Dilip Kumar Maurya

Uterine artery pseudoaneurysm: a rare cause of secondary postpartum haemorrhage following caesarean section

A 30-year-old woman, para 2, who underwent an uneventful repeat elective lower segment caesarean section with sterilisation presented on the 23rd postnatal day to our Obstetric Emergency department with profuse bleeding per vaginum. She had a similar bout of bleeding on the 19th postnatal day and was treated elsewhere with blood transfusion and uterotonics. On ultrasonography, she was diagnosed to have few retained adherent placental bits in the lower part of the uterus with a small left broad ligament haematoma and hence was injected with a single dose of methotrexate. A communication of uterine artery was suspected as the mass was close to the uterus and few pulsations were felt on per vaginal examination while attempting aspiration of haematoma. Uterine artery pseudoaneurysm was diagnosed by Doppler studies and confirmed by contrast enhanced CT. She was treated successfully by bilateral internal iliac artery ligation as facilities for embolisation are not available.

Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial)

Abstract Optimum dose, route and duration of use of prophylactic magnesium sulphate in women with severe pre-eclampsia is still controversial. We compared the efficacy and safety of ‘low-dose Dhaka’ regime with ‘Loading dose only’ regime for seizure prophylaxis in severe preeclampsia using a randomised controlled trial in 402 women. The incidence of eclampsia in the ‘low-dose Dhaka’ regime group was 1.49% and that in the ‘Loading dose only regime’ was 2.98% (p = .321). In the low-dose Dhaka regime, injection site abscess and respiratory depression occurred in one woman each. Neonatal outcomes such as Apgar score at 5 minutes (5.0% vs. 8.05% p = .251) and perinatal mortality (20.4% vs. 21.9%, p = .724) were similar in both groups. Loading dose only regime may be considered an effective alternative regime for the prevention of eclampsia in women with severe preeclampsia. Impact statement What is already known on this subject: Efficacy of therapeutic short regime magnesium sulphate in eclampsia has already been reported. Data regarding prophylactic short regime in women with preeclampsia is sparse. What the results of this study add: We have shown that short regime of magnesium sulphate using only the loading dose in the prevention of seizure in preeclampsia is an effective alternative to the low-dose Dhaka regime. What the implications are of these findings for clinical practice and/or further research: The short regime is less resource-intensive. Further larger studies are needed to confirm the efficacy of this short regime and to establish its cost-effectiveness.

Transvaginal sonographic assessment of cervix in prediction of admission to delivery interval in preterm premature rupture of membranes

Abstract Objective: To assess the usefulness of cervical parameters measured by transvaginal sonography, that is, cervical length and posterior cervical angle, in predicting the admission to delivery interval in women with preterm rupture of membranes. Methods: This prospective study was conducted in a tertiary care centre in South India. Women with preterm premature rupture of membranes at 28–34 weeks, confirmed clinically, not in labour and presenting within 24 hours to hospital were included. We evaluated the relationship between latency interval and transvaginal sonographic parameters (cervical length and posterior cervical angle), parity, age, Amniotic Fluid Index (AFI), total leucocyte count at admission using Cox proportional hazards model. Results: Mean time interval between the membrane rupture and delivery was 96.9 h. Majority of the women (63.8% (n = 51)) delivered within 48 hours. Transvaginal sonographic cervical length was not shown to be associated with latency interval (p = .559), whereas. Posterior cervical angle was shown to be significantly associated with the interval (hazard ratio 1.03, 95%CI: 1.01–1.06; p = .003) Conclusions: Posterior cervical angle assessment using transvaginal sonography is an useful tool in the assessing the latency interval in women with preterm premature rupture of membranes (PPROM). This could help in counselling and planning timely referral to centres with neonatal facilities.

Gestational impaired glucose tolerance (GIGT)-induced suppression of fetal thyroid secretion: effect on fetal outcome.

Abstract Introduction: Gestational impaired glucose tolerance (GIGT) is a milder form of gestational diabetes mellitus (GDM), which is often poorly managed. Although, GDM is known to be associated with increased incidence of thyroid dysfunction, no study has been done to study the effect of GIGT on thyroid status and its effect on fetal outcome. Here, we carried out a study to assess thyroid function and glycemic status in both maternal and cord blood of the subjects with GIGT, and to find their association with the fetal outcome. Materials and methods: Women who came to the hospital for safe confinement during 37–40th weeks of gestation were recruited in the study. Based on the 2 hours post prandial blood glucose levels with 75 grams OGTT, done at 24–28 weeks of gestation, all the subjects were stratified into two groups: (1) Cases or GIGT group – women with blood glucose levels between 120 and 140 mg/dl and (2) Controls – women with blood glucose levels of less than 120 mg/dl. Three milliliters of venous blood was collected from mothers and 3 ml of cord blood was collected during delivery. New-borns were assessed for birth weight, head circumference, abdominal circumference, thigh circumference, and crown-heel length. Glycated hemoglobin was carried out using immunoturbidimetry (DiaSys Diagnostic Systems GmbH, Holzheim, Germany) and fructosamine was estimated using dye binding method (Biosystems, Spain). Estimation of total T3 (TT3), free T3 (FT3), total T4 (TT4), free T4 (FT4), and TSH was done by chemiluminescence in Siemens Advia Centaur CP using competitive immunoassay. Results: Although within the normal reference range, GIGT mothers had higher concentration of free and total T4 than controls. Cord fructosamine levels were significantly higher in babies of GIGT mothers than controls, indicating the reflection of maternal hyperglycemia. There was a positive correlation between the maternal glycated hemoglobin and cord blood fructosamine in the GIGT group. Statistically significant lower levels of total T3 and T4 with high TSH levels were found in babies with GIGT mothers, indicating the suppressive effect of maternal hyperglycemia on fetal thyroid function. Birth weight, head circumference, and thigh circumference were significantly higher in babies born to mothers with GIGT, which may be a combined effect of maternal hyperglycemia and fetal thyroid suppression. Conclusions: Maternal hyperglycemia, even in milder form of GIGT may cause suppression of fetal thyroid function. Both these factors may predispose to change in fetal anthropometry, leading to a large baby. Therefore, it is recommended to evaluate maternal and cord thyroid function for timely management strategies.

Antenatal risk factors associated with need of postpartum antihypertensives in women with preeclampsia in South India: Case control study

OBJECTIVES To investigate the antepartum risk factors associated with the need for antihypertensive medication in the postpartum period in women with pre-eclampsia. METHODOLOGY Matched retrospective case control study was done in a tertiary center in south India between January 2016 and June 2016. We compared 100 preeclamptic women requiring antihypertensive medication in the postpartum period at discharge with 100 preeclamptic women who were not on antihypertensive medication at discharge, matched for age and parity at a ratio 1:1. Demographic data, maternal medical conditions, and delivery data were abstracted from maternal charts. Risk factors were evaluated using conditional logistic regression. RESULTS Gestational age at delivery was comparable in both groups (34.3vs. 35.6weeks, p=0.220). Cesarean section rates were higher in the cases compared to controls (53% vs. 32%, p=0.004). After adjusting for age and parity women who had eclampsia, required prophylactic magnesium sulphate therapy and high peak antenatal systolic blood pressure were associated with postpartum antihypertensives. Using multivariate conditional logistic regression, mean systolic blood pressure (OR=1.03, 95% CI 1.00-1.07), development of eclampsia (OR=6.43, 95% CI 1.03-39.91) and need of prophylactic magnesium sulphate (OR=5.02, 95% CI 2.02-12.47) were found to be associated with the need of postpartum antihypertensives. CONCLUSIONS In women with preeclampsia, development of eclampsia, use of prophylactic magnesium sulphate and high peak antenatal systolic blood pressure are more likely to require antihypertensives in postpartum period.

Pregnancy in women with Klippel-Trenaunay syndrome: Report of three pregnancies in a single patient and review of literature

Klippel-Trenaunay syndrome is characterised by vascular abnormality which increases the risk of thromboembolism and haemorrhage. Physiological changes in pregnancy pose an increased risk to these complications. Being an uncommon disorder, there is limited literature about the management of women with pregnancy and Klippel-Trenaunay syndrome. We report in detail two of three pregnancies in a woman with Klippel-Trenaunay syndrome who had repeated episodes of haematochezia leading to anaemia, managed with Argon laser Photo-Coagulation in pregnancy and also reviewed the complications and the management of pregnant women with Klippel-Trenaunay syndrome.

Diastasis of the pubic symphysis following vaginal delivery

Diastasis of the pubic symphysis following vaginal delivery has been reported to occur during 1 in 300–30 000 deliveries [1, 2]. The present study describes two patients who presented at the Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India, between July 2014 and December 2015 immediately postpartum after instrumental vaginal delivery. The patients provided written informed consent for the publication of the present study. This article is protected by copyright. All rights reserved.

Maternal ascites an independent prognostic factor in severe preeclampsia: a matched cohort study

BackgroundPreeclampsia is a multi-systemic, multi-organ dysfunction associated with increased maternal and perinatal complications. The presence of maternal ascites, a manifestation of endothelial dysfunction and increased capillary permeability, is shown to be associated with adverse outcomes. We aim to investigate the impact of maternal ascites on pregnancy outcome in women with severe preeclampsia.MethodsA matched cohort study was conducted in a tertiary care teaching hospital in South India between March 2014 and March 2015. One hundred and twenty-one severe preeclamptic women with ascites formed the study cohort while age-, parity-, and gestational age-matched group of 121 severe preeclamptic women without ascites formed the control. Primary outcome was the composite maternal adverse outcome defined as the development of any of eclampsia, pulmonary edema, renal failure, or disseminated intravascular coagulation (DIC). Secondary outcome was the composite perinatal outcome defined as the occurrence of any of still birth, hypoxic ischemic encephalopathy or early neonatal death.ResultsFour maternal deaths occurred in the study group. The rates of pregnancies with composite maternal adverse outcome [42 vs 9% RR 4.6 (95% CI 2.5–8.4)] and composite perinatal adverse outcome [36 vs 17% RR 2.1, (95% CI 1.3–3.3)] were significantly more in ascites group than in control group. After adjusting for other confounding variables, ascites was independently associated with adverse maternal events [adjusted OR 16.40 (95% CI 2.88–93.31)] but not adverse perinatal outcome.ConclusionIn women with severe preeclampsia, maternal ascites is an independent risk factor for adverse maternal outcome.

Complete atrioventricular block in pregnancy: report of seven pregnancies in a patient without pacemaker

Obstetric management of a woman with a permanent pacemaker in situ is well reported in the literature; but those who present without pacing are still debatable. The necessity for setting the optimal timing or rate of temporary artificial pacing, specifically for labour, has not been objectively assessed. Temporary pacing in most cases reported in the literature might be to withstand the variations in haemodynamic status during delivery and labour. We report a case of a patient with complete heart block without any pacing who had seven pregnancies without any significant changes in haemodynamic status during labour and delivery. Managing a pregnancy without pacing might be an appropriate alternative for women without any underlying cardiac disorder, as it will not lead to significant changes in the haemodynamic system.

The consequences of missing appendicitis during pregnancy

A 23-year-old second para was admitted for severe anaemia with abdominal distension in the immediate puerperal period following a preterm delivery. She suffered from acute abdominal pain 3 days back (at 32 weeks of gestation) and was evaluated in the emergency medical department for appendicitis/cholecystitis. Abdominal ultrasound was found to be normal and she received antacids for her pain abdomen. Clinical examination the day after delivery revealed abdominal distension, guarding and rigidity. Ultrasonography revealed a normal puerperal uterus with free fluid in the abdomen which on diagnostic aspiration was pus. Emergency laparotomy showed acute suppurative appendicitis with perforation. Appendecectomy with peritoneal lavage was done. Her postoperative period was stormy with high febrile spikes and evaluation confirmed septicaemia. The organism grown on postoperative blood culture and cervical swab culture was Enterococcus fecalis sensitive to vancomycin and she received the same for 10 days and recovered.