labor, You won't have the problem of identifying the cervix. Oh -  She's not O neg (blood type)? If so, be sure Your blood bank is well stocked with products before clamping the rounds  - just had an accreta on one of these and the blood bank  wouldn't give rH pos platelets 'cause it might affect future pregnancy! The resident had to explain to the tech that this issue (ie: pregnancy) would not be a future concern. Platelets can make the difference between a pack and a T - tube... /tj <table width0%> <tr valign=top> <td> <td>rmodugno@aol.com Sent by: ob-gyn-l@obgyn.net 10/14/2005 10:47 AM Please respond to ob-gyn-l <td>                To:        Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>         cc:                 Subject:        Re: Cesarean hysterectomy</table> She has pain with her fibroids requiring narcotics during her pregnancy and has been symptomatic in-between pregnancies. Doing a TAH 6 months postpartum will be her 4th laparotomy.   Robert Modugno MD MBA FACOG Marietta, GA   -----Original Message----- From: Dr Eberhard W Lisse <el@lisse.NA> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net> Sent: Fri, 14 Oct 2005 08:42:10 -0500 Subject: Re: Cesarean hysterectomy In message <<a href="mailto:8C79ED27C74594F-156C-1E226%40MBLK-M13.sysops.aol.com">8C79ED27C74594F-156C-1E226@MBLK-M13.sysops.aol.com</a>>, <a href=mailto:rmodugno%40aol.c>rmodugno@aol.c</a> om writes: > Patient 35 years old.  2 previous cesareans.  Symptomatic fibroids, > multiple wi th last pregnancy and this.  Last cesarean section: multiple > fibroids in upper portion of lower uterine segment.  Largest 6 cms. > Would any of you contemplat e a Cesarean hysterectomy on this patient? No! Why? She gets a Parkland's though. > Or should we send her for UAE if f ibroids continue to be symptomatic > after this pregnancy? Well, we don't have UAE here so I would do the TAH after she stopped breastfeeding or after six months, whatever is later. greetings, el 

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Maybe in reply to: rmodugno@aol.com: "Cesarean hysterectomy"
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