A Journey to Safe Motherhood in Pregnancy with Severe Cardiac Dysfunction- A Maternal Near Miss.

Worldwide about 287,000 maternal deaths occur every year, and significant variation exists between low/high/middle-income populations.[1] Maternal death has direct and indirect causes. Indirect maternal deaths result from conditions existing before maternity or recently developed not related to maternity, e.g. cardiovascular diseases, HIV/AIDS, anaemia, infections. World Health Organization (WHO) outlined it as a condition within which “a woman nearly died, however survived throughout pregnancy, childbirth or within 42 days of termination of pregnancy, just by a chance or good hospital care.”[2] Heart conditions presently represent the most common reason behind indirect maternal obstetrics deaths. Pregnancy is related to substantial and progressive hemodynamic changes beginning early in maternity, reaching their peak at the end of 2nd trimester and remaining comparatively constant till child-birth. Major alterations in maternity include a 30 to 50 percent increase in blood volume and cardiac output and decreased blood pressure. In cardiac pregnant patients, these modifications might cause clinical decompensation, exposing these patients to probably life-threatening situations.[3] Here we represent a similar case of a maternal near miss due to severe cardiac dysfunction reported at 8 months amenorrhea.

Severe Cardiac Dysfunction in Pregnancy- A Maternal Near Miss.

Maternal near miss is defined as a pregnancy which survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.[1] India’s MMR has significantly declined from 167 in 2011-13 to 130 in 2014-16. According to guidelines on Maternal Near Miss given by Ministry of Health and Family Welfare, December 2014, for diagnosing a patient with severe cardiac dysfunction, grade-4 (WHO classification) which is a contra -indication to pregnancy, who met single heart criteria to be defined as MNM with abnormal acid-base values, need for ventilatory support, ICU admission, digitalisation, use of cardio- tonics, inotrope support, intra-cardiac intervention OR patient should meet minimum three criteria one each from clinical findings, investigations and interventions. There are certain single heart criteria like breathlessness, orthopnoea, tachycardia, organic murmurs, abnormal ECG and abnormal 2-D ECHO which puts the patient as MNM.[3]

Increasing Trends in Deep Infiltrating Endometriosis (DIE) with Bilateral Endometrioma from Adolescence till Menopause.

Endometriosis is a clinical and a pathological entity characterised by the presence of tissue resembling functional endometrial gland and stroma outside the uterine cavity. Endometriosis most commonly affects women in the age group of 24-35 yrs.1 Postmenopausal endometriosis accounts for less than 3% of the cases.2 The common clinical presentation in a case of endometriosis include chronic pelvic pain, dysmenorrhoea, infertility, dyschezia, dyspareunia and adnexal mass. Diagnosis is usually suspected on basis of signs and symptoms and confirmed on imaging. Transvaginal ultrasound and MRI (especially in DIE) remains not only a diagnostic modality but also the best guide to decide the management.3 Many a times, gravity of symptoms may not correlate with severity of disease and patient may remain asymptomatic even with severest form of disease. Many a years may be lost before the definitive diagnosis and management of endometriosis is established.

Monozygotic Monoamniotic Twin Pregnancy with TRAP Sequence and Acardiac Amorphous Foetus.

The ‘Twin Reversed Arterial Perfusion (TRAP)’ sequence or acardiac twinning, or chorioangiopagus parasiticus is an anomaly which is unique to the monochorionic multiple pregnancies and is a rare complication that affects around 1 in 100 monozygotic twin pregnancies and about 1 in 35,000 overall, with no recognized familial recurrence.[1] They have almost doubled over the last two decades as a result of both the increasing average maternal age and with the increased use of assisted reproductive techniques. Physiologically, there is lack of a well-formed cardiac structure in one foetus (acardiac) that acts as a parasite as it is haemodynamically dependent on the structurally normal co-twin (pump twin) through a superficial artery-to-artery placental anastomosis. Various theories that explain the pathogenesis of the anomaly attribute it to either dysmorphogenesis or presence of arterio-arterial anastomosis, with latter being the most popular.[2] In arterio-arterial anastomosis there is a reversal of blood flow from the umbilical artery of pump twin into umbilical artery of the perfused twin therefore bypassing the placenta, henceforth poorly oxygenated blood contributes to deficient development of the head, upper limbs, torso and heart while the better oxygenated blood flowing via umbilical artery through common iliac artery and aorta allows better development of the lower part of the body.[1]-[3]

Laproscopic evaluation in primary female infertility

Background: Infertility is defined as inability to conceive within one or more years of regular unprotected coitus. Infertility has now a days not only a medical but a social problem as well. Ignorance and illiteracy, coupled with hesitancy to discuss the problem, complicates the matter further. WHO has listed infertility as a global health issue.Methods: The present study was conducted on 64 patients with female factor primary infertility admitted in department of obstetrics and gynecology at Rajendra Hospital, Patiala over a duration of 1 year (December 2013- November 2014). All the patients had normal semen study of their partner.Results: In our study mean age was 27.87±4.57. No patient was above 40 years of age. Duration of infertility between 1-5 years was in 47 patients (73.43%), nine patients (14.06%) were infertile for 6-10 years. Out of 64 patients of primary infertility, majority of patients were of endometriosis 15(23.43%), followed by pelvic inflammatory disease14(21.87%), tubal blockade in 7(10.9%), PCOD in 6(9.37%). 14.08% patients had normal laproscopic study. 34 patients (53.12%) had bilateral spill while no spill was seen in 12 patients (18.75%). Unilateral spill was seen in seven patients (10.93%) while six patients (9.37%) had delayed spill.Conclusions: Prevalence of infertility is increasing, so is the awareness and treatment seeking behavior. The present study assures that in evaluation and workup of primary infertility patients, after baseline noninvasive investigations, endometrial sampling and HSG, the diagnostic and operative laproscopy is an excellent tool for evaluation of tubal factor. Least expected conditions like endometriosis on clinical evaluation, can be diagnosed and treated with ease on laproscopy. Although tubal factor has been considered to be responsible for a large percentage of cases with female secondary infertility since decades, but in present study laproscopic evaluation confirmed tubal factor in 85.01% cases with female factor infertility.

Elevated serum CA 19-9 levels in dermoid cyst: a predictor of ovarian torsion and tissue necrosis?

Dermoid cyst (mature cystic teratoma) with well differentiated derivatives of all the three-germ cell layer is a benign tumour with ovaries being the commonest site. Dermoid cyst accounts for more than half of ovarian tumours in girls below 20 years of age. 80% of dermoid cyst are seen in reproductive age group between 20-40 years. Size of dermoid cyst usually varies between 5-10 cm and it may be bilateral in 10% of cases. Malignant transformation is very rare occurrence only in 1-3% cases, however torsion may occur in 15% of dermoid cyst. Carbohydrate antigen or cancer antigen 19-9 is usually raised in gastrointestinal tumours, pancreatic malignancy, pseudocyst of pancreas. However, it may be raised in some other malignancies and benign condition like torsion of dermoid cyst. Authors report an unusual case of torsion large dermoid cyst with tissue necrosis along with significantly elevates levels of serum CA 19-9. A 30-year-old P1L1 female presented with chief complaint of heaviness and pain lower abdomen and loss of five kilogram weight for last three months. A provisional diagnosis of dermoid was made. Serum CA 19-9 level were 1126 IU significantly raised. An exploratory laparotomy done under regional anaesthesia. A large demoid cyst 12*10 cm with torsion and areas of gangrene in ovarian tissue was seen replacing left ovary. Large and small intestine, stomach, pancreas were explored to rule out any pathology. Histopathology confirmed diagnosis of mature cystic teratoma. There was significant fall in serum Ca 19-9 levels to 247 U/ml two weeks after surgery and levels returned to normal limit six weeks after surgery.

Para vaginal dermoid cyst: a rare occurrence

Dermoid cyst (cystic teratoma) showing well differentiated derivatives of all three germs cell layers, is a benign germ cell tumour. Ovaries remain the commonest site. Paravaginal dermoid cyst is a rare occurrence. Pre-operative diagnosis is usually difficult in majority of cases. They constitute less than 4% of all extragonadal teratomas. A 28-year old, P2L2 female presented with paravaginal cyst, 10×10cms, non-tender, soft swelling, cystic in consistency occupying posterior and left part of rectovaginal septum. Trans vaginal excision of cyst under regional anaesthesia done. Cyst was ruptured while excision showing putty material with tuft of hairs. A retrospective diagnosis of mature teratoma/paravaginal dermoid cyst was made on histopathological examination. Paravaginal dermoid cyst, a benign cystic teratoma is a very rare occurrence. Transvaginal excision of dermoid cyst under anaesthesia remains treatment of choice. Retrospective diagnosis on histopathological examination remains confirmatory as it may be missed on sonography if teeth are not present in dermoid cyst.