Debjyoti Karmakar

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time

ObjectiveTo find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome.MethodsThis was a prospective observational study of 217 patients who underwent cesarean section at ≥ 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord þH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed.ResultsOut of 3148 patients delivered at ≥ 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord þH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of ≤30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval ≤ 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes.ConclusionNon-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was ≤ 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in ≤ 30 minutes group was significantly higher.

Magnetic resonance imaging findings among women with tubercular tubo-ovarian masses

To assess the usefulness of magnetic resonance imaging (MRI) in women with tubercular tubo‐ovarian masses.

Comparison of PET/CT with other imaging modalities in women with genital tuberculosis

To compare findings with 2‐deoxy‐2‐(18F)fluoro‐D‐glucose positron emission tomography combined with computed tomography (18F‐FDG‐PET/CT) with findings obtained using ultrasound (US), magnetic resonance imaging (MRI), and CT in patients with proven tubercular tubo‐ovarian masses.

Current concepts in voiding dysfunction and dysfunctional voiding: A review from a urogynaecologist's perspective

Background: Female voiding dysfunction is a complex disorder, lacks definition, and is poorly understood and difficult to manage. Causes of Female Voiding Dysfunction: As there is no agreed classification of female voiding dysfunction, it is important to identify the several potential factors that might cause voiding dysfunction, namely anatomic, neurogenic, pharmacologic, endocrine, pharmacological and other causes. Presentation and Clinical Evaluation: Traditional and novel techniques are available and the importance and diagnostic dilemma related to these conditions need to be understood. We conclude by emphasizing the need to simplify the diagnosis and nomenclature of these conditions from a more clinical point of view as against an investigational perspective.

Increased Difficulties and Complications Encountered During Hysteroscopy in Women with Genital Tuberculosis

BACKGROUND Genital tuberculosis (TB) in women is a common disease in developing countries, and hysteroscopy and laparoscopy are vital tools in diagnosis. STUDY OBJECTIVE To retrospectively compare the difficulties encountered and complications of hysteroscopy in women with and without genital TB. DESIGN Case-control clinical audit (Canadian Task Force classification II-1). SETTING Medical college and hospital. PATIENTS Ninety-nine women who underwent hysteroscopy, with or without other procedures, who were found to have genital TB at various investigations (group 1) and 289 women who underwent hysteroscopy during the same period with similar characteristics but without evidence of genital TB (group 2, controls). INTERVENTION Hysteroscopy. MEASUREMENTS AND MAIN RESULTS Difficulties encountered and complications observed were recorded, compared, and analyzed using the χ(2) and Fisher exact tests. Indications for hysteroscopy in the study vs the control group were infertility in 92 patients (92.92%) vs 124 (42.90 %), amenorrhea in 6 (6.66%) vs 12 (4.15%), and postmenopausal bleeding in 1 (1.11%) vs 29 (10.03%). Difficulties and complications were significantly higher in group 1. Inability to distend the cavity was observed in 8 women in group 1 (8.08%) vs 2 in group 2 (0.69%). Excessive bleeding was observed in 5 women in group 1 (5.05%) vs 1 in group 2 (0.35 %). Uterine perforation was observed in 8 women in group 1 (8.08%) vs 5 in group 2 (1.73%), and flare-up of genital TB was observed in 1 woman in group 1. CONCLUSION Hysteroscopy in women with genital TB is associated with difficulty in performing the procedure and with higher rates of complications.

Obstetric Considerations in a Rare Cardiovascular Catastrophe Needing Multidisciplinary Care

Cardiovascular emergencies especially aortic dissections are rare in pregnancy. We report a case of Stanford Type A aortic dissection at 33 weeks of pregnancy presenting in shock. Rapid multidisciplinary approach and special obstetric considerations led to a successful outcome in this case.

Dysgerminoma in the uterine cervix.

⁎ Corresponding author at: Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029, India. Tel.: +91 9650428656; fax: +91 11 26598665. E-mail address: dkcoolmed@yahoo.com (D. Karmakar). In December 2006, a 24-year-old married woman presented to the All India Institute of Medical Sciences, New Delhi, India, with a 1month history of abdominal pain. Examination revealed an abdominopelvic mass; ultrasound and computed tomography (CT) showed a solid cystic tumor originating from the right ovary and measuring 8×8 cm. The level of cancer antigen 125 (CA-125) was 31.5 U/mL; the level of lactate dehydrogenase (LDH) was 2189 U/L; the level of α-fetoprotein was 2.5 ng/mL; the level of β-human chorionic gonadotropin (hCG) was less than 1.2 U/mL. Laparoscopy revealed a right ovarian solid cystic tumor measuring 6×8 cm. There was a 1-cm deposit on the surface of the left ovary. Right ovarian cystectomy was performed, together with left ovarian biopsy and omentectomy (the patient did not give consent for ovariotomy). The woman subsequently received 4 cycles of bleomycin, etoposide, and cisplatin (BEP), following postoperative CT and repeat analysis of tumor markers. For the next 2 years, she was asymptomatic. Approximately 2.5 years after surgery, speculum examination during a followup visit revealed a 2×2-cm globular and friable mass on the anterior cervical lip. Under low-power (10×) magnification, the biopsied mass showed small islands of mildly pleomorphic discohesive cells surrounded by lymphocytic infiltrate. Under high-power (40×)magnification, the field showed discohesive cells with round nuclei, conspicuous nucleoli, and lymphocytic infiltrate—indicative of dysgerminoma (Fig. 1). The serum CA-125 level was 28.5 U/mL; the LDH level was 974 U/L; the α-fetoprotein level was 2.0 ng/mL; the β-hCG level was less than 1.2 U/mL. The woman underwent 3 additional cycles of BEP chemotherapy, and follow-up examination revealed complete regression of the cervical tumor. At the time of writing, shewas in good health after 2 years of follow-up. Dysgerminoma is the most common type of germ cell tumor and generally presents before the age of 40 years, with 75% of cases occurring in the second and third decades of life [1]. Ovarian germ cell tumors account for less than 5% of all ovarian malignancies; Fig. 1. Photomicrographs of cervical biopsy slides. A. Low-power (10×) magnification of stained slides (hematoxylin and eosin [HE]) of the cervical biopsy specimen. Image shows small islands of mildly pleomorphic discohesive cells surrounded by lymphocytic infiltrate, indicative of dysgerminoma. B. High-power (40×) magnification of stained (HE) slides of the cervical biopsy specimen. Image shows discohesive cells with round nuclei, conspicuous nucleoli, and lymphocytic infiltrate, indicative of dysgerminoma.

Treatment of typhoid perforation during pregnancy and the postpartum period

doi:10.1016/j.ijgo.2011.05.013 received the Pritchard regimen) and 53 (42.1%) in the imminent eclampsia group (of whom 37 [69.8%] received the low-dose regimen and 16 [30.2%] received the Pritchard regimen). The regimens were equally effective at preventing the occurrence of convulsions among women with imminent eclampsia; none of these women experienced convulsions. Among the women with eclampsia, none of those receiving the Pritchard regimen experienced recurrence of convulsions, compared with 6 (17.1%) women receiving the low-dose regimen (Table 1). One of these women experienced a 3rd recurrence after the 2nd additional dose of MgSO4 and was prescribed lorazepam instead, amounting to failure of therapy. Most recurrences of convulsions occurred within 0.5–1 hour after the loading dose, indicating that the loading dose of the low-dose regimen (4 g IV) was inadequate for treatment of eclampsia. The Pritchard regimenwas associatedwith severe toxicity, resulting in 1 death due to severe respiratory depression (serum magnesium level, 24 mEq/L). In the present study, only 13 (34.2%) of the women with eclampsia and 8 (50.0%) of the women with imminent eclampsia completed the Pritchard regimen. For 12 (31.6%) eclampticwomen, this regimen had to be discontinued owing to its toxicity. One maternal death occurred among the women receiving the low-dose regimen; it was due to internal bleeding associated with hemolytic anemia, elevated liver enzymes, and low platelet count syndrome and was not related to eclampsia or MgSO4. Thus, although the maternal mortality rates of the regimens were the same, the cause of death in each case was different. The low-dose MgSO4 regimen was associated with significantly lowermagnesium toxicity thanwas the Pritchard regimen (P=0.007), with nodiscontinuations occurringwith the former. Themeannumber ofMgSO4 doses received bywomen undergoing the low-dose regimen was significantly higher than that received by women undergoing the Pritchard regimen (P=0.028). Although MgSO4 is a uterine relaxant, there was no significant difference in themean induction–delivery interval between the regimens (P=0.337). There were no cases of morbidity (e.g. pain, inflammation, phlebitis, or gluteal abscess) related to the injection site. The present results indicate that, in cases of imminent eclampsia, the low-dose MgSO4 regimen is as effective as the Pritchard regimen and is associated with significantly less magnesium toxicity (P=0.014). In cases of eclampsia, its efficacy is significantly lower than that of the Pritchard regimen (P=0.003); however, the Pritchard regimen is associated with severe magnesium toxicity. In the present study, maternal morbidity/mortality and perinatal outcome were similar between the regimens. Further investigation is required to determine the most effective intermediate dosage regimen for slim women with eclampsia.