Rarest variations of ectopic pregnancy: an obstetrician's dilemma

Ectopic pregnancy is an important cause of morbidity and mortality which has always proven to be a challenge to obstetricians. Increased usage of artificial reproductive techniques has not only increased tubal ectopic pregnancies but also other rarer forms of ectopic pregnancies. With newer diagnostic and therapeutic tools, chance of early detection and intervention has increased many fold. Conservative treatment options have also gained importance. Here we discuss 3 peculiar types of rare ectopic pregnancies-heterotopic pregnancy, caesarean scar ectopic pregnancy and rudimentary horn ectopic pregnancy- and their treatment options.

A rare case of spontaneous ovarian hyperstimulation syndrome in a pregnant female managed conservatively

Ovarian hyperstimulation syndrome (OHSS) is a rare syndrome, characterized by cystic enlargement of the ovaries and a fluid shift from the intravascular to the third space due to ovarian neo-angiogenesis and increased capillary permeability. It is generally iatrogenic, occurring due to administration of human chorionic gonadotrophin (hCG) during assisted reproductive techniques. Spontaneous form of OHSS is so rare that is easy to confuse the diagnosis of spontaneous OHSS with other causes. Only few cases have been reported in literature where OHSS was seen without prior stimulation from any exogenous hormones. Here we present a case of spontaneous OHSS in a 30-year-old Indian female who was 5 weeks pregnant. Since there was no history of hormone stimulation before/during this pregnancy, ovarian carcinoma instead of OHSS was thought to be the primary diagnosis. There was presence of breathlessness, ascites and bilateral ovarian masses with raised CA-125. A battery of tests and investigations, the diagnosis of moderate OHSS was made after excluding all other causes. The patient was managed conservatively and her symptoms improved with time. Ovarian hyperstimulation syndrome is generally suspected strongly in patients undergoing infertility treatment whenever there is 3rd space accumulation of fluid or increase in number of follicles in ovary. However, rarely spontaneous ovarian hyperstimulation syndrome can be considered as differential diagnosis in cases where no other causes can be found for presence of abdominal pain, nausea-vomiting, ascites, pleural effusion and enlargement of ovaries specially if the patient is pregnant. Due to increased vascular permeability in such cases along with extravascular loss of fluid, there is intravascular hypovolemia. If the diagnosis is missed, there may be risk of unnecessary interventions and morbidity in such patients. Strict monitoring of patient in hospital is required. In most cases of mild to moderate OHSS only conservative management is needed while in severe cases, intensive care unit (ICU) admission may be necessary

Study of maternal deaths with COVID-19 infection in a tertiary care centre

Background: COVID-19 has been a major speed braker not only for world economy and development but also for health sector. The susceptible population including elderly, co-morbid adults and pregnant females were likewise affected in both major COVID-19 waves in India. Association between COVID-19 cases and pregnancy has been studied throughout the world.COVID-19 is associated with substantial risk of morbidity and mortality in postpartum patients and their infants world-wide, compared with their not-infected pregnant counter-parts, especially if these individuals were symptomatic or have comorbidities.Methods: This single-centre prospective observational study, included all consecutive maternal mortalities with COVID-19 infection admitted to Lokmanya Tilak municipal medical college and general hospital (Mumbai, India), a tertiary referral hospital, from 1 April 2020, to June 2021.In this study, a total of 390 patients were included who were found COVID-19 positive during the study period and 17 patients who died during their admission in hospital. The relation of risk factors and demographics were studied for all the patients.Results: The COVID-19 related maternal mortality was more in women of age group 20-30 years (89%). Most women presented to our centre with complaints of fever, cough, cold or breathlessness (55.5%). Patients who succumbed to COVID-19 were mostly primiparous patients (52.9%) and died within 5 days of delivery (46%). 64% of patients died following 5 days of diagnosis of COVID-19.The co-morbidity present in most patients with COVID-19 associated maternal mortality was pre-eclampsia (31.5%). Most patients were referred with only 17% patients registered at our centre and the type of delay involved in management was mostly Type 1 and 2 (82.2%)Conclusions: Multi-centre retrospective analysis with larger population size is required in order for this to be statistically significant

A prospective study of maternal and fetal outcome in patients with hypertensive disorders of pregnancy and COVID-19 infection in a tertiary care center

Background: During the current COVID-19 epidemic, managing pregnant patients is an issue. Pregnant women with coronavirus infection have an increased risk of miscarriage, preclampsia, caesarean delivery, and neonatal mortality. The additive effect of COVID-19 infection and preclampsia in pregnancy may affect the fetal and maternal outcome in a more complicated way. There have been only a few studies till now to observe the combined effect of both in pregnancy. Our study aims to observe and analyse the maternal and fetal outcomes in pregnancy complicated by preclampsia and COVID-19 infection.Methods: This is a prospective study at a tertiary referral facility. This research included women with hypertension who were hospitalized for delivery and screened for SARS-RTPCR using a nasopharyngeal swab from April 2020 to September 30, 2021. The maternal and neonatal outcomes were studied and analyzed.Results: In our study of 65 women with COVID-19 infection and hypertensive disorders in pregnancy, about 6 (9.2%) had eclampsia, 6 (9.2%) had abruptio placenta, 5 (7.6%) had DIC, 3 (4.6%) had HELLP, 2 (3.07%) had acute kidney injury, 2 (3.07%) had ARDS, and 1 (1.5%) had PRESS. 4 (6.1%) had chronic hypertension. Further, 12 (18.4%) of patients needed ICU admission with ventilatory support; about 5 (7.6%) was the rate of maternal deaths in our study. 43 (65%) of neonates were appropriate for gestational age, while 20 (32%) were low birth weight and 2 (3%) were extremely low birth weight. 45% of women with preclampsia develop complications.Conclusions: Our study concluded that complications from preclampsia are more common in women with COVID-19 infection, but a larger sample size is necessary for statistical significance

A rare life-threatening rectus sheath haematoma in post lower segment cesarean section patient: a case report

Rectus sheath hematoma is a rare but potentially life-threatening complication following any major abdominal surgery. The nonspecific nature and lower incidence of this disorder may cause a delay in the diagnosis, and can often be misdiagnosed as a cause of acute abdomen. A rectus sheath hematoma consists of blood accumulating between the rectus abdominis muscle and the rectus sheath. It is most frequently due to a hemorrhage from the superior or inferior epigastric artery or any non-specific bleeder or a direct tear in the muscle itself. It has many specific risk factors such as local trauma, coagulopathies, anticoagulant use, severe coughing, hypertension, and peripheral vascular disease. In this case, the patient presented with rectus sheath hematoma following cesarean section on the 10th post-operative day. She presented with a history of fall followed by lower abdominal pain. Clinical suspicion and ultrasonography were used to confirm the diagnosis and the patient was managed with exploration and hematoma drainage. Its early diagnosis and management helped to prevent hazardous complications

Study of maternal and foetal outcome in COVID-19 anaemic patients during COVID pandemic in a tertiary centre

Background: The haemoglobin concentration is one of the most critical indicators of the blood's oxygen-carrying ability. Due to the hypermetabolic condition produced by infection, anaemia in COVID-19 positive pregnant women might result in tissue hypoxia due to increased peripheral tissue oxygen demands. Complications such as multi-organ failure and acute respiratory distress syndrome can worsen the prognosis. Since hemoglobin is necessary for tissue oxygenation, anaemia may have a substantial impact on the prognosis of COVID-19 pneumonia, where tissue hypoxia develops as a result of disease pathogenesis. Aim of the current study was to study the effect of COVID-19 on pregnant women with anaemia in pregnancy, including symptoms and foetomaternal outcome in patients admitted to a tertiary care facility.Methods: Observational study done on pregnant females in labour and post-delivery patients who were diagnosed with COVID-19 infection using the SARS COV-2 nasopharyngeal reverse transcriptase polymerase chain reaction (RT-PCR) from 1st April 2020 to 30th June 2021. The required demographic, clinical details and haemoglobin levels were obtained, and selected participants were followed up until they were discharged.Results: In our study, out of 58 women, who had anaemia in pregnancy with COVID-19 infection delivering 59 neonates (1set of twins), 55.5% were in the age group of 25-35 years, 77% reached full term pregnancy and 67% were multigravida. 51.7 % patients were transferred from periphery hospitals. Delivery was by caesarean section in 61% and 39% delivered vaginally. 38.8% neonates delivered had birthweight of <2.5 kg out of which 20% had intrauterine growth restriction and 22.4 % were preterm. 3.4% stillbirth were reported. No maternal deaths were reported.Conclusions: From our study, maternal and neonatal outcome were unaffected by anaemia in COVID-19 pregnant women. Severely anaemic patients with comorbidities should be transferred to centres with appropriate neonatal intensive care facilities for delivery

A survey on the impact of COVID-19 infection on menstrual cycle following second wave of COVID infection in a tertiary care centre in Mumbai

Background: The COVID-19 pandemic has led to poor mental health measures, with emerging evidence suggesting gender differences with poorer outcomes in women. It has also introduced many acute stressors in life of many women and thus, led to worse outcomes. This may have unintended consequences for women’s overall health and well-being, including disruptions to reproductive function as elevated stress is often associated with menstrual cycle irregularities. The objective of this study was to determine if and how the COVID-19 infection and its related stressors have impacted women’s menstrual cyclicity.Methods: An online survey was designed to capture self-reported information on menstrual cycle changes was distributed between April and September 2021. A total of 155 women who met stringent inclusion and exclusion criteria and completed the survey.Results: Of the 155 respondents, more than half (78%) reported changes in their menstrual cycles. These included changes in menstrual cycle length, the duration of menses, or changes in premenstrual symptoms.Conclusions: By uncovering a trend in increased menstrual cycle irregularities during the second wave of the COVID-19 pandemic, this study contributes to our understanding of the implications that the pandemic may have on women’s reproductive health.

Caesarean myomectomy in a patient with multiple maternal and fetal comorbidities: a rare interesting case report

Caesarean myomectomy has been traditionally discouraged due to the fear of complications like intractable haemorrhage, peripartum hysterectomy, and increased postoperative morbidity. Recently, a number of authors in their studies have shown that myomectomy during caesarean section does not increase the risk of haemorrhage or postoperative morbidity, if adequate haemostatic methods are used and done by skilled surgical hands. Caesarean myomectomy was performed in a case of elderly primigravida with 36-week gestation with chronic hypertension with polyhydramnios with anterior wall pedunculated fibroid of 8.6×7.2×8 cm and multiple small fibroids in the anterior wall, fundus and subserosal plane. Caesarean myomectomy is a safe and effective procedure in a tertiary care centre at hands of an experienced surgeon

Didelphys uterus: an interesting case report of pregnancy in a rare Mullerian anomaly

Mullerian duct anomalies (MDAs) are congenital defects of the female genital system that arise from abnormal embryological development of the Mullerian ducts. A didelphys uterus, also known as a double uterus, is one of the least common amongst the MDAs. This report discussed a case of pregnancy with uterus didelphys. This patient was a 27-year-old primigravida with 34.2-week gestation with spontaneous conception who presented with decreased fetal movements. On examination patient had a non-communicating, thick vaginal septum extending from the introitus to the cervix was seen and two cervices one on each side of the septum were located. The patient underwent emergency lower segment caesarean section in view of foetal distress and doppler changes. Intra-operatively, evidence of didelphys uteri was seen. Intraoperative and post-operative period was uneventful. A fetus of 1790 gram was delivered, with APGAR 9/10. There were no renal anomalies on subsequent ultrasonography