Recurring Acute Abdomen, Ovarian Cyst and Hypothyroidism.

Spontaneous ovarian hyperstimulation, large ovarian cyst and multicystic ovaries associated with primary hypothyroidism is infrequently reported and not widely recognized in gynaecologic literature. We report a case of a 15 year old girl who had an acute abdomen and emergency laparotomy revealed bilaterally enlarged ovaries, a large ovarian cyst with torsion in the right ovary and ascites. Thus right adnexa was removed. At that time thyroid dysfunction was neither suspected nor investigated. Five years later patient again developed acute abdomen with a large cyst in the remaining left ovary. Thyroid evaluation at this point of time indicated profound hypothyroidism. Treatment with thyroxin resulted in marked clinical improvement and resolution of the ovarian cyst thus highlighting the significance of assessing thyroid function tests in young girls with above clinical profile. Surgery is indicated if there is a complication or failure to medical treatment. We conclude that severe hypothyroidism was probably responsible for various ovarian disorders that might have resulted from the effects of an excess amount of TSH on immature ovaries.

Chlamydia trachomatis infection among pregnant women: prevalence and prenatal importance.

BACKGROUND: Chlamydia trachomatis infection in pregnant women is suspected to result in low birth-weight and premature infants. We conducted studies to ascertain the prevalence of this infection among pregnant women in our setting and whether its presence is a risk factor for low birth-weight or prematurity. METHODS: In the first study, 94 pregnant women between 26 and 30 weeks of gestation were screened for infection with Chlamydia trachomatis. The second investigated a cohort of 172 pregnant women presenting in spontaneous labour. The infection status was related to perinatal outcome in terms of birth-weight and gestation. In both the studies, Chlamydia trachomatis infection was diagnosed using the Chlamydiazyme test performed on endocervical swabs. RESULTS: The prevalence of Chlamydia trachomatis infection in mid-pregnancy and at labour was 17% (16/94) and 18.6% (32/172), respectively. Women with infection were relatively older than those without it [mean (SD) age: 26.6 (4.5) years v. 24.8 (3.6) years, p = 0.01]. The mean (SD) birth-weight [2869 (611) g v. 2814 (496) g], gestation [38.5 (2.6) weeks v. 38.3 (2.0) weeks], and incidence of low birth-weight [18.7% v. 20.7%] as well as prematurity [9.4% v. 10.7%] were similar among neonates born to women with or without infection. Neonates born to infected mothers experienced purulent conjunctivitis more frequently than those born to non-infected mothers [12.5% v. 2.8%, p = 0.04]. CONCLUSION: Chlamydia trachomatis is a relatively common infection in pregnant women. However, it was not associated with either low birth-weight or prematurity.

Histologic chorioamnionitis & its association with prematurity in a hospital-based study.

This prospective study was undertaken to study the occurrence of histologic chorioamnionitis and determine its association with prematurity; and to assess whether colonization of the genital tract of pregnant women by genital mycoplasmas or Chlamydia trachomatis is a risk factor for histologic chorioamnionitis. A total of 268 women with singleton pregnancies of over 26 weeks gestation were subjected to high vaginal cultures of genital mycoplasmas and endocervical specimens for chlamydia antigen. Placental histopathology was performed on multiple sections. Histologic chorioamnionitis was documented in 22.4 per cent (60/208) placentae. Genital tract colonization with Ureaplasma urealyticum or C. trachomatis was not a risk factor for histologic chorioamnionitis. Neonates born in association with histologic chorioamnionitis had a mean birth weight 111 g lower than those born without this lesion (2626.9 +/- 702 g vs 2737.8 +/- 500 g, NS). The relative risk (95% confidence interval) of prematurity in the presence of histologic chorioamnionitis was 1.49 (0.87-2.53). Analysis of linear trend in proportions for prevalence of histologic chorioamnionitis with decreasing gestation showed a significant association (P = 0.047, 1-tail). These results taken together suggest that histologic chorioamnionitis may be a risk factor of prematurity, but of only a modest magnitude.

Foetal compromise by spontaneous foetal heart rate deceleration in reactive non-stress test and decreased amniotic fluid index.

One hundred and sixty-three consecutive pregnant women with > 32 weeks gestation, undergoing non stress test (NST) and amniotic fluid index (AFI) determination were divided into six groups according to the amniotic fluid index and the nature of decelerations of foetal heart rate. Foetuses with antepartum decelerations had statistically significantly increased incidence of intrapartum decelerations, caesarean section due to intrapartum foetal distress, cord complications and small for gestational age infants. More so with decreased amniotic fluid index (p < 0.001). Low 5 minute apgar score was also significantly increased (p < 0.05). Prediction of foetal compromise might be done by spontaneous decelerations in reactive non-stress tests and with an amniotic fluid index < or = 5 cm.

Polymyositis--an unusual presentation of ovarian malignancy: a case report.

A unique case of carcinoma of ovary with an unusual presentation is reported here. Her presenting complaint was in no way related to ovarian malignancy. She presented to the neurologist with the features suggestive of polymyositis. She did not respond satisfactorily to the conventional treatment by steroids and on investigation, was found to have an underlying advanced ovarian malignancy.

Karyotyping of at risk fetuses by cordocentesis in advanced gestation.

Fetal blood obtained by cordocentesis was cultured to obtain rapid karyotypes of fetuses at risk during the late second trimester. Ninety nine fetal blood samples were studied for chromosomal abnormalities. The commonest indications for the procedure were abnormalities detected on ultrasonography (47.7%), and previous child with Down syndrome. Analysis of the 67 successful cultures showed four (5.9%) karyotypic abnormalities. The technique proved helpful in the obstetrical management of at risk fetuses.

Antenatal fetal assessment using biophysical profile score.

This prospective cross sectional study was conducted in a tertiary hospital in Northern India. The objective of the study was to investigate the utility of recording certain fetal biophysical variables at or near term in high risk pregnancy for predicting the fetal outcome. A fetal biophysical profile score was used for predicting the outcome. The scoring system utilized following variables: non stress test, fetal breathing movement, fetal movement, fetal tone and amniotic fluid volume. One hundred and fifty four pregnant women attending a high risk pregnancy clinic were consecutively included in the study. At a cut off score < or = 4, sensitivity of the scoring system was 12.5% and specificity 99.23%. At score < or = 8, corresponding figures were 70.83% and 91.53%. As compared to each individual variable, the positive predictive value for abnormal perinatal outcome improved considerably after combining all the variables. The negative predictive value for normal perinatal outcome did not improve. Though biophysical profile scoring is used as a valuable adjunct in caring high risk fetuses, a simple and more practical screening test should be sought for. The cost-benefit analysis of such tests should also be performed.

Microcolpohysteroscopy compared with colposcopy in evaluation of abnormal cervical cytology.

Microcolpohysteroscopy (MCH) permits in vivo visualisation of cervical epithelium and is a useful procedure in the diagnostic workup of a patients with abnormal pap smear. Our study compared standard colposcopy with MCH in 45 patients with dysplasia reported on cytology. On comparing with final histopathological diagnosis colposcopy had an accuracy of 95.6 percent in diagnosing cervical intraepithelial neoplasia (CIN) within one grade. MCH had a diagnostic accuracy of 84.4 percent in predicting CIN changes. Further MCH was able to evaluate the endocervical squamocolumner junction in all cases of unsatisfactory colposcopy. Microcolpohysteroscopy is a useful adjunct to colposcopy and is also of value in locating the epicenter of lesions and is diagnosing HPV infection. MCH prior to conisation is of value in tailoring the biopsy to fully include the CIN lesion.

Ultrasonographic normogram of fetal kidney circumference and fetal abdominal circumference ratio for early prenatal diagnosis.

Serial ultrasound scans were done in 300 fetuses between 16 to 24 weeks of gestation to establish the normogram of fetal kidney circumference (FKC) and fetal abdominal circumference (FAC) ratio (FKC/FAC). Of 300 fetuses, 150 fetuses were in the high risk group for fetal malformation and 150 patients were in the control group. The value of FKC/FAC varied from 0.27 to 0.30 from 16 to 24 weeks of gestation. No statistical difference was observed in the value of FKC/FAC in high risk and low risk (control) cases (p > 0.05). The value of FKC/FAC greater than or equal to 0.5 at 20 weeks or more was pathological for enlarged kidney. In 4 cases of multicystic kidney, the value of FKC/FAC ranged from 0.50 to 0.52 which was approximately 6SD above the normal mean ratio for that period of gestation.

Pregnancy with idiopathic thrombocytopenic purpura.

The management of ITP in pregnancy remains controversial, particularly with reference to labour management. Thirteen pregnancies in 9 women with ITP are analysed with respect to maternal and neonatal outcome. One pregnancy culminated in spontaneous abortion. Ten infants were born by vaginal delivery and two by Caesarean section. There were no maternal or perinatal deaths. Maternal morbidity was not increased significantly due to ITP and none of the infants had purpuric manifestations even with low platelet counts. It is concluded that the obstetric management of these patients should be individualised and should not be based on platelet count alone.

Ultrasonographic fetal nomograms of anterior ventricular hemisphere ratio (AVHR) and posterior ventricular hemisphere ratio (PVHR) for early prenatal diagnosis of hydrocephalus.

Serial ultrasound scans were done in 150 fetuses between 14th to 22nd week of gestation to establish the nomograms of anterior ventricular hemisphere ratio (AVHR) and posterior ventricular hemisphere ratio (PVHR). Of 150 fetuses, 100 were in the high risk group for neural tube defect and 50 were in the control group. The study indicates that the value of AVHR decreases from 0.62 to 0.50 and PVHR from 0.60 to 0.50 between 14th to 22nd week of gestation. No statistical difference was observed in the values of AVHR and PVHR in high risk and low risk (control) cases (p > .001). The value of AVHR or PVHR greater than 0.5 after 18 weeks of gestation or more was considered pathological for hydrocephalus. In 2, out of 3 cases of hydrocephalus detected in our series, the value of AVHR and PVHR was 0.7 at 20 weeks and in the third case it was 0.6 at 18 weeks. All of these values were 3 SD above the normal for the period of gestation.

Nomograms of fetal nuchal fold thickness for early detection of Down syndrome.

A prospective study was undertaken in North India to find the normative data on the nuchal fold thickness of randomly selected 150 fetuses between 16-22nd week of gestation. The data revealed that the width of nuchal fold thickness ranged between 2-5 mm. The mean for 16-18, > 18-20, and > 20-22 week's gestation was 2.6 +/- 0.2, 3.8 +/- 0.9, and 4.0 +/- 0.8 mm respectively. In one fetus nuchal fold thickness was 6mm at 18 weeks (> 2SD above the normal value) and thus Down Syndrome was suspected. This was later confirmed by amniocentesis and karyotyping.

Teenage pregnancy and its effect on maternal and child health--a hospital experience.

Sixteen mothers died out of 2279 teenage deliveries contributing a high maternal mortality rate of 7.02 per 1000 during the study period. 15 adolescent mothers who died had no access to prenatal care. An increased incidence of low birth weight (less than 2.5 kg) babies was observed among teenage deliveries. Incidence of premature deliveries were more among teenage mothers. Severe anemia, puerperal sepsis and hypertension were the dominant complications experienced among adolescent mothers.

Rubella infection: a cause of foetal wastage.

A study was conducted on 180 women with 2 or more obstetric losses totalling 410 foetal wastages. Control cases included 100 women without obstetric losses. Significant titre of immunoglobulin M against rubella was found in 17.77% patients with 2 or more obstetric losses in contrast to 9% of control patients (p less than 0.005). Significant titre of immunoglobulin M was observed in cases of abortions (5.75%), preterm deliveries (12.67%), macerated stillbirths (8.19%), fresh stillbirths (8.69%) and neonatal deaths (8.34%).

Congenital adrenal hyperplasia among peripubertal girls with hyperandrogenism.

Fifteen girls with severe hyperandrogenism were investigated by us during the last 6 years. Thirteen of these were cases of untreated congenital adrenal hyperplasia (CAH) and 2 were cases of tumoral (one sertoli leydig cell tumor of the ovary and one adrenal adenoma) hyperandrogenism. Here we present the clinical profile and laboratory data of those with congenital adrenal hyperplasia. All the girls had masculinization of genitalia (clitoromegaly alone 5, clitoromegaly with varying degree of posterior labial fusion 8). Eleven cases had hirsutism and 9 had short stature. Two patients underwent unilateral adrenelectomy with diagnosis of adrenal adenoma. Hormonal profile confirmed the diagnosis of CAH with 21 hydroxylase deficiency (elevated 17 OHP levels with exaggerated 17 OHP response to ACTH) in 12 cases and 3 beta hydroxy steroid dehydrogenase deficiency (elevated DHEAS and 17 pregnenelone levels and exaggerated DHEAS and 17 pregnenelone response to ACTH) in one case.