The Gut Microbiota: a Novel Player in the Pathogenesis of Uterine Fibroids.

Uterine fibroid is a common gynecological disorder that affects women of reproductive age and has emerged as a major public health concern. The symptoms have a negative influence on both their physical health and quality of life. The cost of treatment has a significant impact on the disease's burden. Even though its origin is uncertain, estrogen is thought to be a key player in fibroid pathophysiology. Many theories, including those based on genetic and environmental factors, explain what causes hyper-estrogenic condition in fibroid patients. One such possibility that is currently being explored is the hypothesis that an altered gut microbiome can contribute to the development of diseases characterized by estrogen dominance. Gut dysbiosis is often a "hot area" in the health sciences. According to a recent study, uterine fibroid patients have altered gut microbiome. A variety of risk factors influence both fibroid development and gut homeostasis. Diet, lifestyle, physical activity, and environmental contaminants have an impact on estrogen and the gut flora. A better understanding of uterine fibroids' pathophysiology is required to develop effective preventative and treatment options. A few ways by which the gut microbiota contributes to UF include estrogen, impaired immune function, inflammation, and altered gut metabolites. Therefore, in the future, while treating fibroid patients, various strategies to deal with changes in the gut flora may be advantageous. For developing suggestions for clinical diagnosis and therapy, we reviewed the literature on the relationship between uterine fibroids and the gut microbiota.

Pregnancy associated plasma protein A: An indicator of adverse obstetric outcomes in a South India population.

OBJECTIVE: First trimester aneuploidy screening (FTAS) has become an integral part of antenatal care in most of centers in India. The serum markers used for FTAS are pregnancy-associated plasma protein A (PAPP-A) and beta human chorionic gonadotropin. In the present study, we aimed to assess the role of PAPP-A in specific adverse fetal maternal events. To analyze pregnancy outcomes with low maternal PAPP-A (≤5th percentile) at the FTAS screening test in southern India, and them compared with a control group of >5th percentile value. MATERIALS AND METHODS: A total of 1800 consecutive pregnancies in the first trimester were followed up with PAPP-A levels. The study group consisted 108 subjects, which was compared with a matched control group of 288 subjects. The outcomes considered were spontaneous abortions, fetal anomalies, preterm delivery (PTD), hypertension in pregnancy, intrauterine growth restriction, gestational diabetes, mode of delivery, and birthweight. RESULTS: For our grouped data, the 5th percentile value for PAPP-A was 0.49 multiple of medians, (incidence-6%). The incidence of fetal major anomalies was higher in the study group [odds ratio (OR): 1.87]. The incidence of minor anomalies, gestational diabetes, and hypertensive disorders was higher in the study group but not statistically significant. The total rate of PTDs (OR:2.1), small-for-gestation-age fetuses (OR:2.3), and low birthweight babies (OR- 2.12) was significantly higher in the study group. We found positive likelihood ratio of 1.4 for PTD, 2 for <5th percentile birthweight, and 1.7 for <10th centile birthweight. CONCLUSION: Low PAPP-A pregnancies are at risk of various obstetric complications. Hence, such a pregnancy should have closer surveillance. Further research work on intervention strategy is needed.

Risk Assessment at 11-14-Week Antenatal Visit: A Tertiary Referral Center Experience from South India.

Background: Present study carried out in a tertiary referral hospital in South India attempts to determine the predictive value of integrated screening at 11-14-week antenatal visit. Objectives: To determine the detection rate of fetal abnormalities at 11-14 weeks and also to predict the placental dysfunction disorders based on early integrated evaluation. Method: Integrated screening performed on 440 women between 11 and 14 weeks, including detailed maternal history [medical history, bad obstetric history (BOH)], body mass index (BMI), mean arterial pressure (MAP), detailed ultrasound and maternal serum biochemistry as part of combined first-trimester screening for aneuploidy. Results: There were two proven Down's syndrome foetuses; both detected with combined screening test. There were 12 fetuses with major anomalies, out of whom 7 (58.3%) detected in 11-14-week scan. Among 440, 114 pregnancies (25.9%) developed complications in pregnancy, including 33 (7.5%) gestational hypertension, 8 (1.8%) pre-eclampsia, 41 (9.38%) SGA, 13 (2.9%) abortions, 22 (5%) indicated and 9 (2.04%) spontaneous preterm deliveries, 38 (8.63%) GDM and 3 (0.6%) stillbirth/IUD. Among the risk factors, age >35 years, BMI >23 kg/m2, BOH, MAP >105 mmHg and PAPP-A <0.5 MoM correlated well with adverse outcome. Using early integrated screening, 78.9% of obstetric complications could be predicted although 306 (69.5%) were labeled high risk, among whom 90 (29.4%) developed adverse pregnancy outcomes. Conclusions: Majority of fetal abnormalities can be detected, and majority adverse pregnancy outcomes can be predicted at 11-14-week antenatal visit, although this study shows high screen positivity and low specificity in a tertiary referral unit.

Laparoscopic cystectomy of endometrioma: Good surgical technique does not adversely affect ovarian reserve.

BACKGROUND: The damage to ovarian reserve inflicted by surgery for endometriosis represents a major concern in the balance between reproductive benefits and risks. AIM: To evaluate the ovarian reserve in sub fertile women after laparoscopic endometriotic cystectomy. SETTINGS AND DESIGN: Prospective study, done in Department of Obstetrics and Gynecology, tertiary care hospital between August 2010-2012. MATERIALS AND METHOD: Laparoscopic cystectomy performed by stripping technique for endometriotic cysts. Endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). Ovarian reserve assessed by comparing FSH and LH levels, measurement of residual ovarian volume, antral follicle counts and stromal blood flow on second day of menses pre and postoperatively. Cyst wall was evaluated histologically to note the presence of normal ovarian tissue in resected tissue. STATISTICAL ANALYSIS: SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL) was used for statistical calculations. Wilcoxon signed test and Pearson Chi - Square test were applied. Significance level was P < 0.05. RESULTS: Incidence of minimal, mild, moderate, and severe endometriosis was 4.1%, 21.9%, 28.7%, 45.3% respectively. Ovarian reserve was assessed both by ultrasound and biochemical parameters on day 2 of menses; pre and post-operatively. Preoperative and post-operative values; FSH (7.24 ± 1.21, 7.23 ± 1.51 m IU/ml), LH levels (6.37 ± 1.8, 6.6 ± 2.3 m IU/ml), residual ovarian volume (8.5 cm(3) ± 5.3, 7.4 cm(3) ± 5.8), antral follicle count(3.3 ± 1.9, 4.1 ± 1.5) and stromal blood flow (6.8 cm/sec ± 4.57, 7.1 cm/sec ± 3.55) were statistically not significant. Loss of follicle was seen in 27.2% cyst walls on histopathological examination while 72.73% had no loss. CONCLUSION: Laparoscopic cystectomy when performed for endometriotic cysts with accurate surgical technique leads to no significant ovarian tissue removal.

Correlation of fetal abdominal subcutaneous tissue thickness by ultrasound to predict birth weight.

INTRODUCTION: Fetal growth abnormality is associated with changes in the soft tissue mass, which is decreased in growth restricted fetuses and increased in macrosomia. OBJECTIVE: To correlate fetal abdominal subcutaneous tissue thickness (FASTT) measured by ultrasound at term and birth weight and to obtain a cut-off value of FASTT to predict large and small for gestational age babies in our population. METHODS: FASTT was measured at the anterior 1/3(rd) of abdominal circumference by ultrasound after 36 weeks and weight of the baby measured after birth. RESULTS: There was positive correlation between FASTT and birth weight. FASTT of 6.25 mm was sensitive to predict large for gestational age (LGA) babies and had a high negative predictive value; FASTT measurement for prediction of small babies with birth weight < 2500 g was not sensitive. CONCLUSION: FASTT can be used as an additional indicator to predict large for gestational age babies along with other known birth weight indicators.

Is there a Need for Luteinizing Hormone (LH) Estimation in Patients Undergoing Ovarian Stimulation with Gonadotropin-Releasing Hormone (GnRH) Antagonists and Recombinant Follicle-Stimulating Hormone (rFSH)?

AIM: To find out effect of serum luteinizing hormone (LH) levels on Day 1 (Day 2 of cycle) and Day 5 of stimulation and Day of trigger hCG in controlled ovulation stimulation with antagonist protocol of IVF-ICSI cycle on cycle outcome. MATERIALS AND METHODS: This retrospective study was conducted in a University Hospital setting. One hundred and 62 patients underwent 165 cycles of controlled ovarian stimulation (COS) with recombinant Follicle stimulating hormone (rFSH) and Gonadotropin releasing hormone (GnRH) antagonist protocol in one year were included. Serum LH levels estimated on Day 1, Day 5 and the day of trigger hCG injections were divided into three groups based on the percentile and outcome measured. RESULTS: The average number of follicles >18 mm in size were significant in the patients with LH levels between 25th to 75th percentile group on Day 1, Day 5 and Day of trigger hCG. The fertilization rate was significant (p= 0.04) in the patients with LH levels < 25thpercentile on the day of trigger hCG. Oocyte recovery rate, oocyte maturation rate and average number of best quality embryos (Grade 1) were not affected significantly in all three groups. CONCLUSION: In GnRH antagonist and rFSH protocols, low serum LH concentrations on the day of trigger hCG has better fertilization rate. LH levels between 25th and 75th percentile have an influence on the average number of > 18 mm size follicles. However, the LH level on Day 1, Day 5 and Day of hCG does not affect the cycle outcome in COS with antagonist protocol of IVF cycle. Hence, LH estimation is not mandatory in ART cycles with GnRH antagonist protocol.

An audit of indications, complications, and justification of hysterectomies at a teaching hospital in India.

Objective. Aim of this audit was to analyze indications, complications, and correlation of preoperative diagnosis with final histopathology report of all hysterectomies, performed in a premier teaching hospital. Methods. Present study involved all patients who underwent hysterectomy at a premier university hospital in Southern India, in one year (from 1 January, 2012, to 31 December, 2012). Results. Most common surgical approach was abdominal (74.7%), followed by vaginal (17.8%), and laparoscopic (6.6%) hysterectomy. Most common indication for hysterectomy was symptomatic fibroid uterus (39.9%), followed by uterovaginal prolapse (16.3%). Overall complication rate was 8.5%. Around 84% had the same pathology as suspected preoperatively. Only 6 (5 with preoperative diagnosis of abnormal uterine bleeding and one with high grade premalignant cervical lesion) had no significant pathology in their hysterectomy specimen. Conclusion. Hysterectomy is used commonly to improve the quality of life; however at times it is a lifesaving procedure. As any surgical procedure is associated with a risk of complications, the indication should be carefully evaluated. With the emergence of many conservative approaches to deal with benign gynecological conditions, it is prudent to discuss available options with the patient before taking a direct decision of surgically removing her uterus.

Influence of endomeriotic cyst diameter and the severity of endometriosis on the ovarian parenchyma excised during laparoscopic cystectomy.

INTRODUCTION: Endometrioma is a common form of endometriosis and it is represented by endometriotic deposits within the ovaries which accounts for upto 17-44% of cases. Laparoscopic stripping of ovarian endometriotic cysts is an accepted technique owing to low recurrence rates. Decrease in residual ovarian tissue volume was noted in many studies followed cystectomy. This study aims at estimating whether the size of endometriotic cyst is related to ovarian parenchyma excised along with cyst wall. MATERIAL AND METHODS: Prospective study was done at University teaching hospital for one year. A total of 56 women underwent laparoscopic endometriotic cystectomy. Cystectomy was done by stripping method and endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). The endometrioma wall was evaluated histologically and were categorised into 2 groups based on semi- quantitative scale of 0-4. Group 1 and 2 showed grade 0, 1, 2 and 3, 4 in the cyst wall respectively. RESULTS: Mean age of patients was 31.4 years, duration of infertility was 4.1 years and cyst diameter measured 6.3 cm. 73.2% (n=41) were in Group 1 and 26.8% (n=15) were in Group 2 , mean cyst diameter was being 4.3 cm and 5.0 cm respectively. There was no significant statistical correlation between preoperative cyst diameter and ovarian parenchyma removed (p=0.15). 93.3% (n=14) of group 2, and only 65.8% (n=27 ) of group 1 were found to have moderate to severe endometriosis, indicating there is correlation between disease severity and loss of ovarian tissue (p= 0.04). CONCLUSION: Endometriotic cystectomy when performed with accurate surgical technique leads to no significant ovarian tissue removal. However, disease severity significantly determines the loss of normal ovarian parenchyma.

Tubercular Ascites Simulating Ovarian Hyperstimulation Syndrome following In Vitro Fertilization and Embryo Transfer Pregnancy.

Ovarian hyperstimulation syndrome (OHSS) is a known complication of using ovulation induction drugs in assisted reproductive techniques. Its incidence and severity vary. Tuberculosis is a very common disease in the developing world, and ascites is one of its sequelae. The newer aids in diagnosing tuberculosis include measuring levels of Adenosine DeAminase (ADA) in the third-space fluids or serum. This case report is from a tertiary care center, reflecting how tubercular ascites simulated OHSS, and the right diagnosis was made and managed. This is being presented due to its rarity.

Infection and acute respiratory distress syndrome during pregnancy: a case series of preventable maternal deaths from southern India.

INTRODUCTION: Acute respiratory distress syndrome (ARDS) is common among women admitted to obstetric intensive care units, and it contributes significantly, both directly and indirectly, to maternal deaths. CASE SERIES: We present a case series of ARDS in pregnant women caused by non-obstetric causes. The women were treated at a tertiary hospital in southern India. The striking features were delayed referral from the primary care unit and the lack of a primary diagnosis or treatment. Undiagnosed rheumatic heart disease, anemia, and malaria and H1N1 epidemics contributed to these cases of ARDS and maternal death. CONCLUSION: It is necessary to increase the awareness of evidence-based uniform protocols to tackle common medical complaints during pregnancy.