Laparoscopic evaluation of female genital tuberculosis in infertility: An observational study

Background & objectives: Female genital tuberculosis (FGTB) is an important variety of extrapulmonary TB causing significant morbidity, especially infertility, in developing countries like India. The aim of this study was to evaluate the laparoscopic findings of the FGTB. Methods: This was a cross-sectional study on 374 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling/biopsy for acid-fast bacilli, microscopy, culture, PCR, GeneXpert (only last 167 cases) and histopathological evidence of epithelioid granuloma. Diagnostic laparoscopy was performed in all the cases to evaluate the findings of FGTB. Results: Mean age, parity, body mass index and duration of infertility were 27.5 yr, 0.29, 22.6 kg/m2 and 3.78 years, respectively. Primary infertility was found in 81 per cent and secondary infertility in 18.18 per cent of cases. Endometrial biopsy was positive for AFB microscopy in 4.8 per cent, culture in 6.4 per cent and epithelioid granuloma in 15.5 per cent. Positive peritoneal biopsy granuloma was seen in 5.88 per cent, PCR in 314 (83.95%) and GeneXpert in 31 (18.56%, out of last 167 cases) cases. Definite findings of FGTB were seen in 164 (43.86%) cases with beaded tubes (12.29%), tubercles (32.88%) and caseous nodules (14.96%). Probable findings of FGTB were seen in 210 (56.14%) cases with pelvic adhesions (23.52%), perihepatic adhesions (47.86%), shaggy areas (11.7%), pelvic adhesions (11.71%), encysted ascites (10.42%) and frozen pelvis in 3.7 per cent of cases. Interpretation & conclusions: The finding of this study suggests that laparoscopy is a useful modality to diagnose FGTB with a higher pickup rate of cases. Hence it should be included as a part of composite reference standard.

Role of pelvic and para-aortic lymphadenectomy in epithelial ovarian cancers

Background: Lymphadenectomy in epithelial ovarian cancers has remained a controversial subject. Lack of robust evidence on survival benefits and surgical morbidity associated questions its role in the era of adjuvant chemotherapy. The present study assessed pelvic and para-aortic lymph node removal in epithelial ovarian cancer in Indian women and tried to find clinicopathological correlation of nodal involvement and postoperative implications of lymphadenectomy.Methods: Thirty patients with diagnosis of epithelial ovarian cancer posted for primary debulking surgery were recruited and underwent staging laparotomy along with pelvic and para-aortic lymphadenectomy. Nodal involvement was confirmed on histopathology and various parameters which could predict nodal metastasis were assessed. Patients were followed up for 12 months post-surgery.Results: Nodal yield was ten for pelvic and four for paraaortic nodes. Pelvic node involvement was seen in 26.6% (8/30) of the patients and para-aortic in 15% (3/20) of the patients. Serous histology, higher grade, stage 3 and above, positive peritoneal cytology, omental involvement showed a higher lymph node involvement though not statistically significant. Para-aortic lymphadenectomy was associated with increased operating time, blood loss and longer hospital stay.Conclusions: Lymphadenectomy increases morbidity and decision should be based on predictors of nodal involvement.

Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity

The presence of ovarian or peritoneal metastasis in early-stage cervical malignancy is a rare entity. It often poses a diagnostic challenge whether it is a synchronous primary tumor or a metastatic lesion. A 63-year-old postmenopausal woman presented with Stage 1B1 carcinoma cervix with ascites, and a 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass. She underwent Type III radical hysterectomy, excision of peritoneal mass, with bilateral pelvic and paraaortic lymphadenectomy and infracolic omentectomy. On histopathology, cervix showed features of adenocarcinoma, and the peritoneal mass revealed similar histomorphology as cervical growth with metastatic tumor deposits in omentum. Immunohistochemistry (IHC) was utilized to determine the origin of mass. The early stage disease and histology may not always predict the distant metastasis. Therefore, a thorough pretreatment evaluation, meticulous intraoperative assessment, and IHC are mandatory for optimum management and prognostication

Assessment of Lower Segment Ceasarean Scar by Transvaginal Ultrasound and MRI

Objective: To assess lower segment scar on ultrasound and MRI followed by comparing with the intraoperative findings of scar in lower uterine segment. Methods: This was a prospective observational comparative study with a sample size of 40. Patients were recruited from the antenatal clinic. The study included women with previous one lower segment cesarean section and not willing for trial of labour after birth and those with previous one lower segment cesarean with no H/O previous vaginal birth. Routine obstetric examination was done at 36-37 weeks POG. A detailed obstetric ultrasound was performed. Patients before undergoing elective repeat lower segment cesarean section had Transvaginal ultrasonography (TVS) and MRI for evaluation of previous cesarean uterine scar. Result: The mean age of study group was 29.28 ± 3.48 yrs. The mean scar thickness in study group on TVS was 3.36 mm ± 1.2 mm. Mean scar thickness on MRI was 3.5 mm± 1.12mm. During intra-operative assessments of scar, in 82.5% cases scar was intact while in 15% cases scar was dehiscent. There was a positive correlation between all three modalities i.e. TVS , MRI and intra-operative findings. Conclusion: In this observational comparative done to correlate scar thickness measured on TVS and MRI with the intra-operative scar thickness, based on the findings we conclude that both TVS and MRI can be used for measurement of scar thickness.

Current practices in family planning: a population based study

Background: To study the knowledge, current practices of family planning methods and acceptance post motivation.Methods: Cross-sectional study conducted at family planning OPD of AIIMS, New Delhi, India. A total of 1516 couples who came for MTP at any gestation couple were enquired about knowledge, currently used contraceptive method and reason for abortion. Couple was counseled and allowed to choose contraceptive method using cafeteria approach. Mean values of continuous data were tested using t-test/ANOVA. Categorial data were compared using chi-square/ Fischers exact test.Results: Mean±SD age of the women was 28.89±5.21 years with 9.98±4.56 weeks POG. Around 81% of women had one or more living children with 62.67% women with at least one abortion previously. Majority used male condoms (42.10%) followed by natural method (21.01%), Cu-T (3.80%), OCPs (1.65%), injectable (0.30%), I-pill (0.24%). Awareness was maximum for male condoms, Cu-T, OCPs, female sterilization (100%) and least for female condoms (20%) and LNG-IUS (8.46%). Contraceptive failure (68.90%), congenital abnormality in the fetus (22.40%), maternal disease (5.90%), rape (1.60%), completed family (0.80%) and not using any method (0.30%) were the reasons of abortion. Majority of abortions were in first trimester (70%). Post-motivation around 69.30% of the couples accepted some form of contraception. Female sterilization (32.50%) method accepted by the couples as compares to temporary methods (36.70%) such as Cu-T, OCPs, Injectables etc.Conclusions: Despite of awareness the family planning programme is unsuccessful largely due to inappropriate attitude. Behavioral modification and communication goes a long way to slove the problem.

The Role of Diagnostic Laparoscopy in Patients with Chronic Abdominal Pain – A Prospective Study.

Background: Laparoscopy is defined as the technique in which abdomino-pelvic cavity is visualized through small openings in the wall of abdomen through instruments. In patients with chronic abdominal pain, only diagnostic laparoscopy can be considered as the gold standard and provide correct diagnosis and concurrently may prove to be therapeutic. Methods: This is an observational study which was conducted in Department of Surgery for the period of one year in which clinical diagnosis in the patients was made and then it was confirmed after doing diagnostic laparoscopy. The results were compared statistically. Results: The age group in which chronic abdomen pain occurred predominantly was 30 - 60 years in about 64% of cases. Males (60%) were predominantly involved with the male: female ratio of 3:2. The most common cause of chronic abdominal pain in developing country like India was found to be abdominal tuberculosis (30%) followed by chronic obstructive small bowel disease (22%). Statistically significant difference (<0.001) in comparison of the aetiology of the chronic abdominal pain which was diagnosed both clinically and then by laparoscopy was found in making the diagnosis of tuberculosis, obstructive disease and cholecystitis. Conclusion: Laparoscopy has proven to be admirable modality for diagnosing chronic abdominal pain where other appropriate investigations cannot accurately establish the diagnosis.

A Prospective, Randomised Comparative Study of Lateral Sphincterotomy and Local Application of 2% Diltiazem Gel in Treatment of Chronic Anal Fissure.

Background: Surgical management is used for the treatment of most of the fissures including manual anal dilation or performing lateral sphincterotomy. The present study carries a comparative research between the patients posted for lateral internal sphincterotomy and application of 2% Diltiazem gel in chronic anal fissure. Methods: The study was conducted in Department of General Surgery, Teerthankar Mahaveer Medical College & Research Centre from May 2015 to April 2016. After informed written consent, 60 patients were enrolled in the study. All patients were allocated in two groups; Group S (30 patients) posted for Lateral Sphincterotomy and Group D (30 patients) consisting of 2 % Diltiazem gel therapy. Results: Out of 30 patients, 3 lost during the follow up period in Group D. 19 patients (63.33%) had complete healing at the fissure site upon application of Diltiazem (2%) gel at 4 week follow up. In case of Group S, 26 patients (86.67%) had complete healing of fissure at 4 weeks follow up while 2 patients had complete healing at 8 week follow up visit. 22 (73.33%) of the patients treated with diltiazem (2%) gel were pain free at the end of 4 weeks. 27 (90.00%) out of 30 patients undergoing lateral internal sphincterotomy were free from pain at the end of 4 weeks post operatively. Conclusion: Lateral internal Sphincterotomy is the first line of treatment in patients for the chronic fissure in ano.

Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy.

Background : Office hysteroscopy with endometrial biopsy is usually the first investigation for abnormal uterine bleeding and other uterine diseases. Aims: To evaluate the effect of oral drotaverine with mefenamic acid on pain perception during hysteroscopy and endometrial biopsy and to compare it with that of paracervical block using 1% lignocaine and with that of intravenous sedation using diazepam with pentazocine. Settings and Design : Outpatient gynecological department and open randomized trial. Materials and Methods : One hundred twenty women undergoing hysteroscopy and endometrial biopsy were randomized into 3 groups. Group I received tablet containing drotaverine hydrochloride (80 mg) + mefenamic acid (250 mg), group II received lignocaine paracervically and group III received intravenous diazepam. The intensity of pain during the procedure, 30 and 60 minutes later on visual analog scale (VAS) was assessed. Statistical Analysis : Statistical analysis was performed using Kruskal-Wallis test, with the Bonferroni correction, the t test, and the χ2 test. Results: Groups were similar in age, parity, vaginal birth or relevant medical history. A statistically significant difference in pain scores was noted among the 3 groups during the procedure (group I, 4.13± 1.28; group II, 5.93± 1.26; group III, 5.58± 1.51), (P< 0.001); as well as 30 minutes later (group I, 1.78± 0.89; group II, 2.53± 0.81; group III, 2.23± 0.94), (P< 0.001) and 60 minutes later (group I, 1.2± 0.46; group II, 1.98± 0.83; group III, 1.68± 0.75), (P< 0.001). VAS at different time intervals among the groups was also statistically significant. No adverse effects were observed. Conclusions : Oral drotaverine with mefenamic acid is effective in women undergoing hysteroscopy and endometrial biopsy.

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time.

OBJECTIVE: To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome. METHODS: This was a prospective observational study of 217 patients who underwent cesarean section at > or = 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord thornH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed. RESULTS: Out of 3148 patients delivered at > or = 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord thornH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of < or =30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval < or = 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes. CONCLUSION: Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was < or = 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in </= 30 minutes group was significantly higher.

Effect of human chorionic gonadotropin (hCG) on expression of vascular endothelial growth factor a (VEGF-a) in human mid-secretory endometrial cells in three-dimensional primary culture.

Several lines of evidence suggest that human uterine endometrial cells can bind human chorionic gonadotropin (hCG) which, in turn, influences the physiology of implantation stage endometrium. Vascular endothelial growth factor (VEGF) appears to be a candidate mediator in this process. However, our knowledge about hCG action on VEGF in human endometrial cells is very thin. In the present study, we have examined microscopically hCG binding to dissociated human endometrial cells collected from mid-luteal phase and maintained in three-dimensional primary co-culture on rat-tail collagen type I biomatrix and examined the effect of different concentrations (0, 1, 10, 100 and 1000 IU/ML) of hCG on VEGF expression and secretion by endometrial cells maintained in the above system. We report that both cytokeratin positive epithelial cells as well as vimetin positive stromal cells from human mid luteal phase endometrium could bind hCG and that their number increased (P < 0.01) steadily with time. Administration of hCG enhanced (P < 0.05) immunoreactive VEGF protein expression in dose dependent manner in endometrial cells retrieved from mid-luteal phase of cycle, and co-cultured in a three-dimensional cell culture system, but with no marked change in VEGF secretion. Collectively, it appears that hCG influences VEGF protein synthesis in human midluteal phase endometrial cells, but has little effect on post-translational regulation and secretion. From physiological homeostasis point of view, it is likely that synthesis and secretion of VEGF exhibits a modular and factorial regulation to achieve a fine tuning of this potent vasotropic agent in receptive stage endometrium.

Comparison of Ofloxacin & Ornidazole with Probiotic versus Doxycycline & Metronidazole for the Outpatient Treatment of Pelvic Inflammatory Disease

The aim of the study was to compare the efficacy and cost effectiveness of ofloxacin, ornidazole, serratiopeptidase and Saccharomyces Boulardii combination with traditional doxycycline and metronidazole combination with serratiopeptidase in the outpatient management of pelvic inflammatory disease. A total of one hundred and ninety three women presenting with symptoms of pelvic inflammatory disease (PID) confirmed to be a case of PID on clinical examination were randomized to one of the two treatments. No investigations were performed to cut the cost and to avoid loss of follow up. A total of 98 women (Group I) were prescribed ofloxacin (400mg), ornidazole (500mg), Serratiopeptidase (10mg), Lactic acid bacillus 60 million spores and Saccharomyces Boulardii 2 million spores once a day for 10 days while a total of ninety five women (group II) were given a 10 day course of doxycycline (100 mg BD) with metronidazole (400mg TDS) along with 10mg of serratiopeptidase once daily. All women were seen after 2 weeks for relief of symptoms and possible side effects. The results were then analyzed. It was found that although the efficacy of both drug regimens was similar. The incidence of gastrointestinal side-effects mainly were less in group I. This was probably due to the addition of probiotic Saccharomyces Boulardii and lactic acid bacillus. The once daily administration led to better compliance in the first group.

Comparison of perinatal outcome of growth-restricted fetuses with normal and abnormal umbilical artery Doppler waveforms.

AIMS: To evaluate the role of umbilical artery Doppler in growth- restricted fetuses. MATERIALS AND METHODS: In a prospective observational study, 70 pregnant women with growth-restricted fetuses confirmed by ultrasound, were followed up with Doppler studies of the umbilical artery. The study group consisted of 35 women, where the Doppler waveform in the umbilical artery was compromised (either absent end diastolic flow [AEDF] or reversed end diastolic flow [REDF]). These were compared with an equal number of controls, where growth- restricted fetuses had normal doppler waveforms. Outcome measures were evaluated in both groups and analyzed. RESULTS: The periods of gestation at delivery were 27.2 +/- 3.5 weeks in group 1 and 37 +/- 3.3 weeks in-group II, respectively. Perinatal morbidity and mortality was significantly increased in the group with compromised umbilical artery blood group. Birth weight in group I was 742 +/- 126 grams and in group II was 1680 +/- 259 grams. This difference was statistically significant (P=0.0001). In comparison to AEDF, REDF fetuses had more morbidities. Perinatal mortality was also significantly increased in this group (P=0.001). CONCLUSION: Umbilical artery Doppler should be used in the management of growth-restricted fetuses. In those fetuses in normal Doppler, pregnancy can be prolonged. REDF is an indication for termination of pregnancy.

Maternal antenatal profile and immediate neonatal outcome in VLBW and ELBW babies.

OBJECTIVE: To evaluate the antenatal profile of the mother and the immediate neonatal morbidity and mortality till discharge. METHODS: The study was a retrospective analysis of 92 patients of preterm labour who delivered babies weighing RESULTS: A total of 92 mothers in preterm labour at 26 to 34 weeks were admitted and subsequently delivered 70 VLBW babies (< 1500 gms) and 36 ELBW babies (< 1000 gms) including 8 pairs of twins and 3 triplets pregnancies. Majority of the patients (93.4%) were booked. Amongst the various high risk factors for preterm labour, anaemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and pervious history of preterm labour (18.4%) were common associations. Calcium channel blocker (Depin) tocolysis was effective in postponing labour from 48 hours to more than 2 weeks. The cesarean section rate was very high (67.3%) in our study. The commoner neonatal complications in both VLBW and ELBW babies were RDS, neonatal jaundice and sepsis. Features of IUGR were seen in both the groups (22.8% in VLBW and 22.2% in ELBW babies). The neonatal mortality rate till discharge was 15.7% in VLBW group and 33.3% in ELBW group. The morality rate was highest in 26 to 30 weeks gestation babies and in babies weighing < 800 gms. CONCLUSION: Antenatal profile of preterm labour in our series showed a number of high risk factors. The identification of common high risk factors is important for appropriate prenatal care. A better neonatal survival rate was possible due to timely intervention, appropriate management and NICU care facility available in our tertiary care centre.

Genitourinary Fistula - An Experience from a Tertiary Care Hospital

Genito urinary fistula remains a frustrating condition for patients in the developing world. We retrospectively analysed twenty three women who underwent fistula repair over the last 5 years in one unit at Department of Obstetric and Gynaecology, All India Institute of Medical Sciences. Twenty-seven fistulae were repaired in 23 women of which 78.2% were vesecovaginal fistula. Majority of these fistula (73.9%) were obstetric in origin, as a result of neglected, mismanaged labour. Surgical repair was the mainstay with 100% success for those undergoing primary repair and an overall success rate of 83.3% for vesico vaginal fistula. Though principles of fistula repair were adhered to by the operating surgeon, each patient was unique. Surgeons trained in such repair can individually vary approach and technique to suit each patient giving high success rate.

Simultaneous Caesarian Section with Cerebral Haematoma Decompression

This is a case of spontaneous intracerebral hemorrhage of unknown etiology presenting in the third trimester for which lifesaving intracranial surgery was undertaken along with simultaneous caesarian section to avoid risk of deep anesthesia and fetal morbidity.

Chorioangioma Syndrome: Co-relation of Color Doppler Ultrasound and Pregnancy Outcome

Large chorioangiomas are rare and associated with significant fetal and maternal risks. A case of chorioangioma syndrome is presented with polyhydramnios, pre-eclampsia, preterm labor and fetomaternal hemorrhage. Antenatal diagnosis is possible with ultrasound, and the prognosis for pregnancy outcome can be predicted by evaluating the vascularity of the tumor on color doppler sonography.

Comparison or oral versus vaginal misoprostol & continued use of misoprostol after mifepristone for early medical abortion.

BACKGROUND & OBJECTIVE: Medical abortion though legalized in India, is still not very popular. A disadvantage of medical abortion is the longer duration of bleeding compared with surgical abortion which may reduce acceptability. Due consideration needs to be given to the issues related to medical abortion for improving the reproductive health status of women suffering from consequences of unsafe and illegal surgical abortion. The present study compared the efficacy of oral and vaginal administration of misoprostol after a single dose of 200 mg of mifepristone and evaluated the influence of continuing misoprostol for one week on efficacy and side effects. METHODS: A double-blind randomized controlled trial with 150 healthy pregnant women requesting medical abortion with < 63 days of amenorrhoea was conducted in the gynecological and family planning clinic at All India Institute of Medical Sciences, New Delhi. Mifepristone (200 mg) was administered orally on day one, followed by 0.8 mg misoprostol either orally or vaginally on day three. Women in the oral group and one of the two vaginal groups continued 0.4 mg of oral misoprostol twice daily for seven days. RESULTS: Complete abortion rate in each of the groups was 96-100 per cent. The addition of misoprostol 0.4 mg twice a day from day 4-10 did not help in increasing successful outcome or shortening of duration or amount of bleeding. INTERPRETATION & CONCLUSION: Medical abortion for pregnancy up to 63 days using misoprostol 0.8 mg vaginal/oral after pretreatment with mifepristone 200 mg is a safe and successful procedure. No differences in efficacy or duration of bleeding were observed with addition of oral misoprostol for 1 wk after abortion.

Expectant Management of Ectopic Pregnancy : Analysis of Four Cases

Expectant management of ectopic pregnancy is infrequently used. Used in a select group of patients, the result in terms of success of treatment, tubal patency , later intrauterine pregnancy are comparable to medical and surgical management.We report 4 cases of ectopic pregnancy managed expectantly in one year period and present a review of literature.

Diploid partial mole with neonatal survival--a case report.

Partial mole is a gestational neoplastic disorder with a reported incidence of 0.005 - 0.01% of all pregnancies. The karyotype in such cases is usually triploid, baring a few exceptions. The diploid partial mole is an extremely rare entity with only few cases being documented in literature. The fetal outcome in such cases is usually poor. We describe a case of partial mole, which terminated at 28 weeks with a live diploid male fetus with good neonatal outcome. Follow-up showed no progression to malignant gestational trophoblastic disease.