1

President : Dr. LalithambikaSecretary General: Dr. Fessy Louis T

Immediate Past President: Dr.Kunjamma Roy,President Elect: Dr.ChellammaVice President: Dr.Chellamma,

Vice President Elect: Dr. Vijayan C.P.Joint Secretary: Dr. Bindu K.M.

Treasurer :Dr.lola Ramachandran Journal Editor: Dr. Sangeetha Menon,

Mat. Fetal Med. Chair : Dr.K. AmbujamCRMD : Dr.Paily V.P.

Chair, Reproductive Health : Dr .Philips AbrahamChair,Oncology : Dr.Chitrathara

Chair, Research Committee: Dr. Nirmala CEMOCALS: Dr. Bindu M.

KFOG Managing Comm

ittee

We should congratulate Dr. Prameela forbringing out this issue of the journal. There hasbeen a long gap since the last issue of KFOGjournal. Anyway we have restarted and we hopewe will be able to release 4 journals per year aswas done earlier. The aim of our journal is tokeep members updated on various activities ofKFOG as well as to provide some informativearticles or interesting case discussions which willbe useful in the day to day practice of ourmembers.

We request all members to contribute in theform of articles or case discussions to thejournal.Wishing all success and long life for thisendeavour.

Vol: 8 No: 1September 2014

www. kfogkerala .org

Dear readerGreetings and best wishes for ahappy onam!This issue of the KFOG journalcomes after a long wait.My sincere apologies. DrPrameela has joined the editorialteam and like a breath of fresh air has beensolely instrumental in this release. Her hardwork is commendable. I have been at the fringesappreciating her enthusiasm. The topicsincluded like adenomyosis in infertility, preterm labour, PPH have been carefully chosento make it interesting and practically useful aswell. The Obstetric community in the state mustjoin together and work for the betterment ofhealth services and patient care. EMOCALSwould be the best example of how impartingknowledge can reap huge benefits in terms ofreduction of PPH deaths. We welcomesuggestions and ideas from all , please feel freeto contact us

Dr.Sangeetha MenonEditor KFOG Journal

drsangeethamenon@hotmail.com

Editorial“It doesn’t matter how slowly

you go as long as you don’t stop.” (Confucius- Chinese philosopher and reformer, 551BC-479 BC)

ADENOMYOSIS AND INFERTILITYDr. RAJU NAIR

Evidence Based Management ofPRETERM LABOURHenry Murray

UTERINE RUPTURE IN A NULLIPAROUS..Dr. Saranya N

Role of Vasopressin ..Dr T N Vasudeva Panicker

0206

1012

Dr. Prameela Menon.Sub Editor KFOG Journal

prameelapramod@gmail.com

KFOG Head Quarters: TOGS Academia,East Sooryagramam, Thrissur -5 Ph: 0487 2320233

smritidesign.in

Dear colleagues,

Warm Onamgreetings from

KFOG secretariat.

Dr. LalithambikaPresident KFOG

Dr.Fessy Louis TSecretary KFOG

..................................................................

2

Introduction:

Adenomyosis is a common but neglected disorder of the uterus.

Adenomyosis has been defined as the "benign invasion of

endometrium into the myometrium, producing a diffusely

enlarged uterus which microscopically exhibits ectopic non-

neoplastic endometrial glands and stroma surrounded by a

hypertrophic and hyperplastic myometrium#. Traditionally,

adenomyosis has been associated with heavy and painful periods,

especially towards the end of the reproductive years. However,

until recently, the diagnosis of adenomyosis was invariably

retrospective. Because of the change in the pattern of

reproductive behavior during recent decades, with the

postponement of childbearing towards the end of the

reproductive period of life, premenopausal adenomyosis in

addition to that associated with endometriosis may increasingly

become a factor causing infertility.

Prevalence

Although it has been recognized for over a century, reliable

epidemiological studies on this condition are limited. The

reported prevalence of adenomyosis in available surgical series

varies from 10 to 18% depending on different diagnostic criteria.

Symptomatology

Asymptomatic:

Many ladies with adenomyosis may be asymptomatic and it may

be a coincidental discovery during a routine gynecological

examination; or on a transvaginal ultrasound scan or magnetic

resonance imaging; or co-existing with other pathology like

endometriosis. Several studies have shown that adenomyosis

Dr.Raju Nair

Chief IVF consultant, MathaAssisted Reproductive Centre(M.ARC), Matha Hospital,

Kottayam,

Adenomyosis and

infertility2

3

coexists with other pelvic pathology in

approximately 80% of cases.

Menstrual complaints:

The symptom of heavy bleeding may be

positively related to the depth of penetration of

individual adenomyotic glands into the

myometrium and to the density on histological

inspection of deep endometrial glands within the

myometrium. Irregular bleeding is relatively

uncommon, occurring in only about 10% of

women with adenomyosis. Dysmenorrhoea is

one of the most distressing symptoms of

adenomyosis. It is seen in up to 50% of women

with adenomyosis.

Pressure symptoms:

Pressure symptoms like bladder and bowel

symptoms are unusual presentation of this

disorder. It is mainly related to the size of uterus.

Typically women with adenomyosis are said to

have a tender enlarged uterus.

Infertility, miscarriage, pregnancy

complications

There is minimal information in the literature

regarding infertility and adenomyosis. Alone or

with associated endometriosis now a days a lot

of evidence is there to associate adenomyosis

with infertility, miscarriage and other pregnancy

complications. Adenomyosis had contributed to

pregnancy complications such as postpartum

haemorrhage, uterine atony, and uterine rupture.

Diagnosis:

The disease has been recognized since the end

of the 19th century, but the diagnosis is based on

histological examination of uterine specimens.

It is important to emphasize that the histological

diagnosis of adenomyosis is largely based on

detection of endometrial glands and stroma

within the myometrium, some distance away

from the endometrio-myometrial junction. With

the advent of newer noninvasive modalities the

diagnosis of this condition is more common.The

modalities now used to diagnose this condition

are ultrasound imaging like abdominal, vaginal

ultrasound (TAS, TVU), 3D sonography and

Magnetic resonance imaging (MRI).It is with the

advances in imaging techniques that it became

clear that adenomyosis is not confined to older

women but can be diagnosed in young

symptomatic patients.

Ultrasound:

On TVU, adenomyosis appears as heterogeneous

and hypo echogenic, poorly defined areas in the

myometrium. A diagnosis of adenomyosis can

be made when one or more of the following

sonographic findings are present: [1] a globular

uterine configuration; [2] poor definition of the

endometrial-myometrial interface; [3] sub

endometrial echogenic linear striations; [4]

myometrial anterior-posterior asymmetry; [5]

intramyometrial cysts; [6] a heterogeneous

myometrial echo texture.

More recently, evaluations were made of the use

of three-dimensional (3D) ultrasound, which

enables assessment of the lateral and fundal

aspects of the junctional zone (JZ) and provides

clearer visualization of endometrial protrusion

into the myometrium. 3D TVU may be more

accurate during the luteal phase. Using 3D TVU,

the best markers are related to the JZ

myometrium. A difference (JZdi) of >4 mm

between the area of maximum thickness (JZmax)

and the area of minimum thickness (JZmin) and

its distortion and infiltration had high sensitivity

(88%) and best accuracy (85% and 82%,

respectively). Overall, for 2D TVU and 3D TVU,

respectively sensitivity was 75% and 91%;

specificity was 90% and 88%.

Uterus with adenomyosis

TVS image of adenomyosis

3

4

MRI:

The application of magnetic resonance imaging

(MRI) to the study of the female reproductive

tract resulted in the identification of a new

functional uterine zone: the junction between the

endometrium and the inner myometrium . This

zone, known as the junctional zone (JZ)

myometrium, possesses a specific characteristic

that distinguishes it from other similar junctions

in the human body: it lacks a recognizable

protective layer or membrane, a true submucosa.

This means that endometrial glands lie in direct

contact with the myometrium. Today, through

MRI T2-weighted images, in the uterus of healthy

women of reproductive age, three distinct layers

can be displayed : (i) the innermost zone with a

high signal intensity, corresponding to the

endometrial stripe; (ii) an intermediate inner low-

signal-intensity area adjacent to the basal

endometrium, the JZ myometrium, or

subendometrial layer, measuring in healthy

young women <5 mm in thickness; and (iii) an

outer medium-signal-intensity zone extending all

the way to the serosal layer, or outer

myometrium.

MR imaging is an accurate, non-invasive

technique for the diagnosis of adenomyosis with

a high sensitivity (70- 88%) and specificity (67-

93%). The JZ is generally widest and most clearly

visible in the late secretory phase.The extent of

adenomyosis varies from simple JZ thickening

to more diffuse or nodular lesions involving the

entire uterine wall. The diagnostic criteria and

cutoff point for the diagnosis of adenomyosis

remain controversial. Now the most accepted

consensus on MRI is by Gordts et al. According

to him the classification is as follows:

JZ hyperplasia: JZ thickness measuring >18

mm but <12 mm on T2-weighted images in

women aged 35 years or less. It can be either

partial or diffuse type.

Adenomyosis: JZ thickness >12 mm; high-

signal intensity myometrial foci; involvement

of the outer myometrium: <1/3, <2/3, > 2/3.

Adenomyoma: Myometrial mass with

indistinct margins of primarily low-signal

intensity on all MR sequences. Retrocervical,

retrovaginal, fallopian tube and bladder types.

Even with advanced modern imaging technology,

there are still uncertainties in relation to

diagnosis. New minimal interventional

diagnostic techniques have been introduced.

True-cut transhysteroscopic biopsy, TVU-guided

biopsy of the uterus and laparoscopy-guided

myometrial biopsy. Their practical applicability

is still questionable.

Management:

Today the real challenge is tailoring treatment to

the individual woman$s need, depending on the

type and extent of disease. The options available

are medical, surgical and newer radiological

methods. The medical management option

includes GNRh agonist, Hormones, Danazol,

Mirena. The newer options are uterine artery

embolization, endometrial ablation and the recent

development is MRI-guided focused ultrasound

surgery (MRGFUS). But if fertility is not a

concern the most common management is

surgical, either conservative or hysterectomy.

Data available on treatment ofadenomyosis are

still fairly limited and mostly confined to case

reports or uncontrolled small series

Medical management:

With the establishment of diagnostic criteria for

imaging studies, it is now possible to offer

women the options of non-surgical treatments.

These range from local treatments such as

intrauterine devices (IUDs) to systemic

preparations of gonadotrophinreleasing hormone

(GnRH) analogues and hormonal therapy.

T2 weighted image showing JZ thickening (white

arrow), s/o diffuse adenomyosis

5

Medicated Intra uterine device:

LNG- IUS even though used commonly as a

contraceptive it also has the potential to be used

in women with endometriosis and adenomyosis.

The LNG-IUS releases 20 mcg levonorgestrel per

day and has been shown to result in a profound

reduction in menstrual blood loss in women with

heavy menstrual bleeding. Use of the LNG-IUS

is associated with decidualization of the

endometrium followed by atrophic changes.As

a result there is a marked reduction in menstrual

blood loss. Levonorgestrel also acts directly on

the adenomyotic deposits. Downregulation of

oestrogen receptors, which are present in both

glandular and stromal endometrial tissues, occurs

shortly after placement of the device and persists

for at least the first year of use. The adenomyotic

deposits then reduce in size, and as a result of

these shrinking deposits, uterine contractility

improves and the uterine size decreases. A

danazol-loaded IUD has been developed by

covering a contraceptive IUD containing 300-

400 mg danazol. It is not available in majority of

countries and so far the results are not very

encouraging also.

GnRH agonists:

GnRH agonists bind to the GnRH receptor in the

pituitary gland which results in downregulationof

GnRH activity, inducing a reversible state of

medical menopause. Oestrogenlevels fall, which

induces atrophy of the adenomyotic nodules,

which in turn resultsin a reduction in the uterine

size. The most common side-effects result from

the loweredoestrogen levels and include hot

flushes and reduced bone mineral density.

Oncethe treatment is stopped the adenomyosis

returns and therefore there is little hope ofa

permanent cure with this approach. The length

of the treatmentis usually 3 to 6 months.

Amenorrhoea is induced during treatment.

Laparoscopic excisionhas been used following

the GnRH agonist. GnRH agonists seem to be

able to control the symptoms of adenomyosis

during therapy. However, due to their side-effects

and the possible rebound effect aftercessation of

treatment, their use is limited to cases where

immediate conceptionor other effective treatment

modalities are planned.

Uterine artery embolization (UAE):

There is a small body of published evidence

supporting the use ofUAE for the treatment of

adenomyosis. So far the results are encouraging

and so in near future this may become a main

stay of treatment for adenomyosis. In a

retrospective study in 2001, Siskin et alreported

on the clinicalresponse and MRI appearance of

the uterus in patients who underwent UAE for

thetreatment of menorrhagia in the presence of

either focal or diffuse adenomyosis.

Polyvinylalcohol particles were selected as

embolizationmaterial. Of the 15 patients making

up the study population, five had

diffuseadenomyosis without evidence of uterine

fibroids, one had focal adenomyosis

withoutevidence of uterine fibroids, and nine had

adenomyosis (diffuse or focal) with one ormore

uterine fibroids. The authors described a

statistically significant improvement inthe mean

ability to perform activities of daily life and to

socialize outside the home, overallenergy level,

the degree of pain experienced during sexual

intercourse, and the degreeof pain or cramping

experienced during menstruation when

comparing the responsesobtained before and after

embolization (P < 0.05).All authors stress the

importance ofpre-procedural diagnostic

measures, especially MRI, to arrive at a correct

diagnosisthat may be crucial to assess and

ascertain treatment success with UAE. However,

reportson treatment failures and treatment

successes suggest, at least, that not all casesof

adenomyosis are amenable to UAE treatment. In

view of the lack of alternativetreatments for

women with adenomyosis who wish to maintain

their uterus andhave future pregnancies, even

procedures with some success need to be

refinedand explored.

MRI-Guided Focused Ultrasound Surgery

(MRGFUS)

When ultrasound waves propagate through

humantissue, the resulting pressure wave causes

molecular vibrations which can heatthe tissue.

Sinceultrasound waves carry energy, they are able

to cause a rise in tissue temperature. If the pattern

of the waves ismodified so that they meet at a

single point, one can achieve a localized high

temperaturerise at this focal point. Using this

technique, irreversible cell damage(60- 90 *C)

6

can be generated within a few seconds at such a

focal point.Heatingtissue to temperatures above

55*C leads to protein denaturation and

irreversible celldeath through coagulative

necrosis. Based on these characteristics, high-

intensity focused ultrasound surgery (FUS or

HIFU) has been proposed in the past as a

noninvasivetechnique to treat soft tissue tumors

deep in the body. Now a days many cases of

fibroids and even adenomyosis are treated with

these methods and the results so far are

encouraging. This can be considered as a fertility

sparing option also.

Surgical:

Surgical option includes wedge resection of the

adenomyosis followed by reconstruction of the

uterine wall;but, this approach is associated with

a frequent recurrence of adenomyosis and

spontaneous uterine rupture in pregnancy.

Effective treatment requires more radical

resection of the affected tissues. However, this

may result in creating large defects in the uterine

wall, making the reconstructed uterus incapable

of sustaining a normal pregnancy. Therefore, the

usual treatment forwomen with severe or

disabling adenomyosis is hysterectomy. A newer

uterus sparing surgery has been advocated by

Osada et al radical resection of adenomyomatous

tissue along with a triple- flap method for

reconstructing the uterine wall.

The result of this new technique is encouraging

and pregnancies have been reported after this

novel technique.

More than 1 in 10 babies are born preterm

of which 20-35% are iatrogenic and 65-80%

spontaneous. Prematurity is the leading

cause of newborn deaths. Many survivors

face a lifetime of disability, including

learning disabilities and visual and hearing

problems.

Risk factors

! Mother

Low S/E status,Lifestyle issues ,

Extremes of age, Maternal disease,

Cervical insufficiency

! Pregnancy

Previous preterm birth, PPROM,

Multiple pregnancy, Hydramnios

! Fetus- Fetal anomaly

Prevention

Prepregnancy- Stabilisation of maternal

disease, contraception , Counsel about

Prenatal vitamins/appropriate BMI/smoking

Antenatal !

Monitor maternal disease

Ensure adequate placental support (Aspirin/

LMWH in thrombophilia)

Henry MurrayJohn Hunter Hospital

Newcastle Australia

( Excerpts from his talk at TOGSICON)

Evidence Based

Management of

PRETERM

LABOUR

6

7Place cervical suture for proven cervical

incompetance

Cover with antibiotics in PPROM

Use progesterone for previous PTL (delivery

< 34 weeks)

18-23 weeks scan cervix during morph scan&

use progesterone appropriately

Progesterone vs Short cervix

Placebo controlled trial Progesterone in women

18-23 weeks with cervix < 25mm showed a

decreased delivery < 33 weeks (12.4% vs 22%

RR 0.58: 0.42 ' 0.8.)

PV 100mg or 200mg pessaries daily or IM

injection 17 áhydroxyprogesterone weekly has

same efficacy.

Progesterone therapy should be considered for

women with a singleton pregnancy who have

a history of previous spontaneous preterm

singleton birth, and is recommended for those

where cervical shortening has been detected.

Progesterone therapy should be considered in

asymptomatic women with an incidentally

diagnosed short cervix (<20 mm) on

transvaginal cervical length assessment in the

midtrimester.

Interventions with no evidence

! Recurrent antibiotics without infection

or PPROM

! Prophylactic tocolysis

! Aspirin +/- Heparin without indication

! Prophylactic cervical suture - esp in

twins

! Probiotics

! NSAIDS except if indicated in

hydramnios

! Bed rest

! Maternal contraction monitoring

Treatment of Established PTL

! Steroids for fetal status

Repeat courses should not be used

It should also be given for Elective

LUSCS before 38+6 weeks

! Tocolysis for administration of steroid

Best tocolytic according to Cochrane

review -Calcium Channel Blocker

! Antibiotics for infection for PPROM, or

signs of other maternal infection '

erythromycin after initial IV antibiotic

! MgSO4 for preterm neuroprotection in

severe prematurity ' 4 gm IV loading then

1gm /hr

Mode of delivery

No evidence that LUSCS improves outcomes

if fetus and mother monitored in labour.

TO SUM UP

Management of Preterm Labour Starts in

preconception period and continues in the

forms of prevention in pregnancy with

! Progesterone

! Treatment of hydramnios

! Treatment maternal disease

& managent in labour with

! Steroids, tocolysis

! Antibiotics

! MgSO4

7

8

Ajeesh koshy and Saranya P of Amala

institute of medical sciences ! first prize

KFOG UG quiz

Dr Krishnankutty - life time achievement

award by IMA

8

99

10

1. Introduction

Spontaneous uterine rupture( UR) is extremely rare before onset of

labor, in unscarred uterus and in nulliparous woman, with only a handful

of cases documented in literature. This pathological entity could constitute,

at the onset of symptoms, a challenging diagnosis due to upper or lower

abdominal pain in gravid patients, mimicking other clinical situations related

to the pregnancy/ as gastrointestinal problems. Because of the wide spectrum

of clinical findings, clinicians are rarely aware of the possibility of a UR.

We present a case of complete UR occurring spontaneously during

second trimester pregnancy, in a nulliparous second gravida woman with a

h/o dilatation &curettage for previous missed miscarriage.

2. CASE REPORT

Mrs.M, 38 yrs old G2A1, with H/O missed abortion at 2month

Amenorrhoea, D & C ' 1.5years back, now at 28 wks gestation, referred

from peripheral hospital as fibroid complicating pregnancy with continuous

abdominal pain & vomiting, appreciating fetal movement, no history of

bleeding pv. On admission, patient was not pale, vitals stable, chest clear.

P/A height of fundus corresponds to 34 weeks gestation with fibroid

palpable at fundus, tender, non-tense, no contraction, FHS- 124/min.

Patient was admitted and closely monitored in labour room with D/D

(differencial Diognosis) of red degeneration of fibroid uterus and preterm

labour. Gradually over a period of 4-6 hrs she developed tachycardia,

tachypnea, pallor and spo2 was falling.

Emergency USG done ' moderate free fluid in peritoneal cavity,

single viable fetus of 26 wks and multiple subserous fibroids, fundal

posterior placenta, no retro placental clots. Paracentesis done-

frank blood obtained

Emergency laparotomy under GA planned with D/D of

surface vessel rupture from subserous fibroid and abruption

placenta.

Findings;

Significant hemoperitoneum 2L of fluid blood and 500gm

of blood clots .Uterus enlarged to 30 wks size with

gestation and multiple subserous fibroids largest measuring

6X5 cm. Bilateral tubes and ovaries, loops of sigmoid colon

was densely adherent to posterior surface of uterus.

The posterior aspect of fundus of uterus was disrupted with

a gap of about 6-7 cm in diameter through which the placenta

UTERINE RUPTURE IN A NULLIPAROUS

WOMAN IN SECOND TRIMESTER OF

PREGNANCY

Dr. Saranya N, Senior resident,

Dr.Lalithambica karunakaran Prof. Dept. of OBG,

Govt T.D Medical college, Alappuzha

10

11

and bag of membranes was bulging. The

myometrium surrounding the rent was grossly

disrupted. Loops of bowel adherent to edge of

ruptured area of myometrium. Membranes

ruptured and delivered a live preterm male baby

of 950 gm through the rent. Proceeded with

subtotal hysterectomy , in view of extremely

thinned out and disrupted posterior uterine wall

and multiple fibroids.

Intra operative 7 pint PRC (Packed Red Cells), 4

pint FFP (Fresh Frozon Plasma), 3 pint platelets

given. Postop ventilator support, broad spectrum

antibiotics and blood transfusion given

At discharge POD (Post Operative Day) 12 -

mother well, baby NND ( Neonatal Death) -

day2.

3. Discussion

The current case describes a rupture of

uterus , in a nulliparous woman, generally

considered immune to the rupture. If UR occurs

on an unscarred uterus, in the early or second

trimester, detection is not easy and could be

delayed, with unpredictable results. We

hypothesize that possible contributing factor to

the UR is the history of a D&C, which could have

caused an unknown perforation or a weakness

of uterine wall. Traditionally it is suggested to

keep a high index of suspicion for UR, in all

women presenting with evidence of

hypolvolemia and fetal compromise, regardless

of parity. On review of the literature and in our

experience, initially these conditions are not

always present. The most well known sign of UR

is a non-reassuring fetal heart rate pattern, but in

our case it was reassuring at the patient$s

admission.

We are of the opinion that a woman with

severe abdominal pain and indistinct vague

symptoms associated with an history of D&C or/

and uterine anomalies must be under careful

monitoring and not underestimated, because

these are the major complaints that prompted

patients to seek medical attention. It$s interesting

to note that in all reviewed cases those abdominal

symptoms constitute the initial presentation. The

obstetrician$s vigilance in this context must be

extreme, searching for the least clinical sign in

favor of a pre-rupture of the uterus.

Pre-disposing factors of uterine rupture.

1. Scarred uterus (cesarean section;

myomectomy; partial uterine resection)

2. Previous perforation due to uterine surgery (

3. Congenital uterine malformations

4. Connective tissue disease.

5. Grand multiparity & advanced maternal age

6. Cocaine use

7. Traumatic injuries

8. Obstetrical maneuvers on scarred uterus

9. Misuse of oxytoxic drugs or other

augmentation agents, such as prostaglandins

or misoprostol

10.Obstetrical maneuvers like internal podalic

version, fundal pressure

11. Instrumental deliveries

12.Macrosomic'hydrocephalic fetus

13.Malpresentation or undiagnosed fetopelvic

disproportion

14.Placenta previa-percreta; accreta

4. Conclusion

Even if UR is a rare obstetric complication

especially in nulliparous women with an

unscarred uterus and before labor, more evidence

should be collected to increase the knowledge

of this potentially life-threatening condition. The

overall risk of UR associated with prior D&C is

low, but warrants consideration by obstetrician

when clinical events raise concerns for UR.

References:

1. Vaknin Z, Maymon R, Mendlovic S, Barel O,

Herman A, Sherman D. Clinical, sonographic,

and epidemiologic features of second- and early

third-trimester spontaneous antepartum uterine

rupture: a cohort study. Prenatal Diagnosis

2008;28(6):478'84.

2. Schrinsky DC, Benson RC. Rupture of the

pregnant uterus: a review. Obstetrical and

Gynecological Survey 1978;33(4):217'32.

3. Donnelly JP. Rupture of the uterus. American

Journal of Surgery 1951;82(3):354'9.

11

12

Introduction:

Postpartum hemorrhage (PPH) is the single major

cause of maternal mortality worldwide. More

than 100 thousand maternal deaths occur every

year globally due to PPH alone. Postpartum

hemorrhage is a common obstetric emergency

which cannot be predicted by any means even

today. However many of the deaths can be

prevented if certain simple measures and

precautions are considered. Unpredictable

sudden massive bleeding occurring after delivery

in a difficult situation like low resource settings

results in maternal death. When simpler measures

like uterotonics, uterine massage, uterine

packing, bimanual compression, and balloon

tamponade are not successful, the women has to

be shifted to higher medical centers for further

techniques. Most of the times mothers die in

transit or reach in a state of extreme shock at

higher medical centers. A minimal blood loss

when there is hemodynamic compromise is very

significant and life threatening. There is every

need for simpler and safer techniques, which can

be practiced with minimal expertise even in low

resource settings to treat PPH.

The key to control of PPH and prevention of

mortality lies on early initiation of therapeutic

measures as soon a diagnosis of PPH is made.

Prompt action, safety,efficacy,easy adminis-

tration is requisite for an ideal drug or method

of choice for atonic PPH. In this study we have

used diluted vasopressin intra myometrialy

infiltrated at different sites (also transabd-

ominaly) as an immediate preliminary method

to control atonic PPH which did not respond to

uterotonics. Vasopressin infiltration is simple

procedure which takes only a few minutes like

any intramuscular injection.

Vasopressin is being used widely in

gynecological surgeries like myomectomy

vaginal hysterectomy, abdominal hysterectomy,

ovarian cystectomy, and hysteroscopy. Sub

endometrial injection of vasopressin was reported

for the management of placenta previa, and in

second trimester dilatation and Curettage to

INNOVATIVE THINKING

Role ofVasopressin

in the managementof Atonic Postpartum

Hemorrhage

Dr T N Vasudeva PanickerDA MD DGO

Anesthesiologist and Gynecologist

Consultant Panicke rHospital

Kodungallur, Thrissur

12

13

reduce bleeding by different authors. Lurie et al

had reported about the use of local vasopressin

for control of PPH in placenta accereta. Extensive

literature search revealed the following rare

complications after vasopressin infiltration that

include pulmonary edema, severe hypotension,

myocardial infarction, bradycardia which could

be due to accidental intravascular injection.

Materials & Methods:

When medical management failed to control

bleeding in atonic PPH, 20 units of vasopressin

diluted in 100ml of normal saline was infiltrated

intra myometrially at multiple sites using

23Gauge spinal needle under direct vision at

caesarean section, and trans-abdominally in case

of normal vaginal delivery. Uterus was lifted up

and forwards bimanually and stabilized by an

assistant to avoid bowel injury..

Figure1.Transabdomial intramyometrial

Vasopressin Administration.

Figure 2. Direct Intramyometrial

administration of diluted Vasopressin for

Atonic PPH.

Vital signs were monitored during the procedure.

Always aspirate for blood during intra

myometrial infiltration to avoid intra vascular

injection.

Results:

The study was carried out for 4 years during

which 4400 deliveries were recorded in our

institution. In 92 women excessive bleeding was

observed following delivery. Routine measures

like uterine massage, intravenous methergine and

20U oxytocin infusion and prostaglandin PGF2

alpha was given. In 24 women bleeding could

not be controlled with the above treatment

measures, and the atonic PPH continued. All

these 24 women were treated with intra

myometrial infiltration of vasopressin. A

blanching like effect was observed on

myometrium at the site of infiltration as shown

in Figure 3. The results are displayed in the table

1.There was no major adverse events and

mortality in our series. In four of 24 women PGF

2alpha was contra indicated due to severe asthma.

One of these four women developed atonic PPH

after two hours of caesarean delivery, when she

was getting nebulized with salbutamol.

Table: 1

Sl No. Characteristics Number

1 ParityPrimigravida 42Multigravida 50

2 Medical disorders in pregnancyHypertensive disorders 12Gestational diabetes mellitus 2Bronchial Asthma 4Anemia 12

3 Mode of deliverySpontaneous vaginal delivery 59Instrumental vaginal delivery 15Cesarean delivery 18

4 Routine medical therapy onlyfor Hemorrhage 68TotalPostpartum blood transfusions 03

5 Vasopressin used 24Total Post partum blood transfusions 02

Total Cases 92

In two women secondary PPH occurred 14 days

after caesarean delivery. Bleeding did not stop

with routine measures. Ultra sound scanning

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showed grossly enlarged uterus with wide

endometrial cavity filled with blood clots. Twenty

units of vasopressin in 100 ml saline were

infiltrated in to the myometrium trans

abdominally. Bleeding stopped within

10minutes. Next day repeat scan showed well

contracted uterus with thin endometrial cavity.

Increase in BP was observed in 4 women, which

responded well for nitroglycerin infusion. (25mg

in 500ml normal saline - rate of infusion adjusted

according to the response)

Figure 3. The blanching effect due to profound

vasoconstriction and tonicity of uterus noted after

administration of intramyometrial Vasopressin.

Discussion:

Bleeding after parturition is mainly controlled

by 3 mechanisms. Myometrial contraction and

retraction, clot formation and plugging of open

sinuses at the placental bed, and opposition of

uterine walls. All uterotonic drugs acts by

myometrial contraction only. But vasopressin

stops PPH by (1) Myometrial contraction by

action on oxytocin type receptors. (2)

Vasoconstriction by increased release of intra

cellular Ca+ and blockade of ATP sensitive K+

channels in the vascular smooth muscles - V1

receptor action. (3) By liberation of factor VIII

and Von Willebrand factor and also by platelet

activation at vascular endothelial cells resulting

in increased clot formation - V2 receptor effect.

Vasopressin causes intense vasospasm at the site

of injection, resulting in reduced absorption and

systemic dissemination. However, sometimes it

can produce side effects like bradycardia and

acute hypertension, could be due to accidental

intravascular injection. Severe bradycardia can

occur in women under spinal anesthesia due to

unopposed vagal activity which results due

blockade of cardiac sympathetic fibers. For the

same reason protective reflex tachycardia in

response to hypotension fails. Hence atropine

should be given immediately if bradycardia

begins.

In our series bleeding could be stopped in all

women with atonic PPH with intra myometrial

infiltration of vasopressin within 4 to 8 minutes

and none of them required surgical intervention.

We did not encounter any serious side effects

with this technique. Vasopressin infiltration is a

cost effective technique which require minimal

skills, and should find a place in all PPH kits.

Further randomized trials with larger sample size

will prove the efficacy of vasopressin as drug of

choice for intractable PPH.

Conclusion:

Intra myometrial Vasopressin showed immediate

response with absolute success in all the cases

of our study. This simple Life saving measure

should be considered for both prophylactic and

therapeutic benefits .We recommend Intra

myometrial Vasopressin in the armamentarium

of management of atonic PPH.

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