A clinical alert: Oral glucose tolerance test triggering diabetic ketoacidosis in pregnancy.

Gestational diabetes mellitus is a common medical disorder of pregnancy. Diabetic ketoacidosis is a complication that may affect both maternal and perinatal wellbeing adversely. It is rare, most often involving women with type 1 or type 2 diabetes, but occasionally can be seen in gestational diabetes mellitus. Here are two cases of ketoacidosis seemingly triggered by glucose ingestion for the oral glucose tolerance test in previously normoglycemic women, posing a diagnostic and therapeutic challenge. Prevention of such complications must be considered when treating high-risk pregnant women> 40 years of age, pregnant as a result of assisted reproductive techniques. Fasting blood glucose checked before ingestion of the glucose in a selected group of women may be one way of avoiding this complication. This suggestion may put women at risk of prolonged fasting and stretching services. Glucose tolerance test is a diagnostic test, and these cases demonstrate a rare complication.

Intrauterine Administration of Autologous Platelet-Derived Growth Factor Concentrate (aka Autologous Blood Cell Derivative) Improves the Endometrial Thickness in 'Thin' Endometrium in the Frozen Embryo Transfer Cycle.

Context: Thin endometrium during the frozen embryo transfer cycles leads to cycle cancellation. The embryo transfer cycle getting deferred is an unpleasant experience for the patients and the fertility specialist. Aims: The purpose of this study is to evaluate the effectiveness of Autologous Blood Cell Derivative (ABCD) growth factor concentrate to obtain an optimal thickness of endometrium for embryo transfer during IVF treatments, where rapid regeneration is crucial for the expected therapeutic outcome. Settings and Design: A retrospective cohort study was conducted in Manipal Assisted Reproduction Center, a referral center in Southern India. Methods and Material: Fifty-six patients with thin endometrium were administered three doses of ABCD growth factor concentrate as per the protocol after informed consent. All of them had a history of embryo transfer (ET) cancellation in frozen-thawed embryo cycles due to inadequate growth of the endometrium despite therapy with estrogens and drugs for improving uterine blood circulation. Results: The endometrium thickness during the implantation window in the patients included in the study averaged 6.48 ± 1.19 mm. After the intervention, 55 out of 56 patients (98.2%) showed a considerable change in the thickness of the endometrium layer with an average thickness of 8.48 ± 1.32 mm (< 0.0001, SE 0.233, 95% CI 1.58-2.5). Out of the 55 patients, 20 got pregnant, i.e., 36.4% pregnancy rate. Till date, thirteen pregnancies had live births (65%), three pregnancies (15%) were biochemical pregnancies, 1 (5%) was ectopic, and three pregnancies (15%) had spontaneous miscarriage before eight weeks. When we compared the endometrial thickness (EMT) in the pregnant and non-pregnant groups pre- and post-ABCD instillation, (6.47 ± 1.31 mm vs 6.48 ± 1.4 mm, p = 0.98 and 8.68 ± 1.32 mm vs 8.48 ± 1.32 mm, p value 0.59) the p value was not statistically significant. Conclusions: The implantation, clinical pregnancy and live birth rates were 36.4, 30 and 65%, respectively. This result is a significant improvement for patients with thin endometrium for whom we would otherwise cancel the frozen transfer. An autologous resource is a safe, readily available and inexpensive treatment modality.

Associations, follow up data, and postnatal outcome of antenatally diagnosed Urinary Tract Dilatation - Five-year single tertiary center experience from South India.

BACKGROUND: Urinary tract dilatations (UTD) are frequently diagnosed during Mid-Trimester Anomaly Scan (MTAS), at which time, given their variable progression and heterogeneous classification systems, offering suitable counsel to the couple is challenging. OBJECTIVE: Based on postnatal data, we aimed to guide parental counseling, and further evaluation of UTD diagnosed at MTAS. Specifically, the utility of multi-disciplinary UTD classification system was tested. METHODS: A retrospective observational study of all UTDs included from five years (2015-2020) MTAS register. The multi-disciplinary UTD classification system was used for antenatal/postnatal UTD categorization. Follow-up data were obtained from case records until the current age of children (2-6 years). RESULTS: Out of 527 fetal abnormalities, 103 had UTD at MTAS. Based on the third-trimester ultrasound, 49 were low-risk UTD A1, and 44 were increased-risk UTD A2-3 (including the nineteen UTD A1 at MTAS worsened to A2-3 by third-trimester). On postnatal follow-up of UTD A1 and A2-3, respectively, neonatal UTD P2/P3 was seen in 2% and 40.9%; complete spontaneous resolution was seen in 79.5% and 43.18%; none and 22.7% underwent surgical intervention; persistent P2/P3 UTD were seen on follow-up in 2% and 4.5% (excluding those who needed surgery); impaired renal function was seen in none and 36.3%, and recurrent UTI in 8.1% and 34.09%. The subgroup with progressive UTD (from A1 to A2-3 by third-trimester ultrasound) formed 43% of the final UTD A2-3 category. Among these 19 cases, surgical intervention was performed in eight (42%); impaired renal function was seen in 7 cases (36.8%), and recurrent UTI was seen in eight (42%). DISCUSSION: Given the diverse classification systems for UTD, ours is the second Indian data proving the prognostic utility of multi-disciplinary UTD classification system, specifically at third trimester scan, based on postnatal outcome. In contrast to published guidelines, our data suggests follow-up for renal pelvis anteroposterior diameter (APD) of 4-7 mm at MTAS, as some may worsen. Similar progression has been noted in other Indian studies, but the classification systems are different. Contrary to the published literature, we could not suggest a renal APD cut-off as a single criterion to predict surgical intervention. Significant limitations are retrospective observational design and multiple sonographers. CONCLUSION: Our data helps guide parental counseling and further evaluation for UTD diagnosed at MTAS. The multi-disciplinary Consensus UTD Classification system, was helpful in prognostication.

Clinical utility of aortic isthmus Doppler in the prediction of perinatal outcomes.

BACKGROUND: Doppler studies of uteroplacental-fetal circulation have been proven useful in diagnosing fetal growth restriction, appropriately timing delivery, and improving perinatal morbidity and mortality. There has been an extensive search for the ideal means to identify fetuses between the compensatory and acidemic phase (ie, the "preacidemic phase"), and the aortic isthmus Doppler seems to show promise. OBJECTIVE: This study aimed to investigate: (1) the prevalence of abnormal aortic isthmus Dopplers in a cohort of small-for-gestational-age fetuses and their correlation with other conventional Doppler abnormalities, and (2) the predictive ability of abnormal aortic isthmus Dopplers with regard to short-term adverse neonatal outcomes. STUDY DESIGN: Fetuses diagnosed as small-for-gestational-age at ≥24 weeks' gestation were included. Management was as per the standard protocol. Aortic isthmus Doppler was performed within a week of delivery with other conventional Dopplers. The adverse perinatal outcomes studied were: requirement of neonatal resuscitation at birth, Apgar score at 5 minutes <7, cord blood pH <7, presence of bronchopulmonary dysplasia, hypoxic-ischemic encephalopathy, grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal intensive care unit stay longer than 14 days, and stillbirth or neonatal death. RESULTS: Among 121 small-for-gestational-age fetuses, 67 showed Doppler abnormalities in ≥1 vessels. The prevalence of abnormal aortic isthmus Doppler was 14.87%. Analysis was between group 1 with 103 normal aortic isthmus and group 2 with 18 abnormal aortic isthmus fetuses; 41 cases had some form of adverse perinatal outcome, the frequency of which was comparable between the groups. Abnormal aortic isthmus Doppler had a significant correlation with low cerebroplacental ratio, absent or reversed end-diastolic flow in the umbilical artery, and high pulsatility index in the ductus venosus. The positive likelihood ratio for predicting composite adverse perinatal outcome was 10.2 for absent or reversed end-diastolic flow in the umbilical artery, 9.6 for low cerebroplacental ratio, 2.28 for absent or retrograde flow in the aortic isthmus, and 2 for abnormal ductus venosus. CONCLUSION: Predelivery abnormal aortic isthmus Dopplers performed worse than other conventional Dopplers in predicting abnormal perinatal outcomes.

Crossing the Hurdle of a Low Oocyte Yield in an in vitro Fertilization Cycle to Obtain Mature Oocytes.

The complex process of oocyte maturation involves a coordinated set of events to take place so that an adequate number of oocytes can be obtained during an oocyte pickup procedure following controlled ovarian stimulation. A weak link in any of the steps can yield a sparse number of oocytes which can be a setback in the process.

Random Start Ovarian Stimulation.

Fertility preservation is emerging in recent years as an important option for various indications many of which being for cancer patients and for certain benign conditions as well. In the present case report, we set out to utilise the same protocol, however, for different indications.

We Need to Improve Prenatal Screening Practices in Primary Obstetric Care: A Representative Data from a Fetal Medicine Unit in Coastal Karnataka.

BACKGROUND: The present observational data from the fetal medicine unit aim to identify gaps in prenatal screening modalities employed in the primary obstetric care population in coastal Karnataka. METHODS: A retrospective observational study of all referrals to Fetal Medicine unit is over 2 years. For each fetal abnormality, we reviewed the literature to note the range of gestational age at which the abnormality should almost always be diagnosed. Taking this as standard, the gestational age at which each of these problems was diagnosed and referred was noted down. They were compared and analysed to understand the efficiency of prenatal screening practices in the referral population. The final perinatal outcome was also noted down in order to assess the impact on perinatal mortality/morbidity. RESULTS: A total of 277 cases were referred to fetal medicine unit. Two hundred twenty-eight cases (82.31%) were low risk pregnancies. Among 277 cases, 200 (72.2%) had structural abnormalities, 7 (2.5%) chromosomal/ genetic abnormalities, 61 (22.02%) isolated soft markers, and 9 (3.2%) twin-related problems. Detection rate of structural abnormalities was 33% at 14 weeks and 52.22% at 20 weeks, considering those anomalies usually diagnosed by these gestational age windows. The primary reason for delayed diagnosis was non-performance of ultrasound "on time", rather than missed diagnosis. Fifty-three per cent (106 out of 200) of all the fetal structural abnormalities were diagnosed beyond 20 weeks. Average gestational age at mid-trimester anomaly scan in this group was between 20 and 24 weeks. Sixty-one patients were referred due to isolated soft markers, 30 beyond 20 weeks. Eighty per cent of them did not have any aneuploidy screening in pregnancy. CONCLUSION: Practice of fetal medicine hugely depends upon appropriate prenatal screening practices in the referral population. There is an urgent need to bring in standard protocols for Prenatal Screening across all the primary obstetric care providers, both in the public and private sectors. Considering the huge burden of delayed prenatal diagnosis in our country, the proposed revision of MTP bill is a welcome change in fast-growing field of fetal diagnosis and therapy.

A report of human papilloma virus-16 associated vaginal carcinoma after thirty-two years of successful radiation therapy for cervical cancer.

Once the recommended 5-year recurrence-free follow-up is achieved for cervical cancers regular annual pelvic examination is mandatory. The main aim of presenting this short report is to emphasize the difficulties in the collection and interpretation of cytology samples from stenosed cervix or vault after pelvic irradiation. Radiotherapy can induce changes in the cellular morphology which may persist for many years. A 64-year old post-menopausal lady who had received radiation therapy 32 years back for cervical carcinoma stage IIb presented to the Gynecology outpatient department with vaginal spotting. Even though the patient was under regular follow-up for the initial 2 years, she was lost to further follow-ups. The patient was symptom-free except for one episode of spotting in August 2016 and the histopathological examination of the vault smear had ruled out malignancy. However, 1 month later she again presented with spotting and pelvic examination revealed a warty growth at the lateral vaginal wall. The tissue excision biopsy was tested positive for HPV-16 DNA and the histopathology confirmed vaginal squamous cell carcinoma. The association of human papilloma virus (HPV) in cervical cancers was well established and these patients manifest a higher risk of HPV-induced vaginal cancers. HPV DNA testing during follow-up may facilitate early recognition of HPV-related lower genital tract cancers.

Isolated sixth Cranial Nerve Palsy in a Case Of Severe Pre-Eclampsia Presenting as Postpartum Diplopia.

Visual symptoms in pregnancy are ominous. The spectrum of ocular symptoms seen in pre-eclampsia includes blurring of vision, scotoma, hemianopia and even total cortical blindness. Diplopia, though rare has also been reported in cases of pre-eclampsia and occurs due to pathological changes affecting the 6th cranial nerve. Ocular symptoms of pre-eclampsia usually regress after delivery but occasionally may present in the postpartum period. We present a case of a 34-year-old lady with severe pre-eclampsia at 31 weeks of gestation with diplopia presenting seven days post caesarean section. No identifiable pathology was found and the condition recovered spontaneously once blood pressure control was achieved.

Fallopian tube choriocarcinoma presenting as ovarian tumour: a case report.

Choriocarcinoma of the fallopian tube is a rare form of gestational trophoblastic disease. It can be gestational or non gestational choriocarcinoma, based on the origin. Fallopian tube choriocarcinoma has been reported commonly after ectopic pregnancy. Choriocarcinomas are germ cell tumours formed by trophoblastic elements. A 26-year-old lady presented with pain and mass abdomen of 15 days duration. Clinical examination revealed a ovarian tumour with elevated beta HCG. The working diagnosis was ovarian choriocarcinoma. Patient was also found to be having pulmonary artery hypertension due to the metastasis to lungs. Staging laparotomy was done. Histopathology revealed it to be metastatic gestational choriocarcinoma of fallopian tube with vascular emboli. The stage was stage III and WHO scoring of 15. She received Etoposide, Methotrexate, Actinomicin, Cyclophosphamide and Oncovin therapy. Following treatment there was a significant drop in the beta HCG. Patient tolerated the chemotherapy well. This is a rare presentation of choriocarcinoma with good prognosis.

Predictive value of middle cerebral artery to uterine artery pulsatility index ratio in hypertensive disorders of pregnancy.

Aims and Objectives. (i) To determine the predictive value of cerebrouterine (CU) ratio (middle cerebral artery to uterine artery pulsatility index, MCA/UT PI) in assessing perinatal outcome among hypertensive disorders of pregnancy. (ii) To compare between CU ratio and CP ratio (MCA/Umbilical artery PI) as a predictor of adverse perinatal outcome. Methods. A prospective observational study was done in a tertiary medical college hospital, from September 2012 to August 2013. One hundred singleton pregnancies complicated by hypertension peculiar to pregnancy were enrolled. Both CU and CP ratios were estimated. The perinatal outcomes were studied. Results. Both cerebrouterine and cerebroplacental ratios had a better negative predictive value in predicting adverse perinatal outcome. However, both CU and CP ratios when applied together were able to predict adverse outcomes better than individual ratios. The sensitivity, specificity, positive predictive value, and the negative predictive values for an adverse neonatal outcome with CU ratio were 61.3%, 70.3%, 56%, and 78.9%, respectively, compared to 42%, 57.5%, 62%, and 76% as with CP ratio. Conclusion. Cerebrouterine ratio and cerebroplacental ratio were complementary to each other in predicting the adverse perinatal outcomes. Individually, both ratios were reassuring for favorable perinatal outcome with high negative predictive value.

Twin pregnancy with Hydatidiform Mole and Co-existent Live Fetus: Lessons Learnt.

This is a case report of a twin pregnancy with one fetus and a coexistent mole diagnosed at 13 weeks. After thorough counseling, the pregnancy was continued as per the patient's desire. The pregnancy was closely monitored with serial S ß hCG, ultrasound for fetal growth, size of molar sac, and theca lutein cysts, which gradually decreased in size during the second trimester of pregnancy. An emergency caesarean delivery was done at 36 weeks due to breech in early labour. A live baby weighing 1.8 kg was delivered in good condition. Her S ß hCG reached normal levels at the end of three weeks, and she is now on post-molar surveillance. Though the general trend is to terminate pregnancy in twins with coexistent mole in anticipation of complications, under close surveillance, optimal outcomes can be achieved. Monitoring of S ß hCG, serial ultrasound for fetal growth, size of molar component, and theca lutein cysts can help to predict good patient outcomes.

Placental Teratoma Presenting as a Lobulated Mass behind the Neck of Fetus: A Case Report.

Placental teratoma is a rare nontrophoblastic benign tumour, which is thought to arise from germ cells. These tumours contain elements derived from multiple germ cell layers. We report a case of teratoma, where on ultrasound; there were two echogenic masses of 4 cm × 5 cm and 3 cm × 4 cm, arising from the placenta. Elective lower segment cesarean section was done in view of breech presentation at 38 weeks of gestation. Gross examination of the placenta showed two lobulated masses of 5 cm × 5 cm and 4 cm × 4.5 cm, respectively. Histopathological examination of the placenta was suggestive of teratoma of the placenta. The fetus was normal.The maternal and fetal outcome was good.