Pregnancy with Eisenmenger Syndrome: A Challenge to Obstetrician

Eisenmenger syndrome is defined as the development of pulmonary hypertension in response to a left-to-right cardiac shunt with consequent bidirectional or reversal (right-to-left) of shunt flow. Maternal mortality in the presence of Eisenmenger syndrome is reported to be 30-50%. If the patient continues her pregnancy against advice, a well-coordinated multidisciplinary team approach is advocated. Here, we report a case of pregnancy with Eisenmenger syndrome and its successful outcome.

Stuck situations in morbidly adherent placenta: how to tackle?

Background: Morbidly adherent placenta is associated with high maternal morbidity and mortality. Its increased prevalence seems to be proportional to the increasing number of caesarean sections. In this study the presentation and management of 32 cases was reviewed with morbidly adherent placenta and maternal and perinatal outcomes from 2014 to 2016, at the hospital.Methods: Study type was retrospective. We reviewed clinical information from patients’ case sheets regarding the risk factors, preparations prior to cesarean section, intraoperative and postoperative complications. Results were interpreted and conclusions were withdrawn.Results: Among the 32 cases, 28 were diagnosed prenatally while 4 were diagnosed intraoperatively. Out of 28 patients, 5 patients were diagnosed early between 14 and 18 weeks of gestational age and other 23 were diagnosed during third trimester by ultrasonography. Caesarean hysterectomy was required in 28 cases.4 were managed conservatively, out of which hysterectomy proved to be necessary in the postpartum period because of severe secondary postpartum hemorrhage in 2 cases. Average no of hospital stay is 10 days ranging from 8-18 days.Conclusions: Prenatal diagnosis of morbidly adherent placenta is essential to plan for the better maternal and perinatal outcome. The decision to perform a cesarean hysterectomy or conservation of uterus (using balloon tamponade or putting haemostatic sutures) is based on the extent of infiltration, the patient’s hemodynamic status, and her desire for future pregnancy. The risk of infection and severe hemorrhage remains high if conservative management is chosen and requires prolonged close monitoring postoperatively. Ideally all the cases should be electively planned and operated by senior surgeon and experienced assistants with senior anesthetist, urosurgeon and physician, with full backup of ICU and blood bank.

Evaluation of endometrial polymerase chain reaction in diagnosis of female genital tuberculosis

Background: Genital tuberculosis also known as tuberculous pelvic inflammatory disease can affect any age group, most common being reproductive women of 20-40 years. Clinical diagnosis of genital tuberculosis is a big challenge as the disease is either asymptomatic or has varied presentations. Conventional methods for diagnosis including AFB smear, endometrial histopathology and culture have limitations of low detection rate because of paucibacillary nature of disease. Laparoscopy generally detects macroscopic changes such as peritubal adhesions, tubercles and tubo-ovarian mass but it fails to diagnose disease at early stage. The objective of this study was to evaluate efficacy of TB DNA PCR in diagnosis of genital tuberculosis.Methods: A total of 127 patients (between 2013-2016) who presented in gynecologic OPD with symptoms suggestive of tuberculosis were included in the study. All patients were subjected to endometrial histopathology and TB DNA PCR of endometrial tissue and peritoneal fluid. Since there is no gold standard test available for diagnosis of genital tuberculosis, a diagnostic criteria was adopted in the study based on laparoscopic findings, clinical history and other investigations. Patients were divided in two groups. Group A included patients positive of tuberculosis based on diagnostic criteria. Group B included patients negative for tuberculosis based on diagnostic criteria.Results: In our study sensitivity of endometrial PCR, peritoneal PCR and endometrial histopathology were 73.8%,17.8% and 10.7% respectively. Endometrial histopathology and peritoneal fluid PCR was found to be highly specific (100%) while endometrial PCR was found to be 93% specific. Endometrial PCR although has highest sensitivity and specificity amongst the groups evaluated but high false negative rate was its major limitation.Conclusions: No single test fulfills all criteria to emerge as sole diagnostic test, hence a high degree of suspicion with a detailed history and investigating with a variety of tests is all that is required to diagnose geniatal tuberculosis.

Impact of different grades of anaemia severity during pregnancy on maternal and neonatal outcomes: a prospective study

Background: Anaemia in pregnancy is a universal health problem that may cause a number of obstetrical and neonatal complications. This prospective observational study aims to evaluate and compare maternal and neonatal outcomes in different grades of anaemia severity.Methods: A total of 400 pregnant women with anaemia in third trimester were classified into three groups according to haemoglobin (Hb) levels-group I with Hb:10-10.9 g/dl, group II with Hb:7-9.9g/dl and group III with Hb<7 g/dl. Maternal and neonatal outcomes of women with different severity of anaemia were analyzed and compared. Two groups means were compared by Student’s t-independent test and more than two groups means by one way analysis of variance test followed by post-hoc pairwise comparison using Bonferroni test.Results: The prevalence of anaemia in the study population was 35.2%. Mild, moderate and severe anaemia were found in 58% (n=232), 29.0% (n=116) and 13% (n=52) women respectively. A statistically significant difference in maternal outcomes such as Preterm labor (p=0.001), Prelabor premature rupture of membranes (p=0.044), Intrauterine growth restriction (p=0.002) and postpartum hemorrhage (p=0.001) was observed amongst the three groups. Cardiac failure occurred in 26.9% (n=14) and mortality in 13.4% (n=7) women with severe anaemia. Amongst the neonatal morbidities, the rate of low birth weight, preterm birth, respiratory distress syndrome, septicaemia, pneumonitis and jaundice revealed an increasing trend with rising severity of anaemia which was statistically significant.Conclusions: Targeted interventions addressing early detection and appropriate treatment in early pregnancy can prevent and avoid dismal maternal and neonatal consequences.

Effect of Raised Mid-trimester Serum hCG and a-fetoprotein on Pregnancy Outcome.

Objective: To study the effect of elevated maternal serum human choriogonadotrophin (MShCG) levels and maternal serum a-fetoprotein (MSAFP) levels measured at 14-24 weeks gestation on pregnancy outcome. Material and methods: A prospective study was conducted in 400 antenatal women with gestational age 14-24 weeks attending OPD and Indoor in Dept. of Obstetrics and Gynecology over a period of 12 months. Maternal serum b-hCG and a-fetoprotein levels were measured by fully automated chemiluminesence method. Result: Elevated mid-trimester MShCG levels and MSAFP level were associated with development of pre-eclampsia. Conclusion: Elevated mid-trimester MShCG and MSAFP level may help in the prediction of pre-eclampsia and hence they can be used as screening tools for prediction of pre-eclampsia.