Greetings from

CASE CAPSULES
Prof. Ayesha Jehan

Professor of Obstetrics & Gynaecology,

Deccan College of Medical Sciences, Hyderabad

CASE 1

CASE 1
22/F, Primi gravida, c/o 8 months amenorrhoea and watery leak P/V h/o recurrent attacks of VV + UTI since marriage (11 months) h/o cerclage at 18 weeks GA e/o genital herpes since 16 weeks of pregnancy AN Profile:
Hb: 12 g%, Blood group: A positive OGCT: 90 mg% VDRL: NR, HIV/HbsAg: Negative S.TSH: 1.5 uIU/ml, ECG: WNL CUE: Pus cells: 15-20/HPF, Albumin +, E/C - NIL

.. contd
AN Exam:
Uterus 30 weeks, FH<GA Irritable, FH + regular, NST reactive L/E: Herpetic vesicles seen locally over the external genitalia.

P/V
Cx soft, short, watery leak +

P/S
Thin, profuse WD +, Vagina congested. Cerclage suture + Watery leak intermixed with WD +

Conclusion: PPROM + VV at 32 weeks

QUESTION 1

WHAT IS THE CLINICAL APPROACH IN

THIS CASE?

WATERY LEAK - DDx

1. Vaginal discharge
Physiological vs. Pathological

2. Amniotic fluid
Gush vs. Trickle

3. Urine

QUESTION 2

WHAT IS THE SIGNIFICANCE OF

VAGINAL EXAMINATION IN ANC?

EFFECTS OF RECURRENT VV INFECTIONS AND PID?

VULVOVAGINITIS
40-60% of AN cases Organisms commonly implicated:
Trichomonas Gardenella Beta streptococci, Gonococci

Candida
Chlamydia TORCH, HIV, Kochs

High vaginal swab, endocervical swab indicated.

VULVOVAGINITIS
VV and PID cause: Abortions PPROM: Oligoamnios, CA, Abruptio placenta Preterm birth

Placental insufficiency: IUGR, IUD

PROM & PTB - Prolonged hospital stay:
Psychosocial strain Thromboembolic phenomenon Puerperal sepsis Neonatal complications

VULVOVAGINITIS PATHOGENESIS OF FETOMATERNAL EFFECTS

MEMBRANE INFLAMMATION TISSUE INJURY HYPOXIA DESTABILIZATION OF LYSO MEM PLACENTA
INSUFFICIENCY Infection/anoxia

FOETUS
Sepsis FD IUGR IUD

ACTIVATION OF COX/IL-6/CYT

RELEASE OF AA - PG
ABNORMAL UTERINE ACTIVITY IAP PPROM
CERVICAL CHANGES

MATERNAL SEPTICAEMIA

PRETERM BIRTH

QUESTION 3

WHAT IS THE CAUSE AND

FOETOMATERNAL EFFECTS OF GENITAL

HERPES?

MODE OF DELIVERY?

GENITAL HERPES
5% of high risk pregnancies (rising trend) Caused by HSV-1 & HSV-2 () M-B transmission in first trimester leads to:
Congenital defects: Microcephaly, intracranial calcifications, micro-ophthalmia, chorioretinitis

M-B transmission in later weeks causes neonatal herpes (SEM, CNS, disseminated herpes) 80% HSV positive infants are born to asymptomatic mothers. In primary infection, IgM+ in 7-10 days, IgG low avidity+ in 4 weeks. Intrauterine foetal infection is high in the absence of IgG (Placental barrier) Ascending infection from the cervix is common. PPROM predisposes to IU spread.

GENITAL HERPES
Rx: Acyclovir 400mg TID x 7-10 days Valacyclovir 500mg BD x 7-10 days Famcyclovir 200mg BD x 7-10 days Obstetric management: (1998 AICOG Guidelines)

No lesion No LSCS
Primary herpes LSCS, Recurrent LSCS +/ Invasive intrapartum procedures (FBS, CTG) and instrumental deliveries are avoided.

QUESTION 4

WHAT IS THE PROTOCOL FOR

ANTENATAL SURVEILLANCE IN CASES OF

PPROM?

ANTENATAL SURVEILLANCE PROTOCOL

Twice daily CTG / FH monitoring Maternal Vitals: PR/Temp q4h CBP twice weekly (leucocytosis - IUI)

Non-specific inflammatory markers: ESR, CRP

USG: BBP, Doppler study Repeated high vaginal swabs DEBATED
ascending infections??

QUESTION 5

WHAT ARE THE C/F OF THE FOUR MAIN

COMPLICATIONS OLIGOAMNIOS, CA,

PTB, FOETAL DISTRESS?

QUESTION 6

WHAT IS THE MANAGEMENT IN THIS

CASE?
- CONSERVATIVE - ACTIVE

CONSERVATIVE MANAGEMENT
The Rule in:
NIL/minimal signs of infection NO foetal compromise

CONSERVATIVE MANAGEMENT
Rest and Oxygen therapy
Hydration: IV, Amino infusion +/ Antibiotics (Parental, oral) Steroids Tocolytics Progesterone, hCG Counselling and diet

ACTIVE MANAGEMENT
Termination of pregnancy Cerclage - when to remove?

In our case..
The patient was managed conservatively for 96 hours, after which
pregnancy had to be terminated due to:
leakage of liqour (AFI: 2) Severe variable decelerations on CTG (FD) E/O cord prolapse excluded

LSCS done, alive and healthy female baby weighing 1.8kg delivered, thin MSL, cord friable, placenta showing e/o large retroplacental clots &

calcifications.
Baby admitted to NICU for neonatal care. Puerperum uneventful Healthy mother & baby discharged on Day 14.

TAKE HOME MESSAGES

A vaginal examination is mandatory in all antenatal cases
High vaginal swab & endocervical swab in early pregnancy helps to predict complications Most patients remain asymptomatic but can spur surprises Check couples habits
Smoking, zarda, pan Multiple partners Increased sexual activity In male: DM, UTI, Seminal infections

Most infections are polymicrobial Prophylactic antibiotics complications in HR patients.

INTRAPARTUM SCREENING PROGRAMME

CDC recommended strategies:

Strategy 1: Vaginal + Rectal swab for all patients at 35-37 weeks.

Strategy 2: Intrapartum antibiotic prophylaxis. Strategy 3: Combination of 1+2

Strategy 4: Rapid bed side testing in labour

Dosage recommended: Metronidazole 2g q24h x 2 days Benzyl penicillin 3g stat followed by 1.5g q4h x 2days (or) Metronidazole 200-400mg + Clindamycin 900mg q8h x 2 days Intrapartum prophylaxis is effective only if given 2 hours before delivery

VACCINES A LONG TERM SOLUTION??

Vaccination of all women of child bearing age

is recommended.
But most pathological organisms have various strains, hence, efficacy is not yet satisfactorily established.

CASE 2

CASE 2
A 39 year old woman with 3 children came to the hospital with excessive bleeding P/V following 2 months amenorrhea. She felt unmistakably pregnant.
H/O POP usage + (no slip) Cycles irregular/scanty due to POP UPT + Moderately heavy bleeding for 7 days.

O/E: GC stable. Afebrile. Tachycardia + BP-110/80mmHg, All systems stable. Pallor+, No goitre. P/A: Soft, Tenderness + pelvic region. No guarding. No s/o peritonitis. Ut NS Fx free Cx excitation ve, Bleeding PV +, no clots. Os admits tip.

Investigations:
Hb: 11g%, B+ve, RBS: 70mg%

CUE: few Pus cells, RBC +, UPT +

Serum hCG: 215 IU, After 48 hours, S.hCG: 45IU TVS: Ut NS ET 7mm, Left adnexa showing thin walled ovarian cyst + 2x2cm, free fluid POD Culdocentesis: No blood, 1-2ml clear fluid +

QUESTION 1

WHAT IS THE DIAGNOSIS? DEFINITIVE DIFFERENTIAL ENNUMERATE THE DDX IN THIS CASE

IN OUR CASE A DIAGNOSIS OF

MISCARRIAGE + BENIGN OVARIAN CYST WAS MADE.

QUESTION 2

DOES AN ADNEXAL MASS (CYST) ALWAYS IMPLY ECTOPIC? INCIDENCE OF ADNEXAL CYST IN EP? DEFINITIVE FEATURES OF ECTOPIC GESTATION?

DEFINITIVE FEATURES OF ECTOPIC

UNRUPTURED
EMPTY UTERINE CAVITY
GESTATIONAL SAC + FOETAL POLE IN ADNEXA CULDOCENTESIS 10ML UNCLOTTED BLOOD In the absence of definitive features, the diagnosis of ectopic pregnancy can be missed.

RUPTURED
PERITONITIS ++

UPT + (SUBMINIMAL TITRES) SHOCK +

QUESTION 3

WHAT IS THE MANAGEMENT OF MISCARRIAGE?

MISCARRIAGE - MANAGEMENT
Medical management Misoprostol
600-800ug in single/divided doses

Check curettage Regular follow-up with S.hCG titres/UPT in

48 hours

QUESTION 4

WHAT ARE THE PROGESTERONES USED AND THEIR DOSAGES IN POP?

CAN THEY CAUSE MISCARRIAGES/ECTOPIC? HOW? FAILURE RATE?

PROGESTERONES IN POP
Norethindrone: 0.35mg
Norgestrel: 0.075mg Levonorgestrel: 0.03mg Desogestrel: 0.075mg (75ug)
Progesterones alter tubal motility, make the endometrium hostile to nidation, alter cervical mucous. Failure rate: 0.5 to 1%
Cerazette (desogestrel 75ug) can cause abrupt follicular development in certain cycles (97-99% inhibition)

QUESTION 5

WHAT IS YOUR FURTHER

CONTRACEPTIVE ADVICE TO THIS

COUPLE OF 40-45 YEAR AGE GROUP?

ALTERNATIVE CONTRACEPTIVE ADVICE Permanent contraception Barrier methods Others

TAKE HOME MESSAGES

Contraception is no guarantee against pregnancy. Every adnexal cyst in EP does not imply an ectopic. Benign ovarian cysts like simple follicular cyst/CL cyst should be kept in mind. By TVS incidence of ovarian cyst in EP: 30% In unruptured ectopic a definitive Dx can be made only in 30% of cases. S.hCG levels by 2/3 every 48 hours for 5 weeks on till 8 weeks normally. At 5 weeks, hCG level is 1000-1500 mIU. TVS scan is superior to TAS for early Dx of pregnancy site & viability. By TVS at 5 weeks, GS (>20mm) +; FP+, YS+, hCG level 1000mIU. By TAS GS is seen when hCG level is 6000 mIU. Progesterone assays are helpful in predicting miscarriage
> 60 nmol: Healthy pregnancy, < 20 nmol: miscarriage.

RECENT TERMINOLOGIES

RECENT TERMINOLOGIES
The term ABORTION is OUTDATED. 1. Pregnancy of uncertain viability:
At 6 weeks: only a regular IU sac. FP+, no cardiac activity.

Nil/ bleeding PV
UPT strongly Positive Rescan in 8-10 days Common in cases of endocrinopathies

RECENT TERMINOLOGIES
2. Pregnancy of uncertain location:
UPT +

No adnexal mass
No IU sac/ FP Rescan in 2 weeks/repeat S.hCG titers

3. Pregnancy failure:
Recent terminology for abortion Falling hCG & progesterone levels Blighted / Missed gestation

TOCOGRAPHY
ABNORMAL UTERINE CONTRACTION PATTERNS

ABNORMAL UTERINE CONTRACTION PATTERNS MINOR DEFECTS

Skewed contraction
Causes: CPD Hypotonus In. UA PROM Polyam Minor defects per se do not cause foetal compromise. Can lead to major defects.

Paired contraction

Polysystole

ABNORMAL UTERINE CONTRACTION PATTERNS MAJOR DEFECTS

Hypertonus
Caused by: CPD/POP/Abruptio/

Tachysystole

uterotonics

Lead to:

Foetal compromise

Uterine tetany

Risk of uterine rupture

DDx

ACUTE ABDOMINAL PAIN IN PREGNANCY

ACUTE ABDOMEN IN PREGNANCY

Causes related to pregnancy:

Early pregnancy complications ectopic/miscarriage

Abruptio placenta Uterine fibroids (red degeneration, infection, torsion)

Chorioamnionitis
Uterine rupture Severe pre-ecclampsia + HELLP (epigastric pain)

Severe uterine torsion

Normal rotation by 30-40% to right occurs in 80% cases. If > 90% rotation: Severe torsion

Ovarian tumours (cysts)

ACUTE ABDOMEN IN PREGNANCY

Causes unrelated to pregnancy:
Acute appendicitis UTI + pyelonephritis

Urolithiasis
Cholelithiasis APD + peptic ulceration Intestinal obstruction & Crohns disease Acute pancreatitis Acute fatty liver of pregnancy Rare blood dyscrasias (sickle crisis, blast crisis) Peritonitis due to intra-abdominal hemorrhage

Thank You