Ritu Khatuja

Thyroid dysfunction during pregnancy and in postpartum period: treatment and latest recommendations

Thyroid dysfunction is the second most common endocrine disorder, only after diabetes mellitus, affecting females in reproductive age group. Pregnancy is associated with profound repercussions on the thyroid status of a lady. Thyroid dysfunctions such as hypothyroidism, thyrotoxicosis and thyroid nodules may develop during pregnancy leading to abortion, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring. Thus, maintenance of euthyroid state is of utmost important for maternal and fetal well being during pregnancy as well as after. The Endocrine Society has issued latest guidelines regarding the diagnosis and management of thyroid dysfunction related to pregnancy. All the clinicians should be well aware of the latest recommendations regarding management of thyroid dysfunction in pregnancy and in postpartum phase and practice them accordingly.

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.

Changing trends in use of laparoscopy: a clinical audit.

Aim. To find out the changing trends in indications for use of laparoscopy for diagnostic or operative procedures in gynaecology. Methods. This was a clinical audit of 417 women who underwent laparoscopic procedures over a period of 8 years from January 2005 to December 2012 in the Department of Obstetrics and Gynaecology at a tertiary care centre in Delhi. Results. A total of 417 diagnostic and operative laparoscopic procedures were performed during the period from January 2005 to December 2012. Out of 417 women, 13 women were excluded from the study due to inadequate data. 208 (51.4%) women had only diagnostic laparoscopy whereas 196 (48.6%) patients had operative laparoscopy after the initial diagnostic procedure. Change in trend of diagnostic versus operative procedures was observed from 2005 to 2012. There was increase in operative procedures from 10 (37.03%) women in 2005 as compared to 51 (73.91%) in 2012. The main indication for laparoscopy was infertility throughout the study period (61.38%), followed by chronic pelvic pain (CPP) (11.38%) and abnormal uterine bleeding (AUB) (9.4%). Conclusion. Over the years, there has been a rise in the rate of operative laparoscopy. Though the indications for laparoscopy have remained almost similar during the years, laparoscopy for diagnosis and treatment of CPP and AUB has now increased.

Laparoscopy:as a first line diagnostic tool for infertility evaluation.

INTRODUCTION The role of diagnostic and therapeutic hystero-laparoscopy in women with infertility is well established. It is helpful not only in the identification of the cause but also in the management of the same at that time. MATERIALS AND METHODS In this study, the aim was to analyse the results of 203 women on whom laparoscopy for the evaluation of infertility was done. This study was carried out at a tertiary level hospital from 2005 to 2012. The study group included 121 women with primary infertility and 82 women with secondary infertility. Women with incomplete medical records and isolated male factor infertility were excluded from the study. RESULTS It was observed that tubal disease was the responsible factor in 62.8% women with primary infertility and 54.8% women with secondary infertility followed by pelvic adhesions in 33% and 31.5%, ovarian factor in 14% and 8.5%, pelvic endometriosis in 9.9% and 6.1% women respectively. Thus tubal factor infertility is still a major cause of infertility in developing countries and its management at an early stage is important to prevent an irreversible damage. At the same time, it also directs which couples would be benefited from assisted reproductive technologies (ART).

Menstrual hygiene: a ‘red alert’ situation

[1] Bolton-Maggs PH, Chalmers EA, Collins PW, et al. A review of inherited platelet disorders with guidelines for their management on behalf of the UKHCDO. Br J Haematol 2006;135:603–33. [2] Simon D, Kunicki D, Nugent D. Platelet function defects. Haemophilia 2008;14:1240–9. [3] Jewell M, Magann EF, Barr A, Baker R. Management of platelet storage pool deficiency during pregnancy. Aust N Z J Obstet Gynaecol 2003;43:171–2. [4] Welsh A, McLintock C, Gatt S, Somerset D, Popham P, Ogle R. Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Aust N Z J Obstet Gynaecol 2008;48:12–6. [5] Ahonen J, Jokela R. Recombinant factor VIIa for life-threatening post-partum haemorrhage. Br J Anaesth 2005;94:592–5. Table 1 Menstrual hygiene practices.

Background, Epidemiology and Definition of Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) is defined traditionally as three or more consecutive pregnancy losses. But evaluation of the couple is started following two first trimester pregnancy losses. An earlier evaluation may be needed if fetal cardiac activity was present prior to a loss, woman’s age is 35 years or more, or the couple has history of infertility. RPL affects 0.4–1% of couples. The prevalence of RPL is found to be between 0.6 and 2.3%. There is a huge list of suggested etiologies for RPL which include primarily chromosomal abnormalities in either of the couple, antiphospholipid syndrome, hormonal and metabolic factors, uterine abnormalities, endocrine disorders, inherited and/or acquired thrombophilic defect, immunologic abnormalities, infections, male factors, and environmental factors. In spite of a large list of etiology, approximately half of the cases still remain unexplained.

Repeat caesarean: time to re-evaluate the current practice

We read with interest the article titled Back to ‘‘once a caesarean: always a caesarean’’? a trend analysis in Switzerland by Schmid et al. [1]. They highlighted that the increased demand of caesarean sections (CS) is mostly related with safety in pregnancy and childhood. CS rate has significantly increased worldwide in the last three decades [2]. To review our practice, we conducted a clinical audit of repeat CS done over a period of 1 year in a tertiary care hospital. The indications for the repeat caesarean section and the preoperative findings were correlated. During this period, 11,927 deliveries were conducted, out of which 3126 were caesarean sections (26 %). World Health Organization (WHO) in 1985 issued a statement regarding no justification for any region to have CS rates higher than 10–15 % [3]. But in our study, it is as high as 26 %, because our institute is a tertiary care referral center. The number of repeat caesarean sections was 648 (20.3 % of total CS) with 568 of first repeat CS. The most common indication for repeat CS was short inter-pregnancy interval (19 %), followed by maternal tachycardia (14 %), scar tenderness (12 %), and cephalopelvic disproportion (11 %) in the order of occurrence (Table 1). Short inter-pregnancy (IP) interval highlights the poor contraceptive awareness and usage in our group of women. This can be prevented by wider coverage of post-partum intrauterine copper device (PPIUCD) during the primary CS. Also, though no clear guidelines exist defining a short IP but due to the obstetrician’s and patient’s apprehensions, they were taken up for CS. The next common indication for CS in our group of women was maternal tachycardia, but the preoperative findings did not correlate with scar thickness or dehiscence. Maternal tachycardia per se should not be the indication of CS but decreases the threshold of obstetrician for taking up the woman for a repeat CS, again highlighting the contributory role of previous operative delivery on the future obstetric life of the woman. As suggested by Schmid et al. [1], increasing vaginal birth after caesarean section (VBAC) is a good option to bring down CS rate, but curtailing down the primary CS would go a long way in reducing the rate of repeat CS. So, keeping in mind our main goal to promote safe motherhood, the need of hour is to strike the right balance between

Placental Mesenchymal Dysplasia: A Case Report

Introduction. A rare case of histologically proven placental mesenchymal dysplasia (PMD) with fetal omphalocele in a 22-year-old patient is reported. Material and Methods. Antenatal ultrasound of this patient showed hydropic placenta with a live fetus of 17 weeks period of gestation associated with omphalocele. Cordocentesis detected the diploid karyotype of the fetus. Patient, when prognosticated, choose to terminate the pregnancy in view of high incidence of fetal and placental anomalies. Subsequent histopathological examination of placenta established the diagnosis to be placental mesenchymal dysplasia. Conclusion. On clinical and ultrasonic grounds, suspicion of P.M.D. arises when hydropic placenta with a live fetus presents in second trimester of pregnancy. Cordocentesis can detect the diploid karyotype of the fetus in such cases. As this condition is prognostically better than triploid partial mole, continuation of pregnancy can sometimes be considered after through antenatal screening and patient counseling. However, a definite diagnosis of P.M.D. is made only on placental histology by absence of trophoblast hyperplasia and trophoblastic inclusions.