Management of thromboembolic disorders during pregnancy in resource-constrained settings: An Indian perspective.

Venous thromboembolism (VTE) in pregnancy and resulting thrombotic disorders are increasingly being recognized as an important cause of maternal morbidity and mortality. The diagnosis of VTE during pregnancy has an impact on current as well as future foeto-maternal outcomes. Whereas algorithms to manage VTEs during pregnancy in developed countries exist, these are difficult to implement in resource-constraint settings. In this narrative review, we discuss strategies that can be applied in daily clinical practice by obstetricians and haematologists dealing with these disorders in the country.

Management of Iron Deficiency Anemia in Pregnancy in India.

Iron deficiency anemia (IDA) continues to be the commonest etiology of anemia in pregnancy. The prevalence of iron deficiency (ID) in pregnant Indian women is amongst the highest in the world. Untreated iron deficiency (ID) has significant adverse feto-maternal consequences. Plethora of investigations are available for diagnosis of IDA, each having specific advantages and disadvantages when used in the pregnancy setting. Therapy for ID includes dietary modification, oral iron supplementation, intravenous iron and blood transfusion. Newer parenteral iron preparations are safe and there is mounting evidence to suggest their use in frontline settings for pregnancy associated IDA in the second and third trimester. Through this review, we suggest an algorithm for diagnosis and treatment of IDA in pregnancy depending on the severity of anemia and period of gestation suited for widespread use in resource limited settings. Also, we recommend ways for increasing public awareness and tackling this health issue including the observance of "National Anemia Awareness and Treatment Day."

Safety and efficacy of low dose intramuscular magnesium sulphate (MgSO4) compared to intravenous regimen for treatment of eclampsia.

AIM: This study was performed to compare the safety and efficacy of low dose intramuscular magnesium sulphate (MgSO4) (Dhaka regimen) and intravenous (IV) MgSO4 (Zuspan regimen) for the prevention of eclampsia recurrence and to compare serum magnesium concentration. METHODS: Forty one eligible patients with eclampsia were randomly divided into two groups: group I patients received IV MgSO4 according to the Zuspan regime, while group II patients received intramuscular (IM) MgSO4 according to the Dhaka regimen (i.e. low dose MgSO4). The total dose MgSo4 requirements per patient were calculated and serum MgSo4 level was measured. Maternal and fetal outcomes were compared between the groups. RESULTS: The mean total dose of MgSO4 required for the treatment of eclampsia was higher in group I compared to group II (32 ± 6.8 g vs 25.4 ± 8.8 g, respectively; P < 0.5). The mean serum MgSO4 levels were significantly higher (P < 0.003) in group I compared to group II, although there were no significant differences in seizure recurrence. Statistically, more patients in group I experienced a loss of knee jerk reaction and required dose deferral compared to group II. There was a significantly higher number of babies with poor Apgar scores in group I. Overall the maternal and fetal outcomes were comparable between the groups. CONCLUSIONS: A low dose IM regimen (Dhaka regimen) of MgSo4 is equally efficacious and safe compared to an IV regimen (Zuspan regimen) for the control and prevention of seizures in patients with eclampsia.

Second stage caesarean section: evaluation of patwardhan technique.

OBJECTIVE: To compare the maternal and neonatal morbidities between the Patwardhan technique and the routine "Push" and "Pull" method for extraction of the foetus in second stage caesarean sections. METHOD: Retrospective analysis was done of all caesarean sections performed in full dilatation of cervix in 3 years between 2004 to 2006. All the cases were divided into two groups. Group 1 being the Patwardhan technique group and Group 2 where baby was delivered as cephalic or as breech. Maternal morbidity in terms of uterine extensions, need for blood transfusions, as well as, neonatal morbidity, was compared between the two techniques. RESULTS: Review of 79 patients revealed significantly less number of uterine extensions, as well as, need for blood transfusions with Patwardhan technique, which thus amounted to a decreased maternal morbidity. However, there were no differences in neonatal outcomes in both the groups. CONCLUSION: Patwardhan technique is a superior and a safe technique for delivery of foetus in second stage caesarean sections as compared to "Push" and "Pull" methods. While foetal complications are comparable in both methods, maternal morbidities are lesser in Patwardhan technique.

Paraneoplastic erythrocytosis in a malignant ovarian steroid cell tumour.

Neoplastic polycythemia is a condition in which high hematocrit levels result from a neoplastic lesion in the body. It is a rare condition and occur because of excess erythropoietin or androgen production by the neoplastic cells. Steroid cell tumours of the ovary though notorious for producing endocrine changes in the body have rarely been associated with polycythemia. We present the case of a post menopausal lady who developed polycythemia and features of virilisation. Further investigations revealed that she had steroid cell tumour of the left ovary. Her signs and symptoms resolved after surgical removal of the tumour.

A rare case of ovarian and pelvic filariasis.

Lymphatic filariasis is an important tropic disease associated with significant morbidity. The patients in endemic areas mostly experience problems related to lymphatic obstruction. Physicians practicing in non- endemic areas rarely consider filariasis, especially if it is an uncommon presentation. We present a young woman who posed a significant problem in the diagnosis of ovarian filariasis.

Ovarian Hyperstimulation Syndrome (OHSS) Presented as Massive Hydrothorax.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of controlled ovarian stimulation. Although considered uncommon, the severe form is potentially fatal. Patient can present with varied clinical presentation like pain abdomen, abdominal distension or tachypnea. Diagnosis is made by careful history, examination and investigation. Treatment is conservative and supportive care. Here, we have presented a case of severe OHSS which was missed initially, as the doctor who had first seen probably was not aware of this disease.

Prevalence, associated risk factors and effects of hypothyroidism in pregnancy: a study from north India.

BACKGROUND AND OBJECTIVE: There is a controversy regarding universal versus targeted screening for hypothyroidism during pregnancy. We studied the prevalence and the associated risk factors of hypothyroidism. The secondary objective of the study was to compare the maternal and perinatal outcomes in overt and subclinical hypothyroidism. METHODS: We screened 1,005 antenatal patients for hypothyroidism with a thyrotropin assay. Patients diagnosed with hypothyroidism were further tested for anti-thyroid peroxidase antibodies and free thyroxin to determine the cause and type (overt or subclinical) of hypothyroidism. Maternal and perinatal outcomes were compared in the overt, subclinical and euthyroid groups. RESULTS: The overall prevalence of hypothyroidism was 6.3% (overt 2.9% and subclinical 3.4%). Thirty-four (3.4%) new hypothyroid cases could be detected by universal screening. The risk factors for thyroid dysfunction were not significantly different in the screen-positive versus screen-negative patients except for excessive weight gain (p = 0.00). Targeted screening could have missed one third of subclinical hypothyroid cases. Gestational hypertension was significantly greater in the overt hypothyroid group (p = 0.007), and more patients required induction in this group (p = 0.013) but other maternal complications and perinatal outcomes were similar. CONCLUSION: We recommend universal screening for hypothyroidism in pregnancy in our population, as the prevalence of hypothyroidism is high.

Pelvic tuberculosis mimicking advanced ovarian malignancy.

We sought to identify the characteristic features of pelvic tuberculosis (TB) in women with symptoms and sonogaphic findings which were otherwise consistent with an ovarian malignancy. This study is a retrospective analysis of 138 women who underwent an operation and had a preoperative diagnosis of ovarian malignancy at the Government Medical College Hospital, Chandigarh, from January 2004 to January 2008. Among these 138 women, seven cases (5.7%) of pelvic TB were identified. Abdominal pain and distension were the most common presenting symptoms. All patients had a pelvic mass, six had ascites (85%) and five had a fever (71%). The mean cancer antigen (CA) 125 level was 295 IU (13-529). Pelvic TB can present with symptoms and signs which mimic ovarian malignancy. Therefore, a high-index of clinical suspicion should be maintained when treating patients in countries with a high prevalence of TB.

Scar endometriosis - a series of six patients.

INTRODUCTION: Scar endometriosis is a rare form of extrapelvic endometriosis that is usually confused with other surgical or dermatological conditions leading to delay in diagnosis. METHODS: We reviewed the case records of patients with the diagnosis of scar endometriosis seen in our hospital from January 1996 to December 2008. RESULTS: We found six patients of scar endometriosis in 13 years making it one of the rare conditions. The median age of the patients was 32.5 years (range 28-37 years) and median interval from symptoms to treatment was 2 years (range 1-6 years). Four patients had first presented to either the surgery or dermatology physicians. Cyclic pain and swelling at local site was the most common presenting symptoms. All patients underwent wide excision of the mass with no recurrence of symptoms at a follow up ranging from 9 months to 12 years. CONCLUSIONS: Increasing awareness of this condition among doctors can help in early diagnosis and treatment with gratifying results.

Spontaneous heterotopic pregnancy with tubal rupture: a case report and review of the literature.

INTRODUCTION: Heterotopic pregnancy is diagnosed as the presence of two gestations simultaneously. This is a rare situation with a reported prevalence of 0.08% in normal conception. CASE PRESENTATION: We report a case of a 24-year-old primigravida of Indian origin who was seen in the emergency department with a diagnosis of a ruptured ectopic pregnancy. A careful ultrasound assessment led to the diagnosis of a heterotopic pregnancy. Immediate surgical intervention with supportive measures resulted in a successful outcome. CONCLUSION: An obstetrician should keep in mind the occurrence of a heterotopic pregnancy while dealing with pregnant females. The ectopic gestation invariably ruptures over a period of time leaving the patient in an emergency situation. A quick assessment and careful handling of the normal gestation can lead the patient to term with gratifying results.