Staging of Cervical Cancer: What has Changed?

In India, cervical cancer is the second most common cause of cancer-related fatalities and the fourth most common malignancy worldwide affecting women. India accounts for 25% of all cervical cancer-related deaths worldwide each year. The main drawbacks of clinical staging were the imprecise estimation of tumor size and the challenge of determining the involvement of pelvic and para-aortic lymph nodes with the few studies that FIGO allowed to be done for staging of cancer cervix. The use of 2009 staging approach showed that when many cases were operated based only on clinical findings, they subsequently required adjuvant therapy; hence, treatment-related morbidity was negatively impacted by these errors. Changes have been made to the staging of cervical cancer according to the 2018 revised International Federation of Gynecology and Obstetrics (FIGO) guidelines. Correction to cancer of the cervix staging was published recently in 2024. The horizontal extent (lateral extent) of the disease is not taken into consideration for staging in cases of microinvasive disease. Three subgroups have been identified based on the stratification of tumor size: IB1 ≤ 2 cm, IB2 > 2- ≤ 4 cm, and IB3 > 4 cm. Pathology and imaging modalities are added to clinical diagnosis for staging of cancer cervix. The involvement of lymph nodes (LNs) is now classified based on pathology (p) or imaging (r) which specifies that lymph node involvement is diagnosed using pathology (p) or imaging (r). Stage IIIC has been added [IIIC1 (involvement of pelvic nodes) and IIIC2 (involvement of para-aortic nodes)] is assigned to the case in the event of lymph node positive status. Pathological assessment takes precedence over radiological and clinical findings. The involvement of vascular/lymphatic spaces should not change the staging. The lower staging should be assigned when there is doubt about stage. Overall, the revised FIGO staging of cancer cervix (2024) has a number of advantages, including the inclusion of imaging and pathology, tumor size and LN-based categorization. More studies on staging of cancer cervix in different populations using revised staging of cancer cervix will help to prognosticate use of this staging.

Study of Caesarean Section Births in a Tertiary Care Hospital in Mumbai Using Robson Classification System.

Introduction: Robson ten-group classification system is recommended by WHO (World health organization) as a global standard for assessment and monitoring caesarean section (CS) rates. This classification is simple and robust. It is prospective, easily reproducible and clinically relevant. Methodology: We conducted a prospective observational study of CS births at a tertiary care institute. Caesarean births in a tertiary care hospital were classified using Robson classification system as recommended by WHO. The study was conducted for period of 6 months duration. The ethics committee of the institute approved this study. We enrolled 4771 consecutive women who delivered during this study period. We included patients who had vaginal delivery as well as those who had delivery by CS. Both live births and stillbirths (of at least 500-g birth weight or at least 22 weeks gestation (according to WHO recommendations) were included in this study. Results: During this study period, we had 4771 deliveries, out of which 2231 pregnant women (46.76%) were delivered by CS as compared to 2540 vaginal deliveries. Women with previous CS (term with single cephalic pregnancy) were included in Robson group 5. Group 5 had the highest CS rate (13.41%). Robson group 5, 1 and 10 were the largest contributors to the high CS rates at our institute. Conclusion: In our study, 4771 deliveries were conducted during this study period (6 months). Out of 4771 deliveries, CS was done in 2231 pregnant women (46.76%). 2540 women had vaginal deliveries. Group 5 (13.41%) which comprised of women with previous CS had the highest CS rate followed by group 1 and group 10. The second largest contribution was from Group 1 with CS rate of 9.01%. Robson Group 1 included nulliparous term women with single cephalic pregnancy in spontaneous labour. Group 10 was the third largest contributor to the overall CS. Group 10 included women who delivered preterm (single cephalic presentation). Group 10 contributed to 8.09% of overall CS rate. We should make every effort to provide CS for women requiring this procedure, rather than work towards achieving a specific rate for CS.

Causes and Demographic Factors Affecting Stillbirth in a Tertiary Care Centre in India.

Introduction: Stillbirth is a global health problem having many emotional, social and economic consequences. India has the largest number of stillbirths per year in the world. Objective: The objective of this study is to review the causes of stillbirth and classify the causes into maternal, foetal and placental causes and further classify causes by relevant condition at death (ReCoDe) classification. We intend to observe the causes of and demographic factors contributing to the burden of stillbirths. Using this data, the areas of action can be identified and measures can be formulated to reduce a significant number of perinatal mortalities. Methodology: This is an observational study of data collected over one year (January 2019-December 2019) from a tertiary care centre in Mumbai, India. The maternal demographic characteristics and causes of stillbirth were studied. The causes of stillbirths were classified into maternal, foetal and placental causes and relevant condition at death (ReCoDe) classification [1]. Results: A total of 9074 babies were delivered during this period. There were 275 stillbirths in this year (SBR 30.3 per 1000 total births). Majority of the mothers were in the age group of 26-30 years (32.7%). Almost all the mothers (98.5%) were from urban areas. As per the modified Kuppuswamy classification for urban India, 195 (71.79%) belonged to the upper lower class. 31.2% were primigravidae, and 54.8% had 3 or more antenatal visits. Maternal conditions (pre-eclampsia, diabetes, pre-existing medical disorders) as a group were the cause of maximum number (42%) of stillbirths either directly or as a contributory risk factor. 78% of the stillbirths occurred in the antepartum period. Ours being a referral centre, 65% subjects in the study were referred to us from other peripheral hospitals. 53.8% of the stillborn babies were male. 58.9% were macerated stillbirths. According to the ReCoDe classification, hypertensive disease in pregnancy was the most common cause of stillbirths (76) followed by foetal growth restriction (30). Conclusion: Most of the stillbirths in this study were due to maternal medical conditions. Out of these conditions, hypertensive disorders of pregnancy and its consequences were the most common (66.08%). Better regulation of the private healthcare sector, provision of healthcare providers and better equipments in peripheral health centres and a well-chalked out referral system will contribute to reduction in the number of preventable stillbirths. Regular facility-based stillbirth review meetings and healthcare provider accountability would also help to reduce the burden of this silent epidemic as well as reach the goal of a "single-digit" stillbirth rate by the year 2030.

Laparoscopic Management of Post-Cesarean Section Uterocutaneous Fistula.

A uterocutaneous fistula is a rare clinical presentation that occurs following cesarean section or any other pelvic surgery. We describe a case of uterocutaneous fistula with successful surgical management. A 25-year woman was referred to our hospital with complaints of cyclical bleeding from lower segment cesarean section scar (LSCS scar). It was diagnosed as uterocutaneous fistula on ultrasonography and computed tomography. The fistula tract was excised. Histopathology report was suggestive of sinus tract due to tuberculous etiology. Patient was started on antituberculous treatment. Recovery was uneventful.

An Observational Study to Evaluate the Maternal and Foetal Outcomes in Pregnancies Complicated with Jaundice.

BACKGROUND: Incidence of jaundice in pregnancy, including underlying chronic liver diseases, is 3-5%. However, the maternal mortality rate in some conditions can be as high as 18% in acute fatty liver of pregnancy and 22% in hepatitis E in pregnancy. OBJECTIVES: This is an observational study of the demographics, obstetrical profile, aetiology, maternal morbidity, mortality and neonatal outcomes in pregnancies complicated with jaundice. MATERIALS AND METHODS: This is an observational study conducted in Department of Obstetrics and Gynaecology of a tertiary care hospital, situated amidst the biggest urban slum in Mumbai spanning over 1 year from January 2016 to December 2016. All registered, unregistered and transferred patients with abnormal liver function tests excluding patients with chronic liver diseases were included in this study. RESULTS: Most of the cases of jaundice in pregnancy were seen in primigravida (51%) and age group of 20-30 years (58%). Fifty-three percentage of cases were referred or transferred from periphery hospitals. Hepatitis E was the most common cause (42%) of jaundice in pregnancy. Complications like disseminated intravenous coagulopathy, postpartum haemorrhage, hepatic encephalopathy and hepatoportal hypertension were seen in 65% of cases. Maternal mortality rate and perinatal mortality rate were as high as 40 and 37%, respectively, in our study. CONCLUSION: Incidence of jaundice in pregnancy, mainly due to viral hepatitis, is very high in lower socio-economic, densely populated urban slums. Special efforts should be made to counsel and educate the mothers about initial symptoms and preventive measures for viral hepatitis. Patients along with the relatives should be informed about the severe features of pre-eclampsia to combat these preventable causes of maternal mortality.