PLACENTA ACCRETA IN PRIMIGRAVIDA AT PERIPHERAL SETUP – A RARE CASE REPORT

One of the risk factors for maternal mortality is morbidly adherent placenta (MAP) and accounts for 7–10% of maternal mortality cases worldwide. Placenta accreta is the most common type of MAP, while the other two types are placenta increta and placenta percreta. Placenta accrete accounts for 75–80% of MAP. Here, we present a case of 22 years old, primigravida with no known antenatal risk factors, diagnosed to have placenta accreta intraoperatively after delivering health baby. It is extremely rare for MAP to occur in a patient with no prior risk factors in a primigravida. Peripartum hysterectomy is the only option in a limited care facility with a hemodynamically unstable patient without a proper full-fledged blood bank facility. It is once again reiterated that bleeding from the vagina that does not slow or stop, drop in blood pressure and signs of shock are early signs of blood loss and should be investigated with great concern.

An Elegant Solution to a Ruptured Right Aberrant Subclavian Artery after Oesophageal Stent Removal

Arterioenteric or arteriotracheal fistula is a known complication of an aberrant right subclavian artery (ARSA) and is often associated with prolonged nasogastric or endotracheal intubation or oesophageal stenting. Fistula formation from the ARSA can present unexpectedly with rapid exsanguination with massive haemoptysis or haematemesis, and unless promptly recognised and treated is rapidly fatal. We present a novel endovascular method for treating a fistula between the oesophagus, trachea and an ARSA in an unstable patient following oesophageal stent removal, utilising a covered iliac limb stent, eliminating the need for an open surgical approach.

Simultaneous kissing stents in acute left main total occlusion complicated with cardiogenic shock

We present a case of acute left main bifurcation lesion presenting as very high-risk non-ST elevation acute coronary syndrome. Consequently, an immediate invasive strategy for this complex anatomical lesion in an unstable patient requires an emergent bailout strategy to restore the haemodynamic condition.Our case shows the simultaneous kissing stents technique in a patient with a true left main bifurcation lesion (Medina 1-1-1) as a strategy to overcome the compromised haemodynamics. This protocol would be an alternative life-saving strategy in an acute setting.

HEMODYNAMIC STATUS- PREDICTOR OF OUTCOME IN NON OPERATIVE MANAGEMENT OF ISOLATED TRAUMATIC SPLENIC INJURY

Background: Blunt abdominal trauma is the most common cause of splenic injury and spleen is the most common organ injured in trauma patients both in children and adults. Abdomino-pelvic ultrasound is very efcient radiological investigation in the diagnosis of splenic injuries; it can detect intraperitoneal hemorrhage, splenic capsular tears, and the vascularity of the spleen. Moreover, computed tomography (CT) scan is investigation of choice in hemodynamically stable.CT also guides the surgeon towards management of injuries, and maintaining the low threshold for surgical intervention in correlation with hemodynamic unstable patient with traumatic splenic injury.CT also guides the surgeon towards management of injuries, and maintaining the low threshold for surgical intervention in correlation with hemodynamic unstable patient with traumatic splenic injury. However, even patients with CT scan nding of “blush on CT”, indicating higher grades of injury, if hemodynamically stable still can be managed successfully with NOM as per literature. Methods: This is a hospital based prospective observational study, done on 45 hemodynamically stable patients of splenic trauma, in Accident and Emergency Department of General Surgery, Government Medical College and hospital Srinagar, over a period of 24 months from September 2018 to September 2020. Results:Haemodynamics Status of patient: Our study showed that various parameters dening haemodynamic status of patient are predictors for outcome of study. Various parameters arePulse rate (P-value 0.001), Systolic blood pressure (P-value <0.001), Diastolic blood pressure (P-value 0.001), Haemoglobin (Pvalue <0.001), Haematocrit (P-value <0.001), and Blood transfusions (P-value <0.001). All parameters showed statistical signicance with P-values <0.001. Conclusion: Success of NOM increases, if patient is hemodynamically stable which is predicted by various parameters like pulse rate, blood pressure, urine output, fall in hemoglobin and hematocrit, number of blood transfusions, saturation, temperature and others. NOM in splenic trauma should be management of choice in all hemodynamically stable patients, regardless of blood group and neurological status of patient on admission.Success of isolated splenic injury depends on multiple factors such as availability of ICUs, high dependency units for strict monitoring,blood banks and availability of multidisciplinary team efforts encompassing anesthetics, trauma surgeons, radiologists, for successful outcome. NOM of isolated splenic trauma, is associated with very low morbidity, no complications, and no mortality, when applied in hemodynamically stable patient. Every patient of splenic trauma who is considered for NOM, should be properly counselled about emergency signs and should be advised to report to emergency if any of emergency signs were present. This group of patients must be closely monitored for delayed bleeding in case of NOM of splenic trauma.