Hilary P. Grocott, MD, FRCPC, FASE

As a result treatment nerve damage lamotrigine 25 mg buy free shipping, they allowed a longer second stage to decrease the operative vaginal delivery rate pretreatment purchase lamotrigine with amex. Between 1988 and 1992 medicine quinine proven lamotrigine 25 mg, second-stage labor exceeded 2 hours in a fourth of 6041 nulliparas at term medications list form cheap 25 mg lamotrigine with mastercard. The length of the second stage treatment jammed finger 25 mg lamotrigine order with mastercard, even in those lasting up to 6 hours or more, was not related to neonatal outcome. These results were attributed to careful use of electronic monitoring and scalp pH measurements. These investigators concluded that there is no compelling reason to intervene with a possibly difficult forceps or vacuum extraction because a certain number of hours have elapsed. They observed, however, that after 3 hours in the second stage, delivery by cesarean or other operative method increased progressively. By 5 hours, the prospects for spontaneous delivery in the subsequent hour were only 10 to 15 percent. Newer guidelines have been promoted by the Consensus Committee (2016) for second-stage labor. These recommend allowing a nullipara to push for at least 3 hours and a multipara to push for at least 2 hours before second-stage labor arrest is diagnosed. These authors provide options to these times before cesarean delivery is performed. Also, a specific maximal length of time spent in second-stage labor beyond which all women should undergo operative delivery has not been identified. Intuitively, the goal to lower cesarean delivery rates is best balanced with one to ensure neonatal safety. And, it is problematic that no robust data on neonatal outcomes support the safety of allowing prolonged second-stage labor. Data from many evaluations reveal that serious newborn consequences attend second-stage labors longer than 3 hours (Allen, 2009; Bleich, 2012; Laughon, 2014; Leveno, 2016; Rosenbloom, 2017). Other data, when adjusted for labor variables, show no difference in neonatal complications for these longer second stages (Cheng, 2004; Le Ray, 2009; Rouse, 2009). Grobman and colleagues (2016) have argued that the absolute number of such adverse outcomes is small and "overall outcomes remain good. Thus, to fully ascertain specific effect of these guidelines on morbidity rates, randomized controlled trials are needed. It is possible that prolonged first-stage labor presages that with the second stage. Nelson and associates (2013) studied the relationships between the lengths of the first and second stages of labor in 12,523 nulliparas at term delivered at Parkland Hospital. The second stage significantly lengthened concomitantly with increasing first-stage duration. Maternal Pushing Efforts With full cervical dilation, most women cannot resist the urge to "bear down" or "push" each time the uterus contracts (Chap. The combined force created by contractions of the uterus and abdominal musculature propels the fetus downward. At times, force created by abdominal musculature is compromised sufficiently to slow or even prevent spontaneous vaginal delivery. Heavy sedation or regional analgesia may reduce the reflex urge to push and may impair the ability to contract abdominal muscles effectively. In other instances, the inherent urge to push is overridden by the intense pain created by bearing down. Two approaches to second-stage pushing in women with epidural analgesia have yielded contradictory results. The first advocates pushing forcefully with contractions after complete dilation, regardless of the urge to push. With the second, analgesia infusion is stopped and pushing begins only after the woman regains the sensory urge to bear down. Fraser and coworkers (2000) found that delayed pushing reduced difficult operative deliveries, whereas Manyonda and associates (1990) reported the opposite. Hansen and colleagues (2002) randomly assigned 252 women with epidural analgesia to one of the two approaches. No adverse maternal or neonatal outcomes were linked to delayed pushing despite significantly prolonging secondstage labor. Fetal Station at Labor Onset Descent of the leading edge of the presenting part to the level of the ischial spines (0 station) is defined as engagement. A higher station at the onset of labor is significantly linked with subsequent dystocia (Friedman, 1965, 1976; Handa, 1993). Roshanfekr and associates (1999) analyzed fetal station in 803 nulliparas at term in active labor. At admission, the third with the fetal head at or below 0 station had a 5-percent cesarean delivery rate. The prognosis for dystocia, however, was not related to incrementally higher fetal head stations above the pelvic midplane (0 station). Importantly, 86 percent of nulliparous women without fetal head engagement at diagnosis of active labor delivered vaginally. These observations apply especially for parous women because the head typically descends later in labor. Risks for Uterine Dysfunction Various labor factors have been implicated as causes of uterine dysfunction. As described, neuraxial analgesia can slow labor and has been associated with lengthening both first and second stages of labor and slowing the rate of fetal descent. Chorioamnionitis is associated with prolonged labor, and some clinicians have suggested that this maternal intrapartum infection itself contributes to abnormal uterine activity. Satin and coworkers (1992) studied the effects of chorioamnionitis on oxytocin stimulation in 266 pregnancies. Infection diagnosed late in labor was found to be a marker of cesarean delivery performed for dystocia. Specifically, 40 percent of women developing chorioamnionitis after requiring oxytocin for dysfunctional labor later required cesarean delivery for dystocia. However, this was not a marker in women diagnosed as having chorioamnionitis early in labor. It is likely that uterine infection in this clinical setting is a consequence of dysfunctional, prolonged labor rather than a cause of dystocia. In the past, labor stimulation was initiated if contractions did not begin after 6 to 12 hours. Practice-changing research included that of Hannah (1996) and Peleg (1999) and their associates, who enrolled a total of 5042 pregnancies with ruptured membranes in a randomized investigation. They measured the effects of induction versus expectant management and also compared induction using intravenous oxytocin with that using prostaglandin E2 gel. They concluded that labor induction with intravenous oxytocin was preferred management. This was based on significantly fewer intrapartum and postpartum infections in women whose labor was induced. Subsequent analysis by Hannah and coworkers (2000) indicated higher rates of adverse outcomes when expectant management at home was compared with in-hospital observation. Mozurkewich and associates (2009) reported lower rates of chorioamnionitis, metritis, and neonatal intensive care unit admissions for women with term ruptured membranes whose labors were induced compared with those managed expectantly. At Parkland Hospital, labor is induced soon after admission when ruptured membranes are confirmed at term. In those with hypotonic contractions or with advanced cervical dilation, oxytocin is selected to lower potential hyperstimulation risk. In those with an unfavorable cervix and no or few contraction, prostaglandin E1 (misoprostol) is chosen to promote cervical ripening and contractions. The benefit of prophylactic antibiotics in women with ruptured membranes before labor at term is unclear (Passos, 2012). However, in those with membranes ruptured longer than 18 hours, antibiotics are instituted for group B streptococcal infection prophylaxis (Chap. It may result from an abnormally low resistance of the soft parts of the birth canal, from abnormally strong uterine and abdominal contractions, or rarely from the absence of painful sensations and thus a lack of awareness of vigorous labor. Using this definition, 25,260 live births-3 percent-were complicated by precipitous labor in the United States in 2013 (Martin, 2015). Despite this incidence, little published information describes maternal and perinatal outcomes. For the mother, precipitous labor and delivery seldom are accompanied by serious maternal complications if the cervix is effaced appreciably and compliant, if the vagina has been stretched previously, and if the perineum is relaxed. Conversely, vigorous uterine contractions combined with a long, firm cervix and a noncompliant birth canal may lead to uterine rupture or extensive lacerations of the cervix, vagina, vulva, or perineum (Sheiner, 2004). It is in these latter circumstances that amnionic-fluid embolism most likely develops (Chap. The uterus that contracts with unusual vigor before delivery is likely to be hypotonic after delivery. In one report of 99 term pregnancies, short labors were more common in multiparas who typically had contractions at intervals less than 2 minutes. Precipitous labors have been linked to cocaine abuse and associated with placental abruption, meconium, postpartum hemorrhage, and low Apgar scores (Mahon, 1994). For the neonate, adverse perinatal outcomes from rapid labor may be increased considerably for several reasons. The tumultuous uterine contractions, often with negligible intervals of relaxation, prevent appropriate uterine blood flow and fetal oxygenation. Acker and coworkers (1988) reported that Erb or Duchenne brachial palsy was associated with such labors in a third of cases. Finally, during an unattended birth, the newborn may fall to the floor and be injured, or it may need resuscitation that is not immediately available. As treatment, analgesia is unlikely to modify these unusually forceful contractions to a significant degree. The use of tocolytic agents such as magnesium sulfate or terbutaline is unproven in these circumstances. Use of general anesthesia with agents that impair uterine contractibility such as isoflurane is often excessively heroic. The pelvic inlet, midpelvis, or pelvic outlet may be contracted solely or in combination. Any contraction of the pelvic diameters that diminishes pelvic capacity can create dystocia during labor. Normal pelvic dimensions are additionally discussed and illustrated in Chapter 2 (p. Contracted Inlet Using clinical measures, it is important to identify the shortest anteroposterior diameter through which the fetal head must pass. Therefore, it might prove difficult or even impossible for some fetuses to pass through a pelvic inlet that has an anteroposterior diameter <10 cm. Mengert (1948) and Kaltreider (1952), employing x-ray pelvimetry, demonstrated that the incidence of difficult deliveries rises when either the anteroposterior diameter of the inlet is <10 cm or the transverse diameter is <12 cm. As expected, when both diameters are contracted, dystocia rates are much greater than when only one is contracted. The anteroposterior diameter of the inlet, which is the obstetrical conjugate, is commonly approximated by manually measuring the diagonal conjugate, which is approximately 1. A small woman is likely to have a small pelvis, but she is also likely to have a small neonate. Thoms (1937) studied 362 nulliparas and found that the mean birthweight of their offspring was significantly lower-280 g-in women with a small pelvis than in those with a medium or large pelvis. Normally, cervical dilation is aided by hydrostatic action of the unruptured membranes or after their rupture, by direct application of the presenting part against the cervix. In contracted pelves, however, because the head is arrested in the pelvic inlet, the entire force exerted by the uterus acts directly on the portion of membranes that contact the dilating cervix. After membrane rupture, absent pressure by the head against the cervix and lower uterine segment predisposes to less effective contractions. Cibils and Hendricks (1965) reported that the mechanical adaptation of the fetal passenger to the bony passage plays an important part in determining the efficiency of contractions. Thus, cervical response to labor provides a prognostic view of labor outcome in women with inlet contraction. A contracted inlet also plays an important part in the production of abnormal presentations. In nulliparas with normal pelvic capacity, the presenting part at term commonly descends into the pelvic cavity before labor onset. When the inlet is contracted considerably or there is marked asynclitism, descent usually does not take place until after labor onset, if at all. Cephalic presentations still predominate, but the head floats freely over the pelvic inlet or rests more laterally in one of the iliac fossae. Accordingly, very slight influences may cause the fetus to assume other presentations. In women with contracted pelves, face and shoulder presentations are encountered three times more frequently, and the cord prolapses four to six times more often. It frequently causes transverse arrest of the fetal head, which potentially can lead to a difficult midforceps operation or to cesarean delivery. The obstetrical plane of the midpelvis extends from the inferior margin of the symphysis pubis through the ischial spines and touches the sacrum near the junction of the fourth and fifth vertebrae. A transverse line theoretically connecting the ischial spines divides the midpelvis into anterior and posterior portions. The former is bounded anteriorly by the lower border of the symphysis pubis and laterally by the ischiopubic rami. The posterior portion is bounded dorsally by the sacrum and laterally by the sacrospinous ligaments, forming the lower limits of the sacrosciatic notch. Average midpelvis measurements are as follows: transverse, or interischial spinous, 10. The definition of midpelvic contractions has not been established with the same precision possible for inlet contractions.

Murphy and coworkers (2004) found no association between forceps delivery and epilepsy in a cohort of more than 21 symptoms you need a root canal buy genuine lamotrigine on line,000 adults medications quizlet purchase lamotrigine amex. Last medications medicare covers 25 mg lamotrigine purchase visa, Bahl and associates (2007) noted that the incidence of neurodevelopmental morbidity was similar in those undergoing successful forceps delivery 911 treatment for hair lamotrigine 25 mg buy without a prescription, failed forceps with cesarean delivery symptoms food poisoning discount lamotrigine 200 mg buy on-line, or cesarean delivery without forceps. Broman and coworkers (1975) reported that infants delivered by midforceps had slightly higher intelligence scores at age 4 years compared with those of children delivered spontaneously. Using the same database, however, Friedman and associates (1977, 1984) analyzed intelligence scores at or after age 7 years. They concluded that children delivered by midforceps had lower mean intelligence quotients compared with those delivered by outlet forceps. In yet another report from this database, Dierker and colleagues (1986) compared long-term outcomes of children delivered by midforceps with those delivered by cesarean after dystocia. These investigators reported that delivery by midforceps was not associated with neurodevelopmental disability. Last, Nilsen (1984) evaluated 18-year-old men and found that those delivered by Kielland forceps had higher intelligence scores than those delivered spontaneously, by vacuum extraction, or by cesarean. Moving the woman to an operating room for this attempt, which could be followed by immediate cesarean delivery if operative delivery fails, has merit. If forceps cannot be satisfactorily applied, then the procedure is stopped and either vacuum extraction or cesarean delivery is performed. With the former, if the fetus does not descend with traction, the trial should be abandoned and cesarean delivery performed. With such caveats, cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes if there was a reassuring fetal heart rate tracing (Alexander, 2009). A similar study evaluated 122 women who had a trial of midcavity forceps or vacuum extraction in a setting with full preparations for cesarean delivery (Lowe, 1987). Investigators found no significant difference in immediate neonatal or maternal morbidity compared with that of 42 women delivered for similar indications by cesarean but without such a trial. Conversely, in 61 women who had "unexpected" vacuum or forceps failure in which there was no prior preparation for immediate cesarean delivery, neonatal morbidity was higher. Some factors associated with operative delivery failure are persistent occiput posterior position and birthweight >4000 g (Ben-Haroush, 2007; Verhoeven, 2016). However, Palatnik and associates (2016) found that risk factors poorly predicted success. In general, to avert morbidity with failed forceps or vacuum delivery, the American College of Obstetricians and Gynecologists (2015) cautions that these trials should be attempted only if the clinical assessment suggests a successful outcome. Sequential instrumentation most often involves an attempt at vacuum extraction followed by one with forceps. This most likely stems from the higher completion rate with forceps compared with vacuum extraction noted earlier. This practice significantly increases risks for fetal trauma (Dupuis, 2005; Gardella, 2001; Murphy, 2011). Because of these adverse outcomes, the American College of Obstetricians and Gynecologists (2015) recommends against the sequential use of instruments unless there is a "compelling and justifiable reason. In many programs, training in even low and outlet forceps procedures has reached critically low levels. For residents completing training in 2015, the Accreditation Council for Graduate Medical Education reported a median of only five forceps deliveries, and that for vacuum deliveries was 16. Because traditional hands-on training has evolved, residency programs should have readily available skilled operators to teach these procedures by simulation as well as through actual cases (Skinner, 2017; Spong, 2012). And, the effectiveness of simulation training has been reported (Dupuis, 2006, 2009; Leslie, 2005). In one program, maternal and neonatal morbidity rates with operative delivery decreased after the implementation of a formal education program that included a manikin and pelvic model (Cheong, 2004). In another, a 59-percent increase in forceps deliveries over 2 years was related to a single experienced and proactive instructor assigned to teach forceps to residents in labor and delivery (Solt, 2011). Branches are designated left or right according to the side of the maternal pelvis to which they are applied. Of these, the outward cephalic curve conforms to the round fetal head, whereas the upward pelvic curve corresponds more or less to the curve of the birth canal. Some blades have an opening within or a depression along the blade surface and are termed fenestrated or pseudofenestrated, respectively. With pseudofenestration, the forceps blade is smooth on the outer maternal side but indented on the inner fetal surface. The goal is to reduce head slipping yet improve the ease and safety of application and removal of forceps compared with pure fenestrated blades. In general, fenestrated blades are used for a fetus with a molded head or for rotation. In most situations, however, despite these subtle differences any are appropriate. Locks are found on all forceps and help to connect the right and left branches and stabilize the instrument. They can be located at the end of the shank nearest to the handles (English lock), at the ends of the handles (pivot lock), or along the shank (sliding lock). Although varied in design, handles, when squeezed, raise compression forces against the fetal head. Blade Application and Delivery Forceps blades grasp the head and are applied according to fetal head position. The handle of the left branch is grasped between the thumb and two fingers of the left hand. The blade tip is then gently passed into the vagina between the fetal head and the palmar surface of the fingers of the right hand. For application of the right blade, two or more fingers of the left hand are introduced into the right posterior portion of the vagina to serve as a guide for the right blade. With each blade, the thumb is positioned behind the heel, and most of the insertion force comes from this thumb. The fetal head is perfectly grasped only when the long axis of the blades corresponds to the occipitomental diameter. Applied in this way, the forceps should not slip, and traction may be applied most advantageously. With most forceps, if one blade is applied over the brow and the other over the occiput, the instrument cannot be locked, or if locked, the blades will slip off when traction is applied. With both branches in place, it should be an easy matter to articulate the handles, engage the lock, and correct asynclitism if present. Asynclitism is resolved by pulling and/or pushing each branch along the long axis of the instrument until the finger guards align. When the head is at 0 to +2 of +5 station, the initial direction of traction is quite posterior, almost toward the floor. As a teaching tool for this, a Bill axis traction device can be attached over the finger guards of most forceps. When the arrow points directly to the line, traction is along the path of least resistance. With traction, as the vulva is distended by the occiput, an episiotomy may be performed if indicated. Additional horizontal traction is applied, and the handles are then gradually elevated. During the birth of the head, mechanisms of spontaneous delivery should be simulated as closely as possible. The force produced by the forceps on the fetal skull is a function of both traction and compression by the forceps, as well as friction produced by maternal tissues. It is impossible to ascertain the amount of force exerted by forceps for an individual patient. Traction should therefore be intermittent, and the head should be allowed to recede between contractions, as in spontaneous labor. Except when urgently indicated, as in severe fetal bradycardia, delivery should be sufficiently slow, deliberate, and gentle to prevent undue head compression. After the vulva has been well distended by the head, the delivery may be completed in several ways. If this is done, however, the blade volume adds to vulvar distention, thus increasing the likelihood of laceration or necessitating a large episiotomy. To prevent this, the forceps may be removed, and delivery is then completed by maternal pushing. Importantly, if blades are disarticulated and removed too early, the head may recede and lead to a prolonged delivery. The first is fetal head flexion to provide a smaller diameter for rotation and subsequent descent. Second, slight destationing of the fetal head moves the head to a level in the maternal pelvis with sufficient room to complete the rotation. Importantly, destationing should not be confused with disengaging the fetal head, which is proscribed. Concurrently, some prefer to also place the other hand externally on the corresponding side of the maternal abdomen to pull the fetal back up toward the midline in synchrony with the internal rotation. Le Ray and colleagues (2007, 2013) reported a success rate of greater than 90 percent with manual rotation. The handles are then slowly elevated until the occiput gradually emerges over the upper margin of the perineum. The forceps are directed downward again, and the nose, mouth, and chin successively emerge from the vulva. The characteristic features are minimal pelvic curvature (A), sliding lock (B), and light weight. With experienced operators, high success rates with minimal maternal morbidity can be achieved (Burke, 2012; Stock, 2013). Either standard forceps, such as Simpson, or specialized forceps, such as Kielland, are employed. With Kielland forceps, each handle has a small knob, and branches are placed so that this knob faces the occiput. The station of the fetal head must be accurately determined to be at, or preferably below, the level of the ischial spines, especially in the presence of extreme molding. With the wandering method, the anterior blade is first introduced into the posterior pelvis. To permit this sweep of the blade, the handle is held close to the maternal left buttock throughout the maneuver. Insertion of the left branch of the Kielland forceps directly posterior along the hollow of the sacrum. This branch is inserted to the maternal right of the anterior branch to aid in engaging the sliding lock. The first and second fingers of the left hand are placed over the finger guards with the palm against the handles. For rotation in a counterclockwise direction, the wrist of the left hand supinates, to direct this palm upward. Simultaneously, two fingers of the right hand press on the edge of the right parietal bone that borders the lambdoid suture. The second type of blade application introduces the anterior blade with its cephalic curve directed upward to curve under the symphysis. After it has been advanced far enough toward the upper vagina, it is turned on its long axis through 180 degrees to adapt the cephalic curvature to the head. With either application, after rotation completion, the operator may choose from two acceptable methods for delivery. In one, the operator applies traction on the Kielland forceps using a bimanual grip described previously for conventional forceps (p. When the posterior fontanel has passed under the subpubic arch, the handles can be elevated to the horizontal. Raising the handles above the horizontal may cause vaginal sulcus tears because of the reverse pelvic curve (Dennen, 1955). Alternatively, the Kielland forceps can be removed after rotation and replaced with conventional forceps. With this approach, moderate traction is first employed to seat the head before switching instruments. Face Presentations With a mentum anterior face presentation, forceps can be used to effect vaginal delivery. The blades are applied to the sides of the head along the occipitomental diameter, with the pelvic curve directed toward the neck. Then, by an upward movement, the face is slowly extracted, with the nose, eyes, brow, and occiput appearing in succession over the anterior margin of the perineum. Forceps should not be applied to the mentum posterior presentation because vaginal delivery is impossible except in very small fetuses. In the United States, vacuum extractor is the preferred term, whereas in Europe it is commonly called a ventouse. Theoretical benefits of this tool compared with forceps include simpler requirements for precise positioning on the fetal head and avoidance of space-occupying blades within the vagina, thereby mitigating maternal trauma. The Kiwi OmniCup contains a handheld vacuum-generating pump, which is attached via flexible tubing to a rigid plastic mushroom cup. Vacuum cups may be metal or hard or soft plastic, and they may also differ in their shape, size, and reusability. In the United States, nonmetal cups are generally preferred, and there are two main types. The soft cup is a pliable bell-shaped dome, whereas the rigid type has a firm flattened mushroom-shaped cup and circular ridge around the cup rim (Table 29-2). When compared, rigid mushroom cups generate significantly more traction force (Hofmeyr, 1990; Muise, 1993).

Am J Obstet Gynecol August 4 medicine disposal buy lamotrigine cheap, 2017 [Epub ahead of print] Sohn C medications similar to abilify 50 mg lamotrigine with mastercard, Fendel H medicine 74 buy discount lamotrigine on-line, Kesternich P: Involution-induced changes in arterial uterine blood flow [German] symptoms joint pain and tiredness discount lamotrigine 200 mg free shipping. J Reprod Med 31:203 treatment of ringworm 200 mg lamotrigine free shipping, 1986 Tekay A, Jouppila P: A longitudinal Doppler ultrasonographic assessment of the alterations in peripheral vascular resistance of uterine arteries and ultrasonographic findings of the involuting uterus during the puerperium. Birth 29:83, 2002 Tulman L, Fawcett J: Return of functional ability after childbirth. Obstet Gynecol 101:279, 2003 World Health Organization: Exclusive breastfeeding for six months best for babies everywhere. Whitridge Williams (1903) Although the woman who recently gave birth is susceptible to several potentially serious complications, pelvic infection continues to be the most important source of maternal morbidity and mortality. That said, puerperal complications include many of those encountered during pregnancy. These infections as well as preeclampsia and obstetrical hemorrhage formed the lethal triad of maternal death causes before and during the 20th century. Fortunately, because of effective antimicrobials, maternal mortality from infection has become uncommon. Creanga and associates (2017) reported results from the Pregnancy Mortality Surveillance System, which contained 2009 pregnancy-related maternal deaths in the United States from 2011 through 2013. In a similar analysis of the North Carolina population from 1991 through 1999, Berg and colleagues (2005) reported that 40 percent of infectionrelated maternal deaths were preventable. Puerperal Fever Several infective and noninfective factors can cause puerperal fever-a temperature of 38. Using this conservative definition of fever, Filker and Monif (1979) reported that only about 20 percent of women febrile within the first 24 hours after vaginal delivery were subsequently diagnosed with pelvic infection. It must be emphasized that spiking fevers of 39°C or higher that develop within the first 24 hours postpartum may be associated with virulent pelvic infection caused by group A streptococcus, discussed on page 667. Other causes of puerperal fever include breast engorgement; infections of the urinary tract, of perineal lacerations, and of episiotomy or abdominal incisions; and respiratory complications after cesarean delivery (Maharaj, 2007). Approximately 15 percent of women who do not breastfeed develop postpartum fever from breast engorgement. Urinary infections are uncommon postpartum because of the normal diuresis encountered then. The first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. Atelectasis following abdominal delivery is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery. Fever associated with atelectasis is thought to stem from normal flora that proliferate distal to obstructing mucus plugs. Uterine Infection Postpartum uterine infection or puerperal sepsis has been called variously endometritis, endomyometritis, and endoparametritis. Because infection involves not only the decidua but also the myometrium and parametrial tissues, we prefer the inclusive term metritis with pelvic cellulitis. Predisposing Factors the route of delivery is the single most significant risk factor for the development of uterine infection (Burrows, 2004; Koroukian, 2004). In the French Confidential Enquiry on Maternal Deaths, Deneux-Tharaux and coworkers (2006) cited a nearly 25-fold increased infection-related mortality rate with cesarean versus vaginal delivery. Rehospitalization rates for wound complications and metritis were increased significantly in women undergoing a planned primary cesarean delivery compared with those having a planned vaginal birth (Declercq, 2007). Women delivered vaginally at Parkland Hospital have a 1- to 2-percent incidence of metritis. For women at high risk for infection because of membrane rupture, prolonged labor, and multiple cervical examinations, the frequency of metritis after vaginal delivery is 5 to 6 percent. If intrapartum chorioamnionitis is present, the risk of persistent uterine infection increases to 13 percent (Maberry, 1991). These figures are similar to those reported from a cohort of more than 115,000 women by the Maternal Fetal Medicine Units Network in whom the overall pelvic infection rate approximated 5 percent (Grobman, 2015). Because of the significant morbidity following hysterotomy, single-dose perioperative antimicrobial prophylaxis is recommended for all women undergoing cesarean delivery (American College of Obstetricians and Gynecologists, 2016b). Antimicrobial prophylaxis has done more to decrease the incidence and severity of postcesarean delivery infections than any other intervention in the past 30 years. Such practices decrease the puerperal pelvic infection risk by 65 to 75 percent (Smaill, 2010). The magnitude of the risk is exemplified from earlier reports that predate antimicrobial prophylaxis. Cunningham and associates (1978) described an overall incidence of 50 percent in all women undergoing cesarean delivery at Parkland Hospital. Important risk factors for infection following surgery included prolonged labor, membrane rupture, multiple cervical examinations, and internal fetal monitoring. Women with all these factors who were not given perioperative prophylaxis had a 90-percent serious postcesarean delivery pelvic infection rate (DePalma, 1982). It is generally accepted that pelvic infection is more frequent in women of lower socioeconomic status (Maharaj, 2007). Except in extreme cases usually not seen in this country, it is likely uncommon that anemia or poor nutrition predispose to infection. Bacterial colonization of the lower genital tract with certain microorganisms-for example, group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, and Gardnerella vaginalis-has been associated with an increased postpartum infection risk (Andrews, 1995; Jacobsson, 2002; Watts, 1990). Other factors associated with an increased infection risk include general anesthesia, cesarean delivery for multifetal gestation, young maternal age and nulliparity, prolonged labor induction, obesity, and meconiumstained amnionic fluid (Acosta, 2012; Leth, 2011; Siriwachirachai, 2014; Tsai, 2011). Microbiology Most female pelvic infections are caused by bacteria indigenous to the genital tract. Over the past 25 years, there have been reports of group A -hemolytic streptococcus causing toxic shock-like syndrome and life-threatening infection (Castagnola, 2008; Nathan, 1994). Prematurely ruptured membranes are a prominent risk factor in these infections (Anteby, 1999). In reviews by Crum (2002) and Udagawa (1999) and their colleagues, women in whom group A streptococcal infection was manifested before, during, or within 12 hours of delivery had a maternal mortality rate of almost 90 percent and fetal mortality rate >50 percent. Although this variant is not a frequent cause of puerperal metritis, it is often implicated in abdominal incisional infections (Anderson, 2007; Patel, 2007). Bacteria responsible for most female genital tract infections are listed in Table 37-1. Although the cervix and vagina routinely harbor such bacteria, the uterine cavity is usually sterile before rupture of the amnionic sac. As the consequence of labor and delivery and associated manipulations, the amnionic fluid and uterus become contaminated with anaerobic and aerobic bacteria. Intraamnionic cytokines and C-reactive protein are also markers of infection (Combs, 2013; Marchocki, 2013). In studies done before the use of antimicrobial prophylaxis, Gilstrap and Cunningham (1979) cultured amnionic fluid obtained at cesarean delivery in women in labor with membranes ruptured more than 6 hours. Anaerobic and aerobic organisms were identified in 63 percent, anaerobes alone in 30 percent, and aerobes alone in only 7 percent. Anaerobes included Peptostreptococcus and Peptococcus species in 45 percent, Bacteroides species in 9 percent, and Clostridium species in 3 percent. Aerobes included Enterococcus in 14 percent, group B streptococcus in 8 percent, and Escherichia coli in 9 percent of isolates. Sherman and coworkers (1999) later showed that bacterial isolates at cesarean delivery correlated with those taken from women with metritis at 3 days postpartum. Although important because of the severity of infections they cause, clostridial species rarely cause puerperal infections (Chong, 2016). Bacteria Commonly Responsible for Female Genital Infections Aerobes Gram-positive cocci-group A, B, and D streptococci, enterococcus, Staphylococcus aureus, Staphylococcus epidermidis Gram-negative bacteria-Escherichia coli, Klebsiella, Proteus Gram-variable-Gardnerella vaginalis Others Mycoplasma and Chlamydia, Neisseria gonorrhoeae Anaerobes Cocci-Peptostreptococcus and Peptococcus species Others-Clostridium, Bacteroides, Fusobacterium, Mobiluncus the role of other organisms in the etiology of these infections is unclear. Observations of Chaim and colleagues (2003) suggest that when cervical colonization of U urealyticum is heavy, it may contribute to the development of metritis. To add evidence to these observations, Tita and associates (2016) recently reported that azithromycin-based extended-spectrum antimicrobial prophylaxis reduced postoperative cesarean delivery infections from 12 to 6 percent compared with -lactam agents given alone. Chlamydial infections have been implicated in late-onset, indolent metritis (Ismail, 1985). Finally, Jacobsson and associates (2002) reported a threefold risk of puerperal infection in a group of Swedish women in whom bacterial vaginosis was identified in early pregnancy (Chap. Routine genital tract cultures obtained before treatment serve little clinical use and add significant costs. In two earlier studies done before perioperative prophylaxis was used, blood cultures were positive in 13 percent of women with postcesarean metritis at Parkland Hospital and 24 percent in those at Los Angeles County Hospital (Cunningham, 1978; DiZerega, 1979). In a later Finnish study, Kankuri and associates (2003) identified bacteremia in only 5 percent of almost 800 women with puerperal sepsis. Blood cultures might be reasonable in women with exceedingly high temperature spikes that may signify virulent infection with group A streptococci. Pathogenesis and Clinical Course Puerperal infection following vaginal delivery primarily involves the placental implantation site, decidua and adjacent myometrium, or cervicovaginal lacerations. The pathogenesis of uterine infection following cesarean delivery is that of an infected surgical incision. Bacteria that colonize the cervix and vagina gain access to amnionic fluid during labor. Parametrial cellulitis next follows with infection of the pelvic retroperitoneal fibroareolar connective tissue. With early treatment, infection is contained within the parametrial and paravaginal tissue, but it may extend deeply into the pelvis. Intuitively, the degree of fever is believed proportional to the extent of infection and sepsis syndrome. Women usually complain of abdominal pain, and parametrial tenderness is elicited on abdominal and bimanual examination. Leukocytosis may range from 15,000 to 30,000 cells/L, but recall that delivery itself increases the leukocyte count (Hartmann, 2000). Although an offensive odor may develop, many women have foul-smelling lochia without evidence for infection, and vice versa. Some other infections, notably those caused by group A -hemolytic streptococci, may be associated with scant, odorless lochia (Anderson, 2014). Treatment If nonsevere metritis develops following vaginal delivery, then treatment with an oral or intramuscular antimicrobial agent may be sufficient (Meaney-Delman, 2015). For moderate to severe infections, however, intravenous therapy with a broad-spectrum antimicrobial regimen is indicated. Improvement follows in 48 to 72 hours in nearly 90 percent of women treated with one of several regimens discussed below. Persistent fever after this interval mandates a careful search for causes of refractory pelvic infection. These include a parametrial phlegmon-an area of intense cellulitis; an abdominal incisional or pelvic abscess or infected hematoma; and septic pelvic thrombophlebitis. In our experience, persistent fever is seldom due to antimicrobial-resistant bacteria or due to drug side effects. The woman may be discharged home after she has been afebrile for at least 24 hours, and further oral antimicrobial therapy is not needed (French, 2004; Mackeen, 2015). Although therapy is empirical, initial treatment following cesarean delivery is directed against elements of the mixed flora shown in Table 37-1. For infections following vaginal delivery, as many as 90 percent of women respond to regimens such as ampicillin plus gentamicin. In contrast, anaerobic coverage is included for infections following cesarean delivery (Table 37-2). Antimicrobial Regimens for Pelvic Infections Following Cesarean Delivery In 1979, DiZerega and colleagues compared the effectiveness of clindamycin plus gentamicin with that of penicillin G plus gentamicin for treatment of pelvic infections following cesarean delivery. Women given the clindamycin-gentamicin regimen had a 95-percent response rate, and this regimen is still considered by most to be the standard by which others are measured (French, 2004; Mackeen, 2015). Because enterococcal cultures may be persistently positive despite this standard therapy, some add ampicillin to the clindamycin-gentamicin regimen, either initially or if there is no response by 48 to 72 hours (Brumfield, 2000). Many authorities recommend that serum gentamicin levels be periodically monitored. At Parkland Hospital, we do not routinely do so if the woman has normal renal function. Once-daily dosing and multiple-dosing with gentamicin both provide adequate serum levels, and either method has similar cure rates (Livingston, 2003). Because of potential nephrotoxicity and ototoxicity with gentamicin in the event of diminished glomerular filtration, some have recommended a combination of clindamycin and a second-generation cephalosporin to treat such women. Others recommend a combination of clindamycin and aztreonam, which is a monobactam compound with activity similar to the aminoglycosides. The spectra of -lactam antimicrobials include activity against many anaerobic pathogens. Some examples include cephalosporins such as cefoxitin, cefotetan, cefotaxime, and ceftriaxone, as well as extended-spectrum penicillins such as piperacillin, ticarcillin, and mezlocillin. The -lactamase inhibitors clavulanic acid, sulbactam, and tazobactam have been combined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extend their spectra. This agent given with ampicillin and an aminoglycoside provides coverage against most organisms encountered in serious pelvic infections. These offer broad-spectrum coverage against most organisms associated with metritis. Imipenem is used in combination with cilastatin, which inhibits its renal metabolism. It seems reasonable from both a medical and an economic standpoint to reserve these drugs for serious nonobstetrical infections. It is used in lieu of -lactam therapy for a patient with a type 1 allergic reaction and given for suspected infections due to Staphylococcus aureus and to treat C difficile colitis (Chap. Perioperative Prophylaxis the use of periprocedural antimicrobial prophylaxis is common in obstetrics. Even so, no rigorous studies have evaluated providing prophylaxis following operative vaginal delivery or manual removal of the placenta (Chongsomchai, 2014; Liabsuetrakul, 2017). But, as discussed, antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the postoperative pelvic and wound infection rates.

One ongoing randomized trial regarding potential benefits of treatment will help guide future management (Vissenberg medications heart failure cheap 100 mg lamotrigine amex, 2015) treatment zygomycetes lamotrigine 50 mg purchase visa. Less than in the first trimester medicine yoga discount 100 mg lamotrigine with visa, the spontaneous loss rate in the second ranges from 1 medications prolonged qt lamotrigine 100 mg online. Unlike earlier miscarriages that frequently are caused by chromosomal aneuploidies medications 8 rights lamotrigine 200 mg buy online, these later fetal losses are due to a multitude of causes (Table 18-6). One frequently overlooked factor is that many second-trimester abortions are medically induced because of fetal abnormalities detected by prenatal screening programs for chromosome aneuploidy and structural defects. Some Causes of Midtrimester Spontaneous Pregnancy Losses Fetal Anomalies Chromosomal Structural Uterine Defects Congenital Leiomyomas Incompetent cervix Placental Causes Abruption, previa Defective spiral artery transformation Chorioamnionitis Maternal Disorders Autoimmune Infections Metabolic Management Midtrimester abortions are classified similarly to first-trimester miscarriages (p. Management is similar in many regards to that used for second-trimester induced abortion, described later (p. One exception is cervical cerclage, which may be employed for cervical insufficiency. Cervical Insufficiency Also known as incompetent cervix, this is a discrete obstetrical entity characterized classically by painless cervical dilatation in the second trimester. It can be followed by prolapse and ballooning of membranes into the vagina, and ultimately, expulsion of an immature fetus. Although the cause of insufficiency is obscure, previous cervical trauma has been implicated. However, cerclage is not beneficial for women solely with this risk and without a preterm birth history (Zeisler, 1997). Of other surgeries, dilation and evacuation carries a 5-percent risk of cervical injury, but neither it nor dilation and extraction raises the likelihood of cervical insufficiency (Chasen, 2005). Last, cervical ripening changes, such as altered hyaluronan or collagen content, discussed in Chapter 21 (p. Surgical Indications For women with an unequivocal history of second-trimester painless delivery, prophylactic cerclage placement is an option and reinforces a weak cervix by an encircling suture. However, some women have a history and clinical findings that make it difficult to verify-classic cervical insufficiency. In one randomized trial of almost 1300 women with an atypical history, cerclage was found to be only marginally beneficial-13 versus 17 percent-to prolong pregnancy past 33 weeks (MacNaughton, 1993). In addition to history, the physical finding of early dilation of the internal cervical os may be an indicator of insufficiency. In a systematic review, cerclages that were placed based on this finding provided superior perinatal outcomes compared with expectant management (Ehsanipoor, 2015). Transvaginal sonography is yet another tool, and cervical length and the presence of funneling are sought. The latter is ballooning of the membranes into a dilated internal os, but with a closed external os. In women with these findings, early randomized trials were inconclusive in proving the clinical value of cerclage to prevent preterm birth (Rust, 2001; To, 2004). A multicenter randomized trial of 302 high-risk women with cervical length <25 mm reported that cerclage prevented birth before viability but not birth before 34 weeks (Owen, 2009). Subsequently, however, Berghella and coworkers (2011) included five trials in a metaanalysis and showed that cerclage for these high-risk women significantly reduced preterm birth before 24, 28, 32, 35, and 37 weeks. Cervical length screening is now recommended by both the American College of Obstetricians and Gynecologists (2016b) and the Society for Maternal-Fetal Medicine (2015) for women with prior preterm birth. If an initial or subsequent cervical length is 25 to 29 mm, then a weekly interval is considered. If the cervical length measures <25 mm, cerclage is offered to this group of women. Notably, for women without a history of preterm birth but with a short cervix incidentally identified sonographically, progesterone therapy is offered instead of cerclage. With twin gestations, one retrospective analysis found no improved outcomes in women with a cervical length <25 mm (Stoval, 2013). Presurgical Preparation Contraindications to cerclage usually include bleeding, contractions, or ruptured membranes, which substantially raises the likelihood of failure. At times, the cervix instead is found to be dilated, effaced, or both, and an emergent rescue cerclage is performed. The conundrum is that the more advanced the pregnancy, the greater the risk that surgical intervention will stimulate preterm labor or membrane rupture. At Parkland Hospital, cerclage procedures are generally not done once supposed fetal viability is reached after 23 to 24 weeks. Others, however, recommend placement later than this (Caruso, 2000; Terkildsen, 2003). When outcomes of cerclage are evaluated, women with similar clinical presentations are ideally compared. For example, in the study of elective cerclage by Owen and associates (2009), approximately a third of women delivered before 35 weeks, and complications were few. By contrast, in a 10-year review of 75 women undergoing rescue cerclage procedures, Chasen and Silverman (1998) reported that only half were delivered after 36 weeks. Importantly, only 44 percent of those with bulging membranes at the time of cerclage reached 28 weeks. There were 11 liveborn neonates, and these researchers concluded that success was unpredictable. Our experiences at Parkland Hospital are that rescue cerclages have a high failure rate, and women are counseled accordingly. If the clinical indication for cerclage is questionable, a woman may instead be observed. Most undergo cervical examinations weekly or every 2 weeks to assess effacement and dilatation. Unfortunately, rapid effacement and dilation can develop despite such precautions (Witter, 1984). When either technique is performed prophylactically, women with a classic history of cervical incompetence have excellent outcomes (Caspi, 1990; Kuhn, 1977). For either vaginal or abdominal cerclage, there is insufficient evidence to recommend perioperative antibiotic prophylaxis (American College of Obstetricians and Gynecologist, 2016b,i). Thomason and coworkers (1982) found that perioperative tocolytics failed to arrest most labor. Some operators do not use potentially irritating antiseptic solution on the exposed amnionic membranes and instead use warm saline (Pelosi, 1990). Although steps are described subsequently, a thorough and illustrated review of cerclage technique is provided by Hawkins (2017). Continuation of suture placement in the body of the cervix so as to encircle the os. The suture is tightened around the cervical canal sufficiently to reduce the diameter of the canal to 5 to 10 mm, and then the suture is tied. A second suture placed somewhat higher may be of value if the first is not in close proximity to the internal os. A transverse incision is made in the mucosa overlying the anterior cervix, and the bladder is pushed cephalad. A 5-mm Mersilene tape on a swaged-on or Mayo needle is passed anterior to posterior. This diminishes the distance that the needle must travel submucosally and aids tape placement. The tape is snugly tied anteriorly, after ensuring that all slack has been taken up. During placement, the suture is placed as high as possible and into the dense cervical stroma. Rescue cerclage with a thinned dilated cervix is more difficult and risks tissue tearing and membrane puncture. Replacement of the prolapsed amnionic sac back into the uterus will usually aid suturing (Locatelli, 1999). Options include steep Trendelenburg or filling the bladder with 600 mL of saline through an indwelling Foley catheter. However, these steps may carry the cervix cephalad and away from the operating field. Membrane reduction can also be achieved by pressure from a wide moist swab or by placing a Foley catheter through the cervix and inflating the 30-mL balloon to deflect the amnionic sac cephalad. The balloon is then deflated gradually as the cerclage suture is tightened around the catheter tubing, which is then removed. Simultaneous outward traction created by ring forceps placed on the cervical edges may be helpful. In some women with bulging membranes, transabdominal amnionic fluid aspiration to decompress the sac may be considered. This balances the risk of preterm birth against that of cervical laceration from a cerclage in place with labor contractions. Transvaginally placed cerclages are typically removed even with cesarean delivery to avoid rare long-term foreign-body complications (Hawkins, 2014). With scheduled cesarean delivery, the cerclage may be removed at 37 weeks or deferred until the time of regional analgesia and delivery. During extraction, particularly with a Shirodkar cerclage or a cerclage using Mersilene tape, analgesia helps ensure patient comfort and adequate visualization. Transabdominal Cerclage At times, suture placed at the uterine isthmus can be used and left until completion of childbearing. Because of significantly greater risks of bleeding and complications during placement, this approach is reserved for selected instances of severe cervical anatomical defects or prior transvaginal cerclage failure. Placement of a cervicoisthmic cerclage was originally described using laparotomy, but several reports additionally detail laparoscopic or robotically assisted cervicoisthmic cerclages. Placement before pregnancy and during pregnancy was similar, whether performed laparoscopically or by laparotomy. Following incision and sharp dissection in the vesicouterine space, the bladder is mobilized caudally. At the level of the internal os, a window is made in free space medial to the uterine vessels. In this case, the knot is tied anteriorly, and the vesicouterine peritoneum is closed with absorbable suture in a running fashion. Importantly, 3 percent of women who underwent transabdominal cerclage had serious operative complications, whereas there were none in the transvaginal group. Whittle and coworkers (2009) described 31 women in whom transabdominal cervicoisthmic cerclage was done laparoscopically between 10 and 16 weeks. The procedure was converted to laparotomy in 25 percent, and there were four failures due to chorioamnionitis. Complications Principal among these are membrane rupture, preterm labor, hemorrhage, infection, or combinations thereof. In the multicenter study by Owen and colleagues (2009), of 138 procedures, there was one instance each of ruptured membranes and bleeding. In the trial by MacNaughton and associates (1993), membrane rupture complicated only 1 of more than 600 procedures done before 19 weeks. In our view, clinical infection mandates immediate removal of the suture with labor induced or augmented. Similarly, with imminent abortion or delivery, the suture should be removed at once because uterine contractions can tear through the uterus or cervix. Following cerclage, if subsequent cervical thinning is detected by sonographic assessment, then some consider a reinforcement cerclage. In one retrospective study, however, reinforcing cerclage sutures placed later did not significantly prolong pregnancy (Contag, 2016). Membrane rupture during suture placement or within the first 48 hours following surgery is considered by some to be an indication for cerclage removal because of the likelihood of serious fetal or maternal infection (Kuhn, 1977). Definitions used to evaluate these statistically include: (1) abortion ratio-the number of abortions per 1000 live births, and (2) abortion rate-the number of abortions per 1000 women aged 15 to 44 years. Overall, abortions most likely are underreported in the United States because clinics inconsistently list medically induced abortions. For example, the Guttmacher Institute found that 926,000 procedures were performed in 2014 (Jones, 2017). But for 2013, only about 664,400 elective abortions were reported to the Centers for Disease Control and Prevention (Jatlaoui, 2016). Classification Therapeutic abortion refers to termination of pregnancy for medical indications. Inclusive medical and surgical disorders are diverse and discussed throughout this text. The most frequent indication currently is to prevent birth of a fetus with a significant anatomical, metabolic, or mental deformity. The term elective abortion or voluntary abortion describes the interruption of pregnancy before viability at the request of the woman, but not for medical reasons. Most abortions done today are elective, and thus, it is one of the most frequently performed medical procedures. Abortion in the United States Legal Influence the legality of elective abortion was established by the United States Supreme Court in the case of Roe v. The Court defined the extent to which states might regulate abortion and ruled that first-trimester procedures must be left to the medical judgment of the physician. After this, the state could regulate abortion procedures in ways reasonably related to maternal health. Finally, subsequent to viability, the state could promote its interest in the potential of human life and regulate and even proscribe abortion, except for preservation of the life or health of the mother. The 1976 Hyde Amendment forbids use of federal funds to provide abortion services except in case of rape, incest, or lifethreatening circumstances. Casey and upheld the fundamental right to abortion, but established that regulations before viability are constitutional as long as they do not impose an "undue burden" on the woman. Subsequently, many states introduced counseling requirements, waiting periods, parental consent for minors, facility requirements, and funding restrictions. One major choice-limiting decision was the 2007 Supreme Court decision that reviewed Gonzales v.

Laminaria immediately after being appropriately placed with its upper end just through the internal os treatment 8th feb purchase generic lamotrigine from india. Several hours later the laminaria is now swollen medicine ball exercises purchase cheap lamotrigine on-line, and the cervix is dilated and softened symptoms 2 weeks after conception lamotrigine 100 mg buy with amex. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes medications vs grapefruit purchase lamotrigine master card. Of 17 women who chose to continue their pregnancy medicine mart order generic lamotrigine online, there were 14 term deliveries, two preterm deliveries, and one miscarriage 2 weeks later. None suffered infection-related morbidity, including three untreated women with cervical cultures positive for Chlamydia trachomatis. In similar circumstances with four second-trimester terminations, Siedhoff and Cremer (2009) described two preterm and two term deliveries. The typical dose is 400 g administered sublingually, buccally, or placed into the posterior vaginal fornix 3 to 4 hours prior to surgery. Instead, oral administration proves less effective and may take longer (Allen, 2016). Another effective cervicalripening agent is the antiprogestin mifepristone, 200 mg given orally 24 to 48 hours before surgery (Ashok, 2000). Its cost and greater delay to the procedure, however, typically favor misoprostol use instead. In comparing hygroscopic dilators and misoprostol for ripening, randomized studies show equal or slightly greater dilation with hygroscopic dilators. Other surgical parameters do not vary significantly (Bartz, 2013; Burnett, 2005; MacIsaac, 1999). Hygroscopic dilators extend procedure time and can be uncomfortable, whereas misoprostol introduces fever, bleeding, and gastrointestinal side effects. If not done as part of early prenatal care, hemoglobin level and Rh status are assessed. Screening for gonorrhea, for syphilis, and for human immunodeficiency virus, hepatitis B, and chlamydial infections is also completed. To prevent postabortal infection after a first- or second-trimester surgical evacuation, prophylactic doxycycline, 100 mg orally 1 hour before and then 200 mg orally after, is provided (Achilles, 2011; American College of Obstetricians and Gynecologists, 2016a). Prophylaxis specifically for infective endocarditis prevention in those with valvular heart disease is not required in the absence of active infection (Nishimura, 2017). No recommendations specifically address venous thromboembolism prophylaxis for suction curettage in low-risk gravidas. Vacuum Aspiration Also called suction dilation and curettage or suction curettage, vacuum aspiration is a transcervical approach to surgical abortion. For this, a rigid cannula is attached either to an electric-powered vacuum source or to a handheld 60-mL syringe for its vacuum source. Sharp dilation and curettage (D & C) in which contents are mechanically scraped out solely by a sharp curette is currently not recommended for pregnancy evacuation due to greater blood loss, pain, and procedural time (National Abortion Federation, 2016; World Health Organization, 2012). Importantly, this practice is distinguished from brief sharp curettage following initial aspiration. After bimanual examination is performed to determine uterine size and orientation, a speculum is inserted, and the cervix is swabbed with povidone-iodine or equivalent solution. The cervix, vagina, and uterus are richly supplied by nerves of Frankenhäuser plexus, which lies within connective tissue lateral to the uterosacral and cardinal ligaments. Thus, vacuum aspiration at minimum requires intravenously or orally administered sedatives or analgesics, and some add a paracervical or intracervical blockade with lidocaine (Allen, 2009; Renner, 2012). Uterine sounding measures the depth and inclination of the cavity before other instrument insertion. If required, the cervix is further dilated with Hegar, Hank, or Pratt dilators until a suction cannula of the appropriate diameter can be inserted. Pratt and Hank dilators are sized in French units, which can be converted to millimeters by dividing the French number by three. With dilation, the fourth and fifth fingers of the hand introducing the dilator should rest on the perineum and buttocks as the instrument is pushed through the internal os. This technique minimizes forceful expansion and provides a safeguard against uterine perforation. Note that the fourth and fifth fingers rest against the perineum and buttocks, lateral to the vagina. This maneuver is an important safety measure because if the cervix relaxes abruptly, these fingers prevent a sudden and uncontrolled thrust of the dilator, a common cause of uterine perforation. Following dilation, for most first-trimester aspiration procedures, an 8- to 12mm Karman cannula is appropriate. Small cannulas carry the risk of leaving retained intrauterine tissue postoperatively, whereas large cannulas risk cervical injury and more discomfort. The cannula is gradually pulled back toward the os and is slowly turned circumferentially to cover the entire surface of the uterine cavity. In the movement of the curette, only the strength of these two fingers should be used. To identify placenta, the aspirated contents are rinsed in a strainer to remove blood, and then placed in a clear plastic container with saline and examined with back lighting (MacIsaac, 2000). With gestations 7 weeks, the failed abortion rate approximates 2 percent (Kaunitz, 1985; Paul, 2002). Abortion Complications In women undergoing abortion, complication rates rise with gestational age. Of these, uterine perforation and lower-genital-tract laceration are uncommon but potentially serious. In one systematic review of first-trimester abortion, the uterine perforation rate was 1 percent, as was the cervical or vaginal laceration rate (White, 2015). Perforation is usually recognized when the instrument passes without resistance deep into the pelvis. Risk factors include operator inexperience, prior cervical surgery or anomaly, adolescence, multiparity, and advanced gestational age (Allen, 2016; Grimes, 1984). If the uterine perforation is small and fundal, as when produced by a uterine sound or narrow dilator, observation of vital signs and for uterine bleeding is usually sufficient. If a suction cannula or sharp curette passes into the peritoneal cavity, considerable intraabdominal damage can ensue. In these cases, laparotomy or laparoscopy to thoroughly examine the abdominal contents is often the safest course. Uterine perforation is not a contraindication to completing the curettage under direct guidance during laparoscopy or laparotomy (Owen, 2017). Following curettage, uterine synechiae may form, and the risk of synechiae increases with the number of procedures. However, of Asherman syndrome cases, one series found that two thirds were linked to first-trimester curettage (Schenker, 1982). Other first-trimester abortion complications are hemorrhage, incomplete removal of products, and postoperative infections, and these are germane to both surgical and medical abortion techniques. One supported by the Society for Family Planning is bleeding that prompts a clinical response or bleeding in excess of 500 mL (Kerns, 2013). For first-trimester surgical abortions, hemorrhage complicates 1 percent (White, 2015). Atony, abnormal placentation, and coagulopathy are frequent sources, whereas surgical trauma is a rare cause. In one study of more than 42,000 Finnish women undergoing pregnancy termination with pregnancies less 63 days, hemorrhage complicated 15 percent of medical abortion but only 2 percent of surgical cases (Niinimäki, 2009). In another review of nearly 46,000 first-trimester abortions, the postoperative infection rate was <0. For medical abortion, this neared 5 percent in one systematic review (Raymond, 2013). Reaspiration rates following surgical abortion are typically <2 percent (Ireland, 2015; Niinimaki, 2009). In sum, first-trimester surgical abortion offers higher efficacy rates (96 to 100 percent) than medical abortion (83 to 98 percent). Medical abortion also carries a greater cumulative risk of complications, although differences are small (Lichtenberg, 2013). These are balanced against the greater privacy of medical abortion and the more invasive steps of curettage. Medical Abortion Agents Used In appropriately selected women, outpatient medical abortion is an acceptable option for pregnancies with a menstrual age <63 days (American College of Obstetricians and Gynecologists (2016c). Three medications are used alone or in combination: mifepristone, methotrexate, and misoprostol. Of these, mifepristone augments uterine contractility by reversing progesteroneinduced myometrial quiescence, whereas misoprostol directly stimulates the myometrium. It is used less frequently now due to current availability of the more effective mifepristone. Contraindications to medical abortion have evolved from exclusion criteria that were used in initial clinical trials. Cautions include current intrauterine device; severe anemia, coagulopathy, or anticoagulant use; long-term systemic corticosteroid therapy; chronic adrenal failure; inherited porphyria; severe liver, renal, pulmonary, or cardiovascular disease; or uncontrolled hypertension (Guiahi, 2012). Of note, misoprostol is suitable for early pregnancy failure in those with prior uterine surgery (Chen, 2008). Thus there must be a commitment to completing the abortion once these drugs are given (Auffret, 2016; Hyoun, 2012; Kozma, 2011). With mifepristone, for women who choose to continue their pregnancies after exposure, the ongoing pregnancy rate ranges from 10 to 46 percent (Grossman, 2015). The associated major malformation rate was 5 percent in one series of 46 exposed pregnancies (Bernard, 2013). Administration Several dosing schemes are effective, and some are shown in Table 18-7. Because of its greater efficacy, mifepristone/misoprostol combinations are favored. Presently, for gestations up to 63 days, the most widely accepted regimen is mifepristone, 200 mg given orally on day 0 and followed in 24 to 48 hours by misoprostol 800 g, administered by a vaginal, buccal, or sublingual route (American College of Obstetricians and Gynecologists, 2016c). Another earlier regimen used a 600-mg oral mifepristone dose followed in 48 hours by a 400-g oral misoprostol dose (Spitz, 1998). If desired, mifepristone and misoprostol may be self-administered at home (Chong, 2015). At Planned Parenthood clinics, for first-trimester medical abortion, doxycycline 100 mg is taken orally daily for 7 days and begins with abortifacient administration (Fjerstad, 2009). Various Regimens for Medical Termination of Pregnancy Symptoms following misoprostol are common within 3 hours and include vomiting, diarrhea, fever, and chills. Bleeding and cramping with medical termination typically is significantly worse than with menses. If bleeding soaks two or more pads per hour for at least 2 hours, the woman is instructed to contact her provider to determine whether she needs to be seen. At the follow-up appointment, routine postabortal sonographic examination is typically unnecessary (Clark, 2010). Instead, assessment of the clinical course along with bimanual pelvic examination is recommended. If sonography is indicated due to concern for failed abortion or for bleeding, unnecessary surgery can be avoided if scans are interpreted appropriately. Specifically, if no gestational sac is seen and there is no heavy bleeding, then intervention is unnecessary. This is true even when, as is common, the uterus contains sonographically evident debris (Paul, 2000). Measurements <15 mm and <30 mm have been used as thresholds to signal evacuation success (Nielsen, 1999; Zhang, 2005). Another study reported that a multilayered sonographic pattern indicated a successful abortion (Tzeng, 2013). Compared with preprocedural levels, Barnhart and coworkers (2004b) found declines of 88 percent at day 3 and 82 percent at day 8 following misoprostol administration correlated with a 95-percent rate of successful abortion completion. But, in the second trimester, dilation and evacuation (D & E) rather than suction D & C is dictated because of fetal size and bony structure. Of options, D & E is a common means of second-trimester induced abortion in the United States. Of legally obtained abortions in 2013, 9 percent were performed by D & E at gestational ages >13 weeks (Jatlaoui, 2016). Many of the surgical and medical steps for second-trimester abortion mirror those in the first trimester, and differences are emphasized here. Dilation and Evacuation Preparation With D & E, wide mechanical cervical dilation precedes evacuation of fetal parts. The degree needed rises with fetal gestational age, and inadequate dilatation risks cervical trauma, uterine perforation, or tissue retention (Peterson, 1983). Thus, presurgical cervical preparation is advised, and main options include hygroscopic dilators or misoprostol. With laminaria, overnight preparation offers optimal cervical dilation (Fox, 2014). Uncommonly, laminaria may fail to adequately dilate the cervix, and serial laminaria insertion with an increasing number of tents over several days is one option (Stubblefield, 1982). Supplementing laminaria with misoprostol or mifepristone is another choice (Ben-Ami, 2015). It may be preferable for same-day procedures as this device achieves its maximal effect in 4 to 6 hours (Newmann, 2014). The typical dose is 400 g given vaginally or buccally 3 to 4 hours prior to D & E. Randomized trials vary regarding the ability of misoprostol to achieve results equal to that with hydroscopic dilators (Bartz, 2013; Goldberg, 2005; Sagiv, 2015). Misoprostol added to laminaria offers small increases in dilation but also greater side effects (Edelman, 2006). In one, mifepristone alone provided less dilation than hydroscopic dilators (Borgatta, 2012).

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