Manisha Mathur

Medical management of miscarriage

Miscarriage is a common event in women of reproductive age, with an incidence of 10–20%. Traditionally, surgical evacuation of the uterus was the gold standard for the management of miscarriage. Medical management of miscarriage using a suitable prostaglandin analogue is a safe and effective alternative with high efficacy and patient acceptability. Medical management can be routinely offered as an alternative option, thereby increasing womens choice.

Complications and pregnancy outcome following uterine compression suture for postpartum haemorrhage: a single centre experience.

Abstract In the treatment of postpartum haemorrhage from uterine atony, uterine compression sutures, such as the B-Lynch suture and its modifications have a role with the advantage of preservation of the uterus for fertility. There is however, a risk that apposition of the anterior and posterior walls of the uterus will impede drainage of lochia, resulting in undesirable complications. We undertook a five-year retrospective study of all women who underwent uterine compression sutures at the KK Womens and Childrens Hospital, between 2008 and 2012. In total, 23 women had uterine compression sutures during the study period, of which, nineteen women managed to conserve their uterus. Our complication rate was 25%, which included persistent vaginal discharge, pyometra and endometritis. There were three conceptions, with two successful pregnancies. Our study shows uterine compression suture to be a safe and effective alternative to avoid hysterectomy with preservation of fertility at the time of major postpartum haemorrhage. The outcome of subsequent pregnancies is reassuring.

Decidualised fallopian tube endometriotic implant causing spontaneous haemoperitoneum in a twin pregnancy

Spontaneous haemoperitoneum in pregnancy (SHiP) is a rare but serious condition associated with an adverse pregnancy outcome. We present a case of previable twin pregnancy presenting with SHiP secondary to endometriosis, necessitating an emergency laparotomy and hysterotomy as a life-saving measure to achieve haemostasis. At laparotomy there was massive haemoperitoneum with active bleeding from the left fallopian tube and a left salpingectomy was performed. Histological examination showed haemorrhagic foci of endometriosis on the fallopian tube exhibiting florid stromal decidual change. We wish to raise awareness of this uncommon but potentially life-threatening condition requiring early recognition and prompt recourse to surgical intervention to minimise the morbidity and mortality.

Placental site nodule (PSN): an uncommon diagnosis with a common presentation.

Placental site nodule (PSN) is a rare benign lesion of the intermediate trophoblast which is thought to represent incomplete involution of the placental implantation site. PSN usually presents as menorrhagia, intermenstrual bleeding or an abnormal Pap smear. PSN is benign, but it is important to distinguish it from the other benign and malignant lesions like decidua, placental polyp, exaggerated placental site and placental site trophoblastic tumour. Follow-ups of typical PSNs do not show recurrence or malignant potential. PSN is an uncommon condition which should be suspected in cases of abnormal bleeding, especially following uterine surgical procedures preceding last pregnancy. Timely diagnosis and treatment is necessary to differentiate it from potentially malignant placental lesions with a similar presentation.

Severe resistant maternal hypotension following tocolysis with nifedipine

An 18-year-old woman, gravida 3, para 2, presented at 24 weeks of gestation with preterm premature rupture of membranes. She was started on nifedipine for tocolysis and to facilitate administration of steroids. Two and a half hours later, the patient developed tachycardia and hypotension. Sepsis from chorioamnionitis, acute cardiac event and pulmonary embolism were considered as differential diagnoses. Laboratory and radiological investigations, however, ruled out these possible causes of haemodynamic instability. Her clinical condition deteriorated and hypotension remained intractable despite aggressive fluid resuscitation. An emergency caesarean section at 24 weeks of gestation was carried out in the interest of saving the mothers life. The haemodynamic status of the patient recovered rapidly postcaesarean section. This case report highlights the rare but potentially serious adverse effects of hypotension in administration of nifedipine; and thus reminds us of the importance of judicious prescription and careful titration of nifedipine as a tocolytic.

Minimally invasive surgery to manage a complicated case of a caesarean scar ectopic pregnancy.

A 30-year-old woman, gravida 3 para 1, presented at 5 weeks of amenorrhoea with vaginal spotting and mild abdominal pain. A transvaginal scan confirmed a caesarean scar pregnancy (CSP). Serum hCG level at presentation was 4357. She declined treatment initially, but eventually underwent laparoscopic-guided suction curettage and excision of CSP. hCG was undetectable at 5 weeks postoperatively. She had an uneventful recovery and was advised to take oral contraceptives.

Severe distortion of the uterus associated with a B-Lynch suture

negative women (t test, P = 0.01). The median AFI for women on ART (n = 13) was 4.9 cm and for women not on ART (n = 7) was 5.8 cm (Wilcoxon rank sum test, P = 0.50). Low birth weight has been associated with HIV infection [3], and if related to placental insufficiency, oligohydramnios could be expected. Another explanation may be found in the ART regimen that usually contains tenofovir, known to be nephrotoxic [4], possibly reducing fetal urine output. This study could not provide supporting evidence for the role of tenofovir, because ART regimens were not recorded. The results, limited by small sample size, suggest that HIV-1 may be involved in oligohydramnios at advanced gestation. This needs to be confirmed or excluded in a larger focused study. Conflict of interest

Use of Bakri balloon tamponade (BBT) for conservative management of postpartum haemorrhage: a tertiary referral centre case series

Abstract The aim of this study was to investigate the efficacy of the Bakri balloon in the management of PPH. This was a retrospective review of 49 patients, who had Bakri balloon inserted for PPH in KK Hospital between April 2013 and December 2015. The main outcome measure was achievement of haemostasis by Bakri balloon tamponade (BBT). Our success rate was 81.6%. Out of the nine failures (18.0%), five (55.6%) had subtotal hysterectomies and four (44.4%) had total hysterectomies. The causes of PPH in these nine women were unsuspected or foci of placenta accreta (55.6%), uterine atony (33.3%) and retained products of conception (11.1%). Our study suggests that BBT is more likely to fail when bleeding is secondary to undiagnosed focal placenta accreta (p = .011) and when the estimated blood loss is more than 1.5 litres (p < .001). Our study adds to the growing body of evidence that BBT is not only effective for management of PPH in haemodynamically stable patients and in cases secondary to uterine atony and placenta praevia, but also in a small number of undiagnosed focal placenta accreta. Impact statement There is limited evidence regarding efficacy of BBT for PPH. Our study supports the use of BBT for PPH due to uterine atony and placenta praevia and in a small number of undiagnosed placenta accreta.

Leptospirosis in Pregnancy: A Rare Condition Mimicking HELLP Syndrome

We report a case of leptospirosis in pregnancy. A 37-year-old woman of para 1, normal vaginal delivery (NVD) presented at 33 weeks with 3 days of jaundice and diarrhea and no history of fever, abdominal pain, itch or pale stools. Her pregnancy was uneventful except for gestational diabetes. On examination she had jaundice otherwise unremarkable. Investigations revealed proteinuria, hemolysis, low platelets, raised transaminases and bilirubin. Working diagnosis was of atypical hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome owing to absence of hypertension. She progressed into labour 1 day later after preterm premature rupture of membranes (PPROM), had thick meconium and pathological cardiotocography (CTG). She delivered a baby weighing 1,736 g and normal Apgar scores. Arterial cord pH was 7.275, lactate 3.04, base excess of -8.8 and venous pH was 7.316, lactate 2.93, BE -10.6. Leptospirosis EIA IgM antibody was positive and placenta histology showed focus increased perivillous fibrinoid deposits with acute intervillositis and meconium staining. Baby showed no signs of congenital leptospirosis and was discharged on day 15 of life. Patient’s symptoms resolved within 2 weeks and her biochemistry normalized within 1 month. Owning to unusual presentation and rarity, leptospirosis in pregnancy is often misdiagnosed and underreported. It mimics HELLP syndrome, viral hepatitis, obstetric cholestasis and acute fatty liver of pregnancy. It has severe implications of early miscarriages, stillbirths and neonatal leptospirosis requiring high index of suspicion, need for increased awareness, early diagnosis and treatment. J Med Cases. 2018;9(7):198-200 doi: https://doi.org/10.14740/jmc3073w

Uterine artery embolisation for acute dysfunctional uterine bleeding with failed medical therapy: a novel approach to management

A 35-year-old woman with a history of three previous caesarean sections was admitted with acute dysfunctional uterine bleeding (DUB) complicated by anaemia; she had a haemoglobin level of 5.3 g/dL, requiring multiple blood transfusions. Investigations performed excluded pelvic pathology and haematological causes for her acute DUB. Despite the use of various pharmacological agents, her bleeding persisted and she eventually underwent uterine artery embolisation (UAE) to arrest bleeding. She was well postprocedure and was discharged on combined oral contraceptives. However, she presented a year later with another episode of acute DUB that required a repeat UAE. This case report summarises the use of UAE in the management of acute DUB following failed medical therapy.