1. Antepartum Hemorrhage: An Uncommon
Apoorva Reddy, Poonam Yadav, Indu Chawla, Renuka Malik

Cervical varices are a very uncommon cause of antepartum hemorrhage. There are only 10 cases reported in literature so far. We present one such case of a 24 year old G3P1L1A1 who presented at 36+4 weeks of gestation with painless unprovoked bleeding per vaginum. This was her 1st episode. On examination her vitals were stable. The uterus was not tense or tender and corresponded to her period of gestation. There were no palpable uterine contractions. An USG done in emergency showed that the placenta was not low lying and there was no retroplacental clot. Per speculum examination done a day after stoppage of bleeding, revealed a bunch of large varicosities present on the posterior lip of the cervix. There were no vulval or vaginal varicosities. On withdrawing the speculum, profuse bleeding per vaginum was seen. The vagina was tightly packed and patient shifted for emergency cesarean section. There were no varicosities present on the lower uterine segment and the placenta was found to be postero- lateral and low lying. Although the uterus was well contracted and complete hemostasis was achieved, patient continued to have significant fresh bleeding per vaginum. Vaginal packing was done. Patient received 2 units of blood transfusion in her perioperative period. Pack was removed after 24 hours and no vaginal bleeding was noted. She was discharged on postoperative day 7.A per speculum examination done 2 weeks later revealed a healthy cervix with no varicosities seen on it.

2. Early Onset Idiopathic Polyhydramnios: A Diagnostic Dilemma
Pushpa Singh, Veena Ganju Malla, Upma Saxena, Sumitra Bachani, Aparna Tiwari

Mrs. X 29 years old Muslim female, G2P1L0 with previous caesarian section presented at 22 weeks with unexplained hydramnios. Her previous pregnancy one year back was also complicated by early onset hydramnios and preeclampsia and was terminated at 30 weeks, by emergency LSCS, done in view of Abruptio placenta with fetal distress. Structurally normal baby was born who died soon after birth. The present pregnancy antenatal course was complicated by rapid progression of hydramnios and she was managed by indomethacin therapy till 31 weeks. At 34 weeks elective LSCS was done in view of previous preterm LSCS with gross hydramnios with precious pregnancy.

Preterm alive structurally normal female baby was born who became sick on third day of life. After extensive investigations provisional diagnosis of Antenatal Bartter syndrome was considered, which was later confirmed by increased aldosterone level.

Bartter syndrome is a rare group of Autosomal recessive disorder characterized by hypokalemia, hypochloremia, hypercalciuria, metabolic alkalosis and normal to low blood pressure despite increased rennin activity. Antenatal variant is the most severe form of Bartter syndrome, and starts manifesting in early pregnancy. Mutation in the genome leads to decreased sodium and chloride reabsorption in the thick ascending limb of loop of Henle, which cause major polyuria in the fetus and is manifested as gross hydramnios in the mother.

Incidence of Bartter syndrome is 1.2 per million population, and very few cases have been reported from India. Prenatal diagnosis is not yet established, although some studies have reported role of Amniotic fluid biochemistry in the prenatal diagnosis. Definitive diagnosis is possible only by the mutational analysis of the genomic DNA by amniocentesis, but the required genetic probe is not available in India. Prenatal management with indomethacin has shown promising results.

3. Myasthenia Gravis in Pregnancy
Bharti Uppal Nayyar, Bani Sarkar, Bangali Majhi, Alka Goel, Ajeet Sharma

A 23yr./F, G1P0A0, and a diagnosed case of Myasthenia Gravis (undergone Thymectomy in 2008 & now on Tab. Pyridostigmine), presented on 23/06/2011 in emergency with amenorrhoea-6½ months, pedal oedema-1 month & headache-1 day. Her LMP was on 01st Dec.,2010. She was unbooked, 1st visit- two wks. back (POG 27w+1d) when she was adv. admission for high B.P. (140/90mm Hg). Conscious, oriented, PR 92/m, BP 160/110 mmHg,

RR 22/min, Pallor +, Pedal oedema ++, P/A 28 wks sized uterus, relaxed, cephalic, liq.adeq, FHS+Reg. P/V/E- not in labour. She was admitted with diagnosis of Preeclamptic toxaemia with Myasthenia Gravis at 29w+1d gestation. Hgm.9g%/23,000/P84L11E4M1/P.C:1.6 lac; LFT 1.2/0.6/0.6/106/104/153; Urine alb. 2+. Was started on Inj. Dilantin, Tb. Labetalol & broad spectrum anti-biotics, Pyridostigmine continued & closely monitored in ward. Ultrasound- SLIUF, cephalic, 26w+6d, EFW-995 gms., AFI (N), Placenta fundo-anterior, homogenous. Obstetric doppler (N). B.P. stabilized; but after one week, B.P. started increasing & biochem. markers pointing towards HELLP Syndrome. So, Emergency LSCS done under GA on 30th June, 2011 (POG 30w+1d). An alive male baby weighing 1.08kg. delivered. Recd. NTG drip, KCl infusion, 4 Platelet concetrates, 2 FFP, 1 Packed cells. Shifted on ventilator to ICU, weaned & put on CPAP. 8 hrs. after surgery, threw a convulsion at B.P. 190/120 m.m. Hg controlled by i.v. Thiopentone & inj. Dilantin. Remained stable for next 3 days. Later B.P. started rising again; so, Amlodipine, Clonidine, Spironolactone were added & Labetalol tapered. Later had high fever with chills, put on appropriate anti-biotics & anti-malarials. Discharged on day26 with advice to follow up & continue with neurological medication. Myasthenia Gravis- serious muscle weakness with incidence from 3–30 cases per million per year & 1 in 20,000 pregnancies. Below 40 yrs., 3 times common in women; at older ages, both sexes equally affected. Autoimmune neuromuscular disease in which circulating antibodies block Ach Rec. at the post-synaptic NMJ, inhibiting excitatory effects of ACh on nAChR throughout NMJs. Worsening in 19% of which 60% occur in 1st trimester, 28% immediate post partum. MgSO4, Aminoglycosides, Tetracycline group, b-adrenergic agents, Chloroquine contra-indicated.