Comparative study on maternal and fetal outcome in pregnant women with rheumatic heart disease and severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy

Introduction Mitral stenosis due to rheumatic heart disease is a common problem in India causing significant morbidity and mortality. We have compared the maternal and fetal outcome of women with severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy. Methods A total of 24 women of severe rheumatic mitral stenosis who underwent balloon mitral valvotomy before pregnancy (14 women, group 1) or during pregnancy (10 women, group 2) were included in the retrospective descriptive analysis. Results The mean age was 25.5 ± 3.6 yrs in group 1 and 25.7 ± 3.5 yrs in group 2. There was no difference in characteristics –primigravidas, time since diagnosis from pregnancy, NYHA (New York Heart Association) class and associated medical problems in the two groups. There was significant difference in cardiac events during pregnancy in the two groups. New York Heart Association class deterioration was observed in only 3(21.4% women in group 1) as compared to all (10; 100% women) in group 2(p < 0.001). The incidence of arrhythmias and atrial fibrillation was not different in two groups. Obstetric events were similar in the two groups. Mode of delivery and caesarean section rate was also similar in the two groups. There was no significant difference in mean birth weights (2399.75 ± 601.8 gm vs. 2641.70 ± 580.6 gm),rate of fetal growth restriction, still birth and congenital malformation rates in the two groups. Conclusion Percutaneous mitral valvotomy for patients with severe mitral stenosis can be safely performed during pregnancy and has equivalent maternal and fetal outcomes as that performed before pregnancy.

Maternal and fetal outcome in operated vs non-operated cases of congenital heart disease cases in pregnancy

Objectives To study pregnancy outcomes in operated vs non-operated cases of congenital heart disease cases during pregnancy. Materials and methods A total of 55 patients of congenital heart disease who delivered in the authors unit in last 10 years were taken in this retrospective study. These were divided into two groups Group 1:29 (52.7%) patient who had no cardiac surgery and Group 2: 26(47.2%) who had cardiac surgery to correct their cardiac defect before pregnancy. All patients were evaluated for cardiac complications and outcome during pregnancy. Obstetric complications, mode of delivery and fetal outcome was compared in the two groups using statistical analysis. Result The commonest lesion was atrial septal defect (ASD) seen in 22(40%) patients followed by ventricular septal defect (VSD) in 16(29%) .Congenital valvular disease 8(14.5%) and patent ductus arteriosus in 4(7.2%) cases. The mean age was 25.9 ± 3.15 years in Group 1 and 26.3 ± 4.53 years in Group 2. The baseline characteristics were similar in the two groups. There was no difference in cardiac complications, NYHA deterioration and need of cardiac drugs in the two groups. Obstetric complications and mode of delivery were also similar in the two groups.Mean birth weight was 2516.65 ± 514.04 gm in Group 1 and 2683.00 ± 366.00 gm in Group 2 and was similar. APGAR < 8, stillbirth rate and other neonatal complications were also similar in two groups. Conclusion The maternal and fetal outcome was excellent in patients with congenital heart disease and was similar in unoperated and operated cases.

Palliative weekly chemotherapy along with cetuximab in recurrent and metastatic head and neck cancers: A retrospective analysis.

Background: This study was undertaken to report the results of weekly combination chemotherapy with cetuximab in recurrent/metastatic head and neck squamous cell carcinoma (R/M SCCHN). Materials and Methods: Retrospective analysis of 35 R/M SCCHN patients who received cetuximab with weekly paclitaxel and platin (cisplatin/carboplatin) from SCCHN August 2006 to October 2008 at our Institute was performed. Results: Thirty-five patients (33 [94.3%] males and 2 [5.7%] females) received the planned weekly chemotherapy protocol. Median age of these patients was 52 years. Of the SCCHN 32 evaluable patients, 25 patients showed symptomatic improvement and 7 showed no improvement. Radiological responses using RECIST criteria reported CR in 1 patient (3.1%), PR in 17 patients (53.1%), and SD in 6 patients (18.8%). The remaining six patients demonstrated disease progression while two could not be assessed. Median overall survival (OS) was 8.016 months (95% CI; 6.572--9.461) and median PFS was 5.782 months (95% CI; 4.521--7.044). The major chemotherapy-related grades 2 and 3 toxicity recorded was cetuximab-induced rash reported in 24 patients. No treatment-related death within 30 days was observed. Conclusion: Cetuximab with weekly combination chemotherapy (Paclitaxel + Platinum compound) has shown promise, demonstrating comparable response and outcomes with acceptable toxicity in R/M SCCHN patients.

Placental Site Trophoblastic Tumor of the Uterus: A Mistaken Diagnosis.

Placental site trophoblastic tumor (PSTT) is the rarest form of Gestational Trophoblastic Neoplasia (GTN). We present this case of uterine PSTT to illustrate the difficulties in the diagnosis of this tumor and how this led to delay in its appropriate management..

Haematologic paraneoplastic syndromes in pleural mesothelioma: A report of two cases and review of the literature.

Paraneoplastic syndromes are common in mesotheliomas but there is no report from India. Two cases of pleural mesothelioma with paraneoplastic haematologic syndromes, one with neutrophilic leukemoid reaction and the other with thrombocytosis, are presented in this report.

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.

A survey of obstetricians' practice of using prophylactic antibiotics in vaginal deliveries and caesarean sections.

Antibiotics are prescribed in pregnancy but only few reports provide information about the actual practice of prophylactic antibiotics usage in various obstetrical conditions amongst obstetricians. The present study evaluates the practice of obstetricians of Delhi regarding prescription of antibiotics in vaginal deliveries and caesarean sections. The open-ended predesigned questionnaire study incorporated details of the obstetricians working in different hospitals of Delhi and their practice of prescribing antibiotics in vaginal deliveries, episiotomies and caesarean sections was filled by obstetricians. The data was analysed using Student's 't' test and Chi-square test. The mean age of obstetricians was 35.5 years; 90% were females and 48.9% were postgraduate students with 70% less than 5 years experience and 77.8% were working in a government hospital. In episiotomy, 18.9% obstetricians did not use antibiotics while 33.3%, 27.8% and 20% obstetricians used ampicillin, amoxicillin and cephalexin orally for 5 days respectively. Injection cefazolin was used intravenously, 1 g 12 hourly for 3 days by 34.4% and 33.3% obstetricians in elective and emergency caesarean sections respectively, while it was used for 5 days by 35.5% and 41.1% obstetricians respectively. A combination of ampicillin, gentamicin and metronidazole for 5 days was used by 30% and 25.5% obstetricians for elective and emergency caesarean sections respectively. In spite of clear evidence from Cochrane Database of Clinical Reviews that use of penicillin or first generation cephalosporins in single dose therapy is effective; the actual practice is contrary with use of multiagent antibiotics for long periods, being very rampant in actual clinical practice.

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.

Recurrent aggressive angiomyxoma of vagina--a case report.

Aggressive angiomyxoma is a rare tumour, which presents as a painless expanding mass in the vulvo-vaginal region. It usually occurs in 2nd to 3rd decades of life. It behaves like a low-grade sarcoma with high propensity for local spread and recurrence and can involve vulva, perineum, vagina and urinary bladder. It is difficult to differentiate clinically this tumour from other mesenchymal tumours occurring in this region. Microscopically it must be differentiated from malignant tumours with myxoid change, like liposarcoma and myxoid leiomyosarcoma. Hence, histopathologic examination has a central role in diagnosis of this tumour. We are presenting a case of young woman, who came with history of swelling in vulva and perineum. Imaging studies in the perineal region revealed a large pelvic mass. Fine needle aspiration cytology was inconclusive due to scanty material. Enucleation of mass was attempted in first surgery but complete extirpation could not be performed. The swelling recurred within few weeks after surgery and required irradiation. A second surgery, however, was successful in complete removal of the tumour.

Severity, affect, family and environment (SAFE) approach to evaluate chronic pelvic pain in adolescent girls.

BACKGROUND: Pelvic pain is common in adolescent girls in day-to-day practice. Severity, Affect, Family and Environment (SAFE) is a recent interview strategy to approach these patients and their families. AIM: 1. To find the prevalence of pelvic pain in adolescent girls. 2. To find out the feasibility and acceptability of "SAFE" approach in evaluating chronic pelvic pain in adolescent girls. SETTINGS & DESIGN: 200 adolescent girls aged 13-23 years were selected at random from school and colleges nearby hospital campus. METHOD: A questionnaire method was adopted. Adolescent girls selected were divided into two groups, group I (with pain) and group II (without pain). STATISTICAL ANALYSIS: It was performed using chi-square and Fischer tests with significance of p value being taken at 0.05. RESULTS: Out of 200 adolescent girls selected for interview, prevalence of pelvic pain was found to be 37.0%. Dysmenorrhoea was also found to have significant relationship with pelvic pain. Depression and anxiety, school absences and loss of weight were found to have significant association with pain. Pelvic pain was found to be more in adolescent girls with large family size (> 4 members), single parent, both parents working, ongoing marital problems at home and was less reported when there was good parent-child communication about sex and when the teenager was well prepared for menarche by the parents and the association with the above mentioned factors was found to be significant. CONCLUSION: "SAFE" approach contributes in identifying health problems in adolescent girls with chronic pelvic pain.

A preliminary survey of patients' views on awareness, information, choices and expectations in women undergoing hysterectomy.

A questionnaire-study was undertaken among 50 women to take note of their views on awareness, information, choices and expectations on various aspects of hysterectomy performed on them. Most women (92%) did not know the type of hysterectomy and none of them was offered the alternative treatment, various types of hysterectomy done, type of anaesthesia used and hormone replacement therapy. A total of 96% wanted the surgeon to spend time with them explaining to them about various aspects of surgery and 46% thought the staff was sympathetic to them. A total of 26 women (52%) preferred to solve their problems with self-help groups (association of women with similar problems) and 84% wanted a leaflet to be distributed to them about various aspects of hysterectomy. This study concluded that Indian women to be involved in the decision making about their healthcare.

Ciprofloxacin-tinidazole combination, fluconazole- azithromicin-secnidazole-kit and doxycycline- metronidazole combination therapy in syndromic management of pelvic inflammatory disease: a prospective randomized controlled trial.

BACKGROUND: Pelvic inflammatory disease is a common problem faced by the gynecologists in there out patient department. AIM: The aim of the study was to evaluate the efficacy of three treatment combinations in the syndromic management of pelvic inflammatory disease in the out patient setting. SETTING DESIGN: In the medical college hospital patients presenting in gynecology out patient department were enrolled. MATERIAL AND METHODS: One hundred and sixty five women with diagnosis of pelvic inflammatory disease were randomized into three equal groups getting ciprofloxacin (500 mg) and tinidazole (600 mg) combination twice daily for 7 days (Group 1), a kit containing fluconazole (150 mg), azithromycin (1 gm) and secnidazole (2 mg) as one time dose (Group 2) and Doxycycline 100mg twice daily and metronidazole 200 mg thrice daily for seven days (Group 3). Severity score was determined on first visit and after 1 week and 4 weeks when patients were called for follow up. Statistical Analysis: Chisqare test, Krusker wallis test and Mann Whitney test. RESULTS: There was significant reduction in severity score after 1 week of treatment, which was further reduced after 4 weeks in all the three groups. Cure rate was highest in-group 1 (96%) followed by group 2 (93.5) and group 3 (91.3%) but the difference was not statistically significant. Resolution of inflammatory mass was highest in group 1. The incidence of side effects was highest and compliance was lowest in the doxycycline -metronidazole group, but the difference was not statistically significant. CONCLUSION: All the three treatment combinations were found to be equally effective in the syndromic management of pelvic inflammatory disease.

Successful pregnancy outcome after cesarean section in a case of gravid uterus growing in an incisional hernia of the anterior abdominal wall.

We herein report a case of a pregnant woman with previous cesarean section whose uterus herniated in an incisional hernia of the anterior abdominal wall at 34 weeks of pregnancy. Incarceration of the pregnant uterus in an incisional hernia is a rare but serious obstetric situation. Treatment is conservative till term followed by delivery and herniorrhaphy as was done in our case and it was associated with successful outcome.