Clinical Presentation and Management of Peripartum Pubic Diastasis.

Background: Symphysis pubis diastasis (SPD) is an uncommon peripartum complication which can have short-term morbidities secondary to pain and restricted movements as well as long-term complications. It is important to diagnose this condition as it causes significant discomfort to the nursing mothers. We present our experience in five patients with SPD who were managed successfully. Methods: Present study is an observation of five cases of SPD managed in a single unit in a tertiary care center over three years from January 2017 to December 2019. All women with symptoms of SPD with inter-pubic distance of more than 10 mm were selected for the study. The demographic profile, clinical details, diagnostic imaging findings, and treatment provided for such patients were noted down from the individual case records. Follow-up of each patient for improvement in the symptoms and X-ray findings was available till 3 months for each case. Results: Mean age of the women with SPD was 29.8 ± 5.4 years. Four women had vaginal delivery and one had vacuum delivery. Average birth weight is 3.26 ± 0.85 kg. Mean duration of first stage of labor is 6.6 ± 0.89 h and median of second stage is 35 min. Average inter-pubic distance at the time of diagnosis on X-ray was 1.84 ± 0.2 cm. All women were managed conservatively with bed rest, analgesics, pelvic binder and physiotherapy. Improvement in the range of movement was noted over average of 21.8 ± 3.7 days and symptoms resolved over 14.4 ± 2.6 weeks. Conclusion: Treating obstetrician should be aware of this condition as simple treatment measures can avoid the long-term morbidities and complications.

Managing pregnancy in women with Sturge-Weber syndrome: case report and review of the literature.

Sturge-Weber syndrome (SWS) is a sporadic congenital neuro-cutaneous anomaly with capillary-venous malformation involving the brain, eye, and the ophthalmic division of the trigeminal nerve. In these cases, physiological changes in pregnancy, including hormonal and hemodynamic changes, may predispose to increased seizure frequency and even a life-threatening intracranial haemorrhage. There are only few case reports available about the management of women with pregnancy and SWS. We report two patients with SWS diagnosed in childhood and managed during pregnancy and reviewed the outcomes and complications during pregnancy in women with this disorder.

Evaluation of a symptom-based score in combination with CA125 to predict ovarian malignancy in women with adnexal mass.

BACKGROUND: Adnexal masses are a common problem seen in women. The aim of this study was to determine the appropriate cut-off for symptom-based score to predict ovarian malignancy in women with adnexal mass and to evaluate it in combination with CA125. METHODS: This was a prospective study involving 341 women with adnexal mass who underwent surgery. A symptom-based scoring system was administered to the women, preoperatively, and CA125 levels were documented. Receiver operating characteristic curve (ROC) analysis was used to determine the appropriate cut-off for the symptom-based scoring. Results for this symptom-based scoring and CA125 were correlated with surgical pathological findings. RESULTS: Out of the 341 women with adnexal mass, 112 were diagnosed to have ovarian malignancy. The mean age of women was 43.6±13.8 years. Using ROC analysis, symptom score ≥9 was determined to be the appropriate cut-off. The area under curve (AUC) at this cut-off score was found to be 0.87 (95% CI 0.83-0.91). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this cut-off was found to be 84.8%, 88.6%,78.5%, and 92.3%, respectively. Combining CA125 and symptom score resulted in higher sensitivity (96.4%) and NPV (97.4%) with specificity and PPV of 65.5% and 57.8%, respectively. CONCLUSION: Symptom score in combination with CA125 has good ability to predict ovarian malignancy in women with adnexal masses.

The "collateral damage" of the war on COVID-19: impact of the pandemic on the care of epithelial ovarian cancer.

The covid-19 pandemic has impacted the management of non-covid-19 illnesses. Epithelial ovarian cancer (EOC) requires long-duration multidisciplinary treatment. Teleconsultation and shared care are suggested solutions to mitigate the consequences of the pandemic. However, these may be challenging to implement among patients who come from the lower economic strata. We report the disastrous impact of the pandemic on the care of EOC by comparing patients who were treated during the pandemic with those treated in the previous year. We collected the following data from newly diagnosed patients with EOC: time from diagnosis to treatment, time for completion of planned chemotherapy, and proportion of patients completing various components of therapy (surgery and chemotherapy). Patients treated between January 2019 and September 2019 (Group 1: Pre-covid) were compared with those treated between January 2020 and December 2020 (Group 2: During covid pandemic). A total of 82 patients were registered [Group 1: 43(51%) Group 2: 39(49)]. The median time from diagnosis to start of treatment was longer in group 2 when compared to group 1 [31(23-58) days versus 17(11-30) days (p = 0.03)]. The proportion of patients who had surgery in group 2 was lower in comparison to group 1 [33(77%) versus 21(54%) (p = 0.02)]. Proportion of patients who underwent neoadjuvant (NACT) and surgery were fewer in group 2 in comparison to group 1 [9(33%) versus 18(64%) p = 0.002]. Among patients planned for adjuvant chemotherapy, the median time from diagnosis to treatment was longer in group 2 [28(17-45) days, group 1 versus 49(26-78) days, group 2 (p = 0.04)]. The treatment of patients with EOC was adversely impacted due to the COVID-19 pandemic. There was a compromise in the proportion of patients completing planned therapy. Even among those who completed the treatment, there were considerable delays when compared with the pre-covid period. The impact of these compromises on the outcomes will be known with longer follow-up.

A Simple, Novel Prognostic Score in Platinum Sensitive Relapsed Ovarian Cancer.

OBJECTIVES: Epithelial ovarian cancer is one of the commonest gynecologic cancers and one with the highest mortality. This retrospective cohort study was done to identify predictors of outcomes in platinum-sensitive relapsed ovarian cancer patients (PS-ROC). METHODS: Data regarding baseline characters, laboratory findings, therapeutic details and survival outcomes was obtained from the medical records of PS-ROC patients presented between January 2015 and December 2019. Prognostic score was constructed using factors which were significant on multivariate analysis to predict survival outcomes. RESULTS: A total of 71 (PS-ROC) patients were included in the study with a median age of 50 years. Relapse treatment was either chemotherapy alone (n=53, 75%) or chemotherapy plus surgery (n=18, 25%). The estimated progression-free survival (PFS) and overall survival were 10 and 29 months, respectively. The overall response rate after treatment of relapse was 59%. Prognostic score was created with the 3 factors (each scoring 1 point) which were predictive of PFS (higher lymphocyte-monocyte ratio, longer platinum-free interval and secondary cytoreduction). Patients with low score (0,1) had better PFS than those with higher score (2,3) (13 vs. 7 mo [P=0.0001]). CONCLUSIONS: A composite prognostic score could predict outcomes in PS-ROC and potentially identify a subgroup with very poor prognosis. Future studies with a greater number of patients are needed to validate these findings. This information could help tailor more intense therapies to the high-risk patients and attempt to improve outcomes and serve as stratification factors for prospective trials.

Imaging as an alternate diagnostic modality in a presumptive case of abdominopelvic TB in a COVID-19 patient.

A 30-year-old, multiparous widow, with postpolio residual paralysis, presented with complaints of dull aching abdominal pain for 15 days. Ultrasound showed a mixed echogenic right adnexal mass with free fluid in the pelvis and abdomen. CT abdomen and pelvis revealed partially defined peripherally enhancing collection in lower abdomen and right adnexa suggestive of tubo-ovarian abscess. There was mild ileal wall thickening and few enlarged mesenteric lymph nodes. Ascitic fluid did not show acid fast bacilli and cultures were sterile. Extensive diagnostic laboratory work was done which was inconclusive. Diagnostic laparoscopy could not be performed due to non-availability of elective operation theatre in the COVID-19 pandemic. Presumptive extrapulmonary tuberculosis was clinically and radiologically diagnosed. She was started on daily anti tuberculosis treatment. This case shows us the importance of imaging as a diagnostic tool and as an alternative for laparoscopy in COVID-19 pandemic to diagnose abdomino-pelvic tuberculosis.

Role of hysteroscopy and ultrasound in early identification of post-molar gestational trophoblastic neoplasia.

OBJECTIVE: To evaluate the role of hysteroscopy and ultrasound in early identification of gestational trophoblastic neoplasia (GTN) after molar evacuation. METHODS: This was a prospective study involving 52 women with an ultrasound diagnosis of complete hydatidiform mole, attending a tertiary centre in south India between August 2016 and August 2019. Baseline characteristics such as age, serum beta-human chorionic gonadotropin(ß-hCG) level, gestational age, and uterine size were noted. After the evacuation of molar pregnancy, weekly follow-up with ß-hCG was performed, until three consecutive values were normal and then monthly for six months. Findings of transvaginal ultrasound and diagnostic hysteroscopy, performed on follow up at three weeks, were noted. Primary outcome was the development of GTN. Area under the curve(AUC) was calculated to assess the usefulness of these methods in early identification of GTN. RESULTS: Thirteen women (25 %) developed GTN during follow up, within 6 months. Twenty six(50 %) cases had high-risk molar pregnancy. Positive findings on hysteroscopy and ultrasonography were noted in 44.2 % and 19.2 % respectively. AUC was 0.83(95 % CI, 0.70-0.97) for ultrasound and 0.82(95 % CI, 0.72-.92) for hysteroscopy. Sensitivity and specificity were 69.2 % and 97.4 % for ultrasound and it was 92.3 % and 71.8 % respectively for hysteroscopy in identifying those who developed GTN on follow-up. CONCLUSIONS: Transvaginal ultrasound as well as hysteroscopy may help in early identification of women at risk of developing GTN following a molar evacuation. Being a non-invasive method with similar discriminative value, ultrasonographic evaluation may be used for early identification of women with GTN after validation in future studies.

Frequency and correlates of mother-infant bonding disorders among postpartum women in India.

PURPOSE: Disorders of mother-infant bonding have been described since early 20th Century. Previous studies have looked at the prevalence of bonding disorders among mothers with postpartum psychiatric disorders. However, its frequency among healthy postpartum mothers is less studied. METHODS: Two hundred and fifty mother-infant dyads were studied using the Mini International Neuropsychiatric Interview (MINI), the Stafford Interview, Bangalore Maternal Behaviour Scale (BMBS) and Tamil versions of the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Bonding Questionnaire (PBQ). The mothers were interviewed between 4 weeks to six months postpartum. In addition, thirty one mothers with a lifetime history of psychiatric disorders were interviewed using the above scales. RESULTS: The frequency of bonding disorders was found to be 24% among healthy postpartum mothers as against 45.2% in mothers with psychiatric disorder. However, the frequency of mild disorders of bonding was relatively lower at 5.6% among healthy mothers and 6.5% among mothers with psychiatric disorders. We found that mothers in India had a clinging / over-involved subtype of anxiety that prevented them from leaving their baby under care of another competent adult. While infant-related anxiety was seen in 10% of healthy mothers, about 20% of mothers with psychiatric diagnoses had anxiety. The presence of bonding disorders was not correlated with any maternal or infant related factors except difficulty in breastfeeding. CONCLUSIONS: Disorders of mother infant bonding are seen in healthy postpartum mothers. The frequency of mild disorders of bonding appears to be similar across countries and this condition warrants further attention.

Translation, validation and factor structure of the Tamil version of the Postpartum Bonding Questionnaire (PBQ-T).

BACKGROUND: The Postpartum Bonding Questionnaire was developed in English for the purpose of screening for bonding disorders among postpartum mothers. There was a felt need for a Tamil translation of the self-rated instrument. METHODS: The Postpartum Bonding Questionnaire was translated into Tamil (PBQ-T). Two hundred and fifty mother-infant dyads were administered the PBQ-T along with the Stafford Interview. The Stafford Interview was studied by two independent psychiatrists to arrive at a diagnosis of bonding disorders in the mothers. The Edinburgh Postnatal Depression Scale (EPDS) and Bangalore Maternal Behaviour Scale (BMBS) were used for rating depressive symptoms and caregiver reported behaviour of the mother towards the infant. We also did a factor analysis to find the factor structure of the PBQ-T. RESULTS: A 19-item PBQ-T that has five factors grouped into three subscales. The five factors are General Bonding (F1A), Frustration (F1B), Anxiety (F2), Feeling trapped (F3A) and Aggression/ Rejection dimensions (F3B) loading onto three subscales 1, 2 and 3. Total PBQ-T scores were best used to detect 'any disorder of bonding' (cut-off 5/6). Subscale 1 (cut-off 2/3) was useful in detection of mild disorders of bonding, subscale 2 (cut-off 2/3) for infant-focused anxiety and subscale 3 (cut-off 0/1) for Anger/ Rejection. Mothers with bonding disorders had greater psychological distress. Caregiver report of mother's behaviour (BMBS) could detect anxiety and anger/ rejection but not the lack of emotional bond. CONCLUSION: A 19-item Tamil version of the PBQ is useful in screening for disorders of mother-infant bonding among healthy postpartum mothers.

Wilson's disease presenting during pregnancy: A diagnostic and therapeutic dilemma.

Wilson's disease is an autosomal recessive genetic disorder affecting copper transport leading to hepatic and/or neuropsychiatric manifestations. Changes in pregnancy can mimic certain clinical features of chronic liver disease such as spider naevi, and constraints for the use of various investigation for diagnosis pose a challenge to physicians. A high index of suspicion, multi-disciplinary team approach, use of correct non-invasive testing including viral serology, autoantibodies and copper studies and ultrasonography help to diagnose most of the pre-existing, de novo or pregnancy-specific hepatological conditions. We report a case of Wilson's disease diagnosed during pregnancy and discuss the challenges in diagnosis and treatment in pregnancy.