Endometrial stromal nodule: a rare case report

Endometrial stromal nodules (ESN) are benign tumours of mesenchymal origin with features reminiscent of proliferative phase endometrial stroma. Diagnosis of ESNs can be established only by light microscopy and no preoperative diagnostic methods are available. Although ESNs are benign and rare, distinguishing it from other types of invasive stromal tumours is of utmost importance since prognosis and management change considerably with the diagnosis. This was a rare case report of endometrial stromal nodule in a nulliparous woman, 30 years old who presented with complaint of menorrhagia and primary infertility and had a preoperative diagnosis of large leiomyoma with cystic degeneration. She underwent a fertility preserving conservative surgery i.e. myomectomy via abdominal route, histopathology reports of which revealed endometrial stromal nodule that changed the final diagnosis and follow up regime of the patient.

Role of intrauterine instillation of levobupivacaine as a local anaesthetic for outpatient gynaecological procedures: a randomized controlled study

Background: Procedures such as intrauterine device (IUD) insertion and endometrial biopsy, are routinely performed in the outpatient setting for various indications. Satisfactory pain control for women undergoing outpatient gynecological procedures is critical for both patient comfort and procedure success. The perception of pain during gynecological procedures originates from manipulation of the cervix and/or uterus.Methods: This study evaluated the role of intrauterine instillation of 0.5% levobupivacaine as local anesthetic in terms of pain score during and post outpatient gynecological procedures (endometrial aspiration biopsy and IUD insertion), reduction in need for post procedural analgesia and allowance of early return to normal activity. The trial medication was intrauterine anesthesia, either 5 mL 0.5% levobupivacaine or 5 mL 0.9% saline (control group) on 100 patients. Primary outcome was self-reported pain scores on numerical pain scale at various points of procedure, point (0) was a grade for as no pain and the worst pain was graded as ten point (10) in this scale. During the procedure, degree of pain was specified by study subjects at 4 steps. These steps were 1) immediately after tenaculum application, 2) during the solution instillation and 3) IUD insertion or EB and 4) 15 minutes after the procedure and 24 hours later.Results: Pain scores of the intrauterine levobupivacaine groups were found to be significantly lower than the control group also there was reduced need for additional analgesia and also, they had early return to normal activity.Conclusions: Study sought to reduce pain during OPD procedures which might lead to better patient experience, reduce anxiety and produce an overall better outcome.

Comparative evaluation of intravaginal slow release Dinoprostone insert, transcervical foley’s catheter, intracervical Dinoprostone gel for induction of labor in patients with poor Bishop’s score: a randomized control study

Background: Induction of labor is indicated when the continuation of pregnancy poses risk to the mother or fetus. A variety of mechanical and pharmacologic methods are available but the best method of labor induction still remains unknown, study aimed at comparing the efficacy and safety among the two agents: transcervical Foley’s balloon catheter (FBC) and intravaginal slow release Dinoprostone E2 insert (DVI) with dinoprostone gel as control.Methods: A total of 174 patients were randomized into three groups of 58 each (Group A: dinoprostone 10 mg slow release intravaginal insert, Group B: transcervical Foley’s 16 French catheters, and Group C as control: 0.5 mg intracervical Dinoprostone gel. The safety and efficacy was compared among the groups. A p value of < 0.05 was considered statistically significant.Results: The mean insertion to active labor time (in hours) was significantly lower in Group A as compared to Group B (5.88±3.06 versus 13.56±2.8, p < 0.0001). Meantime of insertion to delivery (in hours) was significantly lower in Group A as compared to Group B (10.91±5.24 versus 21.17±2.99, p < 0.0001). The requirement of oxytocin for induction and augmentation in Group A was significantly lower as compared to Group B. Majority of the patients had normal vaginal delivery (NVD) in all the three groups. Regarding safety profile we found that slow-release DVI had more incidence of uterine tachysystole, but none of the cases had any fetal heart rate abnormality. Maternal fever was more in the FBC group, however, neonatal outcomes were comparable in both groups.Conclusions: The study concludes that slow release DVI is better in terms of efficacy as compared to transcervical FBC for induction of labor as assessed by improvement in Bishop score, insertion to active labor time and insertion to delivery time and comparable in terms of safety profile.

Comparative study of sFlt-1/Plgf ratio with uterine artery doppler indices in prediction of preeclampsia at 22-24 weeks period of gestation

Background: Hypertensive disorders like pre-eclampsia along with hemorrhage and infection, contributes greatly to maternal morbidity and mortality. Various pro and antiangiogenic factors like sFlt-1 and Plgf have been linked to the etiopathogenesis of placental vascular disease and their combination with uterine artery doppler studies may improve the prediction accuracy. Present study was conducted to analyze sFlt-1/Plgf ratio and uterine artery doppler indices among high risk patients and to compare these in prediction of preeclampsia.Methods: A prospective observational study was conducted from September 2017 to February 2019 in which 100 patients giving consent and satisfying inclusion criteria were evaluated for various risk factors and were subjected to sFlt-1/Plgf ratio test and uterine artery doppler study at 22-24 weeks period of gestation. They were followed up and maternal outcome was analysed.Results: Among the cohort of 100 women with high risk factors, 35% of the study participants developed pre-eclampsia. Using sFlt-1/Plgf ratio 40% of them were screened positive for pre-eclampsia. This percentage of screened positive was 40%, 43%, and 53% using uterine artery RI, PI, and SD respectively. sFlt-1/Plgf was found to have a sensitivity of 91.4% and specificity of 87.7%. ROC curve analysis showed highest area under curve (AUC) for sFlt-1/Plgf (0.858).Conclusions: sFlt-1/Plgf ratio was found to be a better predictable biomarker than uterine artery Doppler indices in prediction of pre-eclampsia at 22-24 weeks period of gestation.

Postpartum atypical haemolytic uremic syndrome: a rare clinical entity

P-aHUS has incidence of 1 in 25000 pregnancies. It’s characterized by microangiopathic haemolytic anemia, thrombocytopenia and renal failure. Mrs X, 26 year old lady, G2 P1L1 with 39 weeks POG came to emergency of a tertiary care hospital. She underwent LSCS in view of previous caesarean section not willing for trial of labour. Antenatal, intrapartum and immediate post operative period were uneventful. However, she became anuric 36 hours post operatively. Laboratory investigations suggested hemolysis. Complement system evaluation showed decreased complement levels. Diagnosis of p-aHUS was made by taking multidisciplinary approach and renal biopsy. Patient received 4 sessions of plasmapheresis and symptomatic treatment. Gradually her urine output increased and she was discharged with the baby on post operative day 19. Diagnosis of p-aHUS is tricky owing to similar clinical features with many other pregnancy associated conditions. Timely management and diagnosis are imperative to save the mother’s life.

True broad ligament fibroid mimicking ovarian mass in a postmenopausal woman

Fibroids are benign smooth muscle tumors. Large fibroids are known to arise from the uterus, but occasionally from the broad ligament.  Here, we report a case of true broad ligament fibroid which is rare and difficult to diagnose in a 57 year old postmenopausal women with a large mass of 24 weeks size gravid uterus. Patient presented with pain lower abdomen and mass in abdomen with no other co-morbidity. This broad ligament fibroid was mimicking as ovarian tumor on ultrasonography and MRI as left ovary was not visualised separately, thus leading to diagnostic dilemma of ovarian malignancy. Mass resection with total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed. No local or distant metastasis observed, and Histopathology showed true broad ligament fibroid of left side weighing 3.57 kilograms.

Highly Aggressive Small-cell Neuroendocrine Carcinoma Cervix: A Rare Case Report.

Neuroendocrine tumors consist of a spectrum of malignancies that arise from the diffuse neuroendocrine cell system. Prognosis is dependent on histologic subtype and site of origin. The family of well-differentiated neoplasms (carcinoid and atypical carcinoid) is morphologically and clinically distinct from high-grade neuroendocrine carcinoma (small cell and large cell). This latter entity is closely related to pulmonary small-cell carcinoma, is highly aggressive and is generally managed with a multimodality approach including platinum-based chemotherapy. Neuroendocrine tumors primary to the gynecologic tract are still considered to be uncommon, with limited prospective data available to guide decision making. We are reporting a case of a highly aggressive small-cell neuroendocrine carcinoma cervix in a 38-year-old female with good initial response with chemotherapy and is under our follow-up.

Pelvic Tuberculosis Mimicking Ovarian Malignancy: A Case Report.

Tuberculosis is a global health problem, primarily seen in developing countries, where there are insufficient health services and high prevalence of human immunodeficiency virus (HIV) has further increased the burden of disease. Pelvic tuberculosis can cause ascites and an abdominal mass that may masquerade as ovarian cancer. CA125 levels are raised in peritoneal tuberculosis. CT scan and MRI also give a similar picture and diagnosis is often difficult. We are presenting an unusual case of pelvic tuberculosis being referred to us as a case of adnexal mass with ascites and raised tumor marker.