CASE REPORTS

.JAI BHAGWAN SIIARMAeAASHISH KUMAR

NIRMAL GULATI

Case 1. A 22 years old primigravida who was in labour for 18 hours came in cmergei1cy. She was in second �s�t�a�g�t �~� ftu 2 hours and was having features of obstmcted labour. She spon­taneously delivered a full term male bahy weigh­ing 3 kgm with Apgar of 4/10 and 5/10 only at 1 and 5 minutes. On examination, there was big caput and moulding of fetal head. On �f�u�n�~�u�s� examination, disc was normal in size, shape and colour, vessels were normal. Macula was normal. There were present multiple patches of flame shaped superficial retinal haemorrhages on and around the disc and also in the peripheral fundus. Vitreous haemorrhage was also present in the inferomcdial quadrant. Baby was shifted to nurs­ery where it died after 6 hours of asphyxia.

CASE/I

A full tnm second gravida came as emer­gency with labour pains for 14 hrs and leaking P/V for 10 hours. Midforceps were applied for

Dept. of Obst . & Gynaec. & Ophthalmology, Medical Coll ege & llospital Rohtak, Haryau a Ac­cepted for Publication 26 I 5 I 90.

fetal distress and a full term female baby weigh­ing2.9 kgm witbApgarof6/10at 1 min. and 7/10 at 5 minutes was extracted as vertex. Baby had big caput and moulding. On fundus examination there were two patches of superficial haemor­rhage just below and temporal to the disc.

Baby had mild jaundice and was shifted to nursery where phototherapy was given. Baby did not have any convulsion. On 7th day when baby was discharged most of the haemorrhages had disappeared and only few superficial haemor­rhages could be seen. On further follow up of baby after one 1\lOJlth there was no remnant of retinal haemorrhage and baby was well .

CASElli

A full term 18 years old primigravida came was emergency with labour pains for 18 hours and leaking P/V for 12 hours. Patient was in second stage for one hour 30 minutes. Head was at + 1 station and mid pelvis was borderline. Vacuum cup was applied and traction given but cup slipped after some pull. It slipped thrice. As there was fetal bradycardia and head was now at + 2 station, midforceps delivery was done and a male baby weighing 3.2 kgm with Apgar of6/10, 7/10 and 8/10 at 1 min, 5 min, 10 min respectively was extracted. There was cephalhaematoma on fetal scalp. On fundus examination there were multiple superficial haemorrhages on and around the disc.

116 JOURNAL OF OBSTETRICS AND GYNAECOLOGY

Baby bad jaundice and was shifted to nurs­ery. Baby bad few cm_wulsions and was given phenobarbitone therapy.

On repeat fundus examination on 7th day, a few haemorrhages were still present. Baby was discharged and followed up after one month and six months. After one month fundus was com­pletely normal.

MAiffiUKH K. JOSill e MEIIERNOSII F. ASLI

Y AS MINK. MOKADAM

A gravida seven, para four woman with only one surviving child delivered a 1.3 kg. small for date male infant at 33 wks. gestation. She bad repeated bouts of fever with rigors before and during present pregnancy. She bad splenomegaly and was pale. Her blood film did not show any malarial parasites but her spleen receded after a course of Chloroquine and Primaquin which was given to her after the present delivery. In previous pregnancies she had two spontaneous abortions and two babies died at ages 12 and R days respec­tively from hyperbilirubinemia.

The baby was born in good condition but developed jaundice with diarrhoea on the 6th day. The serum bilirubin rose from 8.2 to 22.1 mg% (dir. 19.8 mg%) on the 8th day, with no blood group incompatibility. The only +ve find­ings on TORCH and sepsis screening was a +ve C-reactive protein. The serum bilirubin receded

• with cholestyramine and phenobarbitone. On the 20th day the child had a bout of fever ht>patosplenomegaly and pallor. Ring forms ofP.

Dept. of Pediatrics, Ma.sina Hospital Bombay

Falciparum and P. vivax were seen on the blood film which cleared only after a course ofChloro­quine and 7 days of Sulfadozine and pyrimethamine.. The LFT on day 36 was: serum bilirubin 10.69 mg% ( dir. 9.84 mg%) SGOT 380 u/I, SGPT 332 u/I. At present the child is 11!2 yrs. nld and thriving.

Transplacental transfer of malaria to the fen1s carries a high mortality and considerable morbidity. Maternal lgG, placental barrier, high fetal hemoglobin and secretion of lymphokines protect the newborn from acquiring infection. Though the placenta is affected in 30% of cases of maternal malaria the incidence in the fetus is 0.3% in immune mothers and 10% in non-im­mune ones. Both maternal and fetal loss is high during pregnancy es1h·L"ially when the placenta is infected. Babies arc born prematurely and are also growth retarded. Mothers may be asymptomatic or suffer from intermittent bouts of fever. Parasitemia in the blood is uncommon.

80% of infants have fever, anemia and hepatosplenomegaly. Uncommonly seizures, thrombocytopenia, diarrhoea and acute renal failure may develop. Jaundice is present in 30%. It is hemolytic in 60% and obstructive in 20%. Treatment should be continued till the ring forms of the parasite have disappeared from the blood.

Though our initial diagnosis was Idiopathic neonatal hepatitis this was later revised to Congenital Malaria in view of the direct evidence in the baby anu indirect evidence in the mother. Also we faikd to find ·any other cause for the high bilirubin. The 2 abortions and the early neonatal deaths could now be &ttributcd to malaria in the mother.

Considering the high incidence of malaria in India, mothers with a bad obstetric history should be screened for malaria with other TORCH in infections.

CASE REPORT

G. SHINDE eA. KALE e A. MEliTA

S. PALNITKAR

Mrs. A.B., 35 yt>ars old, a case of previous two cesarean sections was transferred to us on 18th August 1989, in a state of shock and con­tinuous bleeding per vaginum following a first trimester M.T.P. Ergometrine and prostaglandins bad failed to control the bleeding. Menstrual period on 27th June 1989 was very scanty. There was a episode of pain less brisk bleeding on 30th July 1989. Thereafter she �c�o�n�t�i�n�u�t�~�d� to bleed in­termittently when pregnancy test, advised by family physician came positive. Per vaginal bimanual examination done by a specialist revealed 8-10 wks size pregnancy. Cervix very thin and taken up, extemal os admitting just tip of the finger. Per speculum examination was probably not done. Ultrasound examination ini­tially proposed, was omitlt'd, as patient desired M.T.P. and sterilisation. Clinically there was no evidence of intra abdominal injury. Persistent bleeding per vaginum necessitated an emergency hysterectomy. The peritoneal cavity was ab­solutely clean without any visceral injury. A gynaccoid uterus over a ballooned, ecchymosed cervix, a so-called hour glass appearance made the diagnosis of cervical prt>gnancy clear. Total abdominal hysterectomy obviously requirrd extra clamps over the paracolpos. Specimen when cut open showed empty corpus uteri, closed internal os and trophoblastic tissue adherent to the wall of endocervix, with open external os. Patient required total 11 units of whole blood. Postoperative recovery was uneventf11l. HbsAg done was negative. Histopathology report read

Dept. of Obst. & Gynaec., Seth G.S. Medical College, Dr. R.N. Cooper Hospital, Bombay

117

endometrium - secretory, myometrium un­remarkable, cervix showing ulceration of en­docervical mucosa, lined by trophoblastic tissue with chorionic villi.

Diagnosis-cervical pregnancy.

HIIUPINDER KAUR

Patient A.K. 32 years old; G2; Pl; was admitted on 26.3.1989 with full term pregnancy. She had labour pains for the last 12 hours. She had not received any antenatal check-up. She had one full term home delivery three years back. Physical examination and routine investigations were normal.

ABDOMINAL EXAMINATION

Full tenn pregnancy with head in the right iliac fossa (Oblique lie). On PN examination: Cervix was 3 ems dilated and was pushed behind the symphysis pubis and towards the right side. Membranes were intact. A cystic mass was felt through the left lateral and posterior fomiccs. Provi-..ional diagnosis of obstructed labour bc-c:l" " 1 111 impacted ovariau cyst was made.

ifYDAT/D CYST

RECTUM

I J:GENDS TO IJ.I .USTR/\TIONS Fig.J �D�i�~�g�r�a�m�a�t�i�c� representation of the hydatic cyst in the

pelvis.

118 JOURNAL OF OBSTETRICS AND GYNAECOLOGY

L.S.C.S. was performed and an as­phyxiated female baby was delivered. After com­pletion of L.S.C.S., uterus was delivered through the abdominal wound. Both ovaries and �t�u�b�l �~ �S�

�w�e�r�t �~� found to �b�l�~� normal and a cystic mass in relation to the posterior surface of ldt broad ligament and going into the pelvis �w�a�~� seen (Fig.l). Transverse incision was given at the upper-part of the cystic mass. After �i�n�c�i �~ �1�n�g� the capsule the cust could be easily l'llll< leated, which was oval in shape 7"x5"xT' in ' 11e, having white smooth shining surra'., ;111d 11 was a hydatid cyst. After enLKkation of �t�h�l �~� �c�~� :-1 the capsule which was a part of left broad ligament was obliterakd to prevent internal herniation. One blood transfusion was given during operation. Post operative period was uneventful. His­topathology confinncd the diagnosis of hydatid cyst.

In the post-operative period the following • tests were performed.

i. Casoni 's test was non-reactive

ii . Ultrasound scanning of the Liver was nor­mal

iii. X-Ray dH''' of the patient was normal

iv. Blood count-TLC and DLC, within normal limit>..

BIH JI'INDER Ki\IJR

Patient C.K. 2RF. G3; P2; AO; LCB - ., years; was admitted on I 0.2.88 as a case of full tam pregnancy with loss of foetal movements ol one month's duration with B.P. 130/80mm Hg. PIA- Full �t�c�r�m�n �~ �p�h�a�l�i�l�'� �p�r�e�s�l �~ �n�t�a�t�i�o�n� with absent faetlll heart sounds. On P/V �l �~ �x�;�u�n�i�n�a�t�i�o�n� a hard rounded mass was fl'lt bulging through tht· posterior fornix which could �h�t�~� slightly pushnl

Dl'pt . vf ()(," t . &: (;ytwl' c., Govt. Mr•dical Col· IP!fe I Rortulrll I lnstJitol. Patio Ia

upwards. It was difficult to reach the cervix which was lying behind the public symphysis. Investigations revealed Hh 10.5Gm%; Urine -NAD. Plain X-Ray abdomen showed cephalic presentation with positive spalding sign (Fig.l). Ultrasonography - revealed overlapping of skull bones and without any mention of pregnancy whether it was uterine or extra uterine.

On 16.2.88 soap water enema and pitocin drip failed to start uterine contractions and there was no vaginal hkl·ding. On 18.2.89Iaparotomy was performed through suprapublic midline in­cision. Uterus was lying pushed up anteriorly ahnn· the public symphysis and was nnrm;d.

\ \{ ;'Y adhom cn �~ �l�w �w �i�n�g� positivl' SJL dd lll:...' · �~�~ �~ �~�

CASE REPORT

A big mass coming out of pelvis and ex­tending upwards to the epigastrium was lying posterior to the uterus. The mass was recognised as left ovarian. An inCision in the mass revealed a macerated male foetus which was delivered as breech. Placenta was not removed initially. (Fig.2). Right ovary was normal. Omentum and gut coils were adherent posteriorly with the mass, which were separated and thus ovarian mass ... alongwith placenta was removed. Post-operative period was uneventful. Microscopic examination demonstrated the presence of ovarian tissue.

REFERENCES

1. Grimes t!l a/: Obstetrics and Gynaecology, 61:174, 1983.

2. Lehfeldt, H., Tietze, C., Gorstein, F.: AmJ. Obstet., Gynecol. 108:1005, 1970.

A.DUTTACHOWDHURY

AsiS CHATTERJEE

Mrs. S.A., 22 yrs, house wife, Hindu G3 Pl+l (Regn No. 1534/22977/88) was admitted for chronic I.U.G.R. she had H/0 Threatened abortion in the same pregnancy at 10 weeks and was treated conservatively outside with DUVADILAN, GESTANIN, vitamins and a digestive enzyme preparation. She was having persistent I.U.G.R. Her first pregnancy was suc­cessful and normal (healthy female baby). Her second pregnancy ended in spontaneous abortion in 1st Trimester.

All investigations including Blood sugar were normal.

She delivered vaginally an alive but abnor­mal baby weighing 1.99 kg on28.9.88. The baby cried after birth but expired after 5 hours.

Dept. of Obst. & Gynaec., Rajendra Hospital, Patiala.

119

Extrenally, the baby looked like a mythical MERMAID. Both lower limbs were absent, in­stead, it had an elongated TAIL-like stump below the waist No sex organs were visible. Hip bones were ill developed. No anus was present.

An X-Ray was taken post mortam. It showed:

1. Complete absence of Right Lower limb bones

2. Presence of left femur and tibia.

3. Maldevelopment of hip bones.

Autopsy was refused by the party. So by strict definition, it was a case of amelia of right lower limb and hemi-malia of left lower limb, associated with absence of external genitalia and anus.

Interestingly, no known teratogens were found to be operative in this case.

P. PANIGRAHI

Mrs X aged 28 years presented with amenorrhoea for 8 months. She used to get periods only after taking hormone preparations. Four years ago, she had undergone D&C and Endometrium was reported as Proliferative phase with no significant lesion. Three years ago, she had undergone Laparoscopy and was reported to have enlarged ovaries on both sides and bilateral patent tubes. She was treated intermittently with Clomiphene Citrate, Human Chorionic Gonadotrophin (HCG) and Human Menopausal Gonadotrophin (HMG) for 2 years.

She had attained Menarche at 13 years and was married for seven years. Her menstrual cycles were irregular and used to have amenor­rhoea for 6-8 months. She was of moderate built,

Dept. o{Obst. & Gynaec., Durgapur Steel Plant Hospital, Durgapur.