Facial Dysmorphism: An Unreported Teratogenicity with Levetiracetam.

Levetiracetam (LEV) is a relatively newer anticonvulsant drug used to treat epilepsy and is approved by United States Food and Drugs Administration (USFDA). The drug binds to a synaptic vesicle glycoprotein and inhibits presynaptic calcium channels, thus reducing neurotransmitter release. Commonly reported side effects include drowsiness, weakness, unsteady gait, mood changes and loss of appetite. Like most other antiepileptics, it is a Category C drug in pregnancy. We report the first case of facial dysmorphism in the neonate of a mother taking LEV antenatally. A 30-year-old lady, G2P1L1 presented at 38 weeks gestation with history of previous caesarean and leaking per vaginum. She was a known epileptic, taking carbamazepine since three to four years. She was switched over to LEV at fifth week of pregnancy. Her antenatal period was uneventful. Basic investigations including anomaly scan were normal. Unfavourable cervix necessitated caesarean section. Neonate (female) had dysmorphic facies with bilateral preauricular appendages and lateral cleft. Infantogram was suggestive of bifid vertebra in thoracic region. Computed Tomography (CT) scan chest revealed bifid vertebral body at D5 level with fusion of spinous process of D5 and D6 vertebra on left side. This is the first case of LEV induced facial dysmorphism, highlighting the need of further studies on LEV safety during pregnancy.

Laparoscopy in the diagnosis of tuberculosis in chronic pelvic pain.

BACKGROUND: To estimate the prevalence of genital tuberculosis in women with idiopathic chronic pelvic pain on laparoscopy, correlate laparoscopic findings with microbiological and histological diagnosis of tuberculosis and assess the response to anti tubercular treatment (ATT) in these cases. METHOD: In a prospective cohort study, fifty women with idiopathic chronic pelvic pain were enrolled. Diagnostic laparoscopy was done in all women and fluid from pouch of Douglas and/or saline washings were sent for acid fast bacilli (AFB) smear, conventional and rapid culture and DNA polymerase chain reaction (PCR) analysis for diagnosis of genital TB. The results of these tests were analyzed and agreement with laparoscopy was assessed using Kappa statistics. Pain scores using visual analogue scale were compared before and after treatment. RESULTS: Pelvic pathology was present in 44 (88%) women of idiopathic chronic pelvic pain, with a 34% prevalence rate of genital tuberculosis. Pelvic inflammation was associated with positive peritoneal fluid PCR (n=4) and AFB culture (n=3). Acid fast bacilli PCR had substantial agreement (kappa statistics=0.716) with visual findings at laparoscopy. There was a significant reduction in pain scores after treatment. CONCLUSION: Genital tuberculosis contributes to one-third cases of chronic pelvic pain. Pelvic inflammation is an early feature of genital TB and peritoneal fluid PCR has the best co-relation with laparoscopic findings of genital tuberculosis.

Genital tuberculosis: Unusual presentations.

Genital tract tuberculosis is usually secondary to extragenital tuberculosis. The upper genital tract is usually involved; involvement of cervix and vulva is very uncommon. We present two such rare cases of vulval and cervical tuberculosis diagnosed on histopathology and treated with antitubercular chemotherapy.

Comparison of combined hormonal vaginal ring and low dose combined oral hormonal pill for the treatment of idiopathic chronic pelvic pain: a randomised trial.

OBJECTIVE: To compare the efficacy and acceptability of combined hormonal vaginal ring with combined oral hormonal pill in women with idiopathic chronic pelvic pain. STUDY DESIGN: Randomised prospective interventional trial conducted in 60 women with idiopathic chronic pelvic pain. Women were randomised into two groups of 30 each. In each group, treatment was given for 84 days using either combined vaginal ring or combined oral hormonal pill. Hormonal vaginal ring releases 15mcg of ethinyl estradiol and 120mcg of the etonogestrel per day while the hormonal pill contained 30mcg of ethinyl estradiol and 150mcg of levonorgestrel. There was no ring or pill free week. After every 28 days, pain relief was measured using visual analogue scale (VAS), and verbal rating score (VRS) calculated by summing dysmenorrhea, non-cyclic pelvic pain (NCCP) and deep dyspareunia scores. Side effects, compliance, satisfaction, and user acceptability were also measured. Data was analyzed using various parametric and non-parametric tests. RESULTS: Reduction in mean VAS score at end of treatment in ring group was 6.23 (95% confidence interval [CI], 5.45-7.01; p<0.001) as compared to 5.53 in pill group (95% CI, 4.83-6.23; p<0.001). Reduction in mean VRS score was 5.63 in ring users (95% CI, 4.84-6.42; p<0.001) versus 4.36 in pill users (95% CI, 3.63-5.10; p<0.001). A significantly higher persistent relief in NCPP score was observed in vaginal ring group as compared to oral pill group at end of one month after stopping treatment. Compliance, satisfaction, and user acceptability were higher in ring users (80%) than pill users (70%) and a higher incidence of nausea was seen in pill group. CONCLUSION: Present study demonstrates for first time that both vaginal and oral hormonal therapy are effective in treatment of idiopathic chronic pelvic pain and vaginal ring may be a better choice with higher satisfaction rate and fewer side effects.

Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding.

OBJECTIVE: To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB). METHODS: An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat. RESULTS: Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic. CONCLUSION: TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.

Indwelling Catheterization in Caesarean Section: Time To Retire It!

BACKGROUND: Routine placement of indwelling catheter preoperatively in Caesarean Section is being practiced without justified scientific evidence. AIM: To evaluate the effect of routine indwelling catheterization on the postoperative ambulation, morbidity and hospital stay in women undergoing Caesarean section. SETTINGS AND DESIGN: Case-Control study carried in a tertiary teaching hospital. MATERIALS AND METHODS: This study was carried over 150 women undergoing primary Caesarean section without any medical complication or pre-existing Urinary Tract Infections (UTI). The subjects were randomly allocated to 2 groups i.e. Group 1(Non-Catheterized; NC) and Group 2 (Catheterized for 24 hours postoperatively; C). Parameters noted were; duration of surgery, time of ambulation, postoperative voiding discomfort {graded as - no, mild, moderate-severe, by Visual Analog Scoring (VAS)}, incidence of UTI, postoperative urinary retention, need of postoperative antibiotics and duration of hospital stay. STATISTICAL ANALYSIS: Results were analysed using unpaired t-test. RESULTS: There was no significant difference in duration of surgery and postoperative urinary retention in both groups. However, it was seen that non-catheterized patients had significantly earlier ambulation, shorter hospital stay, took less time for first voiding, lesser voiding discomfort, less incidence of UTI and lesser use of postoperative antibiotics. CONCLUSION: The routine use of indwelling catheter in Caesarean section is unscientific and unnecessary. There should be selective rather than routine catheterization.

Awareness and practice patterns of family planning methods among antenatal women in Indian community: Are we hitting the bull's eye?

A questionnaire-based cross-sectional survey was undertaken to assess the awareness and practice patterns of family planning among the antenatal women in North India. The study included 400 respondents. Three-fourths of the respondents (74.2%, n = 297) were aware of family planning methods. Condoms were the most commonly used family planning method (78.2%), while intrauterine devices and oral contraceptive pills were used by 25.5% and 16.7% respondents, respectively. The main reasons cited for not using contraception were inadequate knowledge and fear of side-effects. Post counseling, 90.5% (n = 362) of the respondents clearly conveyed their desire to use one of the family planning methods in the postpartum period. Awareness and acceptance of family planning methods in the Indian community needs strengthening. Family planning counseling during antenatal check-up is likely to increase the acceptance of family planning methods in the postpartum period.

Comparison of antiresorptive effect of hormone therapy and ibandronate in postmenopausal osteoporotic women by assessing type I collagen C-telopeptide levels.

OBJECTIVES: The aim of this study is to compare the antiresorptive effect of hormone therapy and oral ibandronate in postmenopausal osteoporotic women by measuring bone mineral density (BMD) and degradation products of C-terminal telopeptide of type I collagen (CTX) using serum crosslaps ELISA. STUDY DESIGN: The study is a randomized comparative trial. METHODS: About 60 women with age > 40 years, having either surgical or medical menopause with T- or Z-score below -2.5 SD were included in the study. They were randomized into two groups of 30 each; one group received conventional hormone therapy (group I) and the other group received ibandronate monthly (group II). The treatment was given for 6 months. RESULTS: The BMD increased from 0.894 g/cm(2) to 0.933 g/cm(2) (p < 0.01) in group I and from 0.865 g/cm(2) to 0.934 g/cm(2) (p < 0.01) in group II. The increase in BMD in group I (4.3%) was less than group II (7.9%) which was significant (p < 0.01). The serum CTX levels also showed significant reduction in both groups after 6 months of therapy; more reduction was seen in group II as compared to group I (41.5% vs. 4.6%, p < 0.01). CONCLUSION: Ibandronate can be used as a substitute to hormone therapy in women presenting with osteoporosis. Long-term studies are needed to authenticate the observation.

Changing trends in use of laparoscopy: a clinical audit.

Aim. To find out the changing trends in indications for use of laparoscopy for diagnostic or operative procedures in gynaecology. Methods. This was a clinical audit of 417 women who underwent laparoscopic procedures over a period of 8 years from January 2005 to December 2012 in the Department of Obstetrics and Gynaecology at a tertiary care centre in Delhi. Results. A total of 417 diagnostic and operative laparoscopic procedures were performed during the period from January 2005 to December 2012. Out of 417 women, 13 women were excluded from the study due to inadequate data. 208 (51.4%) women had only diagnostic laparoscopy whereas 196 (48.6%) patients had operative laparoscopy after the initial diagnostic procedure. Change in trend of diagnostic versus operative procedures was observed from 2005 to 2012. There was increase in operative procedures from 10 (37.03%) women in 2005 as compared to 51 (73.91%) in 2012. The main indication for laparoscopy was infertility throughout the study period (61.38%), followed by chronic pelvic pain (CPP) (11.38%) and abnormal uterine bleeding (AUB) (9.4%). Conclusion. Over the years, there has been a rise in the rate of operative laparoscopy. Though the indications for laparoscopy have remained almost similar during the years, laparoscopy for diagnosis and treatment of CPP and AUB has now increased.

Role of BRCA1 and BRCA2 gene mutations in epithelial ovarian cancer in Indian population: a pilot study.

Ovarian cancer is a silent killer as most patients have non-specific symptoms and usually present in advanced stage of the disease. It occurs due to certain genetic alterations and mutations namely founder mutations, 187delAG and 5385insC in BRCA1 and 6174delT in BRCA2 which are associated with specific family histories. These highly penetrant susceptibility genes responsible for approximately half of families containing 2 or more ovarian cancer cases account for less than 40% of the familial excess malignancy risk. The remaining risk may be due to single nucleotide polymorphisms (SNPs) which are single base change in a DNA sequence with usual alternatives of two possible nucleotides at a given position. Preliminary study involving 30 women with histologically proven epithelial ovarian cancer was conducted and their detailed genetic analysis was carried out. Regions of founder mutations on BRCA1 and BRCA2 were amplified and sequenced using primers designed based on 200 bp upstream and downstream regions of the mutation sites. Five sequence variants in BRCA1 were identified of which three novel sequence variants were found in 23 patients while in BRCA2, one novel sequence variant was found. The three founder mutations 187delAG, 5385insC in BRCA1 and 6174delT in BRCA2 were not seen in any of the subjects.

Bilateral exudative retinal detachment in a patient with early onset severe preeclampsia.

This article describes a rare case of early onset severe preeclampsia presenting with loss of vision in both eyes due to retinal detachment. Retinal detachment has been mainly reported in late onset preeclampsia unlike in this case. Though, some authors believe that occurrence of maternal retinal detachment in cases of preeclampsia has no prognostic implication to the fetus, in this case, presence of retinal detachment was associated with foetal demise.

Proximal femoral focal deficiency revisited: a case report.

Proximal femoral focal deficiency (PFFD) is a rare anomaly with an estimated incidence of < 0.2/ 10,000 births. The aetiology of PFFD is unknown though various agents have been implicated including anoxia, ischaemia, mechanical or thermal injury. Herein is reported a case of a 22-year-old primigravida who delivered a baby with PFFD. This patient had developed high grade fever and had undergone ischiorectal abscess drainage at 7 weeks of gestation; maternal hyperthermia combined with anoxic injury might have been contributory factors in the causation of this disorder. So, it is of prudent importance to do prenatal targeted ultrasonography in patients who develop febrile illness in early pregnancy.

Awareness about Human Papilloma Virus and its Vaccine Among Medical Students.

BACKGROUND: Cancer of the uterine cervix is the most common malignancy amongst women in India. Identification of its pre-cancerous lesions and prevention by HPV vaccine may go a long way in decreasing the incidence. AIM: The aim was to study the awareness about the various aspects of the HPV infection and vaccine among medical students. SETTINGS AND DESIGN: It was a cross-sectional study conducted in a tertiary care hospital of Delhi. MATERIALS AND METHODS: 150 medical students aged between 18-25 years were requested to complete a 35 point questionnaire regarding cervical malignancy, HPV infection, HPV vaccine and the answers were then analyzed. RESULTS: None of the students knew the correct incidence of cervical cancer in India and 18% of them did not know that the HPV vaccination prevents cervical cancer and 50% thought that vaccination induces false sense of security. Fifty percent were unaware of HPV infection and its association with other STD's and cervical cancer. The information regarding the mechanism of action, dosage, schedule and cost of the HPV vaccine was lacking in majority of them. The limitation of this study is that it does not reflect the knowledge or awareness of a layman or full-fledged medical doctor. CONCLUSIONS: To conclude gaps in knowledge regarding HPV infection and vaccination existed amongst the medical students and a more integrated teaching regarding HPV carcinogenesis, vaccination and cervical cancer needs to be introduced.

Pregnancy with metastatic gastrointestinal stromal tumor (GIST) on imatinib chemotherapy: an oncologist's nightmare and obstetrician's dilemma.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are among the few cancers amenable to successful treatment by targeted molecular therapy with KIT receptor inhibitors like imatinib mesylate. Increasing incidence of this tumor and its successful treatment has given rise to issues of fertility and child bearing in patients affected at young age. Although contraception advice and termination of early pregnancy have been the standard practice in patients on such therapy, an occasional patient who desires pregnancy can leave both obstetrician and oncologist perplexed. CLINICAL PRESENTATION: We report our experience in a rare patient of metastatic GIST who had a successful normal pregnancy while on imatinib therapy. We further attempt to evaluate similar evidence in literature.

Postpartum peripheral symmetrical gangrene: a case report.

BACKGROUND: Symmetrical peripheral gangrene is usually associated with underlying medical problems and it is seldom seen in pregnancy. Sepsis though common in a setting of delivery by unskilled midwife is rarely accompanied by symmetrical gangrene. CASE PRESENTATION: We report a case of symmetrical peripheral gangrene which occurred in the winter, triggered possibly by sepsis and a single dose of ergot. A high index of suspicion, early diagnosis and intervention with appropriate measures will result in favorable outcome in such cases. CONCLUSION: Although postpartum period is of high risk for sepsis and use of ergot alkaloids is common in labor but occurrence of peripheral symmetrical gangrene is rare. A high index of suspicion for the diagnosis and timely intervention will prevent irreparable damage and loss of limb.

Sex cord stromal tumors-unusual presentations.

OBJECTIVES: The sex cord stromal tumors (SCST) account for approximately 7% of all malignant ovarian tumors. They are endocrinologically active tumors of which granulosa cell tumors are the commonest. We describe an analysis of all cases of SCST managed, in our department over the last five years and discuss two cases of unusual presentation of these tumors. METHODS: Ten cases of SCST which were managed in the Department of Gynecology and Obstetrics at University College of Medical Sciences (UCMS) & associated Guru Teg Bahadur hospital, Delhi from Jan. 01 to Dec. 05 were analyzed. RESULTS: Of the total 312 ovarian tumors which were operated in these 5 years, 73 (23.3%) were malignant, 10 cases (13.6%) out of the malignant ovarian tumors were SCST. The age of presentation varied from 4 to 70 years. Four women presented with lump abdomen as their chief complaint, 2 had postmenopausal bleeding, 2 presented with irregular bleeding per-vaginum, 1 woman had secondary amenorrhea and one young girl who was only 4½ years old developed precocious puberty. The majority of cases (70%) were granulosa cell tumors, 10% were fibromas and 20% thecomas. Maximum patients 9 (90%) were stage I at the time of surgery and only 1 case was stage IV with tumor infiltrating into omentum and gut. CONCLUSION: SCST tumors are rare endocrine active tumors that are essentially unilateral, benign or with a low malignant potential. Though most patients present with one or a combination of symptoms ranging from abnormal vaginal bleeding, abdominal distention and abdominal pain, the signs of Paraneoplastic syndrome (PNS) may be the first indication of the presence of an ovarian malignancy and can even facilitate its diagnosis.

Comparison of cardiac autonomic functions among postmenopausal women with and without hormone replacement therapy, and premenopausal women.

The aim of present study was comparison of cardiac autonomic status during different phases of reproductive life in women - in premenopausal women between proliferative and secretory phase, in postmenopausal women and in postmenopausal women receiving hormone replacement therapy (HRT). The study included 30 premenopausal women (Group 1) who were assessed in both proliferative (Group 1A) and secretory phase (Group 1B) of menstrual cycle, 30 postmenopausal women (Group 2) and 30 postmenopausal women on HRT (Group 3). Various autonomic function tests were done to assess parasympathetic and sympathetic functions. Results were obtained by ANOVA followed by Tukey test. The postmenopausal women (Group 2) showed increased sympathetic and decreased parasympathetic tone compared to premenopausal women (Group1). The women on HRT (Group 3) showed parasympathetic dominance and decrease in sympathetic activity compared to postmenopausal women (Group 2). Across the menstrual cycle, increased parasympathetic activity was seen in secretory phase while no change was observed in the sympathetic activity in the two phases.