Surgical Apgar score in prediction of post-operative complications in gynecological surgery

Background: This study was aimed at estimating the ability of 10-point “Surgical Apgar Score” (SAS) to predict postoperative complications in gynecological surgery.Methods: All women undergoing laparotomy (elective and emergency) in the Department of Obstetrics and Gynecology at Kasturba Hospital, Manipal, between November 2014 and June 2015, were included. Age, BMI, comorbidities and postoperative complications were analyzed. The SAS was calculated from the estimated blood loss, lowest heart rate, and lowest mean arterial pressure. Descriptive statistics and univariate statistics were used. Occurrence of major postoperative complications represented the primary outcome.Results: A total of 146 cases meeting the inclusion criteria were analyzed. The patients belonged to the age group of 20-60 years. One or more comorbidities were seen to be present in 50 (34.2%) of the patients. With regard to BMI, 62 (42.5%) of the patients were in the normal category. Major post-operative complications were identified in 11 cases (7.5%). On univariate analyses, occurrence of postoperative complications were associated with presence of comorbidities (p=0.047) and SAS belonging to the high-risk category (p=0.001).Conclusions: The SAS is a significant predictor of postoperative complications following gynecological surgery. This metric, along with a consideration of comorbidities, can be helpful in determining prognosis, directing decision making in the operation theatre, and in postoperative care.

A clinical audit of hysteroscopy in a tertiary care teaching. What challenges did we face?

Background: The aim of the study was to evaluate indications, operative findings and complications in patients undergoing hysteroscopy.Methods: The data of all patients who underwent hysteroscopy in the department of obstetrics and gynecology in a tertiary care teaching hospital were included retrospectively from November 2017 to October 2018.Results: There were 59 patients who had hysteroscopy for various indications. Twelve patients and forty-seven patients were subjected to diagnostic and operative hysteroscopy respectively.  Indications for diagnostic hysteroscopy were for postmenopausal bleed (3), carcinoma of the breast on tamoxifen with bleeding PV (3), recurrent implantation failure (6). Operative hysteroscopy was performed for endometrial polyp (30), myomectomy (9), septal resection (7), copper T removal (1). Complications of hysteroscopy were: media efflux and poor visualization in 10 (17%), minor hemorrhage (9) 15.1%, perforation 2 (3.3%). Minor hemorrhage was managed with tranexamic acid. The perforation in two patients happened during the dilatation of the cervix with metal dilators.Conclusions: One of the major challenges encountered was the efflux of the distension media due to excessive cervical dilatation, which did not provide satisfactory hysteroscopic view. Another complication was perforation during cervical dilatation using Hegars dilator. Use of misoprostol and the use of small sheath hysteroscopes have minimized the need for cervical dilatation

Low platelet counts in pregnancy: an alarm signal for abruption!

Background: Thrombocytopenia, defined as a platelet count less than 150 million/mm3, affects 6% to 10% of all pregnant women and other than anemia is the most common hematologic disorder in pregnancy.Methods: We studied all patients with thrombocytopenia in pregnancy from June 2012 to May 2013. There were 86 patients recruited into the study. Pregnant women with preeclampsia and suspected connective tissue disorder were also screened for thrombocytopenia. All women with platelet count of <1.50,000/µl during the study period were included.Results: Patients were grouped in to mild thrombocytopenia (platelet 100,000-149,999/µl), moderate thrombocytopenia (platelet 50,000-99,999/µl) and severe thrombocytopenia (platelet <49,999/µl. Pregnancy specific cause of thrombocytopenia was in 63 (73.2%) women and non-pregnancy specific were in 23(26.7%) patients.Conclusions: Preeclampsia and HELLP syndrome is more common cause of thrombocytopenia in pregnancy. Abruption can occur in patients with severe thrombocytopenia. Though platelet count is not routinely done in pregnancy it is advisable to do so as it may help in detecting gestational thrombocytopenia or other immune related condition

Incarcerated foreign body in the vagina of a postmenopausal lady

Vaginal foreign bodies retained for long duration are uncommon in present day scenario. When a female presents with recurrent foul smelling vaginal discharge, foreign body should be suspected. Here is a report of foreign body in the vagina of a postmenopausal lady

Influence of placental position on obstetric morbidity in placenta previa

Background: In placenta previa, the placenta occupies lower uterine segment and is likely to separate during pregnancy, resulting in significant maternal and perinatal morbidity and mortality. It has been well studied as the degree of placenta previa increases, the risk of bleeding also increases. However, there are few studies regarding configuration of placenta in relation to uterine wall (anterior, posterior or lateral) and associated complications. The primary purpose of this retrospective cohort study is to examine the whether the location of placenta in relation to lower uterine segment during caesarean delivery influences development of bleeding complications necessitating various surgical interventions. The secondary objective was to study various factors such as preterm delivery, fetal growth restriction, perinatal deaths and postpartum haemorrhage in relation to location of placenta.Methods: We conducted a retrospective study of 89 patients with placenta previa with ultrasonographically mapped placenta over a period of 5 years. The subjects were further categorized into anterior, posterior and lateral group depending upon location of placenta in relation to uterine wall. Differences between age, parity, history of previous caesarean delivery, antepartum haemorrhage, preterm deliveries, foetal growth restriction, perinatal deaths, operative complications and surgical interventions, placenta accreta and postpartum haemorrhage were studied and also were compared to traditional classification of placenta previa in relation to internal cervical ostium. The statistical analysis of the data was performed according to Pearson Chi-square test, one way ANOVA test using SPSS Software.Results: The overall incidence of placenta previa was 1.01%. Placental location was anterior in 23 women (25.8%), posterior in 49 women ((55%) and lateral in 17 (19.1%). No significant differences were found in these groups regarding age, gestational age at delivery, parity, previous history of caesarean delivery, incidence of antepartum and postpartum haemorrhage. Need for surgical interventions such as uterine artery ligation, internal iliac artery plication, caesarean hysterectomy was not specific any type of placenta previa. 39.1% of anterior, 40% of posterior and 35.2% of lateral placenta previa received blood component therapy and this variation was not statistically significant. The overall perinatal mortality was 45/1000 live births and mortality rate did not vary significantly in any of the groups.Conclusions: It is difficult to assign a maternal or perinatal morbidity risk to a particular type of placental location. The need for specialized surgical intervention such as uterine / internal iliac artery ligation, peripartum hysterectomy can arise irrespective of placental location, whether underneath the surgical incision (anterior), proximity to main uterine trunks (lateral) or encountered after the delivery of the baby (posterior). Pregnancies complicated by placenta previa must be delivered in the hospitals having expertise of senior and skilled surgeons and well equipped blood bank and good neonatal intensive care unit

Prepare and prevent rather than repair and repent: Study of maternal mortality in tertiary care hospital

Context: Maternal death signifies the quality of healthcare provided in the population. It is the young, relatively healthy women who die of various reasons. Audit of such mortality would prevent the recurrence by taking appropriate measures. Aims: To find the causes of maternal mortality. Settings and Design: Retrospective observational study. Materials and Methods : All maternal deaths in a tertiary care referral center from January 2007 to September 2012 were studied for their demographic profile and causes of death. Results: All 62 women were referred from other healthcare units. Twenty-nine patients died within 24 h of admission and 33 women died after 24 h of admission. Death of 34 patients was due to direct obstetric causes and of 26 patients due to indirect obstetric causes. There were 2 maternal deaths due to accidental causes. Conclusions: The corrective action to prevent the recurrence of such deaths should be taken. Sepsis was found to be the commonest cause for maternal mortality followed by hemorrhage. It important to note that, in the present study, all mothers received antenatal care, had hospital delivery (none had home delivery), no teenage pregnancy or grand multigravidas, and no obstructed labor or rupture uterus, and yet they died. There is a change in the trend of causes of maternal mortality. Strengthening of the first referral units with equipment, blood bank, and adequately competent staff should be of prime importance. Continued medical education of the medial personnel at the periphery is required. Maternal deaths occur in inspite of atenatal care and hospital delivery which is alarming. Contributing factors may be delay in referral or the travel which should be looked in to inorder to minimize such death of young women

Surgical Apgar score in prediction of post-operative complications in gynecological surgery

Background: This study was aimed at estimating the ability of 10-point “Surgical Apgar Score” (SAS) to predict postoperative complications in gynecological surgery.Methods: All women undergoing laparotomy (elective and emergency) in the Department of Obstetrics and Gynecology at Kasturba Hospital, Manipal, between November 2014 and June 2015, were included. Age, BMI, comorbidities and postoperative complications were analyzed. The SAS was calculated from the estimated blood loss, lowest heart rate, and lowest mean arterial pressure. Descriptive statistics and univariate statistics were used. Occurrence of major postoperative complications represented the primary outcome.Results: A total of 146 cases meeting the inclusion criteria were analyzed. The patients belonged to the age group of 20-60 years. One or more comorbidities were seen to be present in 50 (34.2%) of the patients. With regard to BMI, 62 (42.5%) of the patients were in the normal category. Major post-operative complications were identified in 11 cases (7.5%). On univariate analyses, occurrence of postoperative complications were associated with presence of comorbidities (p=0.047) and SAS belonging to the high-risk category (p=0.001).Conclusions: The SAS is a significant predictor of postoperative complications following gynecological surgery. This metric, along with a consideration of comorbidities, can be helpful in determining prognosis, directing decision making in the operation theatre, and in postoperative care.

Low platelet counts in pregnancy: an alarm signal for abruption!

Background: Thrombocytopenia, defined as a platelet count less than 150 million/mm3, affects 6% to 10% of all pregnant women and other than anemia is the most common hematologic disorder in pregnancy.Methods: We studied all patients with thrombocytopenia in pregnancy from June 2012 to May 2013. There were 86 patients recruited into the study. Pregnant women with preeclampsia and suspected connective tissue disorder were also screened for thrombocytopenia. All women with platelet count of &lt;1.50,000/µl during the study period were included.Results: Patients were grouped in to mild thrombocytopenia (platelet 100,000-149,999/µl), moderate thrombocytopenia (platelet 50,000-99,999/µl) and severe thrombocytopenia (platelet &lt;49,999/µl. Pregnancy specific cause of thrombocytopenia was in 63 (73.2%) women and non-pregnancy specific were in 23(26.7%) patients.Conclusions: Preeclampsia and HELLP syndrome is more common cause of thrombocytopenia in pregnancy. Abruption can occur in patients with severe thrombocytopenia. Though platelet count is not routinely done in pregnancy it is advisable to do so as it may help in detecting gestational thrombocytopenia or other immune related condition

Placental Teratoma Presenting as a Lobulated Mass behind the Neck of Fetus: A Case Report

Placental teratoma is a rare nontrophoblastic benign tumour, which is thought to arise from germ cells. These tumours contain elements derived from multiple germ cell layers. We report a case of teratoma, where on ultrasound; there were two echogenic masses of 4 cm × 5 cm and 3 cm × 4 cm, arising from the placenta. Elective lower segment cesarean section was done in view of breech presentation at 38 weeks of gestation. Gross examination of the placenta showed two lobulated masses of 5 cm × 5 cm and 4 cm × 4.5 cm, respectively. Histopathological examination of the placenta was suggestive of teratoma of the placenta. The fetus was normal.The maternal and fetal outcome was good

Incarcerated foreign body in the vagina of a postmenopausal lady

Vaginal foreign bodies retained for long duration are uncommon in present day scenario. When a female presents with recurrent foul smelling vaginal discharge, foreign body should be suspected. Here is a report of foreign body in the vagina of a postmenopausal lady