Classic polycystic ovarian syndrome (PCOS) is one of the commonest endocrine metabolic disorders in women of reproductive years. It is very disappointing that we have still not been able to know the exact cause, and hence, we cannot completely cure this syndrome. With availability of effective drugs and lifestyle modification, it can only be controlled and symptoms can be reduced. There are some well-defined factors which lead to PCOS phenotype. A concept of secondary PCOS is being described recently. This condition, even though rare, is completely curable, as majority of these factors are treatable. Hence, it is advisable to actively look for these conditions and offer treatment in time. This editorial gives an account of various causes of secondary PCOS, gives broader view of PCOS phenotypes and aims for an insight into pathophysiological aspects of PCOS. The clinical categorization by HA-PODS nomenclature of both primary and secondary PCOS can minimize diagnostic and therapeutic pitfalls and will serve as a checklist to ensure the appropriate investigation is ordered and specific treatment is initiated as per diagnostic code. This will achieve uniformity in therapies offered and also enable better comparison of data and a smooth conduct of research which is much needed in this field.
Hypothalamic–pituitary–gonadal axis regulates the reproductive system. The overall health and wellbeing of a woman is subject to fluctuations in the sex hormones throughout her lifespan. Menopause, either natural or surgically induced, is often associated with cognitive complaints, especially memory disturbances. Sex hormones, besides affecting the reproductive function, affect the central nervous system in many ways. Here, we aim to review the role of sex hormones in cognition and the current evidence on use of or against menopausal hormonal therapy as a cognition enhancer in women with cognitive disturbances, including those with Alzheimer’s disease.
Aim: Aim of the study is to evaluate the myocardial performance index in intrauterine growth restricted fetuses and compare this index with appropriate for gestational age fetuses.
Materials & Methods: A prospective study was conducted in S.M.S Medical College Jaipur, involving 72 singleton fetuses C 28 weeks of gestation divided into two groups: 36 intrauterine growth restricted fetuses (IUGR) and 36 appropriate for gestational age fetuses (AGA). Myocardial performance index was obtained by fetal echocardiography.
Results: The mean myocardial performance index in the IUGR fetuses and AGA fetuses was statistically significant and that was 0.62 ± 0.02 and 0.45 ± 0.01, respectively; (p value:\0.0001). These findings suggest that IUGR induces primary cardiac changes, which could explain the increased predisposition to cardiovascular disease in adult life. This study concluded that Fetal echocardiographic parameters (MPI) identify a high risk group within the IUGR fetuses, which could be targeted for early screening of blood pressure and other cardiovascular risk factors, as well as for promoting a healthy diet and physical exercise.
Background: Deficiencies of enzymes in the folate cycle may lead to the generation of homocysteine, a toxic metabolic intermediate with pro-oxidant effect and ability to induce oxidant stress and lipid peroxidation as part of the pathophysiological process in gestational hypertension (GH) and pre-eclampsia (PE).
Aim: The aim of this study is to assess the reliability of plasma homocysteine (hcy) 5, 10 methylenetetrahydrofolate reductase (MTHFR) enzyme and oxidative stress parameters as indicators of aetio-pathogenesis and severity of gestational hypertension and pre-eclampsia.
Subjects and Methods: This was a comparative cross-sectional study conducted over 6 months. Two hundred pregnant women were recruited from two sites. They were divided into gestation hypertension (n = 40), pre-eclampsia (n = 60) and control groups (n = 100). Parameters evaluated for statistical analysis were MTHFR enzyme level, plasma homocysteine and malondialdehyde (MDA) levels, with glutathione (GSH), superoxide dismutase (SOD) and catalase (CAT) activities.
Results: Mean plasma hcy level and MDA were significantly higher in pre-eclampsia and gestational hypertension when compared to control group (p < 0.05). However, MTHFR enzyme level, GSH, SOD and CAT were significantly higher in normotensive females when compared to PE and GH subgroups (p < 0.05). Pre-eclampsia was significantly associated with an increased risk of lipid peroxidation (OR = 4.923; p = 0.007).
Conclusion: Pre-eclampsia and gestational hypertension are associated with marked homocysteine metabolic derangement and increased lipid peroxidation induced by oxidative stress and reduced MTHFR enzyme activity which may be the significant risk factors in the aetio-pathogenesis of GH and PE.
Pre-eclampsia, Gestational hypertension, Antioxidant, Lipid peroxidationObjective: To assess the safety and efficacy of postpartum IUCD in caesarean section patients.
Methods: This prospective observational study included 200 women, who gave informed consent for postpartum intrauterine contraceptive device (PPIUCD) insertion during caesarean section from January 2013 to May 2014. These patients were followed up at 6 weeks and 6 months.
Results: There were no major complaints in either group in post-operative period. At 6-month follow-up in PPIUCD users, 89.5% of patients continued to use this method. 5.5% were lost to follow-up, 2.5% had spontaneous expulsion, and 2.5% removed the IUCD due to various reasons. Eight per cent of patients who wanted removal of IUCD in the second follow-up were counselled to continue, and they did so.
Conclusion: The results of our study suggest that immediate intra-caesarean IUCD insertion appears to be a safe and effective method of contraception. The acceptability of intra-caesarean IUCD was high, and its continuation rate has demonstrated its safety.
Background: Transversus abdominis plane (TAP) block is a fascial plane block providing postoperative analgesia after lower abdominal surgeries including Cesarean section. Conventionally, it is administered under ultrasound guidance or by blind technique. We studied a novel transperitoneal surgical TAP block for providing safe and effective analgesia after Cesarean section through transverse incision.
Methods: A hundred patients who fulfilled the inclusion criteria were included in the study after obtaining informed written consent. They were randomized in two groups: Group A with surgical TAP block and Group B without TAP block as control. Surgical TAP block was administered by transperitoneal route before the closure of peritoneum with 0.25% bupivacaine (dose adjusted with weight of the patient), and visual analogue score was assessed by a blind assessor. Time for rescue analgesia was noted and analyzed with the ‘two independent sample t test.’
Results: The duration of postoperative analgesia in hours was significantly longer in the TAP block group compared with the control group (5.14 ± 1.63 vs 2.61 ± 0.89, p < 0.001). There was no reported complication of the surgical technique or any adverse effect of the used drug.
Conclusion: Surgical TAP block via the transperitoneal route is a safe, easy and effective mode of providing postoperative analgesia after Cesarean section. This technique does not need any costly specialist equipment, overcomes the technical limitations of ultrasound-guided TAP block and can be used in obese patients also. It has almost no side effects, and the technique can be easily mastered.
Background: With the availability of neuroimaging, it is possible to know the exact underlying CNS pathology in eclampsia, and thus, the therapy can be targeted at the same. The present study was undertaken to find out the neurological changes in cases of eclampsia and to find the incidence of PRES in association with eclampsia and to study the role of Inj. Mannitol in cases of eclampsia with PRES who do not respond to Inj. MgSO4 alone.
Methods: This is a referral hospital-based prospective study of 110 consecutive cases of eclampsia who were subjected to MRI/CT scan brain without contrast. All 110 women with eclampsia were treated with routine principles of management of eclampsia. Inj. MgSO4 was the drug of choice as anticonvulsant. Inj. Mannitol was added as antiedema agent in patients who did not respond to MgSO4 alone.
Results: All patients of eclampsia showed PRES on neuroimaging. 40 (36.36%) patients received inj. Mannitol as they had either recurrent convulsions or extreme irritability or deep coma after multiple convulsions and did not recover consciousness after convulsions were controlled.
Conclusion: PRES is the core component of the pathogenesis of eclampsia, and the incidence is 100% in our study. Inj. MgSO4 is the drug of choice, and addition of Inj. Mannitol in cases with recurrent convulsions, extreme irritability, visual symptoms and severe headache plays a dramatic role in control of convulsions and recovery of the patients.
Objective: Construction of reference centile chart of middle cerebral (MCA) and umbilical artery (UA) Doppler along with cerebroplacental ratio from 24 to 40 weeks gestation in Indian population.
Method: It was a cross-sectional observational study; antenatal women between 24 and 40 weeks gestation underwent the MCA and UA Doppler. The centile charts for MCA, UA and cerebroplacental ratio (CPR) were derived.
Results: Total 300 antenatal women were included; the MCA PI, RI, S/D ratio values showed a parabolic curve with the peak at 33–35 weeks; the umbilical artery Doppler and cerebroplacental ratio showed a linear decrease with increasing gestational age. The regression analysis showed a weak correlation between the Doppler parameters and the gestational age. The MOM values of all Doppler parameters, across the gestational age, were also derived.
Conclusion: The constructed MCA, UA and CPR charts along with their MOM values could be used as reference for the regional population.
Objective: To determine critical factors and barriers to postpartum intrauterine contraceptive device (PPIUCD) use in India in order to guide programs aimed at reducing maternal and child mortality.
Methods: All pregnant women were enrolled for contraception counseling during their visit to the antenatal outpatient clinic. Women who opted for PPIUCDs were enrolled in the study and offered PPIUCD insertion, irrespective of mode of delivery. Those who withdrew consent when in labor or soon after delivery, experienced severe bleeding, or exhibited unstable vital signs were excluded, as were febrile women and those diagnosed with chorioamnionitis.
Result: A total of 66,508 women were enrolled in the study. 86.1% indicated they discussed family planning options with their partners/husbands before making a decision. 178 respondents (0.3%) could not mention one advantage of PPIUCDs, while 23.1% could not mention one disadvantage. 13.9% of the women withdrew consent. Family member objections (43.44%), husband/partner objection (27.94%), and deciding on another method (15.59%) were the main reasons for consent withdrawal.
Conclusion: Awareness of PPIUCDs is not a limiting factor in women’s consent to PPIUCD insertion. As a woman’s decision to use a PPIUCD is significantly influenced by family members and her partner/husband, awareness initiatives that target these populations should be considered.
Background: Herlyn–Werner–Wunderlich syndrome is an uncommon entity characterized by uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis (also called OHVIRA syndrome). Due to rarity and varied presentations, often correct diagnosis is missed out during work up, leading to management problems. We describe our dependence on detailed preoperative work up and minimally invasive endoscopic approach in management of the eight patients of OHVIRA syndrome.
Methods: In this retrospective case series study, eight patients of OHVIRA syndrome were managed from January 2012 to March 2018 with the help of improved imaging facility and diagnostic work up. Precise diagnosis helped in adopting minimally invasive approach in management. Patients were reviewed, focusing on presentation, radiologic findings and surgical management.
Results: Median age at diagnosis was 19 years (range 13–41 years). Abdominal pain and dysmenorrhea were the main presenting complaint. All patients except one had associated ipsilateral renal agenesis. Surgical excision of the obstructed hemivaginal septum and hematometra drainage was the main treatment. In seven patients, vaginoscopic resection of vaginal septum was done with resectoscope except one 41-year-old patient, where resection of vaginal septum was performed laparoscopically along with hysterectomy.
Conclusion: Vaginoscopic resection of obstructed hemivaginal septum is an effective method. Management has shifted to minimally invasive approach due to improved imaging, precise preoperative diagnosis and proper understanding of the disease.
Objectives: To assess the diagnostic performance of International Ovarian Tumor Analysis (IOTA) simple ultrasound rules to discriminate adnexal masses as benign or malignant.
Materials and Methods: It was a prospective observational study, which included 156 primigravidas with uncomplicated term singleton pregnancy with spontaneous onset and progression of labor, who had normal vaginal delivery with good maternal and neonatal outcome.
Methods: A cross-sectional prospective study was conducted on women scheduled for elective surgery due to adnexal masses. Ultrasound examiner systematically assessed the tumors according to the IOTA simple rules to determine the risk of the tumor being malignant. If the simple rules yielded inconclusive result, pattern recognition was used to categorize the mass. Results were then compared with histologic findings after surgery. Diagnostic performance was assessed by calculating sensitivity and specificity.
Results: Two hundred and five women undergoing surgery were included. The rules were applicable in 183 (89.3%) of the tumors; and for these tumors, sensitivity was 92.8% (95% CI 77–99%) and specificity was 92.9% (95% CI 88–96.4%). Of the tumors, 144 were benign and 39 were malignant. The simple rules yielded inconclusive results in 22 masses which were analyzed by pattern recognition.
Conclusion: IOTA simple rules provide excellent discrimination between benign and malignant adnexal masses.
IOTA simple rules, Adnexal mass, Ultrasound, Benign ovarian tumorAbstract
Background: Chromohysteroscopy is expected to help in diagnosing subtle endometrial pathologies which could be missed on conventional hysteroscopy and also help in targeting biopsy from endometrium.
Objective: To study staining pattern of endometrium in patients undergoing chromohysteroscopy and to evaluate and compare the histopathology of chromohysteroscopy-guided endometrial biopsy with conventional endometrial sampling.
Method: This was a cross-sectional study conducted during the period of 18 months in Department of Obstetrics and Gynaecology, ESI PGIMSR, New Delhi, India, from September 2016 to February 2018. Totally, 60 women with complaints of infertility, failed intrauterine insemination (IUI), recurrent spontaneous abortions (RSA), heavy menstrual bleeding (HMB), intermenstrual bleeding (IMB) and postmenopausal bleeding (PMB) meeting inclusion criteria were evaluated and enrolled in the study. In patients with normal looking endometrium on hysteroscopy, methylene blue dye was administered through the hysteroscopic inlet. Tissue samples were obtained from stained areas followed by blind endometrial sampling immediately. The results of chromohysteroscopy-guided biopsy from light- and dark-blue-stained areas and blind biopsy were compared.
Results: Mean age of the study group was 37 years, with mean BMI of 24 kg/m2. There were 24 cases of HMB, 9 of IMB, 7 of PMB, 15 of infertility, 2 of failed IUI and 3 with RSA. On chromohysteroscopy, 39(65%) cases showed light-stained endometrium (group I) and 21(35%) showed dark-stained endometrium (group II). Comparison was done between histopathology obtained through chromohysteroscopy and blind endometrial sampling. The diagnostic accuracy of chromohysteroscopyguided endometrial biopsy in evaluation of endometrial pathology was 86.67% with sensitivity of 91.67%, specificity of 85.41%, PPV of 61.12% and NPV of 97.61% (P <0.001).
Conclusion: Chromohysteroscopy was able to detect endometrial pathology which was missed on conventional hysteroscopy and detected more cases of endometrial pathology than blind endometrial sampling.
Objective:To compare intra- and post-op complications between non-descent vaginal hysterectomy and laparoscopic hysterectomy and establish the better method for hysterectomy in non-descent uterus.
Methods: A prospective comparative study of 80 hysterectomies was done over a period of January 2017–Dec 2017, with 40 cases each in one group of non-descent vaginal hysterectomy (NDVH) and other group of total laparoscopic hysterectomy (TLH). Demographic characteristics, co-morbid conditions, indications for surgery, operative time, intra-operative blood loss, post-operative analgesia requirements, post-operative hospital stay and post-operative complications were compared between both groups.
Results: The most common age in both groups was 41–50 years. Fibroid uterus was the most common indication for surgery in both groups. The mean operative time in NDVH group was 40 min while it was 120 min in TLH group, and the mean blood loss in NDVH group was 50 ml, while it was 120 ml in TLH group. P < 0.001 when intraoperative blood loss and operative time were compared between both groups. There were no conversions to laparotomy in NDVH group, while there were three conversions to laparotomy in TLH group. Both groups were similar in post-operative analgesia requirement and post-operative hospital stay. Post-operative complications were similar in both groups.
Conclusions: Non-descent vaginal hysterectomy has advantage over laparoscopic hysterectomy as scarless surgery with fewer complications.
Background: Osteogenesis imperfecta (OI) also known as the brittle bone disease is a connective tissue disorder typically characterized by bone fractures due to defective collagen synthesis. In case of no known family history of the parents related with OI, the prenatal diagnosis of the disease and definition of the subtype for additional information of the family to decide on the fate of pregnancy is of paramount importance. Case presentation We report a prenatal-case, of challenging bone disease diagnosed as OI type III during pregnancy with the differential diagnosis and its prenatal management.
Dermoid cysts are the most common ovarian lesions, accounting for about 10-20% of all ovarian tumors. They are usually seen in younger age group females as compared to epithelial tumors. Usually remains asymptomatic, but complications can lead to varied presentations. Dermoid cyst perforating bladder is a very rare presentation. Here we report two cases of ovarian dermoid perforating in bladder and patient presented with complaints of passage of hair in urine (Pilimiction). Imaging confirmed the finding in both the cases. Surgery remains the mainstay of treatment including removal of the mass along with bladder repair.
A uterocutaneous fistula is a rare clinical presentation that occurs following cesarean section or any other pelvic surgery. We describe a case of uterocutaneous fistula with successful surgical management. A 25-year woman was referred to our hospital with complaints of cyclical bleeding from lower segment cesarean section scar (LSCS scar). It was diagnosed as uterocutaneous fistula on ultrasonography and computed tomography. The fistula tract was excised. Histopathology report was suggestive of sinus tract due to tuberculous etiology. Patient was started on antituberculous treatment. Recovery was uneventful.
Background: Fetal arrhythmias constitute 10 to 20% of the total referrals to fetal cardiology unit. Ventricular tachycardia (VT) is a rare form of fetal tachyarrhythmia.
Materials and methods: This report describes the clinical presentation, diagnostic features, and successful management of VT in a fetus at 32 weeks of gestation. Transplacental therapy with sotalol resulted in the termination of tachyarrhythmia in 48 h, followed by good postnatal outcome.
Conclusion: Fetal m-mode showing ventricular rate higher than atrial rate with atrio-ventricular dissociation is suggestive of VT. Early diagnosis and institution of transplacental therapy prior to development of hydrops seem to carry a good prognosis even in malignant fetal arrhythmias like VT.
Fetal tachyarrhythmia, Ventricular tachycardia, Prenatal diagnosis, Transplacental therapy