Jeevan P. Marasinghe

Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

Aim:  To report the occurrence of morbidity and mortality associated with carefully phenotyped pre‐eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease.

History, pelvic examination findings and mobility of ovaries as a sonographic marker to detect pelvic adhesions with fixed ovaries

To compare the performance of history and examination findings combined with transvaginal ultrasound (TVS) ‘soft marker’ evaluation of ovarian mobility for the prediction of fixed ovaries secondary to endometriosis at laparoscopy.

Modified anchored B-Lynch uterine compression suture for post partum bleeding with uterine atony

A prospective observational study was performed to evaluate the performance of a modified uterine compression suturing technique for the management of refractory post partum hemorrhage (PPH) at two leading tertiary referral centers in Colombo, Sri Lanka. An modified anchored B‐Lynch suture was done in 17 women with PPH due to uterine atony. In 13 of the women (76%), bleeding was arrested and the uterus conserved. Four women (24%) did not respond to the anchored compression sutures, necessitating emergency post partum hysterectomy. Mean age was 31.2 years. Nine of the women (53%) were primiparous and eight (47%) parous. Mean estimated blood loss was 1994 ml (range 1200–3300 ml). This newly modified anchor B‐Lynch compression suture appeared effective in controlling about 75% of PPH due to uterine atony, which allowed uterine conservation. This simple modification can provide a first line surgical step to control PPH.

Uterine compression sutures for post‐partum bleeding with atony; modification of the B‐Lynch suture

We have described a modification of the B‐Lynch uterine compression suture which is simple and effective. This technique apposes the anterior and posterior uterine walls, obliterating the cavity and thereby provides effective control of post‐partum haemorrhage as a result of uterine atony. It comprises of vertical compression sutures and is distinct from B‐Lynch and Haymens suture by having an additional firm puncture just below the uterine fundus. This means that the suture is transfixed at the uterine fundus, thus eliminating the risk of the sutures sliding off at the uterine fundus.

Comparison of transabdominal versus transvaginal ultrasound to measure thickness of the lower uterine segment at term

To compare the accuracy of transvaginal (TVS) versus transabdominal (TAS) ultrasound to assess the thickness of the lower uterine segment (LUS).

Pregnancy complicated by a uterine fundal defect resulting from a previous B‐Lynch suture

defect resulting from a previous B-Lynch suture YVAL Saman Kumara, JP Marasinghe, G Condous, U Marasinghe a Department of Obstetrics and Gynaecology, Colombo south Teaching Hospital, Kalubowila, Sri Lanka b Early Pregnancy and Advanced Endosurgery Unit, Nepean Clinical School, Nepean Hospital, University of Sydney, Sydney, New South Wales, Australia Correspondence: Dr JP Marasinghe, Senior Registrar in Obstetrics and Gynaecology, Colombo south Teaching Hospital, Kalubowila, Sri Lanka. E-mail jeevanmarasinghe@yahoo.com

Uterine Balloon Tamponade Device and Cervical Cerclage to Correct Partial Uterine Inversion during Puerperium; Case Report.

A healthy 26-year-old woman was noted to have residual uterine inversion after manual replacement of puerperal uterine inversion under general anaesthesia. This was corrected by the insertion of a balloon tamponade device. A cervical suture was applied to prevent ballooning of the device through the cervix. This little modification was immediately successful in preventing ballooning of the tamponade device. The whole idea was to overcome the need for a laparotomy. A review of the literature and the mechanism of action are discussed here.

Re: Intrauterine contraception as an alternative to interval tubal sterilization

We read with interest the article by Grimes and Mishell on intrauterine contraceptive devices (IUD) and tubal sterilization. They elaborate on the usefulness of IUD compared to interval tubal sterilization. However there are some issues that need further consideration. The cost of IUD especially the cost of levenogestrel-releasing IUD (LNG-IUS) should gather the most speculation. It is important to analyze 5-year cost of contraceptives and their effectiveness and choose the least expensive methods. Nonetheless the initial cost of LNG-IUS which is approximately £100 is not comparable with cost of interval tubal sterilization in low- and middle-income countries. Due to economic constraints LNG-IUS is yet a novel method of contraception in developing countries. There are other hindrances for effective implementation of IUD. Myths perpetuated by women regarding dangers of IUD must not be ignored. Misconception regarding IUD needs eradication by education that gains clients trust and reports of user satisfaction with IUD. Most complaints are related to cultural difficulties in accepting changes in menstrual pattern. Single-rod implantable contraceptive containing etonogestrel is another attractive method that can be offered to a variety of clients. It has high contraceptive efficacy and a satisfactory safety profile. The insertion and removal of it is an office-based procedure is fast and is uncomplicated. The action lasts for 3 years with prompt return of fertility. Contraceptive action is mainly by inhibition of ovulation. It can be offered to a wide range of age body weight and cultural backgrounds. Although disturbed bleeding pattern and weight gain are some known side effects the discontinuation rates can be lowered by counseling. This method can be offered to women after child birth with a variety of clinical problems such as maternal heart disease diabetes hypertension and autoimmune disease. It can also be offered to a breast-feeding mother. In our institution in which we have specialized clinics to cater to high-risk pregnancies nearly 30 women with medical disorders have accepted this method since its introduction in October 2007. At the time of reporting none required removal for medical reasons (unpublished data). In conclusion single-rod implantable contraceptive containing etonogestrel is another safe option for clients with comparable efficacy with IUD. (full text)

Polycystic ovary syndrome: a transgenerational evolutionary adaptation

Sir, We found the commentary by Shaw and Elton on a possible evolutionary advantage and differential survival of polycystic ovary syndrome (PCOS) most interesting.1 However, there are certain issues in this article that need further attention and consideration. In the food deprivation hypothesis, the authors have tried to explain ovulation among obese women who are genotypically PCOS by their rapid weight loss caused at times of seasonal deprivation of food. However, they fail to give a clear explanation of the possible mechanism for a reproductive advantage in this group. Reported interpopulation variation in the phenotypic expression of PCOS occurs in areas where there is not much seasonal food deprivation,2 which challenges this hypothesis. In the refeeding hypothesis, they have tried to explain the ready recruitment of part-recruited follicles that line the edge of the ovary in women with PCOS as they come out of severe food deprivation. Their conclusion that the first to ovulate by this mechanism have a reproductive advantage needs further explanation. The authors refer to the problem of these peripherally situated ova causing hyperstimulation in assisted reproduction, which might in fact imply that these ova are of questionable quality and not advantageous. This disadvantage in PCOS is supported by the demonstration of poor developmental capability of primary oocytes of women with PCOS when compared with normal women.3 Psychological stress might be yet another environmental factor that determines the phenotypic expression of a genetic susceptibility. PCOS itself is a generator of profound psychological distress. However, little is known regarding stress as a causative factor of PCOS. Stress-induced anovulation might increase the susceptibility of a woman to PCOS because increased sympathetic activity is reported to play a role in its development.4 More importantly, the evolving human experience in the past few decades on postponing the initial pregnancy,5 child spacing and reducing the family size must not be underestimated. Can PCOS be considered an adaptation of the ovaries for the futile effort that they have made, each month, over years, for continued propagation and expansion of mankind? Have the ovaries realised the fruitlessness of their monthly efforts? Could such an adaptation of ovaries have caused an evolutionary change by a transgenerational impact? Will there be an increasing trend of PCOS in the future due to change in the fertility pattern, use of hormonal contraception and stressful lifestyle of our contemporary global village? Hence, we propose further study on the relationship between stress, child spacing and PCOS. j

Acute acalculous cholecystitis due to dengue hemorrhagic fever during pregnancy.

A 29‐year‐old pregnant woman presented with fever, right hypochondrial pain and fatigability at 29 weeks of gestation. Dengue hemorrhagic fever was diagnosed based on clinical, hematological and serological features. However, ultrasound scanning was suggestive of acute acalculous cholecystitis. The patient was managed symptomatically and made a good recovery 8 days following onset of fever. This is the first case of acute acalculous cholecystitis coinciding with dengue hemorrhagic fever reported during pregnancy from an endemic country in Asia. The possible viral and host factors for the development of such a severe form of disease and preventive measures are discussed.