MRI Brain Lesions in Eclampsia: A Series of 50 Cases Admitted to HDU of a Tertiary Care Hospital.

Objective: To correlate the Magnetic Resonance Imaging findings and clinical presentation in patients of eclampsia. Materials and methods: This one year prospective study was conducted in the HDU of Department of Obstetrics and Gynecology, PT.B.D.Sharma, PGIMS, Rohtak .A total of 50 women with eclampsia (both antepartum and postpartum) were divided into two groups: a) study group patients with abnormal MRI b) control group: b) control group: patients with normal MRI.Comparison was done using chi-square test and unpaired student 't' test. Results: MRI revealed abnormal findings in 24% of women, commonest diagnosis being CVT without infarct (10%) followed by infarct (8%), PRES (4%) and HLE (2%).Totally 66% (n = 33) of the women presented with postpartum eclampsia while 34% (n = 17) had antepartum eclampsia.96%(n = 48) were unbooked cases. Unconsciousness, altered sensorium, headache, blurring of vision, seizures, GCS < 3 correlated well with MRI findings (p = 0.000, p = 0.027, p = 0.001, p = 0.007, p = 0.005, p = 0.000 respectively) whereas fundoscopic changes did not (p = 0.520). The mean uric acid and serum creatinine levels was higher (0.41 ± 0.11 mmol/ L vs 0.26 ± 0.10 mmol/ L and 80 ± 18 µmol/ L vs 71 ± 9 µmol/ L) in the study group and this was statistically significant (p = 0.003, p = 0.04 respectively).There was no statistically significant difference between blood pressure values of cases with or without MR imaging evidence of brain lesions. There was no maternal mortality among 50 cases. The sensitivity, specificity, positive predictive value and negative predictive value of neurological findings for abnormal MRI in patients with eclampsia was found to be 91.7%, 73.7%, 52.4%, 96.6% respectively. Conclusion: Unconsciousness, altered sensorium, headache, blurring of vision,seizures, GCS < 3, elevated uric acid and serum creatinine levels in the follow-up of pregnant patients with preeclampsia/eclampsia should be a warning for possible brain lesions whereas booking status, mean BP, fundoscopy, platelet, hemoglobin, liver enzymes were not significantly associated with positive MRI findings in patients of eclampsia.

Efficacy of combined hormonal vaginal ring in comparison to combined hormonal pills in heavy menstrual bleeding.

OBJECTIVE: To compare the efficacy, acceptability and compliance of combined hormonal vaginal ring (CVR), with combined hormonal pills (CHP) in patients with heavy menstrual bleeding (HMB). STUDY DESIGN: This prospective study was conducted in 50 women with HMB in age group of 25-40 years. Patients were divided in two groups of 25 each and followed for six treatment cycles. In each group, cycle comprised of three weeks of CVR (releases 15µg of EE and 120µg of the etonogestrel per day) or CHP (containing 30µgm of EE and 150µgm of LNG) use, followed by one ring or pill free week. After each cycle, patients were evaluated about the amount of blood loss and duration of bleeding by the pictoral blood assessment chart (PBAC), early bleeding (EWB), continued bleeding (CWB), intermenstrual bleeding, intended bleeding, compliance, and user acceptability. The collected data were analyzed using the Chi square test, t-test and ANOVA test. RESULT: Reduction in PBAC score for CVR (70.73%) and CHP group (70.02%), duration of bleeding and incidence of EWB was comparable among the two groups. The incidence of intermenstrual bleeding was lower in CVR than in CHP group in cycle 3 and 4 with significant p value. The incidence of CWB was significantly lower and the incidence of intended bleeding pattern in CVR group was significantly higher in cycle 3, 4, 5 and 6, signifying better cycle control. Compliance was also higher in CVR (88%) than CHC (75.33% of all cycles). CONCLUSION: This trial suggests that both the CVR and CHP are very effective short-term treatments for HMB in reproductive age group. However, women had better cycle control and compliance with CVR. This may be an attractive option among the wide variety of medications used to treat HMB.

Efficacy and safety of mifepristone and buccal misoprostol versus buccal misoprostol alone for medical abortion.

OBJECTIVES: To evaluate the efficacy and safety of mifepristone and buccal misoprostol versus buccal misoprostol alone in medical abortion of ≤56 days. STUDY DESIGN: One hundred pregnant women having gestational age ≤56 days were randomized to group A and group B. In group A, patients received 200 mg mifepristone on day 1, followed by buccal misoprostol 800 µg on day 2, and in group B patients received 800 µg buccal misoprostol only on day 1. MAIN OUTCOME MEASURES: Complete abortion was the principal outcome measure. Secondary outcome measures were side-effects and acceptability. RESULTS: Forty-six (92%) patients in group A and 37 (74%) patients in group B aborted successfully (p value 0.017). Four (8%) patients in group A and eight (16%) patients in group B had incomplete abortion with retained products of conception. In group B, three (6%) patients had missed abortion and two (4%) patients had continued pregnancy whereas none of the patients in group A had missed abortion or continued pregnancy. The overall method acceptance was 100% whereas the overall route acceptance was 83%. CONCLUSION: Misoprostol-alone regimen is a low-cost regimen as compared to mifepristone/misoprostol regimen. Though the efficacy of mifepristone followed by buccal misoprostol is better, buccal misoprostol alone can be used for termination of pregnancy in patients where mifepristone is either unavailable or contraindicated.

Comparative evaluation of isosorbide mononitrate and alendronate in management of postmenopausal osteoporosis.

BACKGROUND: Osteoporosis, a skeletal disorder that adversely affects bone strength , is common among postmenopausal women primarily due to reduced ovarian estrogens. PURPOSE: The present study was taken up to evaluate the role of isosorbide mononitrate (IMN) in the management of postmenopausal osteoporosis and to compare its efficacy with that of alendronate. METHODS: This prospective systematic randomized study was conducted on 90 postmenopausal women with lumbar spine BMD >2.5 SD below the young adult reference range. The participants received either Tab Alendronate 70 mg orally, once weekly (Group I) or Tab IMN 40 mg orally once daily (Group II) for 9 months, in addition to 500 mg of oral calcium daily. The BMD of the lumbar spine was measured using DEXA scan at enrolment and after 9 months. The data was analyzed by Student's t test and Chi-square test. RESULTS: The mean baseline BMD was 0.67 + 0.097 and 0.68 + 0.067 g/cm(2) in Group I and II, respectively. An increase of 11.94% in the mean BMD was noted after 9 months of treatment with alendronate as against 8.82% with IMN. Headache, flushing and palpitations in Group II and nausea, epigastric pain and heart burn in Group I were the most common adverse effects. CONCLUSION: IMN has a beneficial effect on bone turnover in cases of postmenopausal osteoporosis and that the effect is comparable to that of alendronate. IMN is a promising and safe alternative to alendronate for the management of postmenopausal osteoporosis.

Conjoined twins in a spontaneous trichorionic quadruplet pregnancy: a case report.

BACKGROUND: Multifetal pregnancies are high-risk pregnancies. Coexistence of conjoint twins with multifetal pregnancies further increases the risk factor, which is already considerably high with multiple births. Assisted reproductive techniques lead to an increase in multifetal pregnancies, especially monozygotic pregnancies, which in turn lead to an increase in the rate of conjoined twins. CASE: A spontaneously achieved quadruplet pregnancy with coexisting conjoint twins has not been reported previously. We report one such case of spontaneously achieved quadruplet pregnancy with coexisting conjoined twins. CONCLUSION: Early (preferably first trimester) recognition of multifetal pregnancy, chorionicity, amnionicity and fetal malformation help in proper pregnancy management and optimizing outcome.

Diagnostic laparoscopy in chronic pelvic pain.

INTRODUCTION: Laparoscopy, because of its availability and safety, provides a valuable tool in the evaluation of undiagnosed chronic pelvic pain. It is a simple and definitive means of establishing the presence or absence of pelvic pathology without resorting to major abdominal surgery. OBJECTIVE: To evaluate the causes of chronic pelvic pain using laparoscopy and to correlate between clinical examination, ultrasonography, and laparoscopy. MATERIAL AND METHODS: The present prospective study was done in the Department of Obstetrics and Gynecology of Pt. BD Sharma, PGIMS Rohtak. Fifty cases of chronic pelvic pain attending gynae OPD were included in the study. After detailed history, examination, investigations, and ultrasonography, the patients were subjected to laparoscopy. RESULTS: The mean age and parity of the patients with CPP was 30.88 ± 7.71 years and 1.74 ± 1.38, respectively. The mean duration of pain was 2.8 years (6 months-8 years). The commonest finding on laparoscopy was adhesions in 40%, endometriosis in 18%, and pelvic congestion syndrome in 20%, while 10% of the patients had normal pelvis. Laparoscopic findings were taken as gold standard and pelvic examination and ultrasonographic findings were compared with it. CONCLUSION: Clinical examination and ultrasonography has a sensitivity of 8.1 and 2%, respectively. Laparoscopy helps in detecting many causes of CPP which clinical methods and ultrasonography fail to identify. This enforces the position of laparoscopy as a gold standard in evaluation of this condition.

Randomized trial of oral versus sublingual misoprostol 24 h after mifepristone for medical abortion.

OBJECTIVES: To assess the efficacy, side effects, and acceptability of medical abortion using oral mifepristone (200 mg) followed 24 h later by oral or sublingual misoprostol (400 µg). MATERIALS AND METHODS: A total of 93 women with pregnancies up to 56 days of gestational age were assigned to two groups according to the different misoprostol regimen (group I 400 µg orally and group II 400 µg sublingually). The principle outcome measure was complete abortion defined as a complete expulsion of intrauterine contents without a need for surgical intervention 7 days after the procedure. RESULTS: Successful abortion occurred in 87.5% of patients in group 1 and 95.5% patients in group 2 (p = 0.166, 95% CI -0.194, 0.033). The patient acceptability and satisfaction rates were similar in both the groups. CONCLUSION: It is concluded that 400 µg of sublingual misoprostol is as effective as oral misoprostol 24 h after mifepristone for medical abortion of ≤ 56 days.

Aggressive angiomyxoma of vulva and vagina: a series of three cases and review of literature.

BACKGROUND: Aggressive angiomyxoma is a rare locally aggressive mesenchymal tumor of unknown etiology usually affecting the vulva, perianal region, buttocks or pelvis of reproductive age women. MATERIAL: A series of three cases, one each of vaginal, vulval and labial angiomyxoma is being presented. The etiology, presentation, diagnosis and management of this rare genital tumor are outlined. CONCLUSION: Angiomyxoma of vulva and vagina refers to a rare disease; diagnosis is not at all clinical, thus, cases presenting as bartholin cyst, benign vulval lesions and vaginal wall cysts should have complete radiological work up before excision, as pre-diagnosis can change the treatment modality and prognosis of patient.

Comparison of isosorbide mononitrate and misoprostol for cervical ripening in termination of pregnancy between 8 and 12 weeks: a randomized controlled trial.

AIM: The present study was undertaken to compare the efficacy of isosorbide mononitrate (IMN) and misoprostol for cervical ripening in termination of pregnancy between 8 and 12 weeks. MATERIALS AND METHODS: This prospective randomized single blind study enrolled 40 women with singleton pregnancy seeking surgical termination of pregnancy between 8 and 12 weeks of gestation. They were divided into two groups--group I received IMN 40 mg while group II received misoprostol 40 mg vaginally, 3 h prior to suction and evacuation. All women were monitored for effects of cervical ripening and adverse effects. RESULTS: The mean sizes of dilators that could be negotiated without any resistance was 5.9 ± 1.33 in group I and 8.6 ± 0.94 in group II (p < 0.001, 95% CI 0.58, 0.41). The mean dilator sizes at which resistance was first encountered was 6.9 ± 1.37 in group I and 9.9 ± 1.23 in group II (p < 0.001, 95% CI 0.60, 0.54). The mean blood loss was 61.5 ± 13.86 ml in group I and 36.25 ± 12.80 ml in group II (p < 0.001, 95% CI 6.07, 5.63). Headache was the most common adverse effect seen with IMN use. CONCLUSION: The results show that IMN has a definite role and better safety profile than misoprostol in first trimester cervical ripening, although misoprostol is more effective and causes less blood loss.

Use of 24-hour urinary protein and calcium for prediction of preeclampsia.

OBJECTIVE: To assess the efficacy of 24-hour urinary protein and calcium for the prediction of preeclampsia. MATERIALS AND METHODS: Two hundred normotensive women at 20-28 weeks' gestation were enrolled in the study. All women were asked to collect a 24-hour urine sample. Urinary protein and calcium were measured and expressed as milligrams per 24 hours. Sensitivity, specificity and predictive values were calculated for each test, and cutoff values were calculated using receiver operating characteristic curves. RESULTS: Twenty-one of the 200 women developed preeclampsia, including eight who developed severe preeclampsia and 13 who developed mild preeclampsia. Compared with the normotensive women (n = 179), the hypertensive patients (n = 21) had significantly lower urinary calcium excretion (167.23 +/- 80.63 mg vs. 277.43 +/- 60.38 mg) and higher proteinuria (351.14 +/- 41.58 mg vs. 296.33 +/- 30.03 mg). CONCLUSION: A decrease in 24-hour urinary calcium and increase in protein between 20-28 weeks' gestation are risk factors for preeclampsia.

Successful twin pregnancy in a unicornuate uterus with one fetus in the non-communicating rudimentary horn.

Rudimentary horn is a rare anomaly and results from arrested development of the mullerian ducts. We report a case of twin pregnancy in a unicornuate uterus with a non-communicating rudimentary horn, in which two siblings each in separate horn were delivered successfully by caesarean section.

Puerperal uterine inversion associated with unicornuate uterus.

Twenty-year-old para 1 presented with acute puerperal uterine inversion. Manual reposition and O'sullivan methods were tried but failed. She refused for any other corrective procedure. She again presented after 10 months with chronic puerperal inversion. Haultain operation was done. At laparotomy, inverted uterus was unicornuate, right kidney and ureter were absent.

Efficacy of hyoscine-N-butyl bromide (Buscopan) suppositories as a cervical spasmolytic agent in labour.

OBJECTIVE: To evaluate the efficacy and safety of hyoscine-N-butyl bromide (Buscopan) suppositories in the active phase of labour, i.e. once the labour is established. METHODS: A non-randomised controlled prospective study was carried out on 200 women in labour. In the active phase of labour, at 3 cm or more cervical dilatation, 100 women were administered Buscopan via suppository and 100 women (control) were not given any drug. RESULTS: The duration of first stage of labour was 123.86 +/- 68.89 (mean(+)-standard deviation) minutes in the study group and 368.05 +/- 133.0 min in the control group. These differences were statistically significant. There were no differences in the duration of the second and third stages of labour. There was no increased incidence of operative deliveries in the study group. No adverse effects were noted on the mother or fetus. CONCLUSION: Hyoscine-N-butyl bromide (HBB, Buscopan) suppositories were highly effective in shortening the duration of the first stage of labour.