Lower Uterine Caesarean Section Research Articles

Prediction of Cerebral Palsy and Other Motor Developmental Trajectories in High-Risk Neonate Using the Rapid Neurodevelopmental Assessment (RNDA)

Background: Cerebral Palsy (CP) is a prevalent motor disability affecting children globally, emphasizing the need for early identification and intervention. The Rapid Neurodevelopmental Assessment (RNDA) offers a comprehensive approach to predict CP and other motor developmental trajectories in high-risk neonates. Objective: This longitudinal cohort study aims to evaluate the effectiveness of RNDA in predicting CP and motor developmental trajectories. Method: Seventy term neonates from Dhaka Shishu (Children) Hospital were included, with neurodevelopmental assessments conducted using RNDA. Assessments were performed at 3 months and 6-9 months, with CP evaluation at 12 months using clinical examinations. Results: Prolonged labor (44.3%) and delayed cry after birth (31.4%) were common among the study patients (n=70), with varying modes of delivery including normal vaginal delivery (50.0%), vaginal delivery with complications (12.9%), and lower uterine cesarean section (37.1%). Muscle tone, primitive reflexes, gross and fine motor skills, epilepsy, and microcephaly were evaluated across visits to identify impending CP. Significant associations were found between hypertonicity, primitive reflex impairment, gross motor impairment, and fine motor impairment with impending CP across visits, particularly in the 3rd visit (p<0.05). Sensitivity, specificity, accuracy, and predictive values varied across parameters and visits, with fine motor skills and gross motor skills showing the highest sensitivity in the 3rd visit (86.4% and 100.0%, respectively). Additionally, abnormal EEG, USG of the brain, and MRI findings were significantly associated with impending CP, with USG of the brain demonstrating the highest sensitivity (93.3%) and MRI showing the highest specificity (70.0%). Conclusion: RNDA emerges as a valuable tool for early prediction of CP and motor developmental trajectories in high-risk neonates. Early identification through RNDA facilitates timely interventions, optimizing long-term neurodevelopmental outcomes.

Comparison Between Pethidine and Nalbuphine Hydrochloride Combating Epigastric Pain During Mopping of Intraperitoneal Blood in Lower Uterine Caesarean Section Operation

A randomized prospective single blind trial was conducted in the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka, Bangladesh, between July 2021 and February 2022, to compare the effects of intravenous pethidine and nalbuphine hydrochloride combating epigastric pain and discomfort during mopping of intraperitoneal blood in lower uterine caesarean section (LUCS) operation. A total of 120 women participated in the study. They were randomly divided into two groups: group A (n=60) received intravenous diluted (with normal saline) 20-25 mg of pethidine, while group B (n=60) received intravenous diluted 10-20 mg of nalbuphine hydrochloride. There were no differences observed in mean age, weight, height, and duration of operation between two groups (P>0.05). However, participants of group B reported less or no epigastric pain and discomfort during mopping of intraperitoneal blood than that of group A (P<0.05), i.e., episode and intensity of pain measured by using visual analogue scales indicated that nalbuphine hydrochloride has a longer duration of action than pethidine. Our study revealed that intravenous diluted nalbuphine hydrochloride works better than pethidine to minimize epigastric pain and discomfort during mopping of intraperitoneal blood in lower uterine caesarean section (LUCS) operation. 
 CBMJ 2023 January: Vol. 12 No. 01 P: 81-86

Antimicrobial Prophylaxis in Lower Uterine Segment Caesarean Section: A Prospective Observational Data-based Study

Introduction: Any major surgery like lower uterine Caesarean Section (CS) can be hazardous due to postoperative nosocomial infection. Pregnant mothers are at greater risk during such surgical intervention as compared to vaginal delivery. Prophylactic antibiotic administration is a standard practice across the globe to prevent such anticipated postoperative infection. Aim: To evaluate the prophylactic antimicrobial use with regards to the choice of antimicrobials, dose, route, timing and duration, any possible Adverse Drug Reaction (ADR) as well as to assess the frequency of the postoperative morbidity due to infection (if any). Materials and Methods: A prospective observational databased study was conducted in the Department of Pharmacology in collaboration with Department of Obstetrics and Gynaecology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India, from February 2016 to October 2017. Study was conducted on 1944 pregnant women of reproductive age group planned or scheduled for elective/emergency lower segment CS, but otherwise healthy and received prophylactic antimicrobials for the surgery. They were prospectively observed regarding the treatment they received with focus on antimicrobial agents from the period of antimicrobial prophylaxis during their stay at hospital to till their discharge. Demographic data, vital signs, indication of CS, postoperative infections and ADR if any were recorded in predesigned proforma. The study population was divided into two groups: group A included 995 mothers, who received ceftriaxone sodium (1 g intravenously) and metronidazole (15 mg/kg) infusion and group B included 949 mothers, who received ampicillin (2 g intravenously), metronidazole (15 mg/kg) infusion and injection gentamycin (5 mg/kg) for 0.5 hour before initiation of CS. The data were statistically analysed by standard statistical software Microsoft Excel 2010 and Statistical Package for the Social Sciences (SPSS) sotware version 27.0 (SPSS Inc., Chicago, IL, USA) expressed as mean and standard deviation and percentage. Independent t- test and Chi-square test were used for analysis. Results: The mean age of group A was 22.36±3.07 years and group B was 22.76±2.47 years. Endomyometritis was documented in 4 (0.4%) from group A and 2 (0.21%) from the group B. Wound infection was present in 3 (0.3%) for group A and five (0.5%) for the group B. Infection related complications like chest infection seen in 7 (0.7%) for group A and in 3 (0.31%) for group B and urinary tract infection was noticed in 6 (0.6%) for group A and 5 (0.52%) for group B. Any incidence of maternal mortality was not evident among the two study groups and statistically insignificant ADR like vomiting and maculopapular rash (p-value=0.324) was observed in both the study groups with the use of above-mentioned antimicrobial therapy. Conclusion: Prophylactic use of ceftriaxone plus metronidazole and combination of triple antimicrobial therapy of ampicillin, metronidazole, and gentamycin therapy at the usual standard dose were commonly used antimicrobials at the present set up and they are safe and equally effective in decreasing considerably the incidence of post caesarean maternal infection thereby reducing their morbidity and mortality

Outcome of Planned Vaginal Birth at Term after One Previous Caesarean Section

Background & objective: Pregnant women with a previous caesarian section may be offered either vaginal birth or elective repeat caesarian section (ERCS). Detailed antenatal counseling and methodical intrapartum management of women are the key factors for success of planned vaginal birth after caesarean (VBAC). The present study was undertaken to determine the incidence of successful vaginal birth and the maternal and perinatal complications in patients undergoing planned vaginal birth after one previous caesarean section.
 Methods: This prospective observational study was carried out in the Department of Obstetrics and Gynaecology, Sir Salimullah Medical College & Mitford Hospital (SSMC & MH), Dhaka over a period of one year between January to December 2016. A total of 96 term pregnant women, aged 20 – 35 years, having previous experience of one lower uterine caesarean section with spontaneous onset of labour, vertex presentation of the fetus and adequate pelvis were consecutively included in the study. The main primary outcome variable was fate of trial VBAC (successful vaginal delivery either spontaneous or assisted or ERCS). The secondary outcome variables were maternal and perinatal complications (morbidity and mortality).
 Result: Over 55% of the women under trial VBAC were 25 – 30 years old with mean age of the women being 26.8 ± 3.7 years. Nearly three-fifths (58.3%) of the women were of normal BMI, 40.6% were overweight. None of the women was obese. Only 15% women had gestational age 40 weeks. The mean interval between the current and the previous births was almost 3 years. In terms of primary outcome, over 60% of the planed VBAC were successfully delivered (52.2% spontaneously and 9.3% with the aid of forceps and vacuum extraction). While maternal complications were uterine rupture (6.2%), hysterectomy (6.2%) and haemorrhage needing transfusion (14.6%), neonatal complications were respiratory distress syndrome (17.7%), perinatal death (10.4%), hypoxic ischemic encephalopathy (4.2%) and sepsis (8.3%).
 Conclusion: The study concluded that planned VBAC is appropriate for majority of women with a singleton pregnancy of cephalic presentation who have had a single previous lower segment caesarean section (LSCS). However, as the maternal complications (like hysterectomy, haemorrhage etc.) and the perinatal complications including death were much high, utmost caution is advised in selecting the right candidate for VBAC so that the incidence of successful VB could be maximized and complications minimized.
 Ibrahim Card Med J 2021; 11 (1): 54-61

Study of Analgesic Effect of Magnesium Sulphate with Bupivacaine in Ultrasonogram Guided Transversus Abdominis Plane Block for Post-Operative Analgesia in Lower Uterine Cesarean Section

Background: Transversus abdominis plane (TAP) block has proven to be an effective component of postoperative pain management for different abdominal procedures particularly in Lower uterine cesarean section (LUCS) done under Sub arachnoid block. Magnesium sulphate (MgSO4) is a N-methyl-D-aspartate receptor antagonist has the potential to act as an adjuvant in TAP block. For this reason this study was planned to assess the role of Magnesium Sulphate as an adjuvant to bupivacaine in ultrasound-guided transverse abdominis plane (TAP) blocks for postoperative analgesia in patients undergoing LUCS after regression of block of Sub arachnoid block.
 Methods: This was a hospital based randomized controlled trial which was conducted in Dhaka Medical College Hospital (DMCH) at the department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine for 2 years of period. Formal ethical approval was taken from the Ethical Review Committee (ERC) of DMC. Patients having LUCS were approached for the study. A total of 60 patients of LUCS under Sub arachnoid block were selected in the study among them 30 patients received TAP block with bupivacaine 0.25% with saline, and the other 30 received bupivacaine 0.25% with 150 mg Magnesium Sulphate immediately following surgery. Primary outcome was focused on duration of analgesia, pain score, time of first need of rescue analgesic and total opioid consumption. Pre-block and immediately post block Visual analog pain scores (VAS) (0–10) were obtained. After pre-anesthetic checkup & discussion about study procedures written informed consent was taken from the patient. Separate case record form was used in each case. Data analysis was done by SPSS version 22.
 Observation and Results: Mean age of group B (GB) and group-BM (GBM) patients were 25.57± 2.76 & 25.9 ± 3.17SD (years). No significant difference demographic profile was observed (p>0.05). Mean duration of analgesia was significantly prolonged in Group BM compared to Group B (263.13 ± 34.39) min vs. 222.23 ± 30.58 min; P-value <0.001) which was evident by increased VAS score at 16th hour postoperatively in magnesium sulphate group than normal saline group. Total postoperative requirement of opioid was also lower in Group BM (p<0.05).
 Conclusion: Magnesium Sulphate could be used as an adjuvant with bupivacaine in ultrasound guided transversus abdominis plane (TAP) blocks for management of post-operative analgesia in LUCS patient.
 CBMJ 2021 January: vol. 10 no. 01 P: 09-17

Canavan Disease - A Rare Case Report

Canavan disease is a rare autosomal recessive disorder characterized by progressive leukodystrophy involving white matter of the brain. Disease leads to severe psychomotor retardation, seizures and premature death. More prevalent among Jewish population. Among non-Jewish population incidence is approximately 1:100000. Prognosis is guarded with current management only symptomatic and supportive. There is no effective treatment, however early gene therapy has improved the quality of life of patients. Furthermore, Lithium citrate has also shown certain positive results in experimental models using rats. Even few human studies have also been done, however promising results require larger controlled trials. Keywords: MRI: Magnetic Resonance and Imaging, EEG: Electro Encephalogram, CD: Canavan Disease, ASPA: acetyl aspartate, LUCS: Lower Uterine Cesarean Section, OFC: Occipito Frontal Circumference, NAA: N-acetyl aspartate

Co-presentation of Acute Sheehan Syndrome with Raised Intracranial Pressure in a Post-partum Lady

Sheehan’s syndrome (SS) or necrosis of pituitary gland is a rare complication of severe postpartum hemorrhage. It may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. Sheehan’s syndrome though rare is still one of the commonest causes of hypopituitarism in developing countries like ours. The presence of an intercurrent infection and administration of thyroxine exacerbated her corticosteroid insufficiency. Intracranial hypertension (IH) manifested as bilateral optic disc swelling with reduced visual acuity, bilateral sixth nerve palsies, and impaired consciousness. Intracranial hypertension (IH) has been associated with hypocortisolism caused by either primary adrenocortical insufficiency or corticosteroid withdrawal. The author describes a case of a young lady with IH with acute SS who presented on 3rd day postpartum after lower uterine cesarean section with acute severe symptomatic hyponatremia which was complicated by postpartum hemorrhage. The clinical manifestations of IH resolved with corticosteroid replacement

The impact of previous cesarean section on the outcome of patients with non-adherent placenta previa

ObjectiveTo evaluate the impact of previous lower segment cesarean section on maternal and fetal outcomes of patients with non-adherent placenta previaMethodsThis is a retrospective study of all patients who delivered at a tertiary referral university hospital by lower uterine cesarean section with non-adherent placenta previa, over a 10-year period. Data were obtained through hospital registry and medical records. The differences in demographic, obstetric characteristics, peripartum complications, and fetal outcome between patients with no previous cesarean and those with previous cesarean section were analyzed.ResultsNinety patients with non-adherent placenta previa were included, 54 patients with no previous cesarean and 36 patients with previous cesarean section. Patients with previous cesarean section were significantly more likely to incur inadvertent organ injury, transfusion of 4 or more units of packed red blood cells, transfusion of fresh frozen plasma, uterine brace compressive sutures, uterine artery ligation, and peripartum hysterectomy.ConclusionThere is a significant increase in the incidence of inadvertent neighboring viscus injury, transfusion of 4 units or more of packed red blood cells, transfusion of fresh frozen plasma, uterine brace compressive sutures, uterine artery ligation, and peripartum hysterectomy in patients with non-adherent placenta previa and previous cesarean section, compared to those with non-adherent placenta previa and no previous history of cesarean section, with no difference in perinatal outcome.

Perinatal outcome of babies delivered to eclamptic mothers: A retrospective study in a rural teaching hospital of western Maharashtra

Background: Eclampsia is an important cause of significant neonatal morbidity in terms of prematurity, Intrauterine Growth Retardation (IUGR), Low Birth Weight (LBW), and birth asphyxia. Objective: The objective of the study was to assess the perinatal outcome with respect to maternal and neonatal characteristics and to evaluate the neonatal morbidity/ mortality. Materials and Methods: Medical records of 75 cases of eclampsia, 68 liveborn neonates and 39 neonates admitted at the teaching Hospital, situated in rural Maharashtra from January 2020 to November 2020 were analysed and findings were presented in tables. Results: Of 75 eclamptic mothers, 55 (73.33%) were primipara and 20 (26.67%) were multipara. Mean maternal age was 22 years. Mean gestational age was 34 + 6 weeks. Fifty-six (75%) mothers needed lower uterine caesarean section. The majority of eclamptic mothers had less than optimal antenatal care, primigravidae (74.67%) and young (less than 20 years). Out of 68 live born neonates 60.3 % were preterm. One fourth of them were very preterm. Three fourth neonates born were low birth weight (LBW), amongst them 2 were extremely LBW. Nearly one fourth neonates were small of gestational age (SGA). More than half of neonates required specialised care in neonatal unit. Indications for admission were prematurity, respiratory distress syndrome, growth retardation, perinatal asphyxia and early-onset sepsis. Overall neonatal mortality was 5.26% (4/68) and 10% (4/39) amongst admitted newborns. Causes of death were extreme LBW and sepsis. Conclusion: Significant neonatal morbidity has been observed in neonates born to eclamptic mothers in the rural population. Neonatal problems requiring special/intensive neonatal care were prematurity, LBW, IUGR, and birth asphyxia. Neonatal mortality amongst admitted newborns was 10%. Extreme LBW and sepsis were the causes for neonatal death.

Prediction of Perinatal Outcome with Meconium-stained Liquor

Background & objective: Passage of meconium in the amniotic fluid during labor has long been considered as fetal compromise resulting from fetal hypoxia or increased vagal activity from cord compression. It is also a sign of normal gastrointestinal tract maturation under neuronal control. However, presence of meconium in the amniotic fluid is traditionally viewed as unfavorable perinatal outcome. So, the present study was contemplated to find the association between grade of meconium during labor and perinatal outcome.
 Methods: The present prospective study was conducted in the North Bengal Medical College, Sirajganj between January 2016 – April 2017. Based on predefined criteria, 53 singleton pregnant women with meconium-stained liquor (MSL) on spontaneous or artificial rupture of membrane after 37 completed weeks of gestation were included in the study. Meconium-stained liquor was graded as “Thick” if the fluid was dark green in colour, viscous, tenacious, opalescent or opaque containing large amount of particulate materials and “Thin” if the fluid was translucent, light yellow green in colour without particulate material. The perinatal outcome was evaluated in terms of APGAR score of neonates at 1 and at 5 minutes of birth, NICU admission, resuscitation needed, jaundice and respiratory distress syndrome (RDS) due to meconium aspiration. Asphyxia neonatorum was diagnosed if APGAR at birth and/or at 5 minutes was < 7. All the outcomes were then compared between mothers forming ‘Thick’ and ‘Thin’ meconium cohort.
 Result: Of the 53 meconium-stained liquor, nearly half (49%) was with ‘Thick’ meconium and the half (51%) was with ‘Thin’ meconium. Approximately 85% of the neonates were delivered by lower uterine caesarean section (LUCS) and 80% of the neonates were asphyxiated at birth which reduced to 15.1% at 5 minutes. More than three-quarters (75.5%) of the neonates required resuscitation and 28.3% had respiratory distress syndrome (RDS). The incidences of asphyxia neonatorum, resuscitation needed and RDS were significantly higher in ‘Thick’ meconium cohort than those in ‘Thin’ meconium cohort with risks of having these conditions in the former cohort being 6(95% CI = 1.1–31.2), 4.5(95% CI = 1.1–18.9) and 4.2(95% CI = 1.1–15.7) times higher respectively than those in the latter cohort (p = 0.021, p = 0.031 and p = 0.026 respectively).
 Conclusion: Majority of the neonates born of mothers with thick meconium cohort are asphyxiated, need resuscitation and/or develop RDS. Asphyxia neonatorum, need for resuscitation and RDS are significantly higher in ‘Thick’ meconium cohort than those in ‘Thin’ meconium cohort with risks of having these conditions in the former cohort being several times higher than those in the latter cohort.
 Ibrahim Card Med J 2019; 9 (1&2): 67-73

Study on Risk Factors and Microorganisms for Surgical Site Infection following Caesarean Section among 100 Patients in a Tertiary Hospital in Bangladesh

Background: Lower uterine caesarean section is a common mode of delivery now and surgical site infection is one of the most common and dreaded complication of surgery. It is associated with significant morbidity and delayed recovery and it lengthens hospital stay and costs. Identifying risk factors for surgical site infection in caesarean wound and modifying them can be beneficial for patient management during surgery and optimizing good clinical outcome. Identifying microorganisms with their sensitivity has epidemiological as well as therapeutic implications.
 Objective: To identify risk factors for surgical site infection in caesarean section wound and find out microorganisms responsible for such infection.
 Materials and Methods: In this study 100 women with surgical site infection after caesarean section were included. They were selected randomly from four maternity units of Dhaka Medical College Hospital. Each patient of caesarean section was followed strictly up to discharge from hospital and also for 30 days postoperatively for any evidence of infection. Wound swab was sent in each case for microbiological study. Data were collected in structured questionnaire and analysed by computer using spreadsheet.
 Results: Among 100 women studied, 73% had inadequate or no antenatal check-up, 52% had duration of labour pain >12 hours, 52% had duration of ruptured membrane >12 hours, 94% women underwent emergency caesarean section, 62% had operation time >1 hour, 61% had haemoglobin level <60%, 46% women had intervention by untrained birth attendant, and 43% women had >500 mL blood loss during operation. In bacteriological study, microorganisms were identified in 55% cases, among them Staphylococcus aureus (20%), E. coli (11%), Acinetobacter (7%), Pseudomonas (6%) and Proteus (5%). During sensitivity test Staphylococcus aureus was mostly sensitive to ceftriaxone (50%) and amikacin (33%) and E. coli to amikacin (80%). In four cases (2 proteus and 2 pseudomonas) out of 55 organisms were resistant to all antibiotics.
 Conclusion: Most of the risk factors for surgical site infection during caesarean section identified in this study can be modified through intervention. However, the microorganisms detected from our patients showed a high degree of resistance for commonly prescribed antimicrobials in our set-up.
 J Enam Med Col 2019; 9(2): 90-96

Maternal and Perinatal Outcome in Gestational Diabetes Mellitus Compared to Pregestational Diabetes Mellitus

Background: Diabetes mellitus is the most frequently encountered endocrine disorder in pregnancy and is associated with adverse outcomes if remain undiagnosed or untreated. This study was done to compare the maternal and perinatal outcome of pregestational diabetes mellitus (PGDM) with that of gestational diabetes (GDM).
 Methods: This observational analytical study with group comparison was carried out in the Department of Obstetrics and Gynaecology, BIRDEM General Hospital, Dhaka from July 2015 to June 2016. This study was conducted on two groups of pregnant women: group A (PGDM) and group B (GDM). A total of 100 cases were selected and in each group 50 pregnant women were enrolled. Singleton pregnancy and age 18 to 45 years were included. Pregnancy with hypertension, heart disease, renal disease and other metabolic disorders were excluded.
 Results: In this study mean gestational age of the study subjects were 35.72 ± 2.61 weeks and 36.58 ± 2.34 weeks in PGDM and GDM groups. History of GDM [34.0% vs 16.0%], intrauterine death (IUD) [14.0% vs 2.0%] and abortion [22.0% vas 6.0%] were significantly higher among PGDM patients than GDM patients. Regarding present pregnancy complications, polyhydramnios [32.0% vs 14.0%], preterm delivery [38.0% vs 20.0%], vulvovaginitis [28.0% vs 12.0%] and premature rupture of membrane (PROM) [24.0% vs 8.0%] were significantly higher in PGDM than GDM patients. Wound infection was significantly high in PGDM groups [35.7% vs 11.1%] among the patients delivered by lower uterine Cesarean section (LUCS). Regarding perinatal complications, hypoglycemia [22.0% vs 8.0%], birth asphyxia [24.0% vs 8.0%], RDS [24.0% vs 8.0%] were significantly higher among PGDM comparing GDM patients.
 Conclusion: The maternal and perinatal outcomes of pregestational diabetes mellitus were less favorable than those of gestational diabetes mellitus.
 Birdem Med J 2019; 9(2): 127-132

Spectrum of Neonatal Pneumothorax at a Tertiary Care Hospital of Bangladesh : A Retrospective Observational Study.

Introduction: Pneumothorax occurs more frequently in the neonatal period than in any other period of life & is associated with increased mortality and morbidity. Several risk factors for pneumothorax, including respiratory pathology, invasive and non-invasive respiratory support & predictors of mortality have been described.
 Objective: To evaluate the prevalence of pneumothorax, to identify underlying causes & to describe the clinical characteristics, management and outcome of neonates with pneumothorax, as well as to identify predictors of mortality in these neonates.
 Methods: A retrospective chart review of neonatal records included all neonates hospitalized in the NICU of 'Ad-din Women’s Medical College' Dhaka, between January 2016 & December 2017 with the diagnosis of pneumothorax. The collected data included: demographics & perinatal data, characteristics of pneumothorax, classification, treatment & clinical outcomes. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 16.
 Results: Our study included 83 neonates, of whom 48 were male (57.83%) & 60 (72.29%) born by lower uterine caesarean section (LUCS). Median gestational age(GA) was 36 (32-41) weeks & the median birth weight(BW) was 2,558 (1500-3800) grams. The prevalence of neonatal Pneumothorax in our centre was 2.60% & that of Spontaneous Pneumothorax was 1.53%. The analysis of perinatal data showed statistically significant differences in APGAR score at 5th minute (p = <0.00001) & in resuscitation at birth (p < 0.00001). Pneumothorax was significantly associated with RDS, pneumonia, Meconium aspiration syndrome (MAS) & Perinatal asphyxia (PNA), (p=0.235893) and all (n=6) death were observed in neonates who had coexisting diseases, (p=0.00226). Forty nine (59.04%) was SP (p = 0.002) & mainly observed in the right lung (77.11 %( (p=0.00011). To treat the pneumothoraces, 64 (77.11%) neonates only received oxygen therapy, 16 (19.28%) neonate needed MV along with chest tube (CT) drain, 02(2.41%) thoracentesis with needle aspiration, and 01 (1.20%) needle aspiration & chest tube (CT) drain (p <0.00001). Clinical data suggest that complications such as sepsis, severe hypotension, Necrotizing enterocolitis (NEC), DIC, Intraventricular haemorrhage (IVH) can negatively affect immediate outcomes (p=0.00025). The mortality rate was 7.23%. All the mortalities observed in neonates who got respiratory support with mechanical ventilation (MV) along with CT insertion (p=<0.00001). Hypotension, sepsis, DIC, IVH, MV and thoracentesis followed by a CT insertion were found to be predictors of mortality in neonates with pneumothorax.
 Conclusion: NP may develop during the neonatal period, especially in the presence of underlying clinical conditions, and neonates with pneumothorax managed with CT drain and respiratory support (MV), despite treatment have a high mortality rate.
 Bangladesh Crit Care J March 2019; 7(1): 12-19

Effect of Mifepristone and misoprostol combined with hysteroscopic resection of endometrial uterine incision cesarean scar pregnancy

Objective To investigate the clinical effect of mifepristone and misoprostol combined with hysteroscopic resection of endometrial uterine incision cesarean scar pregnancy. Methods A retrospective study was conducted to analyze 135 cases of scar pregnancy of endogenous lower uterine cesarean section from January 2015 to October 2017. According to the treatment methods, they were divided into group A (mifepristone and misoprostol combined with hysteroscopy), group B (methotrexate combined with hysteroscopy), group C (Uterine artery embolization + curettage) .Each group had 45 cases, and the therapeutic effects of the three methods were compared. Results There was no significant difference in gestational sac size and serum human chorionic gonadotropin [beta-human chorionic gonadotropin (HCG)] levels among the three groups before operation (P>0.05). After operation, the operation time, intraoperative bleeding volume, serum beta-HCG dropping to normal time, vaginal bleeding time and hospitalization time in A and C group were significantly lower than that in B group (P>0.05). There was no significant difference between group A and group C in operation time, serum beta-HCG to normal time, vaginal bleeding time and hospitalization time (P>0.05). The menstruation time of group A was significantly shorter than that of group B and group C (P 0.05); The complication rates of A, B and C groups were 2.22%, 13.33% and 4.44% respectively, with no significant difference in the three groups (P>0.05). Conclusions The three methods are effective in the treatment of cesarean scar pregnancy. The mifepristone and misoprostol combined with hysteroscopy have the advantages of less operative trauma and faster postoperative recovery. Key words: Mifepristone/AD; Misoprostol/AD; Hysteroscopy; Pregnancy, ectopic/TH; Cicatrix

Caesarean Section in Eclampsia and its Outcome in Bangladesh

This prospective study was carried out on a total number of 58 eclamptic subjects during the period of July 2010 to June 2012 where 38 were undergone caesarean section (LUCS - Lower Uterine Caesarean Section) and 20 received conservative management. Mean (±SD) Age of the subjects who undergone Caesarean Section and conservative management (NVD) were 23.67±8.63 and 23.45±9.31 years respectively. Significant mean age difference was also present between these two groups. In 38 subjects of LUCS 34 subjects were recovered and rest 4 cases were died. Possible causes of death were due to heart failure and post partum pulmonary embolism. Among these 20 subjects who were treated conservatively 14 were recovered and 6 subjects were died. Causes of death in these groups were pulmonary embolism, Septic pneumonia, and HELLP syndrome. Significant difference was found between these two treatment options. It was observed that socio-demographic, economic status and BMI had significant effects on management outcome.KYAMC Journal Vol. 6, No.-1, Jul 2015, Page 583-586

Vesicocervical fistula following vesicovaginal fistula repair report

Vesicocervical fistula following vesicovaginal fistula repair is a very rare condition. It is a complication following repeated lower uterine cesarean section. We report a case of an young married woman who was admitted in the depart­ment of urology, Banghabandhu Sheikh Mujib Medical University Hospital with vesico-cervical fistula following vesico­vaginal fistula repair. Reposition of cervix into vaginal vault and repair of urinary bladder was done. There was no such report of vesicocervical fistula following vesicovaginal fistula repair from Bangladesh.

Axillary Artery Thrombosis in a NeonateIn Utero: A Case Report

We describe a neonate of 38-week and 6-day gestation born by lower uterine cesarean section for breech presentation, where it was evident on delivery that there was significant edema of the right arm from the deltoid to the distal tips of the fingers. Doppler flow ultrasound revealed extensive arterial thromboembolus. Intravenous heparin was prescribed for three days at a dose of 27.5 U/kg/h, targeting an activated partial thromboplastin time (APTT) of 60–75 seconds, followed by a course of subcutaneous enoxaparin at a dose of 1.8 mg/kg and then 2 mg/kg twice daily, titrated to a factor Xa level of 0.5–1.0 U/mL for another three days. Significant clinical improvement occurred and the child was eventually, discharged on subcutaneous enoxaparin. Magnetic resonance imaging showed multiple intracranial abnormalities. At five months increased upper limb tone, brisk reflexes, and small head circumference were noted. At one year, increased tone and increased paucity of movement on the right side persisted, and some speech delay and visual inattention were noted. Recent follow-up at 16.5 months of age demonstrated a right sided hemiplegia with increased tone and brisk reflexes. We describe the case in detail and review current knowledge regarding the management of arterial thrombosis in the neonate.

Immediate Perinatal Outcome of Neonates with Maternal Hypertensive Disorders in Pregnancy

Introduction: Hypertensive disorders of pregnancy seem to be one of the major causes of maternal morbidity and mortality leading to 10-15% of maternal deaths especially in the developing world. This study examines the perinatal outcome of neonates with mothers having hypertensive disorder of pregnancy. Materials and Methods: Seventy three mothers and their newborn babies were selected. Mothers with Gestational hypertension, preeclampsia, eclampsia, chronic hypertension, preeclampsia superimposed on chronic hypertension were included. Gestational diabetics (GDM), chronic maternal diseases, infant of diabetic mother (IDM), babies with major congenital malformations were excluded. Results: Thirty five mothers (47.9%) had regular antenatal check up (ANC) and 38 (52%) had irregular. Nineteen mothers (26%) were primipara and 54 (74%) were multipara. Forty four mothers (60%) had positive family history or had own history of hypertensive disorder during their previous pregnancy. 13 mothers (17.8%) had normal vaginal delivery (NVD), 60 mothers (82.19%) had lower uterine cesarean section (LUCS). 30 babies (41%) were admitted. 44 mothers (60%) had gestational hypertension, 21 had (28.6%) pre-eclamtic toxemia (PET), 3 had (4.1%) eclampsia, 5 had (6.8%) essential hypertension 3 of them subsequently developed PET. Mean maternal age 26.86 years, gestational age 34.15 (±1.46)weeks among admitted and 36.30 (±1.6)weeks among non-admitted group. Mean birth weight was 1.69 (±0.39) kg. among admitted and 2.71 (±0.31) kg. in non-admitted babies. Seven pregnancies (9.58%) were twin, macerated 1 twin among was among 2 pregnancies (2.7%), 5 intra uterine death (IUD) observed in single pregnancy. Conclusion: Significant number of babies with maternal hypertensive disorder of pregnancy needed hospitalization, mean birth weight and gestational age was less than that of the non-admitted group. DOI: http://dx.doi.org/10.3126/jnps.v33i3.9252 J. Nepal Paediatr. Soc. 2013;33(3):190-195

Acute Postpartum Pulmonary Edema in a 32-Year-Old Woman Five Days after Cesarean Delivery

Acute dyspnea after pregnancy is a rare presentation, and a number of important conditions may accompany it. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration and pulmonary edema are some of the potential causes that must be considered. The percentage of pregnancies that are complicated by acute pulmonary edema has been estimated 0.08%. The most common contributing factors include the administration of tocolytic agents, underlying cardiac disease, iatrogenic fluid overload and preeclampsia. Here we report a case of 32- year-old woman of 5th postpartum day following lower uterine cesarean section with acute dyspnea from her first pregnancy who was admitted in coronary care unit with history of one episode of raised blood pressure 160/90 mm Hg and cough on 1st postoperative day. Clinical examination and relevant investigations explored that it was a case of bilateral pulmonary edema. Patient was kept in ventilator and was treated with nitroglycerine (GTN), frusemide and ACE inhibitor. After diuresis, considerable improvement was observed in her respiratory status. From the 4th day, the patient became hemodynamically stable and was weaned off the ventilator. After five days, all the biochemical parameters became normal and she had no dyspnea. Journal of Enam Medical College; Vol 3 No 2 July 2013; Page 113-116 DOI: http://dx.doi.org/10.3329/jemc.v3i2.16135

Surgical site infection by Mycobacterium tuberculosis following caesarian section

Surgical site infection by M. tuberculosis is uncommon and its diagnosis can be missed unless there is strong clinical suspicion coupled with laboratory confirmation. We report a case of primary tuberculous surgical site infection without any evidence of pulmonary, skeletal or gastrointestinal tuberculosis in an immunocompetent patient, presented as non healing discharging wound following lower uterine caesarean section (LUCS). This is the first case report of its kind from Bangladesh to the best of our knowledge. The case was diagnosed by detection of acid fast bacilli (AFB) in pus by Ziehl Neelsen staining and histological evidence of granulomatous lesion compatible with tuberculosis found in surgically excised granulation tissue. The patient was treated with 4 anti-tubercular drugs regimen for initial two months and responded well showing complete healing of her wound. The case is being reported primarily for its unusual site and rarity as Mycobacterial infection.