Outcomes of Mechanical Resection of Endometrial Polyps and Submucosal Fibroids Through TruClear™ Hysteroscopy.

OBJECTIVE: To assess the efficacy of mechanical resection through TruClear™ hysteroscopy in patients with endometrial polyps and submucosal fibroids. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Obstetrics and Gynaecology, Shifa International Hospital, Islamabad, Pakistan, from June 2018 to 2022. METHODOLOGY: Patients diagnosed with endometrial polyps and submucosal fibroids confirmed by abdominal or transvaginal ultrasonography were included. Patients having a history of congestive cardiac failure, chronic kidney disease, and bleeding diathesis were excluded from the study. Data about the complete removal of pathology (endometrial polyps and submucosal fibroids), mean operating time, and postoperative complications such as bleeding and perforation were extracted. The follow-up was set up to 6 months after the procedure. RESULTS: The average age of the 45 patients was 35.62 ± 7.46 years. Heavy menstrual bleeding was the most prevalent symptom, seen in 73.3% of cases, followed by irregular vaginal bleeding (IVB) in 11.1% of cases. The most frequent disease identified by sonography was a polyp in 21 (47%) instances, followed by submucosal fibroids in 12 (27%) cases, mixed pathology in 10 (22%), and malignancy in 2 (4%) cases. The overall average operative time was 36.46 ± 24.94 minutes. A hundred percent removal of lesions was observed in this study. Persistent symptoms were observed in 13% of patients after the surgery so they were treated with other interventions. The most common intervention was an intrauterine hormonal device. Intraoperative bleeding was observed in only one patient and was managed by intraoperative intrauterine balloon insertion. The recurrence rate was 8.9% (4/45). CONCLUSION: TruClear™ hysteroscopy showed a major advantage in the successful and complete removal of the pathology, low operation time, and complications. KEY WORDS: Fibroids, Hysteroscopy, Polyps, Endometrial resection, Menstrual bleeding.

Uterine adenosarcoma arising from a subserosal adenomyoma: A case report.

•Adenosarcoma is a rare tumor of the uterus and cervix occuring mostly in post-menopausal women.•Our patient was a 37-year old nullipara presenting with lower abdominal pain and backache.•She was diagnosed as a case of multiple leiomyomata and proceeded for myomectomy.•Intraoperative findings raised suspicion of malignancy.•She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histology confirmed the diagnosis.

Obstetrics and COVID-19 Experience: Challenges and Strategies Adapted by a Tertiary Care Hospital in a Developing Country.

Novel coronavirus disease 2019 (COVID-19) pandemic has produced profound effects on the global healthcare systems including every specialty. Pregnant women are physiologically immunocompromised and may be affected more by the pandemic than the general population. New and unique challenges were encountered by hospitals and healthcare providers (HCPs) related to medical, surgical and strategic management involved in obstetric care. Data of obstetric patients presenting in labour and delivery unit from April to July 2020 was studied. In all 533 patients presented, 46 (8.6%) were COVID-19 positive. Overall, 41% cesarean sections were performed with one mortality and one COVID-19-positive neonate. The challenges faced by HCPs regarding delivery of care and collective successive measures taken to overcome those challenges as well as challenges faced by patients related to healthcare provision are also addressed. Strategies adopted for timely intervention to overcome those challenges were implemented for smooth and safe care to all patients and staff. We believe that planning and preparing proactively is the key to address any pandemic like COVID-19. Key Words: COVID-19, Pregnancy, Obstetric care, Challenges.

Misoprostol for term labor induction: a randomized controlled trial.

OBJECTIVES: The aim of this study was to compare the efficacy of vaginal misoprostol with vaginal dinoprostone for term labor induction. MATERIAL AND METHODS: It was a randomized controlled trial done in the Obstetrics Department, Shifa Community Health Centre, Shifa International Hospital (Teaching Hospital of Shifa College of Medicine, Islamabad). All pregnant women at term pregnancy coming for induction of labor were enrolled. 246 women fulfilled the inclusion criteria. Out of them 208 women consented to be part of the study. These women were then randomized to receive either Treatment A (vaginal misoprostol) or Treatment B (vaginal dinoprostone). Data were completed for 200 women. These included induction labor and induction-delivery interval, fetal and maternal complications, and baby apgar score. RESULTS: Out of 200 women in the study, 100 were in Group A and 100 in Group B. Labor commenced in a mean of 6.67 hours (± 3.63) in Group A whereas it took a mean of 8.41 hours (± 5.13) in Group B (p=0.00). Actual induction to delivery (of the baby) interval was a mean of 11.68 hours (± 4.55) for misoprostol and 15.37 hours (± 5.30) for dinoprostone group (p=0.00). There were no cases of uterine rupture in both groups; however, there were 10 cases of uterine hyperstimulation in Group A and 4 in Group B (p=0.09). CONCLUSIONS: It is time to re-evaluate the role of misoprostol for term labor induction. It is an efficacious and cost-effective alternative to the presently licensed treatment.

The effect of modes of delivery on infants' feeding practices.

Breast feeding has a great impact on the infant morbidity and mortality. According to Pakistan Demographic and Health survey (PDHS) infant mortality rate is 78 deaths per 1,000 live births. World Health Organization recommends that exclusive breast feeding for six months can decrease infant mortality rate by one-third. The objective of the study was to find out how the mode of delivery had impact on the practice of breast feeding. Data were collected for 2500 consecutive patients during a period of two years, and it was seen that maternal initiative to breast feed was low and problems with lactation were much more in cases delivering their babies via cesarean sections than those delivering theirs by normal delivery. Vaginal and cesarean section deliveries took place in 54% and 46% of the case, respectively. Thirty percent of the women studied felt that they had no problems regarding breastfeeding, but 70% of them had some sort of problems with breastfeeding their babies. When the women were matched for the mode of delivery, 58% of women who had breastfeeding problems belonged to the cesarean delivery group and 42% of complaining mothers were from women with normal delivery. The relative risk of having problems with breastfeeding for women subjected to cesarean was 1.38 and the odds ratio was 0.61. The findings of the present study indicate that more in depth counseling sessions are required for women undergoing operative delivery to improve breast feeding among them.

Validity of hysteroscopy and histopathology in patients with menstrual irregularity.

BACKGROUND: Abnormalities in menstrual cycle is the most common presenting symptom in Gynaecology out-patient. Dilatation and curettage has been the diagnostic investigation of choice for decades in such cases. With the advent of new more valid and safe methods, it has been replaced by hysteroscopy as gold standard. The objective of this study was to know the sensitivity and specificity of hysteroscopy in patients presenting with menstrual irregularity. METHODS: Validity study was conducted over 269 cases for a period of two years at Maternal and child health centre, Pakistan Institute of Medical Sciences, Islamabad. Inclusion criteria were age > 35 years and abnormal uterine bleeding. Patient with positive pregnancy test, recent cervicitis, vaginitis, endometritis, pelvic infection were excluded. Hysteroscopy and curettage was performed after taking informed consent, mostly on outpatient basis. A predesigned Performa was used for a detailed record of hysteroscopic findings, which were later compared with histopathology report. Data was analysed using MS Excel, and Cross Tabulation was done using Epi-info. Sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy was calculated against histopathology, the gold standard. RESULTS: Sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy was calculated against histopathology after excluding 46 (17.1%) cases of uterine fibroid that were diagnosed only at hysteroscopy. Hysteroscopy has shown highest sensitivity for retained products of conception and adenocarcinoma (100%) while a specificity of 90% and above for all hysteroscopic findings. Seventy eight percent of the procedures were performed on outpatient basis, 95% under intravenous sedation and 95% with no operative complication. CONCLUSION: Hysteroscopy should be used as an adjunct procedure to curettage as it is a better tool for diagnosis of intracavity lesions, with a high sensitivity and specificity for endometrial carcinoma.

Old procedures are still valuable: avoiding unnecessary cesarean section to decrease risk in the next pregnancy.

OBJECTIVE: In the past, obstetricians were highly skilled in obstetric procedures. An increase in cesarean section rates, especially in developed countries, has led to a gradual loss of obstetric skills. CASE REPORTS: Two cases are reported, the first being a case of face presentation in the mentoposterior position and the second a case of transverse lie with a prolapsed hand, both with intrauterine death. CONCLUSION: Cesarean sections in both cases, although justified, were avoided after a successful trial of other obstetric procedures.

Validity of pipelle endometrial sampling in patients with abnormal uterine bleeding.

BACKGROUND AND OBJECTIVES: We compared endometrial sampling by pipelle endometrial curette with conventional dilatation and curettage (D&C) in patients with abnormal uterine bleeding. METHODS: Endometrial sampling with pipelle curette was performed on 100 patients followed by formal D&C. Samples were labeled as A and B, respectively, and sent to a histopathologist who was blinded as to the method of sampling. The histopathology reports of both samples were compared, taking D&C as the gold standard. RESULTS: An adequate sample was obtained in 98% of cases by pipelle and in 100% of cases by D&C. Pipelle had a sensitivity, specificity, positive predictive value and negative predictive value of 100% for diagnosing endometrial carcinoma, hyperplasia and secretory endometrium. Pipelle also had high diagnostic sensitivity, specificity and negative predictive value (100%, 98% and 100%, respectively) for hyperplasia with atypia, and low sensitivity (57%) and positive predictive value (57%), but high specificity (97%) and negative predictive value (97%) for endometritis. Similarly, for proliferative endometrium, the pipelle technique had values of 94% and 93% for sensitivity and specificity, respectively. Both samples labeled as inadequate for histology by pipelle were polyps on the D&C report. Difficult endotracheal intubation was encountered in two cases of D&C. No other complications of the procedure were observed. CONCLUSION: The pipelle is a safe device for getting an adequate endometrial sample for histology, with a high sensitivity and specificity for detection of hyperplasia and malignancy.

Change in trend of contraceptive uptake--effect of educational leaflets and counseling.

BACKGROUND: The study was conducted to determine the impact of counseling and educational leaflets on contraceptive practices of couples. STUDY DESIGN: Randomization of 600 women was done in two groups matched for age, parity and socioeconomic status at the Department of Obstetrics and Gynaecology, Shifa Foundation Community Health Centre, Shifa International Hospital, Islamabad, Pakistan. In Group A, the intervention group was exposed to contraceptive counseling and educational leaflets in the postnatal ward after delivery, whereas in Group B, the nonintervention group was not given any formal contraceptive advice. Later on, both groups were assessed regarding their contraceptive practices. RESULTS: At their follow-up visit (8-12 weeks) postpartum, 19 (6.3%) women in the nonintervention group had started contraceptive use, whereas 153 (50.8%) had decided to start contraception in the next 6 months, and 129 (42.8%) women were still undecided. The main contraceptive user was the male partner (n=117, 38.8%), and the most common method used was coitus interruptus (n=62, 36.3%). In the intervention group, 170 women (56.9%) had started using contraceptives, whereas 129 (43.1%) had decided to start contraceptive use in the next 6 months. The predominant contraceptive user was the females (n=212-70.9%), and the most popular method chosen was oral contraceptive pills (n=111, 37.1%). CONCLUSION: There is a definite increase in contraceptive uptake in women provided with educational leaflets and counseling session with a shift toward use of more reliable contraceptive methods.