Joydev Mukherji

Aromatase inhibitors in recurrent ovarian endometriomas: report of five cases with literature review

OBJECTIVE To determine the role of the aromatase inhibitor letrozole in the treatment of recurrent ovarian endometrioma cases. DESIGN Nonrandomized proof of concept study. SETTINGS Outpatient tertiary-care center. PATIENT(S) Five premenopausal patients with documented ovarian endometriomas and chronic pelvic pain, all of whom were previously treated with surgery and medicine with unsatisfactory results. INTERVENTION(S) Ovarian endometriomas were diagnosed by biopsy after laparoscopic ovarian cystectomy and subsequently treated with hormones. After a 6-month washout of endometriosis hormone therapies, women took letrozole (2.5 mg), one tablet of 0.15 mg of desogestrel, and 0.03 mg of ethinyl estradiol, calcium (1,200 mg), and vitamin D3 (800 IU) daily for 6 months. MAIN OUTCOME MEASURE(S) Size of endometriomas (monitored by ultrasound), assessment of pelvic pain (by visual analog scale), and bone density (DEXA scan). RESULT(S) Disappearance of ovarian endometrioma and reduction in pelvic pain in all cases at the end of 6 months. The size of ovarian endometriomas was reduced after 3 months. Pain scores decreased only after 1 month of treatment and continued decreasing in each treatment month. Overall, no significant change in bone density was detected. CONCLUSION(S) Letrozole given with combined pills achieved complete regression of recurrent endometriotic cysts and pain relief in all cases.

Relaparotomy after cesarean delivery: Experience from an Indian teaching hospital

Aim:  Analysis of cases requiring relaparotomy following cesarean delivery (within 6 weeks of surgery).

Maternal mortality and cesarean delivery: An analytical observational study

Aim:  Pregnant women and their doctors need to know the maternal risks associated with different methods of delivery. There are few publications with ideal study design and adequate power to establish the relationship between maternal mortality and mode of delivery. The present retrospective cohort study was undertaken to evaluate the intrinsic risk of maternal death, directly attributed to cesarean delivery (CD) compared to vaginal delivery (VD), and to evaluate further the differential risk associated with antepartum and intrapartum CD.

Outcome in Second- versus First-Stage Cesarean Delivery in a Teaching Institution in Eastern India

We evaluated the maternal and perinatal complications of cesarean delivery performed in the second stage compared with the first stage of labor in nulliparous women. We performed a hospital-based cohort study in a teaching institution in Kolkata, West Bengal, India. The primary maternal outcomes measured included intraoperative surgical complications, duration of surgery, need for blood transfusion, wound infection, transfer to intensive care unit, and length of hospital stay. The neonatal outcomes included 5-minute Apgar score 3 or less, need for endotracheal intubation, admission to neonatal intensive care unit, fetal injury, septicemia, neonatal seizures, and neonatal death. There were 1702 cesarean deliveries performed in the first stage and 124 cases in the second stage. Cesarean deliveries performed in the second stage were associated with longer operation time and increased need for blood transfusion, rates of wound infection, intraoperative complications, and need for transfer to intensive care unit. Neonatal complications included significantly low Apgar score at 5 minutes, increased neonatal death, admission to neonatal intensive care unit, increased need for intubation, septicemia, neonatal seizures, and fetal injury (all having P < 0.05). Cesarean deliveries performed in the second stage of labor were associated with higher rates of maternal and neonatal complications.

Maternal mortality in India: a 20-year study from a large referral medical college hospital West Bengal.

Aim:  The present study was carried out to analyze the maternal death rate and its changing trends over a 20‐year period in a large referral/teaching institution in Eastern India.

Does route of delivery affect maternal and perinatal outcome in women with eclampsia? A randomized controlled pilot study

OBJECTIVE The route of delivery in eclampsia is controversial. We hypothesized that adverse maternal and perinatal outcomes may not be improved by early cesarean delivery. STUDY DESIGN This was a randomized controlled exploratory trial carried out in a rural teaching institution. In all, 200 eclampsia cases, carrying ≥34 weeks, were allocated to either cesarean or vaginal delivery. Composite maternal and perinatal event rates (death and severe morbidity) were compared by intention-to-treat principle. RESULTS Groups were comparable at baseline with respect to age and key clinical parameters. Maternal event rate was similar: 10.89% in the cesarean arm vs 7.07% for vaginal delivery (relative risk, 1.54; 95% confidence interval, 0.62-3.81). Although the neonatal event rate was less in cesarean delivery-9.90% vs 19.19% (relative risk, 0.52; 95% confidence interval, 0.25-1.05)-the difference was not significant statistically. CONCLUSION A policy of early cesarean delivery in eclampsia, carrying ≥34 weeks, is not associated with better outcomes.

Randomized controlled trial of elevation of the fetal head with a fetal pillow during cesarean delivery at full cervical dilatation

To evaluate whether use of the Fetal Pillow (Safe Obstetric Systems, Shenfield, UK) affects maternal and fetal morbidity in cesarean delivery at full cervical dilatation.

Pleural Endometriosis: An Exceptional Cause of Hemorrhagic Pleural Effusion

The differential diagnosis of bloody pleural effusions is relatively narrow. Trauma, iatrogenic or otherwise, represents the most common cause of hemothorax. Other common causes of bloody pleural effusion include malignancy (primary or metastatic), tuberculosis, pulmonary embolism, and serositis from collagen vascular diseases such as rheumatoid arthritis and systemic lupus erythematosus. Clinical history along with pathologic, microbiologic, and biochemical evaluation pleural fluid evaluations confirm the diagnosis in most cases. However, if repeated pleural fluid examination reveals only hemorrhagic effusion without corroborative history or mass lesion in lung, or evidence of microorganisms, then a search for uncommon etiology is necessary. Endometriosis most commonly occurs in the ovaries, uterine ligaments, rectovaginal septum, Cul-de-sac, and the surrounding peritoneum of pelvic organs [1]. Thoracic endometriosis syndrome (TES) is an exceptional condition. There were reported only 38 pathologically documented cases of TES (pleural–21 cases, and parenchymal–17 cases) in the literature till the year 2000 [1]. One such rare case of pleural endometriosis which created an enormous diagnostic dilemma and ultimately confirmed by histopathologic study is being described.

Cervical length measurement in nulliparous women at term by ultrasound & its relationship to spontaneous onset of labour

Background & objectives: Data on serial cervical length (CL) measurements in pregnancy at term to predict spontaneous labour onset are scarce and conflicting. This study was conducted to observe CL changes preceding spontaneous onset of labour, by serial transvaginal sonography (TVS) and transabdominal sonography (TAS), in nulliparous Indian women near term. Methods: Only nulliparous women with a singleton foetus in cephalic presentation and who confirmed their gestational age were recruited. Sonographic CL measurements were taken at weekly intervals from 36 wk gestation onwards by a single ultrasonologist. Transabdominal and transvaginal measurements were undertaken using the suitable transducer probes with the women in the supine position. Results: A total of 104 women with spontaneous onset of labour were evaluated. There was substantial variation in CL measurements, both by TVS and by TAS, from 36 to 40 wk gestation, although the two sets of measurements correlated closely. Mean CL changed significantly over the last three weeks before delivery. However, only one-third of the women showed CL change of >5 mm per week in the last three weeks. There was poor correlation between gestational age at delivery and the last measured CL, either by TVS or TAS. Length >3.1 mm, measured by TVS at 38 wk gestation, predicted post-dated pregnancy to a limited extent. Interpretation & conclusions: Inter-individual variations in CL and in CL changes were large. Thus, it was not practical to predict spontaneous onset of labour by sonographic CL measurement near term. Post-dated pregnancy may be predicted with limited success. Further studies should explore other parameters, in addition to CL.

THE IMPACT OF CERV ICAL DILATATION AT ADMISSION ON LABOUR OUTCOMES

Objective of the study was t o examine the outcome differences between women presenting in early and late phase of labor. We evaluated all low - risk women with t erm (37 – 42 weeks), singleton , vertex presentation who presented in early labor ( 4cm cervical dilatation at admission only 9.6% nulliparas and 5.9% multipara required Caesarean section. Women presenting at <4 cm dilatation also spent less time in labor before their first vaginal examination; they had a higher rate of ARM and oxytocin administration as methods for labor augmen tation. The study confirms that interventions like caesarean delivery, operative vaginal delivery and augmentation of labor are increased if patients are admitted in the earl y labor . However, the fact that delayed admission has advantages in this regard ne eds to be corroborated through further studies.