Bindiya Gupta

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.

Primary umbilical endometriosis: a rare entity

Primary umbilical endometriosis accounts for 0.5–1% of extragenital endometriosis. Clinical presentation is typical and treatment involves complete excision. It is important to consider it in differential diagnosis of an umbilical nodule.

Drotaverine hydrochloride versus hyoscine-N-butylbromide in augmentation of labor.

Objectives: To study and compare the efficacy and side effects of drotaverine hydrochloride and hyoscine‐N‐butylbromide in the augmentation of labor. Methods: A prospective randomized trial of 150 women in active labor included 50 women given drotaverine (group 1), 50 women given hyoscine‐N‐butylbromide (group 2), and 50 women given no medication (group 3). Duration of labor, rate of cervical dilation, mode of delivery, side effects, and neonatal outcome were compared among the groups. Results: The mean duration of the active phase of labor was 4.48 ± 2.26 h, 3.9 ± 2.42 h, and 3.6 ± 2.07 h in groups 1, 2, and 3, respectively. The mean rate of cervical dilation was 2.6 cm/h, 2.4 cm/h, and 2.5 cm/h, respectively. The differences were not statistically significant. There was no difference in the duration of the second and third stages of labor. No adverse maternal or fetal outcomes were noted. Conclusion: Drotaverine hydrochloride and hyoscine‐N‐butylbromide do not have a role in augmentation of labor.

Rupture of intrapartum unscarred uterus at the fundus: a complication of passive cocaine abuse?

Uterine rupture is a potential obstetric catastrophe. We report a case of a gravida 2 para 1 with intrapartum unscarred uterine fundal rupture. Immediate resuscitation, laparotomy and hysterectomy, was done with maternal survival. History of passive cocaine smoke exposure elicited postoperatively was the possible etiology leading to complete fundal rupture. This case is an eye opener as regards to ill effects of drug abuse even though passive. A careful history of drug abuse must be elicited when the common causes of uterine rupture have been excluded or the rupture site is unusual.

Poland syndrome with Mullerian agenesis: a rare occurrence.

A young girl, 20 years old, presented with complaints of unequal breast development, primary amenorrhea and deformity of the right hand. She had no history of cyclical abdominal pain, nipple discharge, other limb deformities, or visual or hearing problems. Her mother and two sisters were normal and had attained normal menses. On examination her height was 157.5 cm and weight 55 kg. The chest was asymmetrical with depression in the bony cage on the right upper side, indicating absent pectoralis major muscle, and with an underdeveloped right breast, but there was no bony involvement. Claw hand deformity was present in the right hand (Fig. 1). Dorsally the right scapula was less prominent than the left. Axillary hair was also absent on the right side. On auscultation the apex beat was present in the 5th right intercostal space. Examination of the eyes, ears, nose, facial symmetry, palate, and dentition was normal. Pubic hair was Tanner’s stage 3 and external genitalia were normal. There was a blind vagina 3 cm in length and rectal examination revealed that the uterus was absent. X-ray chest showed scoliosis, thinning of the anterior ends of the right 1st–3rd ribs and dextrocardia (Fig. 2). X-ray of the right hand showed flexion deformity of the right 1st metacarpophalangeal joint and 2nd–5th interphalangeal joints, and soft tissue atrophy but no bony fusion (Fig. 3a,b). Pelvic ultrasound revealed that the uterus was absent and the ovaries were normal. A diagnosis of Poland syndrome with Mullerian agenesis (Mayer Rokitansky Kustner Hauser syndrome) was made. The patient was counselled, referred to a surgeon for reconstructive surgery and since the blind vagina was distensible she was advised on graduated dilatation with a mould. Poland’s syndrome occurs in approximately 1/30,000 live births [1]. It is primarily characterized by partial or total aplasia of the greater pectoral muscle and the ipsilateral breast or nipple [2]. Associated clinical anomalies are predominantly musculoskeletal,

First Trimester Abortion: A Rare Cause of Intrauterine Bony Spicules

Bony fragments in the uterus occur after second trimester termination of pregnancy following retained fetal bones. Very rarely, they can form following first trimester loss. Clinical symptoms range from pain, menstrual symptoms, and infertility. Ultrasound shows a hyperechoic shadow, and treatment is by curettage or hysteroscopic removal.

Indications and Contraindications of Vaginal Hysterectomy

Vaginal route is a feasible and safe option for various indications of hysterectomy like fibroid, adenomyosis, abnormal uterine bleeding, cervical intraepithelial neoplasia III, cervical carcinoma in situ in older women and Stage I endometrial cancer. The contraindications are mainly based on factors like uterine size, mobility, descent, vaginal width, need for concomitant salpingo-oophorectomy, multiple previous surgeries, skill and experience of the surgeon. Vaginal hysterectomy is considered the safest of all hysterectomies and must be considered the first choice whenever applicable.

Unexplained Recurrent Miscarriage: A Dilemma

Unexplained recurrent miscarriage indicates that there is no underlying cause for this condition and up to 50% of patients remain without a diagnosis. The most common cause is the factor of chance alone which constitutes the type 1 pregnancy losses. Other suggested mechanisms are endogenous factors like poor oocyte, sperm and embryo quality, and environmental risk factors constituting the type 2 unexplained RPL group. Treatment includes psychological and supportive care, and role of drug therapy is still not proven.

Cervical Cerclage: Does It Help?

The role of cerclage in recurrent pregnancy loss is in patients of true cervical incompetence which complicates less than 1% of all pregnancies. Cervical cerclage may be offered in women with history of three or more second-trimester pregnancy losses or extreme premature deliveries or in women with two or less midtrimester losses if cervical length is less than 2.5 cm before 24 weeks. Cerclage may be transvaginal or transabdominal; the latter is preferred preconceptionally in select cases with failed vaginal cerclage.

The Evolving Role of Genetics in Recurrent Pregnancy Loss

Genetic causes involving changes in the parental or fetal chromosomes are an important etiology for recurrent pregnancy loss. 3–6% of Recurrent miscarriages are due to chromosomal abnormalities of one of the two partners. Chromosomal trisomies are the most common cause, while single most specific cause is monosomy X. Numerical abnormalities and single gene defects are other important genetic abnormalities. Translocations are present in 2.2% of couples after one miscarriage, 4.8% after two miscarriages, and 5.7% after three miscarriages. Once a genetic defect is identified by parental or fetal karyotype, genetic counseling should be offered to the couple. There is insufficient evidence to support the use of available strategies to minimize the risk of having an affected child like preimplantation genetic screening and diagnosis.