Uterine atony: An innovative Dutta’s scoring system for elective cesarean section

Abstract

Uterine atony appears suddenly and is mostly unpredictable and accounts for 80% of causes of postpartum hemorrhage (PPH), it is also one of the important causes of maternal death. Objective: To analyze the efficacy of Dutta’s score for early diagnosis and management of uterine atony during elective lower segment cesarean section (LSCS) to prevent PPH. Study methods: This study was undertaken at JNM, NSGH, CN at Kalyani, Nadia, West Bengal, India, from 1st June 2008 to 31st Dec 2012. Six hundred cases undergoing elective LSCS were selected for randomized trial. Clinical observations were made after placental expulsion for scoring which includes shape and size of uterus, rugosity, tone, placental localization and time of placental expulsion. Scores of 0, 1, 2 were given on each observation. Three groups are created depending on scoring: group A (n = 300)—8 to 10, group B (n = 220)—5 to 7 and group C (n = 80)—<5 for better management. Management protocols were formulated in the three groups for prevention of PPH: group A—oxytocin 10 U (5U IM + 5U IV 30 drops/min in Ringer’s lactate 500 ml), group B—oxytocin 15U (5U IM + 10U IV 30 drops/min in Ringer’s-lactate 500 ml) + methylergometrine (0.25 mg IM) + anterior posterior uterine wall compression, group C—oxytocin 20 U (5U IM plus 15 U IV 30 drops in ringer lactate 500 ml) + methylergometrine (0.5 mg IM) + carboprost (250 mcg IM) + lateral followed by anterior posterior uterine wall compression + isthmus compression of uterus + misoprostol 800 mg per rectal during postoperative period. Results: After adopting Dutta’s score and management protocols, it was interesting to observe that intra and postoperative, blood loss (within 2 hours) were found to be significantly reduced in group A—73.3% (<300 cc), 88% (<200 cc) and group B—63.6% (<300 cc), 81.8% (<200 cc). Intraoperative blood loss >500 cc were also found to be reduce in group A—14.7%, group B—16.3%. In group C, intraoperative blood loss >500 cc were seen in 41.25% and postoperative –37.5% respectively. Hemoglobin level below 11 gm% were found to be not reduced in group A (1.4%), group B (2.6%) and group C (8.7%) after 24 hours of delivery hemodynamic status in all groups were found to be uneventful. Maternal mortality was found to be nil. Conclusion: Early diagnosis and management of uterine atony during elective LSCS after adopting Dutta’s score were found to be not only reduce intra- and postoperative blood loss but also was found to maintain a satisfactory hemoglobin level and hemodynamic status. Maternal mortality was found to be nil. This randomized trial highlighted the importance of prompt treatment in group C to reduce intra- and postoperative blood loss and maternal mobidity and mortality.