KERALA FEDERATION OF OBSTETRICS AND GYNAECOLOGY

Vol: 3 No: 1

June 2009

As I asumed the office of the President of Kerala Federation of Obstetrics &

Gynaecology, I am reminded of the immense responsibility that goes with the
post. As a Federation we will have to keep pace with the rest of the world in every
field of obstetrics and gynaecology, while understanding the limitations placed on
us due to various economic and social problems that are unique to our country.
To improve our understanding of various problems we have also formed
different subcommittees in newer fields in addition to the existing committees. It is imperative that
we 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 in
terms of academics and professional yard sticks.
Dr. N.S. Sreedevi

Dr. Fessy Louis T.

Editor KFOG Journal
CIMAR, Edappal Hospital, Edappal, Kerala-679 576
Mob: 09846055224 E-mail: fessylouis@gmail.com
Design : Smriti, Thrissur, Printing: Anaswara, Cochin

2
7

Dr. Fessy Louis T

CRITICAL CARE IN OBSTETRICS

Dr Pankaj Desai

ICOG GUIDELINES FOR MANAGEMENT OF ECLAMPSIA

8
13

Dr Uday Thanawala
AKCOG CALICUT PHOTOS

LAPAROSCOPIC HYSTERECTOMY IN FROZEN PELVIS

Dr Paul P.G

www. kfogkerala.org

KFOG

Address of Correspondence

Dear colleagues,
During 2009-2010, we are planning to bring
out three issues of KFOG Journal. Members can
contribute interesting and clinically relevant
short articles. Societies can contribute photos of
their social activities to be included in the KFOG images page.
We are trying to make the journal more & more reader centric
by offering the readers valuable new informations to help them
provide better patient care. However it is important to read them
critically.
I hope by this time you must have got the KFOG directory. If
you have not received the same, please write to me. Also log on
to our website www.kfogkerala.org to know the updates of KFOG
activities and conferences.

CONTENTS

President
Dr. Sreedevi.N.S
Secretary General
Dr .Jayandhi Raghavan T
Immediate Past President
Dr.Girija Gurudas
President Elect
Dr.Narayanan.T
Vice President
Dr.Abdulla.B
Vice President Elect
Dr. Vinayachandran. S
Joint Secretary
Dr. Sangeetha Menon
Treasurer
Dr.Rajalakshmi Janardhanan
Journal Editor
Dr. Fessy Louis .T
Chair, Maternal & Foetal Medicine Committee
Prof. V. P. Paily
Chair, Academic Committee
Dr. V. Rajasekharan Nair.V
Chair, Adoloscent Committee
Dr.V.K.Chellamma
Chair, Reproductive Health Committee
Dr .K .K . Gopinathan
Chair,Oncology Committee
Dr.Sumangala Devi
Chair, Research Committee
Dr. P.K.Sekharan

CRITICAL CARE
IN OBSTETRICS

DR. PANKAJ D. DESAI

Past FOGSI President

KFOG

INTRODUCTION:
A critically ill obstetric patient is one who, because of
abnormal pregnancy, delivery and puerperium or because of
effects of pre-existing systemic disease, anesthesia and surgery
and other acquired condition on a normal pregnancy, delivery
or in puerperium develops complications threatening her life for
which she needs intensive monitoring, therapy and/or life support
system. In another definition these are defined as maternal nearmiss mortality, as those women requiring critical care or transfer
to an intensive care unit. Because maternal deaths are rare in
developed countries, it has been suggested that a more accurate
measure of the standard of maternal care is to study the nearmiss 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 without
transfer.
3. Conditions requiring intensive care may not necessarily
mirror causes of maternal mortality e.g. maternal mortality
for PPH is lower than for amniotic fluid embolism.
Vaginal delivery following labour may be the shortest but
most hazardous journey made by any individual. Hypoxia,
trauma and infection are inherent risks. The mother faces the
brunt 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 losing
her life/or that of the newborn. The art of intrapartum care now,

is evidence based. Medline literature review between 1987-94

revealed that the percentage of obstetric patients requiring
intensive care is 0.1- 0.3
So a team consisting of obstetricians, anesthetist and an
internist is required for management of labor in a critically ill
patient. Trained nursing staff and neonatologists will complete
the list of required personnel.
Hemorrhage, hypertensives disorders, cardiac disease,
and sepsis are some of the common problems threatening life
during labor. Severe anemia and jaundice in pregnancy are two
important causes of maternal mortality in our country especially
in 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 support
d. 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 and
consumption, and pharmacological support with an arrhythmic
inotropic, vasodilators and alpha blocking drugs. Examples of
new equipments are intra-arterial BP monitors, pulse oximeters,
pulmonary artery catheters (PAC), continuous mixed venous
oxygen saturation monitors, intracranial pressure monitors,
ventilators, computerized tomographic (CT) scanners, USG
machines, echocardiography, machine bronchoscopes and other
endoscopy equipments. Emergency equipments include
defibrillators, suction machine, ECG, portable fetal monitors, etc.
In addition to routine, the ability to insert radial and pulmonary
artery catheters, perform endotracheal intubations, manage a
ventilator, direct cardio-pulmonary resuscitation and perform
cesarean hysterectomy or bilateral hypo-gastric artery ligation
are also a part of critical management in obstetrics.
PRINCIPLES OF MANAGEMENT:
1. Clinical monitoring
2. Respiratory support
3. Cardiovascular support
4. Correction of cause
Clinical Monitoring:

Mental status

Pulse

Respiration

Temperature

Skin color

Capillary refill

Sweating
Urine volume
Because of increased blood volume in pregnancy,
hemodynamic instability indicating need for transfusion may not
occur 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 between
high and low flow states (TABLE 1).
Table1
Assessment of the state of perfusion
Manifestation
Low flow state
Mental status
Low
Urine output
Low
Capillary refill
Low
Extremities
Cold
Manual blood pressure Low
Pulse pressure
Low
Lactate
Low

High flow State

Low
Low
Normal
Warm
Low
Normal or low
Low

Inadequate circulating volume or pump dysfunction or

both causes low flow states; High hypo-perfusion is typical of
septic shock, liver disorders, etc.
INVASIVE HEMODYNAMIC MONITORING:
Intra-arterial BP : Per cutaneous placement of intra-arterial
canula allows continuous monitoring and repeated samplings
of blood for gas and acid base analysis. This is essential when
rapid hemodynamic changes are anticipated, e.g. when
administering inotropic / vasoactive drugs.
CVP is a simple method for assessing circulating volume
and filling status of right heart chambers. However the absolute
value is often unhelpful except in extreme cases of hypervolemia,
fluid overload or heart failure. Correct interpretation requires
assessment of changes in CVP. CVP does not accurately reflect
left ventricular filling in patients with preeclampsia, pulmonary
and cardiac disease. In these situations, utilizing a pulmonary
artery catheter is helpful in determining relative volume status.
Pulmonary artery catheterization: The Swan-Ganz
pulmonary artery catheter introduced in 1970 has given an
identity to the practice of critical care medicine. Continuous
central venous and pulmonary artery pressures and intermittent
capillary wedge pressure (PCWP) measurements are obtained.
Cardiac output can be measured by thermo-dilution technique.

As with CVP correct interpretation requires assessment of

changes in response to treatment together with alterations in
clinical signs and other monitored variables. Because of lack of
correlation between measurements on the right and left sides
of the heart in patients with significant cardiopulmonary disease,
PCWP is monitored to optimize ventricular preload to avoid
pulmonary edema.
Thus, in critically ill obstetric patients, discrepancies are often,
seen between measurements, of PCWP and CVP. In such
situations clinical use of CVP alone would be deleterious. With
rare exception, the complications seen with pulmonary artery
catheterization associated with obtaining central venous access
are similar whether a CVP line or pulmonary artery catheter is
used. For these reasons, in modern perinatal intensive care unit,
CVP monitoring alone is seldom indicated.
Indications for Pulmonary Artery Catheterization
1. Refractory/unexplained pulmonary edema and heart failure
2. 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. ARDS
6. 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 with
one of these conditions, nor is this an all-inclusive list. Invasive
monitoring has its own hazards. Therefore it is recommended
only in patients where precise hemodynamic data can improve
decision making and where better interventions are possible.
Pulmonary edema: Swan-Ganz catheter is used to measure
pulmonary capillary wedge pressure to differentiate cardiogenic
from non-cardiogenic pulmonary edema: cardiogenic pulmonary
edema results from increased hydrostatic pressure within
pulmonary capillaries whereas non-cardiogenic pulmonary
edema 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 are
required, invasive monitoring is helpful.
Oliguria:
To assess volume status in hypertensives disorders, CVP is
a poor guide. PAC better guides changes in wedge pressure
and cardiac output in response to fluid challenge.

KFOG

In Hemorrhagic Shock:
Clinical parameters like pulse, BP, urine output, respiration
and temperature are commonly utilized. Invasive technique
measurements are useful in some cases. An arterial canula also
allows frequent measurement of blood gases and acid-base
state. In patients deteriorating after initial response a pulmonary
catheter may be useful. After initial resuscitation during
subsequent 24 to 48 hrs, the catheter may guide fluid therapy in
complex cases in which it is not clear whether internal bleeding
is 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. Assessment
of response to therapy may be done through parameters such
as oxygen delivery (DO2) and oxygen consumption (VO2), (DO2cardiac output X arterial oxygen content). Oxygen consumption
increases many folds in critically ill patients with multi-organ
dysfunction.
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 changes
in treatment. Nevertheless, its influence on outcome remains
uncertain, in obstetrics. Some studies have suggested that the
use of catheters may be associated with a worse outcome. Large
prospective randomized trials would be needed for a final answer
in obstetric patients.

KFOG

RESPIRATORY SUPPORT:
The first priority is to secure the airway and if necessary
provide mechanical ventilation. Because mechanical ventilation
minimizes the work of breathing reduces oxygen consumption
and improves oxygenation, early respiratory support benefits
patients with severe shock and mechanical ventilation. These
patients 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 arterial
CO2 partial pressure (PaCO2) = 50 mm. The blood gas analysis
reveals what the patient is accomplishing. It does not reveal
how hard she is working to do it. If the patient is severely
dyspneic, restless, confused and fatigued, it may be wise to
intubate her prophylactically.
The art of fluid administration and hemodynamic support is
one of the most challenging aspects of treating critically ill
patients.
Determinants of Cardiac Output:
Circulatory support involves manipulation of the three
determinants of stroke volumes (preload, myocardial contractility
and after load) as well as heart rate.
Preload optimization is the most efficient way of increasing
cardiac output and is a pre-requisite for restoring tissue perfusion.
Controversy continues about whether colloids or crystalloid are
preferable. Data from 19 randomized trials involving a total of
1315 patients indicate that albumin and non-albumin colloids
increased absolute of death by 4 percent.
HYPOVOLEMIC SHOCK:
Important pathophysiology in hypovolemic shock includes
sodium and water entry into skeletal muscles and cellular
potassium lost to extra cellular fluid. Replacement of extra cellular
fluid is important. Indeed, survival appears to be reduced in acute
hemorrhagic shock when blood alone compared with blood and
lactated Ringer solution is administered.
Initial fluid infusion should involve about 3 times as much
crystalloid as the estimated blood loss. Establish intravenous
access with two wide bore drip sets. In most cases red cell
replacement proves sufficient. The exception is the women with
torrential bleeding.
The use transfusion in critically ill patients varies widely with
different Hb, thresholds being between 7 to 12 gm/dl. The
optimal transfusion practice for various types of critically ill patients
with anemia has not been established. A restrictive strategy of
red blood cell transfusion is at least as effective and possibly
superior to a liberal transfusion policy. Transfusion in young
patients seems prudent when Hb falls below 7 gm/dl.
If signs of shock persist despite volume replacement and
perfusion of vital organs is jeopardized, ionotropic or other

may be responsible for sudden CCF. A central venous pressure

monitor should maintain close watch particularly during labor in
cases of severe hypertension, valvular disease, severe anemia
and chronic obstructive respiratory disease. If the CVP rises
above 10 cm of H2 O then rapid Frusemide injection 40 mgms
I.V. should be given with a close watch on urinary output which
should be optimally 0.5 ml/kg/hour. During labor with each uterine
contraction the systolic BP may be raised by about 30mm Hg
and diastolic B.P. may go up by 10 to 15 mm of Hg. This
phenomenon may be responsible for acute pulmonary edema,
which should be carefully monitored by CVP, serial chest X-ray
and breathlessness.
Third stage of labor: The third stage is the most critical
phase of labor because of: a) massive auto transfusion of 1000
to 1200 ml of blood and (b) shift of extra vascular space fluid
into vascular compartment thereby temporarily raising the blood
volume acutely.
A close watch therefore should be kept on the
cardiovascular system specially by observing the following

Table 2:
Homodynamic therapy for contractility preload and after load
Contractility Pre load Contractility After load
Vasoactive drugs
Crystalloid
Volume expansion
Dopamine
Colloid
Ionotropic support
Dobutamine
Blood
Vasopressors, Phenylnephrine Epinephrine, Calcium
Norepinephrine
Digitalis, Materaminol
Diuretics
Nifedipine
Frusemide
Hydralazine
Mannitol
Labetalol
Venodilators
Mixed Arth-Vn dilator
Orsemide
Nitroprusside
Nitroglycerine
Venous dilator, Nitroglycerine
(Low dose)
(high doses)
Morphine

Having outlined the general concepts of care of the critically

ill the following points are highlighted especially for the
intrapartum 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 pregnancy
operates during labor also. During labor, uterine contractions
increase CVP, which increases dramatically during the efforts
of second stage. The CVP also increases by I.V. ergometrine
injection.
Soon after delivery there is a sudden rise in the right-sided
venous return, which may alarmingly raise the preload, and this

parameters.
Position of patient: supine hypertension
should be avoided by keeping the
patient in the lateral position in between
contractions.
The patients should be propped up if
there are early suggestions of
pulmonary edema.
Oxygen inhalation particularly in cases
of severe anemia, cardiac disease and
pulmonary obstructive disease should
be maintained.
Pulse oximetry indicating oxygen
saturation should be instituted
compulsorily during labor.
Endotracheal intubations and

controlled ventilation should start ventilatory procedures for

pulmonary edema during labor.
Close watch should be kept on blood loss in third stage, which
even in small amounts of 300 ml may precipitate disaster, in
anemia or hypertensives patients.
If oxytocics are necessary oxytocin drip should be
undertaken.
Antibiotics like cephalosporins should be recommended.
Analgesia: spinal or epidural analgesia must compulsorily
be preceded by volume expansion especially in severe
preeclampsia.

KFOG

vasoactive agents may be given to improve cardiac output and

blood pressure.
Commonly used vasoactive drugs are as follows (Table 2).
1. Dopamine: Acts on both and receptors depending on
dose. Ionotropic vasoconstrictor widely used in cardiogenic
and septic shock, first few hours of oliguria / renal failure.
2. Dobutamine: Ionotropic vasodilator, used in heart failure.
In low doses, it predominantly acts on 1 receptors: in high
doses acts on 2 receptors.
3. Norepinephrine: 60% and 40 % alpha agonist effect:
Vasoconstrictor for life threatening hypertension
(hypovolemic and septic shock) along with fluid
resuscitation.
4. Sodium Nitroprusside: Equal arterial and venous dilator
used in acute hypertensives emergency. Fetal cyanide
toxicity is possible.
5. Nitroglycerine vasodilators: In low dose, it is
predominantly causes arterial dilation. It may be used in
hypertensions and carcinogenic pulmonary edema.

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 uterine
venous blood will be lowered by any disease that diminish or
transport.
In the anemic gravid, the oxygen carrying capacity of her
blood is diminished. Also maternal acidosis and fever shift the
hemoglobin saturation curve to the right and lower the oxygen
carrying capacity. Treatment should aim to increase oxygen
carrying capacity of maternal blood by replenishing red blood
cells, to maintain intra vascular volume and to correct metabolic
derangements.
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 effects
for fetus. The oxygenation of critically ill patients is often
monitored with pulse oximetry. Although O2 saturation values of
85 to 90 percent may be adequate to provide for maternal
physiological needs an O2 saturation of 95 percent is essential
for adequate fetal oxygenation. Because oxygenation depends

u
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Di

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K

KFOG

on flow, it should be maximized by avoiding supine position and

maintaining intravascular volume should maximize it. The fetal
well-being may be compromised by maternal compensatory
mechanisms, which act to preserve maternal BP at the expense
of uterine blood flow. Fetal heart rate patterns may give warning
signal even when the maternal status is apparently nearly stable.
Continuous electronic fetal heart rate monitoring is an important
part of the care of the critically ill and unstable pregnant patients
even in a medical or surgical intensive care setting. It goes
without saying that there should be adequate provision for
neonatal resuscitation.
CONCLUSION:
In conclusion the critically ill women in labor presents a
unique challenge to the obstetrician. The patients disease, as
well as any potential therapy simultaneously affects two
individuals with vastly different physiology. Such patients
represent the only areas of medicine in which the potential
mortality (or salvage) is 200 percent. The recent surge in critical
care obstetrics is therefore gratifying

Microwave was an accidental

discovery by Dr. Percy Spensor in 1946.
During a radar related research project
he was testing a new vacuum tube
called a magnetron, When he
discovered that the candy bar in his
pocket had melted. This intrigued Dr.
spencer, so he tried another
experiment. This time he placed some
popcorn kernels near the tube,he
watched with an inventive sparkle in his
eye as the popcorn sputtered, cracked
and popped all over his lab.
He fashioned a metel box, with an
opening into which he fed microwave

power. The energy entering the

box was unable to escape,
thereby creating a higher
density electromagnetic field.
When food was placed in the
box and microwave energy fed
in the temperature of the food
rose very rapidly. This
revoltionized cooking, the
microwave oven.

ICOG GUIDELINES FOR

MANAGEMENT OF
ECLAMPSIA
Dr Uday Thanawala
Chairperson, 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

Introduction Eclampsia is a serious complication of pregnancy. Defined

as onset of tonic and clonic convulsions in a pregnant woman
with preeclampsia ( BP more than 140/90, edema, and
protienuria ). The pathophysiology of eclampsia is thought to
involve cerebral vasospasm leading to ischemia, disruption of
the blood brain barrier and cerebral edema.
1. Background
1a 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 immediate
pre and post delivery interval in order to improve the outcome
for the mother and child.
Context:
1a Eclapmsia is a sequele to severe preeclampsia and thus
management should be ideally directed to early detection
of pre-eclampsia and to treat in an attempt to achieve fetal
maturity and prevent maternal complications like cclampsia.
Thus antenatal care and management has a huge role to
play in bringing down the incidence of Ecclampsia.
1b The incidence in our country varies from 1-5% (personal
communication from different regions). More than half the
cases are antepartum ,and approximately 20% of the cases
occurred post partum. Maternal Mortality is 4 -6 % and the
perinatal loss is a whopping 45%! Possibly the incidence is
lower in booked cases verses unbooked cases.
The developed world has a much lower rate of this
complication - incidence in UK 4.9/10,000 with a case
fatality rate of 1.4%.(8)
1c According to RCOG Guidelines even in UK the Confidential
Inquiries into maternal Deaths persistently show a
substandard care in a significant percentage of the death.(1)

In India , where the antenatal care is not accessed by all the

number of cases and the severity is probably much worse,
and thus there is an urgent need to standardize the
treatment.
2. MANAGEMENT
2.1 Fogsi recommends that every maternity unit is equipped to
deal with this obstetric emergency and institutes emergency
management 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 availableOxygen. 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 the
patient.
2.1a The patient should be placed in the left lateral position
and the airway secured. Oxygen should be administered.
General measures to prevent patient from falling down or
biting the tongue should be taken. An IV line secured.
Patients vitals are checked, obstetric examination is
performed, fetal status evaluated.
2.1b Drugs are instituted to abort convulsions and bring
down the blood pressure.
2.2 Treatment and prophylaxis of seizures
2.2a The results of the Collaborative Eclampsia Trial show
that women treated with magnesium sulphate have fewer
recurrent seizures compared with women treated with
diazepam or phenytoin.(2)
2.2b FOGSI recommends
A loading dose of Magnesium Sulphate A loading dose of
4g should be given over 5-10 minutes followed by a

KFOG

ICOG Guidelines for Management Of Eclampsia

31st AKCOG (All Kerala Conference Calicut, 2009)

Inauguration by Hon: Health Minister

Smt. 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

Audience

Audience

Release of AKCOG souvienor

Dr. Varghese Memorial oration plaque given to

Prof. Dr. Bhadran

KFOG

KFOG

intramuscular maintenance regime-5g every 4hrly im,

continued for at least 24 hours after the last seizure or
delivery whichever is later.
2.2c Recurrent seizures should be treated by a further
bolus of 2g. (Grade A recommendation) (4) For status
eclampticus 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 minutes
followed by a intramuscular maintenance regime-5g every
4hrly im, continued for at least 24 hours after the last seizure
or delivery whichever is later. Intramuscular injections are
painful and are complicated by local abscess formation in
0.5% of cases.
Intravenous MgSo4- Both 50% and 25% solutions can be
given intravenously. 4 ampoules of 50% soln. amounts to 4
gm which is diluted in distilled water to make it 20 ml and
give it slow IV. At least 5 minutes should be taken to inject 4
gm.
Intramuscular MgSo4 - For IM injection it should be 50%
solution. Still the volume is 10ml (5gm) and should be given
as deep IM injection in the buttocks. Addition of 1 ml of 1%
xylocaine to the solution may help to reduce the pain at the
injection 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 order
to protect the airway and ensure adequate oxygenation.
Further seizures should be managed by intermittent positive
pressure ventilation and muscle relaxation. Also, consider
possibility of cerebrovascular accidents. Too rapid injection
of MgSo4 should not be given in an attempt to abolish a
convulsion rapidly.
2.2d Strict monitoring of vitals is advocated. An indwelling
catheter is important to monitor the urine output. Respiratory
rate and knee jerks with urine output are important
parameters to pick up magnesium toxicity.

KFOG

10

Magnesium toxicity
If available serum levels of Magnesium should be done. The
normal blood levels are 2meq/L , and the therapeutic level to be
achieved is 4meq/L . If the levels reach 10meq/L the platellar
reflex is lost and at 10meq/L ,and at 15meq/L respiratory
depression sets in.
Thus if the intramuscular regime is used, it is important to
ensure that before administration of a repeat dose
1) urine output is > 30ml/hr;
2) patella reflexes are intact
3) 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 hypertension
2.3a Drugs used
Context:
2.3 Reduction of severe hypertension (blood pressure > 160/
110 mm Hg ) is mandatory to reduce the risk of
cerebrovascular accident. Treatment may also reduce the
risk of further seizures. It is important to lower the BP
promptly but gradually. The diastolic BP should be
maintained 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 an
advantage of quicker action by the sublingual route. Nifidipine
can be given intragastric using a Ryles tube. The dose should
not exceed 10 mg at a time and should not be repeated more
frequently than every 30mts. Oral tablet may act within 10 15
mins, slow release tab within 60 mins
Labetalol - a combined alpha and beta adrenergic??? (20mg
IV escalating to 40 or 80mg every 10 minutes to a maximum
cumulative dose of 300mg or Walker : slow IV 50 mg followed
by infusion of 5mg/ ml initiated at 12ml/hrand titrated to to
achieve the desired BP level . lowers BP smoothly but rapidly,
without tachycardia.
Hydralazine - A vasodilator. Preferred antihypertensive for
the treatment of hypertensive crisis of pregnancy.Side effects:
severe headache, tachycardia, anxiety, restlessness, hyperreflexia, abnormal FHS patterns.
Dose- 5mg IV repeated every 20 minutes to a maximum
cumulative dose of 20mg Other rapidly acting agents- nitro
glycerine, diazoxide, and sodium nitroprusside are usually
preserved for use in a ICU setting or in the OT.
2.4 Fluid therapy
Fluids should be restricted to 80ml/hr.or 1mg/kg body weight.
RCOG recommends fluid restriction so as to avoid fluid overload
and pulmonary edema. Close monitoring of fluid intake and urine
output 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 liver
enzymes 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, Platelet
count, transaminases, urea and creatinine, oxygen
saturation
Clotting profile -Clotting studies are not required if the platelet
count is over 100x 109 /l. For places where facilities are not
available a simple clot observation test may give information

and hypoxia corrected, delivery can be expedited. Vaginal

delivery should be considered but caesarean section is likely to
be required in primigravidae remote from term with an
unfavorable cervix. Vaginal prostaglandins increase the success
of induction and augmentation. Hypertension monitoring and
control should continue vigilantly throughout labor.
If the fetus is premature, and convulsions are absent and
maternal health stable - delivery can be delayed. In this time,
corticosteroids should be given and arrangements could be
made to have a proper neonatal setup available,( Maybe by
transferring the patient to a tertiary centre), though after 24 hours
the benefit of continuing the pregnancy should be reassessed.
Less than 26 weeks
Stabilize
terminate pregnancy
26 34 weeks
expectant management corticosteroids; surveillance, deliver for
maternal or fetal
indication more than 34 weeks
stabilize
Deliver The mode of delivery
depends, 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 relief
is desirable.
LSCS is considered for any obstetric indication ; fetal distress,
or if vaginal delivery is unlikely to occur within a reasonable
time frame the first eclamptic fit. If LSCS is decided upon in an
eclamptic case then the next MgSo4 dose (after 4 hours) may
be deferred, since it may increase chances of accentuating the
action of muscle relaxants, and uterine atony.
Choice of Anesthesia would depend upon the condition of
the patient regional is preferred , provided the coagulation
profile is normal. If General anesthesia is recommended one
must remember that laryngeal edema may make intubations
difficult.
The third stage should be managed by either of the following
so as to prevent hemorrhage (but NOT ergometrine, as this
would 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 renal
disease.
ContexAfter delivery, close monitoring should be continued for a
minimum of 24 hours.Since almost 20% of the patients can have
post partum ecclampsia it is important to be vigilant and
continue treatment for first 24- 48 hours. Antihypertensive

11

KFOG

about the clotting profile. Blood withdrawn in a syringe should

clot and retract in mins.
Rising Serum uric acid > 6mg%, denotes fetal jeopardy and
delivery should be expedited.
Cerebral imaging (MRI or CT) may be indicated to exclude
hemorrhage and other serious abnormalities in women with focal
neurological deficits or prolonged coma.(6)
2.6 Monitoring
Vitals- 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 im
for 24hours is recommended).
2.7 Monitoring the fetus
2.7a- Acertain gestational age and fetal well being
2.7 b- If preterm and if delivery can be delayed
administer steroid /transfer to nicu setting to give the
neonate the best chance.
2.7c Deliver for maternal or fetal indication. Maternal
wellbeing gets priority over fetal condition.
Context:
2.7b Prematurity and IUGR are the main contributors to the
high perinatal mortality.Early detection of preeclampsia and
prompt management in the antenatal period is called for having
a good perinatal outcome. Steroid administration in the antenatal
period is recommended. (see prophylactic measures).
2.7c- Once eclampsia has set in one must weigh maternal
well being over fetal well being and take decisions. Gestational
age needs to be ascertained and assessment with a
cardiotocograph may be desirable. If the woman is in labor,
continuous electronic fetal heart rate monitoring is
recommended. In settings where this is not possible regular
auscultation of FHS especially during and after a contraction is
recommended to pick up late decelerations.If conservative
management is planned then assessment of the fetus with
Ultrasound fetal size, amount of liquor and Doppler studies
can be done. Serial assessment can optimize the timing of
delivery.
2.8 Delivery
2.8 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 are
unlikely to be of value. However, it is inappropriate to deliver an
unstable mother even if there is fetal distress. .
Once seizures are controlled, severe hypertension treated,

KFOG

12

treatment can then be gradually tapered off. But these patients

may require anti hypertensive treatment for several weeks.If
hypertension and proteinurea continue for 6 weeks investigate
for renal disease.
3 Prophylactic measures
3.1-Seizure Prophylaxis
3.2 Prematurity and steroid administration
3.3 Future Pregnancies
Contex3.1 Seizure Prophylaxis
Look out for signs of imminent eclampsia in patients with
severe pre-eclampsia .
Symptoms and signs of impending eclampsia
1) severe frontal headache
2) epigastric pain/tenderness
3) nausea/vomiting
4) visual blurring
5) Hyperreflexia/sustained clonus.
Women with severe preeclampsia ( BP 170/110 with
proteinuria) should be given magnesium sulphate once a
delivery decision has been made and in the immediate post
partum period. If given it should be continued 24 hrs after
delivery or 24hrs after the last convulsion, whichever is later.(8)
3.2 Prematurity and steroid administrationIf the delivery can be delayed and the fetus is premature
steroids for lung maturity can be given( 2 doses of 12mgs of
betamethasone 24 hours apart). However with eclamptics so
much time may not be available,- thus it is recommended that
all preeclamptics receive this during antenatal care. For
eclamptics who have not been given steroids earlier even
a single iv dose of steroid 1 hour before delivery is shown
to decrease the incidence of intraventricular hemorrhage
and necrotizing encephalopathy in pretem infants
Future pregnancies
Post partum adviceImportant to counsel the patients the importance of early
registration and regular follow up. Preeclampsia may not
reoccur. Starting low dose aspirin may be worthwhile.
SUMMARY- Eclampsia cases are best managed in special
regional centres equipped with the proper expertise and
equipment and set up ( ICU ) to manage this complication. Early
involvement of consultant obstetric and anaesthetic staff, and
other specialities(hematologist/ ophthalmologist/neonatologist)
is called for. Referral to a regional centre for advice and/or
assistance should be considered in all cases of eclampsia,
particularly where there are maternal complications.
Magnesium sulphate is the anticonvulsant of choice and
consideration should be given to the provision of treatment packs
containing equipment to establish an intravenous infusion,
magnesium sulphate, calcium gluconate and a copy of the
protocol.(7)

Principles of management Immediate Care -maintain

airway, maintain oxygenation, prevent trauma or injuryControl
seizures & Prevent further seizures magnesium sulphate
(other drugs in case of nonavailability of MgSO4- diazepam or
eptoin. Thiopentone reserved for status eclampticus).Control
Hypertension (diastolic between 95 105) NefidipineHaemodynamically
stabilise
the
patient.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 Parameters
used while planning the delivery Gestational AgeSeverity of
Disease: Seizures/ HypertensionImmediate danger to the
mother/ fetus Postpartum intensive care for 24 48 hrs
This guideline was produced under the direction of the
Indian College Of Obstetrics and Gynecology and Federation
of Obstetrics and Gynecological Societies of India as an
educational aid to obstetricians and gynaecologists. This
guideline does not define a standard of care, nor is it intended
to dictate an exclusive course of management. It presents
recognised methods and techniques of clinical practice for
consideration by obstetricians/gynaecologists for
incorporation into their practices. Variations of practice taking
into account the needs of the individual patient, resources
and limitations unique to the institution or type of practice
may be appropriate
REFERENCES
1) Why Mothers Die. Report on Confidential Inquiries into
Maternal Deaths in the United Kingdom 2000-2002. London:
RCOG Press,2004.
2. Eclampsia Trial Collaborative Group. Which anticonvulsant
for women with eclampsia? Evidence from the Collaborative
Eclampsia 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 and
magnesium sulphate on maternal cerebral circulation in
eclampsia using transcranial Doppler ultrasound. Br J Obstet
Gynaecol 1996, 103:111-6.
4) Management of Eclampsia (10) - Jul 1999; Clinical Green
Top Guidelines
5) Douglas K A, Redman C W G. Eclampsia in the United
Kingdom. Br Med J 1994, 309: 1395-1400
6) . Dahmus M A, Barton J R. Sibai B M. Cerebral imaging in
eclampsia: magnetic resonance imaging versus computed
tomography. Am J Obstet Gynecol 1992, 167:935-41.
7) Fathima Paruk, Jack Moodley; Treatment of severe
preeclampsia / eclampsia syndrome. Progress in Obstetrics
and Gynecology,vol 14,2000,103:114.
8) RCOG Guidelines 10;2005.

Dr Paul P.G,
Pauls Hospital, Kochi, Kerala

rozen pelvis refers to the surgical condition where

reproductive organs and adjacent structures are distorted
by extensive adhesive disease and fibrosis, which obscure the
normal anatomic landmarks and surgical planes, making
dissection extremely difficult and increasing the risk of damage
to vital organs1. Hysterectomy in frozen pelvis is a challenging
surgical condition whether done by laparotomy or laparoscopy.
The overall keys to success in such cases depend on the
knowledge in the pelvic anatomy and operative experience
involving varying degrees of pelvic distortion. Surgeon should
have the flexibility to change the course of surgery when a
particular pathway proves too risky. He should have a realistic
expectation that the operation will be difficult and fraught with
hazards and patience to take things as slowly as necessary.
Laparoscopic hysterectomy is now performed for severe pelvic
adhesions or severe endometriosis as the surgical techniques
have improved and surgeons have gained more experience.
We describe our experience in performing laparoscopic
hysterectomy in frozen pelvis due to severe endometriosis or
pelvic adhesions. It includes some cases where a previous
laparotomy has failed.
Causes for frozen pelvis
The common causes of extensive pelvic disease leading
to frozen pelvis:

13

KFOG

LAPAROSCOPIC
HYSTERECTOMY
IN
FROZEN PELVIS

Infection. Adhesions and fibrosis secondary to infectious

processes such as salpingitis, tubo-ovarian abscess, infected
pelvic hematoma, and ruptured appendix can create severe
pelvic adhesions. Abdominal Kochs can cause extensive Pelvic
adhesions.
Surgery. The type of surgery a patient has undergone may
provide important clues to potential problems. Laparotomy
myomectomies and surgery for endometriosis can also cause
gross adhesions. Residual ovaries and remnant ovaries after
abdominal hysterectomy may require extensive dissection of
the ureter and bowel.
Benign and malignant growths. Severe endometriosis can
lead to a frozen pelvis. Malignant growths of the adnexa, such
as ovarian carcinoma, can necessitiate en bloc resection of
portions 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 each
other, making hysterectomy a challenge. The intestinal and
urinary tracts also must be handled with great care. Even a small
degree of intraoperative trauma to these structures can lead to
postoperative complications including fistula formation.
Patient evaluation
The potential for a frozen pelvis, as well as its causes, can
usually be identified by taking a careful history and documenting
previous surgeries or pelvic problems .When evaluating a patient,
it is important to determine which of above etiological conditions
exist. The physical examination also can be revealing. The type
of laparotomy scars and drain sites will give a clue to the difficulty
of the previous surgery. Be alert for any anatomic changes
apparent at the pelvic examination, which should include a
rectovaginal assessment. If a lesion is palpated, attempt to define
its size and determine whether it is fixed or mobile. Also ascertain
whether the cul-de-sac is free, the uterus can be lifted out of the
pelvis, and the disease process is predominantly uterine,
adnexal, or involves adjacent organs.
Preoperative transvaginal sonography will be of immense
value2. Magnetic resonance imaging may be worthwhile in some
cases. It is particularly important to learn preoperatively whether
there is hydronephrosis and involvement of the ureters.
Other diagnostic steps, such as cystoscopy and
sigmoidoscopy, can be performed at the time of diagnostic
laparoscopy or postponed until the actual surgery.
Preparation for surgery
Give 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 be
called in to assist or to help repair damage to surrounding
structures.
In anticipation of possible enterolysis or intestinal tract
surgery, all patients should undergo preoperative bowel

KFOG

14

preparation.
Plan for an intraoperative ureteral catheterization if gross
pelvic side wall pathologies like severe endometriosis is
diagnosed. The use of catheters helps the surgeon to identify
the ureters intraoperatively and may therefore prevent their injury.
Postoperative wound infections and deep venous
thrombosis, with the potential for life-threatening pulmonary
embolization, are both significantly increased in patients who
undergo pelvic surgery. The prophylactic use of antibiotics and
low-molecular-weight heparin is recommended3,4,5.
Surgical technique
Abdominal entry
The most important step of the surgery is the abdominal
entry. We create pneumoperitonum with a Veress needle at the
Palmers point. The primary trocar entry is with a Ternamian
endotip at the umbilicus , Palmers point or 5 cm above the
pelvic mass.
Omental and bowel adhesiolysis
After entering the abdomen, identify pelvic structures and
their location in relation to one another. Omental adhesions to
parietal peritoneum are very common. Omental adhesions to
parietal peritoneum are released with scissors, unipolar hook
electrode or harmonic scalpel. A combination of blunt and sharp
dissection is necessary in dense adhesions to visualize the
presence of intestine behind the omental adhesions
Bowel adhesiolysis is difficult if there is no space between
the peritoneum and bowel.Dissection is done with hook electrode
, scissors or harmonic scalpel in this situation. A combination of
sharp and blunt dissection can make a space between the
bowel and abdominal wall. Cutting close to peritoneum is safer.
Identify landmarks
After omental or intestinal adhesions have been separated,
move the small and large intestines from the pelvis. Uterine
manipulation with a suitable manipulator will allow the surgeon
to identify the pelvic structures more clearly. We use a Clermont
Ferrand uterine manipulator (Karl Storz)for hysterectomies. Then
identify the following pelvic structures: uterine fundus, round
ligaments, 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 mobilize
because of fibrosis and adhesions in frozen pelvis.
Entry into the retroperitoneum
Once the pelvic structures have identified, determine how
you will be entering the retroperitoneum. This decision is
important because the blood supply to the uterus and adnexa
lies in the retroperitoneum, as do the ureters, which must be
identified and kept under direct vision during coagulation and
division of the IP ligaments and dissection of the peritoneum
around the uterus.
Retroperitoneal entry and elaboration of the retroperitoneal

spaces are keys to the safe performance of a difficult

hysterectomy or removal of retained adnexa in a patient with a
frozen pelvis. The retroperitoneal approach makes it possible
to reach around structures that are fixed in the pelvis, to identify
the blood supply and other vital structures, and to proceed safely.
Several entry sites are possible. In the frozen pelvis, the round
ligament is the ideal location. Identify and divide this ligament
as it enters the internal ring, and incise the peritoneum cephalad
along the course of the IP ligaments.
Adnexal mobilization and division of infundibulopelvic
ligament
In severe endometriosis, the adnexa are released from the
pelvic side wall with blunt and sharp dissection. Dissection starts
from a normal area of pelvis and adnexal is released from the
pelvic side wall by sharp and blunt dissection. The ureter is
identified on both sides before coagulating the IP ligament. This
technique is possible in a good number of cases.
Ureter identification
Never assume the position of the ureter without confirming
it; a major deviation of its course can occur secondary to
pathologic processes in the pelvis. The ureter can be identified
by direct visualization, peristalsis, and palpation with a probe.
Near the level of the pelvic brim on the left side of the body, the
ureter 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 on
the left side, which elevate the ureter in the ventral direction.
Rarely an illuminated ureteric catheter is placed if ureters
cannot be clearly identified. Ureteric cathetrisation can be done
with an operating hysteroscope with little training. The illuminated
ureteric catheter can be visualized laparoscopically by reducing
the laparoscopic light . It also make the ureters rigid for palpation
and dissection
Bladder separation
A history of surgery in the area of the bladder, such as
cesarean section or bladder advancement with uterine
suspension, may leave the bladder adherent to or hard to
separate from the cervix and vagina. Normally, the vesicouterine
peritoneum is flexible, mobile, and easy to free from the cervix
and vagina. A history of disease processes such as
endometriosis, infection, or tumors makes this dissection difficult,
with a real risk of inadvertent cystotomy.
One technique to make this dissection easier and safer is to
enter the retroperitoneum laterally near the round ligament. In
this location, the bladder may not have been involved in the
prior dissection, and the tissue may be more areolar and less
dense than it is in the midline. Bladder is then separated from
the cervix by a hook electrode or harmonic scalpel, remaining
close to cervix. Fornix bulger of uterine manipulator can help in
deciding the limit of bladder dissection. Very rarely filling the
bladder with 200 cc of saline can help in identifying the bladder
limit .

see the urine reflux from both ureteric orifices.

Results
We describe our experience in performing laparoscopic
hysterectomy in frozen pelvis due to severe endometriosis or
pelvic adhesions. There were 16 cases and all had history of
previous surgery for endometriosis. 4 patients had two
laparotomies, 8 had one Laparotomy, 1 had three laparoscopic
surgeries, 4 had two laparoscopic surgeries, 5 had one
laparoscopic surgery. It includes 4 cases where a previous
laparotomy had failed to complete hysterectomy. All had frozen
pelvis and endometriosis with or without adenomyosis.
Laparoscopic adhesiolysis with total laparoscopic hysterectomy
with bilateral/ unilateral salpingo-oophorectomy was done for
all. One patient the biopsy report was well differentiated
adenocarcinoma of the tubal stump. Average duration of surgery
was 2 hours 30 minutes. Blood loss was less than 500 ml. No
blood transfusion was given for any patient. There was no bowel
or bladder injury in this series. Postoperative hospital stay was
2-3 days. 3 patients had postoperative fever which was treated
with antibiotics.
Conclusion
Hysterectomy in frozen pelvis is a difficult surgical procedure
whether done by open or laparoscopic route. A good preoperative
evaluation and planning helps the surgeon to prepare for a
difficult hysterectomy and organize intraoperative urological or
gastrointestinal surgical consultation. Surgical technique has to
be modified for a particular case and surgeon should be prepared
to change the course of surgery. It is possible and safe to perform
total laparoscopic hysterectomy in cases of frozen pelvis by
experienced surgeons.
Reference
1. Donald P. Goldstein, Michael J. Callahan. Surgical
strategies to untangle a frozen pelvis. OBG management
2007; 19:No. 03
2. Brosens I, Puttemans P, Campo R, Gordts S, Brosens J.
Non-invasive methods of diagnosis of endometriosis. Curr
Opin Obstet Gynecol 2003;15:51922
3. Polk HC Jr. Continuing refinements in surgical antibiotic
prophylaxis. Arch Surg. 2005;140:10661067
4. Fejgin MD, Lourwood DL. Low-molecular-weight heparins
and their use in obstetrics and gynecology. Obstet Gynecol
Surv. 1994;49:424426.
5. Lfgren M. Postoperative infections and antibiotic
prophylaxis for hysterectomy in Sweden: a study by the
Swedish National Register for Gynecologic Surgery. Acta
Obstet Gynecol Scand 2004; 83(12): 1202-7

15

KFOG

Coagulation and division of uterine vessels

Once the bladder separation is done , uterine vessels are
identified at the isthmus and skeletonised. The vessels are
coagulated with bipolar forceps and divided. Since the ureters
is already identified, this step of laparoscopic hysterectomy is
similar to any other hysterectomy.
Cul-de-sac obliteration
In pelvis, the posterior cul-de-sac is bounded laterally by the
uterosacral ligaments, posteriorly by the rectum and sacrum,
and caudally by the vaginabut these relationships are usually
lost in the frozen pelvis. Extensive inflammatory disease, tumors
of the tubes and ovaries, extensive pelvic endometriosis, and
prior infection due to a ruptured appendix can obscure the normal
confines of the cul-de-sac. Freeing the peritoneal attachments
both anteriorly and posteriorly, as well as at the sides of the
pelvis, allow elevation of the uterus with the manipulator . Then
the ureter, uterine vasculature, and supporting ligaments can
be identified. Dissection becomes simpler after this point.
However, when the rectum is densely adherent, as they often
are in the frozen pelvis, dissection can become difficult, with a
real danger of rectal perforation. A basic principle in any
hysterectomy is to remain close to the uterus, staying near the
posterior surface of the uterus and cervix using both blunt and
sharp dissection. This eventually makes it possible to find a
reasonable plane to enter the rectovaginal space at the superior
portion of the cul-de-sac between the uterosacral ligaments. The
tissue below this level is not usually involved in the frozen pelvis
and will give way readily once the uterosacral ligaments are
divided. It is unnecessary to operate beyond this level to any
great extent because the surgery already extends distal to the
cervicovaginal junction.
In some circumstances, it may be necessary to open the
vagina anteriorly to define the relationship between the posterior
cervix and adherent bowel. The hysterectomy is completed in a
retrograde fashion. The adherent rectum is then separated from
the uterus by sharp dissection in small steps .
Vaginal closure and hemostasis
Vagina is now closed laparoscopically after removing the
specimen vaginally. The vaginal angle sutures incorporates the
uterosacral and cardinal ligaments for vault support (Fig.12)
Peritoneal cavity is lavaged with saline and complete hemostasis
is ensured. A drain is kept in the pelvis overnight.
Identifying bowel injury
If rectal injury is suspected, insufflate the submersed
rectosigmoid with air . Bubbles signal a breach in the integrity of
the bowel wall. If the bowel has been prepped, and rectal
enterotomy occurs during dissection, closure and drainage are
the only necessary steps.
Cystoscopy
Cystoscopy is performed to look for any bladder injury and

KFOG

16