Background: Peripartum hysterectomy is a life saving procedure performed for intractable obstetric haemorrhage. Uterine atony, rupture, abnormal placentation, retained products etc. are common indications. With the rise of caesarean sections, the incidences of peripartum hysterectomies are increasing worldwide. The aim of the present study is to evaluate the histomorphological findings in peripartum hysterectomy specimens received during a five year period. Material and Method: In this hospital based cross-sectional study during a five year period (Jan 2014 –Dec 2018), 64 peripartum hysterectomy specimens received in the department of Pathology, RIMS, Imphal, Manipur were included. The gross and histomorphological findings were evaluated, studied, statistically analysed and compared with other studies. Results and Observation: The various histomorphological findings were abnormal placentation 28 (43.7%), uterine atony 15 (23.5%), uterine rupture 14 (21.8%), retained placenta/product 6 (9.3%) and subinvolution 1(1.5%). Abnormal Placentation and Placenta cretas were the most common finding in the present study. The lower uterine segment was the most common abnormal site of placental implantation. The age ranged from 21 to 45 years, with majority of the cases were in the 30-39years age group. History of previous caesarean section was noted in 20 cases (31.2%). The relative risk of abnormal placentation was 2.5 times higher in those cases with prior history of caesarean section. Rupture was most commonly associated with multiparous women. Co-morbid overlapping features were seen in few cases. Conclusion: Histopathological diagnosis not only confirmed the clinico-radiological impression, but also highlighted the other co-morbid associations that caused the intractable haemorrhage which warranted a peripartum hysterectomy. Keywords: Peripartum Hysterectomy, Abnormal placentation, caesarean section, chorionic villi.
BACKGROUND Caesarean section delivery, in spite of its popularity has its short-and long-term complications like infections, haemorrhage, adhesions, abnormal placentation, uterine rupture and hysterectomy. Many studies have shown an increasing incidence of abnormal placentation which includes placenta previa, placenta accreta, placenta increta and placenta percreta to be related with the rising trend of caesarean section delivery. Again, abnormal placentation is a life-threatening condition often associated with massive postpartum haemorrhage and in recent studies it is the most common indication for peripartum hysterectomy. Deliveries by caesarean section are also increasing in our institute. METHODS In this hospital based cross-sectional study, 91 peripartum hysterectomy cases received in the Department of Pathology, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, during a ten-year study period (January, 2009 to December, 2018) were included in the study. The gross and microscopic histopathological findings were statistically analysed in relation to age, parity, number of previous caesarean sections using SPSS software. Significance of the risk of abnormal placentation between cases of previous caesarean section and vaginal deliveries was evaluated by chi-square test (p-value of ≤ 0.05) and odds ratio (OR). RESULTS During the ten years study period, 91 peripartum hysterectomy cases were selected and studied. The overall rate of peripartum hysterectomy was 1.27 per 1000 births. The age of the cases ranged from 20 to 45 years and 81.3 % were multiparous (parity two and above). The main pathological lesions were abnormal placentation-41 (45.05%), ruptured uterus-16 (17.58%), uterine atony-21 (23.07%) and retained product of conception-13 (14.28%). In 32 (35.16%) cases, there was history of previous caesarean section once in 14 and twice in 18, of which 23 (71.88%) cases had abnormal placentation pathology comprising of placental praevia 12 (37.50%), placental accreta 4 (12.5%), placental increta 5 (15.62%) and 2 (6.25%) placental percreta. CONCLUSIONS Abnormal placentation which includes placenta praevia, placenta accreta, placenta increta and placenta accreta is one of the most important causes of intractable postpartum haemorrhage necessitating a peripartum hysterectomy. Previous caesarean delivery has a 5.82 times higher risk of developing placentation abnormalities in subsequent pregnancies than previous vaginal delivery.
In order to simplify the criteria whether a drug can be used during pregnancy or not United States Food and Drug Administration (USFDA) has classified all the drugs into five categories. Categories A and B medications usually are considered safe in humans. Category C drugs have not been definitively shown to be unsafe to human fetuses, but reasons exist to be cautious while prescribing them. Category D drugs are those with evidence of human fetal risk based on previous human studies, but the benefits of treatment prevail over the risks. United States Food and Drug Administration Classification System (US-FDA) FDA category Pregnancy category definitionA Controlled studies showed no risk to humans.Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. BNo evidence of risk in humans.Animal studies have revealed no evidence of harm to the fetus. However, there are no adequate and wellcontrolled studies in pregnant women. orAnimal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus. CRisks cannot be ruled out in humans.
Osteoporosis is a progressive bone disease characterized by a decrease in the bone mass and density, which can lead to an increased risk of fracture. Multiple treatments have been formulated for it like calcium, vitamin D supplements, bisphosphonates, raloxifene, hormone replacement therapies, teriparatide and calcitonin. However, all of these have their own shortcomings. Topical nitroglycerin is a cost-effective, novel medication that not only increases bone formation but also decreases its resorption, and also has the potential to decrease vertebral fractures more than that provided by the existing treatments. Therefore, it could be the answer to the need of an efficacious, cost-effective, affordable, safe and a convenient form of therapy for the prevention of post-menopausal bone loss and osteoporosis as a whole. Therefore, we recommend that individuals with osteoporosis be treated with topical nitroglycerin ointment (15 mg/day).
In this current era of resistance, treating urinary tract infections (UTIs) on outpatient department (OPD) basis has become cumbersome. Resistance has dramatically increased for cotrimoxazole, levofloxacin, ciprofloxacin and nitrofurantoin in past few decades. Intravenous drugs increase the cost of treatment and patient may need hospitalization. We searched and analyzed the literature and found fosfomycin to be better alternative in resistant UTI as resistance to this drug is low and is cost-effective in comparison to available intravenous drugs. How to cite this article Agrawal P, Garg R, Yadav S, Singh O. Drug Review: Fosfomycin—A Rarely used but more Practical Approach for Urinary Tract Infections. J South Asian Feder Obst Gynae 2015;7(2):68-70.
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