P. Sinha

Ante-partum haemorrhage: An update

Summary Ante-partum haemorrhage is an important cause of maternal and fetal morbidity and mortality, despite modern improvement in obstetric practice and transfusion service. It is defined as any vaginal bleeding from the 20th week of gestation till delivery. The initial management of ante-partum haemorrhage should concentrate on resuscitation and accurate diagnosis. The most important causes are placenta praevia and abruption accounting for more than half the cases. The numbers of cases of placenta praevia and placenta accreta are increasing with the increasing caesarean section rate. In many cases, it is not possible to make a definite diagnosis, despite all the investigations. Development of ultrasound especially transvaginal scan has helped in the definitive diagnosis and management of placenta praevia. Every unit should have a clear protocol for the management of massive haemorrhage, which should be regularly updated and rehearsed.

Premature ovarian failure

Summary Premature ovarian failure (POF) is gonadal failure before the age of 40 years. Several rare causes have been discovered yet we still fail to identify the cause in many cases. Although it was once thought to be a permanent condition, a substantial number of patients experience spontaneous remissions and even pregnancy. HRT remains the cornerstone of treatment and the only proven method of achieving pregnancy in these patients is by ovum donation. New alternatives to HRT and fertility preservation are under development. Basic understanding of ovarian physiology and pathogenesis of POF is necessary for the development of newer therapies.

Caesarean scar pregnancy: a precursor of placenta percreta/accreta.

In the last decade, diagnosis of caesarean scar (CS) pregnancy and abnormal placental invasion has gone up significantly. It appears that the history of previous caesarean section is the predisposing factor common to both conditions. Until now, these are treated as a separate entity and therefore managed differently. Recent available evidence suggests that these are not a separate entity but rather a continuum of the same condition. If the caesarean scar pregnancy is managed expectantly in the 1st trimester, most likely it evolves into placenta accreta. This leads invariably to peripartum hysterectomy for postpartum haemorrhage (PPH) and severe maternal morbidity. Early diagnosis and intervention may give a favourable outcome.

Non-diabetic macrosomia: An obstetric dilemma

Summary Fetal macrosomia represents a continuing challenge in obstetrics, as it has risk of shoulder dystocia leading to transient or permanent fetal, maternal injury and medicolegal liability. The overall incidence of macrosomia has been rising. Non-diabetic macrosomia is still an obstetric dilemma, as there is no clear consensus regarding its ante-partum prediction and management, as accurate diagnosis is only made retrospectively. The risk of shoulder dystocia rises from 1.4% for all vaginal deliveries to 9.2–24% for birth weights more than 4,500 g. Unfortunately, 50% of all cases of shoulder dystocia occur at birth weights of less than 4,000 g. Brachial plexus injury occurs in 1:1,000 births and permanent damage in 1:10,000 deliveries (12% of all) leading to litigation 1:45,000 deliveries. The prenatal diagnosis of macrosomia remains imprecise. Pre-pregnancy and ante-partum risk factors and ultrasound have poor predictive value. Induction of labour and prophylactic caesarean delivery has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. Caesarean section and induction of labour are associated with increased risk of operative morbidity and mortality with added cost implications.

Prenatal depression leading to postpartum psychosis

Postpartum psychosis is a mood disorder occurring up to 3 months after delivery. Incidence is one to two women every 1,000 live births. If not detected and appropriately treated in time, it may have detrimental effects on both the mother and her baby. We report a case of puerperal psychosis in a patient with a history of depression. We have also reviewed the relevant literature discussing prediction, management and differential diagnosis of postpartum psychosis. We emphasise the importance of early detection and provision of care to all women at risk of mental illness by multidisciplinary team, including GPs, obstetricians, midwives and perinatal mental health professionals.

Coping with placenta praevia and accreta in a DGH setting and words of caution

The incidence of placenta praevia and accreta has been increasing with rising caesarean section rates. We highlight the increasing incidence of severe post-partum haemorrhage due to placenta accreta. Four cases occurred within 3 years (2002 – 2004) in a small District General Hospital (DGH) with a delivery rate of 1,800 per year. All of the cases had previous caesarean sections and three had an associated anterior low-lying placenta. These patients were diagnosed to have placenta accreta in the third stage of labour, as the placenta was completely adherent and was difficult to remove. However, two of them had a provisional diagnosis made of placenta accreta and prophylactic measures had been taken in the form of counselling and consent for possible hysterectomy. Patients were counselled regarding this condition, and the possible need for hysterectomy was discussed. Two of them had to be managed by post-partum hysterectomy and the other two were treated conservatively. The purpose of writing these case reports is to warn others of the need for vigilance, particularly in keeping their primary caesarean section rates down and being prepared for long-term complications.

Vasa praevia: a missed diagnosis.

Summary Vasa praevia is an uncommon obstetric complication, which if undiagnosed is associated with a high fetal mortality because of the rapid haemorrhage from tearing of fetal vessels resulting in fetal exsanguinations. Antenatal diagnosis in most cases is not made and therefore prevention of fetal death is not possible. Outcome depends primarily on prenatal diagnosis and caesarean delivery at 36 weeks or even earlier. Advances in ultrasound have led to an improved ability to diagnose this condition. Evaluation of high-risk patients with transvaginal colour flow Doppler ultrasound should be considered and should be included in the protocol for routine obstetrics scan. We report three cases of vasa praevia presenting as ante-partum and intra-partum bleeding. Two of them had associated suspected low-lying placenta. This occurred within 4 years (2002–2006) in a small DGH with a delivery rate of 1,800 per year. The purpose of writing these case reports is to warn others of the need for vigilance antenatally, especially with a low-lying placenta, velamentous insertion of cord, IVF and multiple pregnancy. Colour Doppler should be used to visualise blood vessels in these high-risk cases and elective caesarean section should be performed at 35–36 weeks in cases diagnosed as vasa praevia.

Expulsion of part of a spontaneously broken IUCD

The IUCD is considered one of the best methods of contraception in modern times. It has high rates of efficacy and acceptability is easily reversible and only periodic check-ups are necessary. However complications include uterine perforation and displacement of the device. Spontaneous breakage of an intrauterine contraceptive device is a very rare occurrence. This rare complication has to be kept in mind when treating cases of missing intrauterine contraceptive devices. (excerpt)

Does caesarean section provide the best outcome for mother and baby in breech presentation? A perspective from the developing world

This is a retrospective analysis of vaginal breech delivery from January 2006 to December 2008 at a maternity hospital in New Delhi. The hospital has approximately 6,000 deliveries per year, and serves a low income population. Most patients are unbooked, have had no antenatal care and attend in an advanced stage of labour, delivering within 2–3 h of admission. The mode of delivery for breech presentation is one of the most controversial in modern obstetrics. The impact of a caesarean section involves not only immediate risk but complications in future pregnancies and on health costs. Outcome measures were expressed in terms of Apgar, SCBU admission, intrapartum death and birth trauma. Caesarean sections should be performed in selected cases after full discussion with the patient. We are ignoring maternal risks and concentrating on a small subset to reduce perinatal morbidity and mortality.

Value of routine transvaginal ultrasound scan in women requesting early termination of pregnancy

This was a retrospective study of 140 women attending a termination clinic from 1 April 2002 to 31 March 2003. All women had a transvaginal ultrasound scan. Of 140 women, 56 women benefited from the scan; 26.7% had non-viable pregnancy, 35.71% did not remember their LMP, 12.5% had discrepancy between the scan and LMP. Incidental findings were noted in 24.6% of which two had a twin gestation, nine had ovarian cysts, one had an ectopic pregnancy, one had a hydatidiform mole, one conceived with an IUCD and one had a bicornuate uterus with pregnancy in one horn. Two of the nine women with ovarian cysts needed a laparotomy. This study concludes that routine transvaginal scan (TVS) scan is an essential investigation for proper assessment of all women requesting termination of pregnancy. TVS is a safe and effective procedure which provides useful information regarding gestational age, viability of pregnancy and uncertain dates. In cases of the ectopic pregnancy and the hydatidiform mole transvaginal ultrasound helped us in appropriate management from the outset and minimised complications.