Case Report Onventricular Septal Defect (VSD) with Pulmonary Hypertention (Eisenmenger Syndrome) with LSCS

Background: A ventricular septal defect is a defect of the ventricular septal wall where the abnormal opening is present in between the two ventricles. Eisenmenger syndrome is a condition it may develop due to unrepaired heart defect and complication of unrepaired heart defect who is born congenitally. The congenital heart defects lead to Eisenmenger syndrome it developed due to abnormal blood circulate throughout the heart and lungs. Case Report: The 23-year-old female was admitted to AVBRH with the chief complaints of a history of amenorrhoea since 8 months, complaints of breathlessness during exertion since the 7th month of pregnancy and she was referred to AVBRH from Amravati on date 27/1/2021. At the age of 14 years, she had a history of cyanosis at the time of fever and had recurrent episodes of fever for 2-3 yrs, lasting for 2-3 weeks. She is primigravida and had undergone LSCS on date 3/2/2021. She delivered a male child on date 3/2/2021 of birth weight 1.9kg at 12:15 pm. Discussion: Patient with pulmonary hypertension and Eisenmenger syndrome where the surgery is contraindicated because in Eisenmenger syndrome surgery is life-threatening. Only medical management is available to treat Eisenmenger syndrome. Conclusion: Ventricular septal defect in adult females where the pregnancy is contraindicated. Epidural anesthesia should be preferred while the patient undergoes the lower segment cesarean section. This case report concludes that in this condition emergency LSCS is the first choice of treatment and oxygen therapy.

Obstetric fracture of the femur during cesarean section in a preterm baby: A case report

Introduction: Obstetric fractures or Birth fractures are rare events following childbirth. Although fracture of the femur is a relatively uncommon injury, it is the most common fracture of the lower extremity in the newborn. Since evolution of cesarean section rates in Africa, it is one of the most commonly practiced modes of delivery for breech. We described one case of fracture of the femur at cesarean section treated at Adlucem hospital in bonabéri-Douala (Cameroon). Case report: A 2.1 kg male infant was delivered by lower segment cesarean section for breech presentation. Clinical and radiological examination showed shaft fracture of femur with good evolution. Discussion: Fractures of the long bones are associated with cesarean section, breech delivery with assistance and low birth weight. Femoral fractures are the most associated long bones fracture with cesarean section. Conclusion: The clinical and paraclinical diagnosis is simple and the management is mostly non-operative. It is important to explain to the parents and especially to the mother the benignity of the lesion.

Maternal and neonatal outcome of twin pregnancy at a tertiary care center

Background: Twin pregnancies occurs in 2 to 4% of the total number of births. Also the perinatal mortality and morbidity associated with it is five to six times higher in comparison with singleton pregnancy. In developing countries, 287,000 annual maternal deaths and 3 million neonatal deaths contributes to 99% of such mortality as per records of the World Health Organization (WHO) estimates that 99% of the world's annual occur in developing countries.Methods: This observational study included 50 women with twin pregnancy with gestational age of 26 weeks or more. Maternal and neonatal characteristics in twin deliveries at a tertiary care center were analyzed. High risk factors and it’s association with maternal and perinatal outcomes was analyzed.Results: Pregnancy induced hypertension (32%) was the commonest, Preterm rupture of membranes (PROM, 22%) was in the next order. Invitro fertilization (44%), malpresentation (26%) main indicators for lower segment cesarean section. Mean weight of first twin was 1.9±0.43 kg and for second twin it was 1.89±0.47kg (Table 1). Most of twins were diamniotic dichorionic (78%).Conclusions: Twin pregnancies are hazardous to both for the mother and the neonate. It is certainly high risk factor which needs early identifications of complications and timely management. Perinatal outcome largely depends on gestational age, birth weight, presentation, mode of delivery.

Diagnostic Accuracy of Lower Uterine Segment Scar Thickness ≤1.6mm in Prediction of Scar Dehiscence in patients

Background: Cesarean section uterine scar dehiscence (CSD) is a rare but notable complication of Lower segment cesarean section (LSCS) surgery. The cause for a uterine scar dehiscence is based on the etiology behind the uterine scar defect or any event that would predispose the cesarean scar to dehisce. Globally accepted option for assessing the CS scar is transvaginal ultrasonography of the non-pregnant uterus. Objective: To determine the diagnostic accuracy of lower uterine segment scar thickness≤1.6mm in the prediction of scar dehiscence in patients with previous one LSCS who are undergoing repeat LSCS after trial of labour taking intraoperative findings as gold standard. Material and methods: This cross sectional study was conducted in Services Hospital, Lahore for 6 months. The Non probability consecutive sampling technique was used to include women with previous one LSCS at 36-38 weeks were asked to get their TVS done for scar thickness. Women with scar thickness≤1.6mm and scar thickness>1.6mm were identified. Their intraoperative findings of scar dehiscence were confirmed. All the data was entered and analyzed on SPSS version 20. Results: The mean age of patients was 29.87±6.07 years. The emergency LSCS was done in 599(49.1%) patients and elective LSCS was done in 621(50.9%) patients. The sensitivity, specificity & diagnostic accuracy of TVS was 98.31%, 99.05% & 98.69% respectively. Conclusion: According to our study results the TVS for uterine scar is a very useful and effective tool in the prediction of scar dehiscence in patients with previous one LSCS taking intraoperative findings as gold standard. Keywords: Transvaginal sonography, TVS, Uterine, Scar, dehiscence, LSCS, Intraoperative

Uterine Myometrial Preischemia: Yet Another Physiological Change of Pregnancy!

Background The uterus shows tremendous increase in size during pregnancy to nurture the fetus within it. It may show a spectrum of physiological changes or pathological lesions that may affect the pregnancy favorably or adversely. The main purpose of our study was to analyze the physiological changes in the uterus during pregnancy and the postpartum period, thereby gaining deeper knowledge. Materials and Methods We studied a total of 152 uterine specimens obtained from obstetric hysterectomies and maternal autopsies for the presence or absence of normal physiological changes. As a control group, an equal number of surgical uterine specimens received for abnormal uterine bleeding were studied. Results Decidual change was observed from 6 weeks of gestation to 16 days postpartum. It was partially deficient to absent in four cases of placenta accreta. Myometrial hypertrophy was seen in 150 cases (98.68%) from 8 weeks of gestation till 30 days postpartum period. Vascular remodeling was partially deficient to absent in eight cases of pregnancy-induced hypertension. Preischemia of myometrial fibers was an unexpected finding noticed from 20 weeks of gestation to 16 days postpartum in 131 cases (86.18%). Cervical wall hemorrhages were seen in 84.84% cases of vaginal delivery and in only 17.64% cases of lower segment cesarean section. Conclusion Ours is the first study to describe the duration of the routine physiological uterine changes during pregnancy. The relationship between cervical wall hemorrhages and vaginal delivery as well as between myometrial preischemia and gestational age, both being normal physiologic findings, was found to be statistically significant.

Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section

Objectives: To compare the effect of blunt and sharp incision of uterus at cesarean section on intra-operative haemorrhage. Methods: This trial was conducted at the Department of Obstetrics and Gynaecology, Pakistan Ordinance Factory Hospital, Wah Cantt from 14th January to 13th July 2012. Total 80 women planned for lower segment cesarean section through Pfannensteil incision were randomized to either blunt uterine incision (Group-A, n=40) or sharp uterine incision (Group-B, n=40). The fall in Haemoglobin and HCT was compared in two groups and analyzed with help of SPSS version 10. Results: Both groups were similar in terms of demographic features like age, parity, gestational age and indication for cesarean section. The participants in Group-A reveled significantly less drop of mean Hb concentration as compared to Group-B (1.47±1.08 and 1.95±0.85 respectively, P value 0.031). Similarly, the fall in mean HCT was significantly less in Group-A in comparison to Group-B (3.21±1.3 and 4.21±2.17 respectively, P-value 0.015) Conclusion: Blunt expansion of uterine incision during caesarean section is associated with less fall in Haemoglobin and HCT as compared to sharp expansion. doi: https://doi.org/10.12669/pjms.37.7.4159 How to cite this:Faiza, Sadaf F, Ameena B, Khan NR. Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4159 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Common complications and outcome of prematurity at DG Khan Medical College and Hospital.

Objective: To evaluate the common complications of prematurity with final outcome. Study Design: Prospective Observational Cohort study. Setting: Neonatal Unit at Dera Ghazi Khan Medical College (DGKMC) & Hospital. Period: 8 Jan 2020 to 29 Feb 2020. Material & Methods: Study population comprised of 100 neonates of gestational ages between 28-36 weeks, admitted for different reasons. Common complications of prematurity like Hypoxic ischemic Encephalopathy (HIE), Sepsis, Respiratory Distress Syndrome (RDS) and Necrotizing Enterocolitis (NEC) were noted and patients were followed for final outcome in terms of survived, Expired and LAMA. Results: Among the total 100 premature newborns, 59 (59.0%) were males and 41 (41.0%) females. There were 57 (57.0%) premature newborns who were delivered through spontaneous vaginal deliveries (SVDs) while 43 (43.0%) through lower segment cesarean section (LSCS). HIE was the most common complication, observed in 31 (31.0%) babies. Sepsis was the second most common complication observed in 18 (18.0%) cases. In terms of outcome, 72 (72.0%) survived, 23 (23.0%) expired and 5 (5.0%) were left against medical advice (LAMA). Conclusions: Hypoxic ischemic encephalopathy was the most common complication observed either presented alone or in association with other observed complications. The most common cause of mortality in the observed population was hypoxic ischemic encephalopathy.

Comparison of Dexmedetomidine and Fentanyl as Adjuvants to Intrathecal Levobupivacaine in Lower Segment Cesarean Section

Objective: To determine the effectiveness of dexmedetomidine on the spinal anaesthesia as an adjuvant to the hyperbaric levobupivacaine in patients undergoing cesarean section. Study Design: Comparative/Observational Place & Duration: The study was conducted at Anesthesiology/Obstetrics and Gynaecology departments of Mayo hospital, Lahore for duration of six months i.e from 1st November 2020 to 30th April 2021. Methods: This analysis included a total of 120 cases. After the informed consent the patients had received comprehensive demographics. Three equal classes of patients were divided into groups A, B and C. Group I had 40 patients and received 2.5 ml isobaric levobupivacane, group II with 40 patients and received 2.5 ml isobaric levobupivacaine and 5μg dexmedetomidine, and group III received 2.5 ml isobaric levobupivacaine and 25 μg fentanyl intrathecally. The outcomes of these groups were analysed in which sensory and motor blockage period were measured from the time the intrathecal drugs were administered. The full SPSS 26.0 version was used to analyze the results. Results: The mean age of the patients in group I was 27.44 ± 7.64 years with BMI 23.19±8.44, mean age in group II was 27.22 ±7.42 years with BMI 24.44 ± 6.16 and in group III mean age was 26.99 ±9.61 years with BMI 24.72 ±4.34. Duration of sensory and motor blockade was observed and resulted that it was earlier in group III as compared to group I and II. Prolonged duration of sensory and motor blockade was observed in group II as compared to groups I and III with significantly P value< 0.001. Conclusion: We concluded that for an adjuvant of 0.5 percent isobaric levobupivalacaine, Intrathecal dexmedetomidine induces both prolonged motor blockage and post operative analgesia than fentanyl. Key words: Levobupivacaine; Spinal anesthesia, Fentanyl, Intrathecal analgesia, Cesarean section; Dexmedetomidine.

A case report of sirenomelia with two umbilical arteries: an unusual finding in a rare case

Sirenomelia also known as Mermaid syndrome is a rarely encountered fusion anomaly of the caudal region of body often associated with Potter’s facies, single umbilical artery and various visceral abnormalities which make it irreconcilable with life. Here we report a case of sirenomelia delivered in our tertiary care hospital by lower segment cesarean section to a 24 year old third gravida with no previous live issues. No high risk factors could be identified with the mother including diabetes mellitus. Baby was born alive with Potter’s facies. Both the lower limbs were merging into each other like a mermaid’s tail (hence called mermaid syndrome). Sex of the baby could not be identified and the urogenital and anal orifices were absent. Umbilical cord stump had two umbilical arteries. The baby died after 20 hours of life. There appears to be no definitive modality for diagnosing sirenomelia in the antenatal period. However, if a patient has consistently low AFI without any history of leaking per vaginum, high resolution USG or colour Doppler should be done at the earliest to look for the cause.