Abstract

Reproductive tract malformations are rare in general population but are commonly encountered in women with infertility and recurrent pregnancy loss. Obstructive anomalies present around menarche causing extreme pain and adversely affecting the life of the young women. The clinical signs, symptoms and reproductive problems depend on the anatomic distortions, which may range from congenital absence of the vagina to complex defects in the lateral and vertical fusion of the Mu¨llerian duct system. Identification of symptoms and timely diagnosis are an important key to the management of these defects. Although MRI being gold standard in delineating uterine anatomy, recent advances in imaging technology, specifically 3-dimensional ultrasound, achieve accurate diagnosis. Surgical management depend on the type of anomaly, its complexity and the proper embryological interpretation of the anomaly and involves multiple specialties; thus, patients should be referred to centres with experience in the treatment of complex genital malformations.

Abstract

Human childbirth has been described as an ‘‘obstetrical dilemma’’. Evolution favours enlargement of the foetal brain, whilst bipedal locomotion demands a reduction in pelvic breadth for improvements in biomechanical efficiency. The result of this conflict is a human pelvis incongruous with the dynamics of childbirth. Acute genital distortion at delivery can inflict lasting damage to female pelvic function. Pelvic organ prolapse, urinary, faecal incontinence and sexual dysfunction are long-term sequelae rarely discussed at antenatal care, impacting upon the expectant mother’s ability to make an informed decision. The alternative option is the elective caesarean section, an abdominal incision bypassing the maladies of a vaginal delivery, although not without complications of its own. Childbirth remains an emotive event where evidence- based medicine can be disempowered, and the rising trend to ‘‘normalise’’ birth can disrupt care of the woman. This needs to be maintained in a healthy balance to best provide competent and safe care for women.

Abstract

Background: Solitary kidney may be congenital or as a result of nephrectomy. There is a lot of literature available on quality of life in these patients, but there is limited data on pregnancy outcome.

Objectives: To study pregnancy outcome in patients with solitary kidney either congenital or due to nephrectomy.

Materials and Methods: Study Design This is a retrospective observational study conducted at tertiary health center in Ahmedabad, from 2011 to 2014. Sample Size There were 164 patients of solitary kidney, out of which two patients had congenital solitary kidney and the remaining had solitary kidney due to nephrectomy. Among 164 patients, 96 (58.53 %) patients had completed family, 37 (22.56 %) patients did not try for pregnancy, 15 (9.14 %) patients have conceived, 12 (7.3 %) were lost to follow up and 4 (2.43 %) patients were infertile. Method Patients in reproductive age group (20–40 years), with solitary kidney either congenital or due to nephrectomy, were included. Maternal and fetal outcome was studied, and patients were followed up till 2 years postpartum. Exclusion Criteria Patients with solitary kidney due to post-renal transplant were excluded.

Results: There were 15 (9.14 %) patients who had conceived, out of which 11 (73.33) patients delivered and 4 (26.67 %) patients had spontaneous abortion. Two patients developed gestational hypertension and one had preeclampsia. On follow-up, all babies were normal and none of them had delayed developmental milestones.

Conclusion: Preconceptional counseling should be done in these patients regarding risk of developing preeclampsia during pregnancy and preterm delivery. These patients can have good pregnancy outcome with close monitoring during antenatal period.

Abstract

Objectives: To evaluate the cerebroplacental ratio which is the ratio of pulsatility index of fetal middle cerebral and umbilical arteries, in normal and high-risk pregnancies during 30–36 weeks of gestation.

Methods: In this study, we included 70 patients, who were scanned for Doppler parameters of Middle cerebral artery and Umbilical artery pulsatility index ratio of fetus, between 30 and 36 weeks, and then were followed till delivery. Thirty-five patients with normal pregnancy and 35 patients with high-risk pregnancy were included. Perinatal outcome was evaluated in relation to indices ratio.

Results: There was cerebroplacental ratio of\1.00 in eight cases of the study group in comparison with the control group in which there is no case of < 1.00 value. It was associated with poor perinatal outcome in terms of need for lower segment cesarean section for fetal distress, Apgar < 8 at 5 min, and admission to nursery.

Conclusion: Cerebroplacental ratio is highly sensitive in diagnosing hemodynamically compromised fetuses and very useful for the prediction of adverse perinatal outcome in these fetuses.

Abstract

Background: Cesarean section is on the rise all over the world; it has become a safe surgery due to better anesthesia, asepsis, blood transfusion and antibiotics. Traditionally, the patients are kept nil orally till they pass flatus. This study was performed to find out acceptance and tolerability of early feeding, its side effects and complications if any.

Methods: This comparative study was conducted in a service hospital. There were two groups of 70 cases each where one was administered early feeding and the second group was put on standard delayed feeding as is traditionally done in most of the hospitals. Gastrointestinal outcomes and other parameters were noted in both the groups and analyzed.

Results: During the study period, every alternate willing case without any exclusion criteria was allotted to each group. Early feeding was started 6 h after surgery in the study group, whereas it was withheld till passage of flatus in the control group. Appearance of bowel sounds and passage of flatus were earlier in study group (21.6 and 34.5 h, respectively) as compared with control group (31.7 and 49.2 h, respectively). There were no complications or side effects of early feeding.

Conclusion: There is no justification to withholding oral feeds as is traditionally done. Early feeding should be initiated without fear of any side effects. Patients have an early postoperative recovery; it is cost-effective and results in higher patient satisfaction.

Abstract

Aim and Objectives: To construct a hybrid model classification for cesarean section (CS) deliveries based on the woman-characteristics (Robson’s classification with additional layers of indications for CS, keeping in view lowresource settings available in India).

Methods: This is a cross-sectional study conducted at Nalanda Medical College, Patna. All the women delivered from January 2016 to May 2016 in the labor ward were included. Results obtained were compared with the values obtained for India, from secondary analysis of WHO multicountry survey (2010–2011) by Joshua Vogel and colleagues’ study published in ‘‘The Lancet Global Health.’’ The three classifications (indication-based, Robson’s and hybrid model) applied for categorization of the cesarean deliveries from the same sample of data and a semiqualitative evaluations done, considering the main characteristics, strengths and weaknesses of each classification system.

Results: The total number of women delivered during study period was 1462, out of which CS deliveries were 471. Overall, CS rate calculated for NMCH, hospital in this specified period, was 32.21% (p = 0.001). Hybrid model scored 23/23, and scores of Robson classification and indication-based classification were 21/23 and 10/23, respectively.

Limitations of the Study: Single-study centre and referral bias are the limitations of the study.

Conclusion: Given the flexibility of the classifications, we constructed a hybrid model based on the woman-characteristics system with additional layers of other classification. Indication-based classification answers why, Robson classification answers on whom, while through our hybrid model we get to know why and on whom cesarean deliveries are being performed.

Abstract

Objective: To compare the incidence, maternal and fetal outcomes of gestational diabetes mellitus using one step versus two steps as a screening procedure.

Methodology: A prospective randomized trial involving screening of 1000 pregnant women for gestational diabetes mellitus was conducted. Women were divided in two groups (500 each). Group A comprised of patients screened with two-step approach (ACOG recommendation), and group B comprised of women screened by one-step method (IADPSG criteria). Women diagnosed with ‘gestational diabetes’ were followed in an antenatal clinic, and incidence of GDM and maternal and fetal outcome between two groups were analyzed using SPSS.

Results: The incidence of GDM was almost double using one-step versus two-step approach which was 19.2 and 11.8%, respectively. Maternal outcomes were comparable in both the groups except the risk of preterm delivery which was 2.5 times more in group A than group B (odds ratio = 2.43 95% CI 1.01–5.79). Further, fetal outcomes were also comparable except neonatal hypoglycemia which was seen in 29.31% in group A versus 7.4% in group B. In the group B, 15 patients (15.8%) with GDM (based on FBS >= 92 mg/dl at first ANC visit) showed clinical symptoms and blood sugars in hypoglycemic range on MNT requiring resumption of normal diet.

Conclusion: The incidence of GDM using IADPSG criteria was almost double versus ACOG criteria. Maternal and fetal outcomes were comparable except in 15.8% women diagnosed as GDM (using FBS C 92 mg/dl at first ANC visit as per IADPSG) and suffered from hypoglycemia. A large trial is being proposed before these criteria are adopted.

Abstract

Introduction: Adenoid cystic carcinoma of vulva (ACCvulva) is an extremely rare entity with < 100 cases reported in the literature so far.

Objective: To study the clinical profile and outcome of ACC-vulva treated at a tertiary cancer care centre in South India.

Methods: This is a retrospective, record-based study of histopathologically confirmed cases of ACC-vulva treated at our centre from January 2005 to March 2016.

Results: Only four patients were diagnosed with ACCvulva during the 11-year period under study. The longest duration of follow-up was 129 months. The age at diagnosis ranged from 32 to 43 years, with a median of 40 years. All patients were married, parous and premenopausal and presented with a painless unilateral vulval swelling. All patients had involvement of the Bartholin’s gland site with normal overlying skin. In all patients, wide excision was performed. Unilateral inguinal node dissection was done in one case. Perineural infiltration was documented in two cases, while positive excision margins were present in three cases. None of the patients had any lymph node involvement at diagnosis or during follow-up. Two patients had recurrence of disease. The disease-free interval was 23 months for one patient and 118 months for the other. In both, local (vulval) and distant (multiple lung) metastases were detected simultaneously.

Conclusion: Adenoid cystic carcinoma of vulva is an extremely rare, slowly progressing neoplasm mostly involving the Bartholin’s gland. The usual treatment includes wide excision and adjuvant radiotherapy (if required). There may be late local and distant recurrence.

Abstract

Introduction: Using an intrauterine device (IUD) is many times safer than pregnancy and more effective in preventing pregnancy than oral contraceptives, condoms, spermicidal, any barrier method, or natural family planning. Benefits of healthy timing and spacing of pregnancy are many. Postpartum contraception is becoming popular after introduction of PPIUCD services.

Objective: To study the incidence, management, clinical outcome of missing strings cases in post-placental and intra-cesarean IUCD.

Materials and Methods: This study was a retrospective observational study, carried out in the district of Balangir, Odisha, India. Status of women who had post-placental and intra-cesarean IUCD insertion in various institutions between January 2010 and December 2012 having followup as per the protocol was taken for the study. All the complications were recorded and studied. Incidence, clinical outcome, and management of missing strings were analyzed.

Results: Records of 1343 clients were studied. Six hundred and seventeen cases had failed to report for follow-up as per the study design. Seven hundred and twenty-six cases had follow-up as per the protocol. Of them, 36 had expulsion, and rest 690 cases were taken for the study. There were 209 missing strings at 3 months. At the end of the study, there was spontaneous descend in 138 cases. More than 50 % cases were asymptomatic. Ultrasonography was the method of diagnosis, and simple sounding of the uterus alone could also establish IUD in uterine cavity. Removal rate was higher in missing strings group, Continuation rate is higher in String visible group.

Conclusion: Post-placental intra-cesarean Copper T 380A insertion is a safe and effective method of reversible contraception; missing string is emerging as a potential distracter of its use. It is important that every user must be followed up and the providers must be competent in managing complication. Better after care in form of effective follow-up and complication management is needed to maintain popularity. Introduction of compensation scheme will also help improving the acceptance.

Abstract

Objective: To study the prevalence, clinical and laparo-scopic characteristics of endometriosis in infertile women.Study DesignThis is a hospital-based prospective study.PatientsFive hundred and two (502) patients underwentdiagnostic laparoscopy for evaluation of cause for infer-tility. Staging of endometriosis was done according to therAFS scoring system.

Results: Out of 502 women, 276 (54.98 %) showed thepresence of endometriosis, while 226 (45.01 %) did nothave endometriosis. One hundred and eighty-three(66.3 %) women had stage I endometriosis, 49 (17.77 %)had stage II, 23 (8.33 %) had stage III and 21 (7.6 %) hadstage IV endometriosis.

Conclusion: More than 50 % of patients in our study wereasymptomatic; however, the presence of menorrhagia,dysmenorrhoea, dyspareunia and chronic pelvic pain arealso clinically statistically significant. So, we would like torecommend the evaluation and treatment of a patientreporting in gynaecological OPD with the above-men-tioned complaints with high suspicion of endometriosis.

Abstract

Objective: The study is to promote the least invasive approach that combines cholecystectomy and hysterectomy at the same operative sitting so as to provide maximum benefits to women.

Method: A series of 45 women between 40 and 75 years age from year 2001 to 2014 from the private practice of author and colleague surgeons in Mumbai were in need of hysterectomy as well as cholecystectomy for gynecological indication and symptomatic gallstones, respectively. Cholecystectomy was performed laparoscopically by general surgeon and was combined with hysterectomy with or without bilateral salpingo-oophorectomy (BSO) via vaginal route by gynecologist.

Result: The average surgical time was 40 min for laparoscopic cholecystectomy and 32 min for hysterectomy and 40 min for hysterectomy with bilateral salpingooophorectomy to 64 min when uteri needed heavy debulking. Total blood loss was approximately less than 50–100 ml for hysterectomy and up to 250 ml for hysterectomy needing fair amount of debulking. Blood loss for laparoscopic cholecystectomy was 10 ml to maximum of 80 ml.

Conclusion: Lesson for both, gynecologists and the surgeons, is to combine these two when required and possible. This provides maximum advantages through minimizing risk of anesthesia and time duration, hospital stay, costeffectiveness.

Abstract

Aim: The prevalence of scar endometriosis is increasing with the increasing caesarean deliveries and laparoscopic procedures done for pelvic endometriosis. To analyse the symptomatology and surgical perspective of scar endometriosis.

Materials and methods: Retrospective review of 16 women who underwent surgery for scar endometriosis in the period of 4 years in Amrita institute of medical sciences.

Results: Mean age of the patients is 35.19 years. Mean interval from the index surgery to the presentation is 4.56 years. Mean size of the swelling is 2.84 cm. In 68.8% of the patients, caesarean section was the inciting surgery. 18.7% had port site endometriosis. Cyclical pain and swelling at the scar site was present in 93.8% of the women. 18.9% had concurrent pelvic endometriosis. All women had involvement of the subcutaneous tissue followed by 11 women with the involvement of rectus sheath. There was no recurrence of the lesion in the operated patients in the mean follow-up period of 11.91 months.

Conclusion: In all women presenting with cyclical scar site pain and swelling, scar endometriosis should be considered. It commonly follows caesarean section and laparoscopic surgeries done for endometriosis. Wide local excision with or without reconstruction is the method of choice for this condition. Role of tumescent solution during surgery and postoperative medical management to reduce recurrence needs further prospective studies.