Resurgence of classical caesarean section in current obstetric practice- A case series

Although, the incidence of placenta accreta spectrum (PAS) and large fibroids is rare but still these cases contributes to a large number of maternal morbidity and mortality. Major obstetric hemorrhage is one the dreadful complication of these types of cases and thus early diagnosis and intervention in such cases helps the physician to minimize the risk to mother and the fetus. Also, current widespread use of ultrasound has helped us to manage these cases judiciously, predict and prevent life threatening obstetric hemorrhage. Here we present three complicated obstetric cases of placenta accreta, large lower segment uterine fibroid and large cervical fibroid which necessitated classical cesarean sections (CCS) thus emphasizing prowess in CCS in modern obstetric era. High index of suspicion, Multidisciplinary approach alongwith expert surgical personnel should be available in high risks cases like placenta accreta syndrome and large fibroids in pregnancy.

Transvaginal ligation of descending branch of uterine artery: could be the first surgical attempt to control post-partum haemorrhage?

Post-partum haemorrhage is the major cause of maternal death worldwide. This severe clinical condition can cause also physical morbidity and psychological distress (anemia, coagulopathy, blood transfusion, anterior pituitary ischemia with delay or failure of lactation, myocardial ischemia, postpartum depression). To date several efforts have been made to prevent and treat this severe condition mainly in three ways: medical, surgical, and interventional radiology even in combination. The surgical approach, needs the knowledge of anatomy of vascular distribution of the uterus. According to Palacios-Jaraquemada the feeding vessels of the body of the uterus is defined S1 area and the lower segment, uterine cervix and upper part of the vagina, S2 area. We report three cases in which the ligation of the descending branch of uterine artery (S2 area) helped the surgeon in the treatment of severe primary post-partum haemorrhage causing a significant reduction in blood loss.

Challenges in the Caesarean Section of a Severely Kyphotic Parturient

Caesarean section in a severely kyphotic patient presents with unique challenges. We report a case of obstructed labor in case of a pregnant lady with severe kyphosis of spine that was managed by caesarean section. Lateral recumbent position with adequate assistance and paramedian or vertical skin incision was used and found to provide good exposure. Baby was delivered by lower segment uterine incision by reverse breech extraction. Postpartum hemorrhage was managed with uterotonics and bilateral uterine artery ligation. Tubal ligation though advised was refused by the patient. Prolonged catheterization was done in view of obstructed labor. Postoperative period was uneventful.

Intrapartal resection of the bicornuete uterus for placenta membranacea percreta

Placenta membranacea is a rare anomaly characterized by failure of villous atrophy during early gestation, and 30% of cases involve some form of placental adherence. Placenta percreta is infrequent, but life-threatening condition. Antenatal diagnosis of these placental anomalies is very difficult, but essential for reduction of the number and extent of possible complications. A 19-year-old primigravida was referred to us with 31- week pregnancy complicated by preeclampsia. Upon admission, ultrasound scan revealed eutrophic fetus in breech presentation, without any signs of retroplacental clot. At laparotomy, hemoperitoneum without any trophoblastic tissue emerging to the peritoneal cavity was found and placental abruption with uteroplacental apoplexy was suspected. In addition, unicervical symmetric bicornuate uterus with pregnancy in the left uterine horn was found. The lower segment uterine section was performed and 1800 grams live baby was delivered. Delivery of the placenta was unusually difficult. It was very large and densely adherent to the posterior uterine wall, which appeared to be composed of serosa in that area only. After removal of placenta, the hemorrhage could not be controlled, and resection of the left uterine horn was performed. Placenta accreta, increta and percreta ought to be considered in all cases of uterine anomalies in pregnancy and in cases of prenatal diagnosis of placenta membranacea.