Girija Hospital & Fertility CenterAzad nagar, near Gujarat Colony, Kothrud, Pune
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Mrs RT, a 28 year old G2A1 was 12 weeks pregnant and was taken care by a local practitioner.
She had complaints of Per vaginal bleeding and that is when she visited me.
She was married for 3 years and It was her second pregnancy.
Her dating scan done outside confirmed the period of gestation 8 weeks.
Other investigations done revealed a normal urine report and a hemoglobin level of 9g/dl( Moderate anemia ).
Her clinical examination revealed threatened miscarriage and she was hospitalized for observations and further investigations.
She had regular menstrual cycles and her dates were excellent.
She had taken treatment for primary infertility which consisted of ovulation induction with clomiphene citrate and
she conceived in the second cycle of stimulation.
She had a spontaneous miscarriage where no cause was known.
In the present pregnancy, she had conceived spontaneously and had not taken any preconception consultation or medications.
On hospitalization, she was diagnosed to be hypothyroid based on TSH ( 16.5 IU ) and positive TPO and antithyroid antibodies.
With a diagnosis of graves’ disease, she was put on thyroxine treatment and natural progestogen supplements.
She was discharged after 4 days of treatment and was advised to have regular follow ups.
She reported after 11 days with similar complaints for which she was admitted for another 3 days.
After that, the patient continued her follow-ups every 15 days, during which she was screened for diabetes by the DIPSI OGCT,
Asymptomatic bacilluria by urine culture and sensitivity.
Supplements of both iron and calcium were given and she was dewormed, counseled about early warning signs of miscarriage.
She underwent a TIFFA( anomaly scan ) scan at 19 weeks & 2 days, which revealed normal growth, placentation, no anomaly and cervical length of 3.2 cms on vaginal scanning.
RT reported at 23 weeks with complaints of mucoid discharge, lower backache, crampy abdominal pain, and anxiety,
and she felt that the current symptoms were similar to her first loss.
Clinical examination revealed a well growing viable pregnancy and uterus was relaxed.
Internal examination showed a closed external OS but a ballooned cervical canal.
USG was undertaken immediately, which showed a completely open canal as shown in the pictures below
Figure 1 Opened up cervical canal
Figure 2 Dilated internal cervical OS
She was hospitalized and given a head low position.
She was put on prophylactic antibiotics, such as ceftriaxone and metronidazole.
Was given nifedepine and indomethacin.
Natural progesterone was continued.
She truly had a huge trust in me. I had asked her to contact my assistant or me, anytime she felt any untoward or new symptoms.
After 72 hours with the USG report, revealing a little resolution in the previous findings, we decided to take her for a rescue encirclage( Fig 3,4 and 5)
Figure 3 Per speculum examination in OR revealed ballooning membranes with patulous external OS
Figure 4 Babcock forceps were used to gently pull the cervical lips over the bulging membranes
Figure 5 Wurms stitch with double stranded number 1 nylon were taken
She was treated with micronized progesterone and indomethacin sustained release preparation from there onwards.
Patient was put on strict bedrest and chose to be in the hospital.
She continued to do well till 32 weeks. By then she had become euthyroid with treatment.
She received magnesium sulphate as neuroprotection for the baby and a prophylacticsteroid dose for lung maturity.
We were contemplating discharge and regular follow ups, when she was at 32 weeks 1 day and complained of spontaneous leak.
The patient was offered counseling by the neonatologist and me, about the mode of delivery and neonatal outcome and she opted for cesarean delivery.
Baby girl weighing 1.6 kgs was born and shifted to NICU in view of low birth weight.
Intra operatively – amniotic fluid was purulent and placental bed was unhealthy.
Placenta was sent for histopathological examination, which revealed degenerative changes and features of chorioamnioitis.
Amniotic fluid was sent for culture and sensitivity which showed no growth.
Her post-operative period was uneventful and was discharged on 8th post-operative after suture removal.
( Picture 1 ) Baby needed an NICU stay of a week, followed by step down NICU care of 10 days .
She comes for a follow up after 3 months with TSH levels of 50 IU for which we treated her.
Lesson learnt : Preconceptional work up and surveillance for anemia and hypothyroidism is mandatory.
This woman was not screened for these diseases and inspite ovulation, induction was done with clomiphene citrate.
Involving the patient in her own care, results into better outcome.
Prophylactic cervical encirclage probably would have been better option in this patient and we were lucky to take her till 32 weeks.
Threatened pre-term labor needs a multi pronged approach.
Dr. Girija Wagh, MD (Obstetrics & Gynaecology), FICOG, FICP, Diploma (Endoscopy, Infertility), Fellowship of Indian College of Ob-Gynec, Women health care specialist, Academician, Acclaimed Orator & Researcher, B. J. Medical 1990-1992, Topper University Of Pune 1992
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