Peripartum hysterectomy

To find out the frequency, indication and its associated morbidity in our setup. Prospective cross-sectional observational study for the period one year [from June 2003 - May 2004] carried out in the Department of Obs / Gynae, Lahore General Hospital Lahore. During the study there were 26 cases of peripartum hysterectomy, of which 14 case were of caesarean hysterectomy, while 10 cases were following normal vaginal delivery and 2 cases followed by instrumental delivery. Uterine atony was the most common indication for peripartum hysterectomy in 12 cases [46.15%]. Uterine rupture including instrumental delivery tear was 2nd most frequent cause in 4 +2=6[23.07%] of cases. In 19.2% [5] of cases abnormal placentation was the cause. In 2[7.6%] of cases sepsis was the cause leading to secondary PPH followed by hysterectomy. A subtotal hysterectomy was carried out in 10 [38.46%] and total hysterectomy was performed in 16 [61.53%] cases. there were 4 maternal deaths. Urinary tract injuries occurred in 3[11.53%] cases, fever, chest infection and wound infection were common morbidity. Anemia was found in almost every case. Intra and post operative Blood transfusion s were given in all cases. Reloparotomy was done in one patient for continues vaginal bleeding. Despite its morbidity and mortality emergency Obstetric hysterectomy remains an essential life saving tool. Uterine atony, uterine rupture and abnormal placentation were mast common indications, reflecting under utilization of existing antenatal, family planning services. Injudicious use of oxytocin, lack of transportation facilities, poverty and delayed referral all contribute to morbidity and mortality associated with emergency Obstetric hysterectomy

Pregnancy with previous mitral valve replacement

Mitral valve replacement has changed many lives of patients with severe mitral stenosis who were doomed due to severe haemodynamic complications. Successful pregnancy outcomes are now numerous. The study was carried out at Services hospital involving 7 pregnant patients with mitral valve replacement, as regards to its antepartum, intrapartum and postpartum management. The study showed the incidence to be 0.2% of all deliveries. StarrEdwards was the most common [71.5%] prosthetic valve with good haemodynamic outcomes. Five [71.5%] patients remained in NYHA class II, showing the efficacy of valvular surgery and I. Five [71.5%] patients ended in vaginal delivery of healthy infants and 2 [28.5%] had evacuation. Six [85.7%] patients received anticoagulants. Oral warfarin was used in all of these six cases throughout the first trimester. One [14.3%] of these patients ended in spontaneous abortion. One [14.3%] patient had blighted ovum and intravenous heparin was replaced for warfarin 24 hours before evacuation at 12 weeks of gestation. The remaining 4 [57%] patients continued warfarin through second trimester, and replaced by subcutaneous heparin at 34 weeks in 3[42.8%] patients and at 36 weeks in one [14.3%] patient. Coagulation monitoring, which was carried out in only 3 [42.8%] cases, revealed ineffective thromboprophylaxis. Ampicillin and gentamycin was given intravenously at start of labour and then 8 hourly for 48 hours in 6 [85.7%] patients. Antenatal antibiotic prophylaxis was provided only to 1 [14.3%] patient by benzathaine penicillin [penidure-LA, Wythe] 1.2 x 106 units per month. Diuretics, digoxin and beta blockers were prescribed according to individual requirements of patients. Two patients developed pulmonary oedema treated effectively in the intensive care unitI.C.U. There was no mortality in this study. A concerted effort by all the concerned specialities in patients management is necessary to ensure safe outcome. The role of subcutaneous instead of intravenous heparin for prophylaxis in pregnancy should be evaluated by further studies