A case series on conservative management in pregnancies with abnormal placentation in obstetrics: placenta accrete, increta and percreta

Adherent placenta is one of the important causes of post- partum hemorrhage. Placenta accreta-related pathologies are an increasing contributor to maternal death from hemorrhage. With the rising caesarean delivery rate the incidence of placenta accreta has significantly increased. Morbidly adherent placenta (MAP) occurs when there is a defect in the decidua basalis, resulting in an abnormal invasion of the placenta into the substance of the uterus. A multidisciplinary approach is relevant in managing these patients in order to reduce morbidity and mortality associated with morbidly adherent placenta. A non-surgical conservative method is to leave the placenta in situ to reabsorb and institute treatment with chemotherapeutic agents, such as methotrexate. With improvement in the medical services conservative management for adherent placenta has gained significance

Study of cases of double mishap in a tertiary care teaching hospital

Background: “Make every mother and child count”- the slogan for World health day 2005 reflects the reality and need of the society even today. In India, many women die due to pregnancy-related complications and those who survive suffer from severe maternal morbidity. Authors have been impressed that the same obstetric conditions that kill mothers are also responsible for most of the stillbirths and many of the neonatal deaths as well. This is the study to identify the risk factors that has an effect on the health of both mother and baby, to evaluate the complications leading to maternal and perinatal morbidity or mortality so that timely interventions to prevent maternal and perinatal morbidity and mortality can be made.Methods: All the cases getting admitted in Dr SCGMC Nanded are analysed for maternal and foetal outcome over the study period of 18 months. The cases with both maternal and perinatal morbidity or mortality are included in the study. The associating factors and comorbidities if associated with the cases of double mishap are studied.Results: During the study period of 18mths, there were 21905 deliveries conducted in the study hospital and 742 reffered cases of outside hospital deliveries, it was found that there were 204 cases of double mishap. Out of 204 cases of double mishap, 71.56% had preeclampsia, 29.41% were anaemic, 6.86% had febrile illness, 4.41% were of placenta praevia, 33.33% had abruptio placenta.Conclusions: Authors can conclude by stating that through better antenatal care, early detection and proper management of risk factors like pre-eclampsia, anaemia and active management of third stage of labour with careful feto maternal monitoring the absolute goal of Obstetrics of having a healthy mother and healthy baby at the end of delivery can be achieved

Glove balloon uterine tamponade for post-partum haemorrhage: indigenous, readily available, cheap, easy to learn and practice, yet effective

Background: Postpartum haemorrhage (PPH) is still a nightmare in obstetrics. It is the leading cause of maternal mortality and morbidity accounting for one quarter of the maternal mortality worldwide. In a simple language, we can say PPH is allowing the delivered woman to bleed till death. Uterine atony is the cause in 80% of cases.Methods: This study is conducted in a tertiary care and teaching hospital between May 2019-2020. There were 5400 vaginal and 2100 caesarean sections conducted in our institute in the study period. 20 patients who underwent vaginal delivery and 12 patients of caesarean section had PPH. Only one patient had unsuccessful glove tamponade who underwent stepwise devascularisation for her survival. Hence the success rate of glove tamponade in our institute is found to be 95% (n=19).Results: We chose glove as it is simple, safe, least invasive, rapidly made without any expertise, non-irritant, doesn’t rupture easily, doesn’t slip and cost effective. We have manually tried out the capacity of the glove and found to be enormous, of 10 litres. After a successful insertion of glove tamponade, it is left in situ for 24 hours in our study.Conclusions: In this era of advanced medical services, it is annoying to say women still die of postpartum haemorrhage. Timely intervention (medical or surgical) in the golden hour can bring back many mothers back to life.

Obstetric hysterectomy: a receding trend

Over 500,000 women die each year due to complications of pregnancy and childbirth, a number that has remained relatively unchanged since 1990, when the first global estimates of the burden of maternal mortality were developed. Hemorrhage due to uterine atony, adherent placenta and PPH are still the causes of maternal death in developing countries. Although advances have been made in the development of conservative medical and surgical treatment of obstetric haemorrhage like brace sutures, internal iliac artery ligation, selective arterial embolization etc emergency obstetric hysterectomy remains a lifesaving procedure in the management of intractable haemorrhage unresponsive to conservative management

Pregnancy emerged thrombocytopenia: maternal and fetal outcome

Background: A low platelet count is often an incidental finding in pregnancy. It can be an indicator of a severe systemic disorder requiring emergent maternal and fetal care or can just be unique to pregnancy with no harm to mother or fetus. Physiological decrease in platelet count is seen in pregnancy due to hemodilution and hypercoagulating state, though the exact pathophysiology is still unclear.Methods: It is a prospective observational study done in a tertiary care centre.Results: In about 11,258 cases screened 46 patients had thrombocytopenia (0.4%). The commonest etiology is found to be gestational thrombocytopenia (n=21, 45.6%) followed by preeclampsia/ eclampsia/ HELLP (haemolysis, elevated liver enzymes, low platelet count) syndrome (n=19, 41.3%). Only one patient had immune thrombocytopenic purpura (ITP) and 7 (15.3%) were associated with amplified fragment length polymorphism (AFLP). Maximum of them (n=19, 41.3%) underwent spontaneous vaginal delivery. 4 patients (8.6%) had postpartum haemorrhage, 6 (13.04%) had ceserean section wound infection, 4 (8.6%) had disseminated intravascular coagulation (DIC) and 4 (8.6%) had multiorgan failure. 13 patients (28.3%) had platelet count between 40 to 60 thousand per cumm, 11 (23.9%) had between 60 to 80 thousand per cumm, 10 (21.7%) had between 80,000 to 1 lakh and none had their platelet count less than 20,000 per cumm.Conclusions: Gestational thrombocytopenia is not a preventable condition. It is an incidental finding in pregnancy. With strict vigilance during intrapartum and postpartum period, even without any treatment proper for the same, the maternal and fetal outcome is found to be good

A study of maternal and fetal outcomes in critically ill obstetric patients

Background: Pregnancy related morbidity is becoming a nightmare in Indian women. Some of these women end up in mortality and a few of them narrowly escape death. Critical care should be and is an authenticated part of obstetric practice. This study is an effort initiated to understand the risk of maternal morbidity, to investigate the contributing factors, foetal outcome, to study the adverse event, cause of maternal death and remedial measures.Methods: All the obstetric cases admitted in Intensive care unit in a government institute in Maharashtra during January 2018 to June 2019 were analyzed prospectively. The indications for transfer into intensive care, risk factors, co morbidities if any were studied. Maternal and fetal morbidity and mortality were included in the study.Results: During the study period, there were 10, 208 deliveries. There were 12 maternal deaths and 98 critically ill patients became morbid. Anemia is found to be a major pre-existing contributing factor (25.5%) and an important risk factor making pregnancy become critical. DIC is found to be a major reason for ICU admission (39.1%), 72.7% needed mechanical ventilator and 60.1% needed ionotropic support.Conclusions: Anemia is a major problem still existing in our country. Gestational hypertension is another leading cause of critical illness in pregnancy. Identification of patients who are going downhill, timely referral to higher centers and appropriate management can improve both the maternal and the fetal outcomes

Clinical study of post partum haemorrhage from a teaching hospital in Maharashtra, India

Background: To study the cases of postpartum haemorrhage, their causes and management in a tertiary care centre.Methods: A retrospective study of cases of postpartum haemorrhage for a period of 3yrs was conducted in Dept. of OBGY at a rural tertiary care center and teaching hospital in Maharashtra. The major causes, management modalities, morbidity and mortality associated with it were discussed.Results: Out of 37515 deliveries over the period of 3 years (2014-2016), there were 1333 cases of PPH out of which accounted for a prevalence of 3.55%. Study showed that 86% of cases were due to atonic PPH, 9.9% due to traumatic PPH, and 0.97% were due to both atonic and traumatic PPH. 2.7% of cases were due to retained placenta, 0.07% were due to bleeding diathesis.Conclusions: In an era with availability of excellent uterotonics and active management of 3rd stage of labour even today postpartum haemorrhage stands first as the cause of maternal morbidity and mortality. Even though with excellent medical and surgical interventions, maternal mortality due to PPH has been significantly reduced, the field still needs extensive research and new modalities to prevent and manage post-partum haemorrhage

A five-year study of postpartum exploratory laparotomy in a tertiary care teaching hospital

Background: Emergency postpartum exploratory laparotomy is a major surgical venture invariably performed in the setting of life threatening conditions during or immediately after abdominal and vaginal deliveries. Tertiary health care centers play a prime role in such cases to avoid any mishap. In spite of that sometimes sudden such incidences in the form of maternal morbidity or mortality occur which makes us think upon.Methods: A retrospective study was conducted in Dr. SCGMC, Nanded, a tertiary health care centre in Nanded Maharashtra, over a period of 5 years in the Department of OBGY i.e. between January 2012 to December 2016 of the cases who required postpartum exploratory laparotomy.Results: Out of the total deliveries in our hospital and cases referred from outside hospital from January 2012 to December 2016 i.e a span of 5 years including 62525 cases under study, 39 cases required postpartum exploratory laparotomy. We found that postpartum hemorrhage is the most common cause requiring postpartum exploratory laparotomy. Other causes requiring postpartum exploratory laparotomy are burst abdomen, puerperal sepsis, rectus muscle hematoma etc.Conclusions: In the era of modern obstetrics, to fulfill the main objective of obstetrics of having healthy mother and healthy baby at the end of pregnancy, postpartum exploratory laparotomy is a procedure done as an extreme measure to reduce maternal mortality and morbidity. We observed that majority of the patients who required exploratory laparotomy in postpartum period suffered morbidity in the form of prolonged hospital stay or transfusion of blood or blood products, need of ventilator support or ICU care. Though the patients suffered morbidity, mortality could be prevented by timely intervention in majority of the patients

Successful laparoscopic management of accessory cavitated uterine mass: a rare case

Accessory cavitated uterine mass (ACUM) is a rare and unique congenital anomaly. The dysmenorrhea presented by these patients is almost never resolved by any medications but only by surgical line of management. Herein, we are discussing a case of ACUM who had medically refractory dysmenorrhea and treated by laparoscopic excision and repair. ACUM is the newly identified popping up cause of dysmenorrhoea requiring surgical line of management only. Fewer than 40 cases, worldwide, have been reported in the literature with the youngest case being a 13-year-old girl. Laparoscopic excision has shown good postoperative results. Dysmenorrhea is a significant cause of reduced quality of life. High degree of suspicion, early investigations and identification of such cases help in appropriate management and reduce the duration of symptoms and thus the seamy side of life can be made better.