Abstract

The use of macroporous monofilament lightweight mesh in cases of vaginal prolapse surgery repair has been in practice for several years now. The type 1 monofilament, macroporous polypropylene should be used because it has been suggested to have the lowest incidence of infection and erosion among the non absorbable prostheses Synthetic meshes have been used with increasing frequency in gynecological surgery, both vaginally and abdominally, over the last 30 years [1].

The use of mesh to augment pubocervical and rectovaginal fascia in cases of cystocele and rectocele, respectively is based on the belief that conventional repair is inadequate and incomplete, resulting in recurrence and poor patient satisfaction. An argument is made that conventional colporrhaphy and perineorrhaphy results in a shortened vaginal length often due to excess excision of healthy vaginal tissue. Mesh use has been advocated to prevent this occurrence. The issue of nulliparous prolapse is also addressed by the procedure of intravaginal slingplasty which is a procedure to help create ‘neo’ uterosacrals in conservative uterine prolapse surgery as well as restore the apex of the vagina in vaginal vault prolapse repair.

The introduction of these procedures have thrown up issues of the necessity, safety, efficacy, complications and desirability of such mesh use in vaginal prolapse surgery. Questions have also been raised whether this methodology of mesh use is market driven what with multiple surgical kits being made available at exorbitant cost. The issue before us therefore is—whether mesh use should be routine in vaginal prolapse surgical repair. Paradoxically the use of tension free vaginal tape or trans obturator tape for stress urinary incompetence is considered routine, is widely performed and accepted and has good evidence supporting its use [2].

Abstract

The Influenza A H1N1 pandemic (A H1N1) occurred between June 2009 and August 2010. Although the pandemic is now over, the virus has emerged as the predominant strain in the current seasonal influenza phase in the northern hemisphere. The A H1N1 influenza is a novel strain of the influenza A virus and is widely known as swine flu. The virus contains a mixture of genetic material from human, pig and bird flu virus. It is a new variety of flu which people have not had much immunity to. Much has been learnt from the Pandemic of 2009/2010 but the messages about vaccination and treatment seem to be taken slowly by the clinical profession. Most people affected by the virus, including pregnant women, suffer a mild viral illness, and make a full recovery. The median duration of illness is around seven days. This influenza typically affects the younger age group i.e. from the ages of 5–65 years. Current experience shows that the age group experiencing increased morbidity and mortality rates are in those under 65 years of age. Pregnant women, because of their altered immunity and physiological adaptations, are at higher risk of developing pulmonary complications, especially in the second and third trimesters. In the United Kingdom, twelve maternal deaths were reported to be associated with the H1N1 virus during the pandemic and clear avoidable factors were identified (Modder, Review of Maternal Deaths in the UK related to A H1N1 2009 influenza (CMACE). www.cmace.org.uk, 2010). The pregnancy outcomes were also poor for women who were affected by the virus with a fivefold increase in the perinatal mortality rate and threefold increase in the preterm delivery rate (Yates et al. Health Technol Assess 14(34):109–182, 2010). There continues to be a low uptake of the flu vaccine and commencement of antiviral treatment for pregnant women.

Abstract

The aim of this study was to see the fetomaternal outcome of pregnancy in HIV positive mother. Methods This study was conducted in the department of OBGYN Medical College Kolkata from 1st January 2004 to 31st December 2007, a period of 4 years since the establishment of PPTCT centre in our institution. All the pregnant women attending the antenatal clinic for consultation and those coming directly to labour room for delivery (unbooked cases) were counseled for HIV testing, informed consent was obtained and blood samples collected for HIV testing. Babies of HIV positive women delivered were followed up to 18 months for testing.

The no. of women detected positive were 28, 53,69 and 98 (total 248) in the consecutive years. Therefore the seroprevalence of HIV was 0.41, 0.63, 0.67 and 0.76% in 2004, 2005, 2006 and 2007 respectively. Out of 248 women who were detected positive in the 3 years, only 103 (41.53%) delivered in our institution. 32 (12.90%) underwent MTP. But unfortunately 113 (i.e. 248 -(103 ? 32) = 113) were lost to follow up during antenatal care. Out of the 95 live births, only 46 babies have been tested so far out of which only one is reactive, 45 are non reactive. Conclusion The main obstacle we faced was in following up the mother and the baby. To achieve a high success rate, PPTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counseling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community.

Objective The aim of this study was to see the fetomaternal outcome of pregnancy in HIV positive mother.

Methods This study was conducted in the department of OBGYN Medical College Kolkata from 1st January 2004 to 31st December 2007, a period of 4 years since the establishment of PPTCT centre in our institution. All the pregnant women attending the antenatal clinic for consultation and those coming directly to labour room for delivery (unbooked cases) were counseled for HIV testing, informed consent was obtained and blood samples collected for HIV testing. Babies of HIV positive women delivered were followed up to 18 months for testing.

Results The no. of women detected positive were 28, 53, 69 and 98 (total 248) in the consecutive years. Therefore the seroprevalence of HIV was 0.41, 0.63, 0.67 and 0.76% in 2004, 2005, 2006 and 2007 respectively. Out of 248 women who were detected positive in the 3 years, only 103 (41.53%) delivered in our institution. 32 (12.90%) underwent MTP. But unfortunately 113 (i.e. 248 - (103 ? 32) = 113) were lost to follow up during antenatal care. Out of the 95 live births, only 46 babies have been tested so far out of which only one is reactive, 45 are non reactive.

Conclusion The main obstacle we faced was in following up the mother and the baby. To achieve a high success rate, PPTCT programmes must have well-trained, supportive staff who take great care to ensure confidentiality. They must be backed up by effective HIV testing and counseling programmes and by good quality HIV/AIDS education, which is essential to eliminate myths and misunderstandings among pregnant women, and to counter stigma and discrimination in the wider community

Abstract

To evaluate lipid profiles in subjects with preeclampsia. To determine if there is any change in lipid profiles in subject of preeclampsia as compared to normal antenatal females, non-pregnant females and post partum females. Methods Study was carried out on pregnant women and non pregnant women attending or admitted in the Obstetrics and Gynecology Department of SSG Hospital, Baroda between 1st June 2007 to 31st May 2008. Each serum sample from different groups was evaluated for Total cholesterol(mg/dl), Triglyceride (mg/dl), HDL-cholesterol (mg/dl), LDL-cholesterol (mg/dl) and VLDL-cholesterol (mg/dl) using diagnostic kits and a comparison drawn and analyzed using t-test and chi-square test.

Preeclampsia is a pregnancy specific condition characterized by hypertension and proteinuria that remits after delivery. It is a characteristic multisystem disorder of pregnancy, is one of the most common complications of pregnancy and is a leading cause of maternal and perinatal morbidity and mortality [1]. Preeclampsia occurs in 7–10% of pregnancies world wide [2]. In India, the national incidence is reported to be 8–10% of pregnancies. The etiology of preeclampsia is still unknown. The hypotheses currently accepted are the placental ischemia hypothesis, genetic hypothesis, the immune maladaptation and hypothesis of the imbalance between free oxygen radicals and scavengers in favour of oxidants. At present, the most popular is the theory of oxidative stress. Abnormal lipid profiles and species may have a role in the promotion of oxidative stress and vascular dysfunction seen in preeclampsia. Predominantly the atherogenic small low density lipoproteins (LDL) and the Vascular Cell Adhesion Molecules (VCAM) are increased in association with hyperlipidemia in preeclampsia. Although there is growing evidence indicating that the risk of preeclampsia is increased in women with elevated levels of oxidized low density lipoproteins and triglycerides [3], the causal relationship of lipid peroxidation in the pathogenesis of preeclampsia is not clear.

Objectives To evaluate lipid profiles in subjects with preeclampsia. To determine if there is any change in lipid profiles in subject of preeclampsia as compared to normal antenatal females, non-pregnant females and post partum females.

Methods Study was carried out on pregnant women and non pregnant women attending or admitted in the Obstetrics and Gynecology Department of SSG Hospital, Baroda between 1st June 2007 to 31st May 2008. Each serum sample from different groups was evaluated for Total cholesterol(mg/dl), Triglyceride (mg/dl), HDL-cholesterol (mg/dl), LDL-cholesterol (mg/dl) and VLDL-cholesterol (mg/dl) using diagnostic kits and a comparison drawn and analyzed using t-test and chi-square test.

Results Dyslipidemia in the form of significantly decreased HDL concentration and significantly increased total cholesterol, LDL, VLDL & Triglycerides concentration is conspicuously evident in subjects of preeclampsia as compared to non pregnant, normotensive pregnant and postpartum subjects.

Conclusion Dyslipidemia is significantly evident in preeclampsia and plays an important pathological role. The various causative factors for dyslipidemia and its prevention need to be further studied and evaluated.

Abstract

Aim The success of induction of labor depends on the cervical status at the time of induction.

Objective For effective cervical ripening both Foley’s catheter and PGE2 gel are used. The aim of this study was to compare the efficacy of intra cervical Foley’s catheter and intra cervical PGE2 gel in cervical ripening for the successful induction of labor.

Study Design A randomized, prospective study was conducted in the Dept of OBGY, GMCH, Aurangabad from July 2005–January 2008. 400 patients at term with a Bishop’s score B3 with various indications for induction were randomly allocated to receive (200 pts) intra-cervical Foley’s catheter or PGE2 gel (200 pts). After 6 h post induction, Bishop’s score was noted labor was augmented if required. Statistical analysis was done using Chi square test and t test.

Result The groups were comparable with respect to maternal age, gestation age, indication of induction and initial Bishop’s score. Both the groups showed significant change in the Bishop’s score, 5.56 ± 1.89 and 5.49 ± 1.82 for Foley’s catheter and PGE2 gel, respectively, P\0.001; However there was no significant difference between the two groups. There was no significant difference in the side effects. Twenty eight cesarean sections (14%) were performed in Group A and 37 (18.5%) were performed in Group B (not significant). The induction to delivery interval was 15.32 ± 5.24 h in Group A and 14.2 ± 5.14 h in Group B (P = 0.291). Apgar scores, birth weights and NICU admissions showed no difference between the two groups.

Conclusion This study shows that both Foley’s Catheter and PGE2 gel are equally effective in pre induction cervical ripening.

Abstract

Objectives To compare the efficacy and safety of patient controlled epidural analgesia with basal continuous infusion versus intermittent bolus for labor analgesia using fentanyl and bupivacaine.

Methods In this prospective study, 60 parturients having singleton term uncomplicated pregnancy in early active labor were included. 30 parturients were allocated to receive patient controlled epidural analgesia ? basal continuous infusion (Group-A) and 30 received intermittent bolus on demand (Group-B). Efficacy of technique was assessed in terms of quality of analgesia on 0–10 cm verbal analogue scale. Effect on labor was assessed by duration of labor, mode of delivery, and parturient’s satisfaction. Neonatal outcome was measured by Apgar score. Data were expressed as mean ± SD and analysed using Student ‘t’ test and chi square test where appropriate. P\0.05 was considered statistically significant.

Results Analgesic efficacy of both the groups was comparable. Maternal satisfaction was better in group A than in group B but the results did not achieve statistical significance. Effect on labor and neonatal outcome were comparable.

Conclusions Both the techniques appear to be safe for the mother and neonate with excellent analgesic efficacy. In a busy obstetric unit with increased demand of epidural analgesia, patient controlled epidural analgesia with basal continuous infusion may be preferred.

Abstract

Objectives The purpose of the study was to compare the efficacy of misoprostol 400 lg per rectally, injection oxytocin 10 IU intramuscular, injection methylergometrine 0.2 mg intravenously and injection (0.5 mg ergometrine ? 5 IU oxytocin) intramuscular on reducing blood loss in third stage of labor, duration of third stage of labor, effect on haemoglobin of the patient, need of additional oxytocics or blood transfusion and associated side effects and complications.

Study Design A prospective non-randomized uncontrolled study was carried out in the Department of Obstetrics and Gynecology, SSG Hospital and Medical College, Baroda enrolling 200 women and dividing them into four groups. Active management of 3rd stage of labor was done using one of the 4 uterotonics as per the group of the patient. The main outcome measures were the amount of blood loss, the incidence of postpartum hemorrhage and a drop in hemoglobin concentration from before delivery to 24 h after delivery.

Results Methylergometrine was found to be superior to rest of the drugs in the study with lowest duration of third stage of labor (P = 0.000096), lowest amount of blood loss (P = 0.000017) and lowest incidence of PPH (P = 0.03). There was no significant difference in the pre-delivery and the post-delivery hemoglobin concentration amongst the four groups with P = 0.061. The need of additional oxytocics and blood transfusion was highest with misoprostol as compared to all other drugs used in the study with P = 0.037 and 0.009, respectively. As regards side effects, misoprostol was associated with shivering and pyrexia in significantly high number of patients as compared to the other drugs used in the study while nausea, vomiting and headache were more associated with methylergometrine and ergometrine–oxytocin. However all the side effects were acceptable and preferable to the excessive blood loss.

Conclusion Methylergometrine has the best uterotonic drug profile amongst the drugs used, strongly favouring its routine use as oxytocic for active management of third stage of labor. Misoprostol was found to cause a higher blood loss compared to other drugs and hence should be used only in low resource setting where other drugs are not available. The role of misoprostol in third stage of labor needs larger studies to be proved

Abstract

Aims & Objective To find out the circadian pattern of blood pressure in normotensive pregnant women and in women with preeclampsia.

Method A cross-sectional prospective observational case control study. Blood pressure was sampled in thirty-five normotensive pregnant women (control) and thirty five preeclamptic women (study group) by using non-invasive automatic ambulatory blood pressure monitoring machine for 72 h.

Results Blood pressure (BP) was not constant over 24 h period and it oscillated from time to time in control group. BP was maximum during early part of afternoon. However, in preeclampsia besides quantitative increase in BP, circadian BP oscillations were less pronounced and in around 50% subjects BP was maximum during evening and night hours.

Conclusion Both systolic and diastolic BP showed definite reproducible circadian pattern in both preeclamptic and normotensive pregnant women. This pattern both quantitatively and qualitatively was different in preeclamptic women. Standardized 24 h BP monitoring allows quantitative and qualitative evaluation of hypertensive status and is important for timing and dosing of antihypertensive medications.

Abstract

Objectives Study was conducted to determine acceptability, efficacy, safety, return of fertility with Implanon.

Methods Volunteers having regular menstruation, requiring spacing formed study population. Implanon was inserted within 5 days of LMP or concurrent with MTP. Woman was asked to record bleeding pattern, side effects. Implanon duration was 3 years but Implanon was removed before, if patient wanted pregnancy/for side effects. Subjects who did not adopt family planning method after removal were followed up for return of ovulation and pregnancy.

Results 200 subjects were enrolled (160 within 5 days of LMP, 40 concurrent with MTP). 74 implanon removals were done. (16 after tenure completion, 58 for other reasons.) 16% cases discontinued implanon for polymenorrhagia, 10% for irregular bleeding, 4.5% for amenorrhea. There was no failure of implanon. 40% had return of ovulation within one month, 95.8% conceived within 12 months.

Conclusions Implanon is safe, effective, well accepted method of contraception.

Abstract

Introduction Abnormal uterine bleeding (AUB) is the commonest presenting symptom in gynaecology outpatient department. Endometrial sampling could be effectively used as the first diagnostic step in AUB, although at times, its interpretation could be quite challenging to the practicing pathologists. This study was done to evaluate histopathology of endometrium for identifying the endometrial causes of AUB. We also tried to observe the incidence of various pathology in different age groups presenting with abnormal uterine bleeding.

Material and Methods This was a study done at Sri Ramachandra Medical College and Research Institute, Chennai, India on 620 patients who presented with AUB from June 2005–June 2006. Out of which 409 cases of isolated endometrial lesions diagnosed on histopathology were selected for the final analyses. A statistical analysis between age of presentation and specific endometrial causes was done using v2 test.

Results The most common age group presenting with AUB was 41–50 years (33.5%). The commonest pattern in these patients was normal cycling endometrium (28.4%). The commonest pathology irrespective of the age group was disordered proliferative pattern (20.5%). Other causes identified were complications of pregnancy (22.7%), benign endometrial polyp (11.2%), endometrial hyperplasias (6.1%), carcinomas (4.4%) and chronic endometritis (4.2%). Endometrial causes of AUB and age pattern was statistically significant with P value \0.05.

Conclusion There is an age specific association of endometrial lesions. In perimenopausal women AUB is most commonly dysfunctional in origin and in reproductive age group, one should first rule out complications of pregnancy. The incidence of disordered proliferative pattern was significantly high in this study, suggesting an early presentation of these patients.

Abstract

Objective To compare the effectiveness and safety profile of LEEP (Loop Electrosurgical Excision Procedure) verses cryotherapy in the treatment of CIN.

Material and Method Women with abnormal pap smears were subjected to VIA and VILLI followed by colposcopy. A total of 200 cases were included in this prospective study. Once the diagnosis of CIN was confirmed on histopathology, the women were subjected to either cryotherapy or LEEP randomly. They were follow up at 1, 6 and 12 months. At 12 months follow up, cervix was subjected to VIA, VILLI and colposcopy. Chi square test was used to analyze the data. Observations The efficacy of cryotherapy was found to be 88% and that of LEEP was 94% which is not significantly different. The overall cure rate of symptoms was 82 and 79% in cryosurgery and LEEP group, respectively.

Conclusion Although LEEP was associated with higher cure rates but the difference is not significant statistically. Either method if used appropriately gives good results in treatment of CIN lesions, however, LEEP seems to have an edge over cryotherapy when used on severe lesions.

Abstract

Objective To evaluate the efficacy of pap smear, HPV DNA testing and colposcopy and to determine the approach for cervical cancer screening in low resource settings.

Methods Eight hundred non pregnant married women above 30 years of age were studied and subjected to pap smear examination. Hysterectomised women were excluded from the study. Selected patients were followed by HPV DNA testing by Hybrid Capture II method, colposcopy and biopsy. Sensitivity, specificity, Positive predictive value (PPV), Negative predictive value (NPV), diagnostic accuracy and kappa value (k) were calculated for each screening test.

Result Out of eight hundred women with mean age 36.5 ± 5.94 years undergoing pap smear, ASCUS was found in 66(8.25%), ASC-H in 2(0.25%), LSIL in 48(6%), HSIL in 8(1%), inflammatory in 540(67.5%). Out of 260 women who underwent HPV DNA testing, 120 (46.15%) had abnormal cytology and/or positive HPV DNA test (Group I, n = 120) and 140(53.8%) had dual negative results (Group II, n = 140) HPV DNA test was found positive in 64 women (53.3%) in Group I. Sensitivity and specificity of pap smear was 69.2 and 63.72% while for HPV DNA testing was 92.3 and 84% respectively. PPV and NPV of pap smear, HPV DNA testing and colposcopy was 18, 40, 76.4% and 94.7, 98.9, 100% respectively. Diagnostic accuracy of pap smear (k = 0.14), HPV DNA test (k = 0.70) and colposcopy (k = 0.81) was 64.29, 84.9, and 96.8% respectively. Combining pap smear & HPV DNA testing (k = 0.25) increased the sensitivity and NPV to 100%.

Conclusion Sensitivity and diagnostic accuracy of HPV DNA test is more than that of pap smear and the test is not influenced by inflammatory conditions of vagina. In low resource settings, women with ASCUS and LSIL on cervical cytology should be subjected to HPV DNA test and only if found positive should be referred for colposcopy thereby reducing colposcopy referrals. Women with HSIL should be directly subjected to colposcopy guided biopsy. Using this approach, most of the preinvasive cervical lesion will be detected but few cases will still be missed among inflammatory smears, if HPV DNA testing is not supplemented.

Abstract

An infertile couple came to our centre for semen cryopreservation. Husband was having nonseminomatous germ cell tumor of testis for which he was advised unilateral orchidectomy followed by chemotherapy. Being a medical professional he was aware of the impact of chemotherapy on the semen quality and the treatment modalities available for future conception. Four vials of semen were frozen over a period of 15 days prior to chemotherapy. He subsequently underwent full treatment for his malignancy. He visited us again after 2 years when he was declared cured.

The couple underwent first cycle of intrauterine insemination (IUI) following gonadotrophins stimulation using one of the four frozen semen samples. She did not conceive during that cycle. As the number of semen samples was few, it was decided to change the treatment to intra cytoplasmic sperm injection [ICSI]. An IVF–ICSI procedure was initiated on the long protocol with 300 IU of recombinant FSH. A total of 13 eggs were retrieved, ICSI was performed using the second sample of frozen-thawed semen. Out of the total nine good quality embryos, three were transferred and the remaining six were frozen. Patient failed to conceive. A thawed embryo transfer cycle was performed a month later, which also failed. A second IVF–ICSI cycle was carried out 3 months later with 375 IU of r-FSH. Twenty-eight eggs were retrieved; ICSI was performed after thawing the third semen sample. Fifteen good quality embryos were formed; two were transferred and the remaining 13 frozen. She conceived during this cycle. b hCG done on day 15th of embryo transfer was 280 mlU/ml. Pregnancy was supported with progesterone capsules of 200 mg three times a day for up to 14 weeks of pregnancy. She had routine antenatal care and had an uneventful pregnancy till term. She opted for an elective cesarean section and delivered a healthy male child weighing 3.2 kg.

Abstract

A nulliparous woman aged 45 years was referred to us with painful swelling in left lower limb. She underwent laparoscopic hysterectomy for menorrhagia 12 days prior to the admission. The laparoscopic surgery was completed in 90 min without blood loss and blood transfusion. The size of the uterus was approximately 12 weeks. Duplex scan of the left lower limb confirmed thrombosis of the left external iliac vein, femoral vein, popliteal vein and tibial veins. On examination the laparoscopic puncture wounds healed well. She was hospitalized for initial anticoagulation with low molecular weight heparin (Enoxapain 1 mg/kg body weight twice daily) and compression bandages. Histological examination of the hysterectomy specimen was noted to be benign (Adenomyosis and cervical Leiomyoma). She responded to anticoagulation therapy and was discharged with an advice to attend the follow up clinic for long term anticoagulation advice for the next 6 months to prevent recurrent thromboembolic episodes.