A. G. Radhika

Fallopian Tube Herniation: An Unusual Complication of Surgical Drain

Background. Surgical drains have been used since time immemorial, but their use is not without complications. By presenting this case we aim to describe an uncommon complication of herniation of fallopian tube following the simple procedure of surgical drain removal. Case Presentation. This case describes a 23-year G2P1L1 who underwent an emergency cesarean section for obstructed labor with intraperitoneal drain insertion. The patient had an uneventful postoperative period, drain was removed on day 4, and she was discharged. She presented on day 8 with the complaint of soakage of drain site dressing. On examination an edematous, tubular structure with early sign of necrosis was seen coming out of drain site and a provisional diagnosis of appendix herniation was made. On emergency laparotomy fallopian tube was seen coming out through the drain site and salphingectomy was done. Conclusion. Drains are not a substitute for good surgical technique. Although herniation of intestine, omentum, appendix, gall bladder, and ovary have been reported, we could not find any case of fallopian tube herniation in the literature searched by us.

Pyoderma gangrenosum following a routine caesarean section: Pseudo-infection in a caesarean wound

A 22-year-old booked primigravida underwent lower segment caesarean section for breech presentation. She developed signs and symptoms of wound infection by the fourth postoperative day. This was initially managed with antibiotics and wound dressing, but debridement was later undertaken after consulting surgeons. This resulted in an alarming worsening of the wound with sudden and fast increase in its size along with systemic symptoms. Wound biopsy established the diagnosis of pyoderma gangrenosum. The patients management included oral medication with prednisolone, cyclosporin and dapsone and wound care. There was a dramatic response to this treatment. The wound completely healed by the eighth postoperative month. The oral medications were tapered off slowly and stopped by that time.

Detection of endometrial nerve fibres – a novel technique to diagnose endometriosis

Purpose To detect the presence of nerve fibres by immunohistochemical staining method using anti-PGP9.5 antibody in the eutopic and ectopic endometrium of patients with endometriosis. Methods Patients presenting with pelvic pain and/or infertility were subjected to premenstrual endometrial biopsy during laparoscopy. Thirty patients diagnosed with endometriosis formed the study group and 30 patients with no histological/laparoscopic evidence of endometriosis formed the control group. Endometrial biopsy tissue of all the 60 patients along with biopsy from endometriomas and peritoneal implants of confirmed cases of endometriosis (n = 30) were subjected to immunohistochemical staining to detect nerve fibres. Results Neural elements were observed in the eutopic endometrium of 24/30 cases (80%) in the study group and in none of the controls (p<0.01), while the sections from endometriomas and peritoneal implants demonstrated nerve fibres in all the 30 cases of confirmed endometriosis. The nerve fibres in the endometrial tissue were heterogeneously distributed and were sparse in number with an observed density of <1 nerve fibre/mm2 while they were present in large numbers in the ectopic endometrium (10 ± 3 nerve fibre/mm2). Also, the presence of nerve fibres in the eutopic and ectopic endometrium positively correlated with the intensity of pain (p<0.001). Conclusion Eutopic endometrium exhibited positivity for nerve fibres in 24 out of 30 cases of proven endometriosis, though the density of nerve fibres was low as compared to that reported in a few studies.

Comparison of diagnostic accuracy of PCR and BACTEC with Lowenstein–Jensen culture and histopathology in the diagnosis of female genital tuberculosis in three subsets of gynaecological conditions

abstract The prevalence of female genital tuberculosis (FGTB) in India has been estimated to be about 19%. Despite an array of diagnostic tests being available, the goal of early diagnosis and treatment remains elusive. The present study was planned to identify better diagnostic tests for early detection of FGTB and also to compare their diagnostic accuracy with the existing standard diagnostic tests in three subsets of gynaecological conditions (infertility, menstrual abnormalities and pelvic inflammatory disease). Total of 90 patients recruited in three groups of 30 each underwent endometrial sampling. The biopsied tissue was sent for histopathological examination, AFB smear examination, culture in Lowenstein-Jensen (L–J) and BACTEC 460 TB culture media and nested PCR testing. BACTEC had a sensitivity of 40% with a specificity of 90% while PCR showed a sensitivity and specificity of 62.5% and 54%, respectively, as compared to conventional methods (L–J culture or histopathology). Addition of PCR to BACTEC improved sensitivity from 40% to 52%. Hence, we conclude that combination of BACTEC and PCR had an improved detection as compared to conventional tests with an advantage of early results.

Comparison of metabolic and endocrinal parameters in obese and nonobese women of polycystic ovarian syndrome with normal controls

Aim: The aim of this study is to compare the metabolic and endocrinal parameters between obese and nonobese polycystic ovarian syndrome (PCOS) women with normal controls. Materials and Methods: The study was a cross-sectional comparative study. One-hundred PCOS women were randomized into two groups: Group I obese (n = 50) and Group II nonobese (body mass index [BMI] cutoff <23 kg/m 2 ). Fifty non-PCOS normal weight women formed the control Group III. Metabolic parameters (lipid profile, blood sugar profile, and serum insulin) and endocrinal parameters (serum luteinizing hormone [LH], follicle-stimulating hormone, and testosterone) were compared between the three groups. Results: Mean age of all the groups was comparable. A significantly higher waist circumference was seen in Group I; however, waist-hip ratio (WHR) was comparable between obese and nonobese PCOS groups. Between Groups I and II, mean fasting blood sugar, mean values of impaired glucose tolerance (IGT), and clinical hyperandrogenism were statistically comparable. Degree of insulin resistance (IR) in Group I versus Group II (44% vs. 36%) and of metabolic syndrome in Group I (20%) versus Group II (8%) was statistically comparable. Degree of hypertension (P = 0.001), IGT (P = 0.001), and dyslipidemia were higher in nonobese PCOS group versus normal group. Mean values of serum LH, serum fasting insulin, and serum testosterone were significantly different in nonobese PCOS women when compared with normal. Prevalence of IR (36% vs. 8%; P < 0.01) and metabolic syndrome was significantly higher in nonobese PCOS than normal controls. Conclusion: PCOS per se has evolved as a risk factor for endocrinal and metabolic derangements irrespective of the BMI status. Prevalence of IR and metabolic syndrome is high in nonobese PCOS as compared to normal controls, risks being as high as that in obese PCOS.

Assessment of Redox Imbalance in Idiopathic Fetal Growth Restricted Pregnancies

Background: Fetal growth restriction (FGR) is one of the most significant causes of perinatal morbidity and mortality. The known causes are poor maternal nutrition, hypertensive disorders complicating pregnancy, maternal medical disorders (multiple pregnancy, congenital fetal malformations), and lifestyle influences. However, in vast majority of cases, the cause still remains unknown. Recent studies have suggested the role of oxidative stress in the pathophysiology of FGR. The aim of this study was to evaluate non-enzymatic oxidative stress biomarkers in maternal and cord blood of idiopathic FGR cases. Methods: A total of 100 women subjects aged 18 to 35 years, who fulfilled the recruitment criteria, were enrolled in the study after taking an informed written consent. Non-enzymatic oxidative stress was measured by the quantification of 8-hydroxy-2-deoxy-guanosine (8-OHdG), malondialdehyde (MDA), protein carbonyl, reduced glutathione (GSH) and ferric reducing ability of plasma (FRAP) in maternal and cord blood samples of FGR pregnancies of idiopathic origin and compared with those of normal healthy mother-infant pairs. Results: The levels of 8-OHdG, MDA and protein carbonyl were significantly higher in the ‘idiopathic’ FGR group as compared to the controls, where as the GSH and FRAP were significantly lower. Conclusion: Increased oxidative stress has been found significantly associated with the increased risk of developing idiopathic FGR.

Primary peritoneal carcinoma: a diagnostic dilemma

We read with deep interest the report by Bhuyan et al. [1] detailing diagnosis and management aspects of extra ovarian primary peritoneal carcinoma (EOPPC). Indeed the clinician is intrigued by the presentation of EOPPC and equally challenging is the management because of limited guidance available in literature with these tumours. We recently diagnosed EOPPC in a 62-year-old lady and would like to share the atypical presentation of the carcinoma. This patient had received six cycles of chemotherapy (paclitexal and cisplatin) for papillary adenocarcinoma. At prior exploratory laparotomy, there was an inoperable mass adherent to transverse colon serosa with liver metastasis. As no primary site of tumour was discernable, biopsies from peritoneum and peritoneal washings were taken revealing papillary adenocarcinoma. Post chemotherapy, computed tomography scan showed resolution of ascitis, normal-sized bilateral adnexa and uterus; however, omental thickening and liver metastasis still persisted. Serum CA125 level decreased from 200 to 17.5 IU/ml. At subsequent debulking laparotomy, there was no free Xuid in abdomen but a large desmoplastic transverse colon [2] was seen. The uterus with bilateral adnexa was normal in size and shape; however, multiple hard peritoneal deposits ranging 1–10 cm in size were present in the mesentery, inWltrating up to the wall of transverse colon. Panhysterectomy and resection of transverse colon mass was done. The second laparotomy again could not reveal the primary site of tumour. Repeated histopathology of colonic segment showed serous papillary adenocarcinoma with numerous psammoma bodies inWltrating serosa and reaching up to muscularis propria. Both ovaries showed superWcial cortical involvement by the same tumour (Figs. 1, 2). Serosal aspect of both fallopian tubes, mesentery and parametrium were also studded with the same tumour. Since the gynaecologic oncology group criteria were fulWlled in our case, a diagnosis of EOPPC was rendered [3]. In our case, positive immunostaining for pan-cytokeratin (CK) and estrogen receptor, and negative staining for calretinin further supported the

Cotyledonoid leiomyoma and non-descent vaginal hysterectomy.

We read with deep interest the article by Driss et al. [1] who emphasize the association of a cotyledonoid dissecting leiomyoma with endosalpigiosis. Cotyledonoid dissecting leiomyoma is an extremely rare variant of uterine leiomyoma with just 24 cases on record [2]. Clinicoradiological diVerentiation from leiomyoma is diYcult, and diagnosis is most often not suspected preoperatively. Imaging modalities oVer no help, and its bizarre macroscopic shape may be confused with malignant neoplasm [3]. We would like to share the intraoperative Wndings of cotyledonoid dissecting leiomyoma in a 52-year-old multiparous woman during a non-descent vaginal hysterectomy (NDVH). The patient had presented with polymenorrhagia for 6 months. She had Wrst degree cervical descent with uniformly enlarged anteverted uterus of size corresponding to 8 weeks. Ultrasound evaluation was suggestive of multiple subserous Wbroid of size 6 £ 7 cm with slight Xuid in peritoneal cavity. During NDVH performed for symptomatic polymenorrhagia, after bisection we attempted to visu-

Assessment of urinary cotinine levels in women with gynecological complaints at a tertiary care hospital: A pilot study

Gynecological effects due to smokeless tobacco exposure are not well studied. This cross-sectional study was undertaken with the objective to evaluate the urinary cotinine levels in women of reproductive age with gynecological complaints. The study was conducted in 2015 at the outpatient clinic of the Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. A total of 192 consecutive women presenting with gynecological complaints (pelvic inflammatory disease (PID), infertility, and menstrual abnormality) were recruited. Their demographic details and tobacco exposure were recorded. All of them denied exposure to any form of tobacco. Urinary cotinine level of each participant was measured. The mean urinary cotinine level was 23.60 ± 12.00 ng/ml. PID was the most common gynecological complaint. Women with PID had significantly higher urinary cotinine levels compared to those with menstrual complaints and infertility: 24.9548 (±12.259) ng/ml versus 20.2042 (±10.9248) ng/ml. This study highlights the importance of addressing the issue of secondhand smoke exposure and reproductive morbidities in women.

An unusual presentation of dengue in postoperative case: a challenge in management.

A 24-year-old para 2 gravida 2 woman was referred to our hospital on the third day after a lower segment Caesarean section (LSCS) for placenta praevia with anaemia (Hb, 7 g/dl) and thrombocytopenia (platelet count, PC, 35,000/mm). She had already received 2 units of packed red cell concentrate (RCC) and 2 units of platelet concentrate. Her vital signs were stable. She had a history of one episode of high grade fever one week previously for which no investigations had been done. A repeat blood count showed worsening anaemia (Hb, 6.7 g/dl), stable thrombocytopenia (PC, 54,000/mm) and a prothrombin time (PT) of 11.3 s (reference range, 10–16 s), and an activated partial thromboplastin time (APTT) of 32 s (reference range, 27–35 s). She was thus transfused 2 further units of RCC in our hospital. In view of the presence of thrombocytopenia and the high prevalence of malaria and dengue during the rainy season in our area (our hospital receives approximately 500–600 patients with dengue per year), a fever screen was carried out. This revealed a leucocytosis of 19,200/mm, a negative malaria antigen, acute dengue serology (IgM antibody negative), chronic dengue serology (IgG antibody) positive, ELISA negative and WIDAL negative, implying the patient had one of several atypical presentations of complicated dengue infection. The following day she developed breathlessness, a sudden onset abdominal distension and marked oozing from the operative wound. An abdominal ultrasound scan showed gross peritoneal fluid with dense echoes suggesting a haemoperitoneum, confirmed by an abdominal tap which demonstrated frank blood. Investigations confirmed deteriorating anaemia (Hb, 4.4 g/dl) and a severe coagulopathy (PC, 27,500/mm), PT of 13.4 s (reference range, 10–16 s), APTT of 70.6 s (reference range, 27–35 s) with a negative D-Dimer