Good Maternal Outcomes Research Articles

428. Trials in low-resource settings: the INFORM study (oral misoprostol versus balloon induction in women with PIH or pre-eclampsia)

Between 62,000 and 77,000 women die annually from pre-eclampsia/eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low cost interventions -low dose oral misoprostol tablets and transcervical Foley catheterisation- are already used in low resource settings. In this open label, parallel randomised study, our objective was to compare their relative risks and benefits. 602 women with a live fetus requiring delivery for pre-eclampsia or hypertension were randomly assigned to labour induction with oral misoprostol 25 micrograms every 2 h (maximum of 12 doses) or a transcervical Foley catheter (size 18 F with 30 ml balloon) which remained until active labour started, the Foley catheter fell out, or 12 h elapsed. Randomisation was computer-generated with allocation concealment by opaque sequentially numbered sealed envelopes. Induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h, and trial registration as with ClinicalTrials.gov (NCT01801410). 302 women were allocated to misoprostol and 300 women to Foley catheter; all were analysed. More women in the misoprostol arm had a vaginal birth within 24 h (57.0% vs. 47.0%; absolute risk difference (RD) 10.0%, with 95%CI 2.0% to 17.9%). Rates of uterine hyperstimulation were very low in both groups (0.7% vs 0.3%; RD 0.3%; −0.8% to 1.5%) and no differences were seen in neonatal morbidity. More women in the misoprostol group would use the same method in the future should they require another induction (82.8% vs. 72.0%; RD 10.8%; 4.2% to 17.4%). Oral misoprostol 25 micrograms was more effective and more acceptable to women than a transcervical Foley catheter for induction of labour in women requiring delivery because of pre-eclampsia or hypertension. MRC/DFID/Wellcome Trust Joint Global Health Trials Scheme (Ref. G1100686/1).

Leadership and the functioning of maternal health services in two rural district hospitals in South Africa.

Maternal mortality remains high in Eastern Cape Province, South Africa, despite over 90% of pregnant women utilizing maternal health services. A recent survey showed wide variation in performance among districts in the province. Heterogeneity was also found at the district level, where maternal health outcomes varied considerably among district hospitals. In ongoing research, leadership emerged as one of the key health systems factors affecting the performance of maternal health services at facility level. This article reports on a subsequent case study undertaken to examine leadership practices and the functioning of maternal health services in two resource-limited hospitals with disparate maternal health outcomes. An exploratory mixed-methods case study was undertaken with the two rural district hospitals as the units of analysis. The hospitals were purposively selected based on their maternal health outcomes: one reported good maternal health outcomes (pseudonym: Chisomo) and the other had poor outcomes (pseudonym: Tinyade). Comparative data were collected through a facility survey, non-participant observation of management and perinatal meetings, record reviews and interviews with hospital leadership, staff and patients to elicit information about leadership practices including supervision, communication and teamwork. Descriptive and thematic data analysis was undertaken. The two hospitals had similar infrastructure and equipment. Hospital managers at Chisomo used their innovation and entrepreneurial skills to improve quality of care, and leadership style was described as supportive, friendly, approachable but ‘firm’. They also undertook frequent and supportive supervisory meetings. Each department at Chisomo developed its own action plan and used data to monitor their actions. Good performers were acknowledged in group meetings. Staff in this facility were motivated and patients were happy about the quality of services. The situation was different at Tinyade hospital. Participants described the leadership style of their senior managers as authoritarian. Managers were rarely available in the office and did not hold regular meetings, leading to poor communication across teams and poor coordination to address resource constraints. This demotivated the staff. The differences in leadership style, structures, processes and work culture affected teamwork, managerial supervision and support. The study demonstrates how leadership styles and practices influence maternal health care services in resource limited hospitals. Supportive leadership manifested itself in the form of focused efforts to build teamwork, enhance entrepreneurship and in management systems that are geared to improving maternal care.

Rituximab - A novel therapy for severe ITP in pregnancy: A case report.

Rituximab is a novel second-line agent for the treatment of immune thrombocytopenic purpura. Minimal data exist on the use of rituximab in pregnancy. This case illustrates the successful treatment of severe immune thrombocytopenic purpura diagnosed in pregnancy, refractory to all other medical management. A 32-year-old nulliparous woman was diagnosed with severe immune thrombocytopenic purpura at the time of booking for antenatal care (platelet level of 13 × 109/L). Standard treatment failed to adequately increase her platelet count. Therapy with rituximab was instituted, and her platelet count rose to normal levels, without side effects, and remained at a normal level throughout the pregnancy. There were no maternal or neonatal ill-effects of rituximab therapy. Rituximab is potentially a safe treatment option for the management of immune thrombocytopenic purpura in pregnancy with good maternal and neonatal outcome when conventional treatments have been unsuccessful. Research is limited to case reports, and therefore limited information currently exists to guide clinicians.

Perinatal Outcomes of 40 Pregnancies with Familial Mediterranean Fever

Objective : To evaluate maternal and fetal outcomes of pregnancies diagnosed with Familial Mediterranean Fever (FMF) Methods : Retrospective analysis of 40 pregnancies diagnosed with FMF who received antenatal care at our perinatology unit between 2012 -2017 included in this clinical study. Clinical characteristics of patients, perinatal and maternal outcomes were evaluated. Results : The mean patient age was 30.75 ±6.15 and the nulliparity rate was 42,5 %. The mean duration of illness was found to be 8,36 ± 5.44 years. 7 patients had an attack during pregnancy. 90 % of the patients received medical treatment. Mean gestational age at delivery was 37,3±4.5 , mean birth weight was 3115±547 g. Preterm delivery, fetal growth restriction and preeclampsia rates were 10, 5, 10 % respectively. Fetal and neonatal loss, congenital anomalous birth was not observed. Conclusion: Multidisciplinary approach to the care of pregnancy diagnosed with FMF is associated with good maternal and fetal outcomes.

Abstract No. 575 A retrospective analysis of a single-center experience with percutaneous nephrostomy during pregnancy

Percutaneous nephrostomy has been used to treat symptomatic renal obstruction. Although there have been small published series describing safety and efficacy, this study assesses our experience over 12 years placing PCNs in pregnant women in a tertiary care academic medical center. In this IRB approved study, all patients undergoing percutaneous nephrostomy (PCN) from 7/1/2005 through 7/1/2017 were identified through a Hi-IQ database search. Only patients who were pregnant at the time of PCN placement were included. A retrospective review was performed to include demographics, gestational age, clinical indications, technical success, maternal outcome, fetal outcome, and complications. Twenty-one subjects were included with a median age of 28 (range, 19-38). The median gestational age at the time of intervention was 26 weeks (range, 8-38). Of the 21 patients undergoing percutaneous nephrostomy 7 (33%) had hydronephrosis secondary to calculi, 7 (33%) due to congenital ureteral dysfunction and childhood ureteral re-implantation, 2 (10%) had failed internal ureteral stenting, 2 (10%) had urosepsis. There was one case each of the following: gravid uterus with ureteral compression, ureteral trauma in the setting of surgery for presumed ovarian torsion, and hydronephrosis with associated flank pain. Eleven (52%) patients had moderate hydronephrosis, 8 (38%) had severe hydronephrosis, and 2 (10%) had mild hydronephrosis. Technical success was 100% (21/21). 91.5% of pregnancies continued to term. One fetus in the cohort was delivered prematurely at 31 weeks (4.7% preterm delivery). One pregnancy was terminated as it was undesired. There were no major or minor complications related to the procedure. Percutaneous nephrostomy during pregnancy has excellent technical success and good maternal and fetal outcomes.

Childhood Onset Nephrotic Syndrome-A Journey Through Two Pregnancies

Nephrotic Syndrome (NS), a unique renal disease complex associated with heavy proteinuria (protein excretion >3.5 gm/day), hypoalbuminemia (<30 gm/L) and peripheral oedema. It is a rare entity in pregnancy, with an incidence of about 0.012-0.025%. There have been very few reports of pregnancy with co-existing NS. We hereby report a case of steroid sensitive childhood onset NS, due to minimal change disease and her course through two pregnancies. While she had a relapse of NS during her first pregnancy, she sailed through her second pregnancy without relapse. Women with NS can have a good maternal and perinatal outcome with multidisciplinary approach. Pregnancy does not always worsen the existing NS by causing a relapse or disease progression.

A Case Report of Transient Exertional Hypoxemia in Pregnancy and Review of Hereditary Hemorrhagic Telangiectasia

A 27-year-old G3P1011 presented at 34 weeks gestation with dyspnoea, which she also reported in her prior pregnancy. Her dyspnoea was accompanied by exertional hypoxemia. After excluding other etiologies of hypoxia such as cardiac anomalies and pulmonary embolism, arterio-venous shunting became the working diagnosis. She was treated successfully with ambulatory oxygen therapy and her symptoms resolved spontaneously after delivery with a good maternal and fetal outcome. Although we were unable to confirm a diagnosis of arteriovenous malformation of hereditary hemorrhagic telangiectasia, we remain suspicious that this is the underlying cause of her symptoms. Review of hereditary hemorrhagic telangiectasia identifies concerns regarding screening and obstetric management. Hereditary hemorrhagic telangiectasia is a rare genetic disease that may present as transient exertional hypoxemia in the third trimester of pregnancy. Pregnancy with arteriovenous shunting can be managed with symptomatic treatment along and careful attention to existing obstetric and anesthetic guidelines.

Labor Pattern Among Primigravida in Local Population.

In this study, we tried to make the customized labor curve by studying the labor pattern among the primigravidas and we compared the cervicograph with Zhang's and Suzuki's curves. This study may be a motivator for future research to create own labor norms for our Indian population which may help in reducing the cesarean section rates, principally in primigravidas. It was a prospective observational study, which included 156 primigravidas with uncomplicated term singleton pregnancy with spontaneous onset and progression of labor, who had normal vaginal delivery with good maternal and neonatal outcome. The shape of the labor curve of this study was similar to Zhang' and Suzuki-Horiuchi's curves which had slower progression. The active phase started from 5 to 6cm of cervical dilatation onwards which was similar to Suzuki-Horiuchi's curve. In the present study, the mean rate of cervical dilatation in the active phase was 1.5cm/hour in contrast to Friedman's study which had a mean rate of cervical dilatation of 3cm/hour with lower limit of 1.2cm/hour as 5th centile. In the present study the mean rate of cervical dilatation in active phase in Indian women was approximately equivalent to the lowest acceptable rate of cervical dilatation in Friedman's study. If we continued to follow Friedman's labor norms, it could result in increasing c-sections. Hence, it would be prudent to create a customized labor curve for the local population served based on their individual characteristics features.

MANAGEMENT OF ENDOCRINE DISEASE: Fertility, pregnancy and lactation in women with adrenal insufficiency.

With the introduction of hormonal substitution therapy in the 1950s, adrenal insufficiency (AI) has been turned into a manageable disease in pregnant women. In fact, in the light of glucocorticoid replacement therapy and improved obstetric care, it is realistic to expect good maternal and fetal outcomes in patients with AI. However, there are still a number of challenges such as establishing the diagnosis of AI in pregnant women and optimizing the treatment of AI and related comorbidities prior to as well as during pregnancy. Clinical and biochemical diagnoses of a new-onset AI may be challenging because of overlapping symptoms of normal pregnancy as well as pregnancy-induced changes in cortisol values. Physiological changes occurring during pregnancy should be taken into account while adjusting the substitution therapy. The high proportion of reported adrenal crisis in pregnant women with AI highlights persistent problems in this particular clinical situation. Due to the rarity of the disease, there is no prospective data-guiding management of pregnancy in patients with known AI. The aim of this review is to summarize the maternal and fetal outcomes based on recently published case reports in patients with AI and to suggest a practical approach to diagnose and manage AI in pregnancy.

Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial

Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions-low-dose oral misoprostol tablets and transcervical Foley catheterisation-are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions. We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 μg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410. Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0-17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI -0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, -1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1). Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets. Medical Research Council, Department for International Development, and Wellcome Trust Joint Global Health Trials Scheme.

Pregnancy, Genetic Risk and Congenital Heart Disease

An increasing number of women with congenital heart disease (CHD) are reaching childbearing age and are considering pregnancy. Pregnancy is tolerated well in most of these women with unoperated, or repaired cardiac lesions; however, the risk is increased considerably in certain situations such as pulmonary hypertension, severe valvular stenosis, pulmonary atresia, mechanical prosthetic valves, with Fontan type circulation, in Marfan syndrome and other aortopathy. Counseling prior to pregnancy in CHD also involves discussion of genetic testing, possibility of transmission to the child, management during pregnancy including preimplantation genetic testing, and recommendations regarding fetal echocardiography. All medications including anticoagulation options if needed should be carefully reviewed prior to pregnancy due to maternal and fetal risks. If needed, cardiac surgery or balloon valvuloplasty can be carried out with an increased risk to mother and fetus. Overall, pregnancy in CHD is feasible in most patients with good maternal and fetal outcome. High risk pregnancy patients with CHD have to be counseled by a multidisciplinary team including cardiologists, obstetricians and anesthesiologists at a tertiary care center.

Acute Pancreatitis in Pregnancy: Maternal and Fetal Outcomes

ABSTRACT Aim and objective To evaluate the maternal and fetal outcomes in patients with acute pancreatitis. Materials and methods It is a retrospective observational study. A total of three patients were admitted with acute pancreatitis complicating pregnancy between January 2013 and June 2015 in the Department of Obstetrics and Gynaecology, M. S. Ramaiah Medical College and Hospital, Bengaluru, India, and were followed up until after delivery. Results Incidence of acute pancreatitis in our study was 1 in 1,620. Mean age was 24 years, and 33.3% were multiparous. Mean gestational age at onset was 33 weeks. One patient (33.3%) in our study had hypertriglyceridemia (870 mg/dL), and 66.7% of patients were idiopathic. The most common complaint was epigastric pain radiating to back. All patients showed leukocytosis and elevated amylase and lipase levels. Ultrasound showed [1] enlarged pancreas with decreased peripancreatic echogenicity and [2] pelvic and abdominal cavity effusions, in all the patients. All patients were managed conservatively in the intensive care unit. Mean duration of hospital stay was 7 days; 33.3% patients developed acute respiratory distress syndrome; 33.3% patients went into preterm spontaneous vaginal delivery. Cesarean section rate was 66.7%. Perinatal mortality was 33.3%. Conclusion Acute pancreatitis in pregnancy remains a challenging clinical problem to manage. The initial assessment, severity, and the initial management of the patient are of great importance in order to support the function and to prevent maternal and fetal mortality and morbidity. Clinical significance Acute pancreatitis either in its mild or its severe form causes maternal and fetal morbidity. However, these rates are declining due to early diagnosis and greater treatment options. Multidisciplinary approach leads to good maternal and fetal outcomes. How to cite this article Jyothi GS, Bhoosanoor SR, Swarup A. Acute Pancreatitis in Pregnancy: Maternal and Fetal Outcomes. J South Asian Feder Obst Gynae 2017;9(2):100-103.

An Unusual Case of Severe Preeclampsia in the Postpartum Period with Hemoperitoneum

ABSTRACT Background HELLP syndrome, consisting of hemolysis, elevated liver enzymes, and low platelet count, is a rare complication of occurring in 10 to 20% of women with severe preeclampsia and in 0.2 to 0.6% of total pregnancies. Delivery is the only definitive treatment, with maternal condition usually improving in the postpartum period. Hemoperitoneum in a woman with preeclampsia is very rare, usually secondary to hepatic hematoma with rupture. While the prevalence of intrahepatic hematoma in these women has been reported to be as high as 39%, capsular rupture is rare, occurring up to 12% in women with capsular hematoma, carrying with it high mortality for both the mother and fetus. Aim We report an unusual case of hemoperitoneum secondary to liver hematoma in severe preeclampsia in the postpartum period that was conservatively managed leading to good maternal outcome. Case report We report a case of postpartum onset of severe preeclampsia in a 25-year-old woman complicated by hepatic dysfunction with coagulopathy and hemoperitoneum. This was secondary to a contained subcapsular hematoma and was conservatively managed resulting in a good outcome. Conclusion Prompt recognition with careful clinical examination, laboratory investigations and imaging, supportive treatment, and early fetal delivery remain the cornerstone in the management. Although reaching the diagnosis was initially challenging in our case study, both mother and baby had a good outcome with an appropriate supportive treatment. Clinical significance Most cases with liver hematomas may lead to hepatic rupture with hemodynamic instability, necessitating an aggressive operative approach. However, conservative management with close monitoring of hemodynamic status can be undertaken if the patient is hemodynamically stable with good outcome, as illustrated in this case. How to cite this article Loh M, Kathirvel R. An Unusual Case of Severe Preeclampsia in the Postpartum Period with Hemoperitoneum. J South Asian Feder Obst Gynae 2017;9(4):363-366.

Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system.

To describe the incidence of mechanical prosthetic heart valves (MPHV) in pregnancy in the UK; rates of maternal and fetal complications in this group of women, and whether these vary with the anticoagulation used during pregnancy. Prospective descriptive population-based study. All consultant-led maternity units in the UK. All women with an MPHV who were pregnant between 1 February 2013 and 31 January 2015. Collection and analysis of anonymous data relating to pregnancy management and outcome, using the UKOSS notification and data collection system. Maternal death, serious maternal morbidity, poor fetal outcome. Data were obtained for 58 women giving an estimated incidence of 3.7 (95% CI 2.7-4.7) per 100 000 maternities. There were five maternal deaths (9%); a further 24 (41%) suffered serious maternal morbidity. There was a poor fetal outcome from 26 (47%) pregnancies. Only 16 (28%) women had a good maternal and good fetal outcome. Low-molecular-weight heparin (LMWH) was used throughout pregnancy by 71% of women. Of these, 83% required rapid dose escalation in the first trimester. Monitoring regimens lacked consistency. This study has estimated the incidence of MPHV in pregnant women in the UK. It includes the largest cohort managed with LMWH throughout pregnancy reported to date. It demonstrates a high rate of maternal death, and serious maternal and fetal morbidity. Women with MPHVs, and their clinicians need to appreciate the significant maternal and fetal risks involved in pregnancy. Care should be concentrated in specialist centres. High rates of poor maternal and fetal outcomes in pregnant women with mechanical prosthetic heart valves.

Bridge Suture for Successful McDonald Emergency Cerclage

Objectives: To create awareness about a surgical technique termed bridge suture, which is performed as a pretreatment before a McDonald cerclage is performed on an emergency to treat severe cervical insufficiency. Methods: Procedures for bridge suture were reviewed in detail and outcomes of 16 patients treated with bridge suture followed by McDonald cerclage were evaluated retrospectively. Results: Using the bridge suture, the edges of uterine cervix were temporarily sutured and the external uterine os was closed, while the hourglass-shaped fetal membranes were concomitantly confined within the cervix; subsequently, a McDonald cerclage was performed. Over a 22-year period, 16 patients with a dilated cervix and bulging fetal membranes were treated using the technique of bridge suture followed by an emergency cerclage. The mean gestational age at cerclage was 22.5 weeks; the mean gestational age at delivery was 30.7 weeks; and the mean interval between cerclage and delivery was 8.2 weeks. In 15 out of 16 cases, cerclage was performed without encountering any complications. No maternal complications, including cervical laceration, were observed. The mean body weight of 17 neonates, including that of a twin, was 1,516 g and of them, 15 neonates survived. Conclusion: The important outcome of bridge suture is the replacement of fetal membranes back into the uterine cavity before McDonald's cerclage is performed. Pretreatment with bridge suture may facilitate the performance of a successful emergency cerclage and contribute to good maternal and neonatal outcomes.

Higher Educational Attainment Associated with Optimal Antenatal Care Visits among Childbearing Women in Zambia.

Attendance of at least four antenatal care (ANC) visits over the period of pregnancy has been accepted by World Health Organization to comprise the optimal and adequate standard of ANC because of its positive association with good maternal and neonatal outcomes during the prenatal period. Despite free ANC being provided, many pregnant women have been found not to meet this minimum number of ANC visits in Zambia. We investigated if educational attainment is associated with optimal ANC visits among childbearing women in Zambia. Data stem from the 2007 Zambia Demographic and Health Survey for women, aged 15-49 years, who reported ever having been pregnant in the 5 years preceding the survey. The linked data comprised sociodemographic and other obstetrical data, which were cleaned, recoded, and analyzed using STATA version 12 (Stata Corporation, College Station, TX, USA). Multivariate logistic regression was used to examine the association of educational attainment and other background variables. Women who had higher education level were more likely to attend at least four ANC visits compared to those with no education (AOR 2.8, 95% CI 1.51-5.15; p = 0.001); this was especially true in the urban areas. In addition, women with partners with higher education level were also more likely to have optimal ANC attendance (OR 2.0, 95% CI 1.3-3.1; p = 0.002). Educational attainment-associated differentials found to be linked with optimal ANC attendance in this population suggests that access to health care is still driven by inequity-related dynamics and imbalances. Given that inequity stresses are heaviest in the uneducated and probably rural and poor groups, interventions should aim to reach this group. The study results will help program managers to increase access to ANC services and direct interventional efforts towards the affected subpopulations, such as the young, uneducated, and rural women. Furthermore, results will help promote maternal health education and advise policy makers and program implementers.

Secondary Advanced Abdominal Pregnancy after Suspected Ruptured Cornual Pregnancy with Good Maternal Outcome: A Case with Unusual Gangrenous Fetal Toes and Ultrasound Diagnoses Managed by Hysterectomy

Incidence of abdominal pregnancy is accounting for 1.4% of all ectopic pregnancies. This is a rare case report of a 35-year-old multigravida who was presented to our hospital at 24 weeks of gestation with advanced live intraabdominal pregnancy diagnosed by ultrasound. The patient was followed up till 28 weeks in hospital for medicolegal viability in Egypt. Midline laparotomy was done, a live baby was delivered, and hysterectomy was done for attached placenta. Mother was discharged in good health, and baby was admitted in neonatal intensive care unit with no congenital anomalies and died after three weeks of sepsis. The management of advanced abdominal pregnancy remains controversial. Diagnosis and management of advanced abdominal pregnancy is still a challenge to today’s medical world. But high index of suspicion aided with imaging studies can help in timely diagnosis, thereby preventing the associated life-threatening complications.

Pregnancy Management of Women with Coronary Artery Aneurysm Due to Kawasaki Disease During Childhood: Case Report and Review of the Literature

Kawasaki disease (KD) is an acute systemic vasculitis occurring during childhood. It could be associated with persistent heart defects such as coronary artery aneurysms (CAA). During pregnancy, there is a theoretical high risk of full myocardial infarction and sudden death. Guidelines do not exist but case report studies found in the literature show that these pregnancies could have a good maternal and fetal outcome dependent upon a careful follow pre-conceptional counselling is important for evaluating the cardiological risk factors. Maternal cardiovascular complications are rare when anticoagulation therapy is given. Low dose aspirin is safe and prescribed to patients with coronary aneurysms. For the management of labour and delivery, assisted second stage of labour with locoregional anesthesia is recommended. C-sections should be offered only to patients with severe cardiological conditions or for obstetrical reasons. In conclusion, multidisciplinary team management of pregnant patients with KD sequellae remains a challenge but is essential for a favourable outcome of the pregnancy.

Epidural anesthesia: A safe option for cesarean section in parturient with severe pulmonary hypertension

Rheumatic heart disease is the most common cardiac disease complicating pregnancy in developing countries. Heart disease accounts for 15% pregnancy-related mortality. In the presence of maternal heart disease, the circulatory changes of pregnancy may result in exacerbation of the hemodynamic perturbations due to complex cardiac valvular lesions leading to decompensation or death of mother or fetus. Determining the ideal anesthetic technique for cesarean section in the presence of complex cardiac conditions remains a much debated topic. General anesthesia is associated with a further increase in pulmonary pressure in response to laryngoscopy and intubation along with myocardial depression by anesthetic agents. Neuraxial blockade may lead to decrease in systemic vascular resistance and cardiac output. We report the successful anesthetic management of a parturient suffering from rheumatic heart disease with multivalvular lesions resulting in severe pulmonary hypertension under epidural anesthesia with good maternal and neonatal outcome. Successful management requires vigilant perioperative monitoring and thorough knowledge of the hemodynamics of complex cardiac valvular disease.

Effectiveness of selected nursing intervention on maternal and newborn outcome among primigravida mothers at selected hospitals

Back ground : Labour is one of the most common stressed and painful situations which adversely affect the maternal and new born outcome leads to many complications. Objective : To assess the effectiveness of selected nursing intervention on maternal and newborn outcome among primigravida mothers. Design : One group true experimental post test only design was adopted for the study. Setting : Government Hospital, Cheyyur, Participants : 20 primigravida mothers completed thirty six weeks of gestation fulfilling the inclusion criteria were selected by simple random sampling. Methods : Nursing interventions like Breathing exercise, massage, position changes implemented during intrapartum period and level of pain perception assessed with universal pain assessment tool during uterine contractions of first stage of labour. Followed by early initiation of breast feeding done through breast crawl technique. Maternal and newborn outcome assessed with ongoing assessment tool. Collected data was analyzed by using descriptive and inferential statistics. Results : In post test the mean score for the level of pain perception in experimental group was 6.5 (SD=1.58) and the control group was 9.1 (SD=0.88) with paired t' value of 4.55. The mean score of experimental group maternal outcome was 23 (SD =3.13) and the control group outcome was 27.4(SD=4.62) with paired t' value of 2.49. In experimental newborn outcome the mean score was 7.7 (SD=1.06) and control group newborn outcome score was 6.8(SD=0.92) with paired t value of 2.04. This showed that the selected nursing interventions were effective for good maternal and newborn outcome during labour. There was a statistically no significant association found between the post test score of the sample with their demographic variables. Conclusion : The findings imply the need for non pharmacological methods of nursing interventions were effective management during labour among primigravida mothers.