Muralidhar Pai

Umbilical laparoscopic scar endometriosis.

Umbilical endometriosis is rare and challenging in both diagnosis and treatment. We report a case of an umbilical scar endometriotic nodule in a 39-year-old lady following laparoscopy-assisted vaginal hysterectomy. The wide local excision of the nodule and histopathological examination confirmed the diagnosis. We discuss the pathogenesis, diagnosis, differential diagnosis, and treatment options for the patient.

Society of Fetal Medicine Practice Guidelines for the Second Trimester Anomalies Scan

Ultrasound is now an established tool in the clinical management of pregnancy. Consequent to its major role in clinical decision-making and its remarkable operator dependence, it is necessary to have guidelines for minimum standards of performance of this modality in each area of obstetric ultrasound. The Society of Fetal Medicine guidelines have been developed for use by all the practitioners performing antenatal ultrasound scans. They are intended to provide the entire medical community with standards for the performance of quality ultrasound examinations. Practitioners are encouraged to go beyond these standards in relevant clinical situations. Each guideline in this document has undergone extensive discussion followed by a consensus. In a rapidly evolving technological and research environment, it is imperative to constantly re-evaluate and update these guidelines. Practitioners are advised to be aware of these updates and incorporate these into their daily practice.

Prenatal Diagnosis of Congenital Mesenchymal Hamartoma of Liver: A Case Report

Hepatic mesenchymal hamartoma is a rare benign tumor. We present an unusual case of a fetal abdominal cyst, later diagnosed histopathologically to be mesenchymal hamartoma of liver. The organ of origin was indeterminate on both prenatal and postnatal ultrasounds. As there are no specific sonological findings, whenever a large multicystic fetal abdominal cyst is seen, mesenchymal hamartoma should be considered as a possibility.

Quantifying Proteinuria in Hypertensive Disorders of Pregnancy

Background. Progressive proteinuria indicates worsening of the condition in hypertensive disorders of pregnancy and hence its quantification guides clinician in decision making and treatment planning. Objective. To evaluate the efficacy of spot dipstick analysis and urinary protein-creatinine ratio (UPCR) in hypertensive disease of pregnancy for predicting 24-hour proteinuria. Subjects and Methods. A total of 102 patients qualifying inclusion criteria were evaluated with preadmission urine dipstick test and UPCR performed on spot voided sample. After admission, the entire 24-hour urine sample was collected and analysed for daily protein excretion. Dipstick estimation and UPCR were compared to the 24-hour results. Results. Seventy-eight patients (76.5%) had significant proteinuria of more than 300 mg/24 h. Dipstick method showed 59% sensitivity and 67% specificity for prediction of significant proteinuria. Area under curve for UPCR was 0.89 (95% CI: 0.83 to 0.95, P < 0.001) showing 82% sensitivity and 12.5% false positive rate for cutoff value of 0.45. Higher cutoff values (1.46 and 1.83) predicted heavy proteinuria (2 g and 3 g/24 h, resp.). Conclusion. This study suggests that random urinary protein : creatine ratio is a reliable investigation compared to dipstick method to assess proteinuria in hypertensive pregnant women. However, clinical laboratories should standardize the reference values for their setup.

MRI Sequence and Characteristic Features in ‘Giant Cell Tumor’ of Clivus

Giant cell tumours of the clivus are rare. These tumours present in the second and third decades of life and they are slightly more frequent in women than in men. We are presenting a case of a 20 years young patient who came with the complaints of headache, retro-orbital pain and recurrent transient bleeding from the nose since two and half months. MRI of the brain with contrast was done and its features were suggestive of a Giant cell tumour of the clivus. A transnasal endoscopic biopsy was done under general anaesthesia and the histopathology report suggested that the features were of a giant cell tumour. Excision of the mass was done by Transnasal endoscopy. Post operatively, the patient did not recover from the lateral rectus palsy which was there on the right side. The patient was discharged with an advice of a follow up and radiotherapy. Radiation therapy and chemotherapy may be effective as adjuvant treatments. Even though a recurrence usually occurs within 4 years of the initial treatment, these patients will need to be carefully followed for the remainder of their lives.

Osteoporosis Prevention and Management

Osteoporosis, defined by BMD at the hip or lumbar spine that is less than or equal to 2.5 standard deviations below the mean BMD of a young-adult reference population, is the most common bone disease in humans affecting both sexes and all races. It’s a silent killer affecting the quality of life due to fractures and postural changes. In osteoporosis there is an imbalance between bone formation and bone resorption in favor of latter. Preventive measures and treatments are available to combat this evil. Counseling is the integral part of prevention as well as treatment of osteoporosis. Preventive strategy includes life style changes, exercise, intake of calcium and vitamin D, avoiding alcohol, smoking and excessive intake of salt. Estrogen therapy/estrogen+progesterone therapy (ET/EPT) is no longer recommended as a first-line therapy for the prevention of osteoporosis. They may be used in the therapy for osteoporosis in women under 60. Diagnosis and classification are made by assessment of BMD using DEXA or ultrasound and laboratory investigations. Management includes estimation of 10-year fracture risk using FRAX, life style and diet modification and pharmacological therapy. The drugs used in osteoporosis may be those that inhibit bone resorption—bisphosphonates, denosumab, calcitonin, SERMs, estrogen and progesterone—or that stimulate bone formation—PTH, Teriparatide. Combination therapies are not recommended as they do not have proven additional BMD/fracture benefits. No therapy should be indefinite in duration. There are no uniform recommendations to all patients. Duration decisions need to be individualized. While on treatment monitoring should be done with BMD assessment by DEXA/ultrasound and bone turnover markers.

Is it worth preserving the uterus? unanticipated pathology in hysterectomy for pelvic organ prolapse (POP)

In recent years concept of uterine conservation has been increasing at the time of surgical management of pelvic organ prolapse (POP) with the popularity of minimally invasive surgeries for pelvic reconstruction. Concerns being unnecessary sacrifice of uterus which is now being considered as an innocent organ in the etio-pathogenesis of POP. Moreover, conserving uterus has been proposed to decrease the risk of vault prolapse because of intact cervical ring of ligamentous supports. Conservation of cervix might also maintain the sexual gratification and thus may provide a better quality of life, after surgery. Studies have also shown that uterine-preserving surgery is associated with greater functional improvement in these cases. Although there are no randomized trials comparing uterine conservation with hysterectomy-based POP procedures, existing evidence cites comparable success rates of 79-100% for multiple uterine-sparing POP procedures. On the other hand as POP is the usually a disease of older age group, who are more at risk of malignant pathology, risk of leaving behind uterus and cervix which might be harboring a pre-malignant or ABSTRACT

Epithelioid leiomyosarcoma: a rare uterine cancer

A uterine epithelioid leiomyosarcoma is a rare malignant tumour that arises from the smooth muscle lining the walls of the uterus. The exact cause of leiomyosarcoma, including uterine leiomyosarcoma accounting for 5 to 10% is unknown. Leiomyosarcoma is the most common subtype of uterine sarcoma, accounts for 1-2% of uterine malignancies. Malignancy should be suspected in menopausal women with tumour growth who are not on hormonal replacement therapy. A 64-year-old female had attained menopause 16 year back and developed postmenopausal bleeding since 2 months, with palpable mass, of 16 weeks size. Ultrasonography showed whorled mass lesions, endometrium and myometrium could not be seen separately. Uterus with both ovaries removed. Intra-operative findings showed 16 weeks uterine mass with size 15×10.5×10cm and weight 1kg with intramural fibroid. Necrotic and haemorrhagic areas with degenerative changes seen on cut section suggestive of malignancy. Histopathology and immunohistochemistry reported epithelioid leiomyosarcoma.

Can Transabdominal Scan Predict a Short Cervix by Transvaginal Scan

Background. To determine whether transabdominal screening can be used to screen women with short cervix on transvaginal scan. Methods. The study was done between 18 and 20 weeks of gestation. Transabdominal scan was done and cervical length was measured. Transvaginal scan was also done and cervical length was measured. An attempt was made to find out whether transabdominal scan be used to predict a cervical length of 25 mm by transvaginal scan. Results. In our study the cut-off for transabdominal scan for detecting a short cervix of 25 mm by transvaginal scan was 29 mm. A transabdominal cervical length of 29 mm could predict a short cervix of 25 mm by transvaginal scan by 100% sensitivity and 92.4% sensitivity. Conclusion. A cut-off of 29 mm by transabdominal scan is very accurate in predicting a short cervix of 25 mm by transvaginal scan.

Occurrence of Synpolydactyly and Omphalocele in a Fetus with a HOXD13 Mutation

Synpolydactyly (SPD) is an autosomal dominant congenital limb disorder due to mutations in HOXD13 . It is a phenotypically heterogeneous condition characterized by syndactyly of the third finger (F3), fourth finger (F4) and/or fourth toe (T4), and fifth toe (T5) with variably associated polydactyly. We report on a mother and fetus with SPD. The mother has a novel mutation (c.708_708delC) in the HOXD13 gene that was also seen in the fetus. However, the fetus had congenital omphalocele in addition to SPD that is an association not reported to date. A chromosomal microarray in the fetus was normal. We report a novel mutation in HOXD13 and document co-occurrence of an omphalocele and SPD in a fetus.