Indian Journal of Obstetrics and Gynecology

Introduction: Abnormal uterine bleeding (AUB) is a common gynecological issue, characterized by change in frequency of menstruation, duration of bleeding phase or amount of blood loss. In gynecological outpatient department about 33% of women have AUB and the percentage raises more in perimenopausal women. It can be associated with various causes like endometrial polyp, leiomyoma, adenomyosis, endometrial hyperplasia, ovulatory dysfunction and sometimes endometrial carcinoma. A number of diagnostic techniques like transvaginal ultrasonography, endometrial curettage and hysteroscopic guided biopsy are available. Aims: To study hysteroscopic findings and its correlation with histopathology of endometrium in AUB. Setting and design: Observational cross-sectional study conducted at a tertiary care hospital. Methods and materials: Demographic details and clinical history were obtained and 70 cases out of 162 were selected based on inclusion and exclusion criteria. Thorough examination and essential investigations like complete blood count and transvaginal ultrasonography (TVUS) were done. After preoperative preparations patients were subjected to hysteroscopy and guided biopsy. Hysteroscope was used to visualize the uterine cavity and to detect uterine malformations, polyps, submucosal fibroids, hyperplastic endometrium or endometrial atrophy. Results and conclusion: The accuracy of hysteroscopy in identification of polyp, endometrial hyperplasia and endometrial carcinoma was found to be 97.1%, 77.1%, 75.7%, respectively and overall accuracy of hysteroscopy in diagnosing pathology behind abnormal uterine bleeding was 67%. Hence, hysteroscopy though can act as an adjunct in diagnosis of AUB, histopathology will continue to be superior and gold standard.

Keywords: Polyps; Endometrial hyperplasia; Endometrial carcinoma; Endometrial curettage; Dilatation and curettage; Endometrial biopsy.

28Background: Uterine rupture is an obstetrical emergency associated with severe maternal and perinatal morbidity and mortality. It is a rare but potentially dangerous event occurs in 1 of 8,000 to 1 of 15,000 deliveries.1 Factors responsible for uterine rupture can be divided into maternal, fetal and social subtypes. By reviewing cases of uterine rupture we will be able to identify incidence, obstetric risk factors, maternal and perinatal morbidity plus mortality and management modalities of uterine rupture in teaching hospital of Kutch district. We will be able to take measures which can help in preventing uterine rupture and its worst outcome. Methods: This is an observational study conducted over a time period of 3 years, one year retrospectively and two years prospectively. All pregnant females admitted or referred to GKGH with uterine rupture were included in the study. All the cases were analyzed and data regarding their demographic characteristics, clinical presentation, risk factors, management, operative findings, postoperative complications, maternal and fetal outcome were studied. Results: The overall incidence of uterine rupture is 2.13. Among them 83% are multigravida. Out of this 22% cases of rupture were due to previous LSCS. All the cases were referred to GKGH and majority of them were not having ANC visits. Two cases of rupture were due to uterine anomaly and another two cases had gross congenital fetal malformations which led to obstructed labor and ultimately resulted in uterine rupture. In one case conjoint twins were delivered vaginally. Two cases resulted in maternal death. Only 22% of the babies survived rest were brought dead (IUFD). Conclusions: Multigravida is still a leading cause of uterine rupture in Kutch district even in today’s modern era where patients prefer more to go for planned cesarean section. Uterine rupture is a major contributor to foetomaternal morbidity and mortality. Routine antenatal check up with ultrasound, identification of high risk women, prompt clinical diagnosis, timely refer, immediate transfer and optimal management is over emphasized to avoid adverse fetomaternal complication. Awareness regarding maternal and child health, routine antenatal check up, adoption of family planning methods, nutrition level should be spread.

Keywords: Uterine rupture; Multigravida; Previous cesarean; Hysterectomy; Obstructed labor, perinatal morbidity and mortality.

Introduction: The McGill Pain Questionnaire1 ranks labor pain in the upper part of pain scale between cancer pain and amputation of digit. So in modern obstetrics, pain relief during childbirth to the parturient has become more demanding and sophisticated. Epidural analgesia is gold standard technique that has been used extensively nowadays but it has drawbacks like delayed onset and some degree of motor block. Recent trend of using local anesthetic in very low dose along with opioid could overcome them. Objective: The objective of this study was to assess the onset, effectiveness, duration and extent of epidural analgesia with ropivacaine in combination with fentanyl and its practical application and acceptability by the parturient. The study also aims to know its effect on progress of labor, mode of delivery, side effects and complications to the mother or fetus. Material and method: This observational study was conducted in OBGY department of SMIMER Surat, from Jan 2017 to Jun 2018. Full-term nulliparous patients from labor room were taken for study. Patients having a single fetus with vertex presentation, with CPD ruled out clinically and those expected to deliver normally were included in the study. Epidural analgesia was given when cervix dilatation was equal to or more than 3 cm. After epidural test dose, 15 ml of 0.2% Ropivacaine with 2 mcg/ml fentanyl was given as first dose with the help of lumbar epidural needle inserted at L3–L4 interspinous space. Pain was assessed by VAS score which if found more than 3, another top up dose equal to first dose was repeated. VAS score <3 was considered as effective analgesia. Observation: Total 40 patients were included in the study. Onset of analgesia was significantly faster as most patients achieved VAS <3 in 10 min. Eighty percent (32/40) of patients graded the adequacy of analgesia as god to excellent i.e. VAS <3. The mean number of top up doses given in this study was 1.35. The mean duration of active stage of first stage of labor was 147.43 min and second stage was of 37.35 min. 82.5% (32/40) mothers had spontaneous vaginal delivery, 10% (4/40) patients had LSCS delivery and only 7.5% (3/40) had instrumental delivery. Thus the rate of operative delivery was very low in this study. No patient had motor block, only 3/40 (7.5%) subjects suffered nausea and vomiting and 4/40 (10%) had urinary retention. Apgar score was >7 at 1 and 5 min in all babies. Conclusion: The use of newer epidural anesthetic agent like ropivacaine in addition with low dose of opioids like fentanyl provides better analgesic effect during labor with minimal motor blockade of abdomino-pelvic muscles which encourages the parturients to actively participate in expulsion of fetus resulting in shorter duration of labor and lower rate of operative deliveries.

Introduction: To determine the incidence, indications, risk factors and fetomaternal complications associated with emergency peripartum hysterectomy. Material and method: This is a retrospective case series where hospital file record of patients who underwent EPH during January 2016 to December 2018 in the department of obstetrics and gynecology, BSAH, New Delhi after ethical approval were thoroughly examined. Data regarding incidence, indications, risk factors and fetomaternal complications of EPH were obtained. Results: During the study period, there were total of 39 emergency peripartum hysterectomies, with the incidence of 1.6 per 1000 deliveries. The various indications for hysterectomy were uterine atony (33%) followed by placenta previa (18%), adherent placenta (18%) and uterine rupture (10%). The risk factors associated were multiparity (74%), previous cesarean section (25%) and obstructed labor (20%). Common postoperative complications were fever, wound infection and DIC. The maternal mortality rate was 13% and perinatal mortality rate was 23%. Conclusion: Emergency peripartum hysterectomy is a potentially lifesaving procedure associated with significant maternal morbidity and mortality. Uterine atony and abnormal placenta were the common indication for emergency peripartum hysterectomy. Previous scar, multiparity and abnormal placentation were the significant risk factors.

Objectives: Incidence of eclampsia in the western world is 1 in 2000 and 1 in 3448 pregnancies, but it is many times high in developing countries with incidence of 1.5% in India. Posterior Reversible Encephalopathy Syndrome (PRES) also known as reversible posterior leukoencephalopathy syndrome occurs in association with a number of causes, most commonly hypertension, pre-eclampsia/eclampsia and renal injury. Aim of the study was to find about the incidence of PRES in patients with antepartum eclampsia by brain imaging using MRI and MRV. Material and methods: It was a retrospective cohort study of all patients of antepartum eclampsia with PRES syndrome over a period of two years from 1st June 2017 to 31st July 2019 managed at Basaveshwar Teaching and General Hospital, attached to Mahadevappa Rampure Medical College, Kalaburagi, Karnataka, India. Results: A Total of 140 patients with antepartum eclampsia delivered at Basaveshwar Teaching and General Hospital, attached to Mahadevappa Rampure Medical College, Kalaburagi, Karnataka during the study period; that is between 1st June 2017 and 31st July 2019. Of these 14 patients had PRES with an incidence of 10% of all patients with antepartum eclampsia. The incidence was more in primigravidas (78%) than in multigravidas (22%). 10 patients were 20–25 age group, 13 presented with multiple seizure episodes. In 12 patients seizures were controlled only with MgSO4. Mode of delivery was by vaginal route in 5 patients. Perinatal mortality was seen in 5 patients. There was no maternal mortality in our study. Conclusion: Incidence of PRES was 10% amongst the patients delivered with antepartum eclampsia at Basaveshwar Teaching and General Hospital, Kalaburagi. Signs of imminent eclampsia headache, epigastric pain and blurring of vision were present in these patients. In the majority of the patients seizures were controlled with MgSO4 alone. MRI and MRV were the investigation of choice. Prognosis of PRES in patients with antepartum eclampsia was favorable.

Objective: To study the baseline characteristics of referred obstetric patients, analyze the reason for referral and characteristics of the referring center to determine effectiveness of current referral system. To determine the fetomaternal outcome of the referred patients. Materials and methods: This was a retrospective observational study carried out from January 2017 to June 2017 in department of obstetrics and gynecology at a tertiary health care institute in South Gujarat. Data related to baseline characteristics, reason for referral, type and distance of referring center, feto maternal outcome were analyzed. Result: The study included 343 subjects referred with obstetric complications during the period contributing to 8% of total admission. The mean period of gestation was 36 weeks during admission. The maximum patients (75.8%) were referred from government centers and minimum from the private hospitals (5.2%). The commonest indication for referral was labor abnormality like prolonged labor, PROM, previous cesarean section (29%) followed by medical disorders complicating pregnancy like hypertension, sickle cell disease (25%). Twentyone percent patients were referred because of unavailability of doctors and resources, 12% due to obstetric hemorrhage and 11% due to severe anemia. 0.8% patients had abortion, 11% had preterm delivery and 0.5% had maternal deaths. 158 full-term patients delivered vaginally while 107 underwent CS. Out of the referred subjects, 90% had livebirth while 9% had stillbirth. Conclusion: To establish effective referral system, peripheral health care system needs to be strengthened by means of proper trained and skilled staff, essential equipment, blood banks, good transportation facility, etc.

28Introduction: Jaundice affects a small share of pregnant women, yet it takes a serious toll on health of both mother and fetus particularly in developing countries like India. Jaundice is responsible for 10% of maternal deaths. Aim: To find out the maternal and fetal outcome in pregnancy complicated with jaundice in a tertiary care hospital. Material and methods: Prospective observational study of fetomaternal outcome included 50 ANC patients with jaundice (Serum bilirubin > 1.2 mg/ dl; SGOT > 40 IU/L; SGPT > 40 IU/L) admitted in SMIMER hospital during January 2018 to December 2018. Parameters like age, socioeconomic status, LFT and Viral markers were recorded. Patients were treated in line with standard protocol and fetomaternal outcome were then studied. Results: Fifty patients had jaundice during pregnancy. The incidence of jaundice was 0.63%. Sixty-eight percent of patients were between 21 and 29 years of age. The most common cause of jaundice in pregnancy was viral hepatitis seen in 52% cases. Maternal mortality was seen in 5 (10%) cases. The common maternal complications were DIC, atonic postpartum hemorrhage, PET, hepatic encephalopathy and multiorgan failure. Perinatal mortality was seen in 16 (32%) cases. Conclusions: Jaundice in pregnancy has adverse fetomaternal outcome. Viral hepatitis is the most common cause of jaundice in pregnancy. Maternal morbidity and mortality increases with rise in serum bilirubin level. Improvement in health awareness, education and regular antepartum checkups, early referrals end in early diagnosis and careful management of jaundice during pregnancy therefore reducing maternal and fetal mortality and morbidity.