Sonographic Optic Nerve Sheath Diameter Following Seizure Prophylaxis in Pre-Eclamptic Parturients With Severe Features: A Prospective, Observational Study.

OBJECTIVES: Neurological manifestations, including raised intracranial pressures, are a hallmark of worsening pre-eclampsia. Invasive methods for measuring intracranial pressure, though a gold standard, are not always a viable option. Maternal ocular sonography is a promising bedside tool, which serves as a noninvasive, cost-effective means for measuring optic nerve sheath diameter (ONSD), a surrogate marker of raised intracranial pressures. We studied the ultrasonographically measured ONSD in severely pre-eclamptic women, and the effect of magnesium sulfate therapy on its values. METHODS: Thirty severely pre-eclamptic women at ≥28 weeks gestation were included. We recorded baseline ONSD values, serum magnesium levels, neurological symptoms, vitals, and repeated them at 4 and 12 hours following magnesium sulfate therapy, and then at 24 hours postpartum. An ONSD value >5.8 mm was suggestive of raised intracranial pressure. Primary outcome measure was to evaluate changes in ultrasonographically measured ONSD following seizure prophylaxis with magnesium sulfate. RESULTS: Women, 73.3%, had baseline ONSD >5.8 mm, with mean diameter being significantly high (6.02 ± 0.77 mm). There was a statistically nonsignificant decline in mean ONSD values at 4 and 12 hours, as well as at 24 hours postpartum. Patients with neurological symptoms declined significantly (from 70 to 10%; p value <.001) following magnesium sulfate therapy. CONCLUSIONS: Majority of severely pre-eclamptic parturients had high ONSD value suggestive of raised intracranial pressures, which persisted in the postpartum period and was unaffected by magnesium sulfate therapy. Ultrasound can thus serve as a point-of-care, cost-effective, easily available bedside tool for indirectly measuring intracranial pressures in this high-risk population.

Prospective randomized trial comparing efficacy of letrozole step-up protocol with letrozole plus gonadotropins for controlled ovarian stimulation and intrauterine insemination in patients with unexplained infertility.

PURPOSE: Empirical treatment options for unexplained infertility treatment include controlled ovarian stimulation (COS) with clomiphene citrate, letrozole or gonadotropins followed by intrauterine insemination (IUI). Achieving consistent multifollicular development with letrozole generally requires addition of gonadotropins. However, the cost and discomfort of injections remains a drawback of this regimen. Therefore, there is a need for evolving newer cost-effective regimens for COS/IUI using orally administered drugs like letrozole. METHODS: Sixty couples with unexplained infertility (on standard infertility investigations) visiting the infertility clinic at a tertiary centre in North India were randomized into two groups. Group A COS was done by step-up protocol of letrozole from day 2 or 3 of menstrual cycle, starting with 2.5 mg and increased by 2.5 mg per day for next 3 days (2.5 mg, 5 mg, 7.5 mg, 10 mg). Group B COS was done with combination of letrozole and hMG (human menopausal gonadotropin). Starting from day 2 or 3 of menses, tablet letrozole 2.5 mg twice a day was given for 5 days. Intramuscular injection of hMG 150 IU was given every alternate day starting from day 7 and titrated according to the response. HCG was given when leading follicle was 17 mm and IUI done 36 h after HCG. RESULTS: Twenty-eight couples in letrozole step-up group (group A) and 30 couples in letrozole plus hMG group (group B), completed follow up for 44 and 55 cycles, respectively. Mean numbers of follicle ≥ 16 mm in both groups were comparable: 1.74 (± 0.83) in group A and 1.94 (± 0.68) in group B (p = 0.178). Ovulation rate of 90.9% (40/44) was achieved in group A, whereas it was 100% (55/55) in group B (p = 0.022), although there was no significant difference in clinical pregnancy rate per patient, which was 3/28 (10.7%) in group A versus 5/30 (16.67%) in group B (p = 0.707). The mean (SD) cost of medicines was significantly lower in group A Rs. 345.00 (00) compared to group B Rs. 2148.64 (515.67) [p < 0.0001]. There was one case each of hyperstimulation and multiple pregnancies in group B, while none in group A. CONCLUSION: It is possible to achieve multifollicular development with use of novel letrozole step-up protocol, even without addition of gonadotropins, at significantly lower cost.

Advanced abdominal pregnancy: a search for consensus. Review of literature along with case report.

BACKGROUND: Advanced abdominal pregnancy is a highly morbid form of extrauterine gestation that demands skilled management. Despite advancement in antenatal care and imaging modalities, undiagnosed cases of advanced abdominal pregnancies are still reported. We report a case of asymptomatic abdominal pregnancy with healthy fetus advanced till 40 + 4 weeks period of gestation. Her diagnosis was not established even after obstetrical evaluation and cesarean section at primary care hospital. To the best of our knowledge, less than 10 postdated cases of abdominal pregnancy have been reported so far in the literature. This case emphasizes the need to re-awaken awareness and high index of suspicion to diagnose such cases. Details of all the cases pertaining to advanced abdominal pregnancies reported after 2013 were reviewed and summarized. METHODOLOGY: We searched electronic medical database in English using keywords related to abdominal pregnancy. Bibliographies of the relevant articles of advanced abdominal pregnancy published from 2013 onwards were reviewed and then cross searched to identify further relevant studies. RESULTS: A total of 26 cases of advanced abdominal pregnancy including index one were reviewed. All preoperatively diagnosed cases of abdominal pregnancy at earlier gestation were given conservative management and resulted in live births. The incidence of malformations in live births was 24%. CONCLUSION: We are of considered opinion that conservative strategy is a feasible option in selected cases of advanced abdominal pregnancy yet there is a need of standardization of treatment principles for such cases to optimize fetomaternal outcome.

Validation of Grobman's graphical nomogram for prediction of vaginal delivery in Indian women with previous caesarean section.

Purpose: To validate Grobman's nomogram for prediction of trial of labour after caesarean section (TOLAC) success in the Indian population. Methods: A prospective observational study of women with previous lower segment caesarean sections (LSCS) who were admitted for TOLAC between January 2019 and June 2020 at a tertiary care hospital We compared the Grobman's predicted VBAC success probability to the observed VBAC rate in the study population and devised a receiver-operator characteristics (ROC) curve for the nomogram. Results: Among the 124 women with prior LSCS who chose TOLAC and were included in the study, 68 (54.8%) had a successful VBAC and 56 (45.2%) had a failed TOLAC. The mean Grobman's predicted success probability for the cohort was 76.7%, significantly higher in VBAC women versus CS women (80.6% vs. 72.1%; p 0.001). The VBAC rate was 69.1% with a predicted probability of > 75% and only 42.9% with a probability of 50%. Women in the > 75% probability group had a nearly similar observed and predicted VBAC rate (69.1% vs. 86.3%; p = 0.002), and a greater number of women in the 50% probability group had successful VBAC than predicted (42.9% vs. 39.5%; p = 0.018). The area under the ROC curve for the study was 0.703 (95% CI 0.609-0.797; p 0.001). Grobman's nomogram had a sensitivity of 57.35%, a specificity of 82.14%, a positive predictive value (PPV) of 79.59%, and a negative predictive value (NPV) of 61.33% at a predicted probability cut-off of 82.5%. Conclusions: Women who had a higher Grobman's predicted probability had greater VBAC success rates than those with low predicted probability scores. The prediction ability of the nomogram was highly accurate at higher predicted probabilities, and even at lower predicted probabilities, women did have good odds of delivering vaginally.

Primary Uterine Alveolar Soft Part Sarcoma in a Postmenopausal Woman: Histopathologic and Immunohistochemical Characteristics of a Rare Case.

BACKGROUND: Primary uterine alveolar soft part sarcoma (ASPS) is a rare, indolent mesenchymal malignancy with less than 40 patients documented in the literature. CASE: We report an example of ASPS in a 61-year-old postmenopausal woman. Macroscopically, the uterus showed multiple nodular masses. Microscopic examination revealed tumor arranged in nests and alveolar pattern. The tumor cells were moderately to markedly pleomorphic, epithelioid to polygonal, with eccentrically placed nuclei, vesicular chromatin, prominent macro-nucleoli, and moderate to abundant eosinophilic cytoplasm. PAS-positive and diastase-resistant intracytoplasmic crystals were also seen in some tumor cells. On immunohistochemistry, the tumor cells showed diffuse positivity for vimentin and nuclear positivity for TFE3, a surrogate marker for ASPS. These were negative for SMA, desmin, CD10, h-caldesmon, cyclin D1, EMA, Melan A, and CD34. SMARCB1 expression was retained. Based on the histopathology and IHC, a final diagnosis of uterine ASPS was rendered. CONCLUSIONS: Knowledge of the characteristic histopathologic and immunohistochemical features can help accurately diagnose such rare tumors. Knowledge of the characteristic histopathologic and immunohistochemical features can help accurately diagnose such rare sarcoma in an uncommon site with an unusual age.

Stable isotope labeling as a promising tool for rapid drug susceptibility testing in Neisseria gonorrhoeae.

The world is heading towards an era of intractable and impending untreatable N. gonorrhoeae, thereby underlining the significance of rapid and accurate prediction of drug resistance as an indispensable need of the hour. In the present study, we optimized and evaluated a stable isotope labeling-based approach using the MALDI-TOF MS (Matrix-Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry) for rapid and reliable detection of ciprofloxacin and azithromycin resistance in N. gonorrhoeae. All the isolates were cultured under three varied condition setups viz. medium supplemented with normal lysine, heavy lysine (isotope), and heavy lysine along with the antibiotics (ciprofloxacin/azithromycin), respectively. After incubation, spectra were acquired using the MALDI-TOF MS which were further screened for unique patterns (media-specific spectra) to differentiate drug-susceptible and resistant isolates. The results of the stable isotope labeling assay were comparable to the results of phenotypic methods used for susceptibility testing.

Prenatal diagnosis for hemophilia A (intron 22 inversion) reveals a rare association with Klinefelter syndrome with diagnostic difficulties in molecular interpretation.

Hemophilia A is an X-linked recessive disorder caused by genetic abnormalities in the F8 . Klinefelter syndrome is sex chromosome aneuploidy caused by nondisjunction during meiosis in the germ cells or mitotic cell divisions in the early embryonic cells. We here report an intriguing case of a prenatal diagnosis where a rare association of hemophilia A and Klinefelter syndrome was found in a fetus. This case highlights the diagnostic difficulty where the inverse-PCR for intron 22 inversion defect leading to hemophilia A did not amplify. Indirect molecular testing was done using multiallelic extragenic variable number tandem repeat (VNTR) DXS52 (St14) and polymorphic markers. The interpretation was further complicated by the presence of Klinefelter syndrome. This case highlights the challenges faced when such rare combinations are found during prenatal diagnosis.

Efficacy of a Proprietary Fenugreek Seed Extract (Trigonella foenum-graecum, Furocyst®) in Women with Polycystic Ovary Syndrome (PCOS): a Randomized, Double-Blind, Placebo-Controlled Study.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenemia, a quite common heterogenous endocrine/hormonal disorder, and accompanied by elevated androgen level, menstrual irregularity, and hirsutism. The consequences include infertility or miscarriage. It is a challenging problem to the physicians. In a one-arm, non-randomized preliminary investigation in fifty premenopausal women, we demonstrated the efficacy of Furocyst®, a patented, standardized Trigonella foenum-graecum extract, in ameliorating the symptoms of PCOS over a period of 90 consecutive days. OBJECTIVE: In the present study, a double-blind, two-arm, single-center, randomized, comparative study was conducted to assess the efficacy of Furocyst® (2 capsules of 500 mg/day) in 208 pre-menopausal women diagnosed with PCOS. METHODS: Ethical committee approval was obtained. A total of 208 subjects (placebo = 95; Furocyst® = 113; age:18-45 years, BMI < 42 kg/m2) completed the investigation. The comparative efficacy of placebo and Furocyst® was assessed on the number of cysts, ovarian volume, hirsutism, LH:FSH ratio, titer of TSH, SHBG, prolactin and free testosterone. Key clinical parameters such as fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels, as well as total blood chemistry were also investigated. RESULTS: Furocyst® supplementation significantly reduced the number of cysts, ovarian volume, and hirsutism levels, as well as normalized the menstrual cycle in Furocyst®-treated subjects as compared to placebo group. Furocyst® significantly reduced luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, and thyroid stimulating hormone (TSH) levels, and reduced the prolactin and SHBG levels. Furocyst® significantly reduced the fasting blood glucose levels, HOMA Index, cholesterol, LDL, and triglyceride levels as compared to the placebo group, while the free testosterone levels were significantly decreased in the Furocyst® group. CONCLUSION: The studies collectively demonstrated the efficacy of Furocyst® as a safe, natural phytochemical-based formulation to alleviate the symptoms of PCOS. No significant adverse events were observed.

A randomized controlled trial to compare antibiotic prophylaxis in elective gynecological surgeries: Single dose of cefazolin versus single dose of cefazolin and tinidazole.

Objectives: To evaluate if addition of an anti-anaerobic agent to standard drug-cefazolin for antimicrobial prophylaxis would further decrease postoperative infectious morbidity or not. This is relevant as most of the infections in gynecological surgeries are anaerobic but cefazolin does not protect against anaerobes. Materials and Methods: The study design was a parallel randomized controlled trial. Two hundred patients undergoing benign gynecological surgeries were divided into two groups of 100 each. Group A received 2 g cefazolin 30-60 min before incision and Group B received 2 g cefazolin 30-60 min and 1.6 g tinidazole 60-120 min before incision. The patients were followed for any infectious morbidity for 1 month postoperatively. The analysis was done separately for abdominal, laparoscopic, and vaginal surgeries. The analysis was also done for surgeries according to the wound category, i.e. clean and clean-contaminated. Results: The two groups were comparable for age and body mass index (BMI). The two groups were comparable for the factors affecting infectious morbidity such as duration of surgery, blood loss, blood transfusions, duration of hospital stay, and need for additional antibiotics. The postoperative infectious morbidity was analyzed in terms of fever, surgical site infection (SSI), and urinary tract infection (UTI). No patient in vaginal and laparoscopic groups suffered from infectious morbidity. In abdominal surgeries group, postoperative fever occurred in 6/74 (8.1%) and 11/74 patients (14.8%) in Groups A and B, respectively (P = 0.38). SSI occurred in 1/74 (1.3%) and 2/74 (2.7%) patients in Groups A and B, respectively (P = 1.0). UTI occurred in 5/74 patients (6.7%) and 2/74 patients (2.7%) in Groups A and B, respectively (P = 0.44). The data were also analyzed for infectious morbidity for clean and clean-contaminated wound categories, and the results were nonsignificant between both groups for each type of wound category (P > 0.05). Conclusion: Cefazolin alone is a sufficient antibiotic prophylaxis for benign gynecological procedures.

Female Dhat syndrome in primary care setting.

AIM: The study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome. METHODOLOGY: Sixty-nine females considered to have nonpathological vaginal discharge after detailed gynecological evaluation, including required investigations, attending a rural community clinic were assessed for their belief about the vaginal discharge. The study subjects were also evaluated on the proposed criteria of female Dhat syndrome by using a semi-structured interview. RESULTS: The mean age of onset of vaginal discharge was 36.1 (standard deviation - 8.5) years. Most of the females considered the loss of vaginal fluid as loss of a vital fluid from the body. Consumption of warm foods and drinks (75.8%) was the most common reason reported for vaginal discharge followed by eating unbalanced food/inappropriate food (73.5%). A majorty of the subjects considered vaginal discharge responsible for bodily weakness (87.0%), backache (71.0%) and stomache (66.7%). About two-third of the participants considered the taking energizing medications like vitamins/tonics/tablets and treatment from a gynecologist the treatment for vaginal discharge. CONCLUSIONS: Significant proportion of females with non-pathological vaginal discharge have a belief that they are losing a vital fluid of the body. The subject attributes their symptoms to factors such as consumption of warm foods and drinks, and eating unbalanced food/inappropriate food. Accordingly, assessment and management of women with Dhat syndrome require addressing these important issues.

The Management of Scar Ectopic: A Single-Center Experience.

PURPOSE: This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP). METHODS:  This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (ß-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their ß-HCG levels became normal. RESULTS: Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial ß- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy. CONCLUSION: CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.

Prevalence and Pregnancy Outcome of Mullerian Anomalies in Infertile Women: A Retrospective Study.

BACKGROUND: Uterine anomalies arise if there is agenesis of one or two mullerian ducts, or absence of fusion or reabsorption of the septum between these ducts. The process may be partial or total and affect one or multiple parts of the tract. AIMS: This study was done to assess the distribution of various types of mullerian anomalies in infertile women, their classification based on ESHRE and AFS, associated anomalies, types of diagnostic modalities used, surgical interventions done(if any), various types of infertility treatment used and their outcomes. SETTING AND DESIGN: A retrospective analysis in a tertiary level hospital. MATERIALS AND METHODS: This was a retrospective study in which the women found to have mullerian anomalies were recruited from infertility clinic from July 2019 to March 2020. They were classified according to ESHRE and AFS criteria and their records were analyzed after taking various factors like age, ovarian reserve, duration of infertility, treatment given , associated ovarian and tubal factors and pregnancy outcomes. STATISTICAL ANALYSIS: Analysis was performed in Excel. RESULTS: There were 30 women with mullerian anomalies. Unicornuate uterus was most common anomaly. Four women required septoplasty in view of septate uterus. Five women had associated renal anomalies in form of shrunken kidney and ectopic kidney. Most of these women were considered for controlled ovarian stimulation followed by intrauterine insemination. In our study 16.6% women had successful pregnancy outcome. CONCLUSION: Mullerian anomalies continue to attract infertility specialist as they pose challenge in making clear diagnosis and its management as obstetrics outcomes are excellent after septum resection in women with septate uterus and conservative management in women with other anomalies. Proper work up of infertility and its management varies from case to case and associated factors like endometriosis, male factor, polycystic ovarian syndrome etc.

Immunohistochemical evaluation of infiltrating immune cells in endometrial biopsy of female genital tuberculosis.

BACKGROUND: Female Genital Tuberculosis (FGTB) causes infertility in a large number of females in developing countries. Presence of granuloma on histopathological examination of endometrial samples is diagnostic of FGTB. But immunohistochemical evaluation of endometrial aspirates has not been explored before. AIM: To evaluate the immunohistochemical delineation of immune cells in FGTB. METHODS: 1515 infertile women from 20 to 35 years were enrolled and underwent endometrial aspiration (EA), which was subjected to microbiological and histopathological examination along with PCR. Patients positive for conventional tests like granulomas, acid fast bacilli, mycobacterial culture on LJ medium or liquid (MGIT) culture were started on antitubercular therapy. Conventional test negative but PCR positive patients were posted for laparoscopy. Immunohistochemistry (IHC) for LCA, CD68, CD3, CD4, CD8, CD 20, CD138, IFN gamma and IL10 were evaluated. RESULT: 38/1515 (2.5%) subjects tested positive for conventional methods. PCR-TB was positive in 615/1515 samples (40.59%). On IHC, the number of CD45 (LCA) positive immune cells (p = 0.03) and IFN gamma (p = 0.002) and IL10 expression (p = 0.012) at 1 + level were higher in the PCR positive samples. Laparoscopy done in 418/463 patients and 89/418 (21.3%) showed definitive findings of tuberculosis. CD3, CD4, CD8, CD20, CD68 and CD138 showed no correlation with PCR and laparoscopy. CONCLUSION: Increased IFN gamma and IL 10 expressing immune cells in PCR positive EA suggests subclinical early changes, and can be useful as a research tool but have no role in diagnosing FGTB.

Leptospirosis as a cause of intrauterine fetal demise: short report of rare presentation.

We present a rare severe leptospirosis in a patient who presented with fever, jaundice, coagulopathy and intrauterine fetal demise. Possibility of leptospirosis should be kept in an obstetric patient with such clinical profile particularly in endemic areas or if there is recent outbreak of disease.

Adenosarcoma of the uterine cervix with heterologous elements: a case report and review of literature.

INTRODUCTION: Adenosarcoma of the uterus is a rare tumor composed of benign epithelial and malignant stromal components, usually encountered in young women. Till date, more than 100 cases of mullerian adenosarcoma of the cervix with homologous elements have been reported. However, only 15 cases of mullerian adenosarcoma of the cervix with heterologous elements are reported. MATERIALS AND METHODS: We describe a case of mullerian adenosarcoma with heterologous elements of rhabdomyosarcoma and benign cartilage presenting as a cervical polyp in a young girl. The clinicopathological features and management of this rare entity is reviewed. CONCLUSION: Cervical adenosarcomas are rare tumors that may appear in reproductive age. Optimal therapy is still unclear, and a long-term follow-up is essential. Such cases need to be reported as accumulation of individual cases will be able to provide knowledge about its optimal therapy and prognosis.

To study the changes in maternal hemodynamics with intravenous labetalol or nifedipine in acute severe hypertension.

OBJECTIVE: To study the maternal hemodynamic changes in acute severe hypertension after treatment with intravenous labetalol or oral nifedipine using color doppler ultrasound. STUDY DESIGN: We evaluated thirty pregnant women with gestational age between 28 and 40 weeks in acute severe hypertension (more than or equal to 160/105 mmHg) which were randomly allocated to receive either intravenous labetalol or oral nifedipine until blood pressure was lowered to less than or equal to 140/90 mmHg. Doppler vascular indices namely pulsatility index, resistance index, S/D ratio of bilateral uterine arteries and maternal renal artery were measured baseline at the time of acute severe hypertension and repeated after control of blood pressure, to assess the changes in maternal hemodynamics if any with labetalol or nifedipine. RESULTS: When evaluating right uterine artery Doppler parameters, a trend to increase in PI and RI was observed in those who received labetalol and nifedipine however the difference was not statistically significant. Whereas, while evaluating left uterine artery indices a trend to decrease PI was seen in nifedipine group but the difference was not statistically significant. On intergroup comparison there was no any significant change in any of uterine artery as well as renal artery indices in either group. CONCLUSION: The use of labetalol and nifedipine were not related to any significant changes in maternal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy.