A study of maternal mortality at the teaching hospital, Hubli, Karnataka

Background: Maternal mortality continues to be a major public health problem in the developing world. Maternal mortality is a vital index of the effectiveness of obstetric services prevailing in a country. The present study was conducted at Karnataka Institute of Medical Sciences, Hubli, which caters to 250 PHC’s/CHC’s and is a major referral centre for 4 districts with an average of 800-1000 deliveries per month.Methods: Data on the maternal deaths at KIMS, Hubli from October 2010 to March 20011 during pregnancy and within 42 days of delivery of any cause, irrespective of the duration and site of pregnancy were collected.Results: The maternal mortality ratio for the study period was per 1,00,000 live births. Among the 40 maternal deaths, 7 deaths (17.5%) occurred in primigravida, 14 deaths (35%) had occurred in primipara, 4 deaths (10%) in gravida 2 and above, 7 deaths (17.5%) in para 2, 5 deaths (12.5%) in para 3 and 3 deaths (7.5%) had occurred in para 4 and above. During the study period, 8 deaths (20%) occurred within 1 hour of admission, 5 deaths (12.5%) within 1-6 hours of admission, 7 deaths (17.5%) between 7-12 hours of admission, 6 deaths (15%) between 13-24 hours, 8 deaths (20%) between 1-2 days and 6 deaths occurred after 2 days of admission. Maternal deaths had occurred mostly in delivered women (75%) compared to undelivered women (25%). During the study period, among the 40 maternal deaths, 34 deaths (85%) occurred due to direct obstetric causes and 6 deaths (15%) due to indirect causes. Among the direct obstetric causes, haemorrhage (30%) and hypertensive disorders of pregnancy (30%) were the leading causes. Pulmonary embolism (10%), rupture uterus (5%), chorioamnionitis (5%), septic abortion (2.5%) and acute inversion of uterus (2.5%) were the other direct causes of maternal deaths. Among the indirect obstetric causes, 4 deaths (10%) occurred due to anaemia which was the leading cause. One death (2.5%) occurred due to cardiac disease and 1 death (2.5%) due to hepatic failure.Conclusions: Reviewing the maternal deaths that occurred in our hospital, there is an urgent need to address the issue of obstetric haemorrhages and early intervention in PIH. Much needs to be done for maternal health care in rural areas as most of the deaths reported from urban institutions are referrals from peripheral centres. Rapid transport facilities should be made available to all remote rural areas with easy accessibility. It is necessary even in urban areas to channel the working of emergency obstetric care. This prevents early intervention and adequate emergency obstetric care. The essential obstetric care for all and early detection of complications and management of emergency obstetric care services need to be seriously looked into. Most maternal deaths are preventable by health education of masses, adequate health care in the community and transport facilities

Emergency peripartum hysterectomy- a study in tertiary care centre and medical college in Hubli, North Karnataka, India

Background: Post-partum haemorrhage is a significant cause of maternal mortality and morbidity. The objective of the study was to evaluate the incidence, predisposing factors & associated complications and outcome of emergency peripartum hysterectomy.            Methods: It is a prospective analysis of emergency peripartum hysterectomy conducted at tertiary care centre at Karnataka Institute of Medical Sciences, Hubli, Karnataka, India between June 2013 to December 2015. Age, parity, traumatic or atonic PPH, risk factors, complications were all studied in detail and analysed.               Results: 43 women underwent peripartum hysterectomy among 28,620 deliveries, accounting to an incidence of 0.15%. Incidence of subtotal hysterectomy after caesarean delivery was higher as compared to vaginal deliveries. The common indications were uterine atony (46.5%), uterine rupture of scared and unscared uterus (44.1%), placenta previa of major degree and sepsis (6.9%). Post-operatively 13 patients developed DIC (30.2%), 5 patients developed febrile illness (11.6%), 5 patients of ruptured uterus experienced injury to the bladder (11.6%). Maternal mortality in this study was 13.9%.Conclusions: Hysterectomy is a lifesaving procedure to control postpartum hemorrhage, but is associated with significant maternal morbidity and mortality. Uterine atony, uterine ruptures, also due to prior caesarean delivery, placenta previa were identified as risk factors. The incidence in this part of Karnataka was found to be significantly high due to referral cases from neighboring 5 government district hospitals. Hence only proper awareness, timely referral and correction of anemia are the key factors to be addressed to this part of the state

A rare case of invasive mole with silent uterine perforation

Invasive mole is a condition where a molar pregnancy, such as a partial hydatidiform mole or complete hydatidiform mole, invades the wall of the uterus, potentially spreading and metastasizing to other parts of the body. Here is a case which presented with history of evacuation for molar pregnancy. She presented with irregular p/v bleeding on and off and after admission silent perforation with massive haemoperitoneum was detected for which emergency laparotomy with hysterectomy was done (operative photographs enclosed). She was given massive transfusion. She recovered and followed up till her beta hCG levels were within normal limits. As patient presented to us with haemoperitoneum and intraoperative there was invasion into whole of the uterus, it could not be saved and hysterectomy was done. Patient received 6 cycles of EMACO regime chemotherapy and was followed up for 6 months after beta hCG levels were within normal limits

Enhancing contraceptive usage by post-placental intrauterine contraceptive devices (PPIUCD) insertion with evaluation of safety, efficacy, and expulsion

Background: More than 100 million women in developing countries would prefer to avoid a pregnancy; but they may not be using any form of contraception. The study was conducted to assess the safety, incidence of perforation /pain/bleeding/foul discharge and expulsion rates at 6 week follow-up and willingness to continue when Cu T 380 A inserted within ten minutes of placental expulsion both in vaginal and C-section deliveries.Methods: This was an open label, prospective, and longitudinal study. The study was approved by the ethics committee of FOGSI.Results: The insertion of Intrauterine Contraceptive Devices (IUCD) at KIMS, Hubli was easy in 99.52% of subjects after normal delivery and 100% in all subjects after assisted vaginal deliveries. The position of the CuT was in situ in 94.78% of subjects, ultra sonogram was used in 24.76 % to confirm location where threads were not visible in the vagina and in 6.19% of subjects the tip of IUCD was in the cervix which was pushed back into the uterus using artery forceps. It was expelled in 5.23% of patients. There was no case of perforation in this series and no other major complications.Conclusions: Inserting CuT 380 A at 10 minutes after placental delivery is safe leading to the expanding of the usage of IUCD meeting the unmet needs. The expulsion rates would be minimal if it was inserted by a trained provider and placed at the fundus

Rare metastasis of carcinoma ovary

This is a case report of a 64 year old para 5 operated 2 years back for ovarian papillary adenocarcinoma presenting 2 years later with cutaneous metastases over anterior abdominal wall.

Pregnancy outcome in a rare case of complex cyanotic congenital heart disease

A 28 year old primigravida with the very rare congenital heart condition of single ventricle with single atrium presented with 34 weeks gestation, and underwent caesarean section with minimal morbidity. As the condition is not known for survival into adulthood, the carrying of a pregnancy successfully to near term makes this an even rarer case

Rare case report of metastatic cervical carcinoma

Although carcinoma of cervix is among the most common malignancies in women, cutaneous metastasis is very unusual. Here we report a case of a parous woman diagnosed with adenocarcinoma of cervix who did not undergo chemotherapy in spite of being advised after initial surgery, presenting with cutaneous metastasis at the operative scar site 2 years later