Akhila Vasudeva

Clinical utility of fetal autopsy and its impact on genetic counseling.

We aimed to analyze the utility of fetal autopsy in terms of its contribution to establishing a definitive diagnosis and its impact on genetic counseling.

Laparoscopic cystectomy of endometrioma: Good surgical technique does not adversely affect ovarian reserve

BACKGROUND: The damage to ovarian reserve inflicted by surgery for endometriosis represents a major concern in the balance between reproductive benefits and risks. AIM: To evaluate the ovarian reserve in sub fertile women after laparoscopic endometriotic cystectomy. SETTINGS AND DESIGN: Prospective study, done in Department of Obstetrics and Gynecology, tertiary care hospital between August 2010-2012. MATERIALS AND METHOD: Laparoscopic cystectomy performed by stripping technique for endometriotic cysts. Endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). Ovarian reserve assessed by comparing FSH and LH levels, measurement of residual ovarian volume, antral follicle counts and stromal blood flow on second day of menses pre and postoperatively. Cyst wall was evaluated histologically to note the presence of normal ovarian tissue in resected tissue. STATISTICAL ANALYSIS: SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL) was used for statistical calculations. Wilcoxon signed test and Pearson Chi – Square test were applied. Significance level was P < 0.05. RESULTS: Incidence of minimal, mild, moderate, and severe endometriosis was 4.1%, 21.9%, 28.7%, 45.3% respectively. Ovarian reserve was assessed both by ultrasound and biochemical parameters on day 2 of menses; pre and post-operatively. Preoperative and post-operative values; FSH (7.24 ± 1.21, 7.23 ± 1.51 m IU/ml), LH levels (6.37 ± 1.8, 6.6 ± 2.3 m IU/ml), residual ovarian volume (8.5 cm3 ± 5.3, 7.4 cm3 ± 5.8), antral follicle count(3.3 ± 1.9, 4.1 ± 1.5) and stromal blood flow (6.8 cm/sec ± 4.57, 7.1 cm/sec ± 3.55) were statistically not significant. Loss of follicle was seen in 27.2% cyst walls on histopathological examination while 72.73% had no loss. CONCLUSION: Laparoscopic cystectomy when performed for endometriotic cysts with accurate surgical technique leads to no significant ovarian tissue removal.

Influence of endomeriotic cyst diameter and the severity of endometriosis on the ovarian parenchyma excised during laparoscopic cystectomy.

INTRODUCTION Endometrioma is a common form of endometriosis and it is represented by endometriotic deposits within the ovaries which accounts for upto 17-44% of cases. Laparoscopic stripping of ovarian endometriotic cysts is an accepted technique owing to low recurrence rates. Decrease in residual ovarian tissue volume was noted in many studies followed cystectomy. This study aims at estimating whether the size of endometriotic cyst is related to ovarian parenchyma excised along with cyst wall. MATERIAL AND METHODS Prospective study was done at University teaching hospital for one year. A total of 56 women underwent laparoscopic endometriotic cystectomy. Cystectomy was done by stripping method and endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). The endometrioma wall was evaluated histologically and were categorised into 2 groups based on semi- quantitative scale of 0-4. Group 1 and 2 showed grade 0, 1, 2 and 3, 4 in the cyst wall respectively. RESULTS Mean age of patients was 31.4 years, duration of infertility was 4.1 years and cyst diameter measured 6.3 cm. 73.2% (n=41) were in Group 1 and 26.8% (n=15) were in Group 2 , mean cyst diameter was being 4.3 cm and 5.0 cm respectively. There was no significant statistical correlation between preoperative cyst diameter and ovarian parenchyma removed (p=0.15). 93.3% (n=14) of group 2, and only 65.8% (n=27 ) of group 1 were found to have moderate to severe endometriosis, indicating there is correlation between disease severity and loss of ovarian tissue (p= 0.04). CONCLUSION Endometriotic cystectomy when performed with accurate surgical technique leads to no significant ovarian tissue removal. However, disease severity significantly determines the loss of normal ovarian parenchyma.

A prospective observational study of early fetal growth velocity and its association with birth weight, gestational age at delivery, preeclampsia, and perinatal mortality

OBJECTIVES We aimed to measure early fetal growth velocity and to correlate this with the birth weight, gestational age at delivery, and with the incidence of adverse pregnancy outcomes specifically preeclampsia and perinatal mortality. METHODS A data based prospective observational study, wherein sonographic biometry data and specific pregnancy outcome related data were collected from pregnant womens records, starting soon after their first antenatal visit. Early fetal growth velocity was measured using BPD growth between 11 and 14 weeks scan and anomaly scan and standardizing this by Z scoring. RESULTS Out of 607 fetuses, 41 (6.7%) were slow growing, 531 (87.4%) normally growing, and 35 (5.7%) fast growing (Z scoring <10th(,) 10-90th, and >90th percentiles respectively). As fetal growth velocity increased, the mean birth weight decreased from 2958.7±388.9 (<10th centile), 2742.1±576.6 (10-90th centile), to 2339.3±729.4 (>90th centile); and gestational age at delivery decreased from 38.5±1.3 (<10th centile), 37.5±2.1 (10-90th centile), to 36.4±2.2 (>90th centile), and both these trends were statistically significant (p<0.001).Faster growing fetuses had a higher risk of preterm delivery(spontaneous+indicated) compared to other 2 groups [OR 4.42 (2.18,8.98)], and slower growing fetuses had a higher risk of postdated deliveries compared to other 2 groups [OR 3.042 (1.44, 6.45)].We found no significant association between early fetal growth velocity and incidence of small for gestational age at birth/low birth weight at term, preeclampsia, and perinatal mortality. CONCLUSIONS Early fetal growth velocity between first and second trimesters, may be one of the important factors influencing ultimate birthweight and gestational age at delivery.

Post-caesarean Haematomas, Septic Collections and Wound Disruptions– Re-Laparotomy Based on Abdominal Imaging

Raising incidence of caesarean section is a global concern, especially in the low resource countries [1,2]. Inadequate aseptic precautions, improper surgical technique, indiscriminate use of antibiotics leading to increasing antibiotic resistance, suboptimal post-operative care and ascending genital infections all contribute to increasing incidence of post-caesarean abdominal sepsis. We present a series of six referrals in 12 months; who presented with post-caesarean haematomas, septic collections and uterine wound dehiscence. Decision for re-laparotomy had to be taken diligently taking clinical picture along with imaging findings.

Neuroendocrine Cancer of Rectum Metastasizing to Ovary

Neuroendocrine carcinomas (NECs) are rare malignancies that originate from the hormone-producing cells of the bodys neuroendocrine system. Rectal high grade NEC (HG-NEC) constituting less than 1% of colorectal cancers can cause large ovarian metastasis that may be the initial presenting complaint. Ovarian Krukenberg tumor from a primary rectal HG-NEC is a very unusual and exceedingly uncommon differential diagnosis for secondary ovarian malignancy. This case report describes one such extremely rare case of a woman who had presented to the gynecology department with features suggestive of ovarian malignancy and was ultimately diagnosed to have Krukenberg tumor originating from neuroendocrine cancer of rectum. We felt this is a good opportunity to spread more light on neuroendocrine neoplasms that are very rare in gynecological practice.

Middle Interhemispheric Variant of Holoprosencephaly - Presenting as Non-Visualized Cavum Septum Pellucidum and An Interhemispheric Cyst in A 19-Weeks Fetus.

Middle Interhemispheric variant (MIH) is a rare subtype of holoprosencephaly (HPE), also known as syntelencephaly. We present a case of MIH, which was diagnosed as an interhemispheric cyst on antenatal sonography at 19 weeks, but later diagnosed as MIH variant of holoprosencephaly after a postabortal MRI and perinatal autopsy.

Primary Cervical Placental Site Trophoblastic Tumor: A Rare Entity with an Unusual Presentation

Placental site trophoblastic tumour (PSTT) is the least common form of gestational trophoblastic neoplasia accounting for only 1-2% of trophoblastic tumors. Approximately 200 cases are reported in English literature. PSTT presenting as a cervical growth is even less common. Differentiation of PSTT from other types of GTN, non-neoplastic gestational trophoblastic disease and non-trophoblastic tumors is important clinically due to differences in their therapeutic approaches.Appreciation of the morphologic features and immunophenotype allows their accurate diagnosis.Although most of the cases of PSTT behave in a benign fashion,the clinical behavior of PSTT can sometimes be variable and several prognostic factors can help to predict the biological behavior of this condition. We report a rare case of placental site trophoblastic tumor, presenting as a cervical mass, in a 38 year old female, and review the literature.

Infection and acute respiratory distress syndrome during pregnancy: A case series of preventable maternal deaths from southern India

INTRODUCTION Acute respiratory distress syndrome (ARDS) is common among women admitted to obstetric intensive care units, and it contributes significantly, both directly and indirectly, to maternal deaths. CASE SERIES We present a case series of ARDS in pregnant women caused by non-obstetric causes. The women were treated at a tertiary hospital in southern India. The striking features were delayed referral from the primary care unit and the lack of a primary diagnosis or treatment. Undiagnosed rheumatic heart disease, anemia, and malaria and H1N1 epidemics contributed to these cases of ARDS and maternal death. CONCLUSION It is necessary to increase the awareness of evidence-based uniform protocols to tackle common medical complaints during pregnancy.

A rare case of recurrent pregnancy loss associated with high-titer positivity for perinuclear anti-neutrophilic cytoplasmic antibodies

We present a case of recurrent pregnancy loss associated with unusual constellation of utoimmunity-related features such as hypertension, severe hrombocytopenia, hypothyroidism and persistent high titers of perinuclear antineutrophilic cytoplasmic antibodies. Her clinical features did not fit into a particular diagnosis of vasculitides, systemic lupus erythematosis (SLE) or other known autoimmune diseases where this autoantibody is found in high titers. We report the unusual association of this autoantibody with recurrent early fetal demise in this case.