Over the past 15 to 20 yrs there has been a rapid expansion of knowledge regarding Thyroid diseases in obstetrics and gynecology.

A remarkable downgrading of the clinical aspects of hypothyroidism and hyperthyroidism has resulted into tremendous increase in the number of Thyroid Function Tests and has also led to the confusion in the diagnosis of Thyroid diseases. In 1997, Weetman AP reported that a diagnosis of clinical hypothyroidism can be made on  the basis of biochemical values only and that signs and symptoms are not necessary 1 .While in the same year Skinner GRB et al disagreed and reported that biochemical tests can be misleading and the diagnosis should be done on clinical ground only.2 Recently, low level of  Thyroid Stimulating Hormone (TSH) is considered to be the most important biochemical  diagnostic test of hyperthyroidism but exact numerical value has not been assigned to the serum concentration of TSH below which suppression of TSH is considered to occur. TSH value varies from centre to centre depending upon the sensitivity of the local assay. Hence, depending upon the serum TSH concentration alone the diagnosis of Thyroid disease has led to become confusion.

Thyroid Stimulating Hormone (TSH) TSH is also known as thyrotropin, an anterior pitutary  hormone which is controlled by hypothalamic hormone TRH. It has been reported that  increased thyroid hormone inhibits anterior pitutary secretion of TSH mainly by direct effect on  the anterior pitutary itself and by much weaker effects acting through the hypothalamus3. Regardless of the mechnism of the feedback, its effect is to maintain an almost constant concentration of free thyroid hormones in the circulating body fluids. The whole basis of TSH as a biological marker is as follows, a high value indicates an underactive gland and a low TSH value indicates an overactive gland. Hence elevated level of TSH indicates primary hypothyroidism and low TSH level indicates hyperthyroidism. The serum TSH is a preferred test since TSH only can detect mild i.e. subclinical degrees of excess or deficient thyroid  hormones.

In the 1950’s, when second trimester spontaneous, abortion was a mysterious entity, there were some therapies described, but none of them yielded satisfactory results.

The relatively rare but distressing problem called for some straight thinking from a brilliant mind.

Dr V N Shirodkar (Figure 1) was just the man who brought a refreshingly fresh insight into the problem. He studied the cervix in the non-pregnant and pregnant states, understanding the  changes in anatomy and physiology. He was particularly interested in the changing nature of the  cervix in normal pregnancy from a fibrous one to a dynamic muscular organ. His answer to the problem of habitual second trimester abortion was a surgery which put him and India firmly on  the map of operative obstetrics and gynecology.

In 1955, Dr V N Shirodkar described the cervical cerclage operation, a surgery which has  stood the greatest test of all – time. He innovated special instruments for the repair of the  incompetent cervix. (Figure 2) There have been a number of modifications, most notably that  by McDonald, but the original surgery is a masterpiece. He described his operation at the  international platform in Paris in 1951 and in Naples, in 1956. The Italian connection was, of  course, strengthened by the fact that a Hollywood star was also successfully operated upon by  him with the same technique. He was astute enough to realize that his operation was not a  panacea for all habitual abortions. He clearly laid out the conditions where the operation was  most likely to be useful and where it would not work. Even as we battle on today about the  role of cervical cerclage in modern day obstetrics, it would be worth taking a leaf out of the master’s book.

The operation and the thought behind it probably came from Dr Shirodkar’s keen sense of questioning everything that was routine. He wrote in the preface to his monograph, “With all due respect to the old masters, I did not reconcile myself to some of the operative procedures  which fell far short of the ideal; ideas came to my mind for improving the time-honoured methods.”

In recent years, Interstitial Cystitis (IC) has undergone a major conceptual evolution. Previously considered a rare disorder, it is now known to be a chronic, severely debilitating disease of the urinary bladder.

This is an important diagnosis, which should be kept in mind for  all patients presenting with pelvic pain or urinary symptoms. Overly restrictive diagnostic   criteria of the past have identified only patients with severe and advanced disease, and led to  misdiagnosis and underreporting of this debilitating condition. The International Continence Society defines interstitial cystitis as a clinical syndrome consisting of suprapubic pain related  to bladder filling, accompanied by other symptoms, such as increased day time and night time    urinary frequency, in the absence of proven infection or other obvious pathology. It is a   symptom-based diagnosis, not one based on cystoscopic findings or on the restrictive  criteria promulgated by National Institutes of Health in 1988. Some people also describe this condition as Painful Bladder Syndrome or Tic Douloureux of Bladder. In fact, in 2002 the  International Continence Society became the first organization to recommend that the term  painful bladder syndrome/interstitial cystitis replace interstitial cystitis as both concept and a  defining term.

Women make up 90 percent of patients with interstitial cystitis (IC), while men comprise the  remaining 10% 1. It is most prevalent in the fourth and fifth decades of life. It has a predilection for Caucasian females although a similar prevalence has been reported in Hispanic  females. The exact prevalence of IC in India is unknown.

It is classified into two different types. The first, early non-ulcerative IC occurs in 90 percent  of affected patients. The more severe form of disease, the classical ulcerative type, is seen in  the remaining 10 percent and is associated with Hunner’s ulcers ( a focal and often multiple  lesion involving all layers of the bladder wall in chronic interstitial cystitis; the surface epithelium  is destroyed by inflammation and the initially pale lesion cracks and bleeds with distention of the bladder).

Abstract

Objectives: To study the incidence, microbial profile and predisposing risk factors of neonatal septicemia, the optimum time for culture observations in diagnosis of septicemia and the rationalization of prophylactic antibiotics in high risk cases.

Methods: This is a prospective study of 1647 babies suspected of neonatal septicemia based on symptomatology and clinical diagnosis. Blood culture and other laboratory diagnostic procedures were analyzed. Predisposing risk factors were correlated with incidence of neonatal septicemia. An optimal time for culture observation was obtained and rationalization of therapy discussed.

Results: The incidence of neonatal septicemia was high (53.2%). Young mothers from rural areas of low socioeconomic status, history of prolonged labor, premature rupture of membranes, poor antenatal care, home deliveries by untrained persons, low birth weight, prematurity, male sex, and instrumental deliveries were predisposing factors for neonatal sepsis. Culture reading for isolation of organisms by day 4 detected 99.55% of infective organisms. More than 50% of neonates developed sepsis within 48 hours of birth. Gram negative bacteria were the predominant organisms to be isolated. Multidrug resistant organisms were found to be most pathogenic. Broad spectrum antibiotic use was the main cause for candidemia (8.3%) resistant to fluconazole.

Conclusion: Neonatal septicemia can be prevented in 50% of cases by antenatal care and institutional delivery. Routine use of broad spectrum antibiotics alters the microbial flora resulting in emergence of resistant organisms and fungal infections. The optimal time for reading culture for detecting most organisms in neonatal septicemia is 4th day.

Abstract

Objectives: To document the feasibility of use of Edinborough Postnatal Depression Scale (EPDS) in a private obstetric setting.

Methods: Consecutive 55 antenatal and 30 postnatal women completed the EPDS self-administered questionnaire.

Results: All the women readily consented and completed the questionnaire. None of them reported feeling uncomfortable doing the questionnaire. Questions related to laugh and see funny side of things, things getting on top of me, and look forward to enjoyment to things were found to be difficult for comprehension. Analysis of the responses revealed that 56% of the respondents (53% antenatal and 63%; post natal women) scored > 9 in the EPDS indicative of being at a greater risk for depressive episodes.

Conclusion: The ready acceptance of the women to undertake the EPDS indicates that it could routinely be used for screening depression by a busy private obstetrician.

Abstract

Objectives: To study the cord blood nucleated RBC count (NRBC) in asphyxiated and nonasphyxiated fetuses at birth and to find out the correlation between NRBC count, fetal acidosis and the clinical markers of asphyxia.

Methods: This is a prospective comparative study conducted between 2002 and 2004. Parturient women who were in labor between 37 and 42 weeks of gestation were selected after satisfying inclusion and exclusion criteria and divided in 2 groups. The control group consisted 51 cases with nonasphyxiated fetuses and study group 52 asphyxiated fetuses. The cord blood was collected soon after birth, one sample for pH determination and the other sample for making smears that were stained with Leishman’s stain. NRBCs were counted against 100 WBCs. The statistical analysis was done using SSPS and Chi-square test to find out the relationship between pH and NRBC count and the correlation between NRBC count, and meconium stained amniotic fluid (MSAF), nonreassuring fetal heart rate pattern and low apgar scores.

Results: The mean NRBC count in the study group was 25.65 ± 10.14 as compared to 12.33 ± 5.51 in the control group (p=0.003). The NRBC count was significantly higher in MSAF and in neonates with low apgar scores of < 6 at 5 minutes (P=0.02).

Conclusion: Acidotic neonates (cord blood pH < 7.1) at birth had higher mean NRBC count compared to nonacidotic neonates and hence NRBC count of cord blood smear serves as a good indicator of fetal asphyxia.

Abstract

Objectives: To determine prevalence of premenstrual syndrome, premenstrual dysphoric disorder (PMDD), and the impact of PMS on education programming among 320 female students who were living in female housing.

Methods: A questionnaire was designed for data collection. The criteria proposed by the diagnostic and statistical manual of mental disorders (DSM-IV) were used to diagnose PMS.

Results: Among 326 nulliparous students, 98.2% of undergraduate students of Teacher Training University who lived in a female housing, experienced symptoms with PMS in most of the last 12 cycles. The prevalence of PMDD was 16.9%. About 25% of participants had fall in education, 50% of participants with PMS took drugs and 57% of participants had a family history of PMS.

Conclusion: PMS is not rare among the students. The university’s authorities should, therefore, take it into consideration and plan for reducing its adverse effects.

Abstract

Objectives: To observe the effect of rosiglitazone on spontaneous and clomiphene citrate induced ovulation in patients of polycystic ovary syndrome (PCOS).

Methods: Thirty diagnosed patients of PCOS were divided into two groups. Group I received only rosiglitazone and patients in Group II were given both rosiglitazone and clomiphene citrate for a period of three months. Serum levels of leutinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, prolactin, progesterone, fasting glucose, and lipids were estimated before and after treatment and compared using paired student ‘t’ test. Ovulation and pregnancy rates were noted.

Results: Ovulation rates of 40% (6/15) and 66.67% (10/15) and pregnancy rates of 26.67% (4/15) and 40% (6/15) were recorded in group I and II respectively. No significant effect on other parameters was observed except a decrease in LH levels after treatment (P<0.01).

Conclusion: Rosiglitazone appears to be a promising adjunct in management of insulin resistance and anovulation associated with PCOS.

Abstract

Objectives: To analyze hysteroscopic procedures performed over a two year period focusing on indications, findings and complications.

Methods: A retrospective study was done of 722 diagnostic and operative hysteroscopic procedures performed from 1st July, 2004 to 27th June, 2006. Indications, results, operative procedures and complications were analyzed.

Results: The most common indications for hysteroscopy were abnormal uterine bleeding and incidental ultrasound finding of increased endometrial thickness in asymptomatic patients. The most common operative procedures were polypectomy, endometrial ablation or resection and myomectomy. The complication rate was 2.35% of all hysteroscopies.

Conclusion: Hysteroscopy is a safe and reliable diagnostic and therapeutic option that can be successfully employed for various clinical conditions.

Abstract

Objectives: To assess the knowledge and attitude regarding family planning and the practice of contraceptives among the women of reproductive age group in east Sikkim and to determine the barriers for contraceptive use among them.

Methods: A cross sectional descriptive study was done in the Obstetrics and Gynaecology Department of the STNM Hospital and Central Referral Hospial, both attached to the Sikkim Manipal Institute of Medical Sciences. The study group included 443 women of reproductive age group (15-44 years) attending the two hospitals during the month of January 2004 to March 2005. Their knowledge, attitude and practice on contraceptives were evaluated with the help of a predesigned questionnaire.

Results: It was found that 98% of the women had knowledge about family planning and 94.2% of them had knowledge aboaut contraceptives. Over 50% had gained information from media. Majority (98%) thought that contraceptive use was beneficial but only 55.2% had used contraceptives and 84% of them were satisfied. Sixty-two percent were currently using contraceptives, 37.9% of them were using oral contraceptives, 37.9% of them were using oral contraceptive pills and 31% were using condoms.

Conclusion: The study highlights that knowledge and awareness doen’t always lead to the use of contraceptives. There is still a need to educate and motivate the couples and improve family planning services to achieve more effectie and appropriate use of contraceptives and to arrest the trend towards increase in population.

Herpes gestationis is an intensely pruritic bullous eruption that may develop in association with pregnancy trophoblastic tumor, hydatidiform mole, and choriocarcinoma 1.

The term herpes is  used because of the frequent presence of grouped or herpetiform lesions in these women 2.  It is a rare disorder which may affect 1 in 1700 to 50000 pregnancies 3. It occurs only   with pregnancy, hydatidiform mole and choriocarcinoma 1. However clinical course may be  modulated by changes in estrogen and progesterone levels. Exacerbations mayoccur with oral  contraceptives or pregnancy and the severity may vary during the menstrual cycle 1.

A 35 year G2 P1 L1 was admitted on 28th July, 2002 in early third trimester with the  complaints of intensely pruritic erythematous papules and urticarial plaques of 4 weeks  duration. They started as itchy red papules and plaques over the abdomen and slowly spread  to involve the limbs, back, palms, and soles over a period of 2 weeks. She noticed tense  blisters on few of those reddish plaques a week back. There was no oral involvement. There  was no history of drug intake prior to the onset. During her last pregnancy she had similar itchy  reddish plaques one week before delivery which subsided a week after delivery. Systemic examination revealed no abormality. Obstetric examination showed 26 weeks pregnancy. On examination there were multiple erythematous papules, urticarial plaques, and  target lesions seen on the abdomen (Figure 1), back, upper and lower limbs including palms and soles. There were tense blisters with clear fluid on few of those plaques on the limbs.

Although spherocytosis is an autosomal dominant trait in a fifth of the cases it appears to be due to new mutations.

A 27 years old primigravida was seen in out patient clinic when she was 16 weeks pregnant. She was a known case of spherocytosis. Because recurrent episodes of hemolytic anemia and jaundice she had multiple blood transfusions and underwent splenectomy at the age of 10 years. Since then she was put on tablet folic acid 5 mg daily and was given 1.2 mega units of injection benzathine penicillin intramuscularly once in 3 weeks for 5 years.

Following splenectomy she suffered from repeated worm infestations and had nearly 24 attacks of malaria over a period of 10 years. During the above period her hemoglobin ranged between 10 and 11 g/dL and the peripheral smear showed mild eosinophilia, moderate hypochromia, platelet clumps and microspherocytosis. None of her family members suffered from similar problems.

On examination she was not anemic and not jaundiced. Her pregnancy was corresponding to 16 weeks of gestation. In view of her previous medical history, besides the usual investigations she was periodically investigated for anemia, malaria and worm infestation. Throughout the antenatal period her hemoglobin ranged between 10.5 and 11 g/dL, PCV was 39% and leukocyte count 9,900/mm3, with differential count P65L29E6. Her peripheral smear showed microcytic hypochromic anemia with few spherocytes. She was given adequate folate supplementation and her pregnancy progressed well. As infection prevention is vital in cases that had splenectomy, she was given anthelmintics at 20 weeks, 28 weeks and 34 weeks and antimalarial prophylaxis with tablet chloroquine 300 mg once weekly from 20 weeks until 38 weeks of gestation.

The presence of a pelvic mass with suspicious clinical features and elevated CA 125 may be suggestive of gynecological malignancy. Large ascites with hydrothorax is usually associated with benign fibroma or thecoma (Meigs syndrome) and completely resolves after surgery. Pseudo-Meigs syndrome refers to the same features associated with other ovarian or gynecological tumors. Struma ovarii may be present with ascites but it is extremely rare for it to present with pseudo-Meigs syndrome and elevated CA 125 levels.

A 52 year old para 4 menopausal woman was admitted on 4th June, 2004 for gradually enlarging abdominal girth since 4-5 months and shortness of breath. On examination she was found to have ascites, a large right pleural effusion with collapsed lung and an irregular right adenexal mass of approximately 10 x 8 cm size. Pelvic ultrasound revealed a mass with solid and cystic areas, normal endometrium, and undetected ovaries. She had an ascitic fluid examination done elsewhere before admission which showed that it was exudative, lymphocytic and free of malignant cells or acid fast bacilli (AFB). CT showed well defined heterogeneous, enhancing, mass of 9 x 7 cm with areas of necrosis in right adenexal region, ascites, right pleural effusion and absence of lymph node enlargement (Figures 1,2,3). Liver function tests, intravenous pyelograms and barium examination, were all within normal limits. The CA 125 level was elevated at 849.510 iu/mL (normal < 35 iu/mL). Pleural fluid drained on many occasions to relieve breathlessness was found negative for AFB and Mature cystic teratomas account for approximately 20% of all ovarian tumors. Struma ovarii is a monodermal variant, which predominantly contains thyroid tissue (greater than 50%). It constitutes about 2.7% of all ovarian teratomas, with an incidence of 0.1-0.3%. Usually seen in 5th and 6th decades of life, it is seldom diagnosed before an exploratory laparotomy for a pelvic mass the most common presenting symptom 1. Less than a third develop ascites and cases of struma ovarii causing pseudo- Meigs syndrome have been rarely reported 2.

“Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information on it.” Samuel Johnson

Knowing a subject well means continuously updating one’s knowledge about it. What we use  in daily clinical practice is what we remember from the top of our knowledge pool. It is  important, as time goes by, to referesh this pool of knowledge. Medical journals provide us with a great opportunity to update ourselves. It gives me great pleasure to don the mantle of   The Editor of the Journal of Obstetrics and Gynecology of India.

I take over from Dr  Mahendra Parikh, an editor of unusual perseverance and insight, who has brought about numerous changes in the journal and its working style. I am only beginning to appreciate his efforts over the last few years.

My association with the Journal began over thirty years ago. I worked with the founder secretary and manager, Dr Gool Vazifdar. We would meet at the office where the articles would be type-set and laid out on a long table according to page numbers. Those were the days of real “desk top publishing”! Seeing the issue through to the print stage involved transporting the blocks to the printers marking “this side up”, and often spending long hours poring over the proofs. In  today’s electronic age, the physical nature of printing journals has been transformed. The challenges of journal editing have changed.