Case reportMrs. AK, a primipara aged 26 years, was referred 12 hours after a caesarean section and B-Lynch procedure with coagulation failure and shock.She had a normal pregnancy till near term when she developed pregnancy-induced hypertension (PIH) for which she was treated with antihypertensives. Following the spontaneous onset of term labour at a peripheral hospital, thick meconium stained amniotic fluid was discovered at 6 cm cervical dilatation and an emergency caesarean section was done only to deliver a fresh stillborn baby. There was no placental abruption. During the caesarean section, an atonic postpartum haemorrhage failed to respond to uterotonic agents and a B-Lynch procedure was performed using a gauge 1 polyglactin suture. Haemostasis was confirmed before abdominal closure. However, post-operatively she developed hypotension, oozing of blood from the abdominal incision and haematuria. There was little vaginal bleeding. After 12 units of whole blood transfusion, she was referred to our unit.On admission, she had a pulse rate of 140/min, a respiratory rate of 42/min, a systolic pressure of 70 mmHg and an oxygen saturation of 86%. The abdomen was distended and she was oozing blood from the incision with minimal vaginal bleeding. The scanty urine was frankly blood stained. The haemoglobin was 6.8 gm/dL, haematocrit 20%, platelet count 18,000/mm 3 , prothrombin time 37 seconds (control 15 seconds), partial thromboplastin time was 54 seconds (control 30 seconds), plasma fibrinogen was 170 mg/dL, serum glutamate aspartate transferase (SGPT) was 167 IU/mL and serum creatinine was 1.2 mg/dL. Abdominal ultrasonography showed the uterus deviated to the right side and was surrounded by multiple haematomata, suggestive of uterine rupture.After 6 units of FFPs and platelet concentrate transfusions, her platelet count rose to 36,000/mm 3 , prothrombin time improved to 21 seconds (control 13 seconds), partial thromboplastin time to 34 seconds (control 27 seconds). At laparotomy, the uterus was congested and distended between the compression sutures giving it a lobulated appearance. The sutures had cut through and embedded in the uterine wall while the intervening portions of the uterine wall had distended with blood. There was bluish black discoloration on the uterine surface with blood oozing out (Fig. 1) The suture line on the lower segment was intact. There was haemoperitoneum of about 2 L. A total hysterectomy with bilateral internal iliac artery ligation was done. Haemostasis was confirmed before closure and placement of appropriate closed drains. In the post-operative period, she had an episode of generalised convulsions on post-operative day one from vasogenic brain oedema, febrile morbidity on post-operative days six and seven, and the syndrome of inappropriate secretion of antidiuretic hormone from day nine which responded to desmopressin. She made a good recovery and was discharged on the 20th day. DiscussionThe B-Lynch suturing technique 1 involves a pair of vertical brace sutures around the uterus, es...

Open PLH for uterine prolapse may be safely performed and gives durable support to the prolapsed uterus with low recurrence risk.

Early scalable process development for the synthesis of ZY12201, a novel TGR5 receptor agonist, as a potential clinical candidate is described. A practical, efficient, and scalable synthetic route provided ZY12201 in seven steps and 32% overall yield. The key step involves an inexpensive acetic acid-mediated cyclization of thiourea 6 for the construction of 2-thio-imidazole derivative 7. The developed process demonstrated cost-effective, high-yielding, kilogram-scalable, and environmentally friendly synthesis of ZY12201. This high-yielding route enabled us to rapidly synthesize large quantities of ZY12201 in 99% purity to support in vivo and toxicity studies.

Placenta accreta spectrum (PAS), particularly placenta percreta, is a dreaded complication of pregnancy in which there is abnormal invasion of placental trophoblast into the muscular wall of usually the lower segment of the uterus and the adjacent urinary bladder with abundant neo-vascularization in the utero-vesical space. Rising cesarean section rates 1 and in vitro fertilization conceptions 2 ensure increasing incidence of PAS disorders.One definitive method of care is classical cesarean section followed by total hysterectomy without disturbing the placenta.Another approach is to resect the part of the myometrium invaded by the placenta and repair the defect to conserve the uterus. 3,4 The major challenge is to control blood loss during separation of the bladder from the invaded lower segment so that remaining steps of hysterectomy can be completed. The numerous newly

Background Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. Case Presentation This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 ? 6 weeks and successful outcome of intrauterine twin pregnancy.