Study of endothelial function in pregnant women with gestational diabetes mellitus by flow mediated dilation of brachial artery

Background: The objective of the study was to assess vascular function in normal pregnant women and women with gestational diabetes and to study its temporal relationship with gestational age at 24-28-week POG and at 36-38-week POG and changes in FMD in postpartum period.Methods: Assessment of vascular function was done at 24-28-week POG, 36-38-week POG and at 6-12-week postpartum by flow mediated dilation of brachial artery in 37 healthy pregnant women and 37 pregnant women with GDM.Results: In GDM group mean FMD at 24-28 weeks of POG, at 36-38 weeks POG was lower as compared to the control group (11.225±6.20,8.464±6.09 versus 14.49±5.21, 10.898±4.12) although the difference in mean FMD in two groups was not statistically significant. It was found that the decrease in FMD at 36-38-week POG as compared to 24-28 weeks POG was statistically significant in both the groups (p<0.001).Conclusions: This study revealed that when endothelial function as assessed by FMD was compared at different period of gestation, the mean decrease in FMD at 36-38-week POG as compared to 24-28-week POG and 6-week post-partum was statistically significant in patients with GDM and as well as the control group, however this trend of change was same in both the groups and was not statistically significant when compared between the two group (GDM versus control). A negative correlation of FMD was found with BMI, and HBA1c, that was stronger in GDM group.

Correlation of HbA1c levels in late pregnancy with maternal and perinatal outcome in patients with gestational diabetes mellitus

Background: Estimation of HbA1c in gestational diabetes mellitus patients is not being recommended by any societies/guidelines as studies regarding the role of HbA1c for monitoring of euglycemic control and predicting the maternal and perinatal outcomes in GDM patients (unlike overt diabetes) are conflicting and sparse.Methods: This was a prospective study with an aim to evaluate the role of HbA1c estimation in late pregnancy (early and late third trimester) for prediction of pregnancy outcomes in GDM patients. 53 patients with GDM (diagnosed before third trimester) were recruited for the study. HbA1c levels were estimated in late pregnancy (at 28-32 weeks and again repeated at 37 - 39 weeks or at the time of delivery). Correlation of HbA1c levels in third trimester with maternal and perinatal outcome was studied in patients with gestational diabetes mellitus and cut off taken was 5.8%.Results: Of the total 53 patients 54.7% had HbA1c levels <5.8% and 45.3% had HbA1c ≥5.8% done at 28-32 weeks. Also when HbA1c levels done at 37-39 weeks POG/ at the time of delivery, 52.8% patients had <5.8% and 47.2% had HbA1c ≥5.8%. Approximately one-fourth of the patients had HbA1c ≥ 5.8% even with normal blood sugar levels (euglycemic) control. There was statistically significant increased incidence of polyhydramnios, LGA (large for gestational age babies) and increased mean birth weight in patients with HbA1c ≥ 5.8%, done in late pregnancy. However there was no statistically significant difference in the incidence of preterm labour, gestational hypertension or preeclampsia, urinary tract infections, vulvovaginal infections, caesarean deliveries and postpartum haemorrhage in patients with HbA1c ≥5.8% compared to patients with HbA1c <5.8%.Conclusions: The study revealed that in patients of GDM with HbA1c levels ≥5.8% done in third trimester was statistically significantly associated with increased incidence of polyhydramnios, large for gestational age babies and increased mean birth weight when compared to patients with HbA1c <5.8%.

Umbilical cord cyst: a diagnostic dilemma

Umbilical cord cyst refers to any cystic lesion associated with the umbilical cord. Cord cysts can be defined as true or false cysts and may occur in any location along the cord. They are irregular in shape and are located between the cord vessels. Authors are reporting the case of an infant with an umbilical cord tumor which had twice been misdiagnosed previously as a hemangioma, based on ultrasound image of its cystic and solid component with good vascular supply. The ultrasound image most likely suggestive of a hemangioma as a differential diagnosis led to caesarean section in our patient (based on large size of the lesion and fear of rupture of same during process of labour). The definitive diagnosis was made only after birth of the baby. Final diagnosis of true umbilical cord cyst was made after histopathological examination. Thus, there can be confusion in the diagnosis between umbilical cord hemangiomas and umbilical cord cysts based on ultrasound.

Outcome of labor with epidural analgesia in primigravida at term

Background: There is widespread acceptance of epidural analgesia among many physicians and patients, but disagreement remains regarding the effect of intrapartum epidural analgesia on the subsequent progress of labour and the mode of delivery. This study was designed to look into the effects of labour analgesia on maternal and fetal outcomes and compare the same with that of opioid analgesics.Methods: It was a prospective randomized controlled trial on 100 patients where parturients were randomly allocated to either group 1-( n=50 patients) who received epidural analgesia or group 2 (n=50) who received intramuscular tramadol. The two groups were compared for duration of labour, analgesic efficacy as assessed by using Visual Analogue Scale (VAS) ,type of delivery – normal/instrumental/operative interventions ,1 and 5 min neonatal Apgar score and  neonatal breast-feeding behavior between the two groups.Results: Epidural analgesic gave better pain relief than tramadol which was found to be stastically significant (p<0.001) on comparing the VAS scores and also gave statistically significantly higher satisfaction levels. Duration of both first and second stage of labor was comparable between the two groups and instrumental deliveries and caesarean sections were also comparable to that in tramadol group. There was a trend of  higher  neonatal  Apgar scores   in the  epidural group than in the  tramadol group.Conclusions: Use of effective analgesia in labour, does not prolong second stage of labor and may facilitate good labour outcome both for the mother and the fetus and should be offered to patients in   tertiary setups and equipped centres when the patients are apprehensive about labor pains.

Role of second trimester uterine artery doppler for the prediction of preeclampsia in high risk pregnancy

Background: The uterine artery Doppler has potentials for screening for complications of impaired placentation. The purpose of study was to assess the role of uterine artery color Doppler waveform analysis in second trimester for the prediction of preeclampsia in a high-risk pregnancy between 18-24 weeks of gestation.Methods: 100 women with moderate or high-risk factors for developing preeclampsia reporting to Obstetrics and Gynaecology department of Government Medical College and Hospital, Sector 32, Chandigarh were enrolled for present study. Transabdominal uterine artery doppler measurements was done at 18-24weeks of gestation in these patients. Doppler . The Doppler indices generated automatically from the machine , the Pulsatility Index (PI), Resistance Index (RI) , presence or absence of diastolic notch and S/D Ratio were recorded, and average was calculated.Results: Out of 100 patients there were 46 primigravidas with no additional risk factors, 22 pateints with two or more risk factors and there were no patients who had three or more risk factors in present study population. Preeclampsia is seen more commonly in primigravida and primigravida is considered as moderate risk factor for preeclampsia. It was found that an elevated second trimester uterine artery RI was significantly associated with developing preeclampsia later in pregnancy. The sensitivity and specificity of uterine artery Doppler velocimetry were found to be 84% and 55% respectively. Receiver operator characteristics (ROC) curves were created to demonstrate the prognostic value of RI and PI of uterine artery doppler indices at 18-24 weeks of gestation for the development preeclampsia. In addition, there were statistically significant positive correlations between mean RI of uterine artery doppler study and patients who developed preeclampsia. With a sensitivity of 84.21% it could identify 31% of the cases of preeclampsia at a false positive rate of 44.4%.Conclusions: Uterine artery doppler study can be used as a predictor of moderate strength for preeclampsia.

A rare case of leiomyosarcoma of cervix and challenges in its management: a case report and brief review of literature.

Leiomyosarcoma of cervix is an aggressive and rare tumour of the cervix with poor prognosis. Management plan differs greatly from other common cervical malignancies. A 38 year old multiparous lady presented with a large circumferential cervical tumour which was diagnosed as leiomyosarcoma of cervix on cervical biopsy. It was a surgical challenge. Patient underwent pre-operative ureteric stenting followed by exploratory laparotomy with hysterectomy with bilateral salphingo-oophorectomy. Surgical difficulties were encountered due to deep impaction of tumour in pelvis and altered anatomy due to the bulk of tumour. Retrograde approach was taken and pouch of Douglas was opened before clamping the mackenrodts and the uterus was bisected and debulking of tumour done simultaneously to facilitate the surgery. Post operatively patient received chemotherapy (Vincristine, adriamycin and cyclophosphamide) followed by radiotherapy. Patient developed vesicovaginal fistula and liver metastasis nine months post- surgery. She received second line of chemotherapy (gemcitabine and docetaxel) after which she was lost to follow up.

Unruptured postdated pregnancy with a live fetus in a noncommunicating rudimentary horn.

Pregnancy in a noncommunicating rudimentary horn is an extremely rare and a life-threatening condition as it mostly terminates by rupture by the second trimester of pregnancy. Postdated pregnancy and delivery of a live fetus in a rudimentary horn have been rarely reported. A case of noncommunicating unruptured rudimentary horn pregnancy progressing to 41 weeks and 3 days period of gestation where the diagnosis was initially missed at obstetric sonogram at 18 and 34 weeks and then misdiagnosed later as abdominal pregnancy is being reported. Preoperative diagnosis, successful delivery of a live fetus and excision of the rudimentary horn was performed.

Choriocarcinoma with negative urinary and serum beta human chorionic gonadotropin (betaHCG)--a case report.

This was a rare case where a patient presented clinically as a case of post abortal sepsis and ultrasound showing the picture of an intramural degenerating fibroid. Her serum and urine both were negative for beta human chorionic gonadotropin (betaHCG). Patient succumbed to choriocarcinoma 1 month later. Failure to detect urinary and serum betaHCG lead to maternal mortality due to the choriocarcinoma. The failure to detect, certain degradation products of HCG which may predominate in gestational trophoblastic neoplasia, by many common HCG testing kits lead to the error of diagnosis. Only 3 of the 7 common commercial serum HCG tests appropriately detects nicked HCG and its free betaHCG, DPC immulite assay, being the most sensitive method. Though of rare occurrence, this awareness is important for diagnosis and follow-up of gestational trophoblastic neoplasia and could have been life saving in our case.