Re: Ultrasound measuments of LUS to evaluate the risk of
From: James Smeltzer (James.Smeltzer@wellstar.org)
Mon Feb 9 06:33:14 2009
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Overall the risk for recurrent uterine rupture is high, about 25%. It is, by definition, potentially catastrophic. I had a woman with a spontaneous uterine rupture of a prior high vertical (classical) incision. With her rupture, she passed out and woke on the floor. It took her 30 min to crawl to the phone to call 911. The baby had died before admission and she was in hypovolemic shock, developed ARF, but did well with resuscitation, three layer uterine repair, and temporary support.
She has had two subsequent uneventful pregnancies, against medical advice. During each I asked her to have a cell phone in a neck holster which she was to carry all the time. When she showered she placed it outside on the floor. When she slept, it was on the bedpost. Subsequently I have given this advice to two other patients with a similar history who presented pregnant. As these women have been transfused, their antibody screen is important. If it is negative, group-specific blood can be given in high volume with low risk of transfusion reaction in an emergency. If it is positive, I would strongly consider autologous banking in the current pregnancy (first and early second trimester), with folate, iron extra supplementation. Old units have the problem that they must be deglyced before use - takes hours. Another is to cross-match several potential whole blood donors in the patient's health care provider system. Red cross donor centers are difficult to work with as they do not allow for pre-hydration IV, and many of these patients will contract if you take a unit from them without doing so in my experience.
The best advice for subsequent pregnancy for a woman with a living child is "for your baby's sake do not try this". Without a living child it is "adopt" or "let your sister or someone else be a surrogate". Uterine ruptures are more frequent with labor but can occur at ANY time, and are catastrophic when they occur.
Anyone have a better idea?
Jim Smeltze
James S. Smeltzer, MD
Consultant, Maternal Fetal Medicine
Wellstar Physicians Group
833 Campbell Hill St., Suite 400
Wellstar NW Women's Care
Marietta, GA 30060
r
>>> On 2/8/2009 at 7:12 PM, in message <200902090011.n190Bh505225@mail.obgyn.net>, Elenita L. Mojica-Veloso <lenvelosomd@yahoo.com> wrote:
. in the At Sun, 24 Feb 2002, dracheng@yahoo.com wrote:
>
>At Wed, 3 Jan 2001, Sabina Norderhaug wrote:
>>
>>>From what I know, 1 cm is quite a thick uterus and there are very few
>>women after caserean who will have such a thick LUS before the delivery.
>>May be you are talking about some certain measuring technique? Is this
>>number based on your own experience? Can you please explain more?
>>
>>According to Patrick Rozenberg and others' study for transabdominal
>>measurements:
>>
>>FINDINGS: The overall frequency of defective scars was 4.0% (15 uterine
>>ruptures and 10 dehiscences). The frequency of defects rose as the
>>thickness of the lower uterine segment decreased: there were no defects
>>among 278 women with measurements greater than 4.5 mm, three (2%) among
>>177 patients with values of 3.6-4.5 mm, 14 (10%) among 136 patients with
>>values of 2.6-3.5 mm, and eight (16%) among 51 women with values of
>>1.6-2.5 mm. With a cut-off value of 3.5 mm, the sensitivity of
>>ultrasonographic measurement was 88.0%, the specificity 73.2%, positive
>>predictive value 11.8%, and negative predictive value 99.3%.
>>INTERPRETATION: Our results show that the risk of a defective scar is
>>directly correlated to the degree of thinning of the lower uterine
>>segment at around 37 weeks of pregnancy. The high negative predictive
>>value of the method may encourage obstetricians in hospitals where
>>routine repeat elective cesarean is the standard procedure to offer a
>>trial of labor to patients with a thickness value of 3.5 mm or greater.
>>
>>According to Asakura and others' study for transvaginal measurements of
>>muscular layer only:
>>
>>Conclusion: Measurement of the lower uterine segment is useful in
>>predicting the absence of dehiscence among gravidas with previous
>>cesarean section. If the thickness of the lower uterine segment is more
>>than 1.6 mm, the possibility of dehiscence during the subsequent trials
>>of labor is very small.
>>
>>Sabina
>>
>>At Thu, 04 Jan 2001, Dr. Fazeel-uz-Zaman wrote:
>>>
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>>>I guess if the scar thickness is less than 1 cms, there is risk og rupture.
>>>Fazeel
>>>I am presently a resident of the Department of Obstetrics and Gynecology at Capitol Medical CEnter, Philippines. I am very interested in doing a research on the thickness of the lower uterine segment in previously sectioned women who would like to undergo trial of labor. I would like to request for copies of journals or previous studies done on this topic. Our department is advocating VDAC (vaginal delivery after a ceasarian), and with this would like to reiterate the possibility of such by doing this research paper. would like to thank you in advance for a favorable response to my request.
--
I am interested in the succeeding pregnancy outcome of women whose ruptured uteri were repaired.
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Overall the risk for recurrent uterine rupture is high, about 25%. It is, by definition, potentially catastrophic. I had a woman with a spontaneous uterine rupture of a prior high vertical (classical) incision. With her rupture, she passed out and woke on the floor. It took her 30 min to crawl to the phone to call 911. The baby had died before admission and she was in hypovolemic shock, developed ARF, but did well with resuscitation, three layer uterine repair, and temporary support.
She has had two subsequent uneventful pregnancies, against medical advice. During each I asked her to have a cell phone in a neck holster which she was to carry all the time. When she showered she placed it outside on the floor. When she slept, it was on the bedpost. Subsequently I have given this advice to two other patients with a similar history who presented pregnant. As these women have been transfused, their antibody screen is important. If it is negative, group-specific blood can be given in high volume with low risk of transfusion reaction in an emergency. If it is positive, I would strongly consider autologous banking in the current pregnancy (first and early second trimester), with folate, iron extra supplementation. Old units have the problem that they must be deglyced before use - takes hours. Another is to cross-match several potential whole blood donors in the patient's health care provider system. Red cross donor centers are difficult to work with as they do not allow for pre-hydration IV, and many of these patients will contract if you take a unit from them without doing so in my experience.
The best advice for subsequent pregnancy for a woman with a living child is "for your baby's sake do not try this". Without a living child it is "adopt" or "let your sister or someone else be a surrogate". Uterine ruptures are more frequent with labor but can occur at ANY time, and are catastrophic when they occur.
Anyone have a better idea?
Jim Smeltze
James S. Smeltzer, MD
Consultant, Maternal Fetal Medicine
Wellstar Physicians Group
833 Campbell Hill St., Suite 400
Wellstar NW Women's Care
Marietta, GA 30060
r
>>> On 2/8/2009 at 7:12 PM, in message <200902090011.n190Bh505225@mail.obgyn.net>, Elenita L. Mojica-Veloso <lenvelosomd@yahoo.com> wrote:
. in the At Sun, 24 Feb 2002, dracheng@yahoo.com wrote:
>
>At Wed, 3 Jan 2001, Sabina Norderhaug wrote:
>>
>>>From what I know, 1 cm is quite a thick uterus and there are very few
>>women after caserean who will have such a thick LUS before the delivery.
>>May be you are talking about some certain measuring technique? Is this
>>number based on your own experience? Can you please explain more?
>>
>>According to Patrick Rozenberg and others' study for transabdominal
>>measurements:
>>
>>FINDINGS: The overall frequency of defective scars was 4.0% (15 uterine
>>ruptures and 10 dehiscences). The frequency of defects rose as the
>>thickness of the lower uterine segment decreased: there were no defects
>>among 278 women with measurements greater than 4.5 mm, three (2%) among
>>177 patients with values of 3.6-4.5 mm, 14 (10%) among 136 patients with
>>values of 2.6-3.5 mm, and eight (16%) among 51 women with values of
>>1.6-2.5 mm. With a cut-off value of 3.5 mm, the sensitivity of
>>ultrasonographic measurement was 88.0%, the specificity 73.2%, positive
>>predictive value 11.8%, and negative predictive value 99.3%.
>>INTERPRETATION: Our results show that the risk of a defective scar is
>>directly correlated to the degree of thinning of the lower uterine
>>segment at around 37 weeks of pregnancy. The high negative predictive
>>value of the method may encourage obstetricians in hospitals where
>>routine repeat elective cesarean is the standard procedure to offer a
>>trial of labor to patients with a thickness value of 3.5 mm or greater.
>>
>>According to Asakura and others' study for transvaginal measurements of
>>muscular layer only:
>>
>>Conclusion: Measurement of the lower uterine segment is useful in
>>predicting the absence of dehiscence among gravidas with previous
>>cesarean section. If the thickness of the lower uterine segment is more
>>than 1.6 mm, the possibility of dehiscence during the subsequent trials
>>of labor is very small.
>>
>>Sabina
>>
>>At Thu, 04 Jan 2001, Dr. Fazeel-uz-Zaman wrote:
>>>
>>>--------------7B8F6A2709897892ECC148E0
>>>Content-Type: text/plain; charset=us-ascii
>>>Content-Transfer-Encoding: 7bit
>>>
>>>I guess if the scar thickness is less than 1 cms, there is risk og rupture.
>>>Fazeel
>>>I am presently a resident of the Department of Obstetrics and Gynecology at Capitol Medical CEnter, Philippines. I am very interested in doing a research on the thickness of the lower uterine segment in previously sectioned women who would like to undergo trial of labor. I would like to request for copies of journals or previous studies done on this topic. Our department is advocating VDAC (vaginal delivery after a ceasarian), and with this would like to reiterate the possibility of such by doing this research paper. would like to thank you in advance for a favorable response to my request.
--
I am interested in the succeeding pregnancy outcome of women whose ruptured uteri were repaired.
____________________________________________________________
____________________________________________________________
This email and any files transmitted with it may contain
confidential and /or proprietary information in the possession of
WellStar Health System, Inc. ("WellStar") and is intended only for the
individual or entity to whom addressed. This email may contain
information that is held to be privileged, confidential and exempt from
disclosure under applicable law. If the reader of this message is not
the intended recipient, you are hereby notified that any unauthorized
access, dissemination, distribution or copying of any information from
this email is strictly prohibited, and may subject you to criminal
and/or civil liability. If you have received this email in error, please
notify the sender by reply email and then delete this email and its
attachments from your computer.
- Thank you.
