Recent Advances in the Use of Uterotonics for the Prevention of Postpartum Hemorrhage

Primary postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. The most common cause of primary PPH is uterine atony. Various uterotonics have been used over the years for the prevention of PPH. Oxytocin, Ergometrine, Misoprostol, and Carboprost have been extensively studied. Recently, Carbetocin, an analog of Oxytocin has been added to the armamentarium of postpartum hemorrhage. However, the optimal route and dose of these drugs are still being studied. Oxytocin induces superior myometrial contractions when compared with Ergometrine, Carboprost and Misoprostol. The effect of Oxytocin is reduced in myometrium of women with Oxytocin-augmented labor; however, it is still superior to the other uterotonics. Although the value of universal use of uterotonics to reduce postpartum hemorrhage after vaginal birth has been well established, their value in cesarean section has received little attention. It has been assumed that the benefits of oxytocics observed at vaginal birth also apply to cesarean section. The route of Oxytocin has been studied by various researchers. Intravenous (IV) infusion of Oxytocin has been preferred during cesarean section as an IV line would have been already secured and it has faster plasma peak concentration as in comparison to the Intramuscular (IM) route. Though IV bolus Oxytocin has been associated with a faster peak plasma concentration of Oxytocin, faster uterine contraction; it also has been associated with sudden hypotension. Carbetocin is also another promising drug. It has been prioritized due to its heat stable and long-acting properties. It also reduces the need for infusions. It is still an expensive drug in many countries. Carbetocin is administered as 100 mcg IM/IV/IV infusion. The dose in elective cesarean may be less as shown in some studies. Misoprostol by oral route has been recommended by WHO at 400–600 mcg in places where Oxytocin cannot be administered. Syntometrine has lesser blood loss compared to Oxytocin alone

A randomized controlled trial of sublingual Misoprostol - 600µg versus intravenous Oxytocin - 10IU in prevention of post partum hemorrhage during cesarean section

Background: Mortality related to pregnancy and childbirth causes half a million women around the world to die annually. About 35% of these deaths are from postpartum hemorrhage (PPH). Prevention of PPH has been advised by the WHO by the use of Oxytocin 10 IU IM or IV and Misoprostol 600 µg in low resource settings in vaginal delivery. However there have been only a few reports on the use of Misoprostol during cesarean section. The best route and dose of Misoprostol is still being debated.Methods: One hundred women with term singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive either Misoprostol 600µg sublingually or intravenous oxytocin 10 IU soon after delivery of the baby. Estimated blood loss and comparative change in preoperative hemoglobin to post operative hemoglobin levels and side effects were evaluated.Results: Blood loss was found to be more in Misoprostol than Oxytocin. Eight patients of the Misoprostol group required additional oxytocics. Oxytocin group did not receive any additional drugs. No surgical intervention was made in either of the groups.  The most common side effect with Misoprostol was shivering (46%) and in Oxytocin group fever (4%).Conclusions: Sublingual Misoprostol of 600µg works to prevent postpartum bleeding. In our study Oxytocin was more effective than Misoprostol in preventing PPH during cesarean section. Late onset of action of Misoprostol in comparison to Oxytocin may render suturing of the uterus difficult due to pooling of blood. In settings in which use of Oxytocin is not feasible, Misoprostol might be a suitable alternative for post-partum hemorrhage

Spontaneous rupture of vaginal varicose veins mimicking placenta praevia

Vaginal varicosities are often an asymptomatic venous disorder that rarely occur in pregnant women. There is little information in medical literature concerning diagnosis and management.1 We present an isolated incident of spontaneous rupture of vulvar varicosities mimicking the presentation of placenta previa. It was successfully managed with a simple surgical approach done under local anesthesia

Giant chorioangioma with severe polyhydramnios presenting with abruptio placenta: a case report

Chorioangioma is the most common non trophoblastic tumor of the placenta which can result in pregnancy complications with attendant maternal and fetal mortality and morbidity.Although majority of them are asymptomatic, clinical course depends mainly on the size of the neoplasm.We present a case of  large symptomatic placental chorioangioma managed successfully at Shri B M Patil Medical College,Vijayapura.The patient presented with acute features of abruptio placenta secondary to sudden decompression of uterus with polyhydramnios associated with large placental capillary chorioangioma of 10 cm size.Immediate intervention with Emergency LSCS helped rescue the baby of Intauterine demise and possible hemorrhagic morbidity in the mother.Further gross and histological examination confirmed the diagnosis

The efficacy of transvaginal ultrasonography and office hysteroscopy in evaluation of abnormal uterine bleeding

Background: Abnormal uterine bleeding (AUB) is a prevalent issue in women of child bearing age group. AUB can be uncomfortable and have a considerable impact on health-related quality of life. AUB is reported to occur in 9 to 14% women between menarche and menopause and reported prevalence in India is around 17.9%. Methods: It is a prospective observational study done in 75 patients with abnormal uterine bleeding attending the gynaecology outpatient department (OPD) at Shri B. M. Patil Medical College, Vijayapura, Karnataka. Patient was thoroughly examined and then transvaginal sonography (TVS) was done after obtaining consent. This was followed by office hysteroscopy(OH) and endometrial biopsy was taken for histopathological examination. Data were gathered and examined and cost analysis of each procedure was done. Results: The most frequent presenting symptom was heavy menstrual bleeding (49.3%). For proliferative and secretory endometrium, the sensitivity of TVS was 81.48% and for the detection of polyps, endometrial hyperplasia, and submucous fibroid it was 45.45%, 42.86%, 100% respectively. The sensitivity of OH for detection of polyps, endometrial hyperplasia, and submucous fibroid which was 46.15%, 100%, 100% respectively. The p value was <0.05 which shows the statistical significance of both tests. TVS demonstrated low correlation for intracavitary diseases. OH was costlier when compared to TVS. Conclusions: TVS has more sensitivity and accuracy in detecting intramural pathologies. OH had showed greater diagnostic accuracy in identifying intra cavitary pathologies of uterus and doing intervention in the same setting

Use of intramyometrial carbetocin in caesarean myomectomy to reduce hemorrhage

Traditionally myomectomy is avoided during caesarean delivery because of potential excessive blood loss. As the size increases, blood supply of leiomyomas also increases in pregnancy, and specifically at term due to the effect of human chorionic gonadotropin. Carbetocin is an oxytocin analog. It is long acting and is effective in preventing blood loss. It has been used in myomectomy to prevent blood loss in non-pregnant uterus. We present a case report where it is used intramyometrial route during caesarean section. A 30-year-old multigravida of 38 weeks period of gestation with previous caesarean section, presented in labor. Her recent ultra sound report showed single live intrauterine fetus of 35 weeks 3 days with a single posterior wall fibroid. The woman requested for myomectomy along with caesarean delivery as she had heavy menstrual bleeding caesarean section was done and myomectomy was planned along with the caesarean section. Intramyometrial carbetocin 100 mcg was used to prevent excessive blood loss. The patient had an uneventful post-operative period. Intramyometrial carbetocin is an effective method to reduce blood loss in myomectomy during caesarean delivery

Why do mothers die? A retrospective analysis of maternal mortality over 7 years in a tertiary care teaching Hospital in North Karnataka, India

 Background: Maternal mortality ratio (MMR) is still high in many developing countries. In Southern India, the maternal mortality is highest in the state of Karnataka. Therefore, a study was conducted at BLDE (DU) Shri BM Patil medical college, hospital and research centre to study the causes of maternal deaths, and to make recommendation to reduce the maternal mortality.Methods: A retrospective analysis of all the maternal deaths between 2012 to 2019 was done.Results: A total of 58 women died due to pregnancy and its complications during the period of 2012-2019. Average age of death was 25.42 years. It was noted that 70.7% of the patients travelled over 30 km to reach Vijayapura city. The predisposing causes of death were post-partum haemorrhage (44.8%) eclampsia (18.9%), anaemia (17.2%), pulmonary or amniotic fluid embolism (12.1%), sepsis (10.3%) antepartum haemorrhage (3.4%) and cardiac disease (6.9%). A death each occurred in patients suffering cholestasis and adult respiratory distress syndrome. A majority of the deaths were post-partum deaths (84%). Most of the deaths of the occurred during the first 12 hours of admission (82.76). A total of 11 patients received blood and blood components. Of the 58 deaths, 56(96%) required ventilatory support., 47 (81%) patients received ionotropic support. 11 (19%) patients underwent peripartum hysterectomy.Conclusions: Timely intervention can save maternal lives. Services of well-equipped hospitals with obstetric intensive care units having a dedicated team of well-trained obstetricians, intensivists and anaesthesiologist are recommended in a facility which is near the residence of the pregnant women. Facilities for quick transfer of the cases who are high risk are required

Menstrual Morbidities, Menstrual Hygiene, Cultural Practices during Menstruation, and WASH Practices at Schools in Adolescent Girls of North Karnataka, India: A Cross-Sectional Prospective Study

Background. Issues of menstrual morbidities, menstrual hygiene, and cultural practices are rarely discussed by adolescents. The burden of menstruation and cultural practices which the adolescent girls have to face has been less quantified. This study aims to assess the issues related to menstruation in school girls. Method. A cross-sectional prospective study was conducted on 1016 school-going adolescent girls in January 2020. A questionnaire in English and in Kannada was distributed to girls of class 8–12 of ages between 10 and 19 years. Results. 70.5% of the girls attained menarche by 12 to 14.9 years, 37.2% of the girls had their periods every 28–34 days, and 12.2% of the girls said they have heavy periods. 61.95% of the girls had dysmenorrheal, and 9.7% of the girls said that they required medications for the pain. 70.7% of the girls were using commercial sanitary napkins, 12.7% were using cloth, and 15.3% were using both. 55.5% of the girls who were using cloth as an absorbent were not drying the cloth in sunlight. 57.1% of the girls were washing their genitals more than 2 times a day. 93.8% were having bath during menses and 87.2% were using soap along with water. 37.7% of the girls disposed their pads by burning them, 50.8% of then disposed them in the dust bin, and 4.9% of them buried them. 8.6% of the girls said that they remained completely absent from school during periods. 17.85% said that they remained absent for a day. 53.4% of the respondents said that they have difficulty in concentrating at school. 76.1% said that they had adequate water and sanitation facilities at school. 22.3% said that there was adequate facility to change their pads at school. 73.2% said that they could get a spare pad at school. 43.3% of the girls said they avoided cultural functions during their periods, and 38.5% said that they avoided religious ceremonies and practices during their periods. 8.7% of the girls were made to sit outside the house during their periods. The girls from rural areas had poorer hygienic habits, in comparison to the urban girls. Cultural restrictions such as sitting outside the house during menstruation and restricting play were more in the rural girls than the urban girls. Conclusion. Menstrual morbidities, menstrual hygiene management, and cultural beliefs all play a role in school absenteeism in adolescent girls. Improvement of facilities at school and conducting awareness programs can help adolescent girls to attend schools