Achla Batra

Evaluation of isosorbide mononitrate for cervical ripening prior to induction of labor for postdated pregnancy in an outpatient setting

To determine the safety and effectiveness of self‐administered treatment with isosorbide mononitrate (IMN) for cervical ripening in Indian women with postdated pregnancies.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section.

INTRODUCTION Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery. OBJECTIVE To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section. MATERIALS AND METHODS This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months. RESULTS A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively. CONCLUSION Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Evaluation of MR Spectroscopy and Diffusion-Weighted MRI in Postmenopausal Bone Strength

Aim: To prospectively investigate the role of MR spectroscopy (MRS) and diffusion-weighted magnetic resonance imaging (DWI) in assessing vertebral marrow changes in postmenopausal women. Materials and Methods: Fifty postmenopausal women, who underwent dual-energy x-ray absorptiometry of the spine, were divided into three bone density groups (normal, osteopenia, and osteoporosis) based on T-score. Both MRS and DWI of the L3 vertebral body were performed to calculate the marrow fat content and apparent diffusion coefficient (ADC). The results were compared between three groups and correlated with BMD. Results: Vertebral marrow fat content was significantly increased in the osteoporotic group when compared with that of the osteopenic group and the normal bone density group. ADC values in the osteoporotic, osteopenic, and normal bone density groups were 338, 408 and 464, respectively, with statistically significant differences (P < 0.001). A statistically significant positive correlation between T-scores and ADC existed (r=0.694, p value <0.001). The vertebral marrow fat content was negatively correlated to the bone density (r=–0.455, p< 0.001) and to marrow ADC (r= -0.302, p < 0.05). Conclusion: The postmenopausal women with osteoporosis exhibited a corresponding increase in vertebral marrow fat content as the bone density decreased. Marrow fat content and ADC were related to the bone density. MRS and DWI are helpful in evaluating the bone marrow changes in postmenopausal women.

Randomized Comparison of Isosorbide Mononitrate and PGE2 Gel for Cervical Ripening at Term including High Risk Pregnancy

Aims. Prostaglandin E2 is the most commonly used drug for cervical ripening prior to labour induction. However, there are concerns regarding uterine tachysystole and nonreassuring fetal heart (N-RFH). Isosorbide mononitrate (IMN) has been used successfully for cervical ripening. The present study was conducted to compare the two drugs for cervical ripening at term in hospital. Methods. Two hundred women with term pregnancies referred for induction of labour with Bishop score less than 6 were randomly allocated to receive either 40 mg IMN tablet vaginally (n = 100) or 0.5 mg PGE2 gel intracervically (n = 100). Adverse effects, progress, and outcomes of labour were assessed. Results. PGE2 group had significantly higher postripening mean Bishop score, shorter time from start of medication to vaginal delivery (13.37 ± 10.67 hours versus 30.78 ± 17.29 hours), and shorter labour-delivery interval compared to IMN group (4.53 ± 3.97 hours versus 7.34 ± 5.51 hours). However, PGE2 group also had significantly higher incidence of uterine tachysystole (15%) and N-RFH (11%) compared to none in IMN group, as well as higher caesarean section rate (27% versus 17%). Conclusions. Cervical ripening with IMN was less effective than PGE2 but resulted in fewer adverse effects and was safer especially in high risk pregnancies.

Heart Rate Variability and Cardiovascular Reflex Tests for Assessment of Autonomic Functions in Preeclampsia

Alterations in the autonomic cardiovascular control have been implicated to play an important etiologic role in preeclampsia. The present study was designed to evaluate autonomic functions in preeclamptic pregnant women and compare the values with normotensive pregnant and healthy nonpregnant controls. Assessment of autonomic functions was done by cardiovascular reflex tests and by analysis of heart rate variability (HRV). Cardiovascular reflex tests included deep breathing test (DBT) and lying to standing test (LST). HRV was analyzed in both time and frequency domain for quantifying the tone of autonomic nervous system to the heart. The time domain measures included standard deviation of normal R-R intervals (SDNN) and square root of mean squared differences of successive R-R intervals (RMSSD). In the frequency domain we measured total power (TP), high frequency (HF) power, low frequency (LF) power, and LF/HF ratio. Cardiovascular reflex tests showed a significant parasympathetic deficit in preeclamptic women. Among parameters of HRV, preeclamptic group had lower values of SDNN, RMSSD, TP, HF, and LF (ms2) and higher value of LF in normalised units along with high LF/HF ratio compared to normotensive pregnant and nonpregnant controls. Furthermore, normotensive pregnant women had lower values of SDNN, TP, and LF component in both absolute power and normalised units compared to nonpregnant females. The results confirm that normal pregnancy is associated with autonomic disturbances which get exaggerated in the state of preeclampsia.

Uterine artery pseudoaneurysm after caesarean section: a rare cause of massive secondary postpartum haemorrhage

Postpartum haemorrhage (PPH) is one of the major causes of maternal morbidity and mortality. A 24 years old woman came to hospital with complain of profuse vaginal bleeding after 45 days of caesarean section. Ultrasound doppler report showed an anechoic cystic space occupying lesion in region of caesarean scar. It filled up colour and showed swirling motion and arterial doppler waveforms. So, lesion was diagnosed as uterine artery pseudoaneurysm and arterial embolisation was done for treatment. After that, since 7 months the patient is asymptomatic.

Leiomyosarcoma of the Broad Ligament - a Case Report

Primary leiomyosarcoma of the broad ligament (LBL) are extremely rare tumours with no defined risk factors. They are mostly reported in postmenopausal women with only 3 case reports of tumor developing before 40 years of age. Diagnosis is difficult as signs and symptoms are nonspecific. None of the reported cases so far have been diagnosed preoperatively. In view of very few documented cases, there are no guidelines for the management of this rare tumor. We report a case of primary leiomyosarcoma of broad ligament with its management.

Can bone marrow apparent diffusion coefficient values identify bone strength: Experience with 107 postmenopausal women

Purpose: The purpose of this article was to prospectively study the relationship between bone marrow apparent diffusion coefficient (ADC) obtained on diffusion-weighted magnetic resonance imaging (DWI) and bone mineral density. Materials and Methods: A total of 107 randomly selected postmenopausal women underwent dual-energy X-ray absorptiometry of the spine and were divided into three groups: normal (n = 25), osteopenic (n = 30), and osteoporotic (n = 45). A total of 100 subjects were examined (7 excluded from study owing to pre-existing marrow pathologies) with DWI at 1.5 tesla using b values of 0 and 1000 s/mm2. ADC values of the L3 vertebral body were calculated, and the results were compared between three groups and correlated with BMDs. Results: The mean ADC values in the normal, osteopenic, and osteoporotic groups were 0.49 ± 0.03 × 10−3, 0.40 ± 0.03 × 10−3, and 0.34 ± 0.04 × 10−3 mm2/s, respectively. The ADC values were significantly different (p < 0.005) in the three groups. For paired data, a significant positive correlation was observed between ADC values and BMDs and also between ADC values and T scores. Conclusions: In this study, bone marrow ADC values were observed to decline in line with a fall in BMDs. This direct relationship between ADC values and BMDs is likely a reflection of an increase in bone marrow fat content, a histomorphological change in osteoporosis. Bone marrow ADC can thus serve as an indirect quantitative measure of bone density as well as bone strength.