Primary fallopian tube endometroid carcinoma: A rare case report.

ABSTRACT: Primary fallopian tube carcinoma is an extremely rare tumor accounting for only 0.14-1.8% of genital tract cancers. A 47-year-old female presented with post-menopausal bleeding and heaviness in the lower abdomen. Imaging revealed the right adnexal mass, suggestive of neoplastic origin. She was prepared for surgery. Per-operatively, there was a solid irregular mass, firm to hard in consistency, around 8 × 5 cm involving the whole of the right fallopian tube, and the right ovary appeared normal. Histopathological examination of the specimen showed endometroid adenocarcinoma of the right fallopian tube. Endometroid carcinoma is important to recognize because it carries the best prognosis of all the fallopian tube cancers. The patient underwent surgery, followed by adjuvant chemotherapy, and was doing well in follow-up.

Primary Pure Large-Cell Neuroendocrine Carcinoma of the Ovary: A Rare Case Report.

Primary pure large-cell neuroendocrine carcinoma is a rare entity with 17 cases reported till now. A 48-year-old, Para6 Live4, postmenopausal woman presented with complaints of pain abdomen, constipation for 6 months, and postmenopausal bleeding for 1 month. On per abdominal examination, an irregular, hard, fixed, and tender mass was felt in the pelvis corresponding to 32 weeks size gravid uterus. Her magnetic resonance imaging findings were suggestive of a large abdominopelvic mass of size 10.2 cm × 12.7 cm × 14.2 cm with inferior extension into the left adnexa and 3.1 cm × 2.2 cm × 2.1 cm right adnexal mass. Debulking surgery was done. The intraoperative findings were of a large abdominopelvic mass adhered to the sigmoid colon and retroperitoneal space. Histopathological and immunohistochemistry findings were suggestive of bilateral large-cell neuroendocrine carcinoma of ovaries with strong positive for Bcl2, CD56, NSE, PR, and P53. The patient was started on tablet etoposide as adjuvant treatment. After 5 months of primary surgery, contrast-enhanced computed tomography of the chest, abdomen, and pelvis revealed recurrence. She succumbed to her illness 6 months after primary surgery. Owing to its rarity and difficulty in diagnosis, it is suggested that all such cases should be registered at national level and critically analyzed to find the high risk and associated prognostic factors.

Enhancement of maternal-neonatal bonding during the COVID-19 pandemic: A quality improvement initiative.

AIM: The COVID-19 pandemic adversely affected the essential care of newborns. In a tertiary care hospital in India, all COVID-19 suspect post-natal mothers awaiting COVID results were transferred to a ward shared with symptomatic COVID suspect female patients from other clinical specialities, due to shortage of space and functional health workforce. Babies born to COVID-19 suspect mothers were moved to a separate ward with a caretaker until their mothers tested negative. Due to shortage of beds and delay in receiving COVID results, mothers and babies were often discharged separately 2-3 days apart to their home. This deprived babies of their mother's milk and bonding. We, therefore, undertook a quality improvement (QI) initiative aiming to improve rooming-in of eligible COVID-19 suspect mother-newborn dyads from 0% to more than 90% over a period of 6 weeks. METHODS: A QI team was formed which ran multiple Plan-Do-Study-Act cycles. The results were reviewed at regular intervals and interventions were adopted, adapted or abandoned. These included advocacy, rearrangement of wards, counselling of mothers and caretakers regarding infection prevention practices and coordination between labour room, post-natal ward and nursery staff. RESULTS: An improvement in rooming-in from 0% to more than 90% was achieved. CONCLUSION: QI methodology is a systematic approach in addressing and solving unexpected unforeseen problems effectively.

Rational use of antibiotics for major elective gynaecological and obstetrical surgical procedures: quality improvement journey from a tertiary care public facility.

BACKGROUND: Antibiotic resistance is a global problem. Irrational use of antibiotics is rampant. Guidelines recommend administration of single dose of antibiotic for surgical antimicrobial prophylaxis (SSAP) for elective obstetrical and gynaecological surgeries. However, it is not usually adhered to in practice. Majority of women undergoing elective major gynaecological surgeries and caesarean sections in the department of obstetrics and gynaecology of our tertiary level heavy case load public health facility were receiving therapeutic antibiotics (for 7-10 days) instead of recommended SSAP. Our aim was to increase the SSAP in our setting from a baseline 2.1% to more than 60% within 6 months. METHODS: After root cause analysis, we formulated the departmental antimicrobial policy, spread awareness and sensitised doctors and nursing officers regarding antimicrobial resistance and asepsis through lectures, group discussions and workshops. We initiated SSAP policy for elective major surgeries and formed an antimicrobial stewardship team to ensure adherence to policy and follow processes and outcomes. The point of care quality improvement (QI) methodology was used. Percentage of patients receiving SSAP out of all low-risk women undergoing elective surgery was the process indicator and percentage of patients developing surgical site infection (SSI) of all patients receiving SSAP was the outcome indicator. The impact of various interventions on these indicators was followed over time with run charts. RESULTS: SSAP increased from a baseline 2.1%-67.7% within 6 months of initiation of this QI initiative and has since been sustained at 80%-90% for more than 2 years without any increase in SSI rate. CONCLUSION: QI methods can rapidly improve the acceptance and adherence to evidence-based guidelines in a busy public healthcare setting to prevent injudicious use of antibiotics.

COVID-19 as an independent risk factor for subclinical placental dysfunction.

BACKGROUND: The pandemic of the severe acute respiratory distress syndrome-associated Coronavirus-2 (SARS-CoV-2) has affected millions around the world. In pregnancy the dangers to the mother and fetus are still being explored. SARS-CoV2 can potentially compromise maternal and neonatal outcomes and this may be dependent on the pregnancy stage during which the infection occurs. OBJECTIVE: The present study was done to find the histopathological alterations in the placenta of SARS-CoV-2 positive pregnancies with either no symptoms or mild coronavirus disease (COVID)-19 related symptoms and its association with neonatal outcomes. STUDY DESIGN: This was a prospective analytical study. Twenty seven asymptomatic or mildly symptomatic SARS-CoV-2 positive pregnant women with a singleton pregnancy delivered between 1st July 2020 and 15th September 2020, were included as cases. An equal number of SARS-CoV-2 negative singleton pregnancies matched for maternal and gestational age during the same period were included as controls. After delivery the histopathological examination of the placenta of these women was done and the findings recorded on a predesigned proforma based on the Amsterdam consensus criteria for evidence of maternal and fetal vascular malperfusion changes. RESULTS: The baseline characteristics were comparable between the cases and controls. The following features of maternal vascular malperfusion (MVM) were significantly higher in the placentae of COVID-19 positive pregnancies: retroplacental hematomas (RPH), accelerated villous maturation (AVM), distal villous hyperplasia (DVH), atherosis, fibrinoid necrosis, mural hypertrophy of membrane arterioles (MHMA), vessel ectasia and persistence of intramural endovascular trophoblast (PIEVT). Fetal vascular malperfusion (FVM) significantly associated with the positive pregnancies were chorioangiosis, thrombosis of the fetal chorionic plate (TFCP), intramural fibrin deposition (IMFD) and vascular ectasia. Additionally, perivillous fibrin deposition was also significantly higher in the placentae of cases. The percentage of spontaneously delivered women was comparable in the two groups. The sex and weight of the newborn and the number of live births were comparable between the two groups. CONCLUSIONS: Asymptomatic or mildly symptomatic SARS-CoV-2 positive pregnant women, with otherwise uncomplicated pregnancies, show evidence of placental injury at a microscopic level. Similar findings have been demonstrated in other studies too. This placental injury apparently does not lead to poor pregnancy outcomes. The extent of this injury in symptomatic cases of COVID-19 pregnancies and its consequences on the outcomes need to be analysed.

Stillbirths and the COVID-19 pandemic: Looking beyond SARS-CoV-2 infection.

OBJECTIVE: To study the impact of the COVID-19 outbreak and subsequent lockdown on the incidence, associated causes, and modifiable factors of stillbirth. METHODS: An analytical case-control study was performed comparing stillbirths from March to September 2020 (cases) and March to September 2019 (controls) in a tertiary care center in India. Modifiable factors were observed as level-I, level-II, and level-III delays. RESULTS: A significant difference in the rate of stillbirths was found among cases (37.4/1000) and controls (29.9/1000) (P = 0.045). Abruption in normotensive women was significantly higher in cases compared to controls (P = 0.03). Modifiable factors or preventable causes were noted in 76.1% of cases and 59.6% of controls; the difference was highly significant (P < 0.001, relative risk [RR] 1.8). Level-II delays or delays in reaching the hospital for delivery due to lack of transport were observed in 12.7% of cases compared to none in controls (P < 0.006, RR 47.7). Level-III delays or delays in providing care at the facility were observed in 31.3% of cases and 11.5% of controls (P < 0.001, RR 2.7). CONCLUSION: Although there was no difference in causes of stillbirth between cases and controls, level-II and level-III delays were significantly impacted by the pandemic, leading to a higher rate of preventable stillbirths in pregnant women not infected with COVID-19.