Placenta percreta: a rare presentation of obstetric emergency in second trimester

Incidence of adherent placenta is on the rise nowadays due to various reasons. Placenta percreta is seen in 5-7% of cases with adherent placenta, patients with morbidly adherent placenta are at increased risk for major obstetric hemorrhage, usually in the third trimester. Here we present an unusual case of placenta percreta presenting with obstetric emergency after trauma to abdomen in the second trimester. Emergency exploratory laparotomy was done for abruptio placentae with scar dehiscence at 20 weeks period of gestation. Consent for obstetric hysterectomy, if needed, was also taken. Intraoperatively, the placenta was found to be adherent to posterior wall of bladder. Emergency obstetric hysterectomy with bilateral internal iliac ligation with cystoscopy with detrusorrhaphy was done. Patient had an uneventful recovery. Multidisciplinary management with obstetricians, urologists and intensivist is presented hereed.

Challenges Faced by an Obstetrician while Dealing with Obstetric Emergency in Cases of Placenta Previa.

Placenta previa itself is a challenge for obstetrician as it may be a fatal condition. Placenta previa is a life-threatening condition and bleeds frequently after second trimester with complaints of bleeding per vagina, mildly or severely. Incidence is 35% of antepartum haemorrhage. We wanted to determine the maternal and foetal outcome at any cost by strengthening the casualty team for emergency management of unpredictable APH and PPH by giving training for the same.METHODSIt is a descriptive observational study was conducted among 35 patients of placenta previa who were diagnosed clinically as well as on ultrasonography, from June 2017 to August 2018 in Gujarat Adani Institute of Medical Sciences. A detailed history was taken as per fixed proforma for all pregnant women.RESULTSPlacenta previa was common in the age group of 21-30 (71.8%) and amongst them multiparous group of more than 5 parity (29%). 3 cases (9.09%) were bilateral uterine artery ligation and 1 case of B-Lynch suture. A single case of internal iliac artery ligation and obstetric hysterectomy was observed. In this study 3 cases of placenta accreta, 1 case of placenta increta, 15 cases of preterm baby, 5 cases (14.2%) of IUFD and 7 cases (20%) of NICU admission were studied.CONCLUSIONSPlacenta previa is a challenging job. A proper multidisciplinary approach based management including expert obstetricians, anaesthetists, neonatologists, radiologists, surgeons as well as trained nursing staff is required for saving mother’s as well as baby’s life.

Urgência subjetiva em emergência obstétrica de alto risco: um estudo psicanalítico / Subjective urgency in high-risk obstetric emergency: a psychoanalytic study / Urgencia subjetiva en emergencia obstétrica de alto riesgo: un estudio psicoanalítico / Urgence subjective en situation d'urgence obstétricale à haut risque: une étude psychanalytique

O período gestacional pode vir acompanhado de complicações emergenciais, capazes de ocasionar iminente ameaça de morte à vida materna e/ou fetal, contribuindo para a crescente taxa de mortalidade nessa população. O encontro com o inesperado, nesses casos, pode provocar experiências em que o sujeito se vê diante de um insuportável, impossível de simbolizar. Em psicanálise, esse momento pode ser atribuído ao conceito de urgência subjetiva. Diante disso, o presente artigo procurou discutir de que maneira a mulher em situação de emergência obstétrica de alto risco pode ser afetada pela experiência da urgência subjetiva e quais desdobramentos diante desse encontro. Propomo-nos a compreender o conceito de urgência subjetiva à luz da teoria psicanalítica e identificar seus entrelaçamentos com a emergência obstétrica de alto risco. Trata-se de uma pesquisa teórica em psicanálise, qualitativa e exploratória, realizada a partir de seleção bibliográfica. A análise dos dados encontrados consistiu na identificação e discussão de conceitos que se entrelaçam com a urgência subjetiva, na tentativa de pensar essa conexão em situações de emergência obstétrica de alto risco. A literatura evidenciou que a urgência subjetiva está associada a um momento de crise, indicando uma ruptura na dimensão discursiva, expondo o sujeito ao real avassalador e desordenado, de modo que angústia, trauma e tempo foram identificados como alguns dos conceitos entrelaçados à urgência subjetiva. No que concerne às situações de emergência obstétrica de alto risco, elementos como perdas, acontecimentos inesperados e rupturas podem indicar a possibilidade de inscrição da urgência subjetiva. No entanto, evidenciou-se que, por vezes, esses acontecimentos são tratados pela via do imediatismo, impossibilitando ao sujeito ressignificar sua experiência. Assim, atenta-se para que, diante do caos instaurado nesses ambientes, dê-se lugar para uma pausa, a fim de resgatar a cadeia discursiva, anteriormente diluída, e o sujeito possa vir a se reorganizar.

The gestational period may follow emergency complications and may cause imminent death threat to maternal and/or fetal life, contributing to the increased mortality rate in this population. Facing the unexpected, in these cases, can provoke experiences in which the subject faces an unbearable moment, impossible to symbolize. In psychoanalysis, this moment can be attributed to the concept of subjective urgency. Given this, the present article seeks to discuss how women in high-risk obstetric emergencies may be affected by the experience of subjective urgency and the consequences of this meeting. We propose to understand the concept of subjective urgency in the light of psychoanalytic theory and to identify its intertwining with the high-risk obstetric emergency. This is theoretical research in psychoanalysis, qualitative and exploratory, conducted from a bibliographical selection. The analysis of the data found consisted of the identification and discussion of concepts that intertwine with subjective urgency, in an attempt to think about this connection in high-risk obstetric emergencies. The literature showed that subjective urgency is associated with a moment of crisis, indicating a rupture in the discursive dimension, exposing the subject to the overwhelming and disordered real, so that anguish, trauma and time were identified as some of the concepts intertwined with subjective urgency. Concerning high-risk obstetric emergencies, elements such as losses, unexpected events and disruptions may indicate the possibility of subjective urgency being inscribed. However, it was evidenced that, sometimes, these events are treated by the immediacy, making it impossible for the subject to redefine his experience. Thus, it is taken care that, in the face of the chaos established in these environments, a pause will be given to rescue the previously diluted discursive chain and the subject may reorganize it.

El periodo gestacional puede venir acompañado de complicaciones de emergencia, que pueden ocasionar inminente amenaza de muerte materna y/o fetal, contribuyendo para la creciente tasa de mortandad en esa población. El encuentro con el inesperado, en estos casos, puede provocar experiencias en que el sujeto se encuentra ante un insoportable, imposible de simbolizar. En psicoanálisis, ese momento puede ser atribuido al concepto de urgencia subjetiva. Ante eso, el presente trabajo buscó discutir de que manera la mujer en situación de emergencia obstétrica de alto riesgo puede ser afectada por la experiencia de la urgencia subjetiva y cuales desdoblamientos ante este encuentro. Nos propusimos comprender el concepto de urgencia subjetiva a la luz de la teoría psicoanalítica e identificar su trama con la emergencia obstétrica de alto riesgo. Esta es una investigación teórica en psicoanálisis, cualitativa y de exploración, realizada a partir de selección bibliográfica. El análisis de los datos encontrados constituyó en la identificación y discusión de conceptos que se unen con la urgencia subjetiva, en el intento de pensar esa conexión en situaciones de emergencia obstétrica de alto riesgo. La literatura puso evidente que la urgencia subjetiva está asociada a un momento de crisis, indicando una rotura en la dimensión discursiva, exponiendo el sujeto al real abrumador y desordenado, de modo que angustia, trauma y tiempo fueron identificados como algunos de los conceptos unidos a la urgencia subjetiva. A lo que se refiere a las situaciones de emergencia obstétrica de alto riesgo, elementos como pérdidas, sucesos inesperados y roturas pueden indicar la posibilidad de inscripción de la urgencia subjetiva. Sin embargo, se evidenció que, por veces, estos sucesos son tratados por la vía del inmediatismo, imposibilitando al sujeto re-significar su experiencia. De este modo, se cuida para que, ante el caos establecido en estos ambientes, haya espacio para una pausa, con el objetivo de rescatar la cadena discursiva, anteriormente diluida, y el sujeto pueda reordenarse.

La période de gestation peut être accompagnée de complications d'urgence et peut entraîner une menace de mort imminente pour la vie maternelle et / ou fœtale. Cela contribue à l'augmentation du taux de mortalité dans cette population. La rencontre avec l'inattendu, dans ces cas, peut provoquer des expériences dans lesquelles le sujet est facé à l'insupportable, impossible à symboliser. Chez la psychanalyse, ce moment peut être attribué au concept d'urgence subjective. Devant cela, le présent article a eu comme objectif de discuter de la manière dont les femmes dans des situations d'urgence obstétricale à haut risque peuvent être affectées par l'expérience de l'urgence subjective et par les conséquences de cette réunion. Nous proposons de comprendre le concept d'urgence subjective à la lumière de la théorie psychanalytique et d'identifier son imbrication dans l'urgence obstétricale à haut risque. Il s'agit d'une recherche théorique en psychanalyse, qualitative et exploratoire, réalisée à partir d'une sélection bibliographique. L'analyse des données trouvées a consisté à identifier et à examiner des concepts qui se mêlent à l'urgence subjective, dans le but de réfléchir à cette relation dans les situations d'urgence obstétricale à haut risque. La littérature a montré que l'urgence subjective est associée à un moment de crise, indiquant une rupture dans la dimension discursive, exposant le sujet à un réel écrasant et désordonné, de sorte que l'angoisse, le traumatisme et le temps soient identifiés comme des concepts entrelacés avec l'urgence subjective. En ce qui concerne les situations d'urgence obstétricale à haut risque, des éléments tels que des pertes, des événements imprévus et des ruptures peuvent indiquer la possibilité d'une inscription de l'urgence subjective. Cependant, il a été démontré que, parfois, ces événements sont traités de manière immédiate, ce qui rende impossible pour le sujet de re-signifier son propre expérience. Ainsi, on fait attention au fait que, face au chaos établi dans ces environnements, une pause soit accordée pour reprendre la chaîne discursive, précédemment diluée, et le sujet peut, donc, se réorganiser.

Emergency obstetric hysterectomy: experience at a tertiary care centre in Central India

Background: Obstetric hysterectomy is an important procedure in modern obstetrics and its proper indications, risks and complications need to be studied for judicious usage and improvement in outcome.Methods: A retrospective, record-based study was carried out over one and a half years at a tertiary care government hospital. All the patients who underwent emergency obstetric hysterectomy at the study centre during study period were studied. Labour room register, operation room register for emergency and elective cases, case records, referral slips and mortality register data were reviewed for the same and outcomes analysed.Results: Total 33 patients underwent emergency obstetric hysterectomy, with the incidence observed at 0.21%. The most common indications were atonic post-partum hemorrhage (42.4%), uterine rupture (33.3%) and morbidly adherent placenta (18.1%). Prior cesarean section (36.4%) and placenta previa (15.1%) were the commonest predisposing factors associated with PPH and uterine rupture. Subtotal hysterectomy (66.7%) was observed to be the preferred type of surgery. Out of total 7 maternal deaths that occurred, 4 (57%) were because of disseminated intravascular coagulation.Conclusions: There is increasing trend in the rate of obstetric hysterectomy along with rise in rate of previous LSCS, emphasizing the importance of the mode of delivery. Measures to reduce the rate of primary cesarean section are advisable.

Embolização de artéria uterina para hemorragia pós-parto: uma revisão de literatura / Uterine artery embolization for postpartum hemorrhage: a review of the literature

A hemorragia pós-parto é uma emergência obstétrica que acomete grande parcela de puérperas e leva à extensa quantidade de óbitos por ano. Entre as suas principais causas estão a atonia uterina e o acretismo placentário. Atualmente, as técnicas mais utilizadas para a resolução do sangramento se apresentam por muitas vezes ineficazes e/ou levam à infertilidade feminina. O presente estudo trata-se de uma revisão da literatura em modelo PRISMA, no qual foram selecionados 35 artigos dos últimos 12 anos, nas bases de dados do UpToDate, SciELO, PubMed, Plos ONE, Lilacs e Datasus, no qual serão apresentadas evidências de que, nas mãos de um profissional treinado, a embolização de artéria uterina se mostra como uma excelente alternativa no tratamento da hemorragia obstétrica, apresentando-se como terapêutica minimamente invasiva, com altas taxas de sucesso, baixo número de complicações e que preserva a função reprodutiva da mulher.(AU)

The post-partum hemorrhage is an obstetric emergency that affects a big percentage of women who have recently given birth and leads to a big amount of deaths per year. Its main causes are uterine atony and placentary accretism. Currently the main techniques for its resolution are the utilization of uterotonics and aggressive surgical approaches to the pelvic structure, which are commonly inefficient or bring long term injuries to the fertility. This study is a literature review structure on PRISMA model, where was selected 35 articles of the last 12 years, in these databases: UpToDate, SciELO, PubMed, Plos ONE, Lilacs and Datasus, in which will be presented evidences of, in expert professional hands, uterine artery embolization being an excellent alternative in the treatment of obstetric hemorrhage, presenting itself a minimally invasive technique, with high rates of success, low numbers of complications and the capacity of preserving the patient reproductive system.(AU)

Maternal mortality / Mortalidad materna

The maternal mortality ratio (MMR) for each population is an indicator of medical and surgical quality control. The World Health Organization has committed to decreasing maternal mortality worldwide. Access to care remains an important facet of improving overall health of populations. Quality control and excellent communications among health care providers is equally important. Standardization of obstetric emergency protocols will further decrease maternal mortality.

La razón de mortalidad materna (RMM) representa un control de calidad médico y quirúrgico para cada población. La Organización Mundial de la Salud se ha propuesto disminuir la mortalidad maternal en el mundo. El acceso al cuidado médico sigue siendo una faceta importante para mejorar la salud poblacional. Es igualmente importante el control de la calidad y la excelente comunicación entre los profesionales de la salud. La estandarización de los protocolos de emergencia obstétrica permitirá una mayor disminución de la mortalidad materna.

Amniotic fluid embolism: historical perspective, pathophysiology and clinical management / Embolia de líquido amniótico: perspectiva histórica , fisiopatología y manejo clínico

Amniotic fluid embolism (hereafter, AFE) is a uniformly devastating event that is both unpredictable and unpreventable. Despite having been first described nearly 80 years ago, it remains a significant cause of maternal mortality worldwide. AFE is characterized by the triad of sudden hypoxia and hypotension, followed in most cases by coagulopathy. The diagnosis of AFE is clinical and prompt recognition and multi-disciplinary intervention essential. This paper seeks to review the history, pathophysiology, potential risk factors, strategies for identification and management, and outcomes of this unfortunate and storied obstetric emergency.

La embolia de líquido amniótico (ELA) es una ocurrencia devastadora, impredecible y no prevenible. A pesar de haber sido descrita por primera vez hace casi 80 años, todavía es causa significativa de mortalidad materna en el mundo. La ELA se caracteriza por la triada consistente en hipoxia súbita e hipotensión, seguida en la mayoría de casos por coagulopatía. El diagnóstico de la ELA es clínico, y es esencial su pronto reconocimiento y la intervención multidisciplinaria. Este artículo trata de revisar la historia, fisiopatología, factores de riesgo potenciales, estrategias para su identificación y manejo, así como los resultados de esta desafortunada y antigua emergencia obstétrica.

Effect of Socio-demographic Characteristics on Obstetric Care-seeking Behaviours and Perinatal Outcome in Sagamu, Nigeria.

Background: The persistence of severe intra-partum events as causes of perinatal mortality may be due to the poor care pregnant women receive in labour. The quality and scope of care received in labour varies with the types of health facilities patronized. Objective: To describe the obstetric care-seeking behaviours of pregnant women in Sagamu, Nigeria and relate this to the perinatal outcome. Methods: A cross-sectional survey of parturient at Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, Nigeria was conducted between August 2013 and November 2014. Data were obtained on the demographic and obstetric profile, details of facilities visited during labour and perinatal outcome for analysis. Results: Out of 145 women, 93 (64.1%) received antenatal care at OOUTH. Of the 84 women who were first admitted in labour, 32 (38.1%) presented with emergencies. There were 140 live births and 10 still births; 34/140 (24.3%) of the live births were hospitalized mostly with asphyxia (13/34; 38.2%). One of the 34 hospitalized babies died from asphyxia thus the overall perinatal mortality rate was 73.3/1000 births. Women who presented with emergencies during labour and traversed other health facilities while in labour characteristically had low maternal education, low socioeconomic status and received antenatal care outside OOUTH. Poor perinatal outcome was significantly associated with unbooked status, presentation with emergencies during labour and traversing other health facilities in labour. Conclusion: Quality antenatal care and timely presentation during labour may influence perinatal outcome positively. Research should be focused on strengthening the existing health care structure.