Shakti Vardhan

Appendicitis During Pregnancy.

Acute appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy [1]. Six young female patients presented with appendicitis during May 1996 to May 2001 in different service hospitals. Five patients underwent emergency appendectomy successfully. Gestational age at presentation included first trimester in 4 patients, second trimester in 2 patients and none in third trimester. 84% had pathologically proven acute appendicitis. One patient presented with appendicular lump in first trimester, proved on ultra sonography examination, which was treated by Oshner Sherren regime and subsequently interval appendectomy was done in second trimester. No long term adverse maternal morbidity or mortality was reported. One patient had premature onset of labour and delivered. Natural history of acute appendicitis is not changed during pregnancy while gestational physiological changes obscure the accurate diagnosis of acute appendicitis.

Intrapartum Electronic Foetal Monitoring : Does it Lead or Mislead?

The importance of foetal monitoring during labour is well recognised. The stress of uterine contractions affects the foetus adversely especially if the foetus is already compromised when the placental reserves are suboptimal or when cord undergoes compression as in diminished liquor amnii maternal metabolic and haemo dynamic alterations (e.g. hypotension due to epidural labour analgesia) or iatrogenic uterine hyperstimulation due to injudicious use of oxytocin. Auscultation of the foetal heart sounds with stethoscope or the use of Doppler is the commonly available method of intrapartum foetal monitoring. However its intermittent nature led to the feeling amongst obstetricians that this form of monitoring is inadequate. Hence continuous electronic foetal monitoring (EFM) came in vogue in the late 1960s. It came with very high expectations that it will be able to pick up all cases of intrapartum foetal distress early in labour and prevent neonatal deaths with improved Apgar-score and decreased Neonatal Intensive Care Unit (NICU) admissions. (excerpt)

Walking Epidural : An Effective Method of Labour Pain Relief.

BACKGROUND Labour pain can be deleterious for mother and baby. Epidural analgesia relieves labour pains effectively with minimal maternal and foetal side effects. A prospective open label study was undertaken to ascertain effective dosing regime for walking epidural in labour. METHODS Fifty women with singleton foetus in vertex position were included. Epidural catheter was inserted in L2-3 / L3-4 interspinous space. Initial bolus of 10 ml (0.1% bupivacaine and 0.0002% fentanyl) solution was injected and after the efficacy of block was established, an epidural infusion of the same drug solution was started at the rate of 5 ml/hour. RESULTS In first stage of labour 80% of the parturient had excellent to good pain relief (visual analogue scale 1 to 3) with standard protocol while 20% parturient required one or more additional boluses. For the second stage, pain relief was good to fair (VAS 4-6) for most of the parturient. The incidence of caesarian section was 4% and 6% needed assisted delivery. No major side effects were observed. CONCLUSION 0.1% bupivacaine with 0.0002% fentanyl maximizes labour pain relief and minimizes side effects.

Modified Technique of LSCS: The Misgav Ladach Method

The emergence of endoscopic surgery has revolutionized the management of endometriosis, infertility, ovarian cyst and ectopic pregnancy. Similarly, Assisted Reproductive Techniques (ART) have provided hope for those infertile couples where other therapies have failed. Notwithstanding the cost factor these options appear attractive. However, no method can replace Lower Segment Caesarean Section (LSCS) as a means of abdominal delivery of the foetus, when indicated. Therefore, any modifications in the technique which reduces the operative time, blood loss and post operative complications would be welcome. Misgav Ladach Technique [1], which involves certain modifications in the routine method of LSCS using Pfannensteil incision, achieves these objectives satisfactorily and is gaining popularity gradually. This method was first practiced in Misgav Ladach Hospital in Jerusalem from where it derives its name.

Hydramnios Associated with Foetal Duodenal Atresia.

Hydramnios, an excessive accumulation of amniotic fluid within the amniotic cavity, is not associated with an identifiable cause in the majority of the cases. However, in about one third of the cases an underlying cause is present. Hydramnios may be a manifestation of underlying foetal anomaly in 13%, maternal disorder such as diabetes mellitus in 14% [1] and rarely Rh isoimmunization in less than 1% [2] of cases. A case of severe hydramnios associated with foetal duodenal atresia is presented.

Derivation of human iPSC line NCCSi002-A from umbilical cord blood (UCB) CD34 + cells of donor from Indian ethnicity

We discuss the reprogramming of CD34+ cells isolated from UCB of a healthy female child of Indian ethnicity. The CD34+cells were nucleofected using episomal vectors expressing Oct4, Sox2, L-Myc, Klf4, Lin28 and p53DD (negative mutation in p53). The colonies were stained for alkaline phosphatase and evaluated for pluripotency marker expression by PCR, immunofluorescence and flow-cytometry. The safety of cells was confirmed by absence of plasmid in subsequent passages by PCR. G-banded karyotype demonstrated a stable genome. The ability of tri-lineage differentiation was confirmed by specific marker expression by immunofluorescence invitro and teratoma formation invivo.

A rare case of early onset severe preeclampsia with PRES

Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiological syndrome. Patients usually present with seizures, visual disturbances, headache, and altered mental state. Most accepted pathophysiology is vasogenic edema. Imaging predominantly shows parieto-occipital white matter changes. We report a 22-year-old G2P1L1 lady who presented at 23 weeks 2 days period of gestation (POG) with high blood pressure (160 /104 mm of Hg) and headache and later on developed diminished vision too. There was no sensory motor deficit. After evaluation a plan of termination of pregnancy was made, in consultation with the patient and her husband. She was put on prophylactic dose of Inj. MgSO4 and anti-hypertensives and termination of pregnancy was done with intracervical application of PGE2 gel followed by vaginal PGE1 tablet (Misoprost) application. Her vision and headache however, didn’t improve even though she was put on Inj. MgSO4 and BP was controlled with antihypertensive. She delivered within 10 hours. In view of persistence of her symptoms, a MRI brain was done in consultation with a neurophysician, two hours after the delivery that suggested edema in occipital and temporal lobe suggestive of posterior reversible encephalopathy syndrome. Approximately 6-8 hours after delivery, gradual clinical improvement in visual acuity and headache was noted. Her vision completely recovered in 6 days. This case highlights the importance of keeping this entity in mind for the prompt diagnosis and early management, thus preventing short and long-term neurological deficits in this reversible condition popularly known as PRES.

Bleeding in Early Pregnancy

Bleeding in early pregnancy may be life threatening. A small amount of bleeding or spotting per vaginum which may be dismissed as trivial can be catastrophic. Hence it is mandatory for all health care providers to understand the condition and aim at an early diagnosis. There are three important causes of bleeding in early pregnancy namely abortion ectopic pregnancy and hydatidiform mole in the order of frequency of their occurrence. However of the three ectopic pregnancy keeps best of the clinicians perplexed and may prove fatal earlier and more often than abortion and hydatidiform mole. (excerpt)

Misoprostol as aid in First Trimester MTP

BACKGROUND Medical Termination of Pregnancy (MTP) is a commonly performed during the first trimester. Dilatation and Evacuation (D & E) mandates rapid dilatation of cervix with metal dilators, which requires anaesthesia and may be associated with trauma to the uterus, cervix and later cervical incompetence. The problem of rapid cervical dilatation is obviated with intravaginal misoprostol. METHODS Intravaginal misoprostol tablet 200 microgram was inserted, a night prior to MTP to ripen the cervix. Cervix was dilated with metal dilators only in cases where cervix did not loosen up sufficiently. Products of conception were removed by suction. RESULTS Out of 108 cases cervical dilatation was not required in 96 cases (88.9%). CONCLUSION Intravaginal misoprostol 200 microgram proved effective as a priming agent prior to MTP in the first trimester.

External Cephalic Version : An Old Art With New Relevance

Dear Editor, External cephalic version (ECV) is a manoeuvre by which an unfavourable presentation like breech or transverse lie is converted into a favourable one i.e. cephalic vetex presentation. This is a simple procedure usually done after 36th week of gestation for breech presentations by applying gentle pressure externally on the anterior abdominal wall of the mother so that the fetus is given either the ‘forward roll’ or ‘backward flip’ taking the shortest route to bring about the change in presentation. There is certainly an increased risk of neonatal morbidity [1] and even mortality, at times, associated with vaginal breech delivery. Although the concept of ECV appears attractive, it can lead to placental abruption, cord entanglement, foetal distress and even rupture uterus if the force used is excessive. This is an old art and has received renewed interest and relevance today, on two counts. Firstly, currently most breech presentations are subjected to caesarean sections due to the fear of litigation on account of adverse perinatal outcome along with the fast vanishing art of conducting an assisted vaginal breech delivery. Secondly, with the widespread availability of ultrasound and electronic foetal monitoring devices a better patient selection, higher success rate and an early detection of any adverse foetal effects of the procedure per se, have been made possible. Besides this, use of tocolytics like Inj Terbutaline 250 mg subcutaneously prior to the procedure may be of considerable help in primigravidas and in those with an irritable uterus. ECV has been conclusively shown to be associated with a significant reduction in the number of breech births and caesarean sections for breech presentation in randomized controlled trials [2,3]. The obstetrician should keep in mind that whereas an adequate amount of liquor with a floating breech are associated with higher chances of success, other factors such as obesity, an engaged breech which required disimpaction or lifting up from the pelvis, foetal back in posterior position or a frank breech with the splinting effect of foetal legs on the skull are all associated with a higher rate of failure of version. A few contraindications for version are a malformed baby, a previously scarred uterus, a contracted pelvis or any condition where vaginal delivery is contraindicated. The average success rate of ECV varies from 40-60% according to different series. A few studies have shown that the rate of LSCS after successful versions is higher compared to primary cephalic presentation [4], but other studies do not corroborate the same. Inspite of this, version does help in reducing the LSCS rate significantly because most obstetricians prefer to do an LSCS for breech presentation so that caesarean rate for breech, approaches close to 100% in many institutions. Very few venture to give a trial of vaginal delivery for breech presentation, in modern obstetric practice. To conclude, ECV should be put to greater use in cases of breech presentation, where contraindications do not exist, to reduce the morbidity associated with operative delivery.