History Of Previous Cesarean Section Research Articles

Low placenta at the mid trimester anomaly scan—A cause for concern?

AbstractObjectiveThis study was aimed to assess the predictive validity of internal os distance (IOD) in mid‐trimester scan for the prediction of third‐trimester low‐positioned placenta, and to define a cut‐off of IOD at which third‐trimester low‐positioned placenta could be identified, see the association of placental site (anterior/posterior), previous history of cesarean section with abnormal location of placenta in third trimester and see the maternal and neonatal outcomes.MethodsIt was a prospective cohort study of women with low‐positioned placenta (IOD < 20 mm) at mid‐trimester anomaly scan followed up in third trimester till birth. Relative risks for a low‐positioned placenta in the third‐trimester were calculated for women with posterior versus anterior, low‐lying placenta versus placenta previa and positive versus negative history of cesarean section. Multilevel likelihood ratios and corresponding ROC curves for different ranges of IOD were calculated.ResultsWomen with posterior placenta had a high risk of low positioned placenta compared to anterior placenta (9.28% vs. 0.74%); RR 1.45, similarly women with placenta previa had high risk compared to low lying placenta (68.57% vs. 1.69%); RR 6.51, so did the women with previous cesarean section (9.41% vs. 5.87%); RR 1.47.Conclusions93.42% placenta which were low positioned in mid trimester were normally situated in third trimester. The cut‐off for IOD in anterior placenta was −40 mm and in posterior placenta was 14.3 mm. IOD measurement and interpretation seems promising.

Maternal Outcome of Pregnancy with Previous History of Caesarean Section with Central Placenta Previa Admitted into DMCH Gynae Department (6 months study)

Background: Placenta previa, a condition where the placenta is abnormally positioned in the lower uterine segment, poses significant risks to both maternal and neonatal health. It has become more prevalent with increasing cesarean deliveries, advanced maternal age, high parity, and assisted reproductive technologies. The impact of placenta previa on subsequent pregnancies, especially in women with a history of cesarean sections, remains an area of concern due to potential complications such as hemorrhage, transfusion needs, and adverse outcomes like peripartum hysterectomy. Objective: This study aimed to assess the maternal and neonatal outcomes in pregnancies with a history of cesarean sections complicated by central placenta previa, admitted to the Department of Obstetrics and Gynecology at DMCH from January 2023 to June 2023. Methodology: A Descriptive Cross sectional study was conducted using medical records from the Department of Obstetrics and Gynecology at DMCH. We analyzed data from 104 women with central placenta previa and previous cesarean sections. Diagnostic criteria were based on trans-abdominal or transvaginal ultrasound. Statistical analysis was performed using SPSS v21.0, employing chi-square and Mann–Whitney U tests for categorical and continuous variables, respectively. Multivariate analysis assessed the association between a history of placenta previa and adverse maternal and neonatal outcomes, with significance set at P < 0.05. Results: The majority of patients were aged between 29-39 years (58.7%). Most had a parity of 1 or 2 (75.0%) and were in their 3rd or 4th gravida category (64.4%). A predominant number were between 35-38 weeks gestation (68.3%). APH was present in 65.4% of patients, and the average number of transfusions required was 4. The uterus was preserved in 63.5% of cases. 36.5% cases peripartum hysterectomy was performed. Maternal outcomes showed a 93.3% improvement rate, with 6.7% mortality. Neonatal outcomes included 86.5% .....

Navigating the unexpected: Insights into bladder injuries during emergency cesarean deliveries

Bladder injury is a recognized complication of emergency cesarean sections, yet comprehensive studies elucidating its incidence and associated risk factors are limited. This retrospective study analyzed data from emergency cesarean deliveries performed over a three-year period at a tertiary care center. Cases with documented bladder injury were identified, and relevant clinical variables including patient demographics, surgical details, various risk factors, and obstetric history were collected and analyzed.Among the emergency cesarean cases reviewed (n= 12218), bladder injury was identified in 22 cases making a incidence rate of 0.18%. The majority of injuries occurred during the initial phase of uterine incision. Significant risk factors associated with bladder injury included a history of previous cesarean sections, presence of adherent placenta, and intraoperative adhesions. Distribution analysis revealed varying prevalence rates across different clinical variables.Bladder injury represents a notable complication of emergency cesarean deliveries, necessitating a comprehensive understanding of associated risk factors and preventive measures. This study contributes valuable insights into the epidemiology and clinical correlates of bladder trauma in urgent obstetric interventions, emphasizing the importance of tailored interventions to enhance patient safety and reduce maternal morbidity.

Acquired uterine arteriovenous malformation after cesarean section

HIGHLIGHTS 1. Acquired uterine arteriovenous malformation (AVM) is an uncommon sequela of cesarean section, warranting consideration in instances of persistent uterine bleeding in the puerperium.2. Embolization represents a viable and well-established treatment modality for AVM, providing a safe and efficacious intervention that serves as an alternative, less invasive modality for patients desiring fertility preservation. ABSTRACT Objectives: To demonstrate that embolization is a viable and well-established treatment for acquired arteriovenous malformations (AVMs), offering a safe and effective, less invasive option for patients seeking to preserve fertility.Case Report: A 20-year-old female experiencing recurrent massive bleeding with a history of previous caesarean section and wound infection resuturing. The transvaginal color Doppler ultrasound showed a hypervascularity in the uterus around the surgical lesion, suggesting a uterine AVM and its confirmed by angiography. The patient underwent a series of uterine artery embolization interventions, which proved to be a successful therapeutic approach. As a result of this treatment modality, not only was the patient's condition effectively resolved, but her fertility was also preserved.Conclusion: Acquired uterine arteriovenous malformation (AVM) is an uncommon sequela of cesarean section, warranting consideration in instances of persistent uterine bleeding in the puerperium. Embolization represents a viable and well-established treatment modality for AVM, providing a safe and efficacious intervention that serves as an alternative, less invasive modality for patients desiring fertility preservation.

PREVALENCE AND ATTITUDE OF WOMEN REGARDING CESAREAN SECTION IN DUHOK CITY-KURDISTAN REGION

Background: The decision of pregnancy delivery mode is important for both mother and fetus health. Although the advancement in surgical approach of cesarean section, the cesarean section has a negative impact on mothers and fetuses health. Objective: To assess the rate of cesarean section in a sample of women in Duhok city and their attitudes toward cesarean section. Methodology: Present study was a descriptive cross sectional that carried out in Obstetrical & Gynecological Clinics of Maternity Hospital, Primary Health Care Centers, Internally Displaced and Refugee Camps and Private Obstetrics Clinics at Duhok city-Kurdistan region/Iraq through duration period of one year from first of November, 2021, to 31st of October, 2022 on sample of four hundred pregnant women. The decision of previous cesarean section for studied women was done by Senior Obstetrician & Gynecologist according to different reasons (clinical or non-clinical). Results: The history of previous cesarean section was positive in 39.8% of pregnant women, with a common frequency of one cesarean section (58.5%). Most pregnant women perceived that normal delivery is better, while 9% perceived that cesarean section is better. In the same way, 87% of pregnant women preferred normal delivery, while 13% preferred cesarean section. Only 20% of pregnant women believed that cesarean section is the normal way of delivery, while 68% of them thought that mother with a history of cesarean section has a normal delivery in the future. However, 79% of pregnant women believed that mother had a risk of death during cesarean section. Conclusions: The cesarean section rate in Duhok city is higher than acceptable recommended rate, although the positive attitude of pregnant women toward normal vaginal delivery.

Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study

BackgroundCaesarean section (CS) rate increased dramatically worldwide, exceeding the World Health Organization's benchmark (10–15 %) in many countries. This rate varies in different regions of the continent. Using various study designs, researchers from across East African countries investigated the prevalence of caesarean section and the factor associated with it but no study shows a pooled prevalence of caesarean section in the Eastern African region. Therefore, this review aimed to systematically summarize and estimate the pooled prevalence of caesarean section and its associated factors in Eastern Africa, 2023. MethodsPubMed, Web of Science, EMBASE, Scopus and CINAHL were rigorously searched to find relevant studies. All identified observational studies reporting the prevalence of CS and its associated factors in East Africa published till August 2023 were considered. Heterogeneity across the studies was evaluated using the I2 test. Publication bias was assessed by funnel plot and Egger's regression test. Finally, a random effect meta-analysis model was computed to estimate the pooled prevalence of CS and qualitative analysis was employed for associated factors. The study protocol was registered in PROSPERO. ResultsThis review was assessed using twenty-six eligible studies from a total of 2223 articles with a total of 600,431 participants. In this meta-analysis, the pooled prevalence of caesarean section in Eastern Africa was 24.0 % (95%CI: 22–27 %). The highest pooled prevalence of caesarean section was in Ethiopia, 28.30 % (95%CI; 21.3–35.2 %), and the lowest was seen in Uganda, 11.9 % (95%CI; 7.9–15.9 %). Urban residency, having high level of wealth asset, education level college and above, advanced maternal age, big birth weight, history of previous caesarean section, private institution delivery, multiple pregnancies, pregnancy-induced hypertension, antepartum haemorrhage and fetal malpresentation were linked with a greater likelihood of having CS. Conclusionsand recommendation: The overall pooled prevalence of CS in Eastern Africa was high compared to the WHO proposed recommended range. Therefore, the finding implies that each East African countries Ministry of Health and health care professionals shall be given particular emphasis made on strengthening antenatal care services and ensure more women have access to skilled healthcare professionals during childbirth. This can help in providing appropriate interventions, support to women and reducing the need for emergency and unnecessary CSs. The result of this research are a baseline data for future researchers to conduct further studies to better understand the reasons behind the high rates and identify potential interventions and solutions specific to the African context.PROSPERO protocol number: CRD42023440131.

Anaesthesia for Emergent Caesarean Section: A Population-based Study on Icelandic and Migrant Women during 2007-2018

General anaesthesia for emergent caesarean section, though uncommon, is vital in expediting deliveries. Studies indicate higher complication risks among pregnant migrant women. This research investigates if migrant women in Iceland are more likely to undergo general anaesthesia for emergent caesarean section compared to their Icelandic counterparts. This population-based cohort study analysed 4,415 emergency caesarean sections in Iceland between 2007 and 2018, sourced from the National Birth Registry. Participants were categorized by citizenship, with migrants further stratified by their country's Human Development Index (HDI). NCSP-IS and ICD-10 codes indexed diseases, interventions, and complications. The impact of variables was assessed through multiple logistic regression analysis. Migrant women received general anaesthesia in 16.1% of cases, slightly surpassing Icelandic women's 14.6%. Adjusting for risk factors showed no increased risk for migrant women. However, they had a higher likelihood of urgent caesarean sections (OR 1.45, 95% CI 1.08-1.94, p=0.015), a known risk factor for general anaesthesia, despite fewer comorbidities. Adjusting for confounders revealed reduced odds with a history of previous caesarean section (aOR 0.73, 95% CI 0.59-0.89, p=0.003) and placement of epidural anaesthesia in the delivery room (aOR 0.49, 95% CI 0.40-0.60, p< 0.001). Migrant women in Iceland do not face increased risks of general anaesthesia for emergent caesarean sections. However, their elevated risk of urgent caesarean sections suggests potential challenges, including language barriers or inadequate antenatal care. Early information dissemination and targeted interventions may mitigate these risks in this vulnerable community.

Anterior abdominal wall desmoid tumors: Reconstructive considerations and challenges in an oncoplastic unit in a low- and middle-income country: A case report

Desmoid tumors (DTs) are rare, locally aggressive tumors. When left untreated, DT can rapidly proliferate and occupy a significant portion of the anterior abdomen, making postresection reconstruction challenging. We present a 32-year-old female with a previous history of cesarean section and a 10-month history of two rapidly growing anterior abdominal wall (AAW) masses. There was no clinical or radiologic evidence of distant metastases. Abdominopelvic computed tomography scan showed no intra-abdominal extension. She had a wide local excision of the masses using an “abdominoplasty” technique and reconstruction of the extensive musculofascial defect with fascia lata grafts and polypropylene mesh. A histologic diagnosis of desmoid-type fibromatosis was made. The patient is scheduled for adjuvant radiotherapy and desires future pregnancies. This case report highlights the reconstructive considerations and challenges associated with surgical resection of huge AAW DT in an oncoplastic unit in a low- and middle-income country.

The Association of Age, Parity, and History of Cesarean Section with the Occurrence of Placenta Accreta Spectrum (Pas) at H. Adam Malik Hospital in Medan 2020-2022

Background: Maternal mortality rate (MMR) is an indicator of the quality of midwifery services in a country. Postpartum hemorrhage is a serious life-threatening complication and the main cause of maternal death especially that caused by placenta accreta spectrum (PAS). This study aims to determine the relationship between age, parity, and history of cesarean section on the incidence of PAS at H. Adam Malik Hospital Medan in 2020-2022.Method: This study was an analytic-observational study with a cross-sectional design. The data used came from the medical records, including information about the population of mothers who gave birth, maternal age at delivery, parity, and previous history of cesarean section. Statistical analysis used univariate and bivariate chi-square tests.Result: The study subjects were 84 people selected by simple random sampling method. The results of the univariate analysis showed the highest frequency of age &gt;32 years, parity 3-4 times, and a history of cesarean section ≥ 2. The results of bivariate analysis showed a significant relationship between age and the incidence of PAS (p=0.016), parity and the incidence of PAS (p&lt;0.001), and a history of cesarean section and the incidence of PAS (p=0.004).Conclusion: There is a relationship between age, parity, and history of cesarean section with the incidence of PAS at H. Adam Malik Hospital Medan in 2020-2022.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

BackgroundMaternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps.MethodsA systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies.ResultsSixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM.ConclusionThe pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.

The Role of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of the Adherent Placenta: An Observational Study.

Introduction Placenta accreta is an important factor responsible for maternal morbidity and mortality and is commonly associated with emergent postpartum hysterectomy. The precise prenatal diagnosis of affected pregnancies allows optimal obstetric management. Ultrasonography (USG) and magnetic resonance imaging (MRI) are the only diagnostic modalities available for the prenatal diagnosis of placenta accreta. Objective This study aims to evaluate the accuracy of USG and MRI in diagnosing adherent placenta. Methods Thirty females with placenta previa or a history of previous cesarean sections were evaluated with USG at 28-30 weeks, followed by MRI. The findings of USG and MRI were compared with the intra-operative findings (gold standard) as determined at surgery and by pathological examination. Results Abnormal bridging vessel (n = 24; 80%) was the most common finding seen on USG, whereas abnormal bulge (n = 22; 73.3%) and heterogenous placenta (n = 21; 70%) were the most common findings seen on MRI. The sensitivity of USG and MRI was in the range of 86.7%-92.9% and 92.9%-100%, respectively, in diagnosing three types of adherent placenta. The positive predictive values (PPV) of USG and MRI were in the range of 86.7%-86.7%and93.8%-100%, respectively, in diagnosing three types of adherent placenta. The accuracy of USG and MRI was in the range of 86.7%-96.7% and 96.7%-100%, respectively, in diagnosing three types of adherent placenta. Conclusion MRI helps to accurately classify placental invasion according to depth, as can be seen from the results of the present study, where the MRI technique was more accurate in diagnosing three types of adherent placenta.

Maternal Satisfaction and Associated Factors with Postcesarean Section Pain Management: A Cross-Sectional Study.

Maternal satisfaction with pain management after cesarean delivery serves as an indicator of the quality of care. Assessing the level of satisfaction with postcesarean delivery pain management is paramount for both the mother and the healthcare institution. This study aimed to assess maternal satisfaction with postcesarean section pain management and associated factors at the Comprehensive Specialized Hospital in Northwest, Ethiopia, in 2023. An institution-based cross-sectional study was conducted from April to June 2023, involving 424 study participants. A consecutive sampling method was utilized for participant selection. Data were entered into Epidata and then exported to SPSS version 25 for analysis. Descriptive and analytic statistics were employed. Both bivariable and multivariable logistic regression analyses were conducted to identify factors associated with maternal satisfaction regarding postcesarean section pain management. Variables with a p value of <0.2 in the bivariable analysis were included in the multivariable analysis. In the multivariable analysis, variables with a p value of <0.05 were considered statistically significant. Crude odds ratio and adjusted odds ratio with 95% confidence intervals were calculated to demonstrate the strength of the association. A total of 424 participants were included in the study with a response rate of 97.8%. The overall maternal satisfaction with postcesarean section pain management was 80.2% (95% CI: 76.1%-83.8%). Urban residence, elective cesarean section, mild pain, two and above previous history of cesarean section, and waiting less than 30 minutes to get analgesia were associated with maternal satisfaction with postcesarean section pain management. The overall maternal satisfaction with postcesarean section pain management was promising. Urban residence, elective cesarean section, previous history of cesarean section, mild pain, and waiting less than 30 minutes to get analgesia were predictor factors for maternal satisfaction with postcaesarian section pain management. We recommend that the stakeholders should give attention to enhancing maternal satisfaction.

Spontaneous Rupture of the Gravid Uterus in a Multigravida Women with a Previous History of Caesarean Section: A Case Report

Spontaneous uterine rupture is a rare obstetric complication that has catastrophic effects on both the mother and foetus, resulting in significant morbidity and 80 to 90% foetal mortality. Rupture of the uterus through a previous lower uterine segment scar is the most common cause in developing nations. However, factors such as lack of antenatal care, inappropriate obstetric interventions, obstructed labour, grand multiparity, unbooked status, limited access to emergency obstetric care, and low socioeconomic status play a crucial role in uterine rupture in developing countries like India. Hereby, the authors present a case report of a 31-year-old pregnant patient at 19 weeks of gestation with sudden severe lower abdominal pain. An ultrasound revealed the absence of foetal cardiac activity, placenta located outside the uterus, an empty endometrial cavity, and minimal free fluid in the pelvis. Further, an Magnetic Resonance Imaging (MRI) of the pelvis showed a rupture of the anterior and right lateral uterine wall, through which the foetus and most of the placental tissue had passed into the peritoneal cavity. After confirming the diagnosis, the patient underwent emergency laparotomy, during which the uterine wall defect was closed with appropriate haemostasis. The patient recovered without any untoward complications.

S. Rao Spiral Suturing (SRSS) of Lower Uterine Segment: An Innovative Hemostatic Technique in the Management of Placenta Previa and Accreta Spectrum.

The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment. In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality. Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine. SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.

Evaluation of Association Between Adenomyosis and Cesarean Scar Defect.

This study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis. This study was conducted as a case-control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images. During 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post-menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P-value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P-value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P-value of .000). Our study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.

Outcome and Indication of Caesarean Section amongst Pregnant Women Experiencing Premature Rupture of Membranes

Premature rupture of membranes (PROM) is characterized by the spontaneous rupture of chorioamniotic membranes more than one hour before the onset of labor. This condition typically arises spontaneously in most cases, affecting a significant portion of pregnancies. Notably, PROM can also occur in full-term pregnancies. This cross-sectional follow-up study was conducted among pregnant women had premature rupture of membranes and experiencing Caesarean Section (CS) in the department of Obstetrics and Gynaecology of Dhaka National Medical College Hospital (DNMCH), Dhaka, Bangladesh during the period of March to August 2011. The main aim of the study was to find out the indication and outcome of pregnant women with PROM and completed CS. A total of 90 data were collected purposively from all pregnant women more than 28 weeks of gestational age with PROM admitted in the Department of Obstetrics and Gynaecology, DNMCH, Dhaka for labour and underwent CS during study period. The data were collected using a semi-structured data sheet through direct questioning of the patients and physical examinations. Daily follow-ups were conducted until the patients were discharged, and data were also obtained from the clinical records of the patients. PROM patients encompassed all age groups, with ages ranging from 18 to 38 years. The overall educational level of the participants was low, with less than two-third (61.1%) belonging to the low socio-economic status. The average gestational age was 36.65 weeks, with 53.3% being primigravida, 45.6% being multigravida and grand multipara was 1 (1.11%). Only two had multiple pregnancies, and 11 respondents had experienced per vaginal bleeding. During previous gestations, 20 had a history of Caesarean section, 12 had experienced abortion, and 2 had previous cases of PROM. Nutritional deficits were found in 36.7% of patients, Pregnancy Induced Hypertension (PIH) in 35.6%, infections in 12.2%, and chronic hypertension in 5.6%. Four foetuses were in breech presentations, one had a single compound presentation, and two had a transverse or oblique lie. All the women were experiencing gushing of fluid per vagina, with one-fifth (20.0%) having meconium-stained and 12.2% blood-stained vaginal discharge. Attempts to prolong pregnancy were not very successful, with the longest duration being 75 hours. Caesarean sections had to be performed in all cases, with 34.4% within 24 hours and 41.2% within the next 24 hours. Elective caesarean sections following PROM were 28.9%. Indications for emergency caesarean section included a previous history of Caesarean section in 19 cases, foetal distress was found in 18 cases, failed induction in 7 cases, chorioamnionitis in 6 cases, foetal malpresentation was in 5 cases, and other reasons in 9 cases. More than one-third (35.56%) respondents had morbid condition to complicate the postpartum period. Among the complications, 21.11% suffered from wound infection; followed by puerperal sepsis 8.89% and postpartum haemorrhage 5.56%. At termination, all 92 foetuses were alive, but 6 babies had an Apgar score &lt;7 at 5 minutes after delivery, 30.4% of babies had low birth weight and 73.9% were in good condition, whereas 26.1% were admitted in neonatal ward, and out of the admitted 7 died with neonatal sepsis being the primary cause of death. A better understanding of the diagnosis babies and management of PROM will enable obstetric care providers to optimize perinatal outcomes and minimize neonatal morbidity and mortality. Therefore, this study finds the indication and outcome of caesarean section in pregnant women experiencing PROM. Bangladesh Med J. 2022 May; 51(2): 45-53

Assessment of Organ Dysfunction and Underlying Causes in Maternal Near-miss Cases at Health Care Facilities in Doiwala Block of District Dehradun - A Retrospective Study.

The extent of maternal morbidity is a good gauge of a nation's maternal health care system. Maternal near-miss (MNM) cases need to be reviewed because they can indirectly contribute significantly to reducing the maternal mortality ratio in India. MNM cases can provide useful information in this context. Such women who survive these life-threatening conditions arising from complications during pregnancy, childbirth and post partum (42 days) share many commonalities with those who die because of such complications. To assess the organ dysfunction and the underlying causes, associated/contributory factors associated with "maternal near-miss" cases in pregnant, in labor, post-partum women (upto42 days) in the health care facilities of Doiwala block, district Dehradun. The present study was conducted over a period of 6 months under the Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh. The cross-sectional study included the medical record files of all pregnant women attending the Department of Obstetrics and Gynecology, in the selected healthcare facilities of Doiwala block, district Dehradun. This study was conducted as per the WHO criteria for "near-miss" by using convenience sampling for the selection of healthcare facilities. The medical record files of all women who were pregnant, in labor, or who had delivered or aborted up to 42 days were included from a period of 01.06.2021 - 31.05.2022. It was found that Out of the women with maternal near-miss (n=91), the majority of women had coagulation /hematological dysfunction (n=45, 49.4%), followed by neurologic dysfunction (n=15, 16.4%), cardio-vascular dysfunction (n=11, 12%). Out of the total women with a maternal near-miss (n = 91), 10 women underwent multiple organ dysfunctions. Of the total 91 maternal near-miss cases, the underlying cause of near-miss was obstetric hemorrhage in almost half the participants (n=45, 49.5%) followed by hypertensive disorders (n=36, 39.5%). Eleven women had a pregnancy with abortive outcomes (12%) and 7 women had pregnancy-related infection. It was also seen that, out of 91 near-miss women, the leading contributory /associated cause was Anemia (n=89, 97.8%) followed by women having a history of previous cesarean section (n=63, 69.2%). Sixteen women had prolonged /obstructed labor (n = 16, 17.58%). Pregnancy should be a positive experience for every woman of childbearing age. A better understanding of pregnancy-related conditions enables early detection of complications and prevents the conversion of mild to moderate maternal morbidity outcomes to severe maternal outcomes with long-term health implications or death. There are already effective measures in place to reduce maternal and newborn mortality and morbidity.

Management of fetal supraventricular tachyarrhythmia - case report

The conduction system of the fetal heart is defined by the16th week of gestation when it matures and normally produces a regular rhythm and rate between 110 and 160 beats per minute (bpm) for the remainder of the pregnancy. Deviations from these parameters are fetal arrhythmias. They are diagnosed in 2% of unselected pregnancies. They are mostly benign and transient but some of them are persistent and associated with structural defects or can cause heart failure, fetal hydrops and intrauterine death. Routine prenatal care includes screening for fetal arrhythmias in the second and third trimester with fetal ultrasound examinations which include a view of the four cardiac chambers and both ventricular outflow tracts. The fetal outcomes are improved upon appropriate antepartum diagnosis and care. Here we present a pregnancy and multidisciplinary management, prenatal evaluation and intervention with maternal transplacental treatment of a 28-year-old female, gravida II, para II, in 28+5 weeks of gestation with fetal arrhythmia, in tertiary university hospital. She had a history of previous caesarean section, in the 40th week of gestation due to an infection of the synus pylonidalis. We confirmed suspected fetal arrhythmia as supraventricular tachyarrhythmia without fetal hydrops, based on the ultrasound doppler M mode imaging, and started transplacental administration of antiarrhythmyc agent, digoxin. It has been considered the first line agent for treatment of fetal supraventricular tachycardia but higher maternal doses are required to maintain a therapeutic serum level. We converted fetal heartbeat into normal sinus rhythm after three days of administration of digoxin. We continued to monitor the fetus once a week with controlling levels of digoxin and electrolytes in maternal blood until the end of the pregnancy at 38+6 weeks of gestation.

Perinatal Outcome in High-Risk &amp; Severe-Risk Pregnancy- A Study in a Tertiary Care Hospital

Introduction: High-risk &amp; severe-risk pregnancies are characterized by increased risks of complications for both the mother and the fetus, which can result from several factors such as maternal age, medical situations, lifestyle habits, and previous pregnancies. These complications are a major concern, mostly in developing countries like Bangladesh, where maternal and infant mortality rates remain high. Maternal complications associated with high-risk and severe-risk pregnancies may include maternal death, severe bleeding, sepsis, and hypertensive disorders, while fetal complications may include preterm delivery, fetal growth restriction, and stillbirth. The objective of this study was to investigate the perinatal outcomes of high-risk and severe-risk pregnancies. Methods: This prospective purposive study was carried out on the admitted patients in the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from July 2007 to December 2007. Total hundreds of risk groups pregnant women (N=100) were enrolled in the study among them eighty-five (n=85) scoring 3-6 included as high risk pregnancy and fifteen (n=15) scoring 7 or more included as severe-risk pregnancy. All relevant data were recorded for each individual study subject on predesigned data collection sheet. All collected data were compiled and analyzed by computer-based statistical software (Instat). Chi-square tests were performed to compare the prevalence of study variables where, p &lt; 0.05 considered the level of significance with 95%CI. Ethical clearance of this study was obtained from the Institutional Review Board (IRB) of BSMMU, Dhaka, Bangladesh. Results: In the high-risk group (n=85), around one-fourth of the patients (22,25.9%) and in a severe- risk group (n=15), one patient (1,6.7%) underwent vaginal delivery, Caesarean section was done in sixty-three patients (63,74.1%) in high-risk pregnant women and fourteen patients (14,93.3%) in severe-risk pregnant women respectively. The distribution of risk group and mode of delivery is statistically highly significant (P &lt;0.001). Out of sixty-three patients (n1=63), nineteen (19, 30.2%) were required to be delivered by caesarean section for fetal distress and fifteen (15, 30.16%) were malpresentation. Out of forty-one patients (n2=14), the most common indications were a history of previous caesarean section with multiple risk factors in eight patients (8, 57.1%). Birth asphyxia was present in nine neonates (9, 13.6%) in a high-risk group (n = 65) and a severe- risk group (n2=14), and birth asphyxia was present in five neonates (5, 35.7%). Based on the outcome, in high-risk pregnancy (n=85), four neonates (4, 4.5%) died and in severe-risk pregnancy (n=15), one (1, 6.3%) died. Conclusion: The study found various obstetric complications and outcomes associated with high-risk and severe-risk pregnancies. The results indicated a significantly higher proportion of caesarean sections performed in severe-risk pregnancies compared to high-risk pregnancies. Moreover, the overall outcome was favorable, with only five neonatal deaths reported among the one hundred maternal risk groups.

Emergency Peripartum Hysterectomy and its Outcome in a Tertiary Care Hospital in Dhaka City, Bangladesh

Introduction: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. EPH is a challanging but life saving obstetric procedure performed when medical and surgical conservative measures fail to control postpartum haemorrhage .The present study aimed to review the peripartum hysterectomies and to compare the incidence, indications and outcome of EPH. Materials and Methods: This retrospective study was conducted at a tertiary care hospital in Dhaka, Bangladesh. Total 62 cases have taken, who had hysterectomy that was performed in Obstetric and gynaecology department of Addin Womens Medical College Hospital during the period between January 2020 and December 2022. Result: There were total of 36371 deliveries over the study period and EPH was performed in 62 cases making an incidence of 0.408. In this study 33.8% patients were between 35 to 39 years. Here 45.16% had their parity between 2nd and 3rd child. Here 61.2% had previous history of caesarean section, 24.19% had previous history of antepartum haemorrhage, 74.19% cases intrapartum operation had done. Among 62 cases of EPH 77.4% cases subtotal hysterectomy had done. Here, among 62 cases of caesarean section 35.48% had placenta accrete and 20.96% had history of placenta previa with haemorrhage and 12.9% had severe PPH due to atony of uterus. 22.5% cases had fetal outcome of still born but 32.25% baby born alive. In this study 51.6% cases patients develop haemorrhage as perioperative complication, 19.5% develop shock but 100% required blood transfusion among which 50% were in post operative period. Here 6 out of 62 cases had bladder injury, 5 patients needed relaparotomy due to haemoperitoneum caused by vaginal cuff bleeding. Mortality rate was 4.83%. Conclusion: Now a days the indication of EPH has changed from uterine atony to abnormal placentation. It is a most important obstetric surgery performed in life threatening haemorrhage. Involvement of an experienced obstetrician at an early stage of management and efforts should be taken to reduce morbidity and mortality. Sir Salimullah Med Coll J 2023; 31: 107-111