Case Presentation (Gynae & Obs Department MMC. pptx

Case Presentation during training of FCPS.

1. Case presentation Presented by Dr. NAZIMA RAHIMOON FCPS-II, Trainee, ( Gynae & Obs ) Supervised by: Gynae & Obs Department

2. History

3. Bio data Name: Mrs X w/o Mr. Y Age: 28 years Address: Sufi Faqeer Gravida : 6 Parity: 1+4 LMP: 01/03/2023 EDD: 08/12/2023 Date of admission: 17/11/2023 Mode of admission: OPD

4. PRESENTING COMPLAIN G estational amenorrhoea of 38 weeks with mild labour pain since 5 hours.

5. History of Presenting complain FIRST TRIMESTER Patient Conceived spontaneously while having regular Menstrual cycle and practicing no contraception and she confirmed her pregnancy by urine pregnancy test following missed periods. First Trimester scan was done which was normal. She experience nausea and vomiting. She has no fever, flu like illness and vaginal bleeding.

6. She booked herself in MMCH in first trimester and considering her recurrent second trimester miscarriages TVS advised for foetal viability, cervical dilatation and cervical length which shows cervix was 0.6cm dilated and length was 2.7cm. Cervical cerclage was applied at 13 weeks of gestation under anaesthesia in operation theatre. She kept on tab: folic acid, Tab: Duphaston BD, Tab: Ascard OD, Cyclogest Pessary OD per rectal.

7. SECOND TRIMESTER, She felt foetal movement at fifth month of gestation. She had regular antenatal visits in second Trimester. Her anomaly scan was done at 20 weeks and she was reassured about the baby. Her baseline labs were done CBC shows Hb was 11.7, BG was B+ve , HBsAg was non reactive, AntiHCV was non reactive and HbA1c was 4.7%. Patient had no complain of fever, flu like illness vaginal bleeding however she has grayish white vaginal discharge and she was adviced antibiotics. Patient advised for Iron, Calcium supplements and continue for first Trimester medications.

8. THIRD TRIMESTER. She had taken regular antenatal visits. Her third trimester scan was done on 11/23 September & 30 October which was normal. Patient came for cerclage removal at 37 completed weeks of gestation, suture was removed, reassured about baby condition and advised to come in labour. Patient came at 38 completed weeks with mild labour pain and admitted in MMCH for further management.

9. Obstetric history Married since 7 years. Consanguineous marriage. G6P1+4 First 4 months pregnancy spontaneously miscarriage at home. Second 5 months pregnancy spontaneously miscarriage at home. Third 5 months pregnancy spontaneously miscarriage at home. Fourth 6 months pregnancy spontaneously miscarriage at home. Fifth Pre-term delivery at 7 months alive baby girl delivered at hospital and died after 3 days. Last baby born 1.5 year ago.

10. Gynaecological history Age of menarche: 13 years Previous menstrual cycle: Menstrual Cycle: Regular 7/28 Menstrual flow: Normal Dysmenorrhoea not present. Dyspareunia not present Intermenstrual bleeding not present. Post-coital bleeding not present. No pap smear.

11. Past history No History of Hypertension, DM, TB, Asthma and Thyroid disorder. No history of blood transfusion. No surgical History .

12. Family history No history of multiple gestation and congenital abnormalities in her family. No history of H ypertension, DM, TB & Asthma in family.

13. Personal History Normal appetite. Normal Sleep. No addiction History. No drug History. No allergy History .

14. Socio Economic History She belongs to a middle class family.

15. General physical examination My patient was young age lady with average height and built, well cooperative and well oriented with time, place and person.

16. Vitals BP = 110/70 mm Hg Pulse = 88 b/min RR = 17 b/min Temp = 98°F

17. Sub-vitals Anaemia not present Jaundice not present Oedema not present Koilonychias not present Clubbing not present Thyroid not palpable Lymph node not palpable

18. Abdominal examination INSPECTION Symmetrically enlarged gravid uterus. Umbilicus is centrally placed. PALPATION SFH = 36 weeks. Lie = longitudinal Presentation = Cephalic 5/5 palpable in relation to pelvic brim FHS = 150 b/min & regular AOL = Clinically Adequate

19. VAGINAL EXAMINATION Vulva vagina normal Cervix thick in consistency and short in length. Cervical os 3.5 cm dilated Membrane intact

20. Differential Diagnosis CERVICAL INCOMPETENCE. BACTERIAL VAGINOSIS. UTERINE ABNORMALITIES. PROTHROMBOTIC FACTORS.

21. Diagnosis CERVICAL INCOMPETENCE

22. Investigation Blood group B+ve Hemoglobin 12.4 g% HbsAg : Non-reactive Anti-HCV: Non-reactive HbA1c: 4.7% Urine albumin not present

23. Anti Phospholipid IgG = Negative Anti Cardiolipin IgG = Negative TORCH PROFILE Toxoplasma IgM = Negative Rubella IgG = Positive Rubella IgM = Negative Cytomegalo virus IgM = Negative Herpes simplex virus – 2 IgM = Negative TPHA = non reactive Free T4 = 1.1 ng /dl TSH = 1.57 µIU/ml

24. MANAGEMENT Her Elective Lower segment Caesarean section done at 38 completed gestation age due to non progress of labour and bad obstetric history. Alive baby girl delivered with good Apgar score. Her postoperative period remains unremarkable. Patient and baby girl discharged on 3 rd postoperative day with satisfactory condition. Follow up advised.

25. Summary A 28-year-old patient, gravida 6 para 1 plus 4, was admitted for an elective lower segment cesarean section after the removal of a cerclage placed at 13 weeks of gestation. The patient received treatment, underwent regular antenatal visits, and eventually delivered a healthy baby girl with a good Apgar score. Both the mother and baby were discharged from the hospital in satisfactory condition.

26. Literature Review

27. RECURRENT MISCARRIAGE Recurrent miscarriage is defined as loss of three or more consecutive pregnancies before viability. The term includes all pregnancy losses from the time of conception until 24 weeks of gestation. Approximately 15% of all pregnancies that can be visualized on ultrasound end in pregnancy. Three or more losses affect 1-2% of women of reproductive age and two or more losses affect around 5%. AETIOLOGY MATERNAL : Systemic(syphilis, diabetes mellitus),hormonal(PCOS), cervical incompetence,uterine abnormalities, immunologic. FOETAL: chromosomal defects in fetus . IDIOPATHIC

28. INVESTIGATION Blood group and Rh typing, complete blood count, urine examination, TORCH titre, Antiphospholipid antibodies, thyroid function tests, glucose tolerance test, ultrasonography. MA NAGEMENT Adequate rest and proper diet Anaemia are corrected if present Systemic illness treated promptly. Incompetent cervical OS-Operative treatment. Anti-phospholipid syndrome-low dose aspirin, steroids, low dose heparin. Hysteroscopic resection of uterine septa. Hormone Therapy for PCOS Control of diabetes and Thyroid disorders.

29. Bacterial vaginosis It is the commonest cause of vaginal discharge in women of child bearing age. It is characterized by an over growth of anaerobic bacteria, predominantly Gardnerella vaginalis and Mycoplasma hominis which replace the normal lactobacillus-dominant vaginal flora. There is also a rise in the vaginal pH from the normal level, below 4.5, to levels as high as 6 or 7. Symptoms: Fishy odor vaginal discharge.

30. Women with bacterial vaginosis an increased risk of second trimester loss and preterm birth. It is associated with Chorioamnionitis . Treatment: Metronidazole either as 200mg three times a day for 7 days or as a single 2gm dose. Alternatively, Clindamycin can be used as vaginal cream.

31. Uterine Abnormalities It may be congenital or acquired. CONGENITAL Septate uterus,bicornuate and arcuate uterus. ACQUIRED Fibroids or intrauterine adhesions ( Ashermans syndrome) Recurrent miscarriage is associated with uterine structural abnormalities. Observational studies suggest that hysteroscopic surgery is effective for septate uteri. Hysteroscopic surgery is effective in reducing mid trimester loss if fibroids are distorting the uterine cavity.

32. PROTHROMBOTIC FACTORS Antiphospholipid syndrome is associated with first trimester reccurent miscarriage and single second trimester miscarriage. Recurrent miscarriage is associated with thrombophilia. We excluded them by lab test which includes anti cardiolipin IgG and anti phospholipid IgG which was negative.

33. Cervical incompetence (cervical insufficiency) The inability of uterine cervix to retain a pregnancy in the absence contraction, labor or both in the second trimester. Cervical incompetence is characterised by painless cervical dilation in the second or early third trimester with ballooning of the amniotic sac into the vagina followed by rupture of membranes and expulsion of usually the live fetus . u sual timing: 16-24 weeks.

34. AETIOLOGY CONGENITAL Developmental weakness of cervix Associated with uterine anomalies like septate uterus. Following in utero exposure to diethyl stilbestrol .

35. Acquired due to previous cervical trauma Forcible dilation during MTP and dilation and curettage (D & C) Conisation of cervix causes a risk of subsequent pregnancy ending up in preterm birth. Cauterization of cervix Amputation of cervix or fothergill’s operation.

36. OTHERS One or more second-trimester miscarriages with no known cause. Cervical insufficiency in a prior pregnancy One or more spontaneous preterm deliveries Uterine abnormality (such as a bicornuate uterus ) Previous surgery on the cervix

37. DIAGNOSIS Diagnosis of cervical incompetence : A history of painless cervical dilation and second trimester deliveries. A history of short labors and progressively earlier deliveries in previous pregnancies. Advance cervical dilation and effacement before week 24 of pregnancy without painful contraction, vaginal bleeding, water breaking (ruptured membranes) or infection.

38. Investigations PREMENSTRUAL HYSTEROCERVICOGRAPHY It mainly shoe the typical funnelling of the internal os . NON PREGNANT STATE: The internal os allows the passage of a No.8 Hegar’s cervical dilation or foley’s catheter filled with 1ml water without resistance.

39. IN PREGNANCY : Transvaginal ultrasound is the ideal method to follow up and detect early incompetence. The normal cervix length at 14 weeks is 35-40 mm and the internal os diameter is less than 20 mm. A cervical length less than 30 mm and a internal os diameter more than 20mm is suggestive of cervical incompetence. Funnelling of the os on USG also indicates cervical incompetence.

40. Management The management is surgical by means of a cervical cerclage . The diagnosis is difficult and cervical cerclage is quite often performed unnecessarily. Cervical cerclage is usually delayed up to 12-14 weeks so that miscarriage due to other causes can be eliminated or it should be done atleast 2 weeks earlier than the lowest period of earlier wastage (not earlier than 10 weeks). SONOGRAPHY should be done prior to cerclage to confirm a live fetus and to rule out anomalies. If there is infection, it should be treated.

41. Types of operation done during Pregnacny with a success rate of about 80-90%. The operations are named after: Shirodkar McDonald Transabdominal Cerclage Principal: The procedure reinforces the weak cervix by a non-absorbable tape, placed around the cervix at the level of internal os .

42. Preoperative evaluation should include the following. Foetal ultrasound assessment for viability, gestational age, and any identifiable anomalies. Clinical evaluation to exclude active bleeding, preterm labour, and PPROM. Consideration of amniocentesis to rule out a subclinical intraamniotic infection, particularly in women with cervical dilatation at the time of presentation.

43. Shirodkar suture It is mainly the vaginal approach to cervix. A high vaginal suture places the stitch at the level of the cardinal ligaments by mobilizing the bladder upwards. The knot is frequently buried requiring regional anaesthesia for removal.

44. McDonald procedure In the lithotomy position cervix is visualized using a sim’s speculum. The anterior and posterior lips held with sponge holding forceps. A low trans vaginal cerclage is often a suture inserted in a ‘purse string’ fashion (sometime known as a McDonald suture), placed at the cervicovaginal junction, without surgical mobilisation of the bladder. Performed under spinal anaesthesia it usually can be removed without anaesthesia.

45. Post operative Care Antibiotics Tocolytics Bed rest for first 24 hours followed by mobilization and activity.

46. Contraindications Intrauterine infection Rupture membranes H/O vaginal bleeding Severe uterine irritability

47. Complications EARLY COMPLICATIONS Infections ( chorioamnionitus , vulvovaginitis ) Bleeding Premature Labour Deep Cervical Laceration. LATE COMPLICATIONS Fistula Formation Cervical Stenosis Preterm deliveries