Papa Dasari

The maximal vertical pocket and amniotic fluid index in predicting fetal distress in prolonged pregnancy

Objective: To determine cut‐off values for amniotic fluid volume (AFV) predictive of fetal distress in pregnancies 40 weeks or longer, assessed using both amniotic fluid index (AFI) and height of the of maximal vertical pocket (MVP). Methods: Amniotic fluid index and MVP were evaluated in 100 women with pregnancies of 40 or more weeks and intact membranes using a 3.5‐MHz linear transducer less than 1 week prior to onset of labor. Both measurements were obtained for each participant by the same obstetrician in one sitting. Oligohydramnios was defined as an AFI of 5 cm or less or an MVP of 3 cm or less. External cardiotocography was performed during intrapartum in all cases. Fetal distress was diagnosed when any one of the nonreassuring fetal heart rate pattern occurred or when the Apgar score at birth was 6 or less. The results were analyzed by the χ2 and the t tests. Results: An AFI of 5 cm or less was a better predictor of fetal distress than an MVP of 3 cm or less (P = 0.000). The most statistically significant cut‐off values for the occurrence of fetal distress in prolonged pregnancies were an AFI of 8 cm or less (odds ratio, 7.50) or an MVP of 2 cm or less (odds ratio, 2.67). There was a significant correlation between these 2 methods (r = + 0.67), with a level of significance of 0.01, as shown by the regression curve. The secondary outcome was the statistically significant association between meconium‐stained liquor and fetal distress (P = 0.001). Conclusion: In pregnancies of 40 weeks or longer there was a risk of fetal distress when the AFV was 8 cm or less by the AFI method or 2 cm or less as measured by MVP. In such cases, intensive intrapartum monitoring should be performed to prevent fetal jeopardy.

Maternal mortality due to hypertensive disorders of pregnancy in a tertiary care center in Southern India

ception (Table 2). When compared with data from some Muslim countries concerning awareness of emergency contraception, for example Kuwait (6.1%) and Iran (8%), our study result was higher [3,4]. Among the women who were aware of emergency contraception, only 29.2% gave the correct answer about utilization time: within 72 hours following unprotected sexual intercourse. When asked about when emergency contraception should be used, 46% gave the correct answer: when the condom tears and after unprotected sexual intercourse. However, no responses were provided when asked whether it could be used after rape. Our study showed that 80 (35.6%) women had used some form of emergency contraception, while 145 (64.4%) had not. Although emergency contraception is not recommended as a routine family planning method, it is a useful method after unprotected sexual intercourse to reduce the chance of unwanted pregnancy. Emergency contraception is particularly useful when barrier methods fail. However, women must be provided with sufficient information about emergency contraception and must be willing to use it for it to be effective [5]. Health providers were the most commonly cited source of information about emergency contraception (29.3%). A smaller proportion stated that they had received information from their family (4.5%). Healthcare providers have been slow to incorporate emergency contraception into routine consulting in Turkey. Family planning services and primary healthcare units provide free information on contraceptive methods for individuals or couples, and these units provide contraceptives free of charge or in return for minimal payment. In the present study, 70.2% of the women reported that they wanted to receive more information about emergency contraception, suggesting that they felt their knowledge was insufficient. The study has some limitations. It was carried out in one area of Turkey and may not be generalizable. The sample size was small and the participantswere all marriedwomen. In Turkey it is difficult to ask unmarried women about sexual matters. The study reveals a lack of knowledge among married women about the effective use of emergency contraception. We suggest that women should be routinely informed about emergency contraception during family planning counseling and other visits that offer potential educational opportunities from health professionals.

The efficacy of metformin and clomiphene citrate combination compared with clomiphene citrate alone for ovulation induction in infertile patients with PCOS

CONTEXT: Low ovulatory and pregnancy rates with clomiphene citrate (CC) in anovulatory polycystic ovarian syndrome (PCOS). AIM: To find out the ovulatory and pregnancy rates in infertile PCOS subjects who receive CC alone and a combination of metformin and CC. SETTING AND DESIGN: A prospective controlled clinical trial conducted in the outpatient department from August 2003 to August 2005. MATERIALS AND METHODS: Twenty-four infertile PCOS women received CC alone at incremental doses of 50 mg up to 150 mg for three cycles and then at a dose of 150 mg for another three cycles (control group). The study group (16 PCOS) received the same dose of CC along with 1500mg of metformin. Ovulation was monitored by transvaginal sonography up to six cycles or till pregnancy occurred. STATISTICAL ANALYSIS: This was carried out using software SSPS, version 10. Fishers exact test was used to calculate the ovulatory rates. Nine subjects of the control group who failed to conceive with CC had opted for CC and metformin and their ovulatory rate was calculated using statistical software, namely SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 using Fischers exact test. RESULTS: The metformin and clomiphene combination resulted in a significantly higher rate of ovulation (P = 0.0016). The pregnancy rate was 8% with CC and 24% with metformin and CC. The CC failure group also ovulated at a similar rate as that of the study group. CONCLUSIONS: The ovulatory rate and the pregnancy rate with the metformin–CC combination was found to be higher when compared with CC alone. Metformin increased the ovulatory rate in CC failures, also implying increased sensitivity to CC.

The expression of immunohistochemical markers estrogen receptor, progesterone receptor, Her-2-neu, p53 and Ki-67 in epithelial ovarian tumors and its correlation with clinicopathologic variables.

BACKGROUND This study aims to evaluate the expression of estrogen receptor alpha (ER α), progesterone receptor A (PRA), Her-2-neu, p53, and Ki-67 in epithelial ovarian tumors and their correlation with various clinicopathologic variables. MATERIALS AND METHODS This study included 60 consecutive cases of epithelial ovarian tumors. Sections of 4 μm were taken from paraffin embedded tissue blocks for immunohistochemistry (IHC). Statistical analysis was done using Chi square test, ANOVA. RESULTS ER α had lower expression in benign (29%) and PRA higher expression in malignant (63.6%) tumors. ERα, PRA had higher expression in serous (72.72%, 57.14%), postmenopausal (81.8%, 71.42%), advanced stage (63.63%, 52.38%), grade 3 (45.45%, 38.09%), and tumors with ascites (90.90%, 85.7%). Her-2-neu, p53 were negative in benign and higher in malignant (21%, 57.6%), serous (71.42%, 57.89%), grade 3 (57.14%, 31.57%), and tumors with ascites (85.7%, 84.21%). Ki-67 had a significant higher expression in malignant (48.6 ± 26.76), serous (55.43 ± 27.85), and grade 3 tumors (68 ± 22). CA-125 levels were significantly higher in malignant, serous, advanced stage, grade 3 and ER α, Her-2-neu and p53 positive tumors. CONCLUSION ERα, PRA expression in tumors with adverse prognostic factors support the mitogenic role of estrogen and estrogenic regulation of PR. Her-2-neu and p53 expression only in malignant tumors suggest their carcinogenic role and aid in the differentiation of borderline and malignant tumors. Higher Ki-67 in tumors with adverse prognostic factors would help in prognostication and differentiation. Lack of co-expression of markers proves the extreme heterogeneity of ovarian tumors. These markers may aid in differentiation and prognostication of ovarian tumors.

Psychological factors in preterm labor and psychotherapeutic intervention.

Prematurity is the leading cause of perinatal mortality in developing countries and nearly 50% have no identifiable clinical risk factor. A few studies have enlightened the role of psychological factors in its causation and psychotherapeutic interventions in the form of hypnosis relaxation exercises and anxiety reducing exercises. The following study was conducted to assess the psychological factors in subjects with preterm labor of unknown cause and to compare the effect of psychotherapeutic intervention along with tocolysis to tocolysis alone. Fifty subjects with preterm labor satisfying the inclusion and exclusion criteria were assessed of psychological stress using modified life inventory and abbreviated psychosocial scale. They were randomly assigned to control group (25) who received tocolysis with nifedipine and study group (25) who received nifedipine along with psychotherapeutic intervention in the form of Luthes relaxation technique and transcendental meditation. The endpoints studied were cessation of uterine contractions prolongation of pregnancy and neonatal outcome. Statistical analysis was done using Graphad Instat employing correlation analysis Students t test and Fischers exact test. (excerpt)

Life-threatening complications following multidose methotrexate for medical management of ectopic pregnancy

A 25-year-old primigravida was diagnosed to be suffering from unruptured ectopic pregnancy. The serum β-human chorionic gonadotropin levels were 2851 mIU/l and the ectopic gestational sac was 2.7×2.7 cm without any fetal pole. It was decided to manage her by expectant therapy. But she received medical therapy with multidose methotrexate because of misinterpretation of expectant therapy as medical therapy. She suffered from methotrexate toxicity, which manifested as high-grade fever, vomiting, melena, oral ulcerations, pneumonitis, subconjunctival haemorrhages and skin pigmentation. She developed severe third space fluid collection and shock, which was mistaken for rupture ectopic gestation. Her haematological picture showed severe neutropaenia and thrombocytopaenia which confirmed the clinical picture to be due to methotrexate toxicity. She also developed septicaemia and candidal infection secondary to immunosuppression. She was managed in intensive care unit with ventilatory support, high-dose leucovorin and injection filgastrim. She responded well to the therapy with dramatic recovery in 4 days.

Uterine artery pseudoaneurysm: a rare cause of secondary postpartum haemorrhage following caesarean section

A 30-year-old woman, para 2, who underwent an uneventful repeat elective lower segment caesarean section with sterilisation presented on the 23rd postnatal day to our Obstetric Emergency department with profuse bleeding per vaginum. She had a similar bout of bleeding on the 19th postnatal day and was treated elsewhere with blood transfusion and uterotonics. On ultrasonography, she was diagnosed to have few retained adherent placental bits in the lower part of the uterus with a small left broad ligament haematoma and hence was injected with a single dose of methotrexate. A communication of uterine artery was suspected as the mass was close to the uterus and few pulsations were felt on per vaginal examination while attempting aspiration of haematoma. Uterine artery pseudoaneurysm was diagnosed by Doppler studies and confirmed by contrast enhanced CT. She was treated successfully by bilateral internal iliac artery ligation as facilities for embolisation are not available.

Colposcopic evaluation of cervix with persistent inflammatory Pap smear: A prospective analytical study

Background: Inflammatory Pap smear is the most common report received by a gynecologist. The cervical screening algorithm for benign cellular changes on the Pap smear recommends treatment of infection if indicated and a repeat Pap smear in 4 to 6 months time. If the inflammatory changes still persist, subject the patient to colposcopy. However, in practice, this is not followed, especially in developing countries like ours where proper screening protocols are not available. Hence, a good number of patients in the premalignant stage are being missed. This study was undertaken to evaluate patients with persistent inflammatory Pap smears without atypia using colposcopy. Methods: A prospective analytical study of 150 gynecologial patients with persistent inflammatory Pap smear between 2006 and 2008 in an out-patient setting. All of them were subjected to colposcopy and biopsy from the abnormal areas. The incidence of cervical intraepithelial neoplasia (CIN)/invasive carcinoma was calculated by proportions/percentages. Results: The incidence of invasive carcinoma was <1%. But, the incidence of pre-malignant lesions (CIN) was high (20.9%). CIN 2/3 and carcinoma in situ were present in 6.9% of the cases. Conclusions: Patients with persistent inflammatory Pap smears can harbour a high proportion of CIN and hence these patients will need further evaluation.

Portal vein thrombosis during pregnancy

A 22-year-old primigravida was diagnosed to have portal vein thrombosis during 20th week of gestation by ultrasound examination which was carried out to rule out congenital fetal anomalies. She had splenomegaly and thrombocytopenia. Investigations did not reveal any prothrombotic disorder. She was managed with anticoagulants which were started at 31 weeks of pregnancy. Labour was induced at 40 weeks of gestation and she delivered a healthy neonate without any complications. Anticoagulants were restarted after delivery and continued through the postpartum period and up to 6 months thereafter.

Expectant and medical management of placenta increta in a primiparous woman presenting with postpartum haemorrhage: The role of Imaging

We report a case of postpartum hemorrhage due to adherent placenta. A 28 year old primiparous woman who underwent manual removal of placenta for primary postpartum haemorrhage soon after delivery was referred to our Institute on her third postnatal day because of persistent tachycardia and low grade fever. Placenta accreta was suspected on initial ultrasonographic examination. MRI examination confirmed the diagnosis of placenta accreta in few areas and revealed increta in other areas. On expectant management she developed genital tract sepsis and hence she was treated with intravenous Methotrexate after controlling infection with appropriate antibiotics. Doppler Imaging showed decreased blood flow to the placental mass and increased echogenecity on gray scale USG after Methotrexate administration. She expelled the whole placental mass on 35th postnatal day and MRI performed the next day showed empty uterine cavity. Morbid adhesion of placenta should be suspected even in primiparous women without any risk factors when there is history of post-partum hemorrhage. MRI is the best modality for evaluation of adherent placenta.