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.

Large supralevator haematoma: a dilemma in diagnosis and management.

This is a case of postpartum haemorrhage following vaginal delivery of a primigravida in her late 20s resulting from a supralevator haematoma. She delivered in a low-resource hospital setting, with a late diagnosis of severe pre-eclampsia and haemolysis, elevated liver enzymes and low platelet count (HELLP), subsequently developed traumatic postpartum haemorrhage and vaginal haematoma, and was referred to our hospital for further management. She was constantly monitored, and serial ultrasonography revealed an expanding paravaginal haematoma. CT, 4 hours after admission, showed a large ill-defined collection with hyperdense areas of blood attenuation measuring ~8.0×6.2×12.2 cm in toto in the vaginal canal and right paravaginal region with supralevator extension, abutting the rectum posteriorly. The expanding haematoma caused gradual hypovolaemic shock, and hence, she was taken up for vaginal evacuation of supralevator haematoma with drainage tube insertion under ultrasound guidance. She received multiple blood product transfusion. Drain tube was removed on postoperative day 3. Follow-up scan was done and resolving haematoma noted. The patient was discharged on postoperative day 5 in a stable condition. She was followed up in outpatient department, and there was complete resolution of haematoma by 4 weeks.

An audit of hysterectomy in a teaching hospital in India: Story of a decade.

BACKGROUND: The appropriateness of hysterectomy has gained an interest in scrutiny and debate. Periodic audits of the prevailing clinical practices are imperative for insight, and to formulate recommendations and guidelines. We report the temporal trends of hysterectomies, over the last 10 years in a teaching hospital. METHODS: Present study involved all patients who underwent hysterectomy at a teaching hospital, from January 1, 2012 to December 31, 2021. Patients were identified by medical record tracking using International Classification of Diseases-9 codes. Case records were reviewed for demography, indication for surgery, approach, complications, hospital stay, and histopathological correlation. RESULTS: Over the years the absolute number of hysterectomies in our hospital has ranged from 414 to 597 (mean 476), barring the coronavirus 19 pandemic year. The proportion of hysterectomy among all gynaecological admissions has ranged from 6% to 9%, except in 2020 where this proportion dropped down to 4%. The indications, age distribution, surgical approach, and complications have remained almost same. CONCLUSION: We report a static trend in hysterectomy over the past 10 years. This audit provides an insight for the need of shifting the abdominal to vaginal route, in carefully chosen patients. This will be beneficial for the patients, and for the trainees, where they can learn under supervision. Availability and patient education about the nonsurgical management options for benign gynecological conditions, as well as awareness about sequelae of hysterectomy, will bring down the rate in countries such as India.

Ultrasound Assessment of Foetal Head-Perineum Distance Prior to Induction of Labour as a Predictor of Successful Vaginal Delivery.

BACKGROUND: In modern obstetrical practice, incidence of induction of labour is on rise for varied maternal and foetal indications. Ultrasound can help obstetricians in counselling patients before induction of labour and explain the probability of successful induction. OBJECTIVES: To study the role of foetal head-perineum distance in predicting successful vaginal delivery and to correlate with other parameters such as cervical length and Bishop score. DESIGN: This study is a prospective case-control study in a tertiary care teaching hospital. POPULATION: There were 250 term patients between 37 and 40+ weeks with singleton cephalic presentation with no contraindications for vaginal delivery. METHODS: Prior to induction of labour, transperineal ultrasound was performed to measure foetal head-perineum distance. Simultaneously, cervical length was performed using transvaginal ultrasound probe. Bishop score was determined at the same time by clinical examination. MAIN OUTCOME MEASURES: Outcome of induction was considered successful when it resulted in vaginal delivery. It was considered to be a failure if patient did not get into active phase of labour or an operative intervention had to be performed because of non-progress of labour in active phase of labour. Cases were excluded if caesarean delivery had to be performed in the event of foetal distress. RESULTS: It was observed that as the transperineal foetal head-perineum distance decreased, the rate of vaginal delivery increased. Similarly, when foetal head-perineum distance increased, the rate of caesarean delivery increased. At a cut-off ≤ 5.5 cm, foetal head-perineum distance had a maximum predictability (sensitivity 97%, specificity 88.1%). CONCLUSION: Transperineal foetal head-distance measured by ultrasound can be used as an important tool to predict vaginal delivery before induction of labour.

Manipal Cervical Scoring System by Transvaginal Ultrasound in Predicting Successful Labour Induction.

INTRODUCTION: Induction of labour (IOL) nowadays is a common procedure in obstetric practice. The success of IOL largely depends upon "favourability" or "readiness" cervix which is traditionally assessed by manual examination and Scored as Bishop Score. However, this method is limited by subjectivity and reproducibility and though done in all the patients prior to IOL, several studies have demonstrated poor correlation between Bishop Score and outcome of labour. OBJECTIVE: To evaluate the role of preinduction transvaginal ultrasonographic (TVS) cervical assessment in predicting labour outcome and to compare its performance against Bishop Score in patients undergoing induction of labour (IOL). SETTING: A tertiary medical college hospital in Southern India. DESIGN: Prospective observational and investigational study. MATERIALS AND METHODS: Transvaginal ultrasound was performed in 131 patients who underwent labour induction at term with intact membranes and live fetus. Bishop Score was assessed by pervaginal examination and was compared with preinduction TVS cervical Score (parameters being cervical length, funneling, position of cervix and distance of presenting part from external os). Labour was induced within one hour of cervical assessment. The labour induction was considered successful if patient could get into active labour i.e., onset of regular uterine contractions (at interval of 2-3 minutes) and cervical dilatation of 4 cm or greater within 24 hours of induction. RESULTS: Labour induction was successful in 86.9% of patients. At cut off Scores of ≥ 4, TVS cervical Score performed better than Bishop Score (Sensitivity 77% vs. 65%, Specificity 93% vs. 86%). ROC analysis indicated that Area Under Curve (AUC) was more for TVS Score (0.90, 95% CI 0.84 - 0.95), compared to Bishop Score. It was found that an increase in cervical length and distance from the os by 1 mm from their means were associated with an increase in odds for failure of induction and there by caesarean delivery by 6.5% and 11% respectively. CONCLUSION: In women experiencing labour induction, transvaginal ultrasound score comprising of five different parameters indicated success of induction better than Bishop Score. Further, two of its components (longer cervical length and increased distance of presenting part from external os) demonstrated significant and independent prediction of the likelihood of failure of induction and risk of operative delivery.

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.

Quantifying proteinuria in hypertensive disorders of pregnancy.

Background. Progressive proteinuria indicates worsening of the condition in hypertensive disorders of pregnancy and hence its quantification guides clinician in decision making and treatment planning. Objective. To evaluate the efficacy of spot dipstick analysis and urinary protein-creatinine ratio (UPCR) in hypertensive disease of pregnancy for predicting 24-hour proteinuria. Subjects and Methods. A total of 102 patients qualifying inclusion criteria were evaluated with preadmission urine dipstick test and UPCR performed on spot voided sample. After admission, the entire 24-hour urine sample was collected and analysed for daily protein excretion. Dipstick estimation and UPCR were compared to the 24-hour results. Results. Seventy-eight patients (76.5%) had significant proteinuria of more than 300 mg/24 h. Dipstick method showed 59% sensitivity and 67% specificity for prediction of significant proteinuria. Area under curve for UPCR was 0.89 (95% CI: 0.83 to 0.95, P < 0.001) showing 82% sensitivity and 12.5% false positive rate for cutoff value of 0.45. Higher cutoff values (1.46 and 1.83) predicted heavy proteinuria (2 g and 3 g/24 h, resp.). Conclusion. This study suggests that random urinary protein : creatine ratio is a reliable investigation compared to dipstick method to assess proteinuria in hypertensive pregnant women. However, clinical laboratories should standardize the reference values for their setup.

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.

Pyoderma gangrenosum in two successive pregnancies complicating caesarean wound.

Pyoderma gangrenosum (PG) is a rare ulcerative cutaneous disorder with tendency to recur in the injured area. Though most of the time is associated with chronic systemic conditions, it can occur in isolation and can be a diagnostic dilemma. The aetiology is poorly understood. The diagnosis is based on clinical features and excluding other causes of skin ulcers, as it does not have characteristic histopathology or laboratory findings. Lesions can develop after surgery, after trauma or de novo. We are reporting a 32-year-old pregnant lady with two previous instances of pyoderma gangrenosum in the previous pregnancy, who in postoperative period following caesarean section developed the same condition for the third time. She responded well to local wound care, oral Prednisolone, and Dapsone and made a good recovery. Pregnancy being an immunologically altered status can play a role in development of pyoderma gangrenosum and one should always rule out its possibility when there is a delayed wound healing.

Significance of maternal and cord blood nucleated red blood cell count in pregnancies complicated by preeclampsia.

OBJECTIVES: To evaluate the effect of preeclampsia on the cord blood and maternal NRBC count and to correlate NRBC count and neonatal outcome in preeclampsia and control groups. STUDY DESIGN: This is a prospective case control observational study. PATIENTS AND METHODS: Maternal and cord blood NRBC counts were studied in 50 preeclamptic women and 50 healthy pregnant women. Using automated cell counter total leucocyte count was obtained and peripheral smear was prepared to obtain NRBC count. Corrected WBC count and NRBC count/100 leucocytes in maternal venous blood and in cord blood were compared between the 2 groups. RESULTS: No significant differences were found in corrected WBC count in maternal and cord blood in cases and controls. Significant differences were found in mean cord blood NRBC count in preeclampsia and control groups (40.0 ± 85.1 and 5.9 ± 6.3, P = 0.006). The mean maternal NRBC count in two groups was 2.4 ± 9.0 and 0.8 ± 1.5, respectively (P = 0.214). Cord blood NRBC count cut off value ≤ 13 could rule out adverse neonatal outcome with a sensitivity of 63% and specificity of 89%. CONCLUSION: Cord blood NRBC are significantly raised in preeclampsia. Neonates with elevated cord blood NRBC counts are more likely to have IUGR, low birth weight, neonatal ICU admission, respiratory distress syndrome, and assisted ventilation. Below the count of 13/100 leucocytes, adverse neonatal outcome is quite less likely.

An audit of indications, complications, and justification of hysterectomies at a teaching hospital in India.

Objective. Aim of this audit was to analyze indications, complications, and correlation of preoperative diagnosis with final histopathology report of all hysterectomies, performed in a premier teaching hospital. Methods. Present study involved all patients who underwent hysterectomy at a premier university hospital in Southern India, in one year (from 1 January, 2012, to 31 December, 2012). Results. Most common surgical approach was abdominal (74.7%), followed by vaginal (17.8%), and laparoscopic (6.6%) hysterectomy. Most common indication for hysterectomy was symptomatic fibroid uterus (39.9%), followed by uterovaginal prolapse (16.3%). Overall complication rate was 8.5%. Around 84% had the same pathology as suspected preoperatively. Only 6 (5 with preoperative diagnosis of abnormal uterine bleeding and one with high grade premalignant cervical lesion) had no significant pathology in their hysterectomy specimen. Conclusion. Hysterectomy is used commonly to improve the quality of life; however at times it is a lifesaving procedure. As any surgical procedure is associated with a risk of complications, the indication should be carefully evaluated. With the emergence of many conservative approaches to deal with benign gynecological conditions, it is prudent to discuss available options with the patient before taking a direct decision of surgically removing her uterus.

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 β 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 β 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 β hCG, serial ultrasound for fetal growth, size of molar component, and theca lutein cysts can help to predict good patient outcomes.

Early second trimester uterine scar rupture.

Spontaneous uterine scar rupture can be lethal in pregnant women. A spontaneous uterine scar rupture in the early mid-trimester is rare and difficult to diagnose. This is a case of a 30-year-old woman (G2P1L1) at 19 weeks of gestation and having undergone a previous caesarean section presented with acute abdomen in shock. Laparotomy revealed a uterine scar rupture, which was resutured after evacuation of products of conception. This case merits that the uterine rupture should be considered as a differential diagnosis in pregnant women presenting with acute abdomen. In this case, although there was uterine rupture in the second trimester and a complete placental separation, fetus was alive which is quite unusual in patients presenting with rupture uterus.

Ethical issues in laparoscopic hysterectomy.

Hysterectomy is performed for a wide range of benign and malignant conditions, such as fibroids, menorrhagia and pelvic pain, and gynaecological malignancies. One in four women has a chance of undergoing hysterectomy in her lifetime. Conventionally abdominal hysterectomy is done through the open approach. However, many patients assume that the modern laparoscopic hysterectomy is superior to the standard approach. Laparoscopic surgical centres are mushrooming in major cities. This article presents ethical considerations involved in the decision-making process of choosing from the surgical options available.

Role of laparoscopy in evaluation of chronic pelvic pain.

INTRODUCTION: Chronic pelvic pain (CPP) is a common medical problem affecting women. Too often the physical signs are not specific. This study aims at determining the accuracy of diagnostic laparoscopy over clinical pelvic examination. SETTINGS AND DESIGN: A retrospective study of patients who underwent diagnostic laparoscopy for CPP. MATERIALS AND METHODS: The medical records of 86 women who underwent laparoscopic evaluation for CPP of at least 6-month duration were reviewed for presentation of symptoms, pelvic examination findings at the admission, operative findings and follow up when available. STATISTICAL ANALYSIS USED: McNemar Chi-square test for frequencies in a 2 × 2 table. RESULTS: The most common presentation was acyclic lower abdominal pain (79.1%), followed by congestive dysmenorrhoea (26.7%). 61.6% of women did not reveal any significant signs on pelvic examination. Pelvic tenderness was elicited in 27.9%. Diagnostic laparoscopy revealed significant pelvic pathology in 58% of those who essentially had normal pervaginal findings. The most common pelvic pathology by laparoscopy was pelvic adhesions (20.9%), followed by pelvic congestion (18.6%). Laparoscopic adhesiolyis achieved pain relief only in one-third of the women. CONCLUSION: The study revealed very low incidence of endometriosis (4.7%). Overall clinical examination could detect abnormality in only 38% of women, where as laparoscopy could detect significant pathology in 66% of women with CPP. This shows superiority of diagnostic laparoscopy over clinical examination in detection of aetiology in women with CPP (P < 0.001). Adhesiolysis helps only small proportion of women in achieving pain control.