Obstetric Cases Research Articles

Pattern and Outcome of Obstetric Admissions into the Intensive Care Unit of a Southeast Nigerian Hospital.

Background and Aims:Although pregnancy and labor are considered physiological processes, the potential for catastrophic complications is constant and may develop rapidly. There is growing evidence that admission of high-risk patients into the Intensive Care Unit (ICU) is associated with a reduction in maternal mortality. This study was aimed at reviewing all obstetric patients admitted into the ICU.Materials and Methods:This was a retrospective study of all obstetric patients who were admitted into the ICU between January 1, 2012, and December 31, 2013.Results:There were 89 obstetric patients admitted and managed at the ICU out of 5176 deliveries, thereby accounting for 1 admission in 58 deliveries. Majority of the patients were between 26 and 30 years, primiparous, and unbooked. The indications for ICU admission in this study were ruptured uterus (36.0%), eclampsia (22.5%), obstetric hemorrhage (19.1%), septicemia (10.1%), severe preeclampsia (6.7%), and obstructed labor (6.7%). The maternal and perinatal mortality was 13.5% and 47.2%, respectively. Maternal unbooked status was significantly associated with maternal mortality (P < 0.05).Conclusion:Ruptured uterus was the most common indication for ICU admission in the center. Maternal mortality was significantly associated with unbooked status. This underscores the importance of booking for antenatal care, prompt presentation at the hospital during emergencies, skilled birth attendance, and provision of adequate facilities for the management of critical obstetric cases in this environment.

Selective inhibition of smooth muscle plasma membrane transport Са2+,Mg2+-АТРase by calixarene C-90 and its activation by IPT-35 compound.

We investigated the influence of calixarene C-90 and IPT-35 on plasma membrane Ca2+- pumping АТРase (PMCA), intracellular calcium homeostasis and myometrium smooth muscle strain contractions. It has been shown that both effectors (100 μM) affect PMCA enzymatic activity: calixarene C-90 inhibits it by 75% and IPT-35 activates it by 40%. These compounds don't affect the Mg2+-АТРase, Mg2+-independent Са2+-АТРase and Na+,K+-АТРase enzymatic activities. C-90 inhibition coefficient I0.5 magnitude was approximately 20 μM and the Hill coefficient nH was 0.55. For IPT-35 activation, constant А0.5 was 6.4 and nH was 0.7. Mathematical modeling demonstrated the implication of calixarene C-90 on unexcited myocytes, which allows for a precise change in cytoplasm Ca2+ concentration and an influence on basal muscle tonus. By the same method, we determined that IPT-35 has a little influence on Ca2+ concentration in unexcited myocytes. It was also shown that calixarene C-90 in vitro can increase velocity of oxytocin-initiated contractions, whereas IPT-35 can suppress this aforementioned parameter. These results are promising for the design of new pharmacological compounds as better regulators of uterine contractions. Calixarene C-90 can be used in obstetric cases for the simultaneous use of oxytocin for enhancing uterine contractions, and IPT-35 for its antispasmodic effect on uterine tone.

Intrapartum Fetal Monitoring: Pathophysiology and Evolution of Various Techniques

Perinatal hypoxia has been a source of major concern for the pregnant woman and her obstetrician alike. The former was plagued by constant worries of neonatal morbidity and mortality and the latter, by constant threat of medical litigations. Intrapartum fetal monitoring (IPFM) played an important role in the attempt to establish equilibrium. Initially, intermittent auscultation was the only method of monitoring the well-being of fetus during labor. Further research led to the evolution of electronic fetal monitoring, scalp blood sampling, fetal pulse oximetry, ST-analysis of the fetal ECG and the use of sophisticated magnetism and infra-red optics. A trial using artificial intelligence in IPFM has recently reached its final phase. Even as more novel methods of monitoring continue to emerge, the perfect monitoring technique still remains to be discovered. Analysis made it evident that no single method was capable of distinguishing true cases of fetal distress from false one, sufficiently accurately. A combination of two or more methods is required for a reliable diagnosis to be obtained, and current treatment protocols should reflect this. The concurrent use of two or more monitoring methods in an algorithmic manner will go a long way in reducing the incidence of perinatal morbidity especially in high risk obstetric cases.

A Review of Obstetric Cases in Intensive Care unit of a Tertiary Care Hospital of West Bengal

A Review of Obstetric Cases in Intensive Care unit of a Tertiary Care Hospital of West Bengal

A Study on Maternal and Perinatal Outcome in Referred Obstetric Cases of Gestational Age More Than 28 Weeks in a Rural Medical College Hospital

A Study on Maternal and Perinatal Outcome in Referred Obstetric Cases of Gestational Age More Than 28 Weeks in a Rural Medical College Hospital

Congenital vaginal atresia: A report of 39 cases in a regional Obstetrics and Gynecology Hospital.

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

Who accesses surgery at district level in sub-Saharan Africa? Evidence from Malawi and Zambia.

To examine age and gender distribution for the most common types of surgery in Malawi and Zambia. Data were collected from major operating theatres in eight district hospitals in Malawi and nine in Zambia. Raw data on surgical procedures were coded by specialist surgeons for frequency analyses. In Malawi female surgical patients had a mean age of 25 years, with 91% aged 16-40 years. Females accounted for 85%, and obstetric cases for 75%, of all surgical patients. In Zambia, female surgical patients had a mean age of 26, with 75% aged 16-40 years. They accounted for 55% of all cases, 34% being obstetric. Male surgical patients in Malawi were on average older (33 years) than in Zambia (23 years). General surgical cases in men and women, respectively, had a median age of 42 and 32 in Malawi and 26 and 30 in Zambia. The median age of trauma patients was 12 in males and 10 in females in both countries. Children aged 0-15 years accounted for 64-65% of all trauma cases in Malawi and 57-58% in Zambia, with peak incidences in 6- to 10-year-olds. Women of reproductive (16-45 years) mainly undergoing Caesarean sections and children aged 0-15 years who accounted for two-thirds of trauma cases are the main patient populations undergoing surgery at district hospitals in Zambia and Malawi. Verification and analysis of routine hospital data, across 10-30% of districts countrywide, demonstrated the need to prioritise quality assurance in surgery and anaesthesia, and preventive interventions in children.

Effects of secondary trimester maternal serum screening on the results of pregnancy

In our study it was aimed to research the relations between pregnancy complications and frequencies of maternal and fetal complications which can be observed after the further follow-ups with biochemical indicators in gravid individuals whom found to be risky in quad test.120 patients who applied and had their labors conducted in İstanbul Training and Research Hospital and took quad test AFP (alpha fetoprotein), HCG (human chorionic gonadotropin), uE3 (unconjugated estriol), inhibin-A are included in our study. Conclusions planned to be obtained in this study are, IUGR (intrauterine growth deficiency), macrosomia, gestational diabetes, preeclampsia and preterm birth. 64 (% 53, 4) out of 120 patients participated in the study had normal labors while 56 (%46, 6) of the patients had labors with caesarean birth. On 70 (%58.3) patients whom did not develop obstetric complications, AFP value calculated as average as 1.00±0.74 MoM, uE3 value calculated as 0.89±0.4 MoM, hCg value calculated as 0.97±0.5 MoM and inhibin A value calculated as an average of 0.95±0.5 MoM. On 50 (%41.6) patients whom developed obstetric complications, AFP value found as average of 1,06±0,74, uE3 value found as 0.96±0.39 MoM, hCG value found as 0.99±0.77 MoM and Inhibin A value found as 1.023±0.62 MoM. There were no significant deviation between the cases with obstetric complications and cases without obstetric complications in terms of AFP, uE3, HCG and Inhibin A values. There were no significant relation between threshold values of AFP, HCG, uE3 and inhibin A which are used in quad test as secondary trimester serum indicators in low risk populations and pregnancy complications.

The evaluation of early initiation breastfeeding implementation in dr. Mohammad Hoesin Hospital of Palembang, Indonesia: Complaints and barriers

Abstract Background: Early Initiation of Breastfeeding (EIB) is a worldwide health demand of both mother and child. EIB programme implementation is the duty and responsibility of all health care practitioners, ranging from executive staff and manager, which haven’t runs well in Dr. Moh. Hoesin hospital. Objective: To identify opportunities and challenges in running the EIB programme in Obstetric Department of Dr. Moh. Hoesin hospital. Method: In this cross sectional study, all of birth mothers and health professionals were included. Samples were selected by purposive sampling. Secondary data were obtained from the questionnaire respondents which have been tested for validity and reliability. Results: During November to December 2016 period, there were 19 (51.3%) patients did EIB while 18 (48.6%) others did not. Most patients in no EIB group had abdominal delivery (p = 0,003) and complained that no EIB policy in operating room. Most of EIB implementers (29 doctors and 14 midwives) stated that EIB were already done well but complained of low level of maternal EIB knowledge and lack of EIB practice support from hospital manager. While managerial staff (n = 12) blaming the EIB implementers worked attitude for this issue. Our study found disintegration EIB implementation between the managerial and implementer staff. Conclusion: Our hospital EIB implementation faces challenges, such no EIB policy in operating room, majority of patients are obstetric referral case with complication and unfit for EIB, managerial staff knowledge of EIB differ greatly, low socialization of EIB regulations and other elements of implementation, patient’s level of knowledge, disintegration between the manager and executive staff causing ambiguity in the implementation of the EIB, and the lack of supervision of EIB implementation in the field. Key words: early initiation of breastfeeding, challenge.

Monitoring and analysis of critical cases in obstetrics in northern-eastern region of the Republic of Kazakhstan in 2015-2017

National Research Center for Maternal and Child Health, part of corporate fund “University Medical Center” (NRCMC, CP “UMC”) conducted a monitoring and analysis of critical cases in obstetrics in 2015-2017. The purpose of the monitoring is to decrease the maternal deaths. The analysis was prepared based on the data presented by the regions. The methods of research are analysis of record forms of pregnant women, parturient women and new mothers in critical condition.

Obstetrical and Gynecological conditions requiring intensive admission from Basra maternity and child hospital A five year survey

Objective:- To assess the obstetrical and gynecological cases admitted to ICU, causes of admission, intervention required, and their morbidity and mortality.Methods :- During the five years period from 1st of Jan 2004 till 1st of Jan 2009, 119 patients were admitted to ICU. Cases were reviewed in detail including age, parity, reason for ICU admission, clinical features, response to intervention and maternal outcome.Result :- mean maternal age was (29.8±6) years the main causes for admission massive bleeding, complications of anesthesia followed by hypertensive disorders of pregnancy (42.8%) (21.8%) (18.4%) respectively, coagulopathy (36.1%) and respiratory failure (26.8%) were the main organ failure, most the admitted patients needed transfusion (50.4%) and ventilatory support (26.50%) specialized intervention like dialysis and surgical intervention were also required (20.1%) .Conclusion:- Invasive hemodynamic monitoring and ventilatory support were the two main interventions, improving quality of care before and after admission to ICU may reduce maternal mortality.

Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia

BackgroundTo estimate the cost-effectiveness of an ambulance-based referral system an dedicated to emergency obstetrics and neonatal care (EmONC) in remote sub-Saharan settings.MethodsIn this prospective study performed in Oromiya Region (Ethiopia), all obstetrical cases referred to the hospital with the ambulance were consecutively evaluated during a three-months period. The health professionals who managed the referred cases were requested to identify those that could be considered as undoubtedly effective. Pre and post-referral costs included those required to run the ambulance service and the additional costs necessary for the assistance in the hospital. Local life expectancy tables were used to calculate the number of year saved.ResultsA total of 111 ambulance referrals were recorded. The ambulance was undoubtedly effective for 9 women and 4 newborns, corresponding to 336 years saved. The total cost of the intervention was 8299 US dollars. The cost per year life saved was 24.7 US dollars which is below the benchmarks of 150 and 30 US dollars that define attractive and very attractive interventions. Sensitivity analyses on the rate of effective referrals, on the costs of the ambulance and on the discount rate confirmed the robustness of the result.ConclusionsAn ambulance-based referral system for EmONC in remote sub-Saharan areas appears highly cost-effective.

Renal cortical necrosis at autopsy: a 12 year experience at a tertiary care centre in Mumbai

Introduction: Renal cortical necrosis (RCN) is an unusual cause of acute renal failure but still causes significant mortality in developing countries. Objective: To review autopsies of histologically proven RCN reported in complete autopsies over the last 12 years. Methods: All autopsies performed from 2004-2016 with RCN were analyzed retrospectively. Results: A total of 13,896 autopsies were done at this centre over this twelve year period from 2004-2016. Of these, 26 cases were diagnosed as RCN, with an incidence of 0.19%. 978 of our total number of autopsies presented with Acute Kidney Injury (AKI) and the incidence of RCN in AKI was 2.7%. There were 844 maternal mortality deaths during this period of which 134 (15.9%) had AKI. RCN accounted for 2% of all maternal mortality deaths during this period. Obstetric cases amounted to 65.4% and non-obstetric cases to 34.6%. Pregnancy induced hypertension; intrauterine foetal death and postpartum hemorrhage were the leading causes of RCN amongst obstetric causes while septicemia, hemolytic uremic syndrome and poisoning were the leading non-obstetric causes. Microscopically, diffuse cortical necrosis was seen in 53.8% autopsies and patchy cortical necrosis was seen in 46.2% autopsies. Histopathology also showed intra-alveolar hemorrhage, bronchopneumonia, cerebral edema and acute respiratory distress syndrome. Conclusion: Our incidence of RCN was 0.19% at general autopsy, 2.7 % in autopsies with AKI and 2% of maternal mortality deaths at a tertiary care centre.RCN in AKI being 2.7% is significantly less than the 6-7% reported in developing countries. Diffuse pattern of cortical necrosis was more common than patchy cortical necrosis.

Bedside Safety Huddles to Manage a Complex Obstetric Case

Multidisciplinary communication is essential to safety in health care. Safety huddles offer an opportunity to develop and implement a standardized care plan to improve outcomes. This is especially true for complex obstetric cases. By conducting huddles at the bedside, a health care team can receive useful input from women and their families. This article describes our team’s use of safety huddles in the care of a woman with a complex health history and highlights the benefit of performing safety huddles at the bedside to improve team function and optimize outcomes.

A case series of urogenital fistulas

Background: Urogenital fistula is an abnormal fistulous communication that occurs between the bladder and cervix or uterus; between the ureter and vagina, uterus, or cervix; and between the urethra and vagina. Most cases in developing countries are of obstetric etiology, resulting from prolonged neglected obstructed labour, and around 1–2 per 1000 deliveries may be affected. The majority of UGFs in developed countries are a consequence of gynecological surgery, mainly hysterectomies. Present study focuses on the various presentations and the different modalities of surgeries done for cases of urogenital fistulas at our institute.Methods: A total 19 cases of urogenital fistula were studied in detail as per proforma. Two patients were operated on emergency basis because of early presentation in postoperative period. For others a pre-operative waiting period of 3-6 months was followed after development of fistula. During this period initially bilateral DJ stenting was tried in all patients, in hope of spontaneous closure of fistulas. Two patients whose fistulas closed spontaneously are not subjected to surgery. Rest all cases were managed surgically by standard surgical procedures.Results: Study was conducted between, February 2015 to February 2017. A total 19 patients studied. In 2 patients, fistula healed spontaneously while in 17 patients, surgery was needed. Most common age group affected is 2nd decade of life about 47.36%. In our study gynecological surgeries predominate with 57.89% followed by obstetric cases in 26.31%. Most of patients presented with continues dribbling of urine through vagina with normal voiding pattern in about 78.94% of cases. Overall transabdominal procedures had nearly 100% success rate, mainly because of better dissection, visualization and use of vascularized graft which prevents recurrence. 1 recurrence was seen in transvesical extraperitoneal approach because of undiagnosed another fistulous tract. Ureteric reimplantation was 100% successful in ureterogenital fistulas. Vaginal approach with use of Mortius flap had 75% success rate with 1 recurrence because of flap necrosis. Mean duration of surgery was 120 minutes and mean hospital stay was 8 days..Conclusions: Urogenital fistulas are the most distressing complications of obstetric and gynecological surgeries. Obstetric causes predominate in developing countries while gynecological surgeries predominate in developed countries. Despite the good results of surgical repair, attempt should be focused on the prevention of VVF.

Obstetric admissions to the critical care unit: a one year experience at a tertiary care referral centre of the developing country

Background: Care of the critically ill pregnant women presents a unique challenge as the assessment, monitoring and the treatment must take into account both maternal and fetal wellbeing as well as physiological changes of pregnancy.Objective: To assess the indications for critical care unit transfer of obstetric and postpartum cases and describe the profile and feto-maternal outcomes of such patients.Methods: This prospective observational study was conducted in department of Obstetrics and Gynaecology of Medical College and Hospital, Kolkata from 1st May 2013 to 30th April 2014.Total 50 cases were included and data was analysed by frequency, percentage, paired and unpaired t test, chi square test and test of equality of proportions using SPSS version 20.Results: 0.9% of total obstetric and postpartum admissions required critical care facilities and contributed to 16.67% of CCU admissions. Mean age of patients included in our study was 25.4 years. Most of the patients were admitted antepartum (n=37, 74%) with mean gestational age at admission being 34.2703+6.85018 weeks. More patients presented with obstetric complications (74%, n=37) as compared to medical complications (26%, n=13). The most common indication for admission were major haemorrhage (n=18, 36%) and hypertensive disorders of pregnancy (n=17, 34%). There were 16(32%) maternal deaths. MODS (31.25%) and hypovolemic shock (18.75%) were the most common causes of maternal death in our study. Conclusion: The overall mortality was high, emphasizing the need for dedicated obstetric high dependency units.

Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis

BackgroundPerinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals.MethodsPerinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model.ResultsOut of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths.ConclusionsFactors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival.

Malpractice and Obstetric Practice: The Correlation of Malpractice Premiums to Rates of Vaginal and Cesarean Delivery

(Am J Obstet Gynecol. 2016;545–546) Malpractice lawsuits can influence patient care, since the burden of professional liability could change the way physicians decide to manage care. Already, liability suits have caused 22% of providers to reduce their patient volume when it comes to high-risk obstetric cases, 14% to discontinue their obstetric practice altogether, and 9% to reduce all obstetric patient volume. Considering this correlation, the authors of this paper attempted to determine how the phenomenon of professional liability might impact the rate of cesarean delivery.

Post-dural puncture posterior reversible encephalopathy syndrome.

We report the case of a young patient with 36 weeks pregnancy, and an acute respiratory infection with severe bronchospasm, who developed an occipital headache and neck pain on the third day of inadvertent dural puncture during placement of combined epidural spinal anaesthesia for caesarian section. It was diagnosed as post-dural puncture headache until generalised tonic clonic seizures occurred the next day raising the suspicion of postpartum eclampsia or meningitis. Posterior reversible encephalopathy syndrome was diagnosed on MRI of the brain which showed features of reversible ischemia in the posterior region of the brain. With anticonvulsant therapy and antibiotics there was complete resolution of neurological symptoms. We highlight the importance of high index of suspicion of this reversible encephalopathy in obstetric cases with intentional or inadvertent dural puncture, with headache similar to post-dural punctural headache, and the essential role of neuroradiology in confirmation of the diagnosis, as placement of an epidural blood patch would be highly detrimental in these cases.

Sociodemographic characteristics and handling of life-threatening obstetric cases by traditional birth attendants in Cross River State, Nigeria

Background: Majority of pregnant women, especially in remote rural areas still desire to be delivered by traditional birth attendants (TBAs) who neither have the skills nor the equipment to treat life‑threatening complications. Objective: To determine the sociodemographic characteristics of TBAs and how they manage life‑threatening obstetric cases. Methodology: This was a prospective study carried out over a 3‑month period during the training of TBAs in the state on the reduction of maternal mortality. A total of 540 TBAs from 18 Local Government Area of the state participated in the study. Data obtained were sex, age, levels of education, number of deliveries conducted per month, difficult cases encountered, and how they managed them. The data were analyzed using Epi Info version‑7 and presented in tables. Results: TBAs are mostly females, i.e. 538 (99.6%) and only 2 (0.4%) were males. Majority of the TBAs were above the age of 55 years, i.e. 488 (88.9%); had primary education 416 (77.0%); married 396 (71.6%); and grand multiparous 293 (54.3%). Most TBAs deliver 4 newborn monthly, i.e. 148 (22.6%), and the mean number of newborn delivered monthly was 3.9. Concerning the mode of handling of the difficult cases, majority, i.e. 338 (62.6%) have a nurse/midwife they always call for assistance while only 147 (27.2%) refer their life‑threatening cases directly to the nearby hospital. Conclusion: TBAs still plays a role in deliveries in most rural and urban areas. Majority of TBAs do not refer their life‑threatening cases directly to the nearby hospital. Therefore, TBAs should be trained on how to identify life‑threatening cases and promptly refer to hospitals for better outcome. Keywords: Cross River State; delivery; emergency obstetrics; maternal mortality; traditional birth attendants