Rachna Agarwal

Oral micronized progesterone for prevention of preterm birth

To evaluate oral micronized progesterone (OMP) to prevent preterm birth (PTB).

Rupture of intrapartum unscarred uterus at the fundus: a complication of passive cocaine abuse?

Uterine rupture is a potential obstetric catastrophe. We report a case of a gravida 2 para 1 with intrapartum unscarred uterine fundal rupture. Immediate resuscitation, laparotomy and hysterectomy, was done with maternal survival. History of passive cocaine smoke exposure elicited postoperatively was the possible etiology leading to complete fundal rupture. This case is an eye opener as regards to ill effects of drug abuse even though passive. A careful history of drug abuse must be elicited when the common causes of uterine rupture have been excluded or the rupture site is unusual.

Role of newer methods of diagnosing genital tuberculosis in infertile women.

Genital tuberculosis is an important under-diagnosed factor of infertility. A vast majority of cases are asymptomatic and diagnosing them will help in treating such patients. We conducted a retrospective study in a tertiary care hospital of Delhi with an aim to compare different methods i.e., histopathological examination (HPE), acid-fast bacilli (AFB) smears, Lowenstein-Jensen (LJ) culture, BACTEC culture and polymerase chain reaction deoxyribonucleic acid (PCR-DNA) for diagnosing endometrial tuberculosis in infertile women. The data from 546 samples of endometrial biopsy histopathology, AFB smears and LJ culture was collected and then analyzed. Of these, HPE for tuberculosis was positive in 13, LJ culture in 10, AFB smear was positive in one case. BACTEC and PCR-DNA were feasible for 90 patients and PCR-DNA was positive in 20 and BACTEC in eight patients. Out of 20 patients with PCR positive results, 15 were only PCR positive and were subjected to hyster-laparoscopy and five had evidence of tuberculosis. Thus, none of the available tests can pick up all cases of genital tuberculosis, but conventional methods i.e., histopathology and LJ culture still has an important role in the diagnosis of endometrial tuberculosis in government setups where BACTEC and PCR are not performed routinely due to lack of resources.

Cesarean scar pregnancy: a diagnostic dilemma and impending catastrophe

We came across an interesting and rare citation of scar dehiscence in cesarean scar ectopic pregnancy (CSEP) [1]. We wish to add on our experience of a similar patient with acute presentation and diagnostic dilemma. With a low incidence of 1:2,226 of all pregnancies and 0.15 % in women with a previous CS [2], every case counts! A high index of suspicion and prompt management could save a life. A 28-year-old third gravida presented with 7 weeks amenorrhea and painless vaginal bleeding. She had one cesarean delivery 7 months prior. On examination, she was in hemorrhagic shock. An abdominal Pfannenstiel scar was present. There was tenderness in the lower abdomen; however, no mass was palpable. On bimanual examination, internal os was open. Finger went on the right side of uterus in a cavity which had a soft fleshy feel and bled on touch. Toward the left, the uterus was felt in continuity with that cavity; however, finger did not enter into the upper uterine cavity. Total uterine size corresponded to 8 weeks of pregnancy. The bilateral fornices were free. Transvaginal ultrasound revealed normal endometrial cavity and cervix. A heteroechoic 5 9 6 cm mass arose from the low corporeal anterior surface with cystic areas and increased vascularity. No definite gestational sac was visible. The myometrium was deficient between the bladder and the mass. There was no free fluid in POD. Bilateral adnexa were clear. A provisional diagnosis of scar pregnancy with dehiscence/bicornuate uterus with abnormally invasive placenta was made. Exploratory laparotomy followed by hysterectomy was done in view of excessive hemorrhage. Per-operatively, the uterus was enlarged and atonic. The lower segment was ballooned and thinned out with a bunch of vessels on the anterior surface at the previous cesarean scar site, more toward the right side. The bladder was densely adherent to the previous scar site. Later, on cut section, a small gestational sac (*4 mm) was embedded at the previous scar site surrounded by blood clots (Fig. 1). Apart from an abnormally invasive placenta, CSEP should be differentiated from spontaneous miscarriage in progress, cervical pregnancy or even trophoblastic tumor [3, 4]. Transvaginal ultrasonography has a high sensitivity of 84.6 % for diagnosing this condition [5]. Ultrasound criteria put forward for the diagnosis of a CSP include an empty uterine cavity and cervical canal without contact with the gestational sac, presence of the gestation sac in the anterior part of the uterine isthmus and deficient myometrium between bladder and sac [6]. Color flow Doppler shows distinct peritrophoblastic perfusion surrounding the gestation sac. In our case, unusual examination findings due to pregnancy being more on the right side of the previous scar and absence of a clear gestational sac on ultrasound posed diagnostic dilemma. Termination of pregnancy in the first trimester is strongly recommended, as there is a high risk of subsequent uterine rupture, massive bleeding and life-threatening complications. Treatments mentioned in literature for stable patients (used singly or in combination) include ultrasound-guided injection of methotrexate, KCl or vasopressin into the embryo or gestational sac, systemic methotrexate administration, uterine artery embolization, laparoscopic or open local resection of the gestation mass, hysteroscopic excision, etc. [7–9]. All these procedures are associated with varying complication rates. According to a recent extensive review, transvaginal or S. Jain (&) A. Suneja R. Malik R. Agarwal K. Guleria N. Vaid Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi 110095, India e-mail: sumeet_singla@rediffmail.com

Multiple intracystic floating balls: an unusual but unique sonographic pattern of mature cystic teratoma

Mature cystic teratoma is the most common benign ovarian neoplasm occurring in the reproductive age group.1 Sonography is invariably the primary modality for diagnosis. The great diversity in components of teratomas results in varied sonographic appearances. Certain features like tip-of-iceberg sign, fat-fluid level, dermoid mesh and rokitansky protuberance (dermoid plug) are specific to this entity and considered diagnostic.2 A sonographic appearance of …

Tuberculous psoas abscess in obstetrics Concerning Kumar S, Malhotra N, Chanana C, Lal S (2009) Psoas abscess in obstetrics. Arch Gynecol Obstet 279:247-249

We read with interest the article by Kumar et al. [1] regarding psoas abscess in obstetrics. Although rare, psoas abscess have been reported during pregnancy. Their subtle symptomatology evades detection clinically. We will like to share our experience of a case of psoas abscess diagnosed during an exploratory laparotomy for ruptured ectopic pregnancy. A para 1, 22-year-old woman presented with 2 months of amenorrhea and pain in abdomen. The pain had worsened in past 3 days and was now associated with vomiting and giddiness. Patient had severe palor, tachycardia and hypotension. On palpation of abdomen, Wndings were a Wxed dull to percussion mass felt in left lumbar region with mild tenderness and rigidity in right iliac fossa. Digital vaginal examination revealed an anteverted normal size uterus associated with cervical motion tenderness and a cystic mass about 4 £ 5 cm was palpable in right fornix extending to pouch of Douglas. The left lumbar abdominal mass was also tipped through left fornix. Blood chemistry revealed hemoglobin of 6 g%. Complete blood count, liver and kidney functions were normal. Urine pregnancy test was positive. On ultrasound evaluation, right adnexa revealed a ruptured ectopic gestational sac with Xuid in pouch of Douglas. Uterus was normal in size and endometrial cavity was empty. Left ovary was normally visualized. The left abdominal mass was suspected to be a psoas abscess extending into the hemipelvis. It was cystic with thick wall and few septations. Patient was taken for urgent laparotomy and right-sided salpingectomy for ruptured ectopic pregnancy. The left retroperitoneal cystic Xuctuant swelling measured approximately 10 £ 15 cm. It was suspected to be tuberculous psoas abscess in view of straw colored Xuid obtained on aspiration peroperatively. Fluid cytology revealed exudative nature with predominance of lymphocytes. The Gram stain and aerobic culture revealed no organisms. The aspirated Xuid investigated by PCR (polymerase chain reaction) tested positive for Mycobacterium. The radiographs of the spine, pelvis with both hips were normal. Computed tomography (CT) of spine and abdomen other than presence of left psoas abscess was also normal. The abscess was drained percutaneously under CT (Fig. 1) guidance postoperatively under cover of multidrug antitubercular chemotherapy. Serial ultrasound has shown remarkable response to the therapy. Psoas abscess is a rare manifestation in pregnancy. Only four cases of psoas abscess diagnosed during ongoing pregnancy have been reported in indexed English literature till date (Table 1) [1, 2]. Other reported cases have either been postabortal or post partum [2–5]. Kumar et al. describes the only other case of tubercular psoas abscess detected during pregnancy [1]. Our case is the Wrst report of psoas abscess diagnosed with ectopic pregnancy. Patient gave no history of previous tuberculosis or exposure on retrospective questioning. The psoas abscess seemed tubercular in view of straw colored Xuid obtained on aspiration peroperatively. There was a risk of tubercular Xare-up with the contamination of abdominal cavity. The percutaneous drainage under CT guidance was done under cover of antitubercular drugs a few weeks later. Wherever possible, percutaneous drainage is the preferred method of abscess drainage as it is much less invasive than open surgical technique. It is technically demanding and requires help of a trained radiologist. R. Agarwal · A. Suneja · S. Raina Department of Obstetrics and Gynaecology, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, Delhi, India

Primary peritoneal carcinoma: a diagnostic dilemma

We read with deep interest the report by Bhuyan et al. [1] detailing diagnosis and management aspects of extra ovarian primary peritoneal carcinoma (EOPPC). Indeed the clinician is intrigued by the presentation of EOPPC and equally challenging is the management because of limited guidance available in literature with these tumours. We recently diagnosed EOPPC in a 62-year-old lady and would like to share the atypical presentation of the carcinoma. This patient had received six cycles of chemotherapy (paclitexal and cisplatin) for papillary adenocarcinoma. At prior exploratory laparotomy, there was an inoperable mass adherent to transverse colon serosa with liver metastasis. As no primary site of tumour was discernable, biopsies from peritoneum and peritoneal washings were taken revealing papillary adenocarcinoma. Post chemotherapy, computed tomography scan showed resolution of ascitis, normal-sized bilateral adnexa and uterus; however, omental thickening and liver metastasis still persisted. Serum CA125 level decreased from 200 to 17.5 IU/ml. At subsequent debulking laparotomy, there was no free Xuid in abdomen but a large desmoplastic transverse colon [2] was seen. The uterus with bilateral adnexa was normal in size and shape; however, multiple hard peritoneal deposits ranging 1–10 cm in size were present in the mesentery, inWltrating up to the wall of transverse colon. Panhysterectomy and resection of transverse colon mass was done. The second laparotomy again could not reveal the primary site of tumour. Repeated histopathology of colonic segment showed serous papillary adenocarcinoma with numerous psammoma bodies inWltrating serosa and reaching up to muscularis propria. Both ovaries showed superWcial cortical involvement by the same tumour (Figs. 1, 2). Serosal aspect of both fallopian tubes, mesentery and parametrium were also studded with the same tumour. Since the gynaecologic oncology group criteria were fulWlled in our case, a diagnosis of EOPPC was rendered [3]. In our case, positive immunostaining for pan-cytokeratin (CK) and estrogen receptor, and negative staining for calretinin further supported the

Cotyledonoid leiomyoma and non-descent vaginal hysterectomy.

We read with deep interest the article by Driss et al. [1] who emphasize the association of a cotyledonoid dissecting leiomyoma with endosalpigiosis. Cotyledonoid dissecting leiomyoma is an extremely rare variant of uterine leiomyoma with just 24 cases on record [2]. Clinicoradiological diVerentiation from leiomyoma is diYcult, and diagnosis is most often not suspected preoperatively. Imaging modalities oVer no help, and its bizarre macroscopic shape may be confused with malignant neoplasm [3]. We would like to share the intraoperative Wndings of cotyledonoid dissecting leiomyoma in a 52-year-old multiparous woman during a non-descent vaginal hysterectomy (NDVH). The patient had presented with polymenorrhagia for 6 months. She had Wrst degree cervical descent with uniformly enlarged anteverted uterus of size corresponding to 8 weeks. Ultrasound evaluation was suggestive of multiple subserous Wbroid of size 6 £ 7 cm with slight Xuid in peritoneal cavity. During NDVH performed for symptomatic polymenorrhagia, after bisection we attempted to visu-

Evaluation of Placental VEGFA mRNA Expression in Preeclampsia: A Case Control Study

ObjectiveThe aim of our case–control study was to determine expression of VEGFA mRNA in placentae of preeclamsia (PE) versus uncomplicated pregnancy to further clarify its differential expression in pregnancy hypertensive disorders.Study DesignThe PE group was subdivided into severe and non-severe; those with or without HELLP syndrome and placental VEGFA characteristics were compared for these cohorts. Additionally, the neonatal and maternal outcomes were recorded. The quantification of placental VEGFA was done using quantitative real-time PCR and results were expressed as fold change.ResultsOut of 42 PE cases, 23 (55%) were non-severe and 19 cases (45%) were severe PE. Out of 19 severe PE patients, 8 (42%) were HELLP syndrome (complete HELLP) and remaining 11 (58%) were non-HELLP severe PE. Compared to controls, the true fold change in PE, HELLP, non-HELLP, severe PE, non-severe PE was − 2.186, − 13.333, − 6.698, − 8.950 and 1.466, respectively.ConclusionsOur results showed a lowered VEGFA expression in PE placentae compared to uncomplicated controls. The finding of initial increase of VEGFA in non-severe PE and subsequent marked lowering in HELLP strengthens the existing hypothesis of decompensated VEGF being a major role player in PE.

Prediction of preeclampsia in primigravida in late first trimester using serum placental growth factor alone and by combination model

Abstract We investigated a placental growth factor alone and combined clinical (mean arterial pressure, MAP), biophysical (uterine artery pulsability index, PI) and biochemical (placental growth factor, PLGF) model for predicting preeclampsia in late first trimester. The inclusion criteria was primigravida (<40 years) attending their first hospital visit with singleton pregnancy at 11–14 weeks of gestation. Of the enrolled and followed 291 subjects, 35 (12%) later developed PE (5.8%)/GH (6.2%). An equal number of randomised women with normotensive non-proteinuric course were considered as reference group. For preeclampsia, PLGF alone had detection rate of 40% and 51% with 5% and 10% FPR, respectively. On addition of MAP, the AUC improved to 0.937 for PE. Further, addition of mean PI slightly improved AUC to 0.965. This signifies that a model with all three markers had better prediction of preeclampsia rather than PLGF alone. Impact statement In view of high morbidity and mortality due to hypertensive disorders in pregnancy, there has been extensive research for developing markers to detect/screen the condition in early pregnancy. Several such markers have been tested in their individual capacities and in combination during early pregnancy. Most of these studies have originated from high income countries and focussed mainly on the second trimester of pregnancy. We investigated a placental growth factor alone and combined clinical (mean arterial pressure, MAP), biophysical (uterine artery pulsability index, PI) and biochemical (placental growth factor, PLGF) model for predicting preeclampsia in the first trimester in primigravida (<40 years). A nested case control model was used for our study. For preeclampsia, PLGF alone had detection rate of 40% and 51% with 5% and 10% FPR, respectively. On addition of MAP, the AUC improved to 0.937 for PE. Further, addition of mean PI slightly improved AUC to 0.965. The present study has been done in an Indian subcontinent setting (where maternal mortality related to preeclampsia are even higher) where very limited studies are available for the role of either PLGF or in combinations for prediction of preeclampsia. Our research pointed shows better predictability for PE when a combination of markers is used especially in low-risk nulligravida. These are easy, cheap and non-invasive measurements that can be taken in all women at their first routine antenatal visit.