Pregnancy in Rudimentary Horn.

Pregnancy in rudimentary horn is an uncommon presentation of an ectopic pregnancy. It needs a very high degree of suspicion for diagnosis and the diagnosis becomes difficult in cases with previous vaginal deliveries. A 25-year-old female patient with two spontaneous vaginal deliveries and a history of spontaneous abortion at five months visited the obstetric emergency department with a history of five months of amenorrhea with pain abdomen and breathlessness for one day. On abdominal examination abdomen was distended, and rigid, and tenderness was present. Paracentesis was done where blood was present. On bimanual examination, cervical motion tenderness was present, and left-sided fornices fullness was present. The patient was admitted, and her sonography was done for suspicion of a ruptured uterus or ectopic pregnancy. The sonography report showed a bulky uterus with decidual reactions and a well-defined pregnancy of 21 weeks and 6 days in the right adnexal region with hemoperitoneum suggesting suspicion of ruptured ectopic pregnancy. After initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, there was a right-sided rupture of non-communicating rudimentary horn pregnancy with a unicornuate uterus. A dead fetus of 600 grams lies in the peritoneal cavity with two liters of hemoperitoneum. Timely diagnosis and laparotomy saved the life of the patient.

Misadventure of an Unsafe Abortion.

We are presenting a case of complicated unsafe abortion that landed in sepsis. A 21-year-old morbidly febrile but conscious female patient was brought on a stretcher by her attendants in the Gynecology emergency room. A foul fecal stench was coming from her body. On detailed and sympathetic questioning, the patient revealed she underwent an abortion by a local birth attendant in her village at 19 weeks of pregnancy. After that, she had pain abdomen, intermittent bleeding per vagina, difficulty in passing stool, loss of appetite, and fever. She took some local treatment but her condition gradually deteriorated and fecal-smelling vaginal discharge started. The patient was immediately shifted to the Intensive Care Unit. The decision for laparotomy was made by the team of gynecologists and surgeons as the patient's condition was not improving. During laparotomy, fetal parts present in the paracolic gutter were taken out. Post laparotomy, the patient was shifted to ICU, and her condition gradually improved then she was shifted to the recovery ward after five days.

Twin Reversed Arterial Perfusion.

Twin reversed arterial perfusion (TRAP) sequence is a rare condition found only in monochorionic pregnancies. It is a sequence in which a severely anomalous twin with an absent or rudimentary heart, also called an "acardiac twin," is perfused by its co-twin. The cardiac system of this co-twin (pump twin) provides circulatory support to the acardiac twin from as early as the first trimester. The exact pathogenesis of TRAP sequence is still unknown. However, the mere presence of vascular anastomoses in the placenta alone cannot lead to the development of TRAP sequence. Moreover, the presence of retrograde blood flow through arterio-arterial anastomoses increases the possibility of TRAP sequence diagnosis in a suspected monochorionic twin pregnancy. This report presents a case of TRAP sequence, which was undiagnosed till the delivery of twins. A 26-year-old patient gravida 3 para 2 (G3P2+0) with previous two normal deliveries, was referred to our emergency labor room at (assumed) 37 weeks of pregnancy, from a primary health center with complaints of vaginal leakage and a non-reassuring fetal status. She was immediately shifted to Operation Theatre and an emergency lower-segment cesarean section was performed. At the time of delivery, she was diagnosed as having a monochorionic diamniotic twin with TRAP sequence as one of the twins was acardiac, while the other was a live male baby (the pump twin) with massive ascites. A TRAP sequence pregnancy with a poor prognostic factor requires twin cord occlusion therapy or another form of intervention. Termination of the pregnancy is also an option, as it saves the patient from unnecessary obstetrical complications and morbidity.

Ovarian Pregnancy.

Ovarian pregnancy is a rare uncommon presentation of an ectopic pregnancy. Without any known risk factors, ovarian pregnancy seems to appear at random. A 29-year-old female patient with previous two cesarean deliveries visited the gynecology emergency department with the complaint of constant dull aching pain in the lower abdomen, aggravated by postural changes. Per vaginal examination, cervical motion tenderness was present. The patient was admitted, and her transvaginal sonography was done along with a urine pregnancy kit test for the suspicion of ectopic gestation. After the initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, left-sided ruptured ovarian pregnancy was confirmed by the Spiegelberg criteria.

Comparing Non-invasive Prenatal Testing With Invasive Testing for the Detection of Trisomy 21.

Background Non-invasive prenatal test (NIPT) is an intermediate step between serum screening and invasive diagnostic testing. It involves analysis of the cell-free fetal DNA (cffDNA) present in the maternal blood sample for determining the likelihood of fetal aneuploidy. Owing to its high sensitivity and specificity, NIPT has quickly gained popularity across the globe since its introduction to clinical practice, making it an attractive alternative to the available screening and diagnostic tests in use. Amniocentesis is currently the gold standard test for obtaining fetal DNA and diagnosing fetal trisomy prenatally, but it is invasive and has procedure-related adverse effects. This study aims to compare NIPT and amniocentesis in pregnancies screened positive for fetal trisomy. Material and methods This is an analytic cross-sectional prospective study conducted in the Department of Obstetrics & Gynecology, Patna Medical College and Hospital, for two and half years from December 2018 to June 2021. A total of 34 pregnant women screened positive for trisomy 21, attending the antenatal care outpatient department, in their second trimester, with their written consent, were enrolled in the study. Results Out of 34 pregnant patients, three refused NIPT and directly opted for amniocentesis. A total of 31 pregnant women have undergone NIPT. A total of 28 cases were positive for trisomy 21 on both NIPT and amniocentesis. The sensitivity of NIPT was 100% with the confidence interval being 87.66% to 100.00%. The specificity of NIPT was 100% with the confidence interval being 29.24% to 100.00%. Conclusion The high performance and effectiveness of NIPT are undeniable. Though the process by which this test has to be integrated into the clinical practice needs more study and should be determined with meticulous assessment.

Lethal Cord Entanglement.

Cord entanglement and conjoined twins are unique complications of monoamniotic monochorionic pregnancy. This case report describes a case of monoamniotic twins' intrauterine demise due to lethal cord entanglement. A 26-year-old unbooked primigravida was reported in the emergency labor room at 32 weeks with the complaint of loss of fetal movements since the previous day. On obstetric examination, the uterus appeared enlarged and discordant with the gestational age, multiple fetal parts were felt on palpation, and the pelvic grip was empty. Doppler could not detect any fetal heartbeat. The emergency obstetric sonography scan showed twins, the first in breech and the second in vertex presentation. Fetal heart sound was not found for either of the twins. The patient was counseled, and the decision was taken to terminate the pregnancy by lower-segment cesarean section. During the cesarean to deliver the babies, monochorionic and monoamniotic pregnancy was confirmed.

Proposing a Hybrid Model Based on Robson's Classification for Better Impact on Trends of Cesarean Deliveries.

AIM AND OBJECTIVES: To construct a hybrid model classification for cesarean section (CS) deliveries based on the woman-characteristics (Robson's classification with additional layers of indications for CS, keeping in view low-resource settings available in India). METHODS: This is a cross-sectional study conducted at Nalanda Medical College, Patna. All the women delivered from January 2016 to May 2016 in the labor ward were included. Results obtained were compared with the values obtained for India, from secondary analysis of WHO multi-country survey (2010-2011) by Joshua Vogel and colleagues' study published in "The Lancet Global Health." The three classifications (indication-based, Robson's and hybrid model) applied for categorization of the cesarean deliveries from the same sample of data and a semiqualitative evaluations done, considering the main characteristics, strengths and weaknesses of each classification system. RESULTS: The total number of women delivered during study period was 1462, out of which CS deliveries were 471. Overall, CS rate calculated for NMCH, hospital in this specified period, was 32.21% (p = 0.001). Hybrid model scored 23/23, and scores of Robson classification and indication-based classification were 21/23 and 10/23, respectively. LIMITATIONS OF THE STUDY: Single-study centre and referral bias are the limitations of the study. CONCLUSION: Given the flexibility of the classifications, we constructed a hybrid model based on the woman-characteristics system with additional layers of other classification. Indication-based classification answers why, Robson classification answers on whom, while through our hybrid model we get to know why and on whom cesarean deliveries are being performed.