Manash Biswas

HPV vaccine: Current status and future directions.

HPV Vaccine was introduced to prevent cervical cancer known to be caused by infection with one or more of the high risk subtypes of the Human papilloma virus (HPV). Since introduction, trials have proven its efficacy in preventing Cervical intraepithelial neoplasia (CIN) beyond doubt and its effectiveness in preventing cervical cancer though presumptive is reasonably certain as per mathematical modelling. It also prevents other HPV related anogenital and oropharyngeal malignancies in both sexes. HPV vaccines have courted many controversies related to its efficacy, safety, ideal age of vaccination, use in HPV infected individuals and use in males. The currently available vaccines are based on L1 Viral like particles (VLP) and hence highly species specific, thermolabile, costly and are purely prophylactic. The quest for a cheaper, thermostable and broad spectrum vaccine has led to many newer prophylactic vaccines. Therapeutic vaccines were born out of the inescapable necessity considering high HPV related morbidity projected in the non HPV naïve population. Therapeutic vaccines would immediately reduce this burden and also help in the management of HPV related cancers alone or as part of combination strategies. Ongoing research is aimed at a total control over HPV related malignancies in the near future.

Tuberculosis of Cervix

Cervical tuberculosis accounts for 0.1-0.65% of all cases of tuberculosis (TB) [1]. Tuberculosis more frequently affects the upper genital tract-namely, the fallopian tubes and endometrium [2]. TB of the cervix is present in about 5% of the cases [3]. We present such a case due to the rarity of this condition and that it clinically mimics carcinoma of cervix.

Hepatic Rupture Complicating HELLP Syndrome in Pregnancy

Subcapsular hematoma and hepatic rupture are very unusual catastrophic complication of preeclampsia/eclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome [1]. The reported incidence of this condition varies from 1 in 40,000 to 1 in 2, 50,000 deliveries [2]. There is no agreement on the best approach to treat this severe complication of pregnancy and optimal management is still evolving. A multidisciplinary approach to the management of these patients can lead to remarkable decrease in the usual high mortality rate. We present a fatal case of severe preeclampsia, which rapidly progressed to HELLP syndrome, liver rupture, disseminated intravascular coagulation (DIC) and renal failure.

A study of assessment of patient safety climate in tertiary care hospitals

BACKGROUND Medical errors are being detected with increasing frequency in healthcare environment, in many cases leading to patient harm. Measurement and improvement of patient safety climate has been identified as a strategic effort towards addressing this vital issue. METHOD Safety Attitude Questionnaire (SAQ), validated by previous research was administered to 300 respondents in three tertiary care hospitals of India, the respondents representing various categories of healthcare workers and variations in safety scale score was analyzed by various statistical tools. RESULTS No variation was observed in the Patient Safety Index score among the study hospitals. However, significant variations were observed among different categories of healthcare workers across dimensions of Teamwork, Perception of Management and Stress Recognition. Multiple Regression models identified Teamwork and Perception of Management to have significant correlation with Patient Safety Index Score. CONCLUSION Patient Safety Climate can be effectively assessed and such assessment utilized for focused improvement efforts towards safety in healthcare organizations.

Medical Abortion-An Alternative to Surgical Abortion

BACKGROUND Termination of early pregnancy has traditionally been done surgically, but agents are now available which can terminate pregnancy if taken orally, vaginally or parenterally. We have used a combination of mifepristone and misoprostol for termination of early pregnancy. MATERIAL AND METHOD Fifty patients having amenorrhoea of upto 56 days with confirmed intrauterine pregnancy, were selected for medical termination of pregnancy. The patients were given tablet mifepristone (200mg) on day 1 and tablet misoprostol (400mcg) on day 3. On day 14, an ultrasound was done to confirm complete abortion. RESULT Majority 35 (70%) patients had amenorrhoea between 40 - 50 days. The duration of bleeding was less than 5 days in 12%, between 5 -10 days in 56%, 10 -13 days in 16% and greater than 14 days in 16%. In all patients with bleeding of more than 14 days ultrasonography confirmed intrauterine products & a suction evacuation was done. In this series there were no failures. CONCLUSION The combination of mifepristone and misoprostol is an effective method for termination of early pregnancy up to 56 days of amenorrhoea.

An analysis of endometrial bleeding patterns in perimenopausal women

Background: Perimenopause is the period surrounding menopause characterized by ovulatory dysfunction and menstrual irregularities. Taking into consideration the importance of perimenopause and its consequences, we decided to study this topic in order to know the different menstrual irregularities in relation to age, the spectrum of endometrial histopathology, in relation to various gynaecological conditions as per the PALMCOEIN classification of AUB. Methods: The study population comprised of 100 women in the age group of 40- 59 years who reported to our tertiary care centre of Armed Forces for evaluation of abnormal uterine bleeding. The study was a community based cross - sectional descriptive study. Patients were examined, using one of the three techniques – Dilatation and curettage, suction aspiration and hysteroscopy and endometrial biopsy. Results: Out of the 100 women evaluated for perimenopausal bleeding, heavy menstrual bleeding was the commonest in 53% cases. The maximum no. of cases was in 40-44-year age group (57.44 %). The clinical diagnosis of fibroid uterus was found in 45% cases, AUB (O) in 36% cases, AUB (Polyp) in 8% cases, AUB (Adenomyosis) in 9% cases and AUB (Malignancy) in 2% cases. On endometrial curettage, proliferative type of endometrium was found in 43% cases, secretory type in 18% cases and hyperplasia was found in 37% cases. Out of 2 cases of atypical hyperplasia 1 case each (50%) was found in the age group of 50-54 years and 55-59 years, respectively. Conclusions: In the present study, there was good correlation between abnormal uterine bleeding, clinical diagnosis and histopathological findings.

ITP with severe thrombocytopenia in pregnancy

Thrombocytopenia is second common hematological disorder in pregnancy with an incidence of 6-15%. Most common cause of low platelets in pregnancy is gestational thrombocytopenia followed by infections, hypertensive disorders of pregnancy and idipathic thrombocytopenic purpura. We are presenting a case of ITP with severe thrombocytopenia resulted in adverse perinatal outcome.

Evaluation of the incidence and outcome of gestational diabetes mellitus using the current international consensus guidelines for diagnosing hyperglycaemia in pregnancy

Background: Diabetes Mellitus in pregnancy has long been recognized as a serious problem for both mother and fetus. Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. Even though there are many diagnostic criteria and guidelines for management of GDM, there still exists lack of consensus regarding diagnosis and management of patients with GDM. After Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, International Association of Diabetes in Pregnancy Study Group (IADPSG) has formulated a new consensus guideline for diagnosing hyperglycaemia in pregnancy which has formed the back bone for this particular study. The aim of this study was to assess the incidence of GDM using current international consensus guidelines with 75g Oral Glucose Tolerance Test (OGTT) and evaluation of maternal and fetal outcome. Methods: All antenatal patients were screened for GDM with 75g OGTT and their glycaemic control was evaluated throughout pregnancy. Either Medical Nutritional Therapy or Oral Hypoglycaemic Agents or Insulin Therapy was advised for glycaemic control. Maternal and neonatal outcomes were evaluated. Results: A total of 856 Antenatal patients were screened and 111 were diagnosed as GDM, showing an incidence of 13%. Medical Nutritional Therapy was found to be an effective method for glycaemic control in GDM. Conclusions: The incidence of GDM in the studied population was found to be 13%. Previous history of GDM was found to be the most significant high risk factor associated with GDM followed by family history of Diabetes. Medical Nutritional Therapy was found to be highly effective in the management of GDM. Only 9% of GDM patients required insulin therapy. With adequate glycaemic control, all late pregnancy complications and neonatal complications can be alleviated.

Abdominal cerclage revisited

Since the initial description in 1658 of the cervix being ‘so slack that it cannot keep in the seed’ by Cole and Culpepper1 few subjects in obstetrics have generated as much controversy as the term ‘cervical incompetence’, or as more recently referred ‘cervical insufficiency’. The incidence of cervical insufficiency in the general obstetric population is reported to vary from 1:100 to 1:2,000.2–4 In patients with a hypoplastic cervix, such as those exposed to diethylstilboestrol (DES) in utero, history of a large cervical conisation or a prior history of failed vaginal cerclage, an abdominal cerclage has been recommended.5 A case of cervical insufficiency treated with transabdominal cerclage (TAC) placement is reported for the rarity of the procedure performed.

Vaginal Agenesis in Mayer Rokitansky Kuster Hauser Syndrome

The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina. The first sign of MRKH syndrome is primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries and karyotype 46, XX [1]. The vaginal agenesis in this syndrome can be treated by various methods, both surgical and nonsurgical. We present a case treated by creating a neovagina using amnion as a graft for the vaginoplasty.