Role of bias in errors of decision making is receiving increasing attention. It is turning out to be one of the main sources of mistakes. Hence, it is important to be aware of biases and to design strategies toward an unbiased approach. Biases are of various types, and the potential sources of bias can be related to the consultant, patients and factors related to working conditions. Availability bias, base rate neglect, confirmation bias, conjunction rule, diagnostic momentum bias, framing effect and confirmation bias are the common types, and these have been discussed in this manuscript using a scenario-based format. Two types of human thinking, the rapid intuitive mode and the slow reflective mode, their pros and cons and their role in biases are discussed. Strategies to enhance awareness of biases, tips to improve reasoning, promote freethinking, enhance decision-making skills and resorting to checklists have been deliberated to achieve an unbiased approach.
Keywords: Bias in practice • Conjunction rate • Availability bias • Diagnostic momentum • Framing effect • Confirmation
bias • Base rate neglect • Commission bias
‘The unexamined thought is not worth thinking’- Socrates.
Medical genetics has evolved over a decade, and hence, all investigations are available for clinical practice. Many diseases are diagnosed accurately today because of new investigations. These advanced investigations are affordable, accessible and available in day-to-day practice. Hence, there is a need and it is a time for us to understand these advanced technologies. Karyotyping and rapid aneuploidy tests are basic tests, while chromosomal microarray and next-generation sequencing are advanced technologies. It is time to update the knowledge and utilize them in day-to-day practice. These tests are utilized both in prenatal diagnosis and in some clinical scenarios, which are elaborated in detail. Karyotyping is the basic tool to detect both numerical and structural abnormalities. It is advantageous in that it is accurate with error of 0.001% but has a resolution of up to 5 MB. Rapid aneuploidy detection tests are equally accurate and detect as good as 99%. They are FISH, QF-PCR and MLPA. They have high sensitivity and specificity, and results are available within 3 days of time. Hence, these tests are apt for Indian scenarios, where late detection of anomalies (18–20 weeks) is common. Chromosomal microarray is the hybridization technique which detects aneuploidy of all chromosomes. This is useful for detection of deletion and duplication in chromosomes. This is not available for prenatal diagnosis in India now, whereas this is available for prenatal diagnosis in developed countries. Whole-exome sequencing and whole-genome sequencing are advanced techniques which have been described and discussed at length.
Keywords: Karyotyping · Rapid aneuploidy detection tests · Chromosomal microarray · Whole-exome sequencing · Whole-genome sequencing
Objective: To derive a risk calculation algorithm suitable for use in India when screening for Down’s syndrome using four first-trimester maternal serum markers either alone or with ultrasound nuchal translucency (NT).
Methods: Stored maternal serum samples (- 20 C) from 411 singleton unaffected pregnancies were retrieved and measured for pregnancy-associated plasma protein (PAPPA), free b-human chorionic gonadotropin (hCG), placental growth factor and a-fetoprotein. Samples were taken at 10–13 weeks’ gestation. Equations were derived to express marker levels in multiples of the gestation-specific normal median, adjusted for maternal weight. Gaussian model parameters were derived and compared with six published non-Indian studies; NT parameters were derived from 27,647 women screened in India. On the basis of the maternal age distribution in 64,473 Indian women screened in 2016–2017, the model was used to predict test performance.
Results: The model predicted a detection rate for a serumonly protocol of 80% for a 5% false-positive rate. Using a 1 in 250 at term Down’s syndrome risk cut-off, the predicted detection rate was 78% and the false-positive rate was 4.1%. When NT was also included, the rates were 95% for 5% and 90% for 1.4%, respectively.
Conclusions: First-trimester screening using four serum markers only can be carried out in India. Performance is expected to be similar to the second-trimester Quad test and will also facilitate early screening for preeclampsia and open spina bifida. A protocol of NT plus the four serum markers enhances the performance compared with NT, PAPP-A and free b-hCG.
Keywords: First trimester • Screening • Down’s syndrome • Prenatal diagnosis • PlGF • AFP
Aim: To evaluate the efficacy and safety of ART in prevention of mother-to-child transmission of HIV.
Methods: All pregnant females who were tested and found positive for HIV from April 2015 to March 2017 were included in this study and started on TLE regimen (Tenofovir 300 mg, Lamivudine 300 mg, Efavirenz 600 mg). After delivery these newborns were given syrup Nevirapine 2 mg/kg for 6 weeks of life if mother was started on ART before 12 weeks of gestation and was continued upto 12 weeks if mother was started on ART later than 12 weeks of gestation. Infants were tested with PCR and Rapid test for HIV was done at 6 weeks, 6 months, 12 months, and 18 months of life.
Results: Out of 66 HIV-positive mothers (26 diagnosed in our institute and 40 referred patients), 53 delivered in our hospital. Out of these 53 deliveries, 3 were stillbirth, so 50 babies were registered. Out of 50 registered babies, 2 babies died in follow-up (one at the age of 12 months due to malnutrition and other at the age of 4 months due to diarrhea). Five babies were referred to nearby ART centers. So, we followed 43 babies out of which two were found to be positive for HIV (transmission rate of HIV was 4.6%).
Conclusions: The risk of transmission of HIV from mother-to-child had declined with the use of combination ART, and the emergence of drug resistance was reduced. The ART used during pregnancy appears to be well tolerated and safe.
Keywords: ART · PPTCT · TLE regimen · Nevirapine
Introduction: Hypertensive disorders of pregnancies complicate around 5–10% of pregnancies worldwide, and together they are a member of the deadly triad along with haemorrhage and infection that contribute to a significant amount of maternal morbidity and mortality.
Aims and Objectives: To compare differences in the fetomaternal outcomes with the use of 150 mg aspirin versus 75 mg aspirin in pregnant women found to be at high risk of PE.
Methodology: This was a two-armed double-blind parallel randomized control trial conducted in the Department of Obstetrics and Gynaecology, King George’s Medical University, carried over a period of 1 year.
Results: Preeclampsia occurred in 15 of 87 participants (17%) in the 75 mg aspirin group compared with 6 of 91 (6.5%) in the 150 mg aspirin group. There were a significantly higher incidence of PE, its severity and lesser period of gestation at delivery in the group given 75 mg dose compared to the group given 150 mg dose. There were significantly higher values of mean arterial pressure and uterine artery PI in women who developed preeclampsia compared to those who do not in both the groups. Foetal outcomes were observed in both the groups of women, and there was no statistically significant difference between them.
Conclusions: This randomized trial showed that among women with singleton pregnancies who were identified by means of first-trimester screening as being at high risk of preterm preeclampsia, use of aspirin 150 mg per day started between 11 and 14 weeks till 36 weeks is a potent intervention to reduce the development of both early- and late-onset preeclampsia as compared to a dose of 75 mg per day.
Keywords: Preeclampsia · Aspirin · MAP · Uterine Doppler
Introduction: Preeclampsia is a multisystem endothelial disease leading to glomeruloendotheliosis with endothelial leak causing significant proteinuria. It is associated with high maternal and fetal risks and fetomaternal morbidity and mortality. Spot urinary albumin-to-creatinine ratio (ACR) leads to earlier detection of glomerular damage leading to prompt management of preeclamptic patients.
Aims and Objectives: To study the correlation between fetomaternal outcomes of preeclamptic patients with spot urinary ACR.
Materials and Methods: Spot urinary ACR was measured in 70 consecutive patients with preeclampsia in Assam Medical College, Dibrugarh. The best cutoff value to differentiate between significant and insignificant proteinuria was calculated. Mean spot urinary ACR was calculated in all maternal outcomes (mode of onset of labor and mode of delivery), and maternal complications (elevated liver enzymes, renal insufficiency, severe hypertension, coagulation disturbances and thrombocytopenia, antepartum and postpartum hemorrhage) and fetal complications and outcomes (birth weight, Apgar score, IUGR, need for resuscitation, NICU requirement, neonatal sepsis, jaundice and mortality) and the correlation were studied.
Results: The best cutoff value to differentiate significant and insignificant proteinuria was calculated as 291.9 mg/g beyond which adverse fetomaternal outcomes and complications were seen. All maternal and fetal outcomes and complications had high mean spot urinary ACR and were found to be significant (p < 0.05). Mode of delivery and birth weight of babies showed no statistical significance though low-birth-weight babies had high mean spot ACR.
Conclusions: Compared with 24-h urinary protein excretion, spot urinary ACR is a simple and accurate indicator of significant proteinuria and helps to detect fetomaternal outcomes in preeclamptic women which may lead to prompt management to reduce fetomaternal complications.
Keywords: Spot urinary albumin to creatinine ratio (ACR) · Preeclampsia · 24-h urinary protein
Background: Predicting spontaneous preterm birth (SPTB) during mid-trimester would be very useful. We used a multimodality screening approach mainly focusing on urogenital infections among unselected obstetric population between 18 and 24 weeks in a tertiary center.
Method: Diagnosis of lower genital tract infection (LGTI) was attempted among 228 pregnant women using several factors— symptom of vaginal discharge, characteristic appearance of discharge on speculum, point of care tests using Amsel’s criteria and gram staining of vaginal swab. Nugent’s scoring was taken as gold standard. Urine microscopy/culture was obtained. Serum inflammatory markers were done. Total leukocyte count, neutrophil/lymphocyte ratio and C-reactive protein were obtained. Data on cervical length were obtained from mid-trimester scan.
Results: Thirty patients complained of vaginal discharge. Speculum examination revealed discharge in 221 (96.92%), appearing pathological in 192 (86.87%). Amsel’s criteria showed poor sensitivity to detect full (57%) and partial (24%) bacterial vaginosis (BV). On gram staining, 104 (45.61%) showed evidence of LGTI; 14 full BV (6.1%); 45 partial BV (19.5%); 40 candidiasis (17.5%); and two each of trichomoniasis and aerobic vaginitis. Appearance of vaginal discharge and microscopic diagnosis of LGTI were poorly correlated. Forty women (17.5%) had SPTB, 24 following membrane rupture and 16 following spontaneous labor. The presence of BV (specifically partial) increased the likelihood of SPTB with OR of 3.347 (CI 1.642, 6.823). Three of seven women with short cervix delivered preterm. No other screening modality was associated with SPTB.
Conclusion: Active screening for LGTI between 18 and 24 weeks shows high prevalence of BV in Indian setting. There is a strong link between partial BV and SPTB.
Screening for preterm delivery, Lower genital tract infection, Bacterial vaginosis, Vaginal discharge, Screening, Amsel’s criteria, Nugent’s criteriaIntroduction: Male factor contributes to almost 50% cases of infertility. There is evidence of the effect of serum vitamin D on male fertility by helping in spermatozoa maturation and initiating acrosomal reaction. In India, vitamin D deficiency has been documented to be in the range of 50–90% among all the age groups. Objective To study the levels of vitamin D and the impact of vitamin D supplementation in vitamin D-insufficient/deficient infertile males with oligoasthenozoospermia.
Material and methods: This study is a longitudinal observation study. Infertile men with either oligozoospermia or asthenozoospermia with vitamin D levels < 30 ng/ml were enrolled. Vitamin D and calcium supplementation was given, and semen and hormone parameters were assessed at the end of 3 and 6 months.
Results: There is significant improvement in the mean sperm concentration and progressive sperm motility in infertile males with oligoasthenozoospermia after 6 months of vitamin D supplementation (p value < 0.001). The overall clinical pregnancy rate in the study was 8.33% after vitamin D supplementation (p value 0.24).
Conclusions: Vitamin D supplementation plays a crucial role in regulating male fertility
Introduction: Granulosa cell tumour (GCT) comprises 2–5% of ovarian malignancies. They are hormonally active tumours and may present with menstrual complaints, abdominal distension or infertility. Prognosis is generally favourable because of the early stage at diagnosis and less aggressive behaviour.
Materials and Methods: Medical records of 32 cases presenting from January 2008 to December 2014 were retrospectively analysed for the patient characteristics, tumour characteristics and the treatment received.
Results: The mean age was 42.75 ± 10.25 years (range: 22 to 70 years). The most common presenting symptom was abdominal distension (50.00%) followed by menstrual complaints. The mean tumour diameter was 15.24 cm (range: 4–25 cm). Endometrial pathology was found in 4 patients (12.50%), and all had simple hyperplasia without atypia. Twenty-four patients underwent primary staging surgery; one patient underwent interval debulking surgery after neo-adjuvant chemotherapy. Seven patients had undergone surgery elsewhere of which 4 underwent re-staging and three were given chemotherapy. All patients had the final histopathology of adult granulosa cell tumour except one patient with juvenile granulosa cell tumour. Most patients had stage I disease (81.25%). Post-operative chemotherapy was administered to 22 patients. The most commonly used regimen was paclitaxel and carboplatin. The overall 5-year survival rate was 90%. The mean overall survival was 36.95 ± 34.08 months (range: 0.50 to 112.00 months). Two patients had recurrence at 38 and 44 months, respectively.
Conclusions: GCT of the ovary is a rare tumour with a tendency for late relapse. Survival is generally excellent as majority of the patients present in early stages.
Purpose of study: Advanced uterovaginal prolapse can significantly affect the quality of life in women and usually requires surgical management. McCall’s culdoplasty (M) or sacrospinous fixation (SSF) are done at the time of vaginal hysterectomy with pelvic floor repair (VHPFR) to reduce recurrence, but recurrence rates of 15% and 33% have been reported with these procedures respectively. We hypothesize that combining VH-PFR with both McCall’s culdoplasty and sacrospinous fixation (VH-PFR-M-SSF) may decrease recurrence rates compared to VH-PFR-M without significantly affecting other perioperative outcomes.
Methods: All patients with advanced uterovaginal prolapse and willing for VH-PFR at our institute from January 2015 to March 2018 were included after informed consent, except for medically unfit women and those preferring alternative management. We conducted a case control study comparing VH-PFR-M and VH-PFR-M-SSF with a follow-up period of 24 months. Qualitative and quantitative data were statistically analysed and Odds ratio and 95% Confidence interval was calculated. Kaplan Meier Curve was drawn and Log Rank test was used to compare recurrence.
Results: Out of 174 patients who underwent surgery in the study period, 131 patients (75.28%) underwent VH-PFR-M and 43 patients (24.71%) underwent VH-PFR-M-SSF. Both groups were comparable for age, body mass index, parity, postmenopausal status, comorbidities and aggravating factors. Patients with higher stage of prolapse were more in group 2 (p < 0.001). There were no intraoperative complications or postoperative surgical interventions in either group. The duration of surgery was not significantly different. Change in haematocrit was more in group 2 but no patient required blood transfusion. There was no statistically significant difference in recurrence rates between the 2 groups.
Conclusion: The procedure (VH PFR M-SSF) is safe and affordable with good results in Stage 3 with advanced bulge and stage 4 prolapse.
McCall’s culdoplasty, Sacrospinous fixation, Uterovaginal prolapse, Vaginal hysterectomy, RecurrenceBackground: Immediate postpartum intrauterine device (PPIUD) is a good solution for reducing low contraceptive coverage in developing countries. However, its use in HIV-infected women is poorly documented. The objective of this study was to assess whether the risk of PPIUD complications was higher in HIV-infected women.
Methods: A retrospective cohort study compared 64 HIV-infected women to 128 HIV-negative women who had had a PPIUD at the University Hospital of Treichville between January 2016 and March 2017, with a match at the insertion time of the PPIUD. The complications considered were pelvic pain, metrorrhagia and genital infections. Chi-squared test and relative risk were used to investigate the association between HIV infection and PPIUD complications.
Results: HIV-infected patients had an average age of 33.1 years, and 85.9% of them were on antiretroviral therapy. PPIUD was inserted during cesarean section in 66.1% of cases. There was no significant association between HIV infection and PPIUD complications (RR = 0.7, 95% CI [0.4–1.3], p = 0.3). The risk of genital infections was not increased in HIV-infected women (RR = 0.6 [0.1–2.7], p = 0.7).
Conclusion: HIV infection does not increase the risk of PPIUD complications. This effective contraceptive strategy can be offered to HIV-infected women. It is therefore necessary to strengthen the training of maternity staff in the installation of PPIUD.
HIV, AIDS infection, PPIUD, Copper IUD, ComplicationsStudy Objective: To evaluate contained bag electromechanical morcellation for removal of myomas and uterus with myomas, laparoscopically (Study group B), and compare it with uncontained laparoscopic morcellation (Control group A) in patients with similar parameters done earlier.
Design: Retrospective Cohort Comparative Study (Canadian Task Force 2-1).
Setting: Advanced Gynaecologic MAS, university recognized tertiary centre, Mumbai, India.
Patients: 720 women had laparoscopic removal of myomas or large uterus with myomas during a study period of 6 years (from 13 May 2012 to 14 August 2018) with contained bag electromechanical or conventional morcellation.
Interventions: Laparoscopic hysterectomy, laparoscopic myomectomy, conventional uncontained morcellation, contained in-bag morcellation.
Main Outcomes Measures: Laparoscopic contained in-bag morcellation was compared with conventional morcellation of myomas and uterus with large myomas during a study period of 6 years. Parameters assessed were operating time, time for insertion of bag, morcellation of tissues and removal of bag, blood loss, complications, conversion to open surgery and histopathologic findings of tissues. In Group A, in the first 3 years, 355 women underwent uncontained morcellation. Myoma size and weight varied from 5 cm to 26 cm and 200 g to 3740 g respectively. The myoma number ranged from 1 to 18. No case of leiomyosarcoma was reported. In Group B, in the next 3 years, 365 women underwent contained bag morcellation in 196 myomectomy cases and 169 hysterectomy cases. Myoma size and weight varied from 4 cm to 20 cm and 200 g to 2100 g respectively. The number of myomas varied from 1 to 17.
Results and Conclusion: Laparoscopic contained bag morcellation for myomas and uterus with large myomas were evaluated. In myomectomy group both conventional and in bag laparoscopic morcellation were comparable in terms of duration of the surgery and blood loss. When all cases ( hysterectomy and myomectomy combined together) and cases of hysterectomy with large fibroid were studied, laparoscopic in bag morcellation took less operative time and there was statistically significant difference in operative time . No case of leiomyosarcoma was found in our study of 720 cases of myomas or uterus with large myomas.
We report an extremely rare case of spontaneous pregnancy in a 38 year women following chemotherapy for Rosai-Dorfman Disease (Rosai-dorfman Disease). What made the case more interesting was the challenges that obstetric team faced managing the patient in the presence of co-morbidities like Gestational Diabetes Mellitus , anemia , sub clinical hypothyroidism , allergic bronchitis , progressive symptoms of Rosai-Dorfman Disease like diplopia and cerebellar ataxia
Objective: Granulosa cell tumor (GCT) is a rare entity of ovarian malignancies. Juvenile GCT is considered a malignant tumor with an indolent course and tendency toward late recurrence. However, the association of this tumor and multiple enchondromas has been reported.
Case Presentation: A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb. X-ray imaging was indicative for Ollier’s disease at the distal part of femur and proximal part of tibia. Postoperative pathological review was compatible with juvenile granulosa tumor of the right ovary.
Conclusion: This case was the first of its kind that ovarian tumor was contralateral to the side involved by enchondromatosis.
Objective: Granulosa cell tumor (GCT) is a rare entity of ovarian malignancies. Juvenile GCT is considered a malignant tumor with an indolent course and tendency toward late recurrence. However, the association of this tumor and multiple enchondromas has been reported.
Case Presentation: A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb. X-ray imaging was indicative for Ollier’s disease at the distal part of femur and proximal part of tibia. Postoperative pathological review was compatible with juvenile granulosa tumor of the right ovary.
Conclusion: This case was the first of its kind that ovarian tumor was contralateral to the side involved by enchondromatosis.
