A study of primary cesarean section-its rate, indications, and complications in a tertiary healthcare in Sikkim

Background: The indication of performing lower uterine section caesarean section has been changing a lot in recent year and they are expected to go on changing on basis of continuing trials. Aims and Objectives: The aims to study are to assess rate, frequency along with complications of primary cesarean section. Along with to study the incidence and indications of primary cesarean section and causes maternal as well as fetal morbidity and mortality in these cases. Materials and Methods: This prospective study included all pregnant women after 28 weeks period of gestation who underwent caesarean section for the 1st time between December 2016 and June 2018 at Central Referral Hospital of Sikkim Manipal Institute of Medical Sciences (SMIMS), Gangtok, Sikkim – India. Over a period of 1.5 years, 750 women at Central Referral Hospital, SMIMS, Sikkim, India, underwent primary cesarean section. Results: The percentage of primary lower uterine section cesarean section was 27.38% and total cesarean section rate was found to be 49.59% which is far more than the expected rate of 15% as proposed by the world health organization. Elective lower uterine section cesarean section was done in 341 cases (45.47%) and emergency lower uterine section caesarean section was done in 409 cases (54.53%). Patient’s desire was the most frequent indication for elective lower uterine section cesarean section (38.40%). Conclusions: There is tremendous rise in rate of primary cesarean section with patient’s request being the most common indication of elective lower uterine section cesarean section.

Vacuum Devices for Treating Postpartum Hemorrhage: Indian Innovation, Indian Pride

Postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. We focus on two innovations by Indian gynecologists, the Panicker’s vacuum suction cannula and the SR suction cannula. These effective devices are economical and easy-to-use, and help prevent and manage PPH. They can also be used to reduce bleeding in non-PPH indications. These Indian innovations are a matter of pride, and need to be studied extensively in diverse settings. This will help ensure that their benefits can be shared across the world.

RETROSPECTIVE ANALYSIS OF COVID-19 POSITIVE PARTURIENTS POSTED FOR CAESAREAN SECTION IN TERTIARY CARE CENTRE

Background And Aims: Parturients posted for LSCS present with physiological changes due to pregnancy and gravid uterus, may have associated co-morbidities, superadded by COVID 19 infection poses a real challenge for an anesthesiologist. Urgency in obstetric anesthesia and extreme precautions needed to avoid this contagious disease further increase the burden on the anesthesiologist. This study focuses on perioperative presentation, management, and outcome of patients in a tertiary level hospital. Method: 329 pregnant females with RAT or RTPCR positive for COVID 19 and undergoing cesarean section from 1st May 2020 to 31st July 2021 were included in this retrospective observational study. Data was collected and analyzed from OT, ICU, WARD records, patient medical and electronic records, and maternal mortality data. Results: Amongst 329 parturients, 98.48%(324/329) received spinal anesthesia, one received epidural anesthesia (0.30%) and 1.21%(4/329) required general anesthesia. The incidence of hypotension was 5.77% (19/329), managed with inj. Mephentermine without inotropes. The intraoperative course was uneventful except for one case of CRA, revived successfully. Nine patients (2.73%) required ICU care. Oxygen support by either nasal prongs or face masks was given to 3.95% (13/329) patients. Three patients (0.91%) required NIV support and three patients (0.91%) required invasive ventilation postoperatively.The overall mortality was 0.61% (2/329). The mean duration of hospital stay was found to be 8.2 ± 5.03 days Conclusion: Neuraxial anesthesia remains a technique of choice for LSCS and can be safely employed in the parturients even with moderate pneumonia. General anesthesia can be reserved for patients of severe covid pneumonia

Previous two lower segment caesarean section with placenta previa and placenta accreta woman with COVID-19 suspect: case report

A pregnant woman with gravida 3, para 2, living 2 and gestational age of 37 weeks and 3 days was referred to a zonal hospital as previous two lower segment caesarean section (LSCS) term pregnancy with placenta previa for safe confinement with complaints of dry cough. She was admitted with a diagnosis of COVID-19 suspect. During her hospitalization, oxygen (O2) saturation was normal. On investigations her counts were normal. Patient was planned for elective LSCS. COVID-19 test i.e. real time-polymerase chain reaction (RTPCR) report was suspect and asked for repeat sampling. During elective LSCS, delivered single live female baby with intra operative findings of placenta previa with adherent placenta and permpartum hysterectomy was done for same. Uterus with placenta was sent for histopathological examination (HPE). During the surgery her oxygen concentration was normal. Her postoperative recovery was uneventful.

Comparison of the efficacy, safety, acceptability and fetomaternal outcomes of combination of mifepristone and foley’s catheter with foley’s catheter alone in induction of labour in term pregnancies with previous lower segment caesarean section

Background: Objective of the study was to compare the efficacy, safety, acceptability, fetomaternal outcomes of combination of mifepristone and Foley’s catheter with Foley’s catheter alone in induction of labor in term pregnancies with previous Lower segment caesarean section (LSCS).Methods: This was a prospective study of 36 women induced with mifepristone and foley’s catheter and 36 women induced with foley’s catheter alone at 37 weeks to 41+6 weeks with previous LSCS.Results: Mean bishop score on admission in combined group (2.44) was comparable with that of foley’s alone group (2.91, p=0.888). Mean Bishop score (BS) after foley’s expulsion in group A and group B was 7.46 and 6.33 respectively, which was statistically significant (p<0.001). In group A 69.5% of women delivered vaginally compared to 52.2% in group B which was comparable (p=0.230). Mean induction to delivery interval was significantly short in combination group (15.5±1.3 hours versus 20.8±1.07 hours, p=0.003). 50% women in group A required oxytocin for induction/ augmentation of labour as compared to 77.8% in group B (p=0.02). Failed induction was statistically higher in group B (p<0.05). No difference was found with regards scar dehiscence, scar rupture, Postpartum hemorrhage (PPH), wound infection, puerperal pyrexia, Meconium stained liquor (MSL), fetal distress, mean birth weight, 1 and 5 minutes Appearance, pulse, grimace, activity, and respiration (APGAR) score, neonatal outcome, hospital stay.Conclusions: Priming with mifepristone before insertion of foley’s catheter results in significant change in BS signifying that combination promotes early cervical ripening as compared to foley’s catheter alone. Mifepristone plays significant role in cervical ripening, reduces induction to delivery interval, oxytocin requirement and failed induction.

The inevitable and incidental caesarian myomectomy

The management of fibroid encountered during caesarean remains controversial. The traditional approach has always been, not to perform myomectomy, because of the fear of haemorrhage due to increased vascularity and uterine atonicity of pregnant uterus and increased morbidity. Caesarean section was performed in 27-year G2P1 in view of previous LSCS, short inter-conception period, frank leaking and poor bishop score. After delivery of baby a fibroid of 6 cm by 5 cm was seen jutting out of left side of incision line. Myomectomy was performed, without any complication, as it was not possible to approximate the incision line without that. No excessive hemorrhage or postoperative complications were encountered.

Decision to delivery interval in emergency LSCS and its impact on fetal outcome

Background: Emergency LSCS can be categorized based on RCOG guidelines into category I and II which indicates maternal or fetal compromise. Here an urgent delivery and the DDI (decision to delivery interval) within 30 and 45 minutes respectively is needed.Methods: This is a retrospective cross-sectional analysis conducted on a sample of 630 patients who underwent caesarean section over a year, from June 2016 to June 2017. The DDI were further classified into ≤30 and >30 minutes for category I, ≤45 and >45 minutes for category II LSCS. The primary objective is to determine whether DDI in Category I and II emergency LSCS has an impact on fetal outcome and secondary objective is to ensure that DDI is within the standard criterion as per RCOG protocol.Results: Out of 630 samples of caesareans, it was found that 173 falls in Category I and 189 falls in Category II. Out of 87 (50.29%) patients delivered within 30 minutes in Category I, 29 babies required NICU admission. DDI was more than 30 minutes in 86 (49.71%) cases in Category I out of which 38 babies got admitted in NICU with low APGAR scores. Out of 176 (93.12%) patients who delivered within 45 minutes in Category II, 56 babies required NICU admission. DDI was more than 45 minutes in 13 (6.88%) cases in Category II and all these babies got admitted in NICU.Conclusions: Decision -delivery interval has a significant impact on fetal outcome.

A clinical study of maternal outcome in post dated pregnancy in a tertiary care hospital

Background: Pregnancy lasting beyond 40 weeks is a known complication of normal delivery. Studies have found incidence between 2-14%. Post-dated pregnancy carries specific hazards to both mother and fetus. While mothers are faced with problems like increased incidences of induced labour, instrumental delivery and LSCS with associated morbidities, fetuses are faced with morbidities ranging from IUGR to macrosomia. We here tried to study maternal outcome in post-dated pregnancy. The objective is to study maternal outcome in post-dated pregnancy and to compare maternal outcome in spontaneous versus induced labour in post-dated pregnancy.Methods: This study was done at a tertiary care hospital in obstetrics and gynecology department for duration of 18 months. After screening according to inclusion criteria, all patients who were admitted in labour wards were grouped in two groups according to clinical examination. First group consists of patients with spontaneous onset of labour and second group consists of patients with induction of labour. In each group same protocol for fetal monitoring were performed, and labor monitored according to standard partograph. Maternal outcomes in both groups were studied.Results: Maternal outcomes were nearly same in both groups; induced and spontaneous onset of labour, except rate of LSCS, Which was more in induced group though not statistically significant.Conclusions: Women with uncomplicated post dated pregnancies with good bishop score should be allowed spontaneous labour and those with poor bishop should be offered induction of labour, while women with any complicating factors LSCS should be considered.

Epidural Anaesthesia a Saviour in a Case of Mitral Stenosis Posted For Emergency LSCS

It is challenging for an Anaesthesiologist to provide correct anaesthesia technique to a patient with Mitral Stenosis posted for Emergency LSCS. In the presence of maternal heart disease, the circulatory changes of pregnancy may result in exacerbation of the hemodynamic changes leading to maternal and fetal morbididty and mortality. We report the successful anaesthetic management with graded epidural technique which minimises the hemodyanamic perturbations. Successful management requires proper perioperative monitoring and thorough knowledge of the valvular heart disease.

Anaesthesia in a Patient Undergoing LSCS with Peripartum Cardiomyopathy- A Case Report

Peri-partum cardiomyopathy(PPCM) is an idiopathic cardiomyopathy presented as heart failure due to left ventricular systolic dysfunction towards the end of pregnancy or in the months after delivery when no other cause of heart failure. In this case report we will discuss the anesthetic mangament in a patient with PPCM posted for LSCS. The anaesthesic goal is to maintain Cardiac output with minimal effect on prelaoad and afterload. No complications were observed.

Prospective, non-randomized, parallel group, comparative observational study to compare maternal and neonatal outcome after regional and general anesthesia for Lower Segment Caesarean Section

Background: LSCS is a routine obstetric procedure performed under general anesthesia (GA) or regional anesthesia (RA). Choice of anesthesia depends on factors like gestational age, parity, co-morbidities, urgency of situation, etc. Both GA and RA involve the use of various medications which may influence maternal and neonatal outcome. As there are few studies comparing maternal and fetal outcome in RA and GA for LSCS in Indian population, the present study was taken up. Objectives of the study was to compare the maternal and neonatal outcome after RA and GA for LSCS.Methods: 60 subjects with indications for LSCS were assigned non-randomly into two groups, 30 for GA and 30 for RA, at the discretion of anesthesiologist. The demographic, anthropometric and clinical data was recorded for all subjects. The maternal outcome after RA and GA for LSCS was assessed by parameters like maternal blood loss, postoperative pain, postoperative nausea and vomiting, maternal satisfaction and neonatal outcome by parameters like birth weight, APGAR scores and NICU admissions. The maternal and neonatal outcome between the two groups was compared.Results: All subjects had clear indications for CS. In most of the subjects it was undertaken as an emergency procedure. GA was preferred in high risk subjects. Maternal blood loss, postoperative pain, NICU admissions, need for resuscitation was less under RA compared to GA. There was no difference in PONV, maternal satisfaction, birth weight and need for intubation.Conclusions: LSCS under RA showed a more favourable maternal and neonatal outcome.

A prospective study of maternal and fetal outcome in repeat LSCS mother

Background: Cesarean section is one of the most commonly performed abdominal operations on women in most countries. The incidence of primary LSCS is increasing all over the world, Consequently, there is a rise in multiple repeat LSCS with associated complications. Previous LSCS is a common indication for repeat LSCS. Primarily, authors aim at studying the influence of repeat LSCS on maternal and fetal outcome in a tertiary centre.Methods: All mothers with one previous LSCS admitted for emergency/elective LSCS at term gestation with singleton pregnancy in A.J. Institute of Medical Sciences and Research centre, Mangalore were recruited in the study from July to December 2018. Detailed history with antenatal risk factors were noted. Intraoperative and postoperative events were noted. Neonatal outcome was also noted correlated.Results: Majority of patients (58%) were in age group of 20-24years. Most of them were between 38 to 39 weeks of gestation. Most common intraoperative complication was bladder adhesion (18% of cases). In postoperative period febrile morbidity (7%) was common followed by urinary tract infection (2%). Most of the neonates (80%) weighed 2.5 to 3kg at birth. The incidence of poor APGAR respiratory distress, NICU admission was not significantly increased. There were 5 morbidly adherent placenta, 1 scar rupture, 4 scar dehiscence, no maternal or perinatal death.Conclusions: Previous caesarean is the most common cause of repeat caesarean and is associated with maternal morbidity. Measures should be taken to reduce primary caesarean sections which indirectly reduces the incidence of repeat cesarean sections.

Comparative study of maternal and perinatal outcome in pregnancies with and without umbilical cord around foetal neck

Background: Umbilical cord around neck of the foetus is called the nuchal cord. The aims and objectives are to find out the incidence of nuchal cord around foetal neck at delivery, and to compare and evaluate intrapartum and postpartum maternal and foetal outcome in those with or without nuchal cord at delivery.Methods: It is a prospective cross-sectional study conducted at tertiary care hospital for period of 12 months. Of 1380 patients, 934 patients were enrolled in present study after meeting the inclusion and exclusion criteria of which 150 patients were included in study group who delivered with nuchal cord and 784 patients in control group who delivered without nuchal cord.Results: Present study showed 18.84% incidence of nuchal cord at delivery. Duration of labour was 6.51hrs in study group and 6.15hrs in control group and the difference was statistically significant. Rest of the intrapartum and postpartum events were statistically not significant. Mean length of cord was more in patients delivered with loop of cord around foetal neck as compared to another group and it is statistically significant.Conclusions: Nuchal cord is a common finding at the time of delivery. However, it is per-se not an indication of LSCS and it only increases the operative morbidity.

Management of cervical heterotopic pregnancy with inevitable miscarriage

The objective is to report a case of successful treatment of heterotopic cervical pregnancy resulting from IVF–ICSI conception. Case report from Amrita Institute of Medical sciences: a tertiary care referral hospital. A 47-year-old Primigravida, diagnosed with heterotopic cervical pregnancy at 6 weeks of gestation, presented with significant first trimester vaginal bleeding. Under IV sedation, Transvaginal ligation of descending cervical branches of the uterine arteries arrested the bleeding. The cervical pregnancy was successfully aborted with minimal bleeding and the intrauterine pregnancy was successfully maintained till 32 weeks, after which she required emergency preterm LSCS in view of Severe preeclampsia superimposed on chronic hypertension a non-reassuring non-stress test (NST). The intervention applied maybe used in treatment of heterotopic cervical pregnancy in a low resource setting to control the bleeding.

Maternal outcome in term premature rupture of membranes

Background: Rupture of Fetal membranes before the onset of labour is called PROM. Premature rupture of membrane (PROM) is associated with various complications. The present study is undertaken to study the maternal morbidity in term PROM.Methods: A prospective cross-sectional study was conducted at Vijaynagar institute of medical science Ballari for a period of one year by Department of Obstetrics and Gynecology from November 2016 to October 2017.  120 cases of spontaneous rupture of membranes with term gestation with confirmed PROM were selected.Results: PROM was common in age group of 20-29 years (80%), and common in primigravida. Study showed majority of them belongs to low socioeconomic status (80%) , 13.33% belonged  to middle socioeconomic status and 6.66% belonged to higher socioeconomic status. In present study, it is observed that 27.05% cases  went  into  spontaneous labour and delivered normally, 56.50% cases delivered by induction and  20% cases  were delivered by LSCS. The rate of maternal morbidity was 16.6%,  which includes febrile morbidity accounting to maximum with 9.6% followed by wound infection 3.33% and others were PPH(1.66%)and puerperal sepsis (each 1.66%).Conclusions: The rate of maternal morbidity was 16.6% and no maternal death observed. Hence an appropriate and accurate diagnosis of PROM is essential for favorable outcome in pregnancy and reduces the maternal morbidity.

Primary lower segment caesarean section in multipara: materno-fetal outcomes

Background: All-natural birth has a purpose and a plan; who would think of tearing open the chrysalis as the butterfly is emerging? Who would break the shell to pull the chick out?” ~ Marie Mongon. It is of particular interest, in light of increased incidence of abdominal delivery throughout the country and in the world, to judge the validity of this procedure when used for the first time in the multipara.Methods: All the cases of Primary caesarean delivery in multipara over a period of 18 months were studied with regards to the indication, associated risks factors, and perinatal morbidity and mortality. The primary objective of the study was to find out the status of primary Lower Segment Caesarean Section (LSCS) in multipara in tertiary care center.Results: The overall incidence of LSCS was 30.7%. The incidence of Primary LSCS in multipara was 23.4%. The most common indication of LSCS was Foetal Distress i.e. 40.8%. Almost all caesarean sections were done in Emergency (99.2%). 12.3% of patients underwent PPH intra-operatively with 0.7% patient requiring Obstetric hysterectomy. Majority of the neonates were admitted in NICU for Respiratory Distress (30%). Major cause of Post-operative morbidity was wound gape seen in 10.8% patients.Conclusions: The fact that a multipara has had one or more vaginal deliveries should be regarded as an optimistic historical fact, not as diagnostic criteria for spontaneous delivery of the pregnancy at hand. Hence a multiparous woman in labour requires the same attention as that of primigravida and may still require a caesarean section for safe delivery. Good antenatal and intrapartum care and early referral will help reduce the maternal and perinatal morbidity.

Elective caesarean section and neonatal outcome: an observational study from a tertiary hospital in Mysore, Karnataka, India

Background: Globally 18.6 percent of all births occur by Caesarean Section (CS) and the trend is increasing. In India CS rates have risen from 2.9% in 1992 to 17.2% in 2015. The optimal timing of CS is still being investigated. Data with regard to elective CS and neonatal outcome from India is sparse and this study aimed to obtain the same in the setting of a South Indian Hospital. The objective was to evaluate neonatal outcome and NICU admissions in elective CSMethods: This was a retrospective study conducted at a tertiary care referral hospital and data collected was of deliveries conducted from Jan 2017 to July 2018. All term singleton pregnancies (>37 gestational weeks) scheduled for elective CS were included in the study.Results: A total of 3174 Caesarean Sections were performed during the study period of which 1087 were elective CS and 2087 were done on an emergent basis. Of these elective CS, 425 (39%) were performed at early term (37+0 until 38+6) and 662 (61%) were performed at full term (>39 weeks). Analysis of adverse neonatal outcomes revealed that a significantly higher rate of NICU admission, low birth weight, respiratory complications in newborns delivered at early term than in those delivered at full term.Conclusions: In the present study newborns delivered at 37- 38 weeks of gestation had a higher rate of NICU admission, low birth weight and respiratory complications compared to newborns delivered after 39 weeks of gestation. Neonatal outcome was found to be better in those elective CS done after 39 weeks in comparison to those delivered at early term (< 39 weeks).

Ginsenoside Rg_1 induces leukemia stem cell senescence via SIRT1/TSC_2 signal axis / 中国中药杂志

The aim of this paper was to investigate the effect of SIRT1/TSC_2 signal axis on leukemia stem cell senescence induced by ginsenoside Rg_1. CD34~+CD38~- leukemia stem cells(CD34~+CD38~-LSCs) was isolated by magnetic cell sorting(MACS) and divided into two groups. The control group cells were routinely cultured, 40 μmol·L~(-1) ginsenoside Rg_1 was added to the control group for co-culture in Rg_1 group. The effect of Rg_l to induce CD34~+CD38~-LSCs senescence were evaluated by senescence-associated β-Galactosidase(SA-β-Gal) staining, cell cycle assay, CCK-8 and Colony-Assay. The expression of senescence associated SIRT1, TSC_2 mRNA and protein was examined by Real-time fluorescence quantitative PCR(FQ-PCR) and Western blot. The results showed that the CD34~+CD38~-LSCs could effectively be isolated by MACS, and the purity of CD34~+CD38~-LSCs is up to(95.86±3.04)%. Compared with the control group, the percentage of positive cells expressed SA-β-Gal in the Rg_1 group is increased, the senescence morphological changes were observed in the CD34~+CD38~-LSCs in the Rg_1 group. The proliferation inhibition rate and the number of cells entered G_0/G_1 phase in the Rg_1 group were increased, but the colony-formed ability was decreased, Rg_1 could significantly inhibit the proliferation and self-renewal ability of CD34~+CD38~-LSCs. The expression of SIRT1 and TSC_2 mRNA and protein were down regulated in the Rg_1 group compared with the control group. Our research implied that Rg_1 may induce the senescence of CD34~+CD38~-LSCs and SIRT1/TSC_2 signal axis plays a significant role in this process.

A Comparative Study Of Combined Spinal Epidural Anaesthesia Versus Epidural Anaesthesia For Elective Caesarean Section

Background and aims This study was done to compare the efficacy of combined spinal epidural(CSEA) anaesthesia with epidural anaesthesia based on the parameters such as onset time,quality of intraoperative analgesia, quality of motor blockade,incidence of hypotension and total local anaesthetic dose requirement Materials and methods– 50 patients undergoing elective LSCS were divided into two groups of 25 each .One group received combined spinal epidural anaesthesia(CSE). The other group received epidural anaesthesia.The combined spinal epidural (CSE) group received 1 ml of 0.5% hyperbaric bupivacaine intrathecally followed by 10 ml of 0.5% plain bupivacaine with adrenaline 5mcg/ml (1 in 2,00,000) epidurally. The epidural group patients received 16 ml of 0.5% plain bupivacaine with adrenaline epidurally. Study parameters were noted. Observation and results In CSE group 72% achieved complete anaesthesia ,while in epidural group only 40% achieved complete anaesthesia which is statistically significant.(p<0.05)Complete motor blockade was achieved in 68% in CSE group and 36% in Epidural group.Incidence of hypotension was similar in both groups.Mean local anaesthetic dose was 55 mg in CSE group compared to 86mg in the epidural group which was statistically significant. Conclusion Combined spinal epidural anaesthesia offers rapid onset of intense neuraxial blockade, better muscle relaxation, better intraoperative analgesia and decrease in the total requirement of local anaesthetic dose when compared with epidural anaesthesia in elective caesarean section.

Perinatal and Maternal Outcome in Pregnant Women with Polyhydramnios: A Hospital Based Study

Background: Polyhydramnios is the term for abnormal increase in the amniotic fluid. It has been shown that AFI is quite reliable in determining normal or elevated volumes. The aim of this study to evaluated the perinatal and maternal outcome in pregnant women with polyhydramnios. Material & Methods: This analytical study was conducted on 300 unselected pregnancies attending in Mahatma Gandhi Hospital, Bhilwara, Rajasthan. Most of the cases of polyhydramnios were admitted in the hospital till they delivered, other patients were followed up as outpatient and they were admitted to the hospital for delivery. Pregnancy outcome were recorded for the patients who were classified as having an excess amount of amniotic fluid. Results: In our study showed that out 0f 300 patients, 168 (56%) were in the age group of 21-25 yrs, 62.3% cases were multigravida in our study. In our study 73% of the cases were delivered vaginally. Out of which 15% were induced and 58% were delivered spontaneously. 27% of the cases were delivered by LSCS, out of which 16% were emergency LSCS and 11% were elective LSCS. In our study there were many perinatal complications. Out of them preterm birth was the most common complication. Conclusion: The conclusion of this prospective study was occurrence of polyhydramnios is directly related to advanced maternal age with multigravida. Caesarean section as a mode of delivery was found to be higher in cases of polyhydramnios.