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PresidentDr. Sreedevi.N.S

Secretary GeneralDr .Jayandhi Raghavan T

Immediate Past PresidentDr.Girija Gurudas

President ElectDr.Narayanan.T

Vice PresidentDr.Abdulla.B

Vice President ElectDr. Vinayachandran. S

Joint SecretaryDr. Sangeetha Menon

TreasurerDr.Rajalakshmi Janardhanan

Journal EditorDr. Fessy Louis .T

Chair, Maternal & Foetal Medicine CommitteeProf. V. P. Paily

Chair, Academic CommitteeDr. V. Rajasekharan Nair.V

Chair, Adoloscent CommitteeDr.V.K.Chellamma

Chair, Reproductive Health CommitteeDr .K .K . Gopinathan

Chair,Oncology CommitteeDr.Sumangala Devi

Chair, Research CommitteeDr. P.K.Sekharan

7 Dr Uday ThanawalaICOG GUIDELINES FOR MANAGEMENT OF ECLAMPSIA

8 AKCOG CALICUT PHOTOS

13Dr Paul P.GLAPAROSCOPIC HYSTERECTOMY IN FROZEN PELVIS

2Dr Pankaj DesaiCRITICAL CARE IN OBSTETRICS

As I asumed the office of the President of Kerala Federation of Obstetrics &Gynaecology, I am reminded of the immense responsibility that goes with thepost. As a Federation we will have to keep pace with the rest of the world in everyfield of obstetrics and gynaecology, while understanding the limitations placed onus due to various economic and social problems that are unique to our country.

To improve our understanding of various problems we have also formeddifferent subcommittees in newer fields in addition to the existing committees. It is imperative thatwe all move together as a federation to succeed in our various endeavors.

I wish that the coming year, inspite of economic recession, will prove to be excellent to us interms of academics and professional yard sticks.

Dr. N.S. Sreedevi

Address of CorrespondenceDr. Fessy Louis T.Editor KFOG Journal

CIMAR, Edappal Hospital, Edappal, Kerala-679 576Mob: 09846055224 E-mail: fessylouis@gmail.com

KERALA FEDERATION OF OBSTETRICS AND GYNAECOLOGY Vol: 3 No: 1 June 2009

www. kfogkerala.org

CONTENTS

Dear colleagues, During 2009-2010, we are planning to bringout three issues of KFOG Journal. Members cancontribute interesting and clinically relevantshort articles. Societies can contribute photos oftheir social activities to be included in the KFOG images page. We are trying to make the journal more & more reader centricby offering the readers valuable new informations to help themprovide better patient care. However it is important to read themcritically. I hope by this time you must have got the KFOG directory. Ifyou have not received the same, please write to me. Also log onto our website www.kfogkerala.org to know the updates of KFOGactivities and conferences.

Dr. Fessy Louis T

Design : Smriti, Thrissur, Printing: Anaswara, Cochin

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INTRODUCTION: A critically ill obstetric patient is one who, because of

abnormal pregnancy, delivery and puerperium or because ofeffects of pre-existing systemic disease, anesthesia and surgeryand other acquired condition on a normal pregnancy, deliveryor in puerperium develops complications threatening her life forwhich she needs intensive monitoring, therapy and/or life supportsystem. In another definition these are defined as maternal near-miss mortality, as those women requiring critical care or transferto an intensive care unit. Because maternal deaths are rare indeveloped countries, it has been suggested that a more accuratemeasure of the standard of maternal care is to study the near-miss cases. The problems with definition include.1. Transfer to ICU may depend on health care facilities and

may not be comparable from one hospital to another.2. All near-miss cases do not result in admission to an ICU,

e.g. a case of PPH is cared for in labour room withouttransfer.

3. Conditions requiring intensive care may not necessarilymirror causes of maternal mortality e.g. maternal mortalityfor PPH is lower than for amniotic fluid embolism.

Vaginal delivery following labour may be the shortest butmost hazardous journey made by any individual. Hypoxia,trauma and infection are inherent risks. The mother faces thebrunt of most of the assaults, pain, apprehension, infection,agony of having operative delivery, extensive tissue traumas,massive bleeding, long-term morbidity and even the risk of losingher life/or that of the newborn. The art of intrapartum care now,

is evidence based. Medline literature review between 1987-94revealed that the percentage of obstetric patients requiringintensive care is 0.1- 0.3

So a team consisting of obstetricians, anesthetist and aninternist is required for management of labor in a critically illpatient. Trained nursing staff and neonatologists will completethe list of required personnel.

Hemorrhage, hypertensives disorders, cardiac disease,and sepsis are some of the common problems threatening lifeduring labor. Severe anemia and jaundice in pregnancy are twoimportant causes of maternal mortality in our country especiallyin the immediate post-partum period.

PRINCIPLES OF CRITICAL CARE:

The basic guidelines of critical care are as follows:a. Optimum oxygen supply to tissues.b. Adequate circulating blood volume, which should neither

be less nor more than adequate.c. Nutritional supportd. Prevention of complications inherent to the modalities of

critical care.New knowledge put into practice in the ICU includes concepts

of prelude augmentation and reduction, oxygen delivery andconsumption, and pharmacological support with an arrhythmicinotropic, vasodilators and alpha blocking drugs. Examples ofnew equipments are intra-arterial BP monitors, pulse oximeters,pulmonary artery catheters (PAC), continuous mixed venousoxygen saturation monitors, intracranial pressure monitors,ventilators, computerized tomographic (CT) scanners, USGmachines, echocardiography, machine bronchoscopes and otherendoscopy equipments. Emergency equipments includedefibrillators, suction machine, ECG, portable fetal monitors, etc.In addition to routine, the ability to insert radial and pulmonaryartery catheters, perform endotracheal intubations, manage aventilator, direct cardio-pulmonary resuscitation and performcesarean hysterectomy or bilateral hypo-gastric artery ligationare also a part of critical management in obstetrics.

PRINCIPLES OF MANAGEMENT:

1. Clinical monitoring2. Respiratory support3. Cardiovascular support4. Correction of cause Clinical Monitoring:· Mental status· Pulse· Respiration· Temperature· Skin color· Capillary refill

DR. PANKAJ D. DESAI

Past FOGSI President

CRITICAL CAREIN OBSTETRICS

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· Sweating· Urine volume Because of increased blood volume in pregnancy,

hemodynamic instability indicating need for transfusion may notoccur until blood loss approaches 1.5 to 2 liters.

Basic Investigations:These include complete blood count, urine examination,

coagulation profile, electrolytes, BUN, creatinine, chest X-ray,ECG, arterial blood gases, serum lactate, urine and blood culture,pulse oximetry.

The initial approach to a critically ill patient is assessment

of the state of perfusion focusing on the distinction betweenhigh and low flow states (TABLE 1).

Table1Assessment of the state of perfusionManifestation Low flow state High flow StateMental status Low LowUrine output Low LowCapillary refill Low NormalExtremities Cold WarmManual blood pressure Low LowPulse pressure Low Normal or lowLactate Low Low Inadequate circulating volume or pump dysfunction or

both causes low flow states; High hypo-perfusion is typical ofseptic shock, liver disorders, etc.

INVASIVE HEMODYNAMIC MONITORING:

Intra-arterial BP : Per cutaneous placement of intra-arterialcanula allows continuous monitoring and repeated samplingsof blood for gas and acid base analysis. This is essential whenrapid hemodynamic changes are anticipated, e.g. whenadministering inotropic / vasoactive drugs.

CVP is a simple method for assessing circulating volumeand filling status of right heart chambers. However the absolutevalue is often unhelpful except in extreme cases of hypervolemia,fluid overload or heart failure. Correct interpretation requiresassessment of changes in CVP. CVP does not accurately reflectleft ventricular filling in patients with preeclampsia, pulmonaryand cardiac disease. In these situations, utilizing a pulmonaryartery catheter is helpful in determining relative volume status.

Pulmonary artery catheterization: The Swan-Ganzpulmonary artery catheter introduced in 1970 has given anidentity to the practice of critical care medicine. Continuouscentral venous and pulmonary artery pressures and intermittentcapillary wedge pressure (PCWP) measurements are obtained.Cardiac output can be measured by thermo-dilution technique.

As with CVP correct interpretation requires assessment ofchanges in response to treatment together with alterations inclinical signs and other monitored variables. Because of lack ofcorrelation between measurements on the right and left sidesof the heart in patients with significant cardiopulmonary disease,PCWP is monitored to optimize ventricular preload to avoidpulmonary edema.

Thus, in critically ill obstetric patients, discrepancies are often,seen between measurements, of PCWP and CVP. In suchsituations clinical use of CVP alone would be deleterious. Withrare exception, the complications seen with pulmonary arterycatheterization associated with obtaining central venous accessare similar whether a CVP line or pulmonary artery catheter isused. For these reasons, in modern perinatal intensive care unit,CVP monitoring alone is seldom indicated.

Indications for Pulmonary Artery Catheterization1. Refractory/unexplained pulmonary edema and heart failure2. Severe PIH with persistent pulmonary edema.3. Massive hemorrhage (unresponsive to volume therapy or

when accompanied by high CVP).4. Septic shock with refractory hypotension/ oliguria.5. ARDS6. Persistent shock of unknown etiology.7. Some chronic conditions when in labor/operative delivery: a. NYHA class III, IV, cardiac diseases b. Pulmonary hypertension.8. Unexplained intrapartum /intra-operative cardiovascular

decompensation.9. Respiratory distress of unknown cause.

Invasive monitoring is not necessary in every patient withone of these conditions, nor is this an all-inclusive list. Invasivemonitoring has its own hazards. Therefore it is recommendedonly in patients where precise hemodynamic data can improvedecision making and where better interventions are possible.

Pulmonary edema: Swan-Ganz catheter is used to measurepulmonary capillary wedge pressure to differentiate cardiogenicfrom non-cardiogenic pulmonary edema: cardiogenic pulmonaryedema results from increased hydrostatic pressure withinpulmonary capillaries whereas non-cardiogenic pulmonaryedema is the result of increased capillary wall permeability.

GUIDE TO THERAPY:

Whenever necessary, manipulations of cardiac output,reduction of preload and after-load and ionotropic therapy arerequired, invasive monitoring is helpful.

Oliguria:To assess volume status in hypertensives disorders, CVP is

a poor guide. PAC better guides changes in wedge pressureand cardiac output in response to fluid challenge.

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In Hemorrhagic Shock:Clinical parameters like pulse, BP, urine output, respiration

and temperature are commonly utilized. Invasive techniquemeasurements are useful in some cases. An arterial canula alsoallows frequent measurement of blood gases and acid-basestate. In patients deteriorating after initial response a pulmonarycatheter may be useful. After initial resuscitation duringsubsequent 24 to 48 hrs, the catheter may guide fluid therapy incomplex cases in which it is not clear whether internal bleedingis continuing, or oliguria, pulmonary edema, liver dysfunction,or coagulopathy are present.

In Septic Shock: Invasive monitoring allows manipulation of cardiovascular

parameters while on fluid and ionotropic therapy. Assessmentof response to therapy may be done through parameters suchas oxygen delivery (DO2) and oxygen consumption (VO2), (DO2-cardiac output X arterial oxygen content). Oxygen consumptionincreases many folds in critically ill patients with multi-organdysfunction.

NYHA Class III and IV cardiac diseases: Monitoring is required for managing fluid and drug therapy

and anesthetic management.

Respiratory distress of unknown causes: Monitoring helps to differentiate heart failure, pneumonia,

pulmonary embolism, ARDS, Chronic pulmonary disorders.

Does Swan-Ganz Catheter Improve Outcome:Pulmonary artery catheterization improves diagnostic

accuracy and provides information that often prompts changesin treatment. Nevertheless, its influence on outcome remainsuncertain, in obstetrics. Some studies have suggested that theuse of catheters may be associated with a worse outcome. Largeprospective randomized trials would be needed for a final answerin obstetric patients.

RESPIRATORY SUPPORT: The first priority is to secure the airway and if necessaryprovide mechanical ventilation. Because mechanical ventilationminimizes the work of breathing reduces oxygen consumptionand improves oxygenation, early respiratory support benefitspatients with severe shock and mechanical ventilation. Thesepatients are those with:· Infective pneumonia.· Aspiration pneumonia· Asthma· Pulmonary edema· Status epilepticus· Septic shock

· ARDS· Post operative hemodynamic instability· High spinal/epidural anesthesia· Difficult intubations· Laryngeal edema· Drug overdose· Cardiac arrest· Hypoxic encephalopathy.

The arterial blood gas criteria for acute respiratory failure

are arterial oxygen partial pressure (PaO2) <50 mm or an arterialCO2 partial pressure (PaCO2) = 50 mm. The blood gas analysisreveals what the patient is accomplishing. It does not revealhow hard she is working to do it. If the patient is severelydyspneic, restless, confused and fatigued, it may be wise tointubate her prophylactically.

The art of fluid administration and hemodynamic support isone of the most challenging aspects of treating critically illpatients.

Determinants of Cardiac Output:Circulatory support involves manipulation of the three

determinants of stroke volumes (preload, myocardial contractilityand after load) as well as heart rate.

Preload optimization is the most efficient way of increasingcardiac output and is a pre-requisite for restoring tissue perfusion.Controversy continues about whether colloids or crystalloid arepreferable. Data from 19 randomized trials involving a total of1315 patients indicate that albumin and non-albumin colloidsincreased absolute of death by 4 percent.

HYPOVOLEMIC SHOCK:

Important pathophysiology in hypovolemic shock includessodium and water entry into skeletal muscles and cellularpotassium lost to extra cellular fluid. Replacement of extra cellularfluid is important. Indeed, survival appears to be reduced in acutehemorrhagic shock when blood alone compared with blood andlactated Ringer solution is administered.

Initial fluid infusion should involve about 3 times as muchcrystalloid as the estimated blood loss. Establish intravenousaccess with two wide bore drip sets. In most cases red cellreplacement proves sufficient. The exception is the women withtorrential bleeding.

The use transfusion in critically ill patients varies widely withdifferent Hb, thresholds being between 7 to 12 gm/dl. Theoptimal transfusion practice for various types of critically ill patientswith anemia has not been established. A restrictive strategy ofred blood cell transfusion is at least as effective and possiblysuperior to a liberal transfusion policy. Transfusion in youngpatients seems prudent when Hb falls below 7 gm/dl.

If signs of shock persist despite volume replacement andperfusion of vital organs is jeopardized, ionotropic or other

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vasoactive agents may be given to improve cardiac output andblood pressure.

Commonly used vasoactive drugs are as follows (Table 2).1. Dopamine: Acts on both á and â receptors depending on

dose. Ionotropic vasoconstrictor widely used in cardiogenicand septic shock, first few hours of oliguria / renal failure.

2. Dobutamine: Ionotropic vasodilator, used in heart failure.In low doses, it predominantly acts on â1 receptors: in highdoses acts on â2 receptors.

3. Norepinephrine: 60% á and 40 % alpha agonist effect:Vasoconstrictor for life threatening hypertension(hypovolemic and septic shock) along with fluidresuscitation.

4. Sodium Nitroprusside: Equal arterial and venous dilatorused in acute hypertensives emergency. Fetal cyanidetoxicity is possible.

5. Nitroglycerine vasodilators: In low dose, it ispredominantly causes arterial dilation. It may be used inhypertensions and carcinogenic pulmonary edema.

Table 2:

Homodynamic therapy for contractility preload and after loadContractility Pre load Contractility After load Vasoactive drugsCrystalloid Volume expansion DopamineColloid Ionotropic support DobutamineBlood Vasopressors, Phenylnephrine Epinephrine, CalciumNorepinephrine Digitalis, Materaminol Diuretics Nifedipine Frusemide Hydralazine Mannitol Labetalol Venodilators Mixed Arth-Vn dilator Orsemide Nitroprusside Nitroglycerine Venous dilator, Nitroglycerine (Low dose) (high doses) Morphine

may be responsible for sudden CCF. A central venous pressuremonitor should maintain close watch particularly during labor incases of severe hypertension, valvular disease, severe anemiaand chronic obstructive respiratory disease. If the CVP risesabove 10 cm of H2 O then rapid Frusemide injection 40 mgmsI.V. should be given with a close watch on urinary output whichshould be optimally 0.5 ml/kg/hour. During labor with each uterinecontraction the systolic BP may be raised by about 30mm Hgand diastolic B.P. may go up by 10 to 15 mm of Hg. Thisphenomenon may be responsible for acute pulmonary edema,which should be carefully monitored by CVP, serial chest X-rayand breathlessness.

Third stage of labor: The third stage is the most criticalphase of labor because of: a) massive auto transfusion of 1000to 1200 ml of blood and (b) shift of extra vascular space fluidinto vascular compartment thereby temporarily raising the bloodvolume acutely.

A close watch therefore should be kept on thecardiovascular system specially by observing the following

parameters.· Position of patient: supine hypertension

should be avoided by keeping thepatient in the lateral position in betweencontractions.

· The patients should be propped up ifthere are early suggestions ofpulmonary edema.

· Oxygen inhalation particularly in casesof severe anemia, cardiac disease andpulmonary obstructive disease shouldbe maintained.

· Pulse oximetry indicating oxygensaturation should be institutedcompulsorily during labor.

· Endotracheal intubations and

Having outlined the general concepts of care of the critically

ill the following points are highlighted especially for theintrapartum care. Labor represents a tremendous “aerobic load”to the mother, and is best postponed/avoided, if possible (e.g.do not undertake induction when oxygen delivery is marginal).

The increased blood volume expected for normal pregnancyoperates during labor also. During labor, uterine contractionsincrease CVP, which increases dramatically during the effortsof second stage. The CVP also increases by I.V. ergometrineinjection.

Soon after delivery there is a sudden rise in the right-sidedvenous return, which may alarmingly raise the preload, and this

controlled ventilation should start ventilatory procedures forpulmonary edema during labor.

· Close watch should be kept on blood loss in third stage, whicheven in small amounts of 300 ml may precipitate disaster, inanemia or hypertensives patients.

· If oxytocics are necessary oxytocin drip should beundertaken.

· Antibiotics like cephalosporins should be recommended.· Analgesia: spinal or epidural analgesia must compulsorily

be preceded by volume expansion especially in severepreeclampsia.

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Did you

Know

?

FETAL RESPONSE: A wide array of conditions in the mother can impair oxygen

delivery to the fetus. Any state that lowers the PO2 of the uterinevenous blood will be lowered by any disease that diminish ortransport.

In the anemic gravid, the oxygen carrying capacity of herblood is diminished. Also maternal acidosis and fever shift thehemoglobin saturation curve to the right and lower the oxygencarrying capacity. Treatment should aim to increase oxygencarrying capacity of maternal blood by replenishing red bloodcells, to maintain intra vascular volume and to correct metabolicderangements.

If a mother has diminished PO2 due to pulmonary dysfunction,fetal oxygenation is impaired. Increasing PO2 by nose breather,facemask or continuous positive airway pressure (CPAP Mask)or mechanical ventilation of inspired air will have favorable effectsfor fetus. The oxygenation of critically ill patients is oftenmonitored with pulse oximetry. Although O2 saturation values of85 to 90 percent may be adequate to provide for maternalphysiological needs an O2 saturation of 95 percent is essentialfor adequate fetal oxygenation. Because oxygenation depends

on flow, it should be maximized by avoiding supine position andmaintaining intravascular volume should maximize it. The fetalwell-being may be compromised by maternal compensatorymechanisms, which act to preserve maternal BP at the expenseof uterine blood flow. Fetal heart rate patterns may give warningsignal even when the maternal status is apparently nearly stable. Continuous electronic fetal heart rate monitoring is an importantpart of the care of the critically ill and unstable pregnant patientseven in a medical or surgical intensive care setting. It goeswithout saying that there should be adequate provision forneonatal resuscitation.

CONCLUSION: In conclusion the critically ill women in labor presents a

unique challenge to the obstetrician. The patient’s disease, aswell as any potential therapy simultaneously affects twoindividuals with vastly different physiology. Such patientsrepresent the only areas of medicine in which the potentialmortality (or salvage) is 200 percent. The recent surge in criticalcare obstetrics is therefore gratifying

Microwave was an accidentaldiscovery by Dr. Percy Spensor in 1946.During a radar related research projecthe was testing a new vacuum tubecalled a magnetron, When hediscovered that the candy bar in hispocket had melted. This intrigued Dr.spencer, so he tried anotherexperiment. This time he placed somepopcorn kernels near the tube,hewatched with an inventive sparkle in hiseye as the popcorn sputtered, crackedand popped all over his lab.

He fashioned a metel box, with anopening into which he fed microwave

power. The energy entering thebox was unable to escape,thereby creating a higherdensity electromagnetic field.When food was placed in thebox and microwave energy fedin the temperature of the foodrose very rapidly. Thisrevoltionized cooking, themicrowave oven.

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ICOG Guidelines for Management Of EclampsiaIntroduction -

Eclampsia is a serious complication of pregnancy. Definedas onset of tonic and clonic convulsions in a pregnant womanwith preeclampsia ( BP more than 140/90, edema, andprotienuria ). The pathophysiology of eclampsia is thought toinvolve cerebral vasospasm leading to ischemia, disruption ofthe blood brain barrier and cerebral edema.

1. Background1a Early pick up and management of preeclampsia could

help in reducing the incidence.1bThe high incidence in India as compared to developed

countries is probably due to lack of antenatal care.1c FOGSI –ICOG recognizes the need to standardize the

approach to the management of eclampsia in the immediatepre and post delivery interval in order to improve the outcomefor the mother and child.

Context:1a Eclapmsia is a sequele to severe preeclampsia – and thus

management should be ideally directed to early detectionof pre-eclampsia and to treat in an attempt to achieve fetalmaturity and prevent maternal complications like cclampsia.Thus antenatal care and management has a huge role toplay in bringing down the incidence of Ecclampsia.

1b The incidence in our country varies from 1-5% (personalcommunication from different regions). More than half thecases are antepartum ,and approximately 20% of the casesoccurred post partum. Maternal Mortality is 4 -6 % and theperinatal loss is a whopping 45%! Possibly the incidence islower in booked cases verses unbooked cases.The developed world has a much lower rate of thiscomplication - incidence in UK – 4.9/10,000 with a casefatality rate of 1.4%.(8)

1c According to RCOG Guidelines even in UK the ConfidentialInquiries into maternal Deaths persistently show asubstandard care in a significant percentage of the death.(1)

In India , where the antenatal care is not accessed by all thenumber of cases and the severity is probably much worse,and thus there is an urgent need to standardize thetreatment.

2. MANAGEMENT2.1 Fogsi recommends that every maternity unit is equipped to

deal with this obstetric emergency and institutes emergencymanagement effectively.

2.1a Immediate care – maintain airway, maintain oxygenation,prevent trauma or injury, access the patient

2.1b abort convulsions,

Context:2.1 When dealing with eclampsia (even severe pre-eclapmsia)

it is recommended that the following are available-Oxygen. suction machine, equipment for resuscitation.Syringes and drug tray with – magnesium sulphate,nefedipine, calmpose, pentothal, atropine, adrenaline,hydralazine, dexamethasone.Once stabilized, obstetric evaluation and plan to deliver thepatient.

2.1a The patient should be placed in the left lateral positionand the airway secured. Oxygen should be administered.General measures to prevent patient from falling down orbiting the tongue should be taken. An IV line secured.Patients vitals are checked, obstetric examination isperformed, fetal status evaluated.

2.1b Drugs are instituted to abort convulsions and bringdown the blood pressure.

2.2 Treatment and prophylaxis of seizures2.2a The results of the Collaborative Eclampsia Trial show

that women treated with magnesium sulphate have fewerrecurrent seizures compared with women treated withdiazepam or phenytoin.(2)

2.2b FOGSI recommendsA loading dose of Magnesium Sulphate A loading dose of4g should be given over 5-10 minutes followed by a

Dr Uday ThanawalaChairperson, Medical Disorders in Pregnancy Committee of FOGSI.(2007 -09)

Team - Dr Sujata Mishra, Dr VP Paily, Dr Hema Divakar, Dr Kartik Bhagat, Dr Sameer Dixshit, Dr Reema Shamim

ICOG GUIDELINES FORMANAGEMENT OF

ECLAMPSIA

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Inauguration by Hon: Health MinisterSmt. Sreemathy Teacher

Release of book “why mothers Die in Kerala”of CRMD committee

Release of book KFOG Obstetric Management Protocol”of Academic committee

Release of First KFOG Directory

AudienceAudience

Release of AKCOG souvienor Dr. Varghese Memorial oration plaque given to Prof. Dr. Bhadran

31st AKCOG (All Kerala Conference Calicut, 2009)

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intramuscular maintenance regime-5g every 4hrly im,continued for at least 24 hours after the last seizure ordelivery whichever is later.

2.2c Recurrent seizures should be treated by a furtherbolus of 2g. (Grade A recommendation) (4) For statuseclampticus – diazepam and thiopentone is used

2.2d Monitor therapy

Context:2.2a Magnesium appears to act primarily by relieving

cerebral vasospasm. (3)

2.2b A loading dose of 4g should be given iv. over 5-10 minutesfollowed by a intramuscular maintenance regime-5g every4hrly im, continued for at least 24 hours after the last seizureor delivery whichever is later. Intramuscular injections arepainful and are complicated by local abscess formation in0.5% of cases.Intravenous MgSo4- Both 50% and 25% solutions can begiven intravenously. 4 ampoules of 50% soln. amounts to 4gm which is diluted in distilled water to make it 20 ml andgive it slow IV. At least 5 minutes should be taken to inject 4gm.Intramuscular MgSo4 - For IM injection it should be 50%solution. Still the volume is 10ml (5gm) and should be givenas deep IM injection in the buttocks. Addition of 1 ml of 1%xylocaine to the solution may help to reduce the pain at theinjection site.

2.2c – A further iv bolus of 2gms.MgSo4.If repeated seizures occur despite magnesium, options

include diazepam (10mg IV) or thiopentone (50mg IV).Intubation may become necessary in such women in orderto protect the airway and ensure adequate oxygenation.Further seizures should be managed by intermittent positivepressure ventilation and muscle relaxation. Also, considerpossibility of cerebrovascular accidents. Too rapid injectionof MgSo4 should not be given in an attempt to abolish aconvulsion rapidly.

2.2d Strict monitoring of vitals is advocated. An indwellingcatheter is important to monitor the urine output. Respiratoryrate and knee jerks with urine output are importantparameters to pick up magnesium toxicity.

Magnesium toxicityIf available serum levels of Magnesium should be done. The

normal blood levels are 2meq/L , and the therapeutic level to beachieved is 4meq/L . If the levels reach 10meq/L – the platellarreflex is lost and at 10meq/L ,and at 15meq/L respiratorydepression sets in.

Thus if the intramuscular regime is used, it is important toensure that before administration of a repeat dose –1) urine output is > 30ml/hr;2) patella reflexes are intact3) respiratory rate is above 16/mins.

For overdose of MgSo4, Ca gluconate is the antidote. 1gm

IV is the dose, but should be given very slowly.2.3 Treatment of hypertension2.3a Drugs used

Context:2.3 Reduction of severe hypertension (blood pressure > 160/

110 mm Hg ) is mandatory to reduce the risk ofcerebrovascular accident. Treatment may also reduce therisk of further seizures. It is important to lower the BPpromptly but gradually. The diastolic BP should bemaintained between 95-105 mmHg.

2.3a Drugs – Nefidipine Lebetol Hydrallizine

Nefidipine A calcium channel blocker. Effective vasodilator.Acts rapidly when given orally-is resorted to and there is anadvantage of quicker action by the sublingual route. Nifidipinecan be given intragastric using a Ryles tube. The dose shouldnot exceed 10 mg at a time and should not be repeated morefrequently than every 30mts. Oral tablet may act within 10 – 15mins, slow release tab within 60 mins

Labetalol - a combined alpha and beta adrenergic??? (20mgIV escalating to 40 or 80mg every 10 minutes to a maximumcumulative dose of 300mg or Walker : slow IV 50 mg followedby infusion of 5mg/ ml – initiated at 12ml/hrand titrated to toachieve the desired BP level . lowers BP smoothly but rapidly,without tachycardia.

Hydralazine - A vasodilator. Preferred antihypertensive forthe treatment of hypertensive crisis of pregnancy.Side effects:severe headache, tachycardia, anxiety, restlessness, hyper-reflexia, abnormal FHS patterns.

Dose- 5mg IV repeated every 20 minutes to a maximumcumulative dose of 20mg Other rapidly acting agents- nitroglycerine, diazoxide, and sodium nitroprusside are usuallypreserved for use in a ICU setting or in the OT.

2.4 Fluid therapyFluids should be restricted to 80ml/hr.or 1mg/kg body weight.

RCOG recommends fluid restriction so as to avoid fluid overloadand pulmonary edema. Close monitoring of fluid intake and urineoutput is mandatory.

2.5 Investigations - Liver function, renal function &clotting profile needs close monitoring.

Ecclampsia is usually part of a multisystem disorder.Associated complications include haemolysis, elevated liverenzymes and low platelets (HELLP) syndrome (3%),disseminated intravascular coagulation (3%), renal failure (4%)and adult respiratory distress syndrome (3%).(5)

Thus, frequent monitoring of- Haemoglobin, TBC, Plateletcount, transaminases, urea and creatinine, oxygensaturation

Clotting profile -Clotting studies are not required if the plateletcount is over 100x 109 /l. For places where facilities are notavailable – a simple clot observation test may give information

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about the clotting profile. Blood withdrawn in a syringe shouldclot and retract in ———mins.

Rising Serum uric acid > 6mg%, denotes fetal jeopardy anddelivery should be expedited.

Cerebral imaging (MRI or CT) may be indicated to excludehemorrhage and other serious abnormalities in women with focalneurological deficits or prolonged coma.(6)

2.6 MonitoringVitals- Pulse, Blood pressure, Respitatory Rate, oxygen

saturation (every 15 mins documentation).Knee jerks and urine output –(every half hourly) Deeply unconscious patients –Airway management may require intubation.CVP Line is desireable.Use of steroids and diuretics be considered to reduce

cerebral edema. Dexamethasone( 32mgiv and 8 mg 6hrly imfor 24hours is recommended).

2.7 Monitoring the fetus –2.7a- Acertain gestational age and fetal well being2.7 b- If preterm and if delivery can be delayed –

administer steroid /transfer to nicu setting to give theneonate the best chance.

2.7c– Deliver for maternal or fetal indication. Maternalwellbeing gets priority over fetal condition.

Context:2.7b Prematurity and IUGR are the main contributors to the

high perinatal mortality.Early detection of preeclampsia andprompt management in the antenatal period is called for havinga good perinatal outcome. Steroid administration in the antenatalperiod is recommended. (see prophylactic measures).

2.7c- Once eclampsia has set in one must weigh maternalwell being over fetal well being and take decisions. Gestationalage needs to be ascertained and assessment with acardiotocograph may be desirable. If the woman is in labor,continuous electronic fetal heart rate monitoring isrecommended. In settings where this is not possible regularauscultation of FHS especially during and after a contraction isrecommended to pick up late decelerations.If conservativemanagement is planned then assessment of the fetus withUltrasound – fetal size, amount of liquor and Doppler studiescan be done. Serial assessment can optimize the timing ofdelivery.

2.8 Delivery2.8 a Definitive treatment of eclampsia is delivery.2.8b Vaginal / LSCS – would depend on obstetric

evaluation of individual patient.Context:The definitive treatment of eclampsia is delivery. Attempts

to prolong pregnancy in order to improve fetal maturity areunlikely to be of value. However, it is inappropriate to deliver anunstable mother even if there is fetal distress. .

Once seizures are controlled, severe hypertension treated,

and hypoxia corrected, delivery can be expedited. Vaginaldelivery should be considered but caesarean section is likely tobe required in primigravidae remote from term with anunfavorable cervix. Vaginal prostaglandins increase the successof induction and augmentation. Hypertension monitoring andcontrol should continue vigilantly throughout labor.

If the fetus is premature, and convulsions are absent andmaternal health stable - delivery can be delayed. In this time,corticosteroids should be given and arrangements could bemade to have a proper neonatal setup available,( Maybe bytransferring the patient to a tertiary centre), though after 24 hoursthe benefit of continuing the pregnancy should be reassessed.

Less than 26 weeks Stabilizeterminate pregnancy

26 – 34 weeksexpectant management corticosteroids; surveillance, deliver formaternal or fetal indication more than 34 weeksstabilize Deliver The mode of deliverydepends, primarily, on the obstetric factors.

2.8b Vaginal Delivery –Principles – Second stage of labor should be short and

elective operative vaginal delivery can be considered. Pain reliefis desirable.

LSCS is considered for any obstetric indication ; fetal distress,or if vaginal delivery is unlikely to occur within a reasonabletime frame the first eclamptic fit. If LSCS is decided upon in aneclamptic case then the next MgSo4 dose (after 4 hours) maybe deferred, since it may increase chances of accentuating theaction of muscle relaxants, and uterine atony.

Choice of Anesthesia would depend upon the condition ofthe patient – regional is preferred , provided the coagulationprofile is normal. If General anesthesia is recommended onemust remember that laryngeal edema may make intubationsdifficult.

The third stage should be managed by either of the followingso as to prevent hemorrhage (but NOT ergometrine, as thiswould result in further increase in blood pressure).

Oxytocin (10units iv or im),Prostaglandin (125mg Or 250mg im ),Misoprostol 400mg (rectal, vaginal, oral)

2.9 Post Delivery –2.9a Continue close monitoring for first 24 hours. Taper

antihypertnsives gradually.Follow up these patients and if hypertension and

proteinurea continue for 6 weeks investigate for renaldisease.

Contex-After delivery, close monitoring should be continued for a

minimum of 24 hours.Since almost 20% of the patients can havepost partum ecclampsia – it is important to be vigilant andcontinue treatment for first 24- 48 hours. Antihypertensive

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treatment can then be gradually tapered off. But these patientsmay require anti hypertensive treatment for several weeks.Ifhypertension and proteinurea continue for 6 weeks investigatefor renal disease.

3 –Prophylactic measures 3.1-Seizure Prophylaxis 3.2 Prematurity and steroid administration 3.3 Future PregnanciesContex-3.1 Seizure ProphylaxisLook out for signs of imminent eclampsia in patients with

severe pre-eclampsia . Symptoms and signs of impending eclampsia –1) severe frontal headache2) epigastric pain/tenderness3) nausea/vomiting4) visual blurring5) Hyperreflexia/sustained clonus.Women with severe preeclampsia ( BP 170/110 with

proteinuria) should be given magnesium sulphate once adelivery decision has been made and in the immediate postpartum period. If given it should be continued 24 hrs afterdelivery or 24hrs after the last convulsion, whichever is later.(8)

3.2 Prematurity and steroid administration-If the delivery can be delayed and the fetus is premature

steroids for lung maturity can be given( 2 doses of 12mgs ofbetamethasone 24 hours apart). However with eclamptics somuch time may not be available,- thus it is recommended thatall preeclamptics receive this during antenatal care. Foreclamptics who have not been given steroids earlier evena single iv dose of steroid 1 hour before delivery is shownto decrease the incidence of intraventricular hemorrhageand necrotizing encephalopathy in pretem infants

Future pregnancies –Post partum advice-Important to counsel the patients the importance of early

registration and regular follow up. Preeclampsia may notreoccur. Starting low dose aspirin may be worthwhile.

SUMMARY- Eclampsia cases are best managed in specialregional centres equipped with the proper expertise andequipment and set up ( ICU ) to manage this complication. Earlyinvolvement of consultant obstetric and anaesthetic staff, andother specialities(hematologist/ ophthalmologist/neonatologist)is called for. Referral to a regional centre for advice and/orassistance should be considered in all cases of eclampsia,particularly where there are maternal complications.

Magnesium sulphate is the anticonvulsant of choice andconsideration should be given to the provision of treatment packscontaining equipment to establish an intravenous infusion,magnesium sulphate, calcium gluconate and a copy of theprotocol.(7)

Principles of management –Immediate Care -maintainairway, maintain oxygenation, prevent trauma or injuryControlseizures & Prevent further seizures – magnesium sulphate(other drugs in case of nonavailability of MgSO4- diazepam oreptoin. Thiopentone reserved for status eclampticus).ControlHypertension (diastolic between 95 – 105) -NefidipineHaemodynamically stabilise thepatient.Investigations: coagualation screen/ renal function/plateletsPrevention of complications: pulmonary oedema,renal failure, CVA, Abruptio, DICOptimize the time to deliver -minimizing the complications to the mother & child Parametersused while planning the delivery Gestational AgeSeverity ofDisease: Seizures/ HypertensionImmediate danger to themother/ fetus Postpartum intensive care for 24 – 48 hrs

This guideline was produced under the direction of theIndian College Of Obstetrics and Gynecology and Federationof Obstetrics and Gynecological Societies of India as aneducational aid to obstetricians and gynaecologists. Thisguideline does not define a standard of care, nor is it intendedto dictate an exclusive course of management. It presentsrecognised methods and techniques of clinical practice forconsideration by obstetricians/gynaecologists forincorporation into their practices. Variations of practice takinginto account the needs of the individual patient, resourcesand limitations unique to the institution or type of practicemay be appropriate

REFERENCES

1) Why Mothers Die. Report on Confidential Inquiries intoMaternal Deaths in the United Kingdom 2000-2002. London:RCOG Press,2004.

2. Eclampsia Trial Collaborative Group. Which anticonvulsantfor women with eclampsia? Evidence from the CollaborativeEclampsia Trial. Lancet 1995, 345:1455-63.

3. Naidu S. Payne A J. Moodley J. Hoffman M, Gouws E.Randomised study assessing the effect of phenytoin andmagnesium sulphate on maternal cerebral circulation ineclampsia using transcranial Doppler ultrasound. Br J ObstetGynaecol 1996, 103:111-6.

4) Management of Eclampsia (10) - Jul 1999; Clinical GreenTop Guidelines

5) Douglas K A, Redman C W G. Eclampsia in the UnitedKingdom. Br Med J 1994, 309: 1395-1400

6) . Dahmus M A, Barton J R. Sibai B M. Cerebral imaging ineclampsia: magnetic resonance imaging versus computedtomography. Am J Obstet Gynecol 1992, 167:935-41.

7) Fathima Paruk, Jack Moodley; Treatment of severepreeclampsia / eclampsia syndrome. Progress in Obstetricsand Gynecology,vol 14,2000,103:114.

8) RCOG Guidelines 10;2005.

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Frozen pelvis refers to the surgical condition where reproductive organs and adjacent structures are distorted

by extensive adhesive disease and fibrosis, which obscure thenormal anatomic landmarks and surgical planes, makingdissection extremely difficult and increasing the risk of damageto vital organs1. Hysterectomy in frozen pelvis is a challengingsurgical condition whether done by laparotomy or laparoscopy.The overall keys to success in such cases depend on theknowledge in the pelvic anatomy and operative experienceinvolving varying degrees of pelvic distortion. Surgeon shouldhave the flexibility to change the course of surgery when aparticular pathway proves too risky. He should have a realisticexpectation that the operation will be difficult and fraught withhazards and patience to take things as slowly as necessary.Laparoscopic hysterectomy is now performed for severe pelvicadhesions or severe endometriosis as the surgical techniqueshave improved and surgeons have gained more experience.We describe our experience in performing laparoscopichysterectomy in frozen pelvis due to severe endometriosis orpelvic adhesions. It includes some cases where a previouslaparotomy has failed.

Causes for frozen pelvisThe common causes of extensive pelvic disease leading

to frozen pelvis:

Infection. Adhesions and fibrosis secondary to infectiousprocesses such as salpingitis, tubo-ovarian abscess, infectedpelvic hematoma, and ruptured appendix can create severepelvic adhesions. Abdominal Kochs can cause extensive Pelvicadhesions.

Surgery. The type of surgery a patient has undergone mayprovide important clues to potential problems. Laparotomymyomectomies and surgery for endometriosis can also causegross adhesions. Residual ovaries and remnant ovaries afterabdominal hysterectomy may require extensive dissection ofthe ureter and bowel.

Benign and malignant growths. Severe endometriosis canlead to a frozen pelvis. Malignant growths of the adnexa, suchas ovarian carcinoma, can necessitiate en bloc resection ofportions of the gastrointestinal tract along with the tumor.

Radiation therapy. When a woman has undergone radiation,pelvic structures are commonly adherent to the uterus and eachother, making hysterectomy a challenge. The intestinal andurinary tracts also must be handled with great care. Even a smalldegree of intraoperative trauma to these structures can lead topostoperative complications including fistula formation.

Patient evaluationThe potential for a frozen pelvis, as well as its causes, can

usually be identified by taking a careful history and documentingprevious surgeries or pelvic problems .When evaluating a patient,it is important to determine which of above etiological conditionsexist. The physical examination also can be revealing. The typeof laparotomy scars and drain sites will give a clue to the difficultyof the previous surgery. Be alert for any anatomic changesapparent at the pelvic examination, which should include arectovaginal assessment. If a lesion is palpated, attempt to defineits size and determine whether it is fixed or mobile. Also ascertainwhether the cul-de-sac is free, the uterus can be lifted out of thepelvis, and the disease process is predominantly uterine,adnexal, or involves adjacent organs.

Preoperative transvaginal sonography will be of immensevalue2. Magnetic resonance imaging may be worthwhile in somecases. It is particularly important to learn preoperatively whetherthere is hydronephrosis and involvement of the ureters.

Other diagnostic steps, such as cystoscopy andsigmoidoscopy, can be performed at the time of diagnosticlaparoscopy or postponed until the actual surgery.

Preparation for surgeryGive the patient as much information as possible about

potential problems with pelvic structures such as the ureters,bowel, and bladder. Also advise her that other surgeons may becalled in to assist or to help repair damage to surroundingstructures.

In anticipation of possible enterolysis or intestinal tractsurgery, all patients should undergo preoperative bowel

Dr Paul P.G,Paul’s Hospital, Kochi, Kerala

LAPAROSCOPIC

HYSTERECTOMY

IN

FROZEN PELVIS

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preparation.Plan for an intraoperative ureteral catheterization if gross

pelvic side wall pathologies like severe endometriosis isdiagnosed. The use of catheters helps the surgeon to identifythe ureters intraoperatively and may therefore prevent their injury.

Postoperative wound infections and deep venousthrombosis, with the potential for life-threatening pulmonaryembolization, are both significantly increased in patients whoundergo pelvic surgery. The prophylactic use of antibiotics andlow-molecular-weight heparin is recommended3,4,5.

Surgical techniqueAbdominal entryThe most important step of the surgery is the abdominal

entry. We create pneumoperitonum with a Veress needle at thePalmers point. The primary trocar entry is with a Ternamianendotip at the umbilicus , Palmer’s point or 5 cm above thepelvic mass.

Omental and bowel adhesiolysisAfter entering the abdomen, identify pelvic structures and

their location in relation to one another. Omental adhesions toparietal peritoneum are very common. Omental adhesions toparietal peritoneum are released with scissors, unipolar hookelectrode or harmonic scalpel. A combination of blunt and sharpdissection is necessary in dense adhesions to visualize thepresence of intestine behind the omental adhesions

Bowel adhesiolysis is difficult if there is no space betweenthe peritoneum and bowel.Dissection is done with hook electrode, scissors or harmonic scalpel in this situation. A combination ofsharp and blunt dissection can make a space between thebowel and abdominal wall. Cutting close to peritoneum is safer.

Identify landmarksAfter omental or intestinal adhesions have been separated,

move the small and large intestines from the pelvis. Uterinemanipulation with a suitable manipulator will allow the surgeonto identify the pelvic structures more clearly. We use a ClermontFerrand uterine manipulator (Karl Storz)for hysterectomies. Thenidentify the following pelvic structures: uterine fundus, roundligaments, infundibulopelvic (IP) ligaments, posterior cul-de-sac,anterior cul-de-sac, prevesical peritoneum, and pelvic brim.These structures may be difficult to recognize and to mobilizebecause of fibrosis and adhesions in frozen pelvis.

Entry into the retroperitoneumOnce the pelvic structures have identified, determine how

you will be entering the retroperitoneum. This decision isimportant because the blood supply to the uterus and adnexalies in the retroperitoneum, as do the ureters, which must beidentified and kept under direct vision during coagulation anddivision of the IP ligaments and dissection of the peritoneumaround the uterus.

Retroperitoneal entry and elaboration of the retroperitoneal

spaces are keys to the safe performance of a difficulthysterectomy or removal of retained adnexa in a patient with afrozen pelvis. The retroperitoneal approach makes it possibleto reach around structures that are fixed in the pelvis, to identifythe blood supply and other vital structures, and to proceed safely.Several entry sites are possible. In the frozen pelvis, the roundligament is the ideal location. Identify and divide this ligamentas it enters the internal ring, and incise the peritoneum cephaladalong the course of the IP ligaments.

Adnexal mobilization and division of infundibulopelvicligament

In severe endometriosis, the adnexa are released from thepelvic side wall with blunt and sharp dissection. Dissection startsfrom a normal area of pelvis and adnexal is released from thepelvic side wall by sharp and blunt dissection. The ureter isidentified on both sides before coagulating the IP ligament. Thistechnique is possible in a good number of cases.

Ureter identificationNever assume the position of the ureter without confirming

it; a major deviation of its course can occur secondary topathologic processes in the pelvis. The ureter can be identifiedby direct visualization, peristalsis, and palpation with a probe.Near the level of the pelvic brim on the left side of the body, theureter will be closer to the IP ligament than it is on the right side,due to the location of the sigmoid colon and its mesentery onthe left side, which elevate the ureter in the ventral direction.

Rarely an illuminated ureteric catheter is placed if ureterscannot be clearly identified. Ureteric cathetrisation can be donewith an operating hysteroscope with little training. The illuminatedureteric catheter can be visualized laparoscopically by reducingthe laparoscopic light . It also make the ureters rigid for palpationand dissection

Bladder separationA history of surgery in the area of the bladder, such as

cesarean section or bladder advancement with uterinesuspension, may leave the bladder adherent to or hard toseparate from the cervix and vagina. Normally, the vesicouterineperitoneum is flexible, mobile, and easy to free from the cervixand vagina. A history of disease processes such asendometriosis, infection, or tumors makes this dissection difficult,with a real risk of inadvertent cystotomy.

One technique to make this dissection easier and safer is toenter the retroperitoneum laterally near the round ligament. Inthis location, the bladder may not have been involved in theprior dissection, and the tissue may be more areolar and lessdense than it is in the midline. Bladder is then separated fromthe cervix by a hook electrode or harmonic scalpel, remainingclose to cervix. Fornix bulger of uterine manipulator can help indeciding the limit of bladder dissection. Very rarely filling thebladder with 200 cc of saline can help in identifying the bladderlimit .

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Coagulation and division of uterine vesselsOnce the bladder separation is done , uterine vessels are

identified at the isthmus and skeletonised. The vessels arecoagulated with bipolar forceps and divided. Since the uretersis already identified, this step of laparoscopic hysterectomy issimilar to any other hysterectomy.

Cul-de-sac obliterationIn pelvis, the posterior cul-de-sac is bounded laterally by the

uterosacral ligaments, posteriorly by the rectum and sacrum,and caudally by the vagina—but these relationships are usuallylost in the frozen pelvis. Extensive inflammatory disease, tumorsof the tubes and ovaries, extensive pelvic endometriosis, andprior infection due to a ruptured appendix can obscure the normalconfines of the cul-de-sac. Freeing the peritoneal attachmentsboth anteriorly and posteriorly, as well as at the sides of thepelvis, allow elevation of the uterus with the manipulator . Thenthe ureter, uterine vasculature, and supporting ligaments canbe identified. Dissection becomes simpler after this point.

However, when the rectum is densely adherent, as they oftenare in the frozen pelvis, dissection can become difficult, with areal danger of rectal perforation. A basic principle in anyhysterectomy is to remain close to the uterus, staying near theposterior surface of the uterus and cervix using both blunt andsharp dissection. This eventually makes it possible to find areasonable plane to enter the rectovaginal space at the superiorportion of the cul-de-sac between the uterosacral ligaments. Thetissue below this level is not usually involved in the frozen pelvisand will give way readily once the uterosacral ligaments aredivided. It is unnecessary to operate beyond this level to anygreat extent because the surgery already extends distal to thecervicovaginal junction.

In some circumstances, it may be necessary to open thevagina anteriorly to define the relationship between the posteriorcervix and adherent bowel. The hysterectomy is completed in aretrograde fashion. The adherent rectum is then separated fromthe uterus by sharp dissection in small steps .

Vaginal closure and hemostasisVagina is now closed laparoscopically after removing the

specimen vaginally. The vaginal angle sutures incorporates theuterosacral and cardinal ligaments for vault support (Fig.12)Peritoneal cavity is lavaged with saline and complete hemostasisis ensured. A drain is kept in the pelvis overnight.

Identifying bowel injuryIf rectal injury is suspected, insufflate the submersed

rectosigmoid with air . Bubbles signal a breach in the integrity ofthe bowel wall. If the bowel has been prepped, and rectalenterotomy occurs during dissection, closure and drainage arethe only necessary steps.

CystoscopyCystoscopy is performed to look for any bladder injury and

see the urine reflux from both ureteric orifices.ResultsWe describe our experience in performing laparoscopic

hysterectomy in frozen pelvis due to severe endometriosis orpelvic adhesions. There were 16 cases and all had history ofprevious surgery for endometriosis. 4 patients had twolaparotomies, 8 had one Laparotomy, 1 had three laparoscopicsurgeries, 4 had two laparoscopic surgeries, 5 had onelaparoscopic surgery. It includes 4 cases where a previouslaparotomy had failed to complete hysterectomy. All had frozenpelvis and endometriosis with or without adenomyosis.Laparoscopic adhesiolysis with total laparoscopic hysterectomywith bilateral/ unilateral salpingo-oophorectomy was done forall. One patient the biopsy report was well differentiatedadenocarcinoma of the tubal stump. Average duration of surgerywas 2 hours 30 minutes. Blood loss was less than 500 ml. Noblood transfusion was given for any patient. There was no bowelor bladder injury in this series. Postoperative hospital stay was2-3 days. 3 patients had postoperative fever which was treatedwith antibiotics.

ConclusionHysterectomy in frozen pelvis is a difficult surgical procedure

whether done by open or laparoscopic route. A good preoperativeevaluation and planning helps the surgeon to prepare for adifficult hysterectomy and organize intraoperative urological orgastrointestinal surgical consultation. Surgical technique has tobe modified for a particular case and surgeon should be preparedto change the course of surgery. It is possible and safe to performtotal laparoscopic hysterectomy in cases of frozen pelvis byexperienced surgeons.

Reference1. Donald P. Goldstein, Michael J. Callahan. Surgical

strategies to untangle a frozen pelvis. OBG management2007; 19:No. 03

2. Brosens I, Puttemans P, Campo R, Gordts S, Brosens J.Non-invasive methods of diagnosis of endometriosis. CurrOpin Obstet Gynecol 2003;15:519–22

3. Polk HC Jr. Continuing refinements in surgical antibioticprophylaxis. Arch Surg. 2005;140:1066–1067

4. Fejgin MD, Lourwood DL. Low-molecular-weight heparinsand their use in obstetrics and gynecology. Obstet GynecolSurv. 1994;49:424–426.

5. Löfgren M. Postoperative infections and antibioticprophylaxis for hysterectomy in Sweden: a study by theSwedish National Register for Gynecologic Surgery. ActaObstet Gynecol Scand 2004; 83(12): 1202-7

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