G. R. V. Prasad

Pelvic artery embolization in the management of obstetric hemorrhage

We studied the role of pelvic artery embolization in management of obstetric hemorrhage by retrospective analysis of 50 cases of obstetric hemorrhage in a tertiary care referral hospital where this procedure was used. Uterine and or internal iliac artery embolization was performed for the management of postpartum hemorrhage (39 cases; 78%), post abortal bleeding (6 cases; 12%) and gestational trophoblastic disease (4 cases; 8%). In one case of postpartum hemorrhage procedure could not be performed due to arterial spasm (2%). Prophylactic embolization was carried out in one case of placenta accreta. The mean age of the women was 27 years and 54% were primiparas. In six women embolization was done after hysterectomy failed to control pelvic hemorrhage. One fourth of women had coagulopathy at the time of presentation. There were five cases of pelvic hematoma and three cases of arteriovenous malformations. The success rate of the procedure was 94% and the procedure was unsuccessful for controlling bleeding in three women. There were no major procedure related complications. Thus, pelvic artery embolization is an effective alternative to surgery in controlling obstetric hemorrhage and as a fertility and life‐saving procedure.

Pregnancy complicated by severe chronic hypertension: a 10-year analysis from a developing country.

Objective: To assess pregnancy outcome in patients with severe chronic hypertension. Methods: A retrospective analysis of a 10-year period (1995–2004) in a referral hospital in northern India. The outcome was compared with those women with mild chronic hypertension who registered in the hypertensive disorders with pregnancy clinic immediately before and after each woman with severe chronic hypertension. Results: Hospital data identified 25 such women. Superimposed preeclampsia (36.4% versus 8%), preterm delivery (86.4% versus 42%), and perinatal mortality (27.2% versus none) were increased in patients with severe chronic hypertension as compared to those with mild hypertension. Conclusions: The small number of cases reflects the lack of antenatal supervision in developing countries. A much larger number of women are referred in the third trimester with eclampsia or severe preeclampsia, at which time it is not possible to identify whether or not they had underlying hypertension. Adverse events were found to occur more often in patients with severe chronic hypertension compared with those with mild hypertension.

Uterine necrosis and lumbosacral-plexopathy following pelvic vessel embolization for postpartum haemorrhage: report of two cases and review of literature

AbstractWe are reporting two cases of uterine necrosis and lumbosacral-plexopathy in patients, who underwent pelvic vessel embolization (PVE) following postpartum hemorrhage. Embolization was performed with gelfoam slurry, polyvinyl alcohol (PVA) particles and coil in one patient and with gelfoam slurry only, in second patient. Both patients had lower limbs weakness and had persistent fever in the postembolization period. Nerve conduction study in both were suggestive of common peroneal and tibial neuropathy. An ultrasonography and computed tomography of abdomen and pelvis revealed bulky uterus with no identifiable endometrium and multiple air foci in subendometrial region suggestive of uterine necrosis, confirmed later by histology of expelled uterine mass. Lumbosacral ischemia resulting in paraparesis and uterine necrosis presenting as longstanding fever after embolization are extremely rare but overwhelming complications of embolization. Only 19 cases of uterine necrosis and <10 cases of lumbosacral plexopathy have been reported in the literature. The overall effectiveness of PVE is high in treatment of obstetric hemorrhage with low complication rate and highly selective PVE may further prevent these complication. To the best of our knowledge the co-existing uterine necrosis and lumbosacral plexopathy secondry to PVE has not been described prevoiusly in patients with postpartum hemorrhage. Both patients recovered with conservative management.

Scrub typhus in pregnancy: a case series.

Scrub typhus, an acute febrile illness caused by Rickettsia and transmitted by mites, is a re-emerging endemic zoonosis in the Asia Pacific region. It is an uncommon entity and very few cases of this disease in pregnant women have been reported. We present a series of six such cases collected over 1 year with poor feto-maternal outcome in 50%.

Obstetric Complications and Management in Chronic Myeloid Leukemia

Chronic myeloid leukaemia (CML) is amongst the most common haematological malignancies encountered in adults. The younger age of onset and increased incidence of CML in Indians leads to higher chances of encountering it in pregnancy. Pregnancy in CML is a complex situation as first line therapy with tyrosine kinase inhibitors (TKI), is fraught with multiple fetal safety issues. The fetal aspects have been elucidated in literature, but there is scarcity of information on the obstetric outcome per se in presence of CML, excluding the influence of TKI. Obstetric outcomes of 5 pregnancies in four patients with CML are being reported. Literature on interplay of CML and bleeding or thrombotic manifestations is reviewed. The major complications encountered were antepartum (APH) and postpartum haemorrhage (PPH), preterm labour, intrauterine growth retardation and intrauterine fetal death. Patients in the reproductive age group with diagnosis of CML should be carefully counseled regarding the effect of disease and TKI on the maternal-fetal health. Bleeding complications, particularly APH and PPH may be encountered in CML patients. Close coordination of the obstetrician, haematologist, and neonatologist is required in managing these cases successfully. The need for absolute contraception till the remission of disease needs to be emphasized for further pregnancies.

Individualistic approach to the management of complete hydatidiform mole with coexisting live fetus

Complete hydatidiform mole with a coexisting live fetus (CHMCF) is a rare obstetric occurrence. So far, approximately 177 cases have been documented in the literature with consequent 66 live births. We report a review article along with two cases of CHMCF, one presenting as incomplete abortion and other continued as CHMCF but terminated because of antepartum hemorrhage. Both had histopathologically proven one normal and other complete molar placenta with coexisting normal fetus. No evidence of persistent trophoblastic disease was observed. The dilemma of continuation versus termination of pregnancy is being emphasized in the review of literature. Pregnancy complicated by CHMCF may result in a viable live born infant in approximately one third of the cases. A potentially viable fetus with CHMCF may result in normal live birth with antecedent high risk maternal complications. A decision of termination of pregnancy in all CHMCF will however nullify all the chances of a live birth. An individualistic approach and an informed doctor patient consensus may improve the likely outcome. Appropriate counseling of the mother regarding high incidence of antenatal complications plays an integral part of decision of continuation of such pregnancies.

Multidrug-Resistant Tuberculosis during Pregnancy: Two Case Reports and Review of the Literature

Multidrug-resistant tuberculosis (MDR-TB) is identified from the time of introduction of antituberculosis treatment and is a known worldwide public health crisis affecting women of reproductive age group. Management issues raised by pregnant women with MDR tuberculosis are challenging due to the limited clinical experience available with the use of second line drugs. We hereby report two cases of MDR-TB during pregnancy: one patient was on second line drugs, while another one was evaluated and diagnosed to have MDR-TB in last trimester. At 6 months of follow-up both mothers and babies are doing well. The approach to such cases along with review of the literature is discussed.

The accuracy of integrated [ 18 F] fluorodeoxyglucose-positron emission tomography/computed tomography in detection of pelvic and para-aortic nodal metastasis in patients with high risk endometrial cancer

Lymph nodal (LN) metastasis is the most important prognostic factor in high-risk endometrial cancer. However, the benefit of routine lymphadenectomy in endometrial cancer is controversial. This study was conducted to assess the accuracy of [18F] fluorodeoxyglucose-positron emission tomography/computed tomography ([18F] FDG-PET/CT) in detection of pelvic and para-aortic nodal metastases in high-risk endometrial cancer. 20 patients with high-risk endometrial carcinoma underwent [18F] FDG-PET/CT followed by total abdominal hysterectomy, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy with or without para-aortic lymphadenectomy. The findings on histopathology were compared with [18F] FDG-PET/CT findings to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of [18F] FDG-PET/CT. The pelvic nodal findings were analyzed on a patient and nodal chain based criteria. The para-aortic nodal findings were reported separately. Histopathology documented nodal involvement in two patients (10%). For detection of pelvic nodes, on a patient based analysis, [18F] FDG-PET/CT had a sensitivity of 100%, specificity of 61.11%, PPV of 22.22%, NPV of 100% and accuracy of 65% and on a nodal chain based analysis, [18F] FDG-PET/CT had a sensitivity of 100%, specificity of 80%, PPV of 20%, NPV of 100%, and accuracy of 80.95%. For detection of para-aortic nodes, [18F] FDG-PET/CT had sensitivity of 100%, specificity of 66.67%, PPV of 20%, NPV of 100%, and accuracy of 69.23%. Although [18F] FDG-PET/CT has high sensitivity for detection of LN metastasis in endometrial carcinoma, it had moderate accuracy and high false positivity. However, the high NPV is important in selecting patients in whom lymphadenectomy may be omitted.

Papanicolaou smear abnormalities in HIV-infected women in north India

Background:  Dysplasia on Papanicolaou (Pap) smears have been reported in 15–40% of HIV‐positive women. These rates are 10–11 times higher than those observed among HIV‐negative women. Both the Center for Disease Control and Prevention and the Agency for Healthcare Policy and Research recommend that HIV‐infected women have a gynecologic evaluation including a Pap smear and pelvic examination as part of their initial evaluation.

Successful Feto-maternal Outcome Following Pregnancy in a Patient with Krukenberg Tumor: Case Report and Review of Literature

Described originally by Friedrich Krukenberg in 1896, Krukenberg tumors represent metastatic ovarian adenocarcinoma usually secondary to a gastric malignancy. Occurrence of Krukenberg tumor during pregnancy is a very rare event [1, 2]. We report a young lady with bilateral Krukenberg tumors and pregnancy who had a successful feto-maternal outcome without active oncologic intervention during pregnancy. Case Report