Saturday 30 April 2016
Sunday 24 April 2016
Successful Case of cesarian myomectomy
Rajshree Dayanand Katke
Department of Obstetrics & Gynaecology, Grant Government Medical College & Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
Succsessful Operated Myomectomy during Caserain Section
- A case of Transverse Lie in Labour
- Huge Myomas (Two) at Incision Site and Lower Segment.
For Video Link
https://www.youtube.com/watch?v=p4lE1MKckkM
Tuesday 19 April 2016
Prediction of outcome of tubal ectopic pregnancy on the basis of site of implantation of embryo in the fallopian tube
Rajshree Dayanand Katke
Department of Obstetrics & Gynaecology, Grant Government Medical College & Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
Received: 06 August 2015
Revised: 09 September 2015
Accepted: 12 September 2015
DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20150725
*Correspondence:
Dr. Rajshree D. Katke,
E-mail: drrajshrikatke@gmail.com
For Article Link
https://www.researchgate.net/publication/282246877
Correlation of site of ectopic pregnancy with the outcome of pregnancy.
Department of Obstetrics & Gynaecology, Grant Government Medical College & Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
Received: 06 August 2015
Revised: 09 September 2015
Accepted: 12 September 2015
DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20150725
*Correspondence:
Dr. Rajshree D. Katke,
E-mail: drrajshrikatke@gmail.com
For Article Link
https://www.researchgate.net/publication/282246877
Prediction of outcome of tubal ectopic pregnancy on the basis of site of implantation of embryo in the fallopian tube
ABSTRACT
Background: Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy.
Methods: This study was an observational analytical type of study in which all the diagnosed cases of tubal ectopic were included. Detailed history and clinical evaluation was done and information was collected in a pre-tested proforma. Data was analyzed by frequency, percentages and chi square test.
Results: In this study total 50 cases were studied. In this we found a significant correlation between site of implantation in tubal ectopic and its final outcome.
Conclusions: Early detection of tubal ectopic and its site of implantation can help in deciding further management especially to go for conservative or surgical management.
Keywords: Ectopic pregnancy, Implantation
Background: Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy.
Methods: This study was an observational analytical type of study in which all the diagnosed cases of tubal ectopic were included. Detailed history and clinical evaluation was done and information was collected in a pre-tested proforma. Data was analyzed by frequency, percentages and chi square test.
Results: In this study total 50 cases were studied. In this we found a significant correlation between site of implantation in tubal ectopic and its final outcome.
Conclusions: Early detection of tubal ectopic and its site of implantation can help in deciding further management especially to go for conservative or surgical management.
Keywords: Ectopic pregnancy, Implantation
INTRODUCTION
Following fertilization and fallopian tube transit, the blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation elsewhere is considered ectopic and comprises 1 to 2 percent of all first-trimester pregnancies in the United States.1 This small proportion disparately accounts for 6 percent of all pregnancyrelated deaths.2,3 In addition, the chance for a subsequent successful pregnancy is reduced after an ectopic pregnancy.
Following fertilization and fallopian tube transit, the blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation elsewhere is considered ectopic and comprises 1 to 2 percent of all first-trimester pregnancies in the United States.1 This small proportion disparately accounts for 6 percent of all pregnancyrelated deaths.2,3 In addition, the chance for a subsequent successful pregnancy is reduced after an ectopic pregnancy.
Nearly 95 percent of ectopic pregnancies are implanted in the various segments of the fallopian tube and give rise to ampullary (70%), isthmic (12%), fimbrial (11%) or interstitial (2-3%) tubal pregnancies.
With tubal pregnancy, because the fallopian tube lacks a sub- mucosal layer, the fertilized ovum promptly burrows through the epithelium. The zygote comes to lie near or within the mascularis, which is invaded in most cases by rapidly proliferating trophoblast.
Outcomes of ectopic pregnancy include tubal rupture, tubal abortion, or pregnancy failure with resolution. With rupture, the invading expanding products of conception and associated hemorrhage may tear rents in the fallopian tube at any of several sites. As a rule, if the tube ruptures in the first few weeks, the pregnancy is most likely located in the isthmic portion, whereas the ampulla is slightly more distensible. However, if the fertilized ovum implants within the interstitial portion, rupture usually occurs later. Tubal ectopic pregnancies usually burst spontaneously but may occasionally rupture following coitus or bimanual examination. Alternatively, the pregnancy may abort out the distal fallopian tube, and the frequency of this depends in part on the initial implantation site. Abortion is common in fimbrial and ampullary pregnancies, whereas rupture is the usual outcome with those in the tubal isthmus4. With tubal abortion, hemorrhage disrupts the connection between the placenta and membranes and the tubal wall. If placental separation is complete, the entire conceptus may be extruded through the fimbriated end into the peritoneal cavity. At this point, hemorrhage may cease and symptoms eventually disappear. Some bleeding usually persists as long as products remain in the tube. Blood slowly trickles from the tubal fimbria into the peritoneal cavity and typically pools in the rectouterine cul-de-sac (Figure 1).
Outcomes of ectopic pregnancy include tubal rupture, tubal abortion, or pregnancy failure with resolution. With rupture, the invading expanding products of conception and associated hemorrhage may tear rents in the fallopian tube at any of several sites. As a rule, if the tube ruptures in the first few weeks, the pregnancy is most likely located in the isthmic portion, whereas the ampulla is slightly more distensible. However, if the fertilized ovum implants within the interstitial portion, rupture usually occurs later. Tubal ectopic pregnancies usually burst spontaneously but may occasionally rupture following coitus or bimanual examination. Alternatively, the pregnancy may abort out the distal fallopian tube, and the frequency of this depends in part on the initial implantation site. Abortion is common in fimbrial and ampullary pregnancies, whereas rupture is the usual outcome with those in the tubal isthmus4. With tubal abortion, hemorrhage disrupts the connection between the placenta and membranes and the tubal wall. If placental separation is complete, the entire conceptus may be extruded through the fimbriated end into the peritoneal cavity. At this point, hemorrhage may cease and symptoms eventually disappear. Some bleeding usually persists as long as products remain in the tube. Blood slowly trickles from the tubal fimbria into the peritoneal cavity and typically pools in the rectouterine cul-de-sac (Figure 1).
The term tubal abortion is also used when an intact, viable pregnancy is surgically removed during an operative intervention in an ectopic pregnancy. Tubal abortion can follow several courses: resorption of the products of conception; intraluminal extension with expulsion of gestational products; and perforation and rupture into the peritoneal cavity.5
In the present study we tried to evaluate the outcome for tubal ectopic pregnancies based on their site of implantation.
In the present study we tried to evaluate the outcome for tubal ectopic pregnancies based on their site of implantation.
METHODS
We conducted an observational analytical study of all the cases of ectopic pregnancies admitted to our hospital between August 2013 and December 2014 after obtaining clearance from the Hospital Ethical Committee. The details of maternal characteristics, clinical presentation, management and complications of the condition were noted from the case records. All the observations were documented and results tabulated. There were total 50 cases of ectopic pregnancy. The diagnosis of cases was based on clinical evaluation followed by a pelvic ultrasound scan.
We conducted an observational analytical study of all the cases of ectopic pregnancies admitted to our hospital between August 2013 and December 2014 after obtaining clearance from the Hospital Ethical Committee. The details of maternal characteristics, clinical presentation, management and complications of the condition were noted from the case records. All the observations were documented and results tabulated. There were total 50 cases of ectopic pregnancy. The diagnosis of cases was based on clinical evaluation followed by a pelvic ultrasound scan.
RESULTS
Site of ectopic pregnancy The ampulla of the tube had the most number of ectopic pregnancies (68%) followed by isthmus, fimbria and cornua. We had 2 cases of ovarian ectopic pregnancies amounting to 4% of all ectopics.
Site of ectopic pregnancy The ampulla of the tube had the most number of ectopic pregnancies (68%) followed by isthmus, fimbria and cornua. We had 2 cases of ovarian ectopic pregnancies amounting to 4% of all ectopics.
Outcome of the ectopic pregnancy
We had three main outcomes viz. ruptured, unruptured or tubal abortion.
We had three main outcomes viz. ruptured, unruptured or tubal abortion.
Ruptured ectopic pregnancies amounted to 48% followed by unruptured and tubal abortion, each amounting to 26%.
Correlation of site of ectopic pregnancy with the outcome of pregnancy.
34% of the ampullary pregnancies ruptured, 18% aborted whereas 16% were left unruptured.
All fimbrial pregnancies (8% of total) underwent tubal abortions. When the same was compared with ampullary pregnancies, a statistically significant correlation was found (p = 0.0261 at 95% Confidence Interval =0.8031/342.2).
All ovarian pregnancies (4% of total) underwent rupture, however, no statistical significance was found on comparing with ampullary pregnancies (p = 1.000). Only 1 cornual pregnancy was observed in our study (2% of total) which was unruptured on diagnosis (p = 0.3462).When unruptured ecpregnancies were considered (26%), none had a statistically significance with the site of the ectopic pregnancy (Figure 2).
DISCUSSION
Effective transport of embryos in the fallopian tube requires a delicately regulated complex interaction between the tubal epithelium, tubal fluid, and tubal contents. This interaction ultimately generates a mechanical force, composed of tubal peristalsis, ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity. This process is subject to dysfunction at many different points that can ultimately manifest as ectopic pregnancy.
Effective transport of embryos in the fallopian tube requires a delicately regulated complex interaction between the tubal epithelium, tubal fluid, and tubal contents. This interaction ultimately generates a mechanical force, composed of tubal peristalsis, ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity. This process is subject to dysfunction at many different points that can ultimately manifest as ectopic pregnancy.
Oocyte migration difficulty is most often associated with abnormal fallopian tube anatomy. This can result from tubal pathology (e.g., chronic salpingitis, salpingitis isthmica nodosa), tubal surgery (e.g. reconstruction, sterilization), or in utero DES exposure. It is thought that alterations in molecular signaling between the oocyte and the implantation site may make an ectopic pregnancy more likely. A number of molecular factors are under investigation for possible involvement in premature implantation. These factors include cellular and extracellular matrix proteins such as lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, and cytokines.
Various ways in which termination of tubal ectopic may occur is elaborated below:
1. Tubal abortion may result in: common mode of termination if implantation occurs in the ampulla or infundibulum.
a. Complete resorption without residual tubal damage and is essentially asymptomatic though it is difficult to prove.
b. Complete abortion: The pregnancy sac is extruded by tubal contractions through the abdominal ostium into the peritoneal cavity .If the ovum is small and the abortion is accompanied by only slight bleeding , the symptoms may be unimpressive and the pregnancy may be completely absorbed.
1. Tubal abortion may result in: common mode of termination if implantation occurs in the ampulla or infundibulum.
a. Complete resorption without residual tubal damage and is essentially asymptomatic though it is difficult to prove.
b. Complete abortion: The pregnancy sac is extruded by tubal contractions through the abdominal ostium into the peritoneal cavity .If the ovum is small and the abortion is accompanied by only slight bleeding , the symptoms may be unimpressive and the pregnancy may be completely absorbed.
c. Incomplete abortion: Here the products of conception reach the abdominal ostium but are only partially
discharged through it. Intratubal or peritoneal reimplantation of the abortus may result from this accident. Some authorities feel that regrowth of such an abortus is probably impossible.
d. Missed abortion (tubalmole): The dead ovum may remain in the tube and be subjected to repeated small chorio-decidual hemorrhages’, which convert it into a carneous mole .If the pregnancy is small, the process can become arrested. The mole is then partly absorbed and partly liquefied to give rise to a small and often symptomless haematosalpinx.
2. Tubal Rupture
discharged through it. Intratubal or peritoneal reimplantation of the abortus may result from this accident. Some authorities feel that regrowth of such an abortus is probably impossible.
d. Missed abortion (tubalmole): The dead ovum may remain in the tube and be subjected to repeated small chorio-decidual hemorrhages’, which convert it into a carneous mole .If the pregnancy is small, the process can become arrested. The mole is then partly absorbed and partly liquefied to give rise to a small and often symptomless haematosalpinx.
2. Tubal Rupture
This outcome is less common than tubal abortion .It is mostly seen when the pregnancy is implanted in the isthmus or interstitial part of the tube where the lumen is narrow and incapable of much distension. The ovum burrows deeply and ultimately erodes through the tube wall. The final break is the result of both distension and erosion and may be sudden. In the process, large arterioles are usually ruptured. The Pregnancy may be completely discharged through the rent; the tube can then retract and arrest the bleeding. More often the pregnancy is only partly extruded, chorionic villi alone may protrude and the bleeding is then heavy and recurrent. Isthmic rupture usually occurs at 6-8weeks, the ampullary one at 8-12weeks and the interstitial one at about 4th month. Rupture can be intraligamentary or intraperitoneal: Intraligamentary (extraperitoneal) rupture: is rare and is accounted for by rupture.
The tube at the point where it is attached to the broad ligament. The pregnancy and the blood are then discharged between the layers of the broad ligament to form a pelvic or broad ligament haematoma. Ultimately one leaf of the broad ligament may give way under the strain of recurrent hemorrhage and a secondary intraperitoneal rupture occurs.
Intraperitoneal rupture: Usually occurs towards the peritoneal cavity and the blood collects there in a partly solid but mainly fluid form. Dramatic signs due to acute blood loss accompany it .If the patient survives this insult without surgical intervention, reimplantation may occur.The blood will collect to form a pelvic haematocoele. Occasionally, if the conceptus is larger, it may remain in cul-de-sac for years as an encapsulated mass or even become calcified to form a lithopaedian.
Intraperitoneal rupture: Usually occurs towards the peritoneal cavity and the blood collects there in a partly solid but mainly fluid form. Dramatic signs due to acute blood loss accompany it .If the patient survives this insult without surgical intervention, reimplantation may occur.The blood will collect to form a pelvic haematocoele. Occasionally, if the conceptus is larger, it may remain in cul-de-sac for years as an encapsulated mass or even become calcified to form a lithopaedian.
3. Viable intra tubal pregnancy many unruptured viable pregnancies are removed intact. Although a majority of these would rupture or abort, a few cases where live infant shave been delivered by abdominal section have been recorded.6
4. To justify such a case as a true tubal gestation, the wall of the appendage must be intact and surround the gestational sac.
5. Intrauterine extrusion with result ant term pregnancy, abortion or rupture.
4. To justify such a case as a true tubal gestation, the wall of the appendage must be intact and surround the gestational sac.
5. Intrauterine extrusion with result ant term pregnancy, abortion or rupture.
6. Chronic ectopic (“Obscure”, “delayed” or “occult” tubal rupture) In this situation , the pregnancy dies but a variation of “Death in utero” takes place with mild chronic symptoms often dominated by anemia. Slow leakage of blood around the adnexa for msa pelvic mass often misdiagnosed as inflammatory disease. Resorption may take place but usually the patient is treated surgically if the mass is discovered.
Wills et al in their study found the incidence of ruptured and unruptured ectopic to be 66% and 34 % respectively. In our study the percentage of ruptured and unruptured ectopic was 48% and 26% respectively.
Ectopic pregnancy can occur at any time from menarche to menopause. It can either present as a case of bleeding PV or as an obstetric emergency. Tubal rupture cannot be predicted on the basis of any known risk factor, ultra sonogram findings, or serum hCG levels.7 However it is a known fact that pregnancy implanted at the ampullary as well as isthmic part of the fallopian tube have a greater risk of tubal rupture. Which among the two is at a greater risk, could not predicted by our study (p = 1.0000).
CONCLUSIONS
Ectopic pregnancy still poses a great risk to maternal health and is one of the leading causes of maternal morbidity and mortality. In the modern era of imaging modalities it is very important to get it diagnose ectopic pregnancy at earliest of gestation but still majority of patients come with complications like ruptured ectopic. Early diagnosis and treatment remains the crucial part in the management strategy. Knowledge about the site of tubal pregnancy may guide the clinician regarding the nature of the outcome of the ectopic pregnancy. Good clinical judgement along with the availability of quick Ultrasound facilities helps in early treatment initiation and thus decreases the immediate as well as late complications of ectopic pregnancy.
Ectopic pregnancy still poses a great risk to maternal health and is one of the leading causes of maternal morbidity and mortality. In the modern era of imaging modalities it is very important to get it diagnose ectopic pregnancy at earliest of gestation but still majority of patients come with complications like ruptured ectopic. Early diagnosis and treatment remains the crucial part in the management strategy. Knowledge about the site of tubal pregnancy may guide the clinician regarding the nature of the outcome of the ectopic pregnancy. Good clinical judgement along with the availability of quick Ultrasound facilities helps in early treatment initiation and thus decreases the immediate as well as late complications of ectopic pregnancy.
The authors would be thankful to Dr. Ashish S. Waje and Dr. Pranay Desai from Grant govt. Medical College and JJ group of hospitals, Mumbai.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
REFERENCES
1. Williams Obstetrics 24th E. Ectopic Pregnancy. Chapter No. 19. Pg. 377.
2. Berg CJ, Callaghan WM, Syverson C, et al. Pregnancy-related mortality in the United States, 1998–2005. Obstet Gynecol. 2010;116:1302.
3. Stulberg DB, Cain LR, Dahlquist I, et al: Ectopic pregnancy rates in the Medicaid population. Am J Obstet Gynecol. 2013;208(4):274.e1.
4. Williams Obstetrics 24th E. Ectopic Pregnancy. Chapter No. 19. Pg. 378
5. Caspi E, Sherman D. Tubal abortion and infundibular ectopic pregnancy. Clin Obstet Gynecol. 1987;30(1):155-63.
6. Gunnar U. A case of fimbrial pregnancy at term with delivery of a living child. Acta obstetricia et gynecologica Scandinavica 39.1. 1960:131-42.
7. Falcone T, Mascha EJ, Goldberg JM, Falconi LL, Mohla G, Attaran M. A study of risk factors for ruptured tubal ectopic pregnancy. J Womens Health.1998;7(4):459-63.
8. Devi S. Laparoscopic Treatment of Ectopic Pregnancy. Journal of Obs and Gyn of India. 2000;50:69.
9. Khera KR. The Journal of Obstetrics and Gyn of India, 1988;38(1):49.
10. Bai KS, Sujatha R. A Study of Incidence, Clinical Presentation and Risk Factors Associated with Ectopic Pregnancy. Journal of Evidence based Medicine and Healthcare. 2015:2922-30.
1. Williams Obstetrics 24th E. Ectopic Pregnancy. Chapter No. 19. Pg. 377.
2. Berg CJ, Callaghan WM, Syverson C, et al. Pregnancy-related mortality in the United States, 1998–2005. Obstet Gynecol. 2010;116:1302.
3. Stulberg DB, Cain LR, Dahlquist I, et al: Ectopic pregnancy rates in the Medicaid population. Am J Obstet Gynecol. 2013;208(4):274.e1.
4. Williams Obstetrics 24th E. Ectopic Pregnancy. Chapter No. 19. Pg. 378
5. Caspi E, Sherman D. Tubal abortion and infundibular ectopic pregnancy. Clin Obstet Gynecol. 1987;30(1):155-63.
6. Gunnar U. A case of fimbrial pregnancy at term with delivery of a living child. Acta obstetricia et gynecologica Scandinavica 39.1. 1960:131-42.
7. Falcone T, Mascha EJ, Goldberg JM, Falconi LL, Mohla G, Attaran M. A study of risk factors for ruptured tubal ectopic pregnancy. J Womens Health.1998;7(4):459-63.
8. Devi S. Laparoscopic Treatment of Ectopic Pregnancy. Journal of Obs and Gyn of India. 2000;50:69.
9. Khera KR. The Journal of Obstetrics and Gyn of India, 1988;38(1):49.
10. Bai KS, Sujatha R. A Study of Incidence, Clinical Presentation and Risk Factors Associated with Ectopic Pregnancy. Journal of Evidence based Medicine and Healthcare. 2015:2922-30.
Sunday 17 April 2016
Practicalities and benefits of human milk banks in India
Rajshree Katke
Department of Obstetrics and Gynecology, Cama and Albless Hospital, Mumbai, Maharashtra, India
Received 22 August 2014
Received in revised form 30 September 2014
Accepted 19 November 2014
For Article Link:
https://www.researchgate.net/publication/274255067
Department of Obstetrics and Gynecology, Cama and Albless Hospital, Mumbai, Maharashtra, India
Received 22 August 2014
Received in revised form 30 September 2014
Accepted 19 November 2014
For Article Link:
https://www.researchgate.net/publication/274255067
Practicalities and benefits of human milk banks in India
WHO describes exclusive breastfeeding as an unparalleled way of providing ideal food for the healthy growth and development of infants, and advocates it for six months. In addition to providing protection against infectious and chronic diseases and lessening mortality from common childhood illnesses, it offers other psychological and practical advantages.
In India, 46.4% of postpartum women practice exclusive breastfeeding for sixmonths [2] compared with 16.3% in the USA [3]. However, India has a higher infantmortality rate of 44 per 1000 [2] comparedwith 6 per 1000 in the USA.
One of the preventable causes of infant mortality is unsterile top-up feedingwith formula milk. This can be prevented by substituting top-up feeds with banked human milk. Artificial feeding is an important risk factor for infant morbidity and mortality, particularly for preterm neonates in low-resource countries.
The Cama and Albless Hospital inMumbai has had a functional milk bank since 2008.Over the last six years, donated milk has benefited over 6000 needy babies in the neonatal intensive care unit (NICU). The aimof the present study was to assess the impact that the milk bank has had on neonatal outcomes at the hospital.
A retrospective study was carried out for the period January 1, 2008, to December 31, 2014. Ethics Committee approval was not required for the study and permission was granted by the head of the institute to access medical records from the NICU and the milk bank.
Data were collected and analyzed to investigate the amount of milk collected and used since 2008, the decrease in neonatal morbidity and mortality since 2008, changes in the average duration of stay in the NICU for pretermand lowbirthweight neonates since 2008, and changing trends in milk donation in 2013 compared with 2008.
The total amount of banked human milk collected since 2008 was 1 127 128 mL. Of this, 987 524 mL was consumed by 6084 NICU babies over six years. A reduction was found in the neonatal mortality rate from 4.7% in 2008 to 2.2% in 2013 (Table 1). Similarly, there was a decrease in the neonatal morbidity rate from 45.7% in 2008 to 23% in 2013. However, there was an increase in the duration of NICU stay for preterm and low birth weight infants, from 10 days in 2008 to 20 days in 2014 (Table 2).
The total amount of milk collected in 2008 was 188 648 mL compared with 293 009 mL collected in 2013. Positive counseling and motivation of patients has led to a 55% increase in the amount of milk donated in 2013 compared with 2008.The reasons for the 53% decrease in neonatal mortality and 49.6% decrease in neonatal morbidity since 2008 are likely multifactorial, but the availability of banked human milk around the clock has played a significant role in these improved statistics.
The total amount of banked human milk collected since 2008 was 1 127 128 mL. Of this, 987 524 mL was consumed by 6084 NICU babies over six years. A reduction was found in the neonatal mortality rate from 4.7% in 2008 to 2.2% in 2013 (Table 1). Similarly, there was a decrease in the neonatal morbidity rate from 45.7% in 2008 to 23% in 2013. However, there was an increase in the duration of NICU stay for preterm and low birth weight infants, from 10 days in 2008 to 20 days in 2014 (Table 2).
The total amount of milk collected in 2008 was 188 648 mL compared with 293 009 mL collected in 2013. Positive counseling and motivation of patients has led to a 55% increase in the amount of milk donated in 2013 compared with 2008.The reasons for the 53% decrease in neonatal mortality and 49.6% decrease in neonatal morbidity since 2008 are likely multifactorial, but the availability of banked human milk around the clock has played a significant role in these improved statistics.
The average duration of stay in the NICU for preterm and low birth weight babies increased from 10 days in 2008 to 20 days in 2013. The reason for this is the decreased neonatal mortality rate for this group. Increased survival has led to an increased average stay as infants are only discharged from the NICU once their weight is greater than 1.8 kg.
The cost of setting up the milk bank was approximately 300 000 rupees (approximately US $5000) and the annual maintenance cost for running the milk bank is approximately 10 000 rupees (US $150), excluding labor and electricity costs. For this minimal investment,every year over a 1000 needy babies benefit from banked human milk.
Despite the minimal expenditure and immense benefits, there are only 10 milk banks across India. Furthermore, all are in the public sector and are attached to government and teaching hospitals. Commercial milk banking, as seen in Colorado [5], is still a distant reality for India.
Milk banks are cost-effective to maintain, create job opportunities, and have an immense cost–benefit ratio. The authorswish to emphasize the need for more milk banks across India.
The cost of setting up the milk bank was approximately 300 000 rupees (approximately US $5000) and the annual maintenance cost for running the milk bank is approximately 10 000 rupees (US $150), excluding labor and electricity costs. For this minimal investment,every year over a 1000 needy babies benefit from banked human milk.
Despite the minimal expenditure and immense benefits, there are only 10 milk banks across India. Furthermore, all are in the public sector and are attached to government and teaching hospitals. Commercial milk banking, as seen in Colorado [5], is still a distant reality for India.
Milk banks are cost-effective to maintain, create job opportunities, and have an immense cost–benefit ratio. The authorswish to emphasize the need for more milk banks across India.
Conflict of interest
The authors have no conflicts of interest.
The authors have no conflicts of interest.
References
[1] World Health Organization website. Nutrition. Exclusive breastfeeding. http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/.
[2] UNICEFwebsite. India. Statistics. http://www.unicef.org/infobycountry/india_statistics.html.
[3] Centers for Disease Control and Preventionwebsite. Breastfeeding. Breastfeeding Report Card 2012, United States: Outcome Indicators. http://www.cdc.gov/breastfeeding/data/reportcard2.htm.
[1] World Health Organization website. Nutrition. Exclusive breastfeeding. http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/.
[2] UNICEFwebsite. India. Statistics. http://www.unicef.org/infobycountry/india_statistics.html.
[3] Centers for Disease Control and Preventionwebsite. Breastfeeding. Breastfeeding Report Card 2012, United States: Outcome Indicators. http://www.cdc.gov/breastfeeding/data/reportcard2.htm.
[4] Vohr BR, Poindexter BB, DusickAM,McKinley LT, Higgins RD, Langer JC, et al. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics 2007;120(4):e953–9.
[5] Kennaugh J, Lockhart-Borman L. The increasing importance of human milk banks. e-J Neonatol Res 2011;1(3):119–25.
Tuesday 5 April 2016
MTP and PCPNDT Act
Rajshree Dayanand Katke
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420540
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420540
MTP and PCPNDT Act
Friday 1 April 2016
Maternal Death Review
Rajshree Dayanand Katke
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420630
Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy.
Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 1,00,000 live births.
• Maternal Mortality Ratio (MMR) in India has shown an appreciable decline from 398/100,000
live births in the year 1997–98 to 254/100,000 live births in the year 2004–06 as per the latest
RGI-SRS survey report, released in April 2009. However, to accelerate the pace of decline of
MMR in order to achieve the NRHM and MDG Goal of less than 100 per 100,000 live births
by 2015, there is a need to give impetus to implementation of the technical strategies and
interventions for maternal health.
• Kerala and Tamil Nadu have achieved the NRHM goal, while Maharashtra is close.
• Andhra Pradesh, West Bengal, Gujarat and Haryana are within striking distance.
• EAG states and Assam would need to further intensify efforts.
Maternal Death Review (MDR) as a strategy has been spelt out clearly in the RCH-II National Programme Implementation Plan document.
Five approaches to help understand why women die:
• Maternal deaths in the community (CBMDR)
• Maternal deaths in facilities (FBMDR)
• Confidential enquiries into maternal deaths
• Learning from women who survived: “Near miss” cases
• Evidence-based clinical audit
ANM cross checks and submits final report to SMO BLOCK PHC by 10th of following month.
SMO BLOCK PHC deputes the designated investigation team for investigation as per Annexure 2
to be completed within 3 weeks of death
Sends report in Annexure 3 to Civil Surgeon within 4 weeks of death.
SMO BLOCK PHC maintains CBMDR Register as per Annexure 5.
Department of Obstetrics and Gynecology, Grant Government Medical College, Byculla, Mumbai-400008, India
For Article Link
https://www.researchgate.net/publication/272420630
Maternal Death Review
India contributes one-fifth of the global burden of absolute maternal deaths; however, it has experienced an estimated 4.7% annual decline in maternal mortality ratio (MMR) and 3.5% annual increase in skilled birth attendance since 1990. While not on track to meet Millennium Development Goal 5, India is making progress in reducing maternal mortality.
Within India, there is marked variation in MMR and health care access between regions and in socioeconomic factors.
Within India, there is marked variation in MMR and health care access between regions and in socioeconomic factors.
Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy.
Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 1,00,000 live births.
• Maternal Mortality Ratio (MMR) in India has shown an appreciable decline from 398/100,000
live births in the year 1997–98 to 254/100,000 live births in the year 2004–06 as per the latest
RGI-SRS survey report, released in April 2009. However, to accelerate the pace of decline of
MMR in order to achieve the NRHM and MDG Goal of less than 100 per 100,000 live births
by 2015, there is a need to give impetus to implementation of the technical strategies and
interventions for maternal health.
• Kerala and Tamil Nadu have achieved the NRHM goal, while Maharashtra is close.
• Andhra Pradesh, West Bengal, Gujarat and Haryana are within striking distance.
• EAG states and Assam would need to further intensify efforts.
Maternal Death Review (MDR) as a strategy has been spelt out clearly in the RCH-II National Programme Implementation Plan document.
It is an important strategy:
• To improve the quality of obstetric care and reduce maternal mortality and morbidity
• To generate evidence for determining interventions, to fill the gaps in service.
• To improve the quality of obstetric care and reduce maternal mortality and morbidity
• To generate evidence for determining interventions, to fill the gaps in service.
To provide the data needed to feed into the national civil registration system for the
computing of MMR.
• A commitment to Act upon the findings. Not for punitive action Avoiding maternal death is possible even in resource-limited countries, but the correct information on which to base maternal health programmes is required. Maternal death review is one of the oldest and the most documented.
computing of MMR.
• A commitment to Act upon the findings. Not for punitive action Avoiding maternal death is possible even in resource-limited countries, but the correct information on which to base maternal health programmes is required. Maternal death review is one of the oldest and the most documented.
Five approaches to help understand why women die:
• Maternal deaths in the community (CBMDR)
• Maternal deaths in facilities (FBMDR)
• Confidential enquiries into maternal deaths
• Learning from women who survived: “Near miss” cases
• Evidence-based clinical audit
The Maternal Death Surveillance Cycle Key
Key Steps in MDR Implementation
• Implementation of MDR has to be supported by a State Government order
• Notification of Maternal Deaths
• Facility based Review and Community based Review
• All health functionaries have a role in MDR
• District Collector (DC) to be involved in MDR with the relatives of the deceased and service
providers
• Implementation of MDR has to be supported by a State Government order
• Notification of Maternal Deaths
• Facility based Review and Community based Review
• All health functionaries have a role in MDR
• District Collector (DC) to be involved in MDR with the relatives of the deceased and service
providers
FBMDR is a process to investigate and identify causes, mainly clinical and systemic, which lead to maternal deaths in the health facilities; and to take appropriate corrective measures to prevent such deaths.
CBMDR is a process in which deceased’s family members, relatives, neighbours or other informants and care providers are interviewed, through a technique called Verbal Autopsy, to elicit information for the purpose of identification of various factors—whether medical, socioeconomic or systemic, which lead to maternal deaths; and thereby enabling the health system to take appropriate corrective measures at various levels to prevent such deaths.
Committee will meet and review the following
a. Circumstances under which the death took place
b. Cause of maternal death: Direct obstetric, indirect obstetric and non-obstetric cause.
c. What steps are required to prevent such deaths in future:
i. Action related to infrastructural strengthening
ii. Action required to augment human resource availability
iii. Action required to strengthen protocols and competence of staff
iv. Supplies and equipment
v. Demand-side interventions to address first and second delays
vi. Management interventions
vii. Other interventions based on the findings of MDR
a. Circumstances under which the death took place
b. Cause of maternal death: Direct obstetric, indirect obstetric and non-obstetric cause.
c. What steps are required to prevent such deaths in future:
i. Action related to infrastructural strengthening
ii. Action required to augment human resource availability
iii. Action required to strengthen protocols and competence of staff
iv. Supplies and equipment
v. Demand-side interventions to address first and second delays
vi. Management interventions
vii. Other interventions based on the findings of MDR
ORIENTATION TRAININGS
For implementing interventions on MDR, one day orientation trainings undertaken.
Power-point presentations on the background: Maternal mortality—causes, current status, rationale of MDR, process of FBMDR, roles and responsibilities, data flow and analysis, monitoring and supervision, review process.
Question by question training on filling up of the formats with help of the reference manuals; interpreting the filled up questionnaire to develop the case summaries. Time lines and incentives given.
List of registers to be maintained at various levels
List of registers to be maintained at various levels
MDR FORMATS
Annexure 1: Facility Based Maternal Death Review Form
Annexure 2: Verbal Autopsy Questionnaire
Annexure 3: MDR Case Summary
Annexure 4: MDR Line Listing Form for All Cases of Maternal Deaths
Annexure 5: Block Level MDR Register for All Women’s Death (15–49 years)
Annexure 6: Format for Primary Informer
The questionnaire has 3 modules that should be filled up according to the type of death,however module 1 must be filled for all.
Annexure 1: Facility Based Maternal Death Review Form
Annexure 2: Verbal Autopsy Questionnaire
Annexure 3: MDR Case Summary
Annexure 4: MDR Line Listing Form for All Cases of Maternal Deaths
Annexure 5: Block Level MDR Register for All Women’s Death (15–49 years)
Annexure 6: Format for Primary Informer
The questionnaire has 3 modules that should be filled up according to the type of death,however module 1 must be filled for all.
Module I
Should be used for collection of general information for all maternal deaths irrespective of whether deaths occurred during antenatal or intranatal or postnatal period or due to abortion.
Module II
Should be used for the deaths occurring during the antenatal period including abortion.
Module III
Should be used for the deaths occurring during delivery or postnatal period.
Should be used for collection of general information for all maternal deaths irrespective of whether deaths occurred during antenatal or intranatal or postnatal period or due to abortion.
Module II
Should be used for the deaths occurring during the antenatal period including abortion.
Module III
Should be used for the deaths occurring during delivery or postnatal period.
FBMDR
Information
Maternal Death reported as follows:
Medical Officer on duty telephonically
Information
Maternal Death reported as follows:
Medical Officer on duty telephonically
|
| Telephonic-ally
Facility Nodal Officer
Facility Nodal Officer
|
| Through Annexure 6
Civil Surgeon, District Comissioner, District Nodal Officer
Civil Surgeon, District Comissioner, District Nodal Officer
Investigation
Completion of Facility Based MDR Form (Annexure 1) in duplicate for every maternal death within 24 hours of its occurrence by the MO on duty in consultation with Facility Nodal Officer and signed by both.
Completion of Facility Based MDR Form (Annexure 1) in duplicate for every maternal death within 24 hours of its occurrence by the MO on duty in consultation with Facility Nodal Officer and signed by both.
|
Monthly review meeting of the Facility MDR Committee on a prefixed date of the following month to review all the maternal deaths occurred in the facility during the month and implementation of the suggested corrective measures. Every maternal death occurring in the facility is given a yearly serial number.
|
Review and Corrective actions taken are reported to Civil Surgeon as “CONFIDENTIAL”
Community Based MDR
Information
ASHA/AWW
Annexure 6 |
ANM
Annexure 6 |
BLOCK Medical Officer PHC
|
Civil Surgeon, District Comissioner, District Nodal Officer
Line listing of all deaths of women of age 15–49 yrs.
ASHA/AWW line lists as per Annexure 4 and submits to ANM by 5th of following month.
ASHA/AWW line lists as per Annexure 4 and submits to ANM by 5th of following month.
ANM cross checks and submits final report to SMO BLOCK PHC by 10th of following month.
SMO BLOCK PHC deputes the designated investigation team for investigation as per Annexure 2
to be completed within 3 weeks of death
Sends report in Annexure 3 to Civil Surgeon within 4 weeks of death.
SMO BLOCK PHC maintains CBMDR Register as per Annexure 5.
(FBMDR + CBMDR)
Monthly review meeting of the District MDR Committee chaired by Civil Surgeon and convened by District Nodal Officer every month on a prefixed date.
Monthly review meeting chaired by D.C., convened by the Civil Surgeon and assisted by the District Nodal Officer (2 relatives of the deceased to attend).
Monthly review meeting of the District MDR Committee chaired by Civil Surgeon and convened by District Nodal Officer every month on a prefixed date.
Monthly review meeting chaired by D.C., convened by the Civil Surgeon and assisted by the District Nodal Officer (2 relatives of the deceased to attend).
STATE LEVEL MATERNAL DEATH REVIEW BY STATE LEVEL TASK FORCE (SLTF)
Review meeting once in 6 months chaired by PSHFW.
The SLTF will meet once in 6 months under the chairmanship of Principal Secretary Health and Family Welfare to discuss the actions taken on the minutes of the last meeting and make recommendations to Government for policy and strategy formulations.
Every year an annual maternal death report for the State prepared and a dissemination workshop organized to sensitise various service providers and managers. The annual report may contain interesting maternal death case studies which may be used during the training of medical and paramedical functionaries.
A serial record of all confirmed maternal death reports received from all districts during the calendar year kept in the Maternal Death Record Register to be maintained in the office of the Director Family Welfare asper the format at Annexure 6A and will be linked with the reporting in the HMIS.
The SLTF will meet once in 6 months under the chairmanship of Principal Secretary Health and Family Welfare to discuss the actions taken on the minutes of the last meeting and make recommendations to Government for policy and strategy formulations.
Every year an annual maternal death report for the State prepared and a dissemination workshop organized to sensitise various service providers and managers. The annual report may contain interesting maternal death case studies which may be used during the training of medical and paramedical functionaries.
A serial record of all confirmed maternal death reports received from all districts during the calendar year kept in the Maternal Death Record Register to be maintained in the office of the Director Family Welfare asper the format at Annexure 6A and will be linked with the reporting in the HMIS.
Current Challenges and Issues in Implementation of MDR Process
• Under-reporting (only 17.6% of total expected deaths reported).
• Quality of maternal death reviews at district/facility level Focus on high case load facilities in high mortality district—need to prioritize on constitution of FBMDR Committees at High Case Load “Delivery Points”
• Capacity building of health care providers and community health workers
• Under-reporting (only 17.6% of total expected deaths reported).
• Quality of maternal death reviews at district/facility level Focus on high case load facilities in high mortality district—need to prioritize on constitution of FBMDR Committees at High Case Load “Delivery Points”
• Capacity building of health care providers and community health workers
Looking Forward to
• Complete reporting through web-based Central Health Management Information System sustainability
• MDR software to be linked with MCTS—in process of development
• Sharing analysed data on maternal deaths is a good way to raise awareness about the issue with the local communities and improve birth preparedness.
• Complete reporting through web-based Central Health Management Information System sustainability
• MDR software to be linked with MCTS—in process of development
• Sharing analysed data on maternal deaths is a good way to raise awareness about the issue with the local communities and improve birth preparedness.
BIBLIOGRAPHY
1. Maternal Death Review Guidebook Maternal Health Division Ministry of Health and Family Welfare
1. Maternal Death Review Guidebook Maternal Health Division Ministry of Health and Family Welfare
Live secondary abdominal pregnancy-by chance!!
Rajshree Dayanand Katke
Department of Obstetrics and Gynaecology, Grant Government Medical College, Byculla, Mumbai- 400008, India
For Article Link
http://dx.doi.org/10.5455/2320-1770.ijrcog20130634
Received: 7 April 2013 Accepted: 14 April 2013
DOI: 10.5455/2320-1770.ijrcog20130634
ABSTRACT
Abdominal pregnancy though rare but is a life threatening situation, if not recognized and managed properly. We are hereby presenting a rare successful outcome in a case of ruptured live Secondary Abdominal pregnancy with placental implants over intestines.
Keywords: Ectopic, Abdominal, Pregnancy
INTRODUCTION
The incidence of ectopic pregnancy in India is 3.86 per 1000 live births among all hospital reported pregnancies as per Indian Council of Medical Research task Force. Among these 95% are tubal1 and 1-4% are abdominal.2 Abdominal pregnancy usually occurs after tubal abortion or tubal rupture. Tubo-abdominal pregnancy results from gradual extrusion of zygote into peritoneal cavity that originally implanted in the neighborhood of fimbriated extremity. We report a case of secondary abdominal pregnancy, with placental implants over the intestines fetus being live!
CASE REPORT
Mrs. X 32 years of age, P2L2 uneducated, belonging to low socio-economic class, working as house maid, came to our O.P.D. walking with chief complaints of pain abdomen and vomiting for the last 2-3 days. Pain was constant but getting severe in between. She had 2 normal vaginal deliveries and her last child birth was 14 years ago. She did not remember her last menstrual period. On repeated questioning she admitted that she might have missed 2 cycles, though her past menstrual cycle was regular. She was not using any contraception. Her past medical and surgical history was not significant and her past gynecological history was unremarkable.
She was well nourished, weight was 59 kg. She was pale looking and had mild dyspnoea and tachycardia (Pulse 110 beats/min). Blood pressure was 100/60mmHg. On per-abdomen examination, abdomen was mildly distended with marked tenderness in right iliac fossa. On pelvic examination uterus was just bulky and there was ill defined mass and fullness in right fornix with marked tenderness. Her urine test was done which; to her surpriseand our dismay, was positive.
Urgent USG showed bulky empty uterus with a right adnexal mass measuring 4.3x4.2cm with a 3.5cm hyper echoic structure within it having cardiac activity, s/o live right adnexal ectopic pregnancy ≈12 weeks POG? Ovarian.
Her investigations revealed hemoglobin of 6.5gm%,hematocrit of 20; rest hemogram, liver function tests and renal function tests were within normal limit. Blood was arranged, supportive therapy started and patient taken immediately for emergency laparotomy as her vitals were falling; she had increased tachycardia and hypotension. On opening the abdomen there was massive hemoperitoneum.1500 cc of chocolate colored fluid was suctioned out. Uterus was bulky. A live Fetus ≈ 13 weeks POG was found lying free in the abdominal cavity with placental bits adherent to bowel loops and omentum. Blood clots were removed which weighed ≈200 grams.
Right tube and ovary were adherent and encased in a pseudo sac, was examined and no signs of pregnancy were found. A diagnosis of abdominal pregnancy with a live fetus was made. Ovarian pregnancy was excluded. Left tube had hydrosalpinx and ovary was normal. Fetus was removed, right salpingectomy done and thorough peritoneal lavage given. No attempt was made to remove the placental tissue as it was adherent to adjoining bowel loops, omentum and fetus. Two pints of blood transfusion were given intra and post operatively. Patient withstood the surgery well.
Funding: None
Competing interests: None declared
Ethical approval: Not required
Department of Obstetrics and Gynaecology, Grant Government Medical College, Byculla, Mumbai- 400008, India
For Article Link
http://dx.doi.org/10.5455/2320-1770.ijrcog20130634
Received: 7 April 2013 Accepted: 14 April 2013
DOI: 10.5455/2320-1770.ijrcog20130634
ABSTRACT
Abdominal pregnancy though rare but is a life threatening situation, if not recognized and managed properly. We are hereby presenting a rare successful outcome in a case of ruptured live Secondary Abdominal pregnancy with placental implants over intestines.
Keywords: Ectopic, Abdominal, Pregnancy
INTRODUCTION
The incidence of ectopic pregnancy in India is 3.86 per 1000 live births among all hospital reported pregnancies as per Indian Council of Medical Research task Force. Among these 95% are tubal1 and 1-4% are abdominal.2 Abdominal pregnancy usually occurs after tubal abortion or tubal rupture. Tubo-abdominal pregnancy results from gradual extrusion of zygote into peritoneal cavity that originally implanted in the neighborhood of fimbriated extremity. We report a case of secondary abdominal pregnancy, with placental implants over the intestines fetus being live!
CASE REPORT
Mrs. X 32 years of age, P2L2 uneducated, belonging to low socio-economic class, working as house maid, came to our O.P.D. walking with chief complaints of pain abdomen and vomiting for the last 2-3 days. Pain was constant but getting severe in between. She had 2 normal vaginal deliveries and her last child birth was 14 years ago. She did not remember her last menstrual period. On repeated questioning she admitted that she might have missed 2 cycles, though her past menstrual cycle was regular. She was not using any contraception. Her past medical and surgical history was not significant and her past gynecological history was unremarkable.
She was well nourished, weight was 59 kg. She was pale looking and had mild dyspnoea and tachycardia (Pulse 110 beats/min). Blood pressure was 100/60mmHg. On per-abdomen examination, abdomen was mildly distended with marked tenderness in right iliac fossa. On pelvic examination uterus was just bulky and there was ill defined mass and fullness in right fornix with marked tenderness. Her urine test was done which; to her surpriseand our dismay, was positive.
Urgent USG showed bulky empty uterus with a right adnexal mass measuring 4.3x4.2cm with a 3.5cm hyper echoic structure within it having cardiac activity, s/o live right adnexal ectopic pregnancy ≈12 weeks POG? Ovarian.
Her investigations revealed hemoglobin of 6.5gm%,hematocrit of 20; rest hemogram, liver function tests and renal function tests were within normal limit. Blood was arranged, supportive therapy started and patient taken immediately for emergency laparotomy as her vitals were falling; she had increased tachycardia and hypotension. On opening the abdomen there was massive hemoperitoneum.1500 cc of chocolate colored fluid was suctioned out. Uterus was bulky. A live Fetus ≈ 13 weeks POG was found lying free in the abdominal cavity with placental bits adherent to bowel loops and omentum. Blood clots were removed which weighed ≈200 grams.
Right tube and ovary were adherent and encased in a pseudo sac, was examined and no signs of pregnancy were found. A diagnosis of abdominal pregnancy with a live fetus was made. Ovarian pregnancy was excluded. Left tube had hydrosalpinx and ovary was normal. Fetus was removed, right salpingectomy done and thorough peritoneal lavage given. No attempt was made to remove the placental tissue as it was adherent to adjoining bowel loops, omentum and fetus. Two pints of blood transfusion were given intra and post operatively. Patient withstood the surgery well.
Figure 1: Rupture of tubal pregnancy into broad
ligament abdominal cavity, leading to secondary
abdominal pregnancy.
ligament abdominal cavity, leading to secondary
abdominal pregnancy.
Figure 2: Fetus (period of gestation approx 12 weeks)
growing in abdominal cavity.
growing in abdominal cavity.
Postoperative recovery was uneventful. Serum β HCG was done on day 7 which was 2336. One dose of Methotrexate (1mg/kg) followed by folinic acid (0.1mg/kg) was given. Repeat β HCG was 321 on day 14 of surgery, second dose was given. On day 21, β HCG was 109. Patient was discharged in healthy condition with advice to follow up for serial β HCG which came down to normal limits (<1.2) within 3 months.
Figure 3: Placental implants over intestines.
7 out of 10 deaths due to ectopic are associated with failure to diagnose or substandard care.3 Abdominal ectopic pregnancy must be recognized in time to prevent drastic, avoidable consequences which sometimes may prove lethal also. The overall mortality rate associated with abdominal pregnancy is 0.5 to 8%.2 Abdominal pregnancy may cause intestinal or ureteric obstruction, intraabdominal hemorrhage. It may be further complicated by infection with abscess formation. Very rarely there is continuation of secondary abdominal pregnancy to term with delivery of a live fetus.
Also, despite of investigatory tools that are available at the disposal of a clinician today, nothing can surpass clinical acumen. This case emphasizes the importance of a detailed/provoked history and to rule out ectopic pregnancy in all women of reproductive age presenting with pain abdomen irrespective of her narrated last menstrual period given by her.
This case brings us to the discussion regarding lack of self care and contraceptive awareness among Indian women. In a study conducted by Srivastva Reena et al majority of couples (55.2%) had never used a contraceptive and the problem is further compounded. when they observed that 38.1% did not even feel its need till an unwanted pregnancy occurred.5 This patient missed her periods twice but did not care to get simple and easily available UPT done in spite of massive advertisements/about it. Despite constant efforts by the Government, an unmet need still remains. We have to get the health machinery within the reach of the unreached. Still a long way to go!!
This patient could have deteriorated if she would not have been timely diagnosed. This case could be successfully managed with timely correct diagnosis, good clinical acumen urgent surgical intervention, and excellent surgical expertise.
Funding: None
Competing interests: None declared
Ethical approval: Not required
REFERENCES
1. Cunningham FG, Gant NF, Leveno KJ et al (Eds). Williams Obstetrics 21st edn. New York, McGraw Hill; 2001:899.
2. Shaw HA, Ezenwa E. Secondary abdominal pregnancy in a Jehovah’s Witness. South Med J 2000;93:898-900.
3. Lewis G. The Confidential Enquiry into maternal and child health (CEMACH). Saving Mothers live: reviewing maternal deaths to make mother hood safer 2003-2005.The Seventh Report of Confidential Enquiry into Maternal Deaths in United Kingdom, London (CEMACH). 2007 Dec. 93-4p.
4. Sharma S, Kumar G. A rare case of viable 32 weeks secondary abdominal pregnancy. J Obstet Gynaecol India 2002;52:119-20.
5. Srivastava R, Srivastava DK, Jina R, Srivastava K, Sharma N, Saha S. Contraceptive knowledge attitude and practice (KAP) survey. J Obstet Gynecol India 2005;55:546-50.
1. Cunningham FG, Gant NF, Leveno KJ et al (Eds). Williams Obstetrics 21st edn. New York, McGraw Hill; 2001:899.
2. Shaw HA, Ezenwa E. Secondary abdominal pregnancy in a Jehovah’s Witness. South Med J 2000;93:898-900.
3. Lewis G. The Confidential Enquiry into maternal and child health (CEMACH). Saving Mothers live: reviewing maternal deaths to make mother hood safer 2003-2005.The Seventh Report of Confidential Enquiry into Maternal Deaths in United Kingdom, London (CEMACH). 2007 Dec. 93-4p.
4. Sharma S, Kumar G. A rare case of viable 32 weeks secondary abdominal pregnancy. J Obstet Gynaecol India 2002;52:119-20.
5. Srivastava R, Srivastava DK, Jina R, Srivastava K, Sharma N, Saha S. Contraceptive knowledge attitude and practice (KAP) survey. J Obstet Gynecol India 2005;55:546-50.
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