Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
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On Sep 2018




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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2864 - 2868

Emergency Obstetric Hysterectomy: A Retrospective Study At A Tertiary Care Hospital

NAJAM R *, BANSAL P**, SHARMA R***, AGARWAL D ****

*Assistant professor, Department of Obstetrics and Gynecology, **Assistant professor, Department of Anesthesiology, ***Associate professor, Department of Obstetrics and Gynecology, ****Associate professor, Department of Pathology, Teerthanker Mahaveer Medical College, Moradabad ,U.P.(India).

Correspondence Address :
Dr. Rehana Najam
Assistant Professor, Department of Assistant professor, Department of Obstetrics and Gynecology, Teerthankar Mahaveer Medical College and University, Near Pakbara town, Moradabad, U.P.(India)
Email: najamnajam@rediffmail.com
Mobile no: 09837291920

Abstract

Objectives: To analyze the cases of emergency hysterectomy due to obstetrical causes with a view to know the incidence, indications, maternal profile and complications following this surgery.
Methods: Retrospective analysis of 24 obstetric hysterectomies which were performed during caesarean sections (n= 550) which were performed over a period of 32 months.
Results: The incidence of emergency hysterectomy in our study was10.05/1000 deliveries, with a maximum numbers of patients (n= 11) in the age group of 26-30yrs. The parity was >5 in patients and ruptured uterus (n=11; 45.8%) was the commonest indication for which this life saving surgery was performed. There was only one case of morbidly adherent placenta. Out of the 24 hysterectomies performed, 19 were subtotal hysterectomy and 5 were total hysterectomy. Post-operatively, fever was commonest complication (n=12; 50%), followed by wound infection (n=4; 16%). There were three maternal deaths and only 4 live births.
Conclusion: Proper antenatal care and early referral are the only potential methods which can be used for preventing this catastrophic event. Moreover, timely decision, liberal blood transfusion and speedy surgery by an experienced clinician are the main pillars in the management of this life saving procedure.

Keywords

: Emergency caesarean hysterectomy, ruptured uterus, post partum haemorrhage (PPH)

How to cite this article :

NAJAM R , BANSAL P, SHARMA R, AGARWAL D . EMERGENCY OBSTETRIC HYSTERECTOMY: A RETROSPECTIVE STUDY AT A TERTIARY CARE HOSPITAL. Journal of Clinical and Diagnostic Research [serial online] 2010 August [cited: 2019 Oct 21 ]; 4:2864-2868. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2010&month=August&volume=4&issue=4&page=2864-2868&id=847

Introduction
Emergency obstetric hysterectomy is usually the last resort in the obstetrician's armamentarium to save the life of the mother. In third world countries, obstetric haemorrhage and uterine atony are the leading cause of maternal deaths, followed closely by ruptured uterus and uterine sepsis (1). Prompt decision making and excellent surgical skills with a speedy intervention are the bedrock of this life saving procedure. Also, the rapidly deteriorating haemodynamic parameters warrant early transfusion and resuscitation to withstand the surgical procedure and anaesthesia.

Emergency hysterectomy during normal vaginal deliveries or caesarean deliveries is performed when all other measures to control maternal haemorrhage have become futile. The commonest indications for emergency hysterectomy which are cited in the literature are uterine rupture and atonic uterus (2). However, due to the increase in the number of caesarean deliveries over the past two decades, placenta accreta has emerged as the most common indication for this operation in developed countries (3). Currently, poor antenatal care and patient ignorance are still the major hindrances in developing countries towards the control of these correctable causes of maternal morbidity. The advent of the uterotonic agents, along with alternative techniques such as the β-lynch suture and uterine artery and internal artery ligation, has further reduced the need for this radical surgery, which has a deep impact on maternal health and psychology, especially in women with low parity (4).

Though, the recent figures point towards an improving trend in maternal morbidity and mortality in our country in last two decades, they represent the larger frame which includes both urban and rural areas (5). In rural parts of the country, the incidence of maternal anaemia and malnutrition is still deep-rooted, thus leading to increased peripartum complications. The purpose of our study was to know the incidence, indications and the maternal profile of the patients undergoing emergency hysterectomies at our tertiary level hospital which mainly caters to the rural population. Secondarily, we aimed to identify the complications which are associated with this emergency surgery.

Material and Methods

A retrospective analysis was performed to identify the number of cases who underwent emergency obstetric hysterectomy during immediate or post-caesarean sections which were performed over a period of 32 months from September 2007 to April 2010. The data were obtained by reviewing the obstetric admission register, operation register, mortality register and the case files. Each case file was analyzed in detail with special emphasis on the indications, maternal profile, type of the operation performed, associated surgeries, maternal morbidity and mortality and also the foetal outcome. Hysterectomies performed for any indication during pregnancy, labour and puerperium have been included in this study.

Results

During the study period of 32 months (September 2007- April 2010), a total number of 2388 deliveries were conducted at our institute, of which 1838 were normal vaginal deliveries and 550 were caesarean sections (Table/Fig 1). During the caesarean section procedure, 24 patients had to undergo emergency hysterectomy owing to several reasons. The incidence of obstetric hysterectomy was recorded to be 10.05/1000 deliveries.

Maternal Characteristics
Among the patients who underwent emergency hysterectomy, 7 cases (29.1%) were of para 5 or above (Table/Fig 2). Parity distribution shows that the incidence of this radical and life saving surgery was more in patients who were para 5 and above. A majority of cases (n=11, 45.8%,) belonged to the age group of 26-30yrs, followed by 6 cases in the 21-25 yrs age group and only 1 (4.1%) patient in the less than 20yrs age group.
Preoperatively, laboratory parameters revealed that the mean haemoglobin values in all the 24 cases which were undergoing hysterectomy was 5.6 gm/dl (range 3.8-7.2 gm/dl) and that haematocrit was 14.8% (range 11.4- 22%). All the patients were transfused liberally with blood, with an average of 3-5 units in each case [mean: 3.8 unit/ case] intra and postoperatively.

Retrospective analysis of the records revealed that the most common indication for emergency hysterectomy was ruptured uterus (n= 11; 45.8%) and all the patients who underwent this procedure were referred from rural areas. The next common indications were PPH and septic abortion (4 cases each) (Table/Fig 3).
The commonest cause of ruptured uterus which was encountered in our study was scar rupture, either due to previous LSCS or due to the previous repair of ruptured uterus. The next commonest cause was obstructed labour with cephalopelvic disproportion (Table/Fig 4).

Type Of Hysterectomy And Associated Surgical Procedure

Out of the 24 hysterectomies performed, 19 were subtotal hysterectomy and 5 were total hysterectomy. 4 patients had associated bladder rupture as well and required bladder repair. 2 patients of septic abortion had bowel perforation as well and were treated by bowel repair.

Intraperitoneal drain was kept in all the cases.

Maternal Outcome
Obstetric hysterectomy, though it was performed to save the life of patients, is associated with innumerous complications as with any emergency surgery. Fever was commonest post operative complication (n=12), followed by wound infection (n=4) (Table/Fig 5). There were three maternal deaths (12.5%), two patients died of endotoxic shock and one patient died of DIC. Perinatal mortality was 83.3% (n=20), with only 4 (16.6%) live births.

Discussion

Emergency obstetric hysterectomy is a radical, life saving operation that is mostly done for indications that are life-threatening for the patient. Quick decision making and performing the operation speedily are the two most important surgeon related factors that affect the maternal and foetal outcome (6). The present study was undertaken to analyze maternal mortality, morbidity, aetiology and foetal outcome.

In developed countries, the reported incidence of emergency hysterectomy is below 0.1% of the total normal deliveries performed, while in developing countries, the incidence rates are as high as 1-5/ 1000 of all the deliveries performed (1),(5). We observed an incidence of 10.05 obstetric hysterectomy/1000 deliveries in our set up, which was higher than the maximal incidence of 5.6/1000 obstetric cases as reported by Siddiq et al in this series (7). The primary reason for this higher incidence is due to the fact that our centre is the only tertiary care centre in a 100 km radius and receives maximal referrals from rural areas. Owing to ignorance and illiteracy, coupled with poor socio-economical conditions, parturients with high risk pregnancies get only a formal treatment from traditional birth attendants (TBA), untrained health workers or quacks. Thus, lack of proper medical attention and delayed referral results in higher foeto-maternal morbidity and mortality in parturients.

A high association of multiparity was also seen with emergency hysterectomy in our study. 7 (29%) cases with parity >5, followed closely by 6 (25%) cases with parity >3 underwent caesarean hysterectomy as compared to 3 (12.5%) cases with parity > 4. The reason for this non-uniform distribution of parity with caesarean hysterectomy could be other confounding factors such as poor general condition, massive haemorrhage and severe anaemia. In comparison to other studies, we additionally observed the preoperative haemoglobin and haematocrit levels and found them to be in a lower range of 3.8-7.2 gm/dl 11.4- 22%, respectively in our study. This warrants the need for liberal fresh blood transfusion to prevent further deterioration of the haemodynamic parameters and to achieve hemostasis by replenishing the coagulation factors.

The commonest indication of emergency hysterectomy in our study was ruptured uterus (45.8%, n=11). All these patients were unbooked cases that never underwent antenatal check ups and were referred from untrained birth attendants. Sahu et al (8) and Mukerjee et al (9), in their seriesd reported an incidence of 38%, but a very high incidence of ruptured uterus was reported by Archana et al (75%) (10).

We observed atonic PPH as the second most common indication of obstetric hysterectomy (16.6%). Similar findings have been reported by Richa Singh et al and Allahabadia et al who observed an incidence of 15.6% and 16% of respectively in their studies (11),(12).

Morbidly adherent placenta was seen in only 1 case (4.1%), in our series. This is in contrast to a study by Praneswari Devi et al, where placenta accreta was seen in 26.9% of the patients undergoing emergency hysterectomy (13). None of our cases required re-exploration for the control of haemorrhage as compared to the previous case series which mentioned the incidence to be between 1-8.8% (5),(8),13].

The maternal mortality rate in our study was 12.5% (n=3), with septicaemic shock, attributing to 2 cases and with DIC attributing to 1 case.. In a series of 41 cases, Kanwar et al (14) reported a maternal mortality rate of 12.2% and Siddiq et al of 9.7% in 61 cases (7). Similar results have been reported in other studies with similar reasons for mortality, except Praneswari Devi et al who reported no mortality in their study (13).

Use of uterotonics and haemostatic agents like tranaxemic acid can help to reduce blood loss, along with the use of certain surgical techniques. These techniques include applying tourniquet at the lower end of the uterine incision, clamping of the vascular pedicles supplying the uterus and delaying suture ligation until the vascular bundles are controlled, all of which have been described as novel methods for ensuring haemostasis in previous studies (7).

Emergency hysterectomy in young women not only leads to high morbidity, but also has serious psychological implications, especially when their parity is low. Decision-making on these issues in emergency is equally difficult for the obstetrician as it is for patients and their relatives.

In our country, improvements in the health care system have to go a long way, which can lead to a dramatic decline in the rates of emergency hysterectomy (15). This requires a multidisciplinary approach including the introduction of refreshing courses for multipurpose workers in identifying high risk pregnancies and their timely referral, upgrading of peripheral health centers with ambulance facilities and posting of specialist doctors in rural areas. As our analysis was retrospective, future investigators can also include patient associated psychological problems which are associated with this surgery, in their studies.

Conclusion

We conclude that proper ante natal care and identification of the high risk groups can prevent and decline the incidence of this catastrophic surgery. We suggest the upgrading of the peripheral health centers and the timely referral of high risk parturients to higher centers that can decline the rate of peripartum complications and improve maternal care and well-being.

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Allahabadia GV,Vaidya P. Obstetric Hysterectomy. (A review of 50 cases from January 1987 to August 1990) . J obstet Gyneco India 1991; 41: 634-7.
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Praneswari devi, RK Singh, Singh D. Emergency Obstetric hysterectomy. J Obstet Gyneco India 2004; 54: 343-5.
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Ahmad SN. , Mir IH: Emergency Peripartum Hysterectomy: Experience at Apex Hospital of Kashmir Valley. The Internet Journal of Gynecology and Obstetrics. 2007 Volume 8 Number 2.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com