Jaswinder Kalra

Pheochromocytoma associated with pregnancy

Pheochromocytoma associated with pregnancy is rare with potentially lethal consequences. Antepartum diagnosis improves the maternal and perinatal outcome. The issue of mode of delivery is unresolved. Its definitive treatment is surgical resection preceded by medical management. Surgical resection may be done during caesarean section as is reported in the present case.

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.

Congenital vesicovaginal fistula with transverse vaginal septum and ectopic ureter opening in proximal vagina: case report and brief review

Congenital vesicovaginal fistula is an extreme rarity. We report on a case of a 22-year-old lady who presented with menouria and infertility. On evaluation, she was found to have congenital vesicovaginal fistula, a nonfunctioning right kidney with ectopic ureter and transverse vaginal septum. Abdominal repair of the fistula, right nephroureterectomy, and excision of the vaginal septum was performed.

Mean gestation at delivery and histological chorioamnionitis correlates with early-onset neonatal sepsis following expectant management in pPROM

Abstract This prospective observational study was carried out in India among 100 women with preterm pre-labour rupture of membranes (pPROM) between 260/7–330/7 weeks on expectant management in order to correlate early-onset neonatal sepsis (EONS) with various features of chorioamnionitis. The incidence of pPROM during the study period of 1.5 years was 7%. The mean gestation at pPROM was 306/7 ± 1.8 weeks and at delivery was 321/7 ± 1 weeks. Features of chorioamnionitis in the form of clinical, microbiological, histological or a combination of these were observed in 70/100 women. Clinical chorioamnionitis was seen in 16%, bacterial isolates were present in 30% on cervical swab and in 39% on placental membrane culture and 19% had histological chorioamnionitis. EONS was present in 23/97 (24%). Clinical chorioamnionitis (p = 0.069), bacterial isolates on cervical swab (p = 0.56) or placental membranes (p = 0.39) were not found to predict EONS; whereas histological chorioamnionitis (p = 0.002) and lower gestation at delivery (p = 0.013) were significantly associated with EONS.

Cervical pregnancy and therapeutic options

Of all forms of ectopic gestation, the possibility of fertility catastrophe is highest with a cervical pregnancy. Though rare, it is a potentially life-threatening condition. In the past it was diagnosed late, after there was profuse hemorrhage from the cervix and it usually required hysterectomy. With ultrasound, diagnosis can be made earlier and conservative management attempted in order to preserve the reproductive potential. Methotrexate has been used both systemically and intra-amniotically to treat cervical ectopic gestation conservatively (1).

Vascular endothelial growth factor (VEGF) induced proliferation of human fetal derived ciliary epithelium stem cells is mediated by jagged-N cadherin pathway.

The pigmented ciliary epithelium (PCE) of mammalian eye harbors resident population of stem cells that lie in apposition with endothelial cells which release vascular endothelial growth factor (VEGF) that may influence the fate and function of these stem cells in ways that remain unclear. We examined the role of VEGF in proliferation of PCE stem cells and expression of Notch, Jagged, N-Cadherin and β-Catenin which are known to maintain proliferation state of neural stem cells. We cultured human PCE cells obtained from 12-20 weeks old fetal eyes. The neurospheres were analyzed for the proliferation capacity of PCE stem cells in presence of VEGF on 3,6 and 9 day. Real time PCR was used to quantitate the mRNA expression of above mentioned genes on PCE derived neurospheres on 3,6 and 9 day. We found increased number of neurospheres when PCE stem cells were stimulated with VEGF along with epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) than EGF and bFGF. BrdU immunostaining was done to analyze the proliferation of CE cells and presence of neural and retinal progenitor markers such as Nestin and Pax6 were also investigated. An increased Notch and Jagged mRNA was observed on 6(th) day in VEGF, EGF and bFGF treated PCE cells as compared to 0,3 and 9 day. A similar pattern was noticed with N-cadherin and β-catenin mRNA levels. These findings may clarify the role of VEGF on PCE stem cell proliferation with possible involvement of Notch, Jagged, N-cadherin and β-Catenin. The data may suggest importance of harvesting 6(th) day neurospheres for transplantation purposes in preclinical investigations pertaining to retinal degenerative diseases, however, additional studies are needed to substantiate the findings.

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%.

Labour induction with an intermediate-dose oxytocin regimen has advantages over a high-dose regimen

Abstract A total of 200 women planned for labour induction were randomised to receive high-dose oxytocin (6 mU/min with similar increments every 45 min) or intermediate-dose oxytocin (3 mU/min with similar increments every 45 min). Oxytocin solution was prepared with 30 units in 500 ml saline with which the infusion rate in ml/h is numerically equal to oxytocin in mU/min. We observed that the caesarean rate (18% vs 6%, p = 0.009), contraction abnormalities (35% vs 14%, p = 0.0005) and neonatal bilirubin levels (7.99 ± 2.70 vs 6.80 ± 2.65, p = 0.002) were higher with high-dose than with intermediate-dose. The induction–delivery interval (IDI) was similar (10 h 13 min with high-dose and 11 h 5 min with intermediate-dose; p = 0.237, NS). Nulliparous women benefited more with intermediate-dose as the caesarean rate was higher with high-dose (24.6% vs 7.9%, p = 0.011). Although the caesarean rate was higher in multiparous women with high-dose oxytocin, it was statistically not significant (5.7% vs 2.7%; p = 0.609). Oxytocin regimens for labour induction are usually high-dose (4–6 mU/min) or low-dose (1–1.5 mU/min). The former is associated with more contraction abnormalities and the latter with prolonged IDI; both result in an increased caesarean rate. In order to offset these disadvantages, an intermediate- dose regimen was selected. The increment interval of 45 min was selected in accordance with the pharmacokinetics of oxytocin. We observed a lower caesarean rate when compared with the high-dose regimen, without any increase in the IDI. Hence, we propose that the intermediate-dose oxytocin regimen should be preferred to the high-dose regimen for labour induction.

Paraneoplastic cerebellar degeneration with ovarian endometroid carcinoma

A 60-year-old woman was admitted with complaints of tremulousness of body and limbs and change in speech of 3 years duration and awareness of mass abdomen of 4 months duration. Initially she noticed tremulousness of hands on target-oriented activities and unsteadiness of gait. Gradually the tremulousness progressed to involve the head and trunk. Speech became slurred, although the volume of the speech was normal and it was coherent. There was no history of diplopia, oscillopsia, decreased vision, headache, vomiting, dysphagia, nasal regurgitation, motor weakness, sensory loss, bladder or bowel dysfunction or cranial nerve involvement. She had noticed a painless mass in the lower abdomen 4 months ago that had gradually increased in size. She had a history of weight loss over the past 3 years although her appetite was normal. There was no history of constipation, cold intolerance or drug intake. She was a housewife, a mother of three children, had attained menopause 10 years ago and had no history of postmenopausal bleeding. There was no family history of similar complaints. On examination the patient was fully conscious, alert and hemodynamically stable. Higher mental functions and cranial nerves were normal. Speech was slow and scanning. Mild generalized hypotonia was present. Sensory system and reflexes were normal. She had signs of pancerebellar dysfunction characterized by the presence of titubation, dysdiadochokinesis, dysarthria, gait and stance ataxia, a positive finger nose and heel knee test, broken pursuits and bilateral gaze evoked nystagmus. There were no meningeal signs. Abdominal examination revealed a hard, nontender, irregular mass about 10 20 cm arising out of the pelvis with restricted mobility. There was no free fluid in the abdomen. The mass was felt through all the fornices. The uterus could not be felt separately. There was no nodularity in the pouch of Douglas. On investigation, the hemogram, chest X-ray, renal, liver and thyroid function were normal. Ultrasound and computed tomography (CT) scan of the abdomen revealed a 10 20 cm echogenic mass with a few anechoic areas arising out of the pelvis and pushing the uterus anteriorly. The ovaries could not be visualized and there was no free fluid. A magnetic resonance imaging (MRI) brain scan did not show any mass lesion or sign of cerebellar atrophy. A diagnosis of PCD due to ovarian malignancy was made. The patient underwent an exploratory laparotomy that revealed a 20 12 cm right ovarian tumor with irregular surface. The left ovary and uterus were normal. There was no macroscopic evidence of metastasis in the abdomen. Total abdominal hysterectomy with bilateral salpingooopherectomy with infracolic omentectomy and pelvic lymphadenectomy was performed. Histopathology of the resected tissues revealed a well-differentiated endometroid carcinoma confined to the right ovary with no extraovarian spread. The postoperative period was uneventful. On followup at 3 months no improvement in neurological status was observed.

Resveratrol restores the level of key inflammatory cytokines and RANKL/OPG ratio in the femur of rat osteoporosis model

ABSTRACT Resveratrol’s effect on bone mineral density (BMD) and expression of cytokines in ovariectomized rats (postmenopausal osteoporosis model) was studied. The study was conducted on 3-month-old Sprague-Dawley rats that were (a) sham-operated, (b) ovariectomized, (c) ovariectomized and treated with β-estradiol (487.5 µg/kg weight/day), and (d) ovariectomized and treated with resveratrol (625 µg/Kg body weight/day). The treatment was for 4 weeks. After sacrifice BMD and gene expression (RANKL, OPG, IL-23, and IL-17A, IL-1β, and TNFα) were measured in tibia and femur respectively. Resveratrol could restore RANKL/OPG ratio, slightly increase BMD, and moderately but significantly reduce IL-23, IL-17A, IL-1β, and TNF-α cytokine expression levels.