Abstract

In the year 1951, India was the first country in the world to launch the Government sponsored Family Planning Program at the National level 1. Subsequently numerous changes have been made in the program with the basic aim of controlling the population of the country and thereby contributing towards more healthy society.

These changes had a target oriented approach, integration with Maternal and Child Health and with existing health infrastructure, a successively increasing budget, multiple goals etc 1. But what is the result? We have achieved the population figure of 1 billion easily. In the present observational study, we have tried to find out the real ground effects of the program over the last two decades and thus to know how much we have succeeded and how far and how hard we still have to go to avoid the population explosion in this very new millennium.

Starting from the year 1981 up to the year 2000, all the 53165 subjects from the population coverage area of the hospital who came for any type of family planning methods were included in this study. All these subjects were counseled by cafeteria approach about available contraceptive methods. The options provided were temporary methods of contraception like male barriers, oral pills, intrauterine devices and permanent methods like vasectomy, and abdominal and laparoscopic tubal ligation. All the subjects were provided with the method they chose and were explained in detail about that method. These data were recorded and maintained along with the hospital statistics. The hospital statistics of the ongoing family welfare activities for this duration was collected, compiled and extensively studied considering various aspects of the present study. Census data were collected for the last two decades 2-5. These 53165 subjects were grouped into 5 yearly subgroups to have an overall idea of the trend of acceptance of individual contraceptive method.

All results were reviewed in the light of available literature and available family welfare statistics and conclusions were drawn on this basis. SSPS software was used and relevant statistical tests were done for each method for the 5 yearly subgroups.

OBJECTIVE (S) : To study the changing trends in the acceptance of contraceptive methods.

METHOD(S) : In this observational study, data were collected for each contraceptive method accepted by the beneficiaries from 1981 to 2000. The methods included were male barrier methods, oral contraceptive pills, intrauterine devices, vasectomy, and female sterilization either by abdominal or laparoscopic approach. Total number of subjects studied was 53165. Statistical analysis with SPSS software and relevant tests was done for each method for 5 yearly subgroups.

RESULTS : There was one and a half times rise in the total number of subjects who accepted contraception, comparable to the rise in the population under study. For male barrier methods the acceptance rate has changed from 19% to 38%, for oral pills it has remained nearly the same, for intrauterine devices from 30% to 18%, for abdominal and laparoscopic tubal ligation from 11% to 8.92% and 9% to 11% respectively, and for vasectomy from 2% to 0.08%. For all the methods of contraception together, the male to female acceptance ratio has increased from 1: 3.7 in 1981-85 to 1: 1.6 in 1996-2000 but for permanent methods it has significantly decreased from 1: 8.5 to 1: 239.

CONCLUSION(S) : For the last two decades, there is statistically significant upward trend in the acceptance of male barriers, a statistically nonsignificant upward trend for laparoscopic tubal ligation, statistically significant downward trend in the acceptance of vasectomy, a slight downward, although statistically nonsignificant, trend for intrauterine devices and abdominal tubal ligation and no much change in the acceptance of oral pills. Overall, the acceptance ratio of male to female methods is increasing.

Abstract

A 27 year old para 2 was admitted on 18th June, 2003 complaining of acute pain in the lower abdomen with vaginal bleeding and nausea.

There was no history of amenorrhea or of recent intervention like uterine evacuation or curettage. She was para 2+0 with a history of miscarriage at home in 7th month of pregnancy nine months back which was followed by menorrhagia for the last 2-3 cycles.

Her pulse was 100/minute and regular. Blood pressure was 90/70mmHg. She was very pale. The abdomen was tense and tender. No abnormality was detected on systemic examination. Her hemoglobin was 6g/dL. Platelet count, blood urea and serum creatinine were within normal limits. Urine was positive for pregnancy test.

Provisional diagnosis of ruptured ectopic pregnancy was made and exploratory laparotomy performed on 18th June, 2003. There was hemoperitoneum and two uterine perforation sites were detected - one at the left side of the isthmic region and another at the left fundal region. Both tubes were healthy and both ovaries were cystic. Uterine repair could not be done due to excessive bleeding and friability of the tissue at the perforation sites. Bilateral internal iliac artery ligation was performed but it could not stop the bleeding and the laparotomy ended in a total abdominal hysterectomy. Four units of whole blood were transfused and subsequently another three units were given. Invasive mole was suspected and serum ß hCG level estimation was asked for. But she refused to undergo the test and went home against medial advice on 25th June, 2003 after an uneventful recovery.

Pathological examination of the hysterectomy specimen revealed that the uterus was bulky and its left lateral side was covered with hemorrhage and necrotic material. There was a perforation on the left side of the fundus measuring 3 cm, a hemorrhagic nodular area in the myometrium and another perforation of 2 cm size near the left upper part of the cervix. But the endometrial cavity was intact (Figure 1).

Spontaneous splenic rupture in pregnancy is rare and occurs most commonly in third trimester or puerperium1. Several case reports have been published since the first case report in 1803 2. This entity is of great importance since it carries a very high rate of maternal and fetal mortality if the possibility is not suspected. We present a rare case of spontaneous rupture of spleen in third trimester of pregnancy, the only one seen over last 10 years in our institution.

A 27 years old G3P1L1A1 was admitted at 8 months amenorrhea with complaints of sudden onset of acute abdominal pain. Pain was associated with nausea, vomiting and syncopal attacks. It was also referred to the left shoulder tip. There was no preceding history of trauma or vaginal bleeding. She had reported to a level II hospital in a state of shock where she was resuscitated and was referred to our tertiary care teaching institution as a case of abruptio placenta.

On general physical examination she was anxious but well oriented. Pallor was moderate with mild circulatory decompensation (pulse rate of 120 per minute and blood pressure of 110/80 of mmHg). On abdominal examination the uterus was of 30 weeks size and fetal heart sounds were clearly heard. There was tenderness all over the abdomen with maximum intensity in left lumbar region. Clinical evidence of free fluid was present. On vaginal examination the os was closed and no vaginal bleeding was noted. Obstetric sonography revealed a single live fetus of 30 weeks gestation with large amount of free fluid in the abdomen. Abdominal paracentesis revealed hemoperitoneum. Emergency laparotomy was done and approximately 3 L of fresh and clotted blood was removed. Source of bleeding was found to be approximately 3x3 cm defect in splenic capsule with active bleeding from the ruptured site. Splenectomy was done by a surgical colleague. The uterus was found to be intact. Liver was palpated and found to be normal. The patient received 4 units of blood transfusion during surgery. Postoperative period was uneventful. Patient received intramuscularly injection proluton depot and two doses of injection decadron 12mg, 12 hours apart along with antibiotics.

Abstract

Silent rupture of uterine fundus during pregnancy is a rare event.

A 24 year old 3rd gravida was admitted with complaints of loss of fetal movement since 3 days following amenorrhea of 9 months. There was no history of labor pains or leaking per vaginum. She was G3P2L1 with a previous LSCS done 2 years back for cephalopelvic disproportion and one preterm vaginal delivery followed by a doubtful history of manual removal of placenta a year ago. On examination, the patient was dyspneic with mild pallor. Her pulse rate was 110 beats/minute and blood pressure 100/70 mm Hg. Her abdomen was distended, tense and tender. The fetus was in breech presentation with absent fetal heart sounds. There was no scar tenderness. She had a ultrasound study done outside just prior to admission. It revealed a single fetus of 35 weeks in breech presentation with intrauterine death. Her routine investigations and coagulation profile were within normal limits. With a suspicion of scar rupture, she was immediately taken up for laparotomy. At laparotomy plenty of thick purulent foul smelling fluid was drained from the peritoneal cavity. The dead baby was lying in the abdominal cavity in breech presentation and was taken out. On exploration, uterine rupture was detected in the fundal region, through which placenta was partially seen. Removal of placenta was tried but it was morbidly adherent to the uterine wall reaching up to the serosa of the uterus, suggesting placenta percreta. The previous scar area was found to be intact. Subtotal hysterectomy was performed and the specimen sent for histopathological examination. Peritoneal lavage was done and the abdomen closed after leaving a drain in place. Two units of blood were transfused and broad spectrum antibiotics given. During the postoperative period, she became febrile and responded to antimalarial treatment. Stitches were removed on the 10th postoperative day and she was discharged in satisfactory condition.

Histopathological examination of the specimen revealed placental tissue infiltrating the whole thickness of the myometrium upto the serosa at some places and showed areas of infarction (Figures 1 and 2). The findings were consistent with the diagnosis of placenta percreta.

Abstract

Primary pulmonary hypertension is a rare, progressive, and currently incurable disease characterized by an increase in pulmonary hypertension without a demonstrable cause 1. When associated with pregnancy, the maternal mortality ranges from 30 to 50%. We share our experience about the successful outcome of a pregnancy with primary pulmonary hypertension by intermittent nocturnal nasal oxygen therapy.

A 32 year old primigravida reported to out patient clinic complaining of exertional dyspnea at 14 weeks of gestation. She was married for 13 months and had spontaneous conception. She was normotensive, with pulse rate 70/ minute and sinus rhythm. Elevated jugular venous pressure (JVP) with features of pulmonary artery hypertension (PAH) was present. Respiratory system was clinically normal. Ultrasonography revealed intrauterine viable pregnancy of 14 weeks gestation. Echocardiography showed enlarged right atrium (RA) and right ventricle (RV), no demonstrable shunts, severe PAH with a pulmonary artery pressure of 74 mm of Hg with adequate left ventricle (LV) function, and mild mitral regurgitation.

Discussion with cardiologist led to the decision to continue pregnancy under close supervision by the team. Past history revealed recurrent syncopal attacks diagnosed 6 years back to be due to primary pulmonary hypertension.

We gave her nicardia, cardace, and low dose aspirin ovally. Intermittent nocturnal oxygen therapy was initiated during hospital stay and was continued at home after discharge following proper patient education.

She reported regularly for antenatal check up and was monitored as high risk pregnancy. At 37 weeks of gestation she developed hypertension with a blood pressure of 200/110 mm of Hg and was hospitalized. Next day lower segment cesarean section was performed under epidural analgesia and a female baby weighing 2.8 kg was delivered with good apgar score. No problems were encountered and nocturnal oxygen therapy was continued postoperatively along with other medication. She was discharged on 10th postoperative day with counseling for contraception.

Abstract

Introduction We report a case of end stage renal disease with two previous cesarean sections on regular hemodialysis who developed eclampsia.

Case report A 3rd gravida with 26 weeks gestation was admitted from the casualty on 11th November, 2004 at 6.30 AM for acute diarrhea of one day. She had two cesarean sections earlier. She was apparently normal till two years back, when in April 2002 she developed acute gastroenteritis, acute renal failure and cortical necrosis. She was on regular biweekly hemodialysis in our institution since then. When seen at 6 weeks of gestation she was advised termination of pregnancy which she refused and did not attend the antenatal clinic. She developed two episodes of generalised tonic clonic seizures soon after admission.