Journal of South Asian Federation of Obstetrics and Gynaecology

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2019 | September-October | Volume 11 | Issue 5

EDITORIAL

Gangadhar Sahoo, Prasanna K Sahoo

Prudent Use of Antenatal Corticosteroids for Fetal Well-being

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:2] [Pages No:279 - 280]

PDF  |  DOI: 10.5005/jp-journals-10006-1737  |  Open Access |  How to cite  | 

Original Article

Radha Vembu, Sithara Dharmarajan

“Hysterectomy by Vaginal Route,” not a Pressure

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:2] [Pages No:281 - 282]

Keywords: Benign gynecological disorders, Hysterectomy, Nondescent vaginal hysterectomy, Non prolapsed uterus

PDF  |  DOI: 10.5005/jp-journals-10006-1709  |  Open Access |  How to cite  | 

Abstract

Vaginal route of hysterectomy is a safe procedure with less morbidity and hospital stay. So there is a need to expand the indication for vaginal hysterectomy beyond uterovaginal prolapse. Aim: To determine the feasibility and outcome of nondescent vaginal hysterectomy (NDVH) and to assess pre and postoperative complications, duration of surgery, and length of hospital stay. Materials and methods: A prospective observational study was conducted between 2012 and 2014 at a tertiary care center. Two hundred fifty-six patients satisfying the selection criteria of hysterectomy for benign gynecological conditions, uterus size <16 weeks and excluding stage IV endometriosis, genital tract malignancy, and uterine prolapse were included. Nondescent vaginal hysterectomy was performed by the standard technique and the following parameters were recorded: age, parity, indication for surgery, duration of surgery, intra operative and postoperative complications, and hospital stay. The data were analyzed using SPSS version 16.0 by frequency and percentage analysis using Chi-squared test. Results: All 256 patients were analyzed. The mean age was 44.4 ± 6.1 years, fibroid uterus was the commonest indication, 89.4% had a uterine size ≤12 weeks, and 59% had uterine volume <200 cm3. The mean duration of surgery was 83.5 ± 11.0 minutes; salpingo-oophorectomy was performed in 25.8% of the patients. Intraoperatively 1.2% had bladder injury and 0.4% required conversion to laparotomy for pelvic hematoma. The mean duration of hospital stay was 4.9 ± 2.2 days and the mean pain score in NRS pain scale was 3.0 ± 0.3. Intraoperative blood transfusion was required in 1.9% of the patients only. Conclusion: Nondescent vaginal hysterectomy is a safe and feasible procedure for benign gynecological disorders. Clinical significance: Nondescent vaginal hysterectomy is a boon in this techno-savvy era by reducing the morbidity and promising early return to work.

Original Article

Shyamala Guruvare, Aaradhita Yadagiri, Vasudev Guddattu

Impact of New International Association of Diabetes in Pregnancy Study Group Criteria for Diagnosis of Gestational Diabetes on Pregnancy Outcome at a Tertiary Care Hospital Setting in Southern India

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:5] [Pages No:283 - 287]

Keywords: Gestational diabetes, Glucose tolerance test, Glycemic control, Pregnancy outcome, Prospective study

PDF  |  DOI: 10.5005/jp-journals-10006-1710  |  Open Access |  How to cite  | 

Abstract

Aim: To find the correlation of maternal and perinatal outcome with a single abnormal oral glucose tolerance test (OGTT) value and with at least two abnormal values, in women with gestational diabetes diagnosed as per International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria. Materials and methods: This was a prospective observational study. Women diagnosed with gestational diabetes as per IADPSG criteria were divided into four groups with a single abnormal value (fasting/one hour/two hour) and at least two abnormal values. Pregnancy outcomes were compared between the groups using Chi-squared test. Results: Among 392 women with gestational diabetes, 146 (37.2%), 44 (11.2%), 50 (12.8%) had fasting value, 1-hour value and 2-hour value abnormal, respectively, and 152 (38.8%) had at least two values abnormal. Women with risk factors for gestational diabetes had at least two abnormal values followed by the fasting abnormal group. Requirement of oral hypoglycemics and/or insulin was in 42/152 (27.6%) and 14/152 (9.2%), respectively, in the groups with at least two values deranged, 34/146 (23.3%) and 6/146 (4.1%) in the fasting abnormal group, which are higher compared to other groups (p = 0.01). Recurrent urinary infection (28%) and polyhydramnios/macrosomia (38%) were significantly in the group with at least two abnormal values. Preterm labor/PROM was more with groups with fasting hyperglycemia (37%) and 2nd hour glucose abnormality (36%). Conclusion: Though more than two abnormal GTT values and fasting hyperglycemia were higher in high risk women who also required antiglycemic medications, the maternal and perinatal outcome was not specifically associated with any of the abnormal GTT value individually. Clinical significance: The study may have a role in decision-making regarding the screening and diagnostic strategies of gestational diabetes to be adopted in the Indian setting.

Original Article

Mayuri S Dixi, Savita A Somalwar, Ganesh R Tathe

Effectiveness of Isosorbide Mononitrate vs Prostaglandin E2 Gel for Cervical Ripening: A Study

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:4] [Pages No:288 - 291]

Keywords: Cervical ripening, Isosorbide mononitrate, Modified Bishop\'s score, Preinduction cervical ripening, Prostaglandin E2 gel

PDF  |  DOI: 10.5005/jp-journals-10006-1712  |  Open Access |  How to cite  | 

Abstract

Background: Till date, search is going on for an ideal agent that can lead to cervical ripening and induction of labor and that is safe for mother and fetus. Isosorbide mononitrate (IMN) is an agent that is also used for preinduction cervical ripening but few studies are done with this drug and hence this study was carried out. Aims and objectives: To study efficacy of IMN and PGE2 gel for preinduction cervical ripening and to study side effects of both drugs. Materials and methods: It was a randomized controlled trial. Participants were selected according to the selection criteria. Group I included 100 participants in whom tab IMN was used. Group II included 100 participants in whom PGE2 gel was used. Outcome measures assessed were age, parity, gestational age, indication for induction of labor, assessment of modified Bishop\'s score (MBS) at 0 and 24 hours, change in MBS, and drug-related side effects. Statistical analysis was done. Results: Mean age, parity, and mean gestational age were comparable in both groups. Postdatism and preeclampsia were indications for induction in both groups. Modified Bishop\'s score at 0 hour was comparable in both groups. Change in the MBS at 24 hours was 2.91 ± 1.34 in group I and 4.52 ± 2.22 in group II. Drug-related side effects were more in group I than in group II. Conclusion: PGE2 gel was more effective for cervical ripening as compared to IMN. Isosorbide mononitrate leads to more side effects.

Original Article

Akshaya Mohan, Rajeswaran Rangasami, Anupama Chandrasekharan, Indrani Suresh, Suresh Seshadri, Chitra Andrew

Role of MRI in the Diagnosis of Fetal Anomalies at 18–20 Weeks Gestational Age

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:5] [Pages No:292 - 296]

Keywords: Antenatal MRI, Fetal anomalies, Pregnancy, Prenatal MRI

PDF  |  DOI: 10.5005/jp-journals-10006-1714  |  Open Access |  How to cite  | 

Abstract

Aim: To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis of fetal anomalies at 18–20 weeks of gestation. Materials and methods: We retrospectively reviewed fetal MRI examinations done during June 2014–May 2018. There were 23 referrals for fetuses at 18–20 weeks gestation, out of the total 330 referrals for fetal anomaly evaluation. The MR images were read independently by two radiologists. When there was discrepancy in the diagnosis, the final diagnosis was arrived by consensus. Results: There were 23 examinations for fetuses at 18–20 weeks of gestational age that showed 27 anomalies. This included 22 central nervous system (CNS), 2 thoracic, 1 gastrointestinal, 1 genitourinary, and 1 miscellaneous anomalies. In the 23 pregnant women, termination of pregnancy was carried out in 18 and three women were managed conservatively. Follow-up was lost in two women. Conclusion: MRI is a complementary tool to ultrasound in the evaluation of fetal anomalies. With advancement of MRI scanner technology and growth of knowledge, more number of anomalies can be diagnosed at or before 20 weeks gestational age. Clinical significance: Diagnosing fetal anomalies at or before 20 weeks by MRI is challenging because of increased fetal movements and small size of the fetus. However, improved techniques may facilitate early detection. This becomes a necessity in some countries where elective termination of pregnancy is allowed only up to 20 weeks. This article highlights that MRI can also provide additional information on select cases during 18–20 weeks.

Original Article

Majida Zafar, Arfa Tabassum, Quratulain A Cheema, Syeda B Mazhar

Role of Red Cell Distribution Width and Mentzer Index in Differentiating Iron Deficiency Anemia from Anemia Due to β Thalassemia Trait

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:4] [Pages No:297 - 300]

Keywords: Anemia, β thalassemia trait, Mentzer index, Red cell distribution width

PDF  |  DOI: 10.5005/jp-journals-10006-1718  |  Open Access |  How to cite  | 

Abstract

Objective: To determine the role of red cell distribution width (RDW) and Mentzer index in differentiating between iron deficiency anemia (IDA) and anemia secondary to β-thalassemia trait. Materials and methods: Study design: cross-sectional study. Setting: Department of Obstetrics and Gynecology, MCH Unit I, PIMS, Islamabad. Duration: Six months. Primigravida with hemoglobin less than 10 mg/dL was selected. All patients were investigated with serum ferritin and Hb electrophoresis for confirmation of the thalassemia trait. Primary outcome measures were the significance of RDW and Mentzer index in differentiating IDA from anemia secondary to β-thalassemia trait. Secondary outcome measures were the prevalence of IDA and β-thalassemia trait in primigravida women. Results: Out of the total 178 women with microcytic hypochromic anemia, 164 (92.1%) had IDA, 9 (5.1%) had coexistent IDA and β-thalassemia trait, and 5 (2.8%) had β-thalassemia trait alone. The mean RDW was 20.6 ± 5.8 in IDA category, 16.4 ± 6.7 in IDA + β-thalassemia trait, and 14.1 ± 6.5 in β-thalassemia trait alone category. RDW was significantly higher in IDA category (p value = 0.01). Similarly, the mean Mentzer index was 21.0 in IDA, 16.1 in IDA + β-thalassemia trait category. However, it was significantly low 12.2 in β-thalassemia trait alone category (p value ≤ 0.001). Conclusion: The RDW and Mentzer index have useful significance in differentiating β-thalassemia trait and IDA, it can be used as a primary tool in low resource settings.

Original Article

Anitha Vijay, Vijaya Koothan, Madhangi V Baskaran

Efficacy of Chromohysteroscopy for Evaluation of Endometrial Pathologies in Abnormal Uterine Bleeding

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:4] [Pages No:301 - 304]

Keywords: Abnormal uterine bleeding, Chromohysteroscopy, Endometrial pathologies

PDF  |  DOI: 10.5005/jp-journals-10006-1719  |  Open Access |  How to cite  | 

Abstract

Aim: To investigate the efficacy of chromohysteroscopy in evaluation of endometrial pathologies in patients with abnormal uterine bleeding (AUB). Materials and methods: Fifty patients with AUB without any macroscopic abnormalities of endometrium on hysteroscopy were included in the study. After instillation of methylene blue dye, chromohysteroscopy was performed. The pattern of endometrial staining was noted. Biopsies were taken from stained and unstained areas and sent for histopathological examination. Results: Of the 50 patients included in the study, 36 had diffuse staining and 14 had focal staining pattern of endometrium. Of the 13 cases with endometrial pathologies on histopathology, 10 had focal staining pattern. The diagnostic accuracy of the stained endometrium in cases with focal staining, for detection of endometrial pathologies was statistically significant when compared to the unstained areas with a sensitivity of 76%, specificity 89%, positive predictive value 71% and negative predictive value of 92%. Conclusion: Chromohysteroscopy helps improve the diagnostic accuracy of conventional hysteroscopy. Clinical significance: Chromohysteroscopy can be used as an adjunct to identify the target areas to be biopsied in cases with macroscopically normal appearing endometrium on hysteroscopy.

Original Article

Surbhi Handa, Yeshita Pujar

Evaluation of Uterine Artery Doppler at 11–13+6 Weeks of Gestation for Prediction of Preeclampsia: A Descriptive Observational Study

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:4] [Pages No:305 - 308]

Keywords: Fetal growth restriction, First trimester, Preeclampsia, Uterine artery Doppler

PDF  |  DOI: 10.5005/jp-journals-10006-1721  |  Open Access |  How to cite  | 

Abstract

Objective: To evaluate uterine artery Doppler between 11 and 13+6 weeks for prediction of preeclampsia. Materials and methods: A descriptive observational study was conducted in a teaching hospital of a tertiary care center. Of 200 women screened, 130 women met eligible criteria and 126 consented for participation in the study. In addition to nuchal translucency and crown-rump length, mean uterine artery pulsatility index (PI) was measured at 11–13+6 weeks, and women were followed up till delivery to observe the development of preeclampsia, gestational hypertension, and fetal growth restriction (FGR). Categorical variables were analyzed using κ agreement, and p = 0.05 was used to calculate significance. Results: Among 117 women followed till delivery, 12 (10.26%) had mean PI >95% and 105 (89.7%) had normal Doppler. A significantly higher number of women with PI ≥95% had preeclampsia (55.56%) (p < 0.001), and the sensitivity of PI in prediction of preeclampsia was 55.56% with specificity of 93.52%. No association was found between PI and FGR (p = 0.228). This study showed a positive association with p value of 0.008 between uterine artery pulsatility index of >95% and development of combined FGR and preeclampsia in a pregnancy. Conclusion: This study showed a positive association between PI >95% with the development of preeclampsia and FGR in pregnancy complicated by preeclampsia. The predictive accuracy of first trimester uterine artery Doppler using PI with cutoff of >95% has low sensitivity in prediction of preeclampsia (55.56%) and FGR (18.75%) but it has high specificity for prediction of both (93.52% and 91.09% respectively).

RESEARCH ARTICLE

Tita H Madjid, Bethy S Hernowo

Simple Immunocytochemistry from Menstrual Blood in Diagnosis of Endometriosis

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:6] [Pages No:309 - 314]

Keywords: Caspase-3, Caspase-9, Endometriosis, Menstrual blood, Noninvasive

PDF  |  DOI: 10.5005/jp-journals-10006-1711  |  Open Access |  How to cite  | 

Abstract

Introduction: The menstrual reflux containing viable endometrial cells precede the development of endometriosis lesion. Based on that, we can assume that we can detect the presence of endometriosis by utilizing the endometrial cells in the menstrual blood sloughing. The purpose of this study was to prove that simple immunocytochemistry technique on a sample of menstrual blood may show endometrial cells. Materials and methods: A case–control study involving 60 women was performed, from February 2007 to February 2008. Screening for suspected endometriosis was performed by history taking, physical diagnosis and additional examination. Diagnostic laparoscopy or laparotomy and biopsy were performed afterward. Endometriosis histopathologically defined as the presence of epithelial cells of endometrial glands and stroma in the tissue being examined. Menstrual blood sampling is performed by taking 20 drops of blood into 20 mL preservative solution. In this study, the cells/tissues staining by immunohistochemistry using diaminobenzene (DAB), and for comparison hematoxylin–eosin staining (HE) was used so that the stromal cells which express caspase-3, caspase-9 and MMP-9 are stained brown with a blue background. Results: The endometrial cells were successfully isolated using a preservative solution, and all samples from endometriosis subjects could be analyzed for the expression of caspase-3, caspase-9, and MMP-9. Discussion: The results of this study lead to a conclusion that immunocytochemistry analysis of the menstrual blood endometrial cells can be applied as a noninvasive method for establishing the diagnosis of endometriosis in daily practice.

RESEARCH ARTICLE

Putri Mirani, Noroyono Wibowo

Urine D-dimer Level in Severe Preeclampsia-complicated Acute Kidney Injury: A Cross-sectional Study

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:3] [Pages No:315 - 317]

Keywords: Acute kidney injury, Severe preeclampsia, Urine D-dimer

PDF  |  DOI: 10.5005/jp-journals-10006-1720  |  Open Access |  How to cite  | 

Abstract

Introduction: Preeclampsia has become the most common glomerular-based kidney disease affecting up to 8% of normal pregnancies.1–3 Thus, a worsening condition of preeclampsia will be related to an increasing risk of renal disease, particularly acute kidney injury (AKI).1,2 Acute kidney injury has become the common renal disease complication due to severe preeclampsia with the incidence up to 5%.4 This complication is mainly caused by thrombotic microangiopathy involving renal arteries, which can be observed with an increasing urine D-dimer level. This study aims to determine the urine D-dimer level in severe preeclampsia-complicated AKI. Materials and methods: A cross-sectional study was conducted in Obstetric Emergency Unit and Obstetric Ward Unit, Cipto Mangunkusumo General Hospital, from January to April, 2013. Subjects were divided into two groups: severe preeclampsia-complicated AKI and normotensive pregnancy. The main outcome of this study was that urine D-dimer level was based on the cutoff point from receiver operating characteristic (ROC). The secondary outcomes were its sensitivity and specificity. Statistical analysis was performed using Mann–Whitney and Spearman correlation tests. Data were analyzed using SPSS 20.0. Results: There were 65 subjects collected during the study and divided into two groups: 35 patients with severe preeclampsia-complicated AKI and 30 patients with normotensive pregnancy. There was a significant increase in the urine D-dimer level in patients with severe preeclampsia-complicated AKI compared with patients with normotensive pregnancy (2503 ng/mL vs 236.2 ng/mL; p = 0.001). Based on the ROC, the cutoff point for the urine D-dimer level was >818 ng/dL with area under the ROC curve was 0.819 (81.9%), sensitivity 80%, and specificity 73%. Conclusion: The urine D-dimer level significantly increased in severe preeclampsia-complicated AKI with a cutoff point of >818 ng/dL, sensitivity 80%, and specificity 73%.

CASE REPORT

Savita A Somalwar, Nirwana Agrawal, Anjali Kawthalkar, Sadhana Mahore, Nikita Vijay

Red Degeneration of Leiomyoma: An Unusual Presentation

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:3] [Pages No:318 - 320]

Keywords: Benign tumor of uterus, Fibroid uterus, Leiomyoma of uterus, Red degeneration of fibroid

PDF  |  DOI: 10.5005/jp-journals-10006-1713  |  Open Access |  How to cite  | 

Abstract

Red degeneration of leiomyoma is a rare type of degeneration. Hyaline, calcareous, and fatty degenerations are being more common. It is a medical enigma because of its peculiar and acute presentation associated with pregnancy. Red degeneration of fibroid is very rare in nonpregnant women. Although uncommon, a gynecologist should be aware of the entity for timely diagnosis and treatment. Here two cases of red degeneration in nonpregnant women are reported. In the first case, a woman was reported with menorrhagia, fever, pain, and urinary complaints. Red degeneration of fibroid was not suspected and, to utter surprise, the histopathology report was suggestive of red degeneration of fibroid. In the second case, a woman was presented with a lump and pain in the abdomen, and history of fever. On the basis of the previous experience, clinical diagnosis of red degeneration was considered. It was confirmed by histopathology.

CASE REPORT

Noor A Zulhijayanti, Rozi A Aryananda, Lynda Hariani, Eko B Koendhori, Ernawati Darmawan

Recurrent Abdominal Burst after Obstetric Surgical Procedure

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:8] [Pages No:321 - 328]

Keywords: Obstetric surgical procedure, Recurrent abdominal burst, Vacuum-assisted closure

PDF  |  DOI: 10.5005/jp-journals-10006-1715  |  Open Access |  How to cite  | 

Abstract

Introduction: Abdominal burst due to obstetric surgery complications is still a concern because it increases maternal morbidity and mortality. Case description: There are 15 cases with abdominal burst obtained from 3,914 obstetric surgical procedures during 2013 to 2018 in Dr Soetomo General Hospital, with 5 cases (30%) of recurrent abdominal bursts. Preoperative risk factors are obtained from the host, such as anemia, hypoalbuminemia, and autoimmune diseases. Two recurrent abdominal burst cases occurred after cesarean section, and three cases occurred in hysterectomy after cesarean section, all of which used retention sutures as initial management, and in reality, it did not prevent repeated bursts. The whole case went to emergency surgery, and surgical site infection was obtained as an agent that aggravates the degree of disease. Selection of management and treatment is based on the patient\'s wound problems. Two cases required intensive and multidisciplinary care and used vacuum-assisted closure (VAC) and modified VAC. There were two patients (6.7%) who died from sepsis, while three other patients had well-closed wounds, and no complications have been found to date. Conclusion: One-third of abdominal burst patients in Dr Soetomo General Hospital had recurrence involving long-term multidisciplinary care and required facilities and an optimal environment. The dominant risk factors are obtained from the inferior conditions of the host, such as anemia, hypoalbuminemia, and autoimmune diseases.

CASE REPORT

Nikita R Vijay, Swati Sarma

Leprosy with Erythema Nodosum Leprosum in Pregnancy: A Rare Phenomenon!

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:2] [Pages No:329 - 330]

Keywords: Erythema nodosum leprosum, Lepromatous leprosy, Multidrug therapy

PDF  |  DOI: 10.5005/jp-journals-10006-1716  |  Open Access |  How to cite  | 

Abstract

Leprosy is a rare event during pregnancy. A high index of suspicion is needed for prompt diagnosis, and a multidisciplinary approach is required for proper management. Multidrug therapy (MDT) is safe and effective during pregnancy and lactation. Hereby, we are reporting a case of lepromatous leprosy with erythema nodosum leprosum (type II lepra reaction) during the third trimester of pregnancy.

CASE REPORT

Sivagnanam Divya, Omni Syamala, G Usha Rani, J Thanka, Sandhya Sundaram

Malignant Ovarian Tumors in Adolescents: A Case Series

[Year:2019] [Month:September-October] [Volume:11] [Number:5] [Pages:5] [Pages No:331 - 335]

Keywords: Abdominal pain, Adolescent, Fertility preservation, Ovarian tumors

PDF  |  DOI: 10.5005/jp-journals-10006-1728  |  Open Access |  How to cite  | 

Abstract

Objective: To analyze the case series of malignant ovarian tumor in adolescents (13–21 years) with various presentations, histopathological types and management. Design: Case series. Settings: Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute (SRMC), Chennai, Tamil Nadu, India. Period: January 2015 to January 2016. Materials and methods: Adolescent female patients with malignant ovarian tumor were included. Clinical history, examination findings, radiological findings, surgical management, histopathology types were analyzed. Results: During the study period of 1 year, 10 girls with malignant ovarian tumors were studied. Majority of patients were 19–21 years of age. The main presenting complaints were pain abdomen in 50% of patients, followed by abdominal distension in 30% and menstrual irregularities in 20%. Of the 10 cases, 8 were of non-epithelial origin and 2 were epithelial. Fertility-conserving treatment was performed in all patients but for a single patient with endodermal sinus tumor (EST). Conclusion: Though benign ovarian lesions are very common, malignant ovarian tumor represent 1.5% of all tumors in adolescents. Clinical examination, radiological and biochemical tests together help us in arriving at an accurate diagnosis. The main attention is towards the timely diagnosis and fertility-conserving procedures in these young patients.

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