Case studies in obstetric problems like PPROM, vulvovaginitis, ectopic pregnancy, watery leak p/v by Prof.Ayesha Jehan

1. Greetings from…

2. CASE CAPSULES
- Prof. Ayesha Jehan
Professor of Obstetrics & Gynaecology,
Deccan College of Medical Sciences,
Hyderabad

3. CASE 1

4. 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

5. .. 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

6. QUESTION 1
WHAT IS THE CLINICAL APPROACH IN
THIS CASE?

7. ‘WATERY LEAK’ - DDx
1. Vaginal discharge
– Physiological vs. Pathological
2. Amniotic fluid
– Gush vs. Trickle
3. Urine

8. QUESTION 2
WHAT IS THE SIGNIFICANCE OF
VAGINAL EXAMINATION IN ANC?
EFFECTS OF RECURRENT VV INFECTIONS
AND PID?

9. VULVOVAGINITIS
• 40-60% of AN cases
• Organisms commonly implicated:
– Trichomonas
– Gardenella
– Beta streptococci, Gonococci
– Candida
– Chlamydia
– TORCH, HIV, Koch’s
• High vaginal swab, endocervical swab indicated.

10. 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

11. VULVOVAGINITIS – PATHOGENESIS OF FETOMATERNAL EFFECTS
MEMBRANE INFLAMMATION PLACENTA FOETUS
INSUFFICIENCY
TISSUE INJURY Sepsis
Infection/anoxia
FD
HYPOXIA DESTABILIZATION ACTIVATION IUGR
OF LYSO MEM OF COX/IL-6/CYT IUD
RELEASE OF
AA - PG↑
ABNORMAL UTERINE ACTIVITY
↑ IAP CERVICAL CHANGES
MATERNAL
SEPTICAEMIA
PPROM PRETERM BIRTH

12. QUESTION 3
WHAT IS THE CAUSE AND
FOETOMATERNAL EFFECTS OF GENITAL
HERPES?
MODE OF DELIVERY?

13. 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.

14. 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.

15. QUESTION 4
WHAT IS THE PROTOCOL FOR
ANTENATAL SURVEILLANCE IN CASES OF
PPROM?

16. 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??

17. QUESTION 5
WHAT ARE THE C/F OF THE FOUR MAIN
COMPLICATIONS –
OLIGOAMNIOS, CA, PTB, FOETAL
DISTRESS?

18. QUESTION 6
WHAT IS THE MANAGEMENT IN THIS
CASE?
- CONSERVATIVE
- ACTIVE

19. CONSERVATIVE MANAGEMENT
• The Rule in:
– NIL/minimal signs of infection
– NO foetal compromise

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

21. ACTIVE MANAGEMENT
• Termination of pregnancy
• Cerclage - when to remove?

22. 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.

23. 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.

24. 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

25. 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.

26. CASE 2

27. 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.

28. 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 +

29. QUESTION 1
WHAT IS THE DIAGNOSIS?
DEFINITIVE
DIFFERENTIAL
ENNUMERATE THE DDX IN THIS CASE…

30. IN OUR CASE A DIAGNOSIS OF
MISCARRIAGE + BENIGN OVARIAN CYST
WAS MADE….

31. QUESTION 2
DOES AN ADNEXAL MASS (CYST)
ALWAYS IMPLY ECTOPIC?
INCIDENCE OF ADNEXAL CYST IN EP?
DEFINITIVE FEATURES OF ECTOPIC
GESTATION?

32. DEFINITIVE FEATURES OF ECTOPIC
UNRUPTURED RUPTURED
• UPT + (SUBMINIMAL TITRES) • SHOCK +
• EMPTY UTERINE CAVITY • PERITONITIS ++
• GESTATIONAL SAC + FOETAL
POLE IN ADNEXA
• CULDOCENTESIS – 10ML
UNCLOTTED BLOOD
In the absence of definitive features, the diagnosis of ectopic
pregnancy can be missed.

33. QUESTION 3
WHAT IS THE MANAGEMENT OF
MISCARRIAGE?

34. MISCARRIAGE - MANAGEMENT
• Medical management – Misoprostol
– 600-800ug in single/divided doses
• Check curettage
• Regular follow-up with S.hCG titres/UPT ↓ in
48 hours

35. QUESTION 4
WHAT ARE THE PROGESTERONES USED
AND THEIR DOSAGES IN POP?
CAN THEY CAUSE
MISCARRIAGES/ECTOPIC? HOW?
FAILURE RATE?

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

37. QUESTION 5
WHAT IS YOUR FURTHER
CONTRACEPTIVE ADVICE TO THIS
COUPLE OF 40-45 YEAR AGE GROUP?

38. ALTERNATIVE CONTRACEPTIVE ADVICE
• Permanent contraception
• Barrier methods
• Others

39. 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.

40. RECENT TERMINOLOGIES

41. 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

42. 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

43. TOCOGRAPHY –
ABNORMAL UTERINE CONTRACTION PATTERNS

44. ABNORMAL UTERINE CONTRACTION
PATTERNS
MINOR DEFECTS
Causes:
• Skewed contraction • CPD
• Hypotonus
• In. UA
• PROM
• Polyam
• Paired contraction
Minor defects
per se do not cause
foetal compromise.
Can lead to major
• Polysystole defects.

45. ABNORMAL UTERINE CONTRACTION
PATTERNS
MAJOR DEFECTS
• Hypertonus
Caused by:
CPD/POP/Abruptio/
↑uterotonics
• Tachysystole
Lead to:
• Foetal compromise
• Risk of uterine rupture
• Uterine tetany

46. DDx
ACUTE ABDOMINAL PAIN IN PREGNANCY

47. 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)

48. ACUTE ABDOMEN IN PREGNANCY
Causes unrelated to pregnancy:
• Acute appendicitis
• UTI + pyelonephritis
• Urolithiasis
• Cholelithiasis
• APD + peptic ulceration
• Intestinal obstruction & Crohn’s disease
• Acute pancreatitis
• Acute fatty liver of pregnancy
• Rare blood dyscrasias (sickle crisis, blast crisis)
• Peritonitis due to intra-abdominal hemorrhage

49. Thank You