Prenatal Ultrasound Diagnosis of Vasa Previa With Careful Intraoperative Management: A Case Report.

Vasa previa is a rare but potentially life-threatening condition to the fetus. Timely antenatal diagnosis and delivery by cesarean section (CS) can lead to a favorable outcome. Here, we report a case of recurrent pregnancy loss (G3A2) with vasa previa, which was diagnosed prenatally by ultrasound. She was admitted at her 31st week with bleeding per vaginum (PV) provisionally diagnosed as antepartum hemorrhage (APH) and managed conservatively as placenta previa. Follow-up ultrasonography (USG) revealed vasa previa at 33 weeks. The fetus was delivered by lower segment cesarean section (LSCS) after careful separation of the membranes and avoiding damage to the vessels as there was velamentous insertion of cord with the lower margin of the placenta in the lower segment. The baby was cared for in the neonatal intensive care unit due to prematurity and discharged after six days. This case report highlights the importance of prenatal ultrasound in diagnosing vasa previa and planning an elective cesarean section with caution intraoperatively for the safe delivery of the baby.

Evaluating the Frequency and Characteristics of Unexpected Ovarian Malignancy in Postmenopausal Women Who Have Undergone Laparoscopic Surgery for Adnexal Masses - A Review of Five Years.

Aim The aim of this study was to estimate the frequent existence of unexpected ovarian malignant lesions after laparoscopic surgery for an apparent benign adnexal mass and assess its clinical and ultrasound characteristics in postmenopausal women. Methods We re-examined the hospital records of 96 cases of postmenopausal women who underwent laparoscopic surgery for benign adnexal mass over five years. The age of the patient, parity, ultrasound findings, tumor markers level, intraoperative findings, and histopathological report were collected. Pearson's Chi-squared test and Fisher's exact test were used for statistical analysis, and a p-value of <0.05 was accepted as statistically significant. Results Of a total of 96, benign adnexal mass was in 93 (96.83%), an unexpected ovarian malignancy was observed in two (2.08%) cases, and one (1.04%) had a borderline ovarian tumor. Tumor marker CA-125 was done for all those cases of adnexal mass in postmenopausal women, and not a single case was found to have above 35 IU/ml, defined as the cut-off value for CA-125. Statistically significant differences were observed between the benign and malignant groups in relation to symptoms (p<0.05), ultrasound score (p=0.001), and bilaterality (p=0.013) of the tumor mass. Conclusion In postmenopausal women, the critical concern for laparoscopic surgery of benign adnexal mass is unexpected malignancy. So it is essential to select patients carefully for laparoscopic surgery. If a benign-looking adnexal mass turned out to be malignant on the histopathological report, we should try to post the patient for subsequent staging laparotomy as soon as possible.

External validation of prediction models for vaginal delivery after the trial of labour among women with previous one caesarean section - A cohort study.

OBJECTIVE: To externally validate three predictive models (the Grobman model (2007), the Zhang model (2020), and the Grobman model (2021)) for identifying women with increased chances of a successful trial of labour after caesarean section (TOLAC). METHODS: This retrospective observational cohort study was conducted in a tertiary teaching hospital from 2018 to 2021. Individual probabilities were calculated for women with previous one caesarean section who underwent TOLAC at term, using the predicted probabilities from the logistic regression models. The primary outcome of this study was vaginal delivery following attempted TOLAC. The predictive ability of the models was assessed using the area under the receiver operative characteristics curves (AUC) and a calibration graph. RESULTS: Of 1515 eligible women who underwent TOLAC, we found an overall rate of successful TOLAC of 60.3 %. No significant difference was noticed in adverse scar outcome and neonatal morbidity while comparing successful and failed TOLAC. The discriminative ability of Grobman-2007 and Grobman-2021 and the Zhang model were fair to poor with the AUC of 0.54(95 % CI 0.51-0.57), 0.62(95 % CI 0.59-0.65) and 0.66(95 % CI 0.63-0.69) respectively. The agreement between the observed rates of TOLAC success and the predicted probabilities for all three models was poor. CONCLUSION: The performance of all three models predicting success after TOLAC was poor in the study population. A population-specific model may be needed, with the addition of factors influencing the labour, such as the methods of induction, which may aid in predicting the outcome.

A Successful Obstetric Outcome in a Woman With Familial Hypokalemic Periodic Paralysis: Challenges in Management.

Hypokalemic periodic paralysis during pregnancy is a rare disease condition that presents during pregnancy. It manifests with acute muscular weakness associated with low potassium levels. We report a case of an antenatal woman presenting with leaking per vagina and weakness of four limbs at 33 weeks of gestation. She had similar episodes in the past but defaulted on taking oral potassium. On physical examination, she had hyporeflexia and flaccid paralysis of all limbs without sensory involvement. A neurology consultation was sought and diagnosed to have flaccid quadriparesis. Her investigations showed low serum potassium along with electrocardiography (ECG) changes. With potassium correction, her weakness improved within four days of initiating treatment. A week later, she had a spontaneous labour onset and delivered a healthy male baby. The peripartum period was uneventful. A timely diagnosis and management, avoiding precipitating factors, and preventing future attacks should be the primary goal of management.

Endometrial carcinoma in asymptomatic post-menopausal women with a thickened endometrium and its influencing factors - A cross-sectional study.

Background: A thickened endometrium upon trans-vaginal ultrasound in asymptomatic post-menopausal women always poses a clinical dilemma. Objectives: To investigate the frequency of endometrial malignancies by histopathological examination and identify the associated factors influencing the thickened endometrium in asymptomatic post-menopausal women. Methods: In trans-vaginal ultrasonography, we enrolled 72 asymptomatic post-menopausal women with a thickened endometrium (>5 mm). Dilatation and curettage were performed for all cases, and the specimen was sent for histopathological examination. According to the data distribution, all the continuous variables were stated as mean ± standard deviation/median (inter-quartile range), categorical variables were expressed in frequency, and percentage will be compared using the Chi-square test/Fisher exact test. Results: In our study, most of the women were multipara. The age of post-menopausal women ranged from 46 to 68 years, and the mean duration of menopause was 8.10. The most common histological findings were benign in 72.22% of the cases. We identified pre-malignant and malignant lesions of the endometrium in 18.05% and 9.72% of the cases, respectively. To predict the condition of the lesion, we noticed no definite cut-off value of endometrial thickness to indicate the state of the lesion. We observed that none of the patient's characteristics showed a significant difference with a thickened endometrium. Conclusion: We observed an increased frequency of endometrial pathology irrespective of the presence or absence of risk factors. The result of this study is justified enough for the need of further evaluation of a thickened endometrium in asymptomatic post-menopausal women.

Placenta accreta spectrum-a catastrophic situation in obstetrics.

Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review.

Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings.

The delivery of high-quality antenatal care is a perennial global concern for improving maternal and neonatal outcomes. Antenatal care is currently provided mainly on a one-to-one basis, but growing evidence has emerged to support the effectiveness of group antenatal care. Providing care in a small group gives expectant mothers the opportunity to have discussions with their peers about certain issues and concerns that are unique to them and to form a support system that will improve the quality and utilization of antenatal care services. The aim of this article is to promote group antenatal care as a means to increase utilization of healthcare.

Diagnostic and management challenges of intraventricular neurocysticercosis presenting in the third trimester of pregnancy: A case report.

The diagnosis of neurocysticercosis in pregnancy is challenging, even in endemic areas, as other neurological conditions with similar manifestations are common. Obstetricians and physicians may be reluctant to do neuroimaging in pregnancy and often the availability is limited in endemic areas. Management of neurocysticercosis depends on the symptomatology. In those presenting with features of increased intracranial pressure early treatment is necessary, taking into consideration the gestational age and the maternal condition at presentation. Presence of intraventricular cysts causing obstructive hydrocephalus necessitates their removal due to the risk of intracranial hypertension which could be life-threatening, particularly peripartum. We report a case of a woman with intraventricular neurocysticercosis, who presented in the third trimester, and described the management dilemmas that were encountered. The differential diagnoses and other aspects of the medical and surgical management of neurocysticercosis in pregnancy are also discussed.

Cervical polyp: evaluating the need of routine surgical intervention and its correlation with cervical smear cytology and endometrial pathology: a retrospective study.

OBJECTIVE: To determine the frequency of premalignant and malignant lesions in cervical polyps in order to examine whether cervical polyps need to be removed routinely and also to appraise its association with cervical smear cytology and endometrial pathologies. METHODS: We retrospectively re-examined the hospital records of 299 cases over a period of 5 years. All patients were segregated into perimenopausal and postmenopausal groups according to their menopausal status. The groups were compared in terms of histological results of cervical polyp biopsy, endometrial pathologies, and cervical smear cytology. Pearson's χ2 test and Fisher's exact test were used for statistical analysis, and a P-value of <0.05 was accepted as statistically significant. RESULTS: In the histopathological reports of cervical polyps, premalignant lesions were found in 2% of cases, and only 0.3% of malignant lesion was observed in menopausal women. Subsequently, no malignancy was noted in cervical smear cytology for both groups. Premalignant and malignant lesions in endometrial histopathology findings were 1.33% and 0.66%, respectively. There was a statistically significant association between the menopausal status of the patient and cervical smear cytology and endometrial pathology, but the histological findings were not statistically significant in relation to the symptomatic status of the patients. CONCLUSION: As per the results, we strongly suggest the removal of all cervical polyps with subsequent histological review. The evaluation of cervical smear cytology prior to polypectomy can provide information about its malignancy potential. We believe that along with cervical polypectomy, endometrial sampling should be recommended, especially for postmenopausal women.

Gynecological problems among adolescent girls in a tertiary care centre of South Andaman district.

Background Gynecological problems of adolescents occupy a special space in the spectrum of gynecological disorders because they are often different from the conditions that affect adult women. The objective of study was to determine the different gynecological problems in adolescent girls attending outpatient departments. Methods Adolescent girls of age 10-19 years were included in this study. Various gynecological problems were evaluated by detailed history taking and thorough clinical examination. Investigations like haemogram, coagulation profile, hormonal assays and ultrasonography were done wherever indicated. Descriptive analysis was done and results are expressed in terms of percentage. Results A total of 824 (8.33%) adolescent girls attended the gynecology outdoor patient department (GOPD) during the study period. Menstrual disorders (67.11%) were the commonest complaint, followed by vaginal discharge (18.68%) and UTI (9.8%). Menstrual disorders varied from irregular menstruation (55.15%), dysmenorrhea (30.74%) and amenorrhea (14.10%). Dysfunctional uterine bleeding was the commonest cause of menstrual irregularity followed by polycystic ovarian disease (PCOD). Teenage pregnancy (0.84%) and ovarian tumor (0.60%) was found in a few cases. Conclusion Adolescent girls' gynecological problems should be evaluated thoroughly and managed accordingly. Adolescent health education needs to increase awareness and give further attention to gynecological problems.

Case report on necrotizing fasciitis following episiotomy

Necrotising fasciitis (NF) is an extremely rare but near fatal bacterial soft tissue infection, complicating the operative wounds. Here is a case report of Necrotising fasciitis in episiotomy wound in low socioeconomic, poorly nourished and anaemic women. A 39 years old, second gravida, delivered normally with medio-lateral episiotomy under local anaesthesia. On postnatal day four, patient developed high grade fever and on examination episiotomy was found to be unhealthy and gaped. She was started on broad spectrum antibiotics empirically but the cellulitis rapidly progressed to vulva, then to the bilateral thighs and extended till knees. Bilateral lower limb Doppler ultrasonography was done to rule out deep vein thrombosis which showed no abnormality. USG abdomen revealed huge pus collection in the lower abdomen. Under anaesthesia, surgical exploration was done, pus was drained followed by wound debridement and pus sent for culture and sensitivity. Pus and blood culture showed growth of Klebsiella pneumoniae, so started on appropriate antibiotics. Patient started recovering, when the wound was healthy, secondary suturing of episiotomy wound done. She was discharged on post-natal day 27 after full recovery. Early diagnosis and aggressive timely management are the corner stone to avoid morbidity and mortality of NF.

Cholestasis of pregnancy: a prospective analysis from a South Andaman teaching hospital

Background: Intrahepatic cholestasis of pregnancy (IHCP) is one of the commonest pregnancy related liver disorder. Although the maternal course is usually benign, there is an increased risk of spontaneous preterm delivery, fetal compromise, meconium stained amniotic fluid and even intrauterine fetal demise. The objective of this study was to study the incidence of IHCP and its impact on maternal and perinatal outcome.Methods: A prospective study carried out in 68 number of IHCP cases. Diagnosis was done on the basis of clinical and laboratory parameters. All the cases were followed up to the puerperium to find out maternal and perinatal outcome.Results: The incidence of cholestasis of pregnancy was 2.73%. Most (88%) of the cases were presented with generalized pruritus, relived with ursodeoxycholic acid and complete recovery was observed after delivery. The rate of instrumental delivery was 8.82% and caesarean section rate was 30.88%. Most common indication of caesarean section was fetal distress and non-progress of labour. There was one stillbirth at 35 weeks however none of the mother had complication during labour or puerperal period.Conclusions: Increased level of liver enzymes in patients of IHCP associated with poor perinatal outcome. Therefore, careful monitoring during antenatal period and termination of pregnancy at term will result in favourable outcome of both mother and baby.

Evaluation of cervical smear in high risk women.

Background: Objectives of current study were (i) To find out the pattern of cervical smear in females having risk factors. (ii) To observe the relationship between abnormal cervical smear with high risk factors. Methods: A cross-sectional descriptive study was carried out in the department of obstetrics and gynecology, Guwahati medical college & hospital from July 2009 to August 2010 with the help of Pathology department. 200 women attending gynecological OPD with associated risk factors were selected at random. Detailed history, demographic information, contraceptive history and coital history were taken. Smear was taken from endocervix with the help of Ayer’s spatula or cytobrush. Results: Out of 200 cases, in 110 (55%) the smear was reported negative for malignancy. 73(36.5%) had an inflammatory smear, 11 (5.5%) had CIN, 1(0.5%) had malignancy and 5(2.5%) the smear was inadequate for cytological examination. In the study mean age of Cervical Intraepithelial Neoplasia (CIN) was 42.64 ± 6.34 years. Low socio-economic status, high parity & the use of oral contraceptive pills were major risk factors. Conclusion: Cervical smear should be routinely used as a reliable diagnostic aid for early detection carcinoma cervix especially in high risk cases. The need of the hour is to create awareness and easy accessibility to proper screening.