Accuracy of 3-D Surface Rendering of 2-D Ultrasound Images of the Uterus Using a Novel Software in Mapping Uterine Fibroids.

OBJECTIVE: Three-dimensional surface rendering of 2-D ultrasound images of the uterus in mapping uterine fibroids is a fast-evolving imaging technique that holds great potential for gynecology. The purpose of this study was to assess the accuracy of 3-D surface rendering of 2-D ultrasound images of the uterus using a new Fibroid Mapping Reviewer Application (FMRA) software for mapping uterine fibroids as compared with the pathological evaluation of uterine fibroids in pre-menopausal women undergoing hysterectomy. METHODS: We enrolled women aged 35-55 y scheduled for hysterectomy for symptomatic fibroids at a tertiary care hospital from 2019 to 2021. Per pre-set guidelines, we recorded 2-D images and videos of the uterus with fibroids during the transvaginal ultrasound. The recordings were transferred through USB, loaded in the FMRA software and post-processed to generate a 3-D rendered uterus model. An experienced pathologist assessed and documented the gross examination details per a set protocol. We compared the pre-specified dimensions related to the size (L1, L2) and location (X, Y) of fibroids between the 3-D model and the pathologist's assessment of the hysterectomy specimen. RESULTS: A total of 25 fibroids in 25 women, the single largest per woman, were considered for analysis. The two methods had good correlation with respect to size (for L1, R² = 0.9723, and for L2, R² = 0.9784) and location (for X, R² = 0.9618, and for Y, R² = 0.9753). Inter-observer analysis revealed that measurements from two sonologists were reproducible (Cronbach's α = 0.9 for the L1, L2 and L3 dimensions of fibroids from the 3-D model). CONCLUSION: The FMRA is a novel tool for mapping fibroids. With its proven accuracy, it will be helpful in planning surgeries and during guided procedures for managing uterine fibroids.

Prevalence and Associated Risk Factors of Antenatal Depression among Pregnant Women Attending Tertiary Care Hospitals in South India.

Background: Antenatal depression (AND) is a common mood disorder that affects both the mother and the child. Objective: The current study is aimed at identifying the prevalence of antenatal depression and the risk factors associated with it in South Indian pregnant women. Materials and Methods: The current study was carried out in a tertiary care teaching hospital where pregnancy and postnatal care are offered. In the study, 314 pregnant women who visited the antenatal clinic for their prenatal checkups were included. To diagnose possible depression, Edinburgh Postnatal Depression Scale (EPDS) was used. The chi-square test was applied to determine the association between antenatal depression and various socioeconomic, obstetric, and medical factors. A logistic regression analysis was performed to identify significant confounding variables. Results: Of the total 314 women, 69 (21.98%) were suffering from possible depression with the mean EPDS score being 10.61 ± 7.48. Women of younger age had greater risks for depression than older women (AOR = 2.01; 95% CI: 0.56-7.20). Maternal age (χ 2 = 0.013, p = 0.009) and the presence of health issues during the current pregnancy (χ 2 = 5.18, p = 0.023) were the factors significantly associated with antenatal depression. Conclusions: Clinical efforts should focus on screening antenatal depression, early identification, and effective care, thus preventing progression to postpartum depression and its detrimental effects.

Correlation of cardiotocography abnormalities with position and attitude of the fetal head in labor.

BACKGROUND: Fetal distress indicated as the cause for cesarean delivery based on cardiotocography findings most often does not reflect in the newborn assessment. Cardiotocography findings are just the decision indicators for cesarean delivery, in the background of labor abnormalities owing to deflexed head or occipitoposterior position. OBJECTIVE: This study aimed to investigate the association between cardiotocography findings and the attitude of fetal head and occiput position. STUDY DESIGN: We conducted a prospective observational study in a tertiary hospital in South India, including 304 women in labor with vertex presentation. Fetal attitude, the position of the head, labor abnormalities, and cardiotocography findings were noted. The chi-square test was applied using MedCalc software (version 19) to investigate the association of cardiotocography findings with the attitude of fetal head and occiput position. RESULTS: Cardiotocography findings had significant association with occipitoposterior position (relative risk, 1.70; 95% confidence interval, 1.32-2.19) and deflexed attitude of the fetal head (relative risk, 1.44; 95% confidence interval, 1.11-1.87). Among cases with occipitoposterior position, 10 of 42 (24%) had pathologic cardiotocography, and 19 of 42 (45%) had suspicious cardiotocography, whereas among cases with deflexed head position, these proportions were 12 of 61 (20%) and 24 of 61 (40%), respectively. CONCLUSION: Pathologic and suspicious cardiotocography tracings were more frequent in women with fetal occipitoposterior and deflexed head position. However, the association was not specific to any cardiotocography pattern.

Sertoli-Leydig cell ovarian tumour: a rare cause of virilisation and androgenic alopecia.

Sertoli-Leydig cell tumours (SLCTs) represent a rare cause of hyperandrogenic state. SLCTs are sex cord ovarian neoplasms, accounting for <0.2% of all ovarian tumours. Most of the sex cord-stromal tumours have a benign clinical course, with 10%-20% of them at risk of aggressive course. We report a case of a woman in her 30s who presented with androgenic alopecia, virilisation and secondary amenorrhoea. The evaluation revealed an extremely high testosterone level. Imaging for the localisation of source of excess testosterone with contrast-enhanced CT of the abdomen revealed a right ovarian mass. Hence, a diagnosis of testosterone-secreting ovarian tumour was considered. The patient underwent right salphingo-oophorectomy, and histopathology was reported as Sertoli cell tumour. Postoperatively, there was normalisation of serum testosterone levels with decrease in virilisation and resumption of spontaneous menstrual cycles. The patient conceived spontaneously after 2 months of surgery.

Investigating feasibility of 2021 WHO protocol for cervical cancer screening in underscreened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC).

BACKGROUND: High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women's participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence. METHODS: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy. DISCUSSION: PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization's recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05234112 . Registered 10 February 2022.

A Novel Risk-Scoring Model for Prediction of Premalignant and Malignant Lesions of Uterine Endometrium Among Symptomatic Premenopausal Women.

PURPOSE: Uterine cancer is the second most prevalent cancer of the female genital tract, with 90% of it being of endometrial origin. The aim of this research was to create and validate a risk-scoring model using patients' clinical variables in predicting premalignant and malignant lesions of the uterine endometrium among premenopausal women with abnormal uterine bleeding (AUB). METHODS: This is a retrospective cohort study conducted at a tertiary hospital of Southern India for a period of 5 years from July 2014 to August 2019, including women aged ≤55 years who had AUB and underwent endometrial biopsy. The incidence of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) was determined, and clinical and demographic variables were compared among cases (AEH/EC) and controls (no AEH/EC) using simple logistic regression. A risk-scoring model was derived and validated with a split-sample internal validation method. RESULTS: A total of 472 premenopausal women presenting with AUB were included in the study. There were 20 women (4.2%) with AEH and eight (1.7%) with EC. We found a statistically significant positive correlation of an anovulatory pattern of bleeding (odds ratio [OR]=3.4; p=0.009), age ≥45 years (OR=1.12; p=0.01), body mass index (BMI) ≥30 kg/m2 (OR=2.46; p=0.04) and diabetes mellitus (OR=3.00; p=0.02) with a higher risk of AEH/EC diagnosis upon histopathological examination of endometrial biopsy specimens of the study population. A risk-scoring model (PAD30) was created using these variables to predict premalignant and malignant endometrial lesions. The best cutoff score derived by the receiver operating characteristics (ROC) curve, of ≥5, had a sensitivity of 85.7% and specificity of 87.6% with an area under the curve (AUC) of 0.84 (95% CI 0.75-0.93; p=0.04). With a positive likelihood ratio of 6.91, our prediction model increases the post-test probability of AEH/EC to 30.6% from 6% of the pre-test probability. CONCLUSION: The proposed model demonstrated a moderate diagnostic accuracy in predicting premalignant and malignant lesions of the uterine endometrium among symptomatic premenopausal women.

Hybrid Transfer Learning for Classification of Uterine Cervix Images for Cervical Cancer Screening.

Transfer learning using deep pre-trained convolutional neural networks is increasingly used to solve a large number of problems in the medical field. In spite of being trained using images with entirely different domain, these networks are flexible to adapt to solve a problem in a different domain too. Transfer learning involves fine-tuning a pre-trained network with optimal values of hyperparameters such as learning rate, batch size, and number of training epochs. The process of training the network identifies the relevant features for solving a specific problem. Adapting the pre-trained network to solve a different problem requires fine-tuning until relevant features are obtained. This is facilitated through the use of large number of filters present in the convolutional layers of pre-trained network. A very few features out of these features are useful for solving the problem in a different domain, while others are irrelevant, use of which may only reduce the efficacy of the network. However, by minimizing the number of filters required to solve the problem, the efficiency of the training the network can be improved. In this study, we consider identification of relevant filters using the pre-trained networks namely AlexNet and VGG-16 net to detect cervical cancer from cervix images. This paper presents a novel hybrid transfer learning technique, in which a CNN is built and trained from scratch, with initial weights of only those filters which were identified as relevant using AlexNet and VGG-16 net. This study used 2198 cervix images with 1090 belonging to negative class and 1108 to positive class. Our experiment using hybrid transfer learning achieved an accuracy of 91.46%.

Utility of three dimensional (3-D) ultrasound and power Doppler in identification of high risk endometrial cancer at a tertiary care hospital in southern India: A preliminary study.

OBJECTIVE: The study was conducted to find the utility of three dimensional (3-D) ultrasound and Doppler sonography in differentiating benign and malignant endometrial lesions and to ascertain the association of sonology parameters with type, grade and stage of endometrial cancer. MATERIALS AND METHODS: Women attending the gynaecology department of a tertiary care hospital, with a provisional diagnosis of carcinoma endometrium were subjected to three dimensional power Doppler ultrasound evaluation and assessment of vascular patterns. VOCAL (Virtual Organ Computer-aided Analysis) software was used to assess volume, Vascularisation Index (VI), Flow Index (FI) and Vascularisation Flow Index (VFI). Ultrasound parameters were compared with histologic diagnosis to evaluate the diagnostic performance using Receiver Operating Characteristic (ROC) Curve. RESULTS: Sixty-four women were included in the study, 33 with benign and 31 with malignant endometrial lesions. Larger endometrial volume and higher Doppler indices correlated with malignant lesions. The variables with good discriminatory potential between benign and malignant status were VI and VFI, having a sensitivity of 90.3% and specificity of around 80%. VFI (adjusted odds ratio of 40.4; (95% CI - 8.46-192.88), p value < 0.001) was the only significant variable identified by multivariate logistic regression, when adjusted for age and post-menopausal status. Multiple global and focal vessel pattern was seen predominantly in malignant cases (specificity 93.9%), although the sensitivity was low (61.2%). Higher stages and grades of tumour and non-endometrioid types had higher Doppler indices, and requires further evaluation. CONCLUSIONS: 3-D ultrasound has good discrimination potential between benign and malignant endometrial lesions and could be useful as a screening tool. However, utility of 3-D tool for differentiation between tumour characteristics needs further validation.

Automation of Detection of Cervical Cancer Using Convolutional Neural Networks.

Classification of digital cervical images acquired during visual inspection with acetic acid (VIA) is an important step in automated image-based cervical cancer detection. Many algorithms have been developed for classification of cervical images based on extracting mathematical features and classifying these images. Deciding the suitability of a feature and learning the algorithm is a complex task. On the other hand, convolutional neural networks (CNNs) self-learn most suitable hierarchical features from the raw input image. In this paper, we demonstrate the feasibility of using a shallow layer CNN for classification of image patches of cervical images as cancerous or not cancerous. We used cervix images acquired after the application of 3%-5% acetic acid using an Android device in 102 women. Of these, 42 cervix images belonged in the VIA-positive category (pathologic) and 60 in the VIA-negative category (healthy controls). A total of 275 image patches of 15 × 15 pixels were manually extracted from VIA-positive areas, and we considered these patches as positive examples. Similarly, 409 image patches were extracted from VIA-negative areas and were labeled as VIA negative. These image patches were classified using a shallow layer CNN composed of a layer each of convolutional, rectified linear unit, pooling, and two fully connected layers. A classification accuracy of 100% is achieved using shallow CNN.

Andriod Device-Based Cervical Cancer Screening for Resource-Poor Settings.

Visual inspection with acetic acid (VIA) is an effective, affordable and simple test for cervical cancer screening in resource-poor settings. But considerable expertise is needed to differentiate cancerous lesions from normal lesions, which is lacking in developing countries. Many studies have attempted automation of cervical cancer detection from cervix images acquired during the VIA process. These studies used images acquired through colposcopy or cervicography. However, colposcopy is expensive and hence is not feasible as a screening tool in resource-poor settings. Cervicography uses a digital camera to acquire cervix images which are subsequently sent to experts for evaluation. Hence, cervicography does not provide a real-time decision of whether the cervix is normal or not, during the VIA examination. In case the cervix is found to be abnormal, the patient may be referred to a hospital for further evaluation using Pap smear and/or biopsy. An android device with an inbuilt app to acquire images and provide instant results would be an obvious choice in resource-poor settings. In this paper, we propose an algorithm for analysis of cervix images acquired using an android device, which can be used for the development of decision support system to provide instant decision during cervical cancer screening. This algorithm offers an accuracy of 97.94%, a sensitivity of 99.05% and specificity of 97.16%.

Ovarian borderline mucinous tumor with squamous overgrowth: An unusual finding with review of literature.

Borderline mucinous tumor (BMT) is often associated with other entities such as dermoid cyst, Brenner tumor, and endometriosis. Squamous areas are often associated which may be a part of BMT or its associated conditions. Here, we describe squamous overgrowth in a case of intestinal type of mucinous borderline tumor in a 29-year-old uniparous female and discuss the diagnostic difficulties.

Fallopian tube choriocarcinoma presenting as ovarian tumour: a case report.

Choriocarcinoma of the fallopian tube is a rare form of gestational trophoblastic disease. It can be gestational or non gestational choriocarcinoma, based on the origin. Fallopian tube choriocarcinoma has been reported commonly after ectopic pregnancy. Choriocarcinomas are germ cell tumours formed by trophoblastic elements. A 26-year-old lady presented with pain and mass abdomen of 15 days duration. Clinical examination revealed a ovarian tumour with elevated beta HCG. The working diagnosis was ovarian choriocarcinoma. Patient was also found to be having pulmonary artery hypertension due to the metastasis to lungs. Staging laparotomy was done. Histopathology revealed it to be metastatic gestational choriocarcinoma of fallopian tube with vascular emboli. The stage was stage III and WHO scoring of 15. She received Etoposide, Methotrexate, Actinomicin, Cyclophosphamide and Oncovin therapy. Following treatment there was a significant drop in the beta HCG. Patient tolerated the chemotherapy well. This is a rare presentation of choriocarcinoma with good prognosis.

Predictive value of middle cerebral artery to uterine artery pulsatility index ratio in hypertensive disorders of pregnancy.

Aims and Objectives. (i) To determine the predictive value of cerebrouterine (CU) ratio (middle cerebral artery to uterine artery pulsatility index, MCA/UT PI) in assessing perinatal outcome among hypertensive disorders of pregnancy. (ii) To compare between CU ratio and CP ratio (MCA/Umbilical artery PI) as a predictor of adverse perinatal outcome. Methods. A prospective observational study was done in a tertiary medical college hospital, from September 2012 to August 2013. One hundred singleton pregnancies complicated by hypertension peculiar to pregnancy were enrolled. Both CU and CP ratios were estimated. The perinatal outcomes were studied. Results. Both cerebrouterine and cerebroplacental ratios had a better negative predictive value in predicting adverse perinatal outcome. However, both CU and CP ratios when applied together were able to predict adverse outcomes better than individual ratios. The sensitivity, specificity, positive predictive value, and the negative predictive values for an adverse neonatal outcome with CU ratio were 61.3%, 70.3%, 56%, and 78.9%, respectively, compared to 42%, 57.5%, 62%, and 76% as with CP ratio. Conclusion. Cerebrouterine ratio and cerebroplacental ratio were complementary to each other in predicting the adverse perinatal outcomes. Individually, both ratios were reassuring for favorable perinatal outcome with high negative predictive value.

Reference ranges of amniotic fluid index in late third trimester of pregnancy: what should the optimal interval between two ultrasound examinations be?

BACKGROUND: Amniotic fluid index (AFI) is one of the major and deciding components of fetal biophysical profile and by itself it can predict pregnancy outcome. Very low values are associated with intrauterine growth restriction and renal anomalies of fetus, whereas high values may indicate fetal GI anomalies, maternal diabetes mellitus, and so forth. However, before deciding the cut-off standards for abnormal values for a local population, what constitutes a normal range for specific gestational age and the ideal interval of testing should be defined. OBJECTIVES: To establish reference standards for AFI for local population after 34 weeks of pregnancy and to decide an optimal scan interval for AFI estimation in third trimester in low risk antenatal women. MATERIALS AND METHODS: A prospective estimation of AFI was done in 50 healthy pregnant women from 34 to 40 weeks at weekly intervals. The trend of amniotic fluid volume was studied with advancing gestational age. Only low risk singleton pregnancies with accurately established gestational age who were available for all weekly scan from 34 to 40 weeks were included in the study. Women with gestational or overt diabetes mellitus, hypertensive disorders of the pregnancy, prelabour rupture of membranes, and congenital anomalies in the foetus and those who delivered before 40 completed weeks were excluded from the study. For the purpose of AFI measurement, the uterine cavity was arbitrarily divided into four quadrants by a vertical and horizontal line running through umbilicus. Linear array transabdominal probe was used to measure the largest vertical pocket (in cm) in perpendicular plane to the abdominal skin in each quadrant. Amniotic fluid index was obtained by adding these four measurements. Statistical analysis was done using SPSS software (Version 16, Chicago, IL). Percentile curves (5th, 50th, and 95th centiles) were constructed for comparison with other studies. Cohen's d coefficient was used to examine the magnitude of change at different time intervals. RESULTS: Starting from 34 weeks till 40 weeks, 50 ultrasound measurements were available at each gestational age. The mean (standard deviation) of AFI values (in cms) were 34 W: 14.59 (1.79), 35 W: 14.25 (1.57), 36 W: 13.17 (1.56), 37 W: 12.48 (1.52), 38 W: 12.2 (1.7), and 39 W: 11.37 (1.71). The 5th percentile cut-off was 8.7 cm at 40 weeks. There was a gradual decline of AFI values as the gestational age approached term. Significant drop in AFI was noted at two-week intervals. AFI curve generated from the study varied significantly when compared with already published data, both from India and abroad. CONCLUSION: Normative range for AFI values for late third trimester was established. Appreciable changes occurred in AFI values as gestation advanced by two weeks. Hence, it is recommended to follow up low risk antenatal women every two weeks after 34 weeks of pregnancy. The percentile curves of AFI obtained from the present study may be used to detect abnormalities of amniotic fluid for our population.

Chemoradiation related acute morbidity in carcinoma cervix and correlation with hematologic toxicity: a South Indian prospective study.

PURPOSE: To assess chemoradiation related acute morbidity in women with carcinoma cervix and to find and correlation between hematologic toxicity and organ system specific damage. MATERIALS AND METHODS: A prospective study was carried out between August 2012 and July 2013 enrolling 79 women with cancer cervix receiving chemo-radiotherapy. Weekly assessment of acute morbidity was done using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 4 and the toxicities were graded. RESULTS: Anemia [77 (97.5%)], vomiting [75 (94.8%)] and diarrhea [72 (91.1%)], leukopenia [11 (13.9%)], cystitis [28 (35.4%], dermatitis [19 (24.1%)] and fatigue [29 (36.71%)] were the acute toxicities noted. The toxicities were most severe in 3rd and 5th week. All women could complete radiotherapy except two due to causes unrelated to radiation morbidity; seven (8.86%) had to discontinue chemotherapy due to leukopenia and intractable diarrhea. Though there was no correlation between anemia and other toxicities, it was found that all with leukopenia had diarrhea. CONCLUSIONS: Chemoradiation for cancer cervix is on the whole well tolerated. Leukopenia and severe diarrhea were the acute toxicities that compelled discontinuation of chemotherapy in two women. Though anemia had no correlation with gastrointestinal toxicity, all of those with leukopenia had diarrhea.

Twin pregnancy with Hydatidiform Mole and Co-existent Live Fetus: Lessons Learnt.

This is a case report of a twin pregnancy with one fetus and a coexistent mole diagnosed at 13 weeks. After thorough counseling, the pregnancy was continued as per the patient's desire. The pregnancy was closely monitored with serial S ß hCG, ultrasound for fetal growth, size of molar sac, and theca lutein cysts, which gradually decreased in size during the second trimester of pregnancy. An emergency caesarean delivery was done at 36 weeks due to breech in early labour. A live baby weighing 1.8 kg was delivered in good condition. Her S ß hCG reached normal levels at the end of three weeks, and she is now on post-molar surveillance. Though the general trend is to terminate pregnancy in twins with coexistent mole in anticipation of complications, under close surveillance, optimal outcomes can be achieved. Monitoring of S ß hCG, serial ultrasound for fetal growth, size of molar component, and theca lutein cysts can help to predict good patient outcomes.

Evaluation of placenta in foetal demise and foetal growth restriction.

AIM: The study objective was to evaluate the pathological changes of the placenta in foetal death and foetal growth restriction and to find correlation of the findings with clinical causes. SETTING AND DESIGN: Prospective study at a tertiary care hospital. MATERIAL AND METHODS: Gross and histopathological examinations of the placentae were carried out in pregnancies with foetal demise (IUD) and Foetal Growth Restriction (FGR). STATISTICAL ANALYSIS: SPSS, version 11.5. RESULTS: Placentae of twenty seven women with foetal demise and of equal number of women with foetal growth restriction were studied. Placental weight was less than 10(th) percentile in 61.5% women in IUD group and in 93% women in the FGR group. Gross examination of placentae showed abnormalities in 12 (44%) women of IUD group and in 16 (59%) women of FGR group. Histopathological abnormalities were observed in 74.1% women of the IUD group and in 66.7% women of FGR group. Placental histopathology correlated with clinical risk factors in 60% women of IUD group and in 40% women of FGR group. Among the women with no clinically explainable cause for IUD and FGR, 86% and 57% had placental histopathological abnormalities respectively. CONCLUSION: The histopathological abnormalities of the placenta can be used to document the clinical causes of foetal demise and growth restriction; it may explain the causes in cases of clinically unexplained foetal demise and foetal growth restriction.