this is a case presentation and discussion of post caesarean pregnancy

1. Dr.Madhuri Y
CASE PRESENTATION

2.  An unbooked case of a 28 year old,Reshma Anjum
W/O Nadeem,resident of Sangareddy belonging to
SEC-3 is a housewife is G3P1L1A1 with 9 months
amenorrhoea came with chief complaints of pain
abdomen since 2 hours
 LMP-19-11-2014
 EDD-26-8-2015

3. HISTORY OF PRESENTING ILLNESS
 G3P1L1A1 presented with complaints of pain
abdomen since 2 hours
 No H/O decreased perception of fetal movements
 No H/O leaking P/V
 No H/O bleeding P/V

4.  No H/O burning micturition
 No H/O swelling of legs
 No H/O headache
 No H/O blurring of vision
 No H/O of epigastric pain
 No H/O frequency of micturition
 No H/O of fever and vomitings
 No H/O of trauma

5. OBSTETRIC HISTORY
 Marital life-5years
 non consanguinous marriage
 No h/o usage of OCP’S or ovulation induction drugs
 Conceived spontaneously 1 year after marriage
 LMP-19/11/2014
 EDD-26/8/2015

6. 1st Pregnancy:
 Antenatal period was uneventful
 Full term, LSCS (indication-CPD), female baby, 2years
 Birth weight was 2.9kg,at narayankhed govt hospital
 Postpartum period was uneventful (no h/o puerperal
fever, wound discharge)
 Exclusive breast feeding for 6 months
 Developmental milestones were normal and baby
immunized till date

7. 2nd Pregnancy:
 Conceived spontaneously 1 year after 1st pregnancy
 Spontaneous abortion in 3rd month followed by dilatation and
curettage.
Present pregnancy:
 Conceived spontaneously 1year after 2nd pregnancy.
 Regular antenatal check ups in outside hospital.
 1st Trimester
 No H/O excessive nausea and vomiting
 No H/O of pain abdomen and bleeding P/V
 Folic acid prophylaxis taken
 No H/O radiation exposure
 No H/O drug intake

8.  2nd Trimester:
 Quickening felt in 5th month
 Iron and calcium supplementation taken
 Two doses tetanus toxoid taken
 3rd Trimester:
 No H/O bleeding or leaking P/V
 No H/O pedal edema

9. MENSTRUAL HISTORY
 Attained menarche at 13years of age
 4-5/30, regular, normal flow, no clots, no
dysmenorrhoea

10. PAST HISTORY
 No H/O Hypertension, Diabetes mellitus, Epilepsy,
Tuberculosis, Asthma or Heart disease and
 No H/O Blood transfusions.
SURGICAL HISTORY
 No significant surgical history except for previous
caesarean and dilatation and curettage done in the
past.

11. FAMILY HISTORY:
 No h/o multiple pregnancy,congenital anomalies
PERSONAL HISTORY
 Diet-mixed, Appetite-good
 Sleep-adequate
 Bowel & Bladder- Regular
 No addictions

12. GENERAL EXAMINATION
 Patient is conscious and coherent, moderately built
and nourished.
 Ht-148cms
 Wt-64kgs
 Pallor-present
 No icterus, cyanosis, clubbing, lymphadenopathy and
pedal edema
 Spine, Breast and Thyroid – NAD

13.  Vitals-Temperature-Afebrile
PR-82/min, normal volume
BP-110/70mm of Hg in right arm supine position
 CVS Examination: S1 and S2 heard, No murmurs
 RESPIRATORY SYSTEM: Bilateral air entry-present,
clear and equal on both sides, No adventitious sounds

14. PER ABDOMEN:
 Uterus uniformly enlarged to size corresponding to
36wks gestational age.
 On palpation fundal height was corresponding to
36wks GA
 Fundal grip: broad, soft and irregular mass suggestive
of breech
 Lateral grip: back felt on left side, limb buds felt on
right side
 1st pelvic grip: cephalic and head was ballotable

15.  Uterus was irritable and scar tenderness was present
 Symphysio fundal height was 34cms
 Abdominal girth-94cms
 Clinically liquor was adequate
 AUSCULTATION:
 FHS heard,at left spino umbilical line,
regular,142/min

16.  P/S-cervix and vagina healthy
 P/V-cervix was 50% effaced,
os admitting 1 finger
membranes+
presenting part vertex at -2 station
pelvis gynecoid
 Single live intrauterine fetus with longitudinal lie and
cephalic presentation, head ballotable and fetal heart
sound heard on left spino-umbilical line and was
142/min.

17. SUMMARY
 A 28year old unbooked case,G3P1L1A1 with 9months
amenorrhoea with prev LSCS with complaints of pain
abdomen since 2hrs
 On examination uterus was corresponding to 36wks
GA with single live fetus with cephalic presentation
with scar tenderness

18. DIAGNOSIS:
 G3P1L1A1 with 36 weeks GA with 1 previous LSCS
with scar tenderness in early labour

19. INVESTIGATIONS
 Hb-10.8gm%
 T.W.B.C-7200cells/cumm
 Neutrophils-53%
 Eosinophils-3%
 Lymphocytes-37%
 Monocytes-6%
 Platelet count-1.8 lakhs/cumm
 CUE-Normal

20.  RBS-70mg/dl
 HIV-NR
 HBsAg-NR
 VDRL-NR
 B/G/T-B+ve
 BT-1min 20 seconds
 CT-3min 30 seconds

21.  Patient was admitted
 High risk consent was taken
 Emergency LSCS was planned

22. Operation perfomed: Emergency LSCS with bilateral
tubectomy under spinal anaesthesia
Operative Procedure
Under complete aseptic conditions abdomen cleaned
and draped.Pfannensteil incision was given over
abdomen
Abdomen opened In layers
Lower uterine segment identified and incised
LUS was thinned out
Kehrs incision given over lower segment of uterus

23.  A single live preterm male baby of birth weight 2.5kg and
APGAR 1-8/10,5-9/10 was delivered on 26th july at 2.30pm.
 Placenta was located in fundal anterior position
 Placenta with membranes was removed in toto
 Uterine suturing done and hemostasis secured.
 Total blood loss was estimated to be 750ml.
 Bilateral tube ligation was done
 Abdomen was closed in layers
 Patient condition was stable and was shifted to post operative
ward.
 Baby was admitted to NICU for observation and was discharged
after 5days.
 Post-operative period was uneventful

24.  Suture removal done on 7th post operative day and
wound was healthy.
 Patient was discharged on 8th postoperative day and
was reviewed in OP after 1 week

25. DISCUSSION OF POST
CAESAREAN PREGNANCY

26.  Pregnancy with prior caesarean delivery is quite
prevalent in present day obstetric practice
 This is due to liberalization of primary caesarean
section with non-recurrent indications
 These cases are called ‘post caesarean pregnancy’

27. Effects On Pregnancy And
Labor
 Increases risk of
 Preterm labor
abortion
Operative interference
Placenta praevia
Adherent placenta(placenta accreta,increta,percreta)
Rupture uterus
Post partum hemorrhage
Peripartum hysterectomy
Injury to bowel and bladder during surgery

28. Effects On The Scar
Increased risk of scar rupture
More risk in classical/ hysterotomy scar than
lower segment scar
Lower segment scar rupture during labor
(incidence is 0.2-1.5%)
Classical/ hysterotomy scar ruptures during
late pregnancy and labor(incidence is 4-9%)
Impairment of healing can cause early scar
rupture

29. Healing of the uterine wound
 Uterine wound is healed by muscles and connective
tissues, if the apposition of the margins is perfect
 Factors of prime importance in impaired wound
healing
1. Imperfect apposition
2. Presence of sepsis
3. Presence of hematoma in the wound
4. Poor general condition
5. Excessive stretching of LUS leading to diminished
vascularity

30. Lower SEGMENT VS CLASSICAL/
HYSTEROTOMY SCAR
Lower Segment Classical /Hysterotomy
Apposition Perfect, no pockets of
blood
Difficult to appose
State of uterus during
healing
The part of uterus
remains inert
The part contracts and
retracts
Stretching effect Along the line of scar At right angles to scar
Placental implantation Attachment on scar
unlikely
Placenta more likely to
implant on scar
Net effect Sound scar Weak scar
Chances of rupture 0.2 - 1.5% 4 - 9%
Mortality following
rupture
Maternal and perinatal
death less
more

31. INTEGRITY OF THE SCAR
CLASSICAL SCAR :
 The scar is weak.
 The scar is more likely to give way during pregnancy with
increased risk to the mother and fetus.
 These cases should be delivered by LSCS
LOWER SEGMENT TRANSVERSE SCAR:
 Usually heals better. During the course of labour the
integrity of the scar need to be assessed.
 High index of suspicion is essential.
 Factor that are to be considered while assessing scar are:
evidences of Scar Dehiscence during labor.

32. PREVIOUS SCAR
 Dehiscence-
separation along
the line of the
previous
scar(without
involving the
peritoneal coat)
 Rupture –
when the unscarred
tissue is also involved
in separation

33. Management
1. Caesarean section
2. VBAC trial of labor (trial of scar)

34. Previous operative notes
 Indication of caesarean section:
(a) Placenta praevia –
 (i) imperfect apposition due to quick surgery and
 (ii) thrombosis of the placental sinuses.
(b) Following prolonged labor-increased chance of sepsis.
 Technical difficulty in the primary operation
leading to tears to involve the branches of
uterine vessels.

35. Hysterography in interconceptional period:
Hysterography, 6 months after the operation, may
reveal defect on the scar(wedge depression of more
than 5mm)
Pregnancy(present and past):
(1) Pregnancy occurring soon after operation
(2)Pregnancy complication such as twins or
polyhydramnios puts stretching effect on the scar
(3)h/o previous vaginal delivery following LSCS
(4)Placenta praevia in present pregnancy

36. Hospitalization
 LSCS scar  Hospitalization at 38 weeks
 Classical CS at 36 weeks  due to possibility of
rupture of scar in pregnancy

37. VBAC TRIAL OF LABOUR
 Proper case selection :- 2/3 of previous CS  TOL; 2/3 of TOL
 VBAC
 Successful trial results in vaginal delivery of a live fetus without
scar rupture
 A failed trial is said to occur when a emergency caesarean
section is required or there is scar rupture
 VBAC is successful in 70-76% of cases

38. Selection of cases of VBAC
1. Type of prior uterine incision 1 LS transverse incision
2. Prior indication  if recurrent, elective CS should be done (success more
when prior indication is breech/fetal distress/placenta praevia/
abruption)
3. Prior vaginal delivery (if woman had H/O vaginal delivery  chance of
VBAC increased)
4. Post-op infection  can make scar weak
5. Pelvis adequate for the fetus
6. Continued labour monitoring possible
7. Informed consent of the woman

39. How many years back was the CS done ??
Min 18 months to heal the scar, so a gap of 18-24
months is necessary

40. Present pregnancy
1) No medical / obstetric complication
2) Average sized baby
3) Vertex presentation
4) No CPD

41. USG
 To assess integrity of scar  if myometrial thickness > 3.5mm,
decreased risk of rupture
 Helps to assess placental location
 If placenta implanted over the scar high chance of adherent
placenta  on USG  no subplacental sonolucent zone

42. Contraindications to VBAC
 Previous classical incision
 Previous two LSCS
 Pelvis contracted or suspected CPD
 Previous inverted T/ extension of incision
 Malpresentations
 Medical /obstetric complication
 Multiple pregnancy
 Resources limited for emergency caesarean delivery
 Patient’s refusal to undergo trial

43. Elective caesarean section
 If VBAC is contraindicated / if patient refuses
 Timing
• if fetal maturity is sure  39wks
• if not  wait for pains to start or membranes to
rupture
• previous classical CS  38 wks

44. Evidence of scar rupture during labor
 Abnormal CTG: late deceleration, most consistent finding
 Suprapubic pain: persisting between contractions
 Shoulder tip pain or chest pain or sudden onset of shortness
of breath
 Acute onset of scar tenderness
 Abnormal vaginal bleeding or haematuria
 Cessation of uterine contractions which were previously
adequate
 Maternal tachycardia, hypotension or shock
 Loss of station of presenting part
 Meconium staining of amniotic fluid

45. ADMISSION AT
38 WEEKS
ADMISSION AT
36 WEEKS
ELECTIVE
HOSPITALIZATION
LOWER
SEGMENT
TRANSVERSE
SCAR
ELECTIVE
C.S.
VAGINAL
DELIVERY
CLASSICAL/
HYSTEROTOMY
SCAR
ELECTIVE
C.S. AT 38
WEEKS
 CASE
ASSESSMENT

FORMULATION
OF Mode OF
DELIVERY

46. MANAGEMENT OF LABOUR
 Iv-Ringer solution
 Blood sample – Hb%, grouping, cross matching
 Spontaneous onset of labor desired
 Monitoring –clinical and electronic
 Epidural analgesia
 Augmentation by oxytocin – selectively & judiciously
 Prophylactic forceps or ventouse to cut short 2nd stage
 Exploration of uterus

47. Delivery
Cut short the second stage with outlet
forceps/vacuum
Look for excessive bleeding in third stage-sign of
scar rupture
If bleeding is excessive- emergency laparotomy
Observe for 4-6hrs in labour ward

48. BENEFITS
Decrease in-
 maternal morbidity
 hospital stay
 need for blood
transfusion
 risk of abnormal
placentation
 need for c-section in
next pregnancy
MATERNAL:
 Uterine rupture
 Risk of hysterectomy
 Infections
 Maternal morbidity
FOETAL:
 Fetal distress
 Low APGAR
 Death
COMPLICATION
S

49. STERILISATION
• Increasing risk after each operation
• During third time CS  sterilization should be
considered unless there is sufficiently strong
reason to withhold it