Acute liver injury in pregnancy.

A woman in her fifth month of pregnancy presented to the outpatient department with vomiting, generalised itching and yellowish discolouration of the skin for 1 week. No history of rashes, fever, pain abdomen or altered stools. In view of four pregnancy losses previously, she was evaluated to have antiphospholipid antibody syndrome and was advised low molecular weight heparin. She was a known type-II diabetic on insulin. Prophylactic oral dydrogesterone and natural micronised progesterone were started at a local hospital 2 months prior, in view of threatened abortion. Investigations revealed grossly elevated serum bilirubin and liver enzymes. Other blood investigations were unremarkable and abdominal ultrasonography was normal. The most likely diagnosis in this case, is drug-induced liver injury due to oral progestin consumption. Causality assessment by Roussel Uclaf Causality Assessment Model was used to establish the diagnosis. High doses of progestin over a prolonged period resulted in acute hepatic toxicity causing itching, jaundice and transaminitis. Cautious use of progestins in appropriate dosage is recommended during pregnancy.

Proteinuria in predicting adverse outcomes in women with severe features of pre-eclampsia from a developing country: A prospective cohort study.

OBJECTIVE: To study the adverse maternal and perinatal outcomes in women with severe pre-eclampsia (SPE) among different ranges of proteinuria. METHODS: This prospective cohort study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, India. After obtaining informed written consent, the 202 singleton women fulfilling the criteria of severe features of pre-eclampsia were stratified based on the value of urine protein-creatinine ratio (UPCR) as mild, moderate, severe, and massive proteinuria during pregnancy. Clinical outcomes were assessed and patients were followed up until 12 weeks postpartum to identify persistent proteinuria and hypertension. RESULTS: Of the 202 women with SPE, adverse maternal outcomes were seen in 34.65% (n = 70) and adverse perinatal outcomes in 75.74% (n = 153). The demographic and clinical factors were similar among women with increasing severity of proteinuria, except for mean systolic blood pressure, serum creatinine and total serum protein. UPCR was found to have a significant correlation with composite adverse perinatal outcome (P < 0.001) and individual outcomes of neonatal intensive care unit admission for >48 h (P = 0.01) and neonatal sepsis (P = 0.02) but not adverse maternal outcomes (P = 0.201). The optimum UPCR cutoff for adverse perinatal outcomes was 1.6 (sensitivity, 73.2%; specificity, 52.7%). In addition, 14.85% of the women had a persistently elevated UPCR and 3.96% had hypertension at 3 months postpartum. CONCLUSION: In women with SPE, severe and massive proteinuria were related to composite adverse perinatal outcome but not composite adverse maternal outcome. Moreover, antenatal 24-h proteinuria was significantly associated with persistent proteinuria. Significant proteinuria in women with SPE poses a risk for chronic renal dysfunction, requiring follow-up.

Risk factors associated with unplanned caesarean section in women with placenta previa: a cohort study.

Unplanned/emergency caesarean section (CS) can lead to an increased risk of increased risk of adverse maternal and perinatal outcomes. This prospective observational study was conducted in a tertiary centre in South India to determine the factors associated with increased risk of unplanned/emergency CS among women with placenta previa (PP). Primary outcome was the unplanned CS defined as emergency CS performed, prior to the scheduled date of delivery, for profuse vaginal bleeding or onset of labour pains. Obstetric morbidity and maternal-foetal outcomes were also compared between major and minor degree of PP. Major degree PP (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS. Identifying these women at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications along with facilities for blood transfusion and interventional radiology can help to optimise maternal and perinatal outcomes.Impact StatementWhat is already known on this subject? With increasing numbers of caesarean sections (CSs) and assisted reproductive techniques, the rate of PP is constantly on the rise. Unplanned CS is associated with increased risk of adverse maternal and perinatal complications.What do the results of this study add? Nearly, 40% among those who underwent CS were unplanned. Major degree placenta previa (PP) (OR 3.56; 95% CI: 1.73-7.32), first episode of bleeding at less than 29 weeks of gestation (OR 6.25; 95% CI: 2.14-18.24), and the haemoglobin level at admission (OR: 0.72; 95% CI: 0.57-0.91) were found to be associated with higher odd for undergoing unplanned CS.What are the implications of these findings for clinical practice and/or further research? Identifying women with PP at high risk of unplanned CS, especially in limited resource setting, helps for a timely and early referral to tertiary centres with expertise to manage complications, facilities for blood transfusion and interventional radiology, which optimise maternal and perinatal outcomes.

Migration of Ventriculoperitoneal Shunt to the Uterus in a Child: A Case Report.

BACKGROUND: A ventriculoperitoneal shunt (VPS) is usually placed inside the peritoneal cavity for cerebrospinal fluid drainage. Rarely, it can migrate to various pelvic visceral organs. Inside the pelvis, the distal end of the shunt can perforate anywhere from the uterus or adnexa to the vulva, and migration through the uterus is extremely rare. CASE: A three-and-a-half-year-old girl presented with a cerebrospinal fluid leak through the vagina after uterine perforation by a VPS. The diagnosis was made with an ultrasound. Her symptoms resolved after revision surgery. CONCLUSION: In a patient with a VPS in situ, presenting with a watery fluid leak through the vagina, perforation of the fornix or uterus must always be kept in mind. Timely diagnosis and intervention can result in the prevention of complications.