Mahantesh Karoshi

Anemia and pregnancy: A link to maternal chronic diseases

Anemia is a global public health problem. It has serious short‐ and long‐term consequences during pregnancy and beyond. The anemic condition is often worsened by the presence of other chronic diseases such as malaria, tuberculosis, HIV, and diabetes. Untreated anemia also leads to increased morbidity and mortality from these chronic conditions as well. It is surprising that despite these chronic conditions (such as malaria, tuberculosis, and HIV) often being preventable, they still pose a real threat to public health. This article aims to review the current understanding of the pathophysiology, risks, prevention, and treatment of anemia in the light of these chronic conditions.

Challenges in managing postpartum hemorrhage in resource-poor countries.

Managing postpartum hemorrhage depends in part on having a prepared mind, a complement of trained coworkers, and full access to modern therapies. The last 2 components are rare in resource-poor areas and their absence may be accentuated by climatic instability and lack of basic transportation. Greater use of the active management of third stage of labor and administration of misoprostol by nontrained birth attendants will provide beneficial reductions in hemorrhage rates in resource-poor areas. Additional improvements depend on increasing public awareness, facilitating existing nongovernmental organizations in their community-related, upgrading training of traditional birth attendants, and providing cell phone communication to workers in remote areas, in addition to providing better access to blood.

The B-Lynch uterine brace suture, and a bit of this and a bit of that…

The widespread application of the B‐Lynch brace suture to control postpartum hemorrhage has sparked interest in a variety of adjunctive methods, used alone or in combination, to control uterine bleeding. Although the B‐Lynch brace suture has been used with good results throughout the world, failures can and do occur in rare instances, especially when the suture is incorrectly placed for use for an inappropriate indication. Four reports of additional methods to control postpartum hemorrhage are published in this issue of IJGO. Three use the B‐Lynch brace suture combined with other techniques. The need for additional techniques reminds the reader of the importance of proper suture application for proper indication. Potential reasons for failure of the B‐Lynch suture are provided.

Urine pregnancy test and intrauterine inseminations

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Delayed postpartum haemorrhage secondary to a ruptured uterine artery pseudo-aneurysm, successfully treated by transarterial embolisation

A 29-year-old woman (gravida 1, para 1) had an uneventful first pregnancy and a delivery by emergency caesarean section at term. The caesarean section was complicated by a massive obstetric haemorrhage of 5000 ml. After closure, an immediate re-laparotomy was indicated due to heavy vaginal bleeding. The site of bleeding was identified as an extension of the uterine incision, and was sutured. She was stabilised by transfusion of blood and blood products in the intensive therapy unit, and discharged 5 days later. The patient was re-admitted 6 weeks later with brisk, painless vaginal bleeding, passing large clots from a well-contracted uterus. Her haemoglobin decreased from 11.8 to 7.8 g/dl overnight. In view of her history, an urgent CT angiogram was performed, which revealed the presence of a pseudo-aneurysm arising from the left uterine artery. This was successfully occluded by transarterial embolisation, obviating the need for further surgical exploration.

Papulonecrotic tuberculids: a rare cutaneous manifestation of tuberculosis in pregnancy

A 31-year-old Moroccan woman with no significant past medical history was seen during her second pregnancy. At 25 weeks gestation she was admitted with a febrile illness associated with a productive cough which was treated as a community acquired pneumonia with oral antibiotics. At 31 weeks gestation she was admitted with a tender swelling in the right groin and underwent incision and drainage of a presumed femoral abscess. At 36 weeks gestation she re-presented with multiple skin lesions on her arms, legs and buttocks. Initial investigation found no obvious cause for her presentation. The decision for induction of labour was taken as the patient was not improving, and resulted in an uncomplicated Caesarean delivery. After delivery, Mantoux and Quantiferon tests were reported to be positive and the patient was diagnosed with papulonecrotic tuberculides.

Ketonuria and HELLP syndrome

We recently managed a patient with the HELLP syndrome (Haemolysis, Elevated Liver enzymes and Low Platelet count) where there was a delay in diagnosis due to gastroenteritis. This case also reiterates the varied or lack of symptomatology in patients developing HELLP and obscuring the initial diagnosis. Patients with HELLP syndrome have significant maternal morbidity and mortality, hence clinical vigilance and high suspicion play a key role in the diagnosis and subsequent management.

Secondary occupational amenorrhea

Multinational production of generic medications is an accepted part of Good Manufacturing Practices (GMP) for many brand names. However, protection of workers has received scant attention. We describe two patients in a rural area of India who were employed by a local governmental facility that produces lowcost oral contraceptives for local consumption, and both developed secondary occupational amenorrhea. A 22-year-old woman came with a 12-month history of amenorrhea. Before her periods ceased, they had become scanty. Prior to that, her periods were always regular. She was not