Rajiv Gandhiuniversity of Health Sciences, Karnataka

RAJIV GANDHIUNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / Name of the Candidate
and Address
(in block letters) / Dr. SAHANA K.P.
D/O Dr. K.S. PRASANNA KUMAR
# 3, 2nd MAIN,
CHAKRAVARTHY IYENGAR LAYOUT,
SESHADRIPURAM,
BANGALORE – 560020.
2. / Name of the Institution / J.J.M.MEDICALCOLLEGE,
DAVANGERE - 577 004.
3. / Course of study and subject / MEDICAL
M.S. IN OBSTETRICS AND GYNAECOLOGY
4. / Date of Admission to course / 29-06-2009
5. / Title of the Topic / “STUDY OF OBSTETRIC EMERGENCIES OCCURING IN HOSPITALS ATTACHED TO J.J.M.M.C., DAVANGERE”
6. / Brief Resume of the intended work :
6.1 Need for the study :
The decline in maternal mortality in the past decade has been phenomenal, but there is still room for improvement. Reports from maternal mortality committees indicate that over 50% of maternal deaths are preventable. Most common causes of death are complications of pregnancies that have often occurred as emergencies. 200 years ago William Hunter said "There are but two things that have much effect on me at labour - haemorrhage and convulsions. These problems remain among the emergencies of today.
As do any emergencies, obstetric emergencies occur at an unexpected time, upset routines and place the obstetrician , her patient and the patient's family under great strain. The problem is complicated because two lives must be considered , and concern for both may directly affect the plan of management.
This thesis attempts to address relatively common emergencies that have the greatest potential impact on the obstetric patient. The list of potential sudden and unexpected obstetric occurrences demanding prompt action is extensive. In fact- only one category of pregnancies that are not emergencies- those that ultimately result in uncomplicated vaginal delivery at term, although this can be established with certainty only after the fact. The present study is undertaken to review obstetric emergency admissions needing critical care, to analyse the primary causes for admission, the clinical features, mode of diagnosis, the interventions that follow in providing timely critical care and the outcome.
6.2 Review of literature :

Kaur Vaneet, Afzal Lalita(2008) - conducted a 3 year study of obstetric patients admitted to the ICU. Cases were reviewed in detail including age, parity, reason for admission to the ICU, clinical features, response to interventions and maternal outcome. They concluded tat invasive haemodynamic monitoring and ventilatory support were the two main interventions.
M. H Sharada(2001)- analysed 100 cases of obstetric emergencies needing critical care in Referral centres like steel plant hospitals. TheirStudy showed high maternal mortality 2.79/1000 deliveries. Preventive services, timely diagnosis and critical care are necessary interventions required before irreversible changes set in and it becomes difficult to save the patient.
Narwadkar Mangesh Vinayak (2004)- studied pregnancy outcomes inobstetric referrals from rural areas. They concluded tat 86% ad notreceived antenatal care, 22% of mothers and 43.4% of fetuses were already in a compromised state on arrival. Distance traveled to reach referral centre, lack of transport, lack of money and maternal condition on arrival all determined the maternal and perinatal outcome.
T. F Baskett (1998)- conducted a study to determine the level of near-miss mortality and morbidity due to severe obstetric complications or maternal disease in a tertiary referral hospital. They concluded that 0.7/1000 people required transfer for critical care. Main reason for transfer was hypertensive disease (25%) , haemorrhage( 22%) and sepsis( 15%o). Transfer to an intensive care was required for 80% , A review of near miss mortality helps delineate the continuing threats to maternal health and type of support services most commonly required.
M Roost (2009)- conducted a study to analyse priorities in obstetric care and to document the frequency and causes of maternal mortality and severe( near-miss) morbidity in Bolivia. They concluded that pre hospital barriers, together with haemorrhage in early pregnancy, eclampsia detection and referral patterns should be priority areas for future research and interventions to improve maternal health. Near-miss upon arrival and near-miss after arrival should be analysed separately to provide additional information on factors contributing to maternal ill-health.

6.3 Objectives of the study :

To identify obstetric cases that arrive as emergencies needing critical care.
To assess the varying clinical presentations and contributing factors forcases arriving as obstetric emergencies.
To identify the need for hospitalisation and admission to intensive care unit.
To understand the various interventions required- critical care management, importance of emergency critical care and its impact on future outcome ofsuch admissions.
To analyse the maternal and perinatal outcome of such obstetricemergencies

7. / Material and Methods :
7.1 Source of data :
The main source of data for the study are patients admitted to the teaching
hospitals attached to J.J.M. Medical College, Davangere namely;

Bapuji Hospital, Davangere
Chigateri General Hospital, Davangere
Women and Children Hospital, Davangere.

7.2. Method of collection of data (including sampling procedure if any):
100 cases admitted to the above hospitals for a study period of 2 years, September 2009 to September 2011 are included for the study.
Inclusion criteria :

Pregnant women irrespective of gestation period and/or within42 days of delivery admitted in any one of the above 3 centres withdocumented need for intensive care, monitoring and interventions.
Cases with singleton or multiple pregnancies.
Cases with obstetric emergencies in 1st and 2nd stage of labour such as malpresentations, malpositions, deep transverse arrest, obstructed labour antepartum haemorrhage, eclampsia, rupture uterus.
Cases with obstetric emergencies in 3rd stage of labour such as retained placenta, post partum haemorrhage, post partum collapse.
Obstetric emergency cases referred from peripheries to any one of the above mentioned centres.

Exclusion criteria :

Pregnancies associated with medical complications such as infective diseases, diabetes etc
Pregnancies associated with surgical complications such as appendicitis, hernia, cholecystitis.

Procedure of study :
100 obstetric emergency cases admitted and managed in Department of OBG in teaching hospitals attached to JJMMC , Davangere from Nov 09 to Nov 2011 are studied.
Data regarding name, age, place of residence, distance commuted to reach referral hospital, socio-economic status, reason for referral, parity , level of antenatal care received in present pregnancy, clinical features upon arrival, present obstetric complications, previous obstetric history, and LMP to calculate gestational age are recorded.
After initial diagnosis and analysis, details regarding the reason for admission to ICU, the status of the patient on admission with respect to vitals, organ failure, treatment received before admission and after- interventions like mechanical ventilation, transfusions, use of vasopressors, continuous monitoring, duration of ICU care needed, process of weaning and recovery, the outcome whether recovery or mortality and reasons for the same are noted.
General physical examination including vital signs, detailed obstetric examination, examination for other complications resulting from the condition, and other systemic examination is done. Mode of delivery, nature of surgeries performed, number of pints of blood transfused, intensive care interventions performed, duration of hospital stay, and maternal and perinatal outcome are recorded.
Results of investigations including CBC, Blood grouping and typing,Serology for associated medical illnesses, Urine routine, USG abdomen, Coagulation profile, RBS, CXR, Renal and Liver function tests, and Vaginal swabs are studied.
Data thus obtained is analysed for incidence and type of obstetric emergency, their presentation, diagnosis , critical care interventions that can be life saving, and the outcome of such interventions.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes

Hb%
Urine for albumin, sugar and microscopy
Blood grouping and Rh typing
HIV and HBsAg
Specific investigations particular to the case studied.

7.4. Has ethical clearance been obtained from your institution in case
of 7.3?
Yes
8. / References :

Kaur Vaneet, Afzal Lalita (2008)- Critical Care in Obstetrics- Scenario in a developing country. J Obstet & Gynaecol India Vol 58 No. 3 May/June 2008 Pages 217-220.
MH Sharada, Janaki Radhakrishnan- Analysis of 100 cases of Obstetric emergencies needing critical care in referral centres like Steel plant hospitals. J Obstet & Gynaecol India 2001 Vol 51 No 6 Nov/Dec Pages 87-90.
Narwadkar Manges Vinayak- Critical study of referrals in Obstetric Emergencies. J Obstet & Gynaecol India Vol 54 No 3 May/June 2004 Pages258-259.
T . F Baskett - Maternal Intensive Care and Near miss mortality in Obstetrics - British Journal of Obstetrics and Gynaeology Vol 105 September 1998 Pages 981-984.
M Roost, V Altamirano- Priorities in Emergency Obstetric Care in Bolivia-Maternal mortality and near-miss morbidity in metropolitan La Paz. British Journal of Obstetrrics and Gynaecology 2009 Vol 116 Pages 1210-1217.

9. / Signature of candidate
10 / Remarks of the guide / Even with improved obstetric care there still lies the need for analyzing the maternal death, which can be further reduced by early identification of risk factors, early diagnosis of the problems and timely care. Therefore this study will further help us to reach higher standard of obstetric care to the patients.
11 / Name & Designation of (in block letters)
11.1 Guide
11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of the
Department
11.6 Signature / Dr. V.S. RAJUM.D.,
Professor,
Department of OBSTETRICS & GYNAECOLOGY,
J.J.M.MedicalCollege,
DAVANGERE - 577 004.
Dr. ANITA m.d.,
Professor,
Department of OBSTETRICS & GYNAECOLOGY,
J.J.M.MedicalCollege,
DAVANGERE - 577 004.
Dr. DAKSHAYINI B.R. M.D., D.G.O.,
Professor and H.O.D.,
Department of OBSTETRICS & GYNAECOLOGY,
J.J.M.MedicalCollege,
DAVANGERE - 577 004.
12 / Remarks of the
Chairman & Principal
12.2. Signature.