Study of magnitude of grand multiparty and its perinatal outcome in a tertiary hospital of rural area in Maharashtra

Background: Grand multiparous pregnancies have been considered to be at higher risk of developing antenatal and perinatal complica?ons like pre-eclampsia, gesta?onal diabetes mellitus, anemia, antepartum hemorrhages, preterm labor, mal-presenta?on, mal-posi?on and feto-pelvic dispropor?on This study was done to know the magnitude of grand mul?para a?ending the ter?ary care center with possible complica?ons related to high parity. Objec?ves:To study the prevalence possible fetomaternal complica?ons associated with grand mul?para at rural setup. Methodology:Descrip?ve cross-sec?onal study conducted in medical college of rural area for 12 months. Grand mul?para with 5 or more deliveries before current pregnancy coming for antenatal checkup and delivery were enrolled. Antenatal history was recorded ?ll delivery and feto-maternal outcomes were noted. Results:Out of 1500 deliveries conducted during study period, 110 (7.5%) cases were grand mul?para. Majority of them (79.5%) were Muslim and 80% were anaemic. 60% delivered with FTND, and 25.4% had emergency LSCS with one intrauterine death and a single breach delivery. Predominantly preeclampsia (23.6%) and malpresenta?on (14.5%) were diagnosed as antepartum complica?ons. Almost one fi?h of them had postpartum hemorrhage which was controlled with no mortality. 13 (11.8%) grand mul?para women had s?ll birth or early neonatal death, though fetal distress was observed in 37 cases. Conclusion: Grand mul?party is s?ll a high-risk pregnancy associated with adverse maternal and fetal outcomes in our facility with mul?ple interrelated but mostly preventable causes.

A CASE OF ANTEPARTUM HEMORRHAGE DUE TO EXTRA PLACENTAL CAUSE –RUPTURED VAGINAL VARICES

Vaginal varix during pregnancy is a rare condition that may be a concern for hemorrhage risk during childbirth.A 32yr old female G3P2L2 with NVD at 30 weeks of gestational age presented to OBG Department (Labor Room)with massive vaginal bleeding without known history of trauma nor any evidence of Placenta previa. On examination: Vital status is unstable and upon pelvic inspection- A stream of blood through a ruptured vein in vagina(Vaginal varices). Immediately vein is clamped with artery forceps and patient is stabilized by crystalloids, Dopamine, Nor-adrenaline and 4 PRBC transfusion and under short general anesthesia (ketamine) transvaginal ligation of vaginal varices is done and pregnancy is prolonged in view of threatened preterm labor( by Isoxsuprine)and terminated by 37 weeks of gestational age by EL.LSCS., Spontaneous resolution of vaginal varices occurred.

Association of Risk Factors with Maternal Outcomes In Abruptio Placenta at Tertiary Care Hospital

Introduction: Abruptio placenta is a serious condition that increases maternal and neonatal morbidity and mortality. The incidence of abruption placenta is between 0.49% -1.8%. Primary cause of abruption is not known but the main precipitating and predisposing factors of abruption are age, parity, anemia, poor nutrition, pregnancy induced hypertension, eclampsia, gestational diabetes mellitus, preterm premature rupture of membrane, and previous medical termination of pregnancy. Methodology:It is a retrospective observational study done by analyzing the case sheets of abruption placenta in tertiary care hospital from January 2020 to December 2020. All those patients of antepartum hemorrhage presenting directly as typical cases of abruption placenta were included. Also, those cases in which placenta previa and other causes were ruled out after clinical, per speculum examination and/or USG examination were ruled out. Result:The total number of abruption placenta collected during this period was 21. We found 38% patients with chronic hypertension, 33 % of patients with severe preeclampsia, 14% with eclampsia, 15% were normotensive. Advanced maternal age and multiparity were also the risk factors of abruption placenta. Conclusion: Antenatal care which identifies the risk factors like PIH plays an important role in decreasing the incidence of abruption placenta. Early detection and active management will reduce morbidity.

The bleeding mother and her baby: a study to determine the fetomaternal outcome in cases of placenta previa

Background: Placenta previa is one of the major causes for obstetric hemorrhagic morbidity and mortality with increasing incidence in recent times. This study aims at determining risk factors, maternal and fetal outcome associated with placenta previa.Methods: This was an observational, retrospective study conducted at a tertiary care hospital in Mumbai from May 2017 to March 2020. A total of 102 women with placenta previa during the study period were included, their case records critically analyzed to identify risk factors, maternal outcome in relation with blood transfusion required, ICU admission, obstetric hysterectomy and fetal outcome pertaining to prematurity, asphyxia and mortality.Results: A total of 102 patients were analyzed. Placenta previa was more common in >26 years of age, multipara (64.7%), with previous history of caesarean sections (21.5%) and previous curettage (11.7%), 44.2% babies born were preterm, 4.4% stillbirths and 8.5% neonatal deaths. Maternal complications like antepartum hemorrhage was seen in 58.8% patients and postpartum hemorrhage in 33.3%, blood transfusion was required in only 18 patients post operatively, bladder rent was seen in 3 patients and there was no maternal mortality. 44 patients required uterine artery ligation, Ashok Anand stitch was taken in 37 patients, uterus compression sutures in 10, obstetric hysterectomy in 7 patients and internal iliac artery ligation in 2 patients.Conclusions: Early identification of women at risk, obstetric preparedness and simple techniques like uterine artery ligation, Ashok Anand stitch and uterine compression sutures can help in effectively reducing need for multiple blood transfusions and morbidity.

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.

Placenta previa: risk factors, feto-maternal outcome and complications

Background: Placenta previa is defined as placenta that is implanted somewhere in the lower uterine segment either over or very near the internal cervical os. Placenta previa and coexistent accrete syndromes contribute substantively to maternal and perinatal morbidity and mortality.Methods: All This is a retrospective study of 88 cases of placenta previa, which were admitted under department of obstetrics and gynecology in our institute during July 2017 to June 2019. All patients of placenta previa with gestational age > 28 weeks up to full term were included in the study. All cases were confirmed by ultrasound examination. Outcome measures prevalence of placenta previa, maternal and neonatal outcomes, and case fatality rate.Results: The total number of deliveries performed during the study period was 16330, of them, 88 cases were placenta previa. Thus, the prevalence of PP was 0.53%. Multiparity was one of the etiological factors in 84.09%, whereas previous LSCS was 47.73%, previous H/O D and E was 14.73%, previous H/O placenta previa was 7.95%. Obstetric hysterectomy was done in 7 (7.95%) patients out of 88 patients. 92.04% of patients delivered with cesarean section and 7.95% patients delivered with normal vaginal delivery. 22 (26.50%) babies out of 83 live born were admitted in NICU.Conclusions: Advancing maternal age, multiparity, prior cesarean section, and prior abortions are independent risk factors for placenta previa. Placenta previa remains a risk factor for adverse maternal and perinatal outcome. The detection of placenta previa should encourage a careful evaluation with timely delivery to reduce the associated maternal and perinatal complications. Measures to reduce the primary caesarean section rate should be adopted.

Consequences of antepartum hemorrhage and its maternal and perinatal outcome

Background: Antepartum haemorrhage, a life-threatening event, is defined as bleeding per vaginum occurring after the fetus has reached the period of viability, considered to be 20 weeks in developed countries and 28 weeks in countries with low resource settings. We evaluated the consequences of antepartum haemorrhage, their maternal and perinatal outcome so as to outline the proper management of patient in order to improve both maternal and perinatal morbidity and mortality.Methods: This one-year prospective study totaled 133 cases of APH fulfilling the inclusion criteria were studied. Data was recorded on the MS excel sheet for further analysis and processing.Results: Total 6693 deliveries were conducted out of which 133 presented as APH and incidence of APH was found out to be 1.98%. Placenta previa was most common. APH was commonly associated with multigravida and most cases were in age group of 26-30 years. Most of the PP and abruption cases were admitted at 34-37 weeks and 31-33 weeks respectively. High risk factors included previous LSCS and D and C, hypertension, multiple pregnancies and malpresentations. Most of the patients underwent preterm LSCS. Most fetal complications were due to prematurity. 58.6% patients were transfused blood. Overall perinatal mortality was 20.1% and maternal mortality was zero.Conclusions: Early diagnoses, timely referrals and transfusion facilities along with trained team of doctors with well-equipped ICU facility goes a long way in avoiding APH related maternak and fetal complications.

Hemorragia de la Segunda Mitad del Embarazo en el Hospital Provincial General Docente Riobamba, Chimborazo, Ecuador 2017 - 2018 / Antepartum hemorrhage in the Hospital Provincial General Docente Riobamba, Chimborazo, Ecuador 2017 - 2018

Introducción: la hemorragia obstétrica es la segunda causa más frecuente de mortalidad materna en el Ecuador, a pesar de ello, es un tema que se ha estudiado poco a nivel provincial y nacional. Objetivo: determinar la ocurrencia e identificar los factores de riesgo, manifestaciones clínicas y comorbilidades más frecuentes de la hemorragia de la segunda mital del embarazo. Métodos: estudio descriptivo, transversal, donde se analizaron las historias clínicas de las pacientes obstétricas con hemorragia de la segunda mitad del embarazo atendidas en el Hospital Provincial General Docente Riobamba (HPGDR) entre junio 2017 y junio 2018. Resultados: de un total de 3 460 pacientes obstétricas atendidas, 0.49% (n = 17) cumplieron los criterios de hemorragia en la segunda mital del embarazo, las cuales tuvieron una edad media de 29 años (desviación estándar = 7), una edad gestacional media de 36 semanas (desviación estándar = 5) y en su mayoría fueron multíparas. El desprendimiento de placenta normoinserta fue la principal patología causante de la hemorragia y el dolor abdominal el principal síntoma manifestado, en la mayoría no se observó otras comorbilidades obstétricas. Conclusión: se observó una baja ocurrencia de hemorragia de la segunda mitad del embarazo en el HGDR entre junio 2017 y junio 2018, siendo la causa más frecuente el desprendimiento de placenta normoinserta y el principal mitivo de consulta dolor abdominal.

Introduction: obstetric hemorrhage is the second most frequent cause of maternal mortality in Ecuador. Nevertheless, the topic has been little studied at a local and national level. Objective: to determine the ocurrence and identify the most frequent risk factors, clinical manifestations and comorbilities in antepartum hemorrhage. Methods: it is a descriptive, cross-sectional study, in which clinical histories of obstetric patients with hemorrhage of the second half of pregnancy were analyzed in the Hospital Provincial General Docente Riobamba (HGPDR) between June 2017 and June 2018. Results: from 3 460 obstetric patients attended, 0.49% (n = 17) met antepartum hemorrhage criteria. Women were in average 29 years old (standard deviation = 7), had an average gestational age of 36 weeks (standard deviation = 5) and were multiparous. Detachment of normoinserta placenta was the main cause of bleeding, abdominal pain was the most frequent symptom reported and in the majority of cases no obstetric comorbilities were observed. Conclusions: it was observed a low ocurrence of hemorrhage of the second half of pregnancy in the HGDR between June 2017 and June 2018. The mots common cause of the patology was detachment of normoinserta placenta and the most frequent complain reported was abdominal pain.

A prospective randomized comparative study of Misoprostol and balloon tamponade using condom catheter to prevent postpartum hemorrhage at M. Y. H., Indore, India in vaginal delivered patients

Background: PPH is responsible for quarter of maternal deaths occurring worldwide and its incidence is increasing in developed world. According to Confidential Enquiries into Maternal and Child Health (CEMACH) report obstetric hemorrhage occurs in around3.7 per 1000 births. The objective of the study is that it was a prospective randomized comparative study of misoprostol and balloon tamponade via condom catheter to prevent postpartum hemorrhage in normal delivered patients at MYH.Methods: A sample size of 200 normal delivered patients between age group 18 and 45 years is chosen with excessive bleeding after third stage of labour and after administration of oxytocics. These 200 patients are divided into two groups: First group receiving Misoprostol and applying condom catheter in other group. Both groups are evaluated for PPH.Results: It was found that CG balloon condom catheter was a much better and more effective alternative in controlling PPH than Misoprostol as the failure rate with CG balloon condom catheter were  much less than that  with misoprostol. Due to its cost effectiveness and being easily available at primary health center and due to absence of any drug reactions and easy technique of formation makes it a better modality in controlling PPH even at PHC.Conclusions: Patients with condom catheter in situ must show better result than patients receiving misoprostol.

Maternal and perinatal outcome in antepartum hemorrhage

Background: Antepartum hemorrhage is defined as any bleeding from or into the genital tract after the period of viability and before the end of second stage of labour. Aim: To study the maternal and perinatal outcome in antepartum hemorrhage. Materials and methods: The present study was a prospective observational study undertaken during a period of 2 years from September 2012 to August 2014 in 50 cases of antepartum hemorrhage. Only patients with APH >28 weeks gestational age willing to participate in study were included. Results: The incidence of antepartum hemorrhage was 3.8%. Abruptio placenta (56%) constituted the largest group. Maximum number of patients was in the age group 20 to 30 years in both abruption (53.5%) and placenta previa (52.5%). In abruption 53.6% and in placenta previa 79% of the patients were multiparous. Majority (56%) of the patients with antepartum hemorrhage had GA of 28 to 34 weeks. Mean period of gestation in APH patients was 33.4 weeks. In abruption, 64% of the patients and in placenta previa 42% were in the age group of 31-34 weeks and 6 days. In the present study, 64% of the patients were anemic at the time of admission. Majority 34% of the anemic patients had Hb of 7.5-9.9 gm. Maximum 35.7% of the patients with abruption had Hb of 5 to 7.4 gm and 42.1% of patients with placenta previa had Hb of 7.5 to 9.9 gm. Pre-eclampsia (36%) was the most common risk factor for APH. The commonest mode of delivery was cesarean delivery i.e. 60%. In abruption majority 53.6% had normal delivery. 89.5% of placenta previa had cesarean section which was the largest group. Post partum hemorrhage was the most common complication observed in 22% of the cases. 5.3% of the patients with placenta previa had placenta accreta. DIC and renal failure were seen in 3.6% each. Majority (64%) of the patients in this study required blood transfusions. 64% of abruption and 68% of placenta previa patients required blood transfusion. IUD or still births were noted in 31% of the cases. Neoantal deaths were observed in 5.8%. Prematurity was the most common complication observed in the present study in 82.8% of the cases followed by neonatal jaundice which G. Sharmila, Prasanna. Maternal and perinatal outcome in antepartum hemorrhage. IAIM, 2016; 3(9): 148-160. Page 149 was observed in 51% of the cases. NICU admissions were present in 8.5% of the cases. In the present study, 56% of the patients had an APGAR score of <7 at 1 min and 63% had an APGAR of 4 to 6 at 5 min. Maximum number of births had birth weight of 1.5-2 Kg. In previa 17, majority (39.2%) of births had birth weight of 1.5-2 Kg and in undetermined majority (66.7%) had birth weight of 2.5-3 Kg. Conclusion: From the present study it can be concluded that antepartum hemorrhage is still a leading cause of maternal morbidity and mortality in our country.

Etiological analysis of obstetric hemorrhage / 中国基层医药

Objective To analyze the etiology of obstetric hemorrhage.Methods The clinical data of obstetrics patients with bleeding in our hospital from January 2008 to May 2012 were retrospectively analyzed.Results The ectopic pregnancy,abortion,cesarean section were the main reasons of obstetric hemorrhage.The uterine inertia was the main cause of postpartum hemorrhage.The proportion of cesarean section induced postpartum hemorrhage had rising trend.The incidence rate of postpartum hemorrhage in natural childbirth was 3.3％,and that in the cesarean section was 9.1％,the difference was statistically significant(x2 =130.55,P ＜ 0.05).The incidence rate of postpartum hemorrhage more than 1 000ml in natural childbirth was 20.0％,and that in cesarean section was 80.0％,the difference was statistically significant (x2 =22.21,P ＜ 0.01).Conclusion The incidence rate of postpartum hemorrhage had a decreasing trend,but the occurrence of abortion,cesarean section,ectopic pregnancy and other common causes had upward trend,to take preventive measures against these common causes of bleeding can effectively reduce the occurrence of obstetric hemorrhage,improve maternal quality of life,reduce maternal mortality.

Prevalence of pregnancy with placenta previa in Siriraj Hospital.

Objective: To determine the prevalence of pregnancy with placenta previa in Siriraj Hospital. Methods: This study conducted a retrospective review of in-patients medical records of a total of 843 singleton deliveries in Siriraj Hospital with gestational age ≥28 weeks during January to February 2009. Data on baseline characteristics of pregnant women, pregnancy course and the outcomes during delivery were collected. Placenta previa was diagnosed by ultrasonographgy and /or direct visualization of placental location during cesarean section. Results: The mean age of the population was 28.4 ± 6.0 years old. Most of these delivered at term gestation (87.4%). The modes of delivery were normal vertex delivery, emergency cesarean section and elective cesarean section which presented in 60.5%, 26.5% and 12.1% of pregnancies respectively. The prevalence of placenta previa was 0.7% (6/843). The factor significantly associated with placenta previa was previous uterine curettage (p = 0.001). The significant outcomes of pregnancy with placenta previa were maternal blood loss >500 mL (P = 0.008) and baby’s APGAR score at 1st minute ≤7 (p = 0.006). Conclusion: The prevalence of pregnancy with placenta previa in Siriraj Hospital was 0.7%.

Unexplained Elevated Maternal Serum Alpha-fetoprotein in Singleton Pregnancies as a Predictor of Fetal Risk / 대한산부인과학회잡지

The aim of the study was to evaluate the significance of unexplained elevated mater- nal serum alpha-fetoprotein in singleton pregnancies as a prediction of fetal risk. The inclusion criteria for patents with unexplained MSAFP elevations were a MSAFP level 2.0 or greater multiples of the median ( MoM ), a single gestation, a confirmed gestatio- nal age and no fetal malformation or death on ultrasonography. In this study, 991 woman who attended the antenatal clinic at Taejeon Eul Ji Hospital from March, 1996 to March, 1997 were reviewed and data from 79 women with elevated maternal serum alpha-fetoprotein levels were analysed. The 67 of 79 patients with elevated maternal serum alpha-fetoprotein levels had on unexplained elevated MSAFP level. 13 women could not follow up. 54 pregnant women with unexplained elevated MSAFP levels were classified as the index group of singleton pregn- ancy and were matched against a control group. 108 patients with MSAFP levels 0.5 to 2.0 MoM served as control group. The incidence of antepartum hemorrhage ( placental previa ), preterm labor, intrauterine growth retardation ( IUGR ), low birth weight and pregnancy induced hypertension ( PIH ) in two groups was analyzed and the results was subjected to Fisher's Exact Test. None of the patients in the index group had chromosomal abnormalites or birth defect. IUGR occurred in 7 ( 12.96% ) of the index group babies but in only 3 ( 2.78% ) in the control group ( p < 0.02 ). preterm labor occurred in 5 ( 9.26% ) in the index group compared with 2 ( 1.85% ) in the control group ( p < 0.05 ). low birth weight occurred in 3 ( 5.5% ) of the index group babies and in 1 ( 0.9% ) in the control group ( p < 0.1 ). This study suggests that patients with unexplained midtrimester elevations of MSAFP are increased risk for IUGR, preterm labor. But no significance differences were observed in the incidence of low birth weight, antepartum hemorrhage ( placental previa ), PIH.