CASE PRESENTATION

Dr.Madhuri YCASE PRESENTATION

An unbooked case of a 28 year old,Reshma Anjum W/O Nadeem,resident of Sangareddy belonging to SEC-3 is a housewife is G3P1L1A1 with 9 months amenorrhoea came with chief complaints of pain abdomen since 2 hoursLMP-19-11-2014EDD-26-8-2015

HISTORY OF PRESENTING ILLNESSG3P1L1A1 presented with complaints of pain abdomen since 2 hours No H/O decreased perception of fetal movementsNo H/O leaking P/VNo H/O bleeding P/V

No H/O burning micturitionNo H/O swelling of legsNo H/O headacheNo H/O blurring of visionNo H/O of epigastric painNo H/O frequency of micturitionNo H/O of fever and vomitingsNo H/O of trauma

OBSTETRIC HISTORYMarital life-5yearsnon consanguinous marriageNo h/o usage of OCPS or ovulation induction drugsConceived spontaneously 1 year after marriageLMP-19/11/2014EDD-26/8/2015

1st Pregnancy:Antenatal period was uneventfulFull term, LSCS (indication-CPD), female baby, 2yearsBirth weight was 2.9kg,at narayankhed govt hospitalPostpartum period was uneventful (no h/o puerperal fever, wound discharge) Exclusive breast feeding for 6 monthsDevelopmental milestones were normal and baby immunized till date

2nd Pregnancy:Conceived spontaneously 1 year after 1st pregnancySpontaneous abortion in 3rd month followed by dilatation and curettage.Present pregnancy:Conceived spontaneously 1year after 2nd pregnancy.Regular antenatal check ups in outside hospital.1st TrimesterNo H/O excessive nausea and vomitingNo H/O of pain abdomen and bleeding P/VFolic acid prophylaxis takenNo H/O radiation exposureNo H/O drug intake

2nd Trimester:Quickening felt in 5th monthIron and calcium supplementation takenTwo doses tetanus toxoid taken

3rd Trimester:No H/O bleeding or leaking P/VNo H/O pedal edema

MENSTRUAL HISTORYAttained menarche at 13years of age4-5/30, regular, normal flow, no clots, no dysmenorrhoea

PAST HISTORYNo H/O Hypertension, Diabetes mellitus, Epilepsy, Tuberculosis, Asthma or Heart disease and No H/O Blood transfusions.SURGICAL HISTORYNo significant surgical history except for previous caesarean and dilatation and curettage done in the past.

FAMILY HISTORY:No h/o multiple pregnancy,congenital anomalies

PERSONAL HISTORYDiet-mixed, Appetite-goodSleep-adequateBowel & Bladder- RegularNo addictions

GENERAL EXAMINATIONPatient is conscious and coherent, moderately built and nourished.Ht-148cmsWt-64kgsPallor-presentNo icterus, cyanosis, clubbing, lymphadenopathy and pedal edemaSpine, Breast and Thyroid NAD

Vitals-Temperature-Afebrile PR-82/min, normal volume BP-110/70mm of Hg in right arm supine positionCVS Examination: S1 and S2 heard, No murmursRESPIRATORY SYSTEM: Bilateral air entry-present, clear and equal on both sides, No adventitious sounds

PER ABDOMEN:Uterus uniformly enlarged to size corresponding to 36wks gestational age.On palpation fundal height was corresponding to 36wks GAFundal grip: broad, soft and irregular mass suggestive of breechLateral grip: back felt on left side, limb buds felt on right side1st pelvic grip: cephalic and head was ballotable

Uterus was irritable and scar tenderness was presentSymphysio fundal height was 34cmsAbdominal girth-94cmsClinically liquor was adequateAUSCULTATION:FHS heard,at left spino umbilical line, regular,142/min

P/S-cervix and vagina healthyP/V-cervix was 50% effaced, os admitting 1 finger membranes+ presenting part vertex at -2 station pelvis gynecoidSingle live intrauterine fetus with longitudinal lie and cephalic presentation, head ballotable and fetal heart sound heard on left spino-umbilical line and was 142/min.

SUMMARYA 28year old unbooked case,G3P1L1A1 with 9months amenorrhoea with prev LSCS with complaints of pain abdomen since 2hrsOn examination uterus was corresponding to 36wks GA with single live fetus with cephalic presentation with scar tenderness

DIAGNOSIS: G3P1L1A1 with 36 weeks GA with 1 previous LSCS with scar tenderness in early labour

INVESTIGATIONSHb-10.8gm%T.W.B.C-7200cells/cummNeutrophils-53%Eosinophils-3%Lymphocytes-37%Monocytes-6%Platelet count-1.8 lakhs/cummCUE-Normal

RBS-70mg/dlHIV-NRHBsAg-NRVDRL-NRB/G/T-B+veBT-1min 20 secondsCT-3min 30 seconds

Patient was admittedHigh risk consent was takenEmergency LSCS was planned

Operation perfomed: Emergency LSCS with bilateral tubectomy under spinal anaesthesiaOperative ProcedureUnder complete aseptic conditions abdomen cleaned and draped.Pfannensteil incision was given over abdomenAbdomen opened In layersLower uterine segment identified and incisedLUS was thinned outKehrs incision given over lower segment of uterus

A single live preterm male baby of birth weight 2.5kg and APGAR 1-8/10,5-9/10 was delivered on 26th july at 2.30pm.Placenta was located in fundal anterior positionPlacenta with membranes was removed in totoUterine suturing done and hemostasis secured.Total blood loss was estimated to be 750ml.Bilateral tube ligation was doneAbdomen was closed in layersPatient condition was stable and was shifted to post operative ward.Baby was admitted to NICU for observation and was discharged after 5days.Post-operative period was uneventful

Suture removal done on 7th post operative day and wound was healthy.Patient was discharged on 8th postoperative day and was reviewed in OP after 1 week

DISCUSSION OF POST CAESAREAN PREGNANCY

Pregnancy with prior caesarean delivery is quite prevalent in present day obstetric practiceThis is due to liberalization of primary caesarean section with non-recurrent indicationsThese cases are called post caesarean pregnancy

Effects On Pregnancy And LaborIncreases risk of

Preterm laborabortion

Operative interferencePlacenta praeviaAdherent placenta(placenta accreta,increta,percreta)Rupture uterusPost partum hemorrhagePeripartum hysterectomy Injury to bowel and bladder during surgery

Effects On The ScarIncreased risk of scar ruptureMore risk in classical/ hysterotomy scar than lower segment scarLower segment scar rupture during labor (incidence is 0.2-1.5%)Classical/ hysterotomy scar ruptures during late pregnancy and labor(incidence is 4-9%)Impairment of healing can cause early scar rupture

Healing of the uterine woundUterine wound is healed by muscles and connective tissues, if the apposition of the margins is perfectFactors of prime importance in impaired wound healingImperfect appositionPresence of sepsisPresence of hematoma in the woundPoor general conditionExcessive stretching of LUS leading to diminished vascularity

Lower SEGMENT VS CLASSICAL/ HYSTEROTOMY SCARLower SegmentClassical /HysterotomyApposition Perfect, no pockets of bloodDifficult to apposeState of uterus during healingThe part of uterus remains inertThe part contracts and retractsStretching effectAlong the line of scarAt right angles to scarPlacental implantationAttachment on scar unlikelyPlacenta more likely to implant on scarNet effect Sound scarWeak scarChances of rupture 0.2 - 1.5% 4 - 9%Mortality following ruptureMaternal and perinatal death less more

INTEGRITY OF THE SCAR CLASSICAL SCAR : The scar is weak. The scar is more likely to give way during pregnancy with increased risk to the mother and fetus. These cases should be delivered by LSCS LOWER SEGMENT TRANSVERSE SCAR: Usually heals better. During the course of labour the integrity of the scar need to be assessed. High index of suspicion is essential. Factor that are to be considered while assessing scar are: evidences of Scar Dehiscence during labor.

PREVIOUS SCAR

Dehiscence-separation along the line of the previous scar(without involving the peritoneal coat)

Rupture when the unscarred tissue is also involved in separation

Management

Caesarean section

VBAC trial of labor (trial of scar)

Previous operative notes

Indication of caesarean section: (a) Placenta praevia (i) imperfect apposition due to quick surgery and (ii) thrombosis of the placental sinuses. (b) Following prolonged labor-increased chance of sepsis.

Technical difficulty in the primary operation leading to tears to involve the branches of uterine vessels.

Hysterography in interconceptional period: Hysterography, 6 months after the operation, may reveal defect on the scar(wedge depression of more than 5mm)

Pregnancy(present and past): (1) Pregnancy occurring soon after operation(2)Pregnancy complication such as twins or polyhydramnios puts stretching effect on the scar(3)h/o previous vaginal delivery following LSCS(4)Placenta praevia in present pregnancy

Hospitalization

LSCS scar Hospitalization at 38 weeks

Classical CS at 36 weeks due to possibility of rupture of scar in pregnancy

VBAC TRIAL OF LABOUR

Proper case selection :- 2/3 of previous CS TOL; 2/3 of TOL VBACSuccessful trial results in vaginal delivery of a live fetus without scar ruptureA failed trial is said to occur when a emergency caesarean section is required or there is scar ruptureVBAC is successful in 70-76% of cases

Selection of cases of VBAC

Type of prior uterine incision 1 LS transverse incisionPrior indication if recurrent, elective CS should be done (success more when prior indication is breech/fetal distress/placenta praevia/ abruption)Prior vaginal delivery (if woman had H/O vaginal delivery chance of VBAC increased)Post-op infection can make scar weakPelvis adequate for the fetusContinued labour monitoring possibleInformed consent of the woman

How many years back was the CS done ??

Min 18 months to heal the scar, so a gap of 18-24 months is necessary

Present pregnancyNo medical / obstetric complication

Average sized baby

Vertex presentation

No CPD

USG

To assess integrity of scar if myometrial thickness > 3.5mm, decreased risk of ruptureHelps to assess placental locationIf placenta implanted over the scar high chance of adherent placenta on USG no subplacental sonolucent zone

Contraindications to VBACPrevious classical incisionPrevious two LSCSPelvis contracted or suspected CPDPrevious inverted T/ extension of incisionMalpresentationsMedical /obstetric complicationMultiple pregnancy Resources limited for emergency caesarean deliveryPatients refusal to undergo trial

Elective caesarean sectionIf VBAC is contraindicated / if patient refuses

Timing

if fetal maturity is sure 39wksif not wait for pains to start or membranes to ruptureprevious classical CS 38 wks

Evidences of scar rupture

Evidence of scar rupture during labor

Abnormal CTG: late deceleration, most consistent findingSuprapubic pain: persisting between contractionsShoulder tip pain or chest pain or sudden onset of shortness of breathAcute onset of scar tendernessAbnormal vaginal bleeding or haematuriaCessation of uterine contractions which were previously adequateMaternal tachycardia, hypotension or shockLoss of station of presenting partMeconium staining of amniotic fluid

MANAGEMENT OPTIONS ADMISSION AT 38 WEEKSADMISSION AT 36 WEEKS

CASE ASSESSMENT

FORMULATION OF Mode OF DELIVERY

MANAGEMENT OF LABOUR Iv-Ringer solutionBlood sample Hb%, grouping, cross matchingSpontaneous onset of labor desiredMonitoring clinical and electronicEpidural analgesiaAugmentation by oxytocin selectively & judiciouslyProphylactic forceps or ventouse to cut short 2nd stageExploration of uterus

Delivery Cut short the second stage with outlet forceps/vacuum

Look for excessive bleeding in third stage-sign of scar rupture

If bleeding is excessive- emergency laparotomy

Observe for 4-6hrs in labour ward

BENEFITSDecrease in-maternal morbidity hospital stayneed for blood transfusionrisk of abnormal placentationneed for c-section in next pregnancyMATERNAL:Uterine ruptureRisk of hysterectomyInfectionsMaternal morbidity

FOETAL:Fetal distressLow APGARDeath

COMPLICATIONS

STERILISATIONIncreasing risk after each operationDuring third time CS sterilization should be considered unless there is sufficiently strong reason to withhold it