A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania.

BACKGROUND: Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania. METHODS: An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results. RESULTS: Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines. CONCLUSION: This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

COVID-19 and gynecological cancers: Asia and Oceania Federation of Obstetrics and Gynecology oncology committee opinion.

Since the outbreak of COVID-19, there have already been over 26 million people being infected and it is expected that the pandemic will not end in near future. Not only the daily activities and lifestyles of individuals have been affected, the medical practice has also been modified to cope with this emergency catastrophe. In particular, the cancer services have faced an unprecedented challenge. While the services may have been cut by the national authorities or hospitals due to shortage of manpower and resources, the medical need of cancer patients has increased. Cancer patients who are receiving active treatment may develop various kinds of complications especially immunosuppression from chemotherapy, and they and their carers will need additional protection against COVID-19. Besides, there is also evidence that cancer patients are more prone to deteriorate from COVID-19 if they contract the viral infection. Therefore, it is crucial to establish guidelines so that healthcare providers can triage their resources to take care of the most needed patients, reduce less important hospitalization and visit, and to avoid potential complications from treatment. The Asia and Oceania Federation of Obstetrics and Gynecology (AOFOG) hereby issued this opinion statement on the management of gynecological cancer patients during the COVID-19.

A 5-year comparative study of efficacy and acceptability of three different sizes of TCu380Ag and TCu380A intrauterine devices.

BACKGROUND: The intrauterine contraceptive device TCu380Ag when compared with TCu380A at 1 year of use had better acceptability and continuation rates. OBJECTIVES: To study the continuation rate, efficacy, and acceptability of TCu380Ag in three sizes versus TCu380A at 5 years of use. METHODS: A total of 600 women opting for intrauterine contraceptive devices were randomized equally into two groups. Group 1 received the TCu380Ag device (Normal, Maxi, and Mini for uterocervical length 7-8.5 cm, 8-9 cm, and 6-7.5 cm, respectively) and Group 2 received the TCu380A device. Follow-up was performed at 5 years to assess efficacy, acceptability, and continuation. Frequency data comparisons was performed across categories using χ2 /Fisher exact test. RESULTS: At 5 years of use, Kaplan-Meier survival analysis showed that TCu380Ag compared with TCu380A had a higher continuation rate (45% vs. 35%, P = 0.010) with 100% efficacy each. TCu380Ag had fewer side effects, including heavy menstrual bleeding (16.6% vs. 34.1%, P < 0.001), abdomen pain (12.1% vs. 23.0%, P = 0.001), and expulsions (4.4% vs. 8.7%, P < 0.050), and fewer discontinuations attributable to contraceptive side effects (42.7% vs. 56.9%, P = 0.012). The mini TCu380Ag had the highest continuation rates and least menstrual irregularity (P < 0.050). CONCLUSIONS: The TCu380Ag device in three sizes is an alternative to TCu380A for women desiring 5 years of contraception with equal efficacy, better continuation, and acceptability. The mini size is preferred for women with a uterocervical length of 6 to 7.5 cm.

Maggots in prolapsed uterus - Polluted progress of life style.

Myiasis is infestation by dipterous larva that thrives on host's living or necrotic tissue and cause massive tissue infection. We present a case of Myiasis in uterine cavity of a prolapsed uterus of a 77-year-old multiparous lady of West Midnapore District, West Bengal, India. It is a very rare case as only a few reports have been previously published in literature. She had presented with genital pruritus and vague perennial discomfort for last 1 month along with bleeding and foul smelling discharge from vagina for last 2 days. Pelvic examination revealed 'Stage-IV' genitourinary prolapse according to POP-Q classification, with a big excavatory ulcer indwelled with maggots of Musca domestica. About 80 to 90 such maggots were subsequently manually removed with a forceps under anaesthesia. She was advised to undergo definitive surgical treatment for prolapsed uterus. Owing to very low socioeconomic condition or for the fear of the operation, the patient ultimately never turned up.

Uncommon Ectopic Pregnancies-Challenges in the Management.

Background: The risk factors for ectopic pregnancy are on the rise. Despite the progress (availability of serum ßhCG, USG and MRI), there are diagnostic and therapeutic challenges in the management. Up to 50% of ectopic pregnancies go undetected. Furthermore, cases seen as emergency with hemodynamic instability need urgent intervention with simultaneous arrangement of transport, blood transfusion and at times multidisciplinary team involvement. This is more challenging in a setting where resources are limited. Objective: To evaluate the outcome of women presenting with uncommon ectopic pregnancies as life-threatening emergency. Challenges encountered in diagnosis, pre-operative evaluation, decision for surgery and the procedure are presented. Patients and Methods: This is a series of twelve cases of uncommon ectopic pregnancies belonging to eight different types. These were managed under the first author during the period 2001 to 2019. Subjects were analyzed retrospectively. Results: Diagnostic dilemma was faced in majority of the cases even with the use of ultrasonography. All the conceptions were spontaneous. Emergency surgical interventions were made on the basis of clinical evaluation. Five cases presented with massive hemoperitoneum. Blood transfusion was needed in nine cases. There was no mortality. One woman (case 4), with abdominal pregnancy, went home with a live baby, after the second laparotomy. Conclusion: Uncommon ectopic pregnancies are life-threatening conditions. Clinical acumen and an alert mind are of superior value in diagnosis. Investigations are supportive. Early diagnosis and intervention are lifesaving.

Knowledge and health care-seeking behavior in relation to gynecological malignancies in India: a study of the patients with gynecological malignancies in a tertiary care hospital of Kolkata.

This cross-sectional observational study was undertaken to find out the knowledge about gynecological malignancies and health care-seeking behavior of patients with gynecological malignancies. In a gynecology out-patient clinic in Kolkata, India, the patients with the suggestive symptoms of gynecological malignancies were screened out. Their diagnoses were confirmed by histopathology. One hundred thirteen patients with histopathologically confirmed gynecological malignancies were interviewed. Eleven patients (9.7%) knew that white discharge or bleeding per vagina was the early symptom and 38 (33.6%) patients knew that gynecological malignancies were treatable. Fifty-six patients (49.5%) had discussed about their symptoms first with their husbands. Most of the patients (91 patients or 80.5%) had visited a private health facility first for their symptoms. Educational level of the patients was found to be inversely associated with the time of presentation at this hospital. This study highlights the need to increase the awareness about gynecological malignancies among women and the community.

Mullerian Malformations and Reconstructive Surgery: Clinicians' Approach.

Mullerian malformations are not uncommon. Overall incidence ranges widely between 1 in 200 women and 4 in 100 women (Chan et al. in Hum Reprod Update 17:761-771, 2011; Grimbizis et al. in Hum Reprod 28:2032-2044, 2013). Other way, these observations suggest presently an increased number of Mullerian abnormalities are diagnosed with more details, following the use of newer diagnostic modalities. Most classifications that are available have limitations. Diagnosis was based on imaging studies that had low diagnostic accuracy. It was focused mainly on the anomalies of the uterus. Less is known about the anomalies of the cervix or the vagina in isolation or in combination with the utero-cervical and vaginal malformations. Improved diagnostic modalities and incorporation of assisted reproductive technology have improved the outcome further. Therefore, a more expanded classification needs to be introduced with wider criteria for the clinicians. This will make clinicians' approach for the management more simple.

Utilization of therapeutic intervention to prevent mother to child transmission of HIV in a teaching hospital in Kolkata, India.

AIM: To assess the uptake of an HIV screening program and therapeutic intervention to minimize the risk of mother to child transmission. METHODS: This was a cross-sectional, observational study with retrospective data obtained from patient medical records. Pregnant women presenting to a tertiary care center in Kolkata, India, from 1 January 2004 - 31 December 2007 underwent HIV serology by rapid test after receiving group counseling. Care was administered using a standard national protocol by a multi-disciplinary team of health-care personnel. Main outcome measures were: acceptance of pretest counseling and HIV testing by pregnant women attending antenatal clinic services, post-test counseling rate, coverage rate of nevirapine to mother-child pairs, and averted HIV infection in children. RESULTS: Of the 52 127 new antenatal booking visits, 49 580 (95.11%) women attended pretest counseling and 47 506 (91.13%) women accepted HIV testing. Eighty-six women were found to be seropositive. The seroprevalence rate of HIV infection was 0.17%. Thirty-seven mothers (88%) and all newborn infants (100%) had received nevirapine prophylaxis. Overall nevirapine coverage rate was 48%. Twenty-four of the mother-infant pairs that we assessed had infants who were aged over 18 months by June 2008. Eleven (45.83%) of these women turned up with their babies for a blood test at 18 months. Three (27.27%) babies tested reactive. CONCLUSION: As uptake of testing is high and detection of HIV-infected women in pregnancy remains very low, a radical rethinking of policies on therapeutic intervention and their implementation now needs to be undertaken.

A 1-year comparison of TCu380Ag versus TCu380A intrauterine contraceptive devices in India.

OBJECTIVE: To compare TCu380Ag and TCu380A intrauterine contraceptive devices after 1 year of use. METHODS: A prospective randomized controlled trial was conducted among healthy married women aged 20-35 years who attended the family planning clinics of three tertiary centers in India between August 1, 2015, to March 31, 2018. The TCu380Ag group (n=300) received one of three sizes of this device depending on uterocervical length: maxi (8.0-9.0 cm), normal (7.0-8.5 cm), or mini (6.0-7.5 cm). The remaining 300 participants received TCu380A. Follow-up was conducted at 3-monthly intervals to assess continuation rate, acceptability, efficacy, adverse effects, and complications. RESULTS: The TCu380Ag group had a higher continuation rate than the TCu380A group at 1 year (84.0% vs 75.8%; P=0.01), with an efficacy of 99.6% versus 100.0% (P>0.05). Overall estimated continuation rates were 94.5% (95% confidence interval [CI] 91.7%-96.4%) and 88.4% (95% CI 83.2%-91.5%), respectively (P=0.026). Use of TCu380Ag was associated with fewer adverse effects (heavy menstrual bleeding, abdominal pain, or expulsion) when compared with TCu380A (P>0.05 for all comparisons). Discontinuation rates owing to adverse effects were 6.59% for TCu380Ag versus 13.26% for TCu380A (P=0.01). CONCLUSIONS: Varying sizes of TCu380Ag could provide an alternative to TCu380A.

Association of Thyroid Dysfunction and Autoimmunity in Pregnant Women with Diabetes Mellitus.

PURPOSE: This study was undertaken to find out the proportion of women with thyroid dysfunction in pregnancy complicated by diabetes mellitus; to find out the association, if any, of thyroid dysfunction and of antithyroid peroxidase (anti-TPO) antibodies during pregnancy in women with pregestational (PGDM) and gestational diabetes mellitus (GDM); and to find out the maternal and perinatal outcomes of pregnancies complicated by both diabetes mellitus and thyroid dysfunction. METHODS: A cross-sectional observational study was conducted in a tertiary care teaching hospital in Kolkata, India, for a period of 1 year. Sixty-four pregnant women with diabetes, both PGDM and GDM, were recruited from the antenatal clinic. They were managed and followed up till 6 weeks postpartum. Their plasma glucose levels were estimated, and thyroid function was evaluated periodically. All relevant data were recorded and analyzed statistically. RESULTS: Most (81.25%) women had GDM. Forty percent women suffered from some form of thyroid disorder, mostly (37.5%) hypothyroidism. Thyroid dysfunction was not associated with the type of diabetes mellitus (GDM or PGDM) (p > 0.05). The higher rate of anti-TPO titers was observed in pregnancies with PGDM compared to pregnancies with GDM; however, this difference was not statistically associated (p > 0.05). All pregnant women with combined endocrinopathy delivered by cesarean section, and the most common neonatal complication observed was jaundice. CONCLUSIONS: Thyroid disorders are quite common during pregnancy complicated by diabetes mellitus. The study findings warrant routine screening for thyroid abnormalities in diabetic pregnant women. These women have increased rate of maternal and neonatal complications.

Perinatal Outcome of the Second Twin at a Tertiary Care Center in India.

PURPOSE: This cross-sectional observational study was undertaken to assess perinatal outcome of the second twin in respect to gestational age, presentation, mode of delivery, and birth weight. METHODS: Seventy women with confirmed twin pregnancy were admitted and managed in a tertiary care teaching hospital in Kolkata, India from May 2008 to April 2009. All relevant data were recorded and analyzed statistically by simple proportions and χ2 test. RESULTS: Women with frequent antenatal visits had highly favorable perinatal outcome than those with fewer or no visits in this hospital (p < 0.001). Higher perinatal mortality was observed among preterm than term (p < 0.01) cases, and among low birth weight than normal babies (p < 0.05). Second twins in vertex-vertex presentation encountered higher perinatal mortality compared to those in vertex-nonvertex and nonvertex-other presentations (p < 0.05). Perinatal outcome was unfavorable when both delivered vaginally than for both cesarean deliveries and cesarean after first vaginal delivery (p < 0.01). Preterm labor was the most frequently observed maternal complication. Birth asphyxia and perinatal mortality were common among second than first twins. CONCLUSIONS: Gestational age, presentation, mode of delivery, and birth weight are the significant determinants of perinatal outcome of the second twin. Women with frequent antenatal care show favorable outcome. The second twin is at higher risk of perinatal morbidity and mortality than the first twin.

Maternal Mortality: A FOGSI Study (Based on Institutional Data).

OBJECTIVE: The aim of this study of maternal deaths through FOGSI members is to see its current STATUS. METHOD: A three-year retrospective observational study from January 2005 to December 2007 formed the basis for collection of the data for analysis. RESULTS: A wide variation of maternal mortality ratio (MMR) in the five zones (West-342; South-229; East-709; North East-709 and North-814) was observed. Leading causes of maternal deaths also varied among the zones [hemorrhage in West (31 %), South (26 %), and North East (21.5 %); hypertension in East (34 %) and North (22 %)]. When the data were analyzed as a whole, the leading causes of deaths were determined as hypertension (29.4 %), hemorrhage (21.56 %), sepsis (15.05 %), and medical disorders (12 %). Analysis of data in India (including Kerala State) for the year 2005 revealed significant drop in MMR to 147. CONCLUSION: MMR in India varied widely in zones. There is significant difference in MMR for the whole country as well as for the south zone with or without inclusion of Kerala. Areas of discrepancy in data had been observed in different sources. Prioritization of causes of death and appropriate allocation of resources are needed. A prospective study for evaluation of exact MMR in India is an immediate necessity.

Clinico-pathological features of gynecological malignancies in a tertiary care hospital in eastern India: importance of strengthening primary health care in prevention and early detection.

BACKGROUND: This cross-sectional observational study was undertaken to establish clinico-pathological characteristics of patients with gynecological malignancies, focusing mainly on symptoms, histological type and stage of the disease at presentation, in a tertiary care setting in Eastern India. MATERIALS AND METHODS: In the gynecology out-patient clinic of a tertiary care hospital in Kolkata, India, the patients with suggestive symptoms of gynecological malignancies were screened. Their diagnoses were confirmed by histopathology. One hundred thirteen patients with histopathologically confirmed gynecological malignancies were interviewed. RESULTS: The most frequently reported symptoms by the patients with histopathologically confirmed gynecological malignancies were excessive, offensive with or without blood stained vaginal discharge (69.0%), irregular, heavy or prolonged vaginal bleeding (36.3%) and postmenopausal bleeding (31.9%). The majority of the patients (61.0%) had squamous cell carcinoma on histopathological examination, followed by adenocarcinoma (30.1%). Nearly half of the patients (48.7%) were suffering from the Federation Internationale des Gynaecologistes et Obstetristes (FIGO) stage III, followed by stage II (40.7%) malignancy. CONCLUSIONS: This study highlights that most of the patients with gynecological malignancies present late at an appropriate health care facility. Ovarian cancer may often have non-specific or misleading symptomatic presentation, whereas cervical cancer often presents with some specific symptoms. These observations point to the need for increasing awareness about gynecological malignancies in the community and providing easily accessible adequate facilities for early detection and treatment of the disease by optimal use of available resources, i.e. strengthening the primary health care system.

Pregnancy complicated by maternal heart disease: a review of 281 women.

OBJECTIVES: To study maternal heart disease in an Indian setting for: (1) different etiological factors, (2) different types of lesions, and (3) maternal and perinatal outcome. METHODS: 281 women with heart disease who delivered ≥28 weeks of gestation at different teaching institutions (tertiary care centres) in India were studied. RESULTS: Rheumatic heart disease (n = 195; 69.4 %) with isolated mitral stenosis (n = 75; 26.7 %) were the commonest. Septal defect (n = 27; 9.6 %) was the predominant lesion among the congenital heart disease (n = 60; 21.3 %) patients, whereas in the miscellaneous group (n = 26; 9.2 %), ischemic heart disease (n = 10; 3.6 %) was the leading cause. Multiple cardiac lesions were also diagnosed in 100 (35.58 %) women. In 87 (31 %) women, diagnosis was made first time in labor. Majority n = 131, (46.6 %) had spontaneous vaginal delivery and few (n = 9; 3.3 %) required induction of labor. Cardiac complications were noted in 72 women (25.6 %). There were three (1.06 %) maternal deaths and perinatal mortality was 4 % (n = 11). CONCLUSION: In this study, rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. In rheumatic heart disease, mitral valve involvement was the commonest and multiple valve lesions were a major observation. Most common obstetric complication was small for gestation baby. Maternal morbidities in the unbooked women are high and congestive cardiac failure was the major cardiac complication.

Gynecological malignancies: epidemiological characteristics of the patients in a tertiary care hospital in India.

BACKGROUND: This cross-sectional observational study was undertaken to identify the epidemiological characteristics of patients with gynecological malignancies in India, in relation to gynecological cancer risk. METHODS: In the gynecology out-patient clinic of a tertiary care hospital in Kolkata, India, the patients with suggestive symptoms of gynecological malignancies were screened. One hundred thirteen patients with histopathologically confirmed gynecological malignancies were interviewed. RESULTS: More than two-thirds of the cases (69.0%) occurred in the age range of 35-64 years and the same proportion of patients was from rural areas. Almost all the patients were "ever-married" (96.5%). More than half (54.9%) were illiterate/just literate. Nearly two-thirds (64.6%) were parity 3 or higher. Among the 18 patients with history of multiple sexual partners of the husband, 94.4% (17) were suffering from cervical malignancy, along with all the 3 patients with history of STD syndromes (sexually transmitted diseases) of their husbands. No one had given a history of condom use by her husband. Most of the patients (91.1%) used old / reused cloth pieces during menstruation. CONCLUSIONS: There is a need to increase awareness among women and the broader community about different epidemiological factors that may be responsible for increased risk of gynecological malignancies.

Yours faithfully -- prevention of parent to child transmission (PPTCT).

The objective of this study is to find out the reasons behind drop out of the mothers from the prevention of parent to child transmission (PPTCT) programme, thereby going undiagnosed of their HIV serostatus. A retrospective 6-year study was undertaken among mothers attending antenatal clinic and the unbooked cases delivering at the medical college. The percentage of mothers taking pretest counselling was 95.19; 94.09 per cent agreed to have their blood tested among those who had registered at the antenatal clinic only. Of them, 33 were found to be seropositive, 12 being found in 2009 alone. But the daily average of unbooked cases delivering at this institution was 16.42 out of 28. And a huge number (58.9%) were unregistered ie, unknown HIV serostatus deliveries were taken place during this 6-year of study (2004-2009). By this study we have found out that our ignorance, work pressure and patients' lack of knowledge, fear of so called 'HIV-AIDS', social stigmas are creating the big gaps in PPTCT programme and thus made it unsuccessful.

Malignant phylloides tumor of breast in a pregnant woman with coincidental nulliparous vaginal prolapse.

Malignant phylloides tumor is a relatively rare and rapidly growing tumor of the breast. Presentation during pregnancy is uncommon. Reports regarding malignancy in these tumors differ greatly in incidence, and most of them are stromal malignancies. We report this case in which 24-year old primigravid patient in the 36(th) week of her pregnancy had a malignant phylloides tumor of breast with sudden growth and fine needle aspiration cytology of the breast was positive for malignancy. Ultimately after her caesarean delivery, excision biopsy was in favor of a malignant process. Pregnancy with nulliparous prolapse is also a rare condition. Those conditions are not associated with each other, but presence of two rare conditions in the same time in the same person is unique.

Symptomatology of gynecological malignancies: experiences in the gynecology out-patient clinic of a tertiary care hospital in kolkata, India.

BACKGROUND: This cross-sectional observational study was undertaken in a gynecology out-patient clinic to identify the symptoms suggestive of gynecological malignancies followed by histopathological confirmation of their diagnoses and to determine the proportion of the histopathologically confirmed cases specific to sites. METHODS: In a gynecology out-patient clinic in Kolkata, India, patients with symptoms suggestive of gynecological malignancies were screened to identify possible cancer cases. Diagnoses were confirmed by histopathology. One hundred thirteen patients with histopathologically confirmed gynecological malignancies were interviewed further. RESULTS: This study shows that 5.3% of the overall outpatients or nearly one-fourth (23.7%) of the patients with the symptoms suggestive of gynecological malignancies was histopathologically confirmed as having gynecological malignancies. Most of the patients (87.0%) with the symptoms suggestive of gynecological malignancies reported excessive, offensive with or without blood stained vaginal discharge, followed by irregular, heavy or prolonged vaginal bleeding (61.4%). The commonest histopathologically confirmed gynecological malignancy was cervical cancer (61.9%), followed by ovarian cancer (23.9%). CONCLUSIONS: This study highlights the need to increase the awareness about the symptoms of gynecological malignancies among women and the community. Health care personnel have a major role to identify the warning symptoms early for further investigation of the possible cases of gynecological malignancies.

Segmental ileal obstruction in neonates--a rare entity.

Congenital segmental dilatation of a portion of the small intestine in neonates causing intestinal obstruction is quite uncommon. We hereby report 2 such cases. In both infants, there was localized dilatation of the ileum with collapse of the distal bowel and functional intestinal obstruction without loss of continuity of the bowel wall or lack of ganglion cells.