Abstract

Oral agents to induce ovulation are the first line therapy for infertile women with polycystic ovarian syndrome (PCOS). The most commonly used drug, clomiphene citrate, leaves us with room for improvement. Ovulation rates of 80% are achieved, but pregnancy rates are close to 40% with clomiphene 1. The need for an alternative oral ovulation induction agent is robust. It is nearly 30 years since the link between abnormal insulin action in PCOS has been demonstrated 2. Though peripheral insulin resistance is most evident in obese patients, it is prevalent in lean women with PCOS. The mechanism(s) underlying insulin resistance and reproductive abnormalities in women with PCOS remain unclear 3. Metformin, a biguanide used as an oral hypoglycemic agent in overweight individuals with diabetes reduces peripheral insulin resistance. This property made it a subject of study and much controversy in women with PCOS. Metformin acts mainly by decreasing hepatic glucose production. Metformin also improves glucose utilization in the periphery, reduces intestinal glucose uptake, and decreases lipolysis reducing the substrate for gluconeogenesis. Additionally, some evidence has suggested that metformin may act directly to attenuate ovarian steroidogenesis 4. The role of metformin has been extended to the lowering of ovarian hypersensitivity to insulin. It has also been proposed that metformin may modify some of the defects in the adipose tissue lipolytic cascades or inflammatory mediators (IGF-1, SHBG) which induce peripheral insulin resistance. Clinical use of metformin The most physiological approach to lowering insulin resistance and inducing ovulation in women with PCOS isweight loss. This should be an integral part of any treatment program. Metformin is available in both short and long acting formulations. The short acting formulation comes in 500, 850 and 1000mg tablets and the extended release formulation in 500 and 750 mg tablets. It is recommended to start at a dose of 500 mg with the largest meal and titrate up to the maximum dose over several weeks depending upon patient tolerance. The slow increase in dosage will prevent or minimize the gastrointestinal side effects such as nausea, vomiting, and bloating. In clinical practice, most women will respond to a dose between 1000 and 1500 mg.

Abstract

The control of cervical cancer has been on the agenda of health care workers all over the world for several years. It is more of a problem in the developing world as 80% of all cases are seen in low resource setting. Approximately 1.2 lakh cases occur in India each year out of these 80,000 present with advanced disease and succumb within a year. However, the scenario changed dramatically in the 20th century. With the introduction of radiotherapy, the concept of precancer, and routine use of Pap smear in the developed world the disease is finally getting under control. Although it has been known since centuries that cervical cancer was in some way related to sexual activity no definite carcinogen was implicated. It was in the 1970s that Zur Hausen 1 in Germany implicated that the human papillomavirus was the causative organism which led to the development of cervical cancer. Further developments were rapid. Over a 100 different types of HPV specific to human beings were discovered. At least 30 of these affect the genital mucosa. They are further divided into high oncogenic potential and low oncogenic potential HPV. Cervical cancer is the first solid tumor associated with virus infection. It is a spherical Zur Hausen’s 2 research resulted in a monumental work which explained molecular pathogenesis of cancer cervix and its causation by a virus, which radically changed our thinking. However, it is only in the last 30 years that there have been substantial changes in the understanding of the disease and major changes in the concepts of control.

Abstract

Postpartum hemorrhage (PPH), defined as any bleeding that results in signs and symptoms of hemodynamic instability 1, is a potentially life threatening complication reported to occur in 2-10% of deliveries 2-4. Hemorrhage occurring within the first 24 hours is termed primary whereas that occuring upto 6 weeks thereafter is defined as late or secondary. Recent estimates indicate that at least one quarter of all maternal deaths are due to hemorrhage i.e. at least 18,000 annually worldwide 5. Most of these deaths occur within 4 hours of delivery 6 and are a result of problems during the third stage of labor. PPH also imparts significant morbidity to the reproductive health due to surgical interventions that may result in permanent sterility and due to exposure to blood products 7. This condition warrants aggressive treatment by an experienced clinician for a favorable outcome. Studies have shown uterine atony as the commonest cause of immediate severe PPH 8. In the etiology of postpartum uterine atony, hypoxia is considered an important factor although some suggest that peripheral oxygen saturation is not influenced by oxygen inhalation in women during the first and second stages of labor 9 and oxygen inhalation does not improve neonatal outcome 10. Oxygen desaturation, however, may occur in laboring women with the use of narcotic analgesics 11. Enhancing oxygen delivery to myometrium through additional inhaled oxygen may improve uterine contractions. Therefore, it is reasonable to consider that oxygen inhalation may promote myometrial contraction and prevent PPH due to uterine atony. The tendency for the uteri to relax in women encountering respiratory problems immediately after cesarean section under general anesthesia (personal observation) further strengthened this theory. In this study, we hypothesized that inhaled oxygen helps maintain uterine retraction during immediate postpartum period and hence reduces vaginal blood loss.

OBJECTIVE(S) : To study the effect of oxygen inhalation immediately after normal delivery on blood loss.

METHOD(S) : Sixty consenting women delivering normally vaginally in our tertiary care teaching hospital were alternatively allocated to either receive 40% oxygen via a facemask for 6 hours after the third stage of labor (study group) or breathe room air (control group) in addition to conventional management. Twenty one women in the oxygen inhalation group and 19 in the room air inhalation group had episiotomy. all women were evaluated hourly for vaginal blood loss.

RESULTS : The study and the control groups were similar in age, parity, body weight and induction rate. Mean vaginal blood loss during the 1st hour was 32.4±34.1mL in controls and 16.9±19.1mL in study group receiving oxygen (P=0.05). The mean hourly vaginal blood loss gradually declined in both the groups and was 12.0±8.4mL in the controls and 7.2±3.8mL in the study group (P=0.01) during the 6th hour.

CONCLUSION(S) : Oxygen inhalation immediately after third stage of labor appears to reduce blood loss after normal vaginal delivery.

Abstract

Female preponderance of autoimmune connective tissue disorders had raised considerable interest regarding the outcome of pregnancies in affected women. In such patients adverse pregnancy outcomes like intrauterine growth restriction (IUGR), prematurity, recurrent pregnancy loss and stillbirth are more common.

Multiple factors e.g. genetic factors, disease activity, renal involvement, previous pregnancy loss, environmental factors (sun exposure), antiphospholipid and lymphocy to toxic antibodies, drugs like sulfonamides and antibiotics, and hormones have been implicated for the adverse pregnancy outcome but precise mechanism is still obscure. Systemic lupus erythematosus (SLE) is the prototype autoimmune connective tissue disorder, the others being rheumatoid arthritis (RA), scleroderma, Behcet’s disease, and Sjogren’s syndrome. In various studies a greater rate of stillbirth and spontaneous abortion is noted in patients with scleroderma but in patients with primary Sjogren’s syndrome and RA contradictory outcomes are reported.

From time to time different antibodies were considered to be responsible for the pathogenesis of these diseases. Various recent studies considered the anti-Ro/SSA antibody as a possible factor for unexplained pregnancy loss. This anti- Ro/SSA antibody is directed against soluble cellular ribonucleoprotein complexes and is present in the serum of more than 10% patients of connective tissue disorders. It is strongly associated with neonatal lupus and congenital heart block - a model of passively acquired autoimmunity. We report the outcome in 18 pregnant women with autoimmune connective tissue disorders.

Eighteen pregnant women with history of autoimmune connective tissue disorders attending the outdoor clinic were studied over the last 2 years. Detailed history was taken with special reference to duration of disease flare, present activity, medications, past obstetric outcomes, multiorgan involvement especially renal status, and present pregnancy complications like threatened abortion, preeclamptic toxemia (PET), preterm labor etc. All of them were thoroughly examined for any dermatological, skeletal, ophthalmological, neurological, gastrointestinal, and vascular manifestation.

OBJECTIVE(S): To study the effects of various immunological connective tissue disorders on pregnancy and the effects of pregnancy on these diseases.

METHOD(S): A total of 18 pregnant women with connective tissue disorders were studied. Of these three had scleroderma, five had rheumatoid arthritis (RA), nine had systemic lupus erythematosus (SLE), and one had SLE with antiphosphotipid antibody (APLA) syndrome. These patients were followed up and outcomes analyzed.

RESULTS: No intrauterine death (IUD) or spontaneous pregnancy loss occurred in scleroderma or RA group, but in SLE group there were four preterm births, four IUDs, one spontaneous abortion, one therapeutic abortion, six preeclamptics and eight cases of flare up of the disease.

CONCLUSION(S): Connective tissue disorders in pregnancy may adversely affect both the mother and the fetus. Disease activity may be flared, but is rarely reduced. SLE patients had more unsuccessful outcomes and disease aggravation than others.

Abstract

Meconium stained amniotic fluid (MSAF) is present in 1- 18% of all deliveries 1. Meconium aspiration syndrome (MAS) occurs in 1-3% of all cases of MSAF and in 10-30 % of neonates meconium is present below the vocal cords 2.

MAS is defined as meconium identified below the laryngeal cords with respiratory distress requiring oxygen or ventilation and with no evidence of sepsis 3. Infants born through MSAF are 100 times more likely to develop respiratory distress compared to their counterparts born through clear amniotic fluid 4. It is the particulate meconium (moderate or thick) which is associated with MAS and poor perinatal outcome. More than 90% develop MAS in patients with thick meconium, probably meconium of greater viscosity is more likely to pass below the cords 1.

The present study was undertaken to find the incidence of MAS in cases with MSAF and to study the morbidity and mortality in newborn babies with MAS. This study was carried out over a period of 9 months from July 1999 to March 2000. All women having full term (>37 weeks) and post term singleton pregnancy with vertex presentation in labor with meconium stained liquor (MSL) or those in whom MSL was detected during cesarean section were enrolled as MSAF. For all the cases enrolled, detailed obstetric and medical history was taken and general, systemic and local examinations carried out. Vaginal examination was done to determine the status of the cervix, station of the head, and color and characteristics of meconium.

OBJECTIVE(S) : To study the incidence of meconium aspiration syndrome (MAS) in meconium stained amniotic fluid (MSAF) and also the morbidity and mortality in newborn babies with MAS.

METHOD(S) : Two hundred and fifty pregnant women were enrolled, 179 having babies with MSAF and 71 having babies with MAS.

RESULTS : MAS developed in 28.4% cases. Need for assisted delivery was 46.37% in MSAF group and 36.62% in MAS group. Apgar score of <5 at 5 minutes was seen in 2.23% in MSAF group and 14.08% in MAS group. NICU admission was 64.23% in MSAF group as compared to 100% in MAS group. Neonatal morbidity was 25.15% in MSAF group as compared to 97.2% in MAS group. Mortality was 9.2% in MSAF group as compared to 25.3% in MAS group.

CONCLUSION(S) : Presence of meconium in amniotic fluid is a poor predictor of fetal outcome. There is increased chance of operative delivery in presence of meconium, specially if associated with abnormal fetal heart sounds.

Abstract

Prelabor rupture of membranes (PROM) affects 10% of all pregnancies. Existing views differ widely regarding the timing and method of induction of labor in PROM at term.

The advent of prostaglandin analogue, misoprostol, has given the obstetricians another alternative to the traditional use of oxytocin for active management of PROM. Prostaglandins are used in obstetrics because of their uterotonic effect. They are used as cervical ripening agents for labor induction and control of postpartum hemorrhage.

Misoprostol is a synthetic analogue of PG E 2. When given orally, it is rapidly absorbed by gastrointestinal tract. It then undergoes deesterification to its free acid, which is responsible for its clinical activity. Peak concentration time and half life of misoprostol acid (the active metabolite) are 12 minutes and 21 minutes respectively. Total systemic bioavailability of vaginally administered misoprostol is three times greater than that of orally administered misoprostol. Misoprostol is extensively used because it is effective, inexpensive, easily stored (shelf life 2 years), not affected by ambient temperature and needs no refrigeration for its storage and no needles or syringes for administration. It has, in comparison to the other prostaglandins, minimal effects on cardiovascular system and bronchial tree smooth muscles and so can be safely used in hypertensives and asthmatics. Vaginal application of misoprostol for induction of labor has been extensively studied. We studied the efficacy of oral misoprostol for induction of labor in PROM. We chose the oral route because of its ease of administration.

OBJECTIVE(S): To evaluate the efficacy of oral misprostolol for induction of labor in women with prelabor rupture of membranes (PROM) at term.

METHOD(S): Three hundred pregnant women at term with PROM, singleton pregnancy and cephalic presentation who were not in labor were taken up for study and were randomly selected for conventional expectant management for 20- 24 hours followed by induction by oxytocin (control group) or oral misoprostol in the dose of 50 µg 4 hourly upto a maximum of six doses (study group). Chi square test and standard error of difference between two means [SE(d)] were used for statistical evaluation.

RESULTS : Cesarean rates were comparable in the two groups (16.7% and 18% in study and control groups respectively). Induction delivery interval was similar (10 hours 26 minutes ± 4 hours 11 minutes and 9 hours 39 minutes ± 2 hours 42 minutes in study and control groups respectively). The mean PROM - delivery interval was significantly shorter in the study group (18 hours 10 minutes ± 7 hours 20 minutes vs 29 hours 55 minutes ± 5 hours 54 minutes). Oxytocin requirement was lower in the study group (38% vs 80%). The average nursery stay was also lower in the study group (3.5 vs 6.4 days).

CONCLUSION(S) : Oral misoprostol significantly reduces the PROM - delivery interval, oxytocin requirement, and average nursery stay, and provides a cheap method of induction of labor in women with PROM.

Abstract

Urinary tract infection (UTI) is a very common condition which causes more than 7 million outpatient visits each year 1 and two-thirds of the patients are women 2. Generally 10-20% of women get symptomatic UTI during their life and about 20 percent of them have recurrence during the next 6 months 2.

The cost of these 7 million episodes of UTI in women in the United States of America is estimated to be more than a million dollars each year 3. The most important complications of UTI are pyelonephritis, sepsis, and premature delivery. Treatment of women with UTI also needs treatment of genital tract infection. The recent observations show that after beginning of sexual activities the incidence of UTI increases considerably in women 1. Before appearance of remarkable bacteriurea, the colonization around urethra is found with the same germs that cause UTI 4,5. UTI is the second most frequent type of infection treated in primary care clinics 6.

It is obvious that the best way to reduce this problem is the recognition of effective factor in pathogenesis which is the lack of lactobacillus producing peroxide hydrogen as a dominant flora of vagina, which facilitates colonization of coliforms in the lower vagina, the skin around urethra and distal urethra 1.

In 1989 the relationship between bacterial vaginosis a(BV) and UTI in women using diaphragm was reported 7,8. In 2000, for the first time, there was a report that women suffering from (BV) are at greatest risk of UTI than others 9. After registering the present research, two other reports were published in 2002 to confirm this hypothesis 10,11.

Considering the presence of only few research studies and lack of information about the incidence of this relationship in Iran and also availability of cheap and fast diagnostic tests we performed this study in women with UTI in 2001- 2002.

OBJECTIVE(S): To study the relationship between bacterial vaginesis (BV) and urinary tract infection (UTI).

METHOD(S): This case control study was carried out on 134 patients labeled as having UTI when urinary culture was positive. Normal individuals with negative culture, matched with the study subjects comprised the control group. Matching was designed for age, frequency of coitus, years of marriage and use of contraception. BV based on standard Amsel criteria was determined in both the groups. The results were analyzed using t test and χ 2 test. The odds ratio and confidence interval were calculated.

RESULTS : Sixty seven patients with UTI were compared with 67 normal individuals. BV was reported in 40.3% and 62.7% in the control and study group respectively (P<0.01, OR = 2.49). Characteristic discharge and pH over 4.5 was reported in 91% , positive whiff in 74% and clue cells in 72% of patients with BV.

CONCLUSION(S) : Individuals with UTI encountered BV significantly more often than those in the control group. Key words : bacterial vaginosis, urinary tract infection, clue cell

Abstract

In the last decade major advances have been made in the field of ovarian stimulation and embryo culture but the technique of embryo transfer (ET) has remained substantially the same. Over the recent years there has been an increasing interest in the methodology of embryo transfer and its influence on success rates of IVF cycles.

A lot of research is going on regarding the prognostic factors for success rates of ET like atraumatic transfers, use of soft catheters, influence of blood, mucus or bacteria in catheters, use of no touch techniques, performing mock transfer and transfers under ultrasound guidance 1,2.

Difficult ET is associated with impaired implantation 3 probably due to endometrial damage 4, presence of blood in the catheter 5, and triggering of uterine contractions due to cervical manipulation.

There is hardly any literature on the effect of time employed for performing ET on the success rates of IVF cycles. Logically, the time employed for performing ET may be an important prognostic factor for implantation and pregnancy rates since external factors like changes in environment, temperature, exposure to light, composition of catheter and embryo handling may have detrimental effects on the survival and growth of the embryo.

A prospective study was done on all women recruited for IVF at our unit between January and March 2005. A total of 103 cases were studied as regards their age, duration of infertility, ease of ET, number of retrieved, inseminated, fertilized and transferred oocytes, and interval between loading and discharge of embryo and its relationship with pregnancy and implantation rates.

OBJECTIVE(S): To study the influence of time taken for embryo transfer on the success rates of IVF.

METHOD(S): A prospective study was done on 103 women recruited IVF at our unit in whom fresh embryo transfer was done. These cases were thoroughly studied as regards their age, duration of infertility, ease of transfer, and duration between loading and discharge of embryo and its statistical relationship with pregnancy and implantation rates.

RESULTS: Pregnancy rate and implantation rate were found to be more among the women having less than 60 seconds duration between loading and discharge of embryo than in women where this duration was more. This difernce was found to be statistically significant (p<0.05). Furthermore, a significantly higher pregnancy and implantation rates were seen with easy embryo transfers.

CONCLUSION : The time taken for loading and discharge of embryo could be an important prognostic factor for implantation and pregnancy rates in invitro fertilization programmes as the shorter the time higher the pregnancy rate.

Abstract

Cervicovaginal cytology has been established as an indispensable tool in differentiating radiation changes from the recurrence in the first few months after treatment and also for detecting recurrence of carcinoma even when there are no clinical signs or symptoms 1,2.

It also helps in detecting cases of postradiation dysplasia originating in the altered mucosa of the irradiated cervix. Since 1992 it has been our practice to call the patients treated with radiation for 3 monthly cervical cytology follow up irrespective of whether they have any symptoms or not. This has helped in detecting recurrences of both cervical dysplasia and carcinoma to provide early treatment and increase the longevity of the patients. Till December 2004, a total of 876 irradiated women have been followed for periods ranging from 6 months to 12 years and the present communication embodies the details of 67 cases of recurrent carcinoma and 75 cases of cervical dysplasia encountered during the study.

Between January 1992 and December 2004, a total of 876 women have been registered at our center, and have been treated with radiation for carcinoma of cervix. Cervical cytology was performed in all cases after completion of treatment to rule out presence of malignant cells. Since majority of the treated patients came from remote places a planned follow up was not possible and the patients were advised to come after every 3 months for repeat Pap smear. Only 741 of them returned for follow up 6 months to 1 year after receiving radiation. Follow up after 2 years was available in 357 and after 3 years in 193, and the number substantially reduced beyond this period.

The cervical smears received from the irradiated women were stained by Papanicalou’s technique and cytopathological grading of the smears was made according to WHO classification of 1973 3.

OBJECTIVE(S) : To evaluate the role of cervicovaginal cytology in detection of postradiation dysplasia and recurrent carcinoma in women treated with radiation for carcinoma cervix.

METHOD(S) : The study comprised of 786 women attending gynecological outpatient clinic between January 1992 to December 2004 in whom cervical cancer in different stages was diagnosed clinically and confirmed on histological examination. These women were treated with radiation and had cytological follow up for periods ranging from 6 months upto 12 years.

RESULTS : The incidence of postradiation dysplasia and recurrent carcinoma was found to be 8.5% and 7.1% respectively. Nineteen cases of small cell carcinoma were also observed. Only 28.3% of the recurrent carcinomas were found to be symptomatic or had clinical signs of any growth. Recurrence of both cytopathologies was seen upto 8 years after radiation and was maximum in women beyond 40 years of age. Both cytopathologies showed tendency to appear late with increasing age and showed rise with increasing stage of cancer.

CONCLUSION(S) :Cytology appears to be valuable tool in detecting postraditiation dysplasia and recurrent carcinoma even when there is no clinical sign or symptom. It alerts the clinicians beforehand for the recurrence and facilitates better chances of survival for the patients

Abstract

Carcinoma of cervix is the commonest cancer in Indian women1. In India, women aged > 50 years constitute 14% of the total population 2. The average annual age specific incidence rates of cervical cancer peak in this age group1.

The atrophic changes in the genital tract cause problems in the Papanicolaou (Pap) smear as well as colposcopy, which are used for screening and confirmation of preinvasive and invasive cervical cancers. There are scant reports (none from India) specifically addressing the problems of colposcopy in postmenopausal women 3-5. Hence, this study was undertaken.

This prospective observational study was conducted by the same colposcopy team. The study population comprised 70 consecutive postmenopausal women referred for colposcopy. The inclusion criteria were complaints of postmenopausal bleeding or abnormal vaginal discharge, postcoital bleeding, an abnormal Pap smear, an unhealthy looking cervix clinically suspicious of malignancy, and evaluation of the vagina following hysterectomy for high grade cervical intraepithelial neoplasia (CIN) or radical surgery for cancer of the cervix or uterus. Women with a history of surgery on the cervix in the past three months or with obvious cervical cancer were excluded. The main outcome measures were procedural and diagnostic problems associated with colposcopy and the corrective measures utilized to overcome the problems.

History, and general and systemic examinations were reviewed. A Pap smear was taken with an Ayre’s spatula and endocervical brush during speculum examination. Colposcopy was performed at the same visit by the saline technique followed by the classical method, using a Leisegang™ (Germany) stereo-photocolposcope model 3BD at magnifications of 7.5 X and 15 X. The cervix was swabbed with 3% acetic acid followed by evaluation of the acetowhite areas with 50% Lugol’s iodine.

OBJECTIVE(S) : To determine the problems of colposcopy in postmenopausal women.

METHOD(S) : A prospective observational study of 70 consecutive postmenopausal women referred for colposcopy was carried out. Problems encountered were noted and appropriate solutions applied. Chi square test with Yates correction when required and Student t test were used for testing significance.

RESULTS: Thirty percent had significant lesions (positive group) and 70% had inflammation (negative group). Colposcopy was unsatisfactory in 91%; the accuracy was 93%. 86.7% had procedural problems. Interpretive problems occurred in 40%. Difficulties due to senile vaginitis (27%) and relaxed vaginal walls (27%) were similar in both the groups. Problems associated with atrophy of introitus (26%), visualizing the cervix flushed with the vault (23%), and performing colposcopy due to continuous bleeding (13%) were significantly more in the positive group. Sim’s speculum, vaginal wall retractors, xylocaine jelly, and estrogen therapy resolved these problems.

CONCLUSION(S) : Atrophic changes cause problems during colposcopy in postmenopausal women. Proper technique and estrogen therapy overcome these problems.

Abstract

Evaluation of adnexal masses is of particular importance in gynecological practice firstly to differentiate benign and malignant masses and secondly for the choice of appropriate surgical treatment, as in many centers the type of surgery performed (laparoscopy versus laparotomy) depends on the probability of malignancy. Majority of adnexal masses are nonneoplastic cysts but 25% are malignant 1.

The optimal ultrasound technique and diagnostic criteria for characterizing a suspected ovarian neoplasm are controversial. Papillary formations on the inside of the cystwall and hyperechoic solid component are the most statistically significant predictors of a malignant ovarian mass. Ultrasound and morphologic parameters have a sensitivity of 80% and specificity of 93% that make this examination a standard for ovarian mass diagnosis 2.

Doppler flow measurement and assessment of tumor vascularity by doppler energy increased the confidence with which a correct diagnosis can be made. Color and pulsed doppler sonography depicts the vascularity of the pelvic organs and can be used for assessment of angiogenesis in tumor masses producing insights in tumor histology. So a prospective study was undertaken to assess the usefulness of ultrasound scanning, color flow mapping and pulsed doppler waveform in differentiating between benign and malignant ovarian tumors.

OBJECTIVE(S) : To assess the usefulness of ultrasound color flow mapping and pulsed doppler waveform in differentiating benign and malignant ovarian tumors.

METHOD(S): Clinically diagnosed ovarian cysts in 50 women were evaluated by sonography (only transvaginal in cysts <10 cm and both abdominal and transvaginal in cysts > 10 cm), color flow mapping and pulsed dopper wave form studies. On the basis of these findings they were classified into simple cysts, complex cysts, complex cysts with solid areas and solid cysts. These were correlated with subsequent laparotomy and histopathological findings.

RESULTS: For identifying malignancy color flow mapping showed 100% specificity, and 87.5% negative predictive value in simple cysts while 100% sensitivity and 100% positive predictive valve in solid cysts. Whereas its sesitivity, specificity, positive predictive value and negative predictive value were 33%, 78.5%, 25% and 84.6% respectively in complex cysts and 100%, 81.8%, 60% and 100% respectively in complex cysts with solid areas. For detecting malignancy pulsed doppler waveform had a sensitivity, specificity, positive predictive value and negative predictive value of 100%, 92.8%, 66.6%, and 100% respectively in simple cysts, 100%, 92.5%, 75% and 100% respectively in complex cysts and 66.6%, 90.9%, 66.6% and 90.9% respectively in complex cysts with solid areas; whereas its sensitivity and positive predictive value were 100% in solid cysts.

CONCLUSION(S): Both color flow mapping and pulsed doppler waveform studies are helpful in predicting malignancy in ovarian cysts.

Abstract

In the year 1951, India was the first country in the world to launch the Government sponsored Family Planning Program at the National level 1. Subsequently numerous changes have been made in the program with the basic aim of controlling the population of the country and thereby contributing towards more healthy society.

These changes had a target oriented approach, integration with Maternal and Child Health and with existing health infrastructure, a successively increasing budget, multiple goals etc 1. But what is the result? We have achieved the population figure of 1 billion easily. In the present observational study, we have tried to find out the real ground effects of the program over the last two decades and thus to know how much we have succeeded and how far and how hard we still have to go to avoid the population explosion in this very new millennium.

Starting from the year 1981 up to the year 2000, all the 53165 subjects from the population coverage area of the hospital who came for any type of family planning methods were included in this study. All these subjects were counseled by cafeteria approach about available contraceptive methods. The options provided were temporary methods of contraception like male barriers, oral pills, intrauterine devices and permanent methods like vasectomy, and abdominal and laparoscopic tubal ligation. All the subjects were provided with the method they chose and were explained in detail about that method. These data were recorded and maintained along with the hospital statistics. The hospital statistics of the ongoing family welfare activities for this duration was collected, compiled and extensively studied considering various aspects of the present study. Census data were collected for the last two decades 2-5. These 53165 subjects were grouped into 5 yearly subgroups to have an overall idea of the trend of acceptance of individual contraceptive method.

All results were reviewed in the light of available literature and available family welfare statistics and conclusions were drawn on this basis. SSPS software was used and relevant statistical tests were done for each method for the 5 yearly subgroups.

OBJECTIVE (S) : To study the changing trends in the acceptance of contraceptive methods.

METHOD(S) : In this observational study, data were collected for each contraceptive method accepted by the beneficiaries from 1981 to 2000. The methods included were male barrier methods, oral contraceptive pills, intrauterine devices, vasectomy, and female sterilization either by abdominal or laparoscopic approach. Total number of subjects studied was 53165. Statistical analysis with SPSS software and relevant tests was done for each method for 5 yearly subgroups.

RESULTS : There was one and a half times rise in the total number of subjects who accepted contraception, comparable to the rise in the population under study. For male barrier methods the acceptance rate has changed from 19% to 38%, for oral pills it has remained nearly the same, for intrauterine devices from 30% to 18%, for abdominal and laparoscopic tubal ligation from 11% to 8.92% and 9% to 11% respectively, and for vasectomy from 2% to 0.08%. For all the methods of contraception together, the male to female acceptance ratio has increased from 1: 3.7 in 1981-85 to 1: 1.6 in 1996-2000 but for permanent methods it has significantly decreased from 1: 8.5 to 1: 239.

CONCLUSION(S) : For the last two decades, there is statistically significant upward trend in the acceptance of male barriers, a statistically nonsignificant upward trend for laparoscopic tubal ligation, statistically significant downward trend in the acceptance of vasectomy, a slight downward, although statistically nonsignificant, trend for intrauterine devices and abdominal tubal ligation and no much change in the acceptance of oral pills. Overall, the acceptance ratio of male to female methods is increasing.

Abstract

A 27 year old para 2 was admitted on 18th June, 2003 complaining of acute pain in the lower abdomen with vaginal bleeding and nausea.

There was no history of amenorrhea or of recent intervention like uterine evacuation or curettage. She was para 2+0 with a history of miscarriage at home in 7th month of pregnancy nine months back which was followed by menorrhagia for the last 2-3 cycles.

Her pulse was 100/minute and regular. Blood pressure was 90/70mmHg. She was very pale. The abdomen was tense and tender. No abnormality was detected on systemic examination. Her hemoglobin was 6g/dL. Platelet count, blood urea and serum creatinine were within normal limits. Urine was positive for pregnancy test.

Provisional diagnosis of ruptured ectopic pregnancy was made and exploratory laparotomy performed on 18th June, 2003. There was hemoperitoneum and two uterine perforation sites were detected - one at the left side of the isthmic region and another at the left fundal region. Both tubes were healthy and both ovaries were cystic. Uterine repair could not be done due to excessive bleeding and friability of the tissue at the perforation sites. Bilateral internal iliac artery ligation was performed but it could not stop the bleeding and the laparotomy ended in a total abdominal hysterectomy. Four units of whole blood were transfused and subsequently another three units were given. Invasive mole was suspected and serum ß hCG level estimation was asked for. But she refused to undergo the test and went home against medial advice on 25th June, 2003 after an uneventful recovery.

Pathological examination of the hysterectomy specimen revealed that the uterus was bulky and its left lateral side was covered with hemorrhage and necrotic material. There was a perforation on the left side of the fundus measuring 3 cm, a hemorrhagic nodular area in the myometrium and another perforation of 2 cm size near the left upper part of the cervix. But the endometrial cavity was intact (Figure 1).

Spontaneous splenic rupture in pregnancy is rare and occurs most commonly in third trimester or puerperium1. Several case reports have been published since the first case report in 1803 2. This entity is of great importance since it carries a very high rate of maternal and fetal mortality if the possibility is not suspected. We present a rare case of spontaneous rupture of spleen in third trimester of pregnancy, the only one seen over last 10 years in our institution.

A 27 years old G3P1L1A1 was admitted at 8 months amenorrhea with complaints of sudden onset of acute abdominal pain. Pain was associated with nausea, vomiting and syncopal attacks. It was also referred to the left shoulder tip. There was no preceding history of trauma or vaginal bleeding. She had reported to a level II hospital in a state of shock where she was resuscitated and was referred to our tertiary care teaching institution as a case of abruptio placenta.

On general physical examination she was anxious but well oriented. Pallor was moderate with mild circulatory decompensation (pulse rate of 120 per minute and blood pressure of 110/80 of mmHg). On abdominal examination the uterus was of 30 weeks size and fetal heart sounds were clearly heard. There was tenderness all over the abdomen with maximum intensity in left lumbar region. Clinical evidence of free fluid was present. On vaginal examination the os was closed and no vaginal bleeding was noted. Obstetric sonography revealed a single live fetus of 30 weeks gestation with large amount of free fluid in the abdomen. Abdominal paracentesis revealed hemoperitoneum. Emergency laparotomy was done and approximately 3 L of fresh and clotted blood was removed. Source of bleeding was found to be approximately 3x3 cm defect in splenic capsule with active bleeding from the ruptured site. Splenectomy was done by a surgical colleague. The uterus was found to be intact. Liver was palpated and found to be normal. The patient received 4 units of blood transfusion during surgery. Postoperative period was uneventful. Patient received intramuscularly injection proluton depot and two doses of injection decadron 12mg, 12 hours apart along with antibiotics.

Abstract

Silent rupture of uterine fundus during pregnancy is a rare event.

A 24 year old 3rd gravida was admitted with complaints of loss of fetal movement since 3 days following amenorrhea of 9 months. There was no history of labor pains or leaking per vaginum. She was G3P2L1 with a previous LSCS done 2 years back for cephalopelvic disproportion and one preterm vaginal delivery followed by a doubtful history of manual removal of placenta a year ago. On examination, the patient was dyspneic with mild pallor. Her pulse rate was 110 beats/minute and blood pressure 100/70 mm Hg. Her abdomen was distended, tense and tender. The fetus was in breech presentation with absent fetal heart sounds. There was no scar tenderness. She had a ultrasound study done outside just prior to admission. It revealed a single fetus of 35 weeks in breech presentation with intrauterine death. Her routine investigations and coagulation profile were within normal limits. With a suspicion of scar rupture, she was immediately taken up for laparotomy. At laparotomy plenty of thick purulent foul smelling fluid was drained from the peritoneal cavity. The dead baby was lying in the abdominal cavity in breech presentation and was taken out. On exploration, uterine rupture was detected in the fundal region, through which placenta was partially seen. Removal of placenta was tried but it was morbidly adherent to the uterine wall reaching up to the serosa of the uterus, suggesting placenta percreta. The previous scar area was found to be intact. Subtotal hysterectomy was performed and the specimen sent for histopathological examination. Peritoneal lavage was done and the abdomen closed after leaving a drain in place. Two units of blood were transfused and broad spectrum antibiotics given. During the postoperative period, she became febrile and responded to antimalarial treatment. Stitches were removed on the 10th postoperative day and she was discharged in satisfactory condition.

Histopathological examination of the specimen revealed placental tissue infiltrating the whole thickness of the myometrium upto the serosa at some places and showed areas of infarction (Figures 1 and 2). The findings were consistent with the diagnosis of placenta percreta.

Abstract

Primary pulmonary hypertension is a rare, progressive, and currently incurable disease characterized by an increase in pulmonary hypertension without a demonstrable cause 1. When associated with pregnancy, the maternal mortality ranges from 30 to 50%. We share our experience about the successful outcome of a pregnancy with primary pulmonary hypertension by intermittent nocturnal nasal oxygen therapy.

A 32 year old primigravida reported to out patient clinic complaining of exertional dyspnea at 14 weeks of gestation. She was married for 13 months and had spontaneous conception. She was normotensive, with pulse rate 70/ minute and sinus rhythm. Elevated jugular venous pressure (JVP) with features of pulmonary artery hypertension (PAH) was present. Respiratory system was clinically normal. Ultrasonography revealed intrauterine viable pregnancy of 14 weeks gestation. Echocardiography showed enlarged right atrium (RA) and right ventricle (RV), no demonstrable shunts, severe PAH with a pulmonary artery pressure of 74 mm of Hg with adequate left ventricle (LV) function, and mild mitral regurgitation.

Discussion with cardiologist led to the decision to continue pregnancy under close supervision by the team. Past history revealed recurrent syncopal attacks diagnosed 6 years back to be due to primary pulmonary hypertension.

We gave her nicardia, cardace, and low dose aspirin ovally. Intermittent nocturnal oxygen therapy was initiated during hospital stay and was continued at home after discharge following proper patient education.

She reported regularly for antenatal check up and was monitored as high risk pregnancy. At 37 weeks of gestation she developed hypertension with a blood pressure of 200/110 mm of Hg and was hospitalized. Next day lower segment cesarean section was performed under epidural analgesia and a female baby weighing 2.8 kg was delivered with good apgar score. No problems were encountered and nocturnal oxygen therapy was continued postoperatively along with other medication. She was discharged on 10th postoperative day with counseling for contraception.

Abstract

Introduction We report a case of end stage renal disease with two previous cesarean sections on regular hemodialysis who developed eclampsia.

Case report A 3rd gravida with 26 weeks gestation was admitted from the casualty on 11th November, 2004 at 6.30 AM for acute diarrhea of one day. She had two cesarean sections earlier. She was apparently normal till two years back, when in April 2002 she developed acute gastroenteritis, acute renal failure and cortical necrosis. She was on regular biweekly hemodialysis in our institution since then. When seen at 6 weeks of gestation she was advised termination of pregnancy which she refused and did not attend the antenatal clinic. She developed two episodes of generalised tonic clonic seizures soon after admission.