Amita Suneja

Low‐dose mifepristone in treatment of uterine leiomyoma: A randomised double‐blind placebo‐controlled clinical trial

Aims: To evaluate the effect of low‐dose mifepristone on leiomyoma‐related symptoms, uterine and leiomyoma in women with symptomatic leiomyomata.

Fetotoxicity of warfarin anticoagulation

IntroductionFetal warfarin syndrome (warfarin embryopathy) is a consequence of maternal ingestion of warfarin during pregnancy. Warfarin fetotoxicity comprises wide range of manifestations including dysmorphology in neonate with characteristic classical features of nasal hypoplasia and stippling of epiphyses.Materials and methodsHere we present a case of a neonate whose mother was on unsupervised warfarin prophylaxis throughout pregnancy. A brief review of literature with suitable options for anticoagulation during pregnancy is discussed.ConclusionThe final consensus over LMWH and warfarin in the first trimester is yet to be finalised. The treatment of warfarin embryopathy is symptomatic. Long term sequels in survivors are still not known.

Maintenance tocolysis with oral micronized progesterone for prevention of preterm birth after arrested preterm labor.

To evaluate the efficacy of maintenance therapy with oral micronized progesterone (OMP) for prolongation of pregnancy in cases of arrested preterm labor.

Transabdominal amnioinfusion in preterm premature rupture of membranes.

To evaluate the effect of transabdominal amnioinfusion on prolongation of pregnancy, and maternal and neonatal outcomes in preterm premature rupture of membranes (pPROM).

Role of uterine artery velocimetry using color-flow Doppler and electromyography of uterus in prediction of preterm labor

Aim:  To evaluate the role of Doppler waveforms of uterine vessels and electromyography (EMG) of the uterus in predicting preterm labor.

Incarcerated procidentia due to cervical fibroid: An unusual presentation

A 35-year-old woman, emaciated, primipara presented to the gynaecology outpatient department of the University College of Medical Sciences and Guru Teg Bahadur Hospital with a 4-month history of ‘something coming out’ of her vulva associated with difficulty in passing urine. There was history of post-coital bleeding preceding this episode. She later revealed that this mass came out suddenly after one episode of heavy weight lifting (one sack of rice) and could not be reduced back. On examination, the patient was cachexic, extremely pale, foul smelling, and unable to walk. Local examination revealed a huge mass lying outside the introitus and the overlying mucosa was dry and ulcerated at various places. A necrotic, firm mass was seen at the caudal end of protruding mass measuring 15 × 20 cm. The mass was so heavy that it could not be lifted with one hand, and it was covered with gangrenous slough such that it resembled a fetal head (Fig. 1). The cervical opening could not be identified either visually or on palpation. The fundus of the uterus was not appreciated, only bogginess was felt all over the lower abdomen and cystocoele or enterocoele could not be differentiated in the prolapsed mass. As it was irreducible, bimanual examination could not be done. Per-rectal examination did not show any abnormality. A provisional diagnosis of uterine inversion with uterine sarcoma was kept in mind but procidentia with carcinoma of the cervix could not be ruled out. The patient’s blood investigations revealed a haemoglobin level of 3.3 g/dL, which improved to 5.1 g/dL after 3 U of packed cells. Her white blood cell count was 23 000/cmm, platelet count: 1.25 × 10/L, and the blood film showed normocytic, normochromic anaemia. A swab culture from the necrotic mass revealed the growth of Pseudomonas and Klebsiella. Her bladder was catheterised and daily dressing of the mass was carried out with silver sulfhadiazine and hydrogen peroxide. When the infection improved, a punch biopsy was taken from the necrotic mass. The histopathology of the mass showed fibromuscular tissue with inflammatory granulation. On sonography, the uterus and ovaries could not be visualised because of bowel shadows; both kidneys were normal and there was no evidence of pressure symptoms. The upper half of both ureters were seen on intravenous pyelography, but the lower parts of both ureters were not seen. These investigations ruled out the possibility of carcinoma of the cervix but the diagnostic dilemma persisted. Antibiotics and haematinics were continued and when her haemoglobin improved to 8.8 g/dL and the necrotic mass became healthy, the patient underwent abdominoperineal exploration under general anaesthesia in the lithotomy position. The abdomen was opened by a Pfannensteil incision, revealing a pelvis filled with bowel loops. The uterus, along with tubes and ovaries, were prolapsed into the everted vagina. As the fundus of uterus was identified, the uterine inversion was ruled out. The uterus could not be lifted into the abdomen owing to the bulk of the mass at the caudal end. There were two subserosal fibroids on the anterior surface of the uterus, both ovaries appeared normal, and the cervix was identified at the caudal end. From the perineal end the mass was excised. The uterus, cervix, and vagina were then repositioned into the abdomen and subsequently total abdominal hysterectomy was carried out (preserving the ovaries). The vaginal vault was suspended with the round and uterosacral ligaments and the abdomen was closed. The patient was transfused 2 U of blood in the postoperative period and her recovery was uneventful. Histopathology revealed the mass to be leiomyoma arising from the cervix.

Role of Misoprostol in Overcoming an Unsatisfactory Colposcopy: A Randomized Double-Blind Placebo-Controlled Clinical Trial

Objective: To assess the effectiveness of vaginal misoprostol in overcoming an unsatisfactory colposcopy and to analyse the factors that might influence the response to misoprostol, i.e. age, menopausal status, duration of menopause and cervical characteristics. Study Design: A randomized double-blind placebo-controlled clinical trial. Methods: Forty patients with unsatisfactory colposcopy were recruited from the colposcopy clinic and were randomly allocated to receive either 400 µg misoprostol or similar-looking placebo tablets vaginally. Repeat colposcopy was performed after 6 h noting the side effects, if any. Results: One patient was excluded from the misoprostol group because postdrug colposcopic examination could not be done due to a technical fault. Of the 19 patients in the misoprostol group, 15 (78.9%) had satisfactory examination compared to only 6 of the 20 (30%) patients in the placebo group. This effect of misoprostol was statistically significant (p = 0.004). Misoprostol in the present study averted 3 cone biopsies and 12 endocervical curettages. The side effects of misoprostol were comparable in both groups. The slit-like external os and the posterior cervical lip as the site of unsatisfactory colposcopy had better conversion rates compared to pinhole os (66.6 vs.81.2%) and anterior lip involvement (85.7 vs.100%). Conclusion: Four hundred micrograms of intravaginal misoprostol is an effective and safe method to convert an unsatisfactory colposcopy into a satisfactory one.

Human Chorionic Gonadotropin in Cervicovaginal Secretions as a Predictor of Preterm Birth

Objective: To compare the qualitative (QL) and quantitative (QN) levels of βhCG in cervicovaginal secretions as predictors of preterm birth. Methods: The study included 100 women. QL and QN assays were done with velocit kit and ELISA, respectively. Results: A positive QL assay had sensitivity of 78%, specificity 95%, positive predictive value (PPV) 90%, negative predictive value (NPV) 88% and odds ratio (OR) = 70.87 (95% CI = 18.50, 271.50). The likelihood ratios (LRs) for positive and negative tests were 15.6 and 0.06, respectively. Using a cutoff value of 34.5 mIU/ml, the QN assay had sensitivity of 86%, specificity 86%, PPV 78% and NPV 92%, OR = 36.90 (95% CI = 10.79, 126.15). The LRs for positive and negative tests were 6.14 and 0.16, respectively. Conclusion: The simple and cheaper QL βhCG test is a better predictor of preterm birth as compared to the QN test.

A Randomised Controlled Trial Comparing the Efficacy and Side-Effects of Intravaginal Ring (Nuvaring®) With Combined Oral Hormonal Preparation in Dysfunctional Uterine Bleeding

INTRODUCTION Combined Oral Contraceptive (COC) pills are being used in patients of abnormal uterine bleeding, especially adolescents and reproductive age women considering their need for contraception. It decreases the blood loss due to haemostatic effect of estrogen and also regularizes the cycle. Intravaginal route has been found to be effective and acceptable; Gastrointestinal absorption and hepatic first-pass metabolism is avoided and steady, uniform blood concentration is achieved. Bioavailability of estrogen and progestogen through oral and vaginal route are same. The convenience of once-a-month administration is another major advantage. MATERIALS AND MATHODS Sixty women fulfilling inclusion criteria were randomised into 2 groups in 1:1 ratio. In one group (n=30), monthly insertion of Nuvaring(®)) was done for three consecutive months. Nuvaring(®) releases 15μg ethinyl estradiol and 120 μg etonogesterol daily. The other group (n=30) received COC pill containing 30μg EE and 150 μg levonorgestrel for three consecutive months. Primary outcome measures were change in menstrual cycle pattern and pictorial Blood Loss Assessment chart (PBAC) score. Other Parameters included side effects, change in haemoglobin and weight. Data was analyzed by statistical software SPSS 20. RESULTS Both Nuvaring(®) and COC were found to significantly decrease blood loss in each cycle. Decrease in PBAC score was more in Nuvaring(®) group compared to COC, however difference was not significant. Ideal bleed (IB) was frequently higher for Nuvaring(®) group than COC in all 3 cycles, although no statistically significant difference was observed between groups (p-value=0.286). Late withdrawl, intermenstural spotting was higher in COC group. Compliance was better and women were more satisfied in Nuvaring(®) group compared to COC group. Minor side effects like headache, mastalgia, nausea and mood changes were seen in both groups, which were not significant. Continuation rate was significantly higher in Nuvaring® group. 30% women discontinued treatment in OCP group after 3 month compare to 10% in Nuvaring(®) group. CONCLUSION Present study shows Nuvaring(®) to be as effective as COC in controlling heavy menstural bleed, better cycle control, with minor acceptable systemic side effects.

Use of the Sequential Organ Failure Assessment score for evaluating outcome among obstetric patients admitted to the intensive care unit

To evaluate the prognostic value of the Sequential Organ Failure Assessment (SOFA) score among obstetric patients admitted to the intensive care unit (ICU).