Rupali Dewan

A Dedicated Postpartum Intrauterine Device Inserter: Pilot Experience and Proof of Concept

Use of the inserter was found to be safe, with high fundal placement in 82% of cases. Complete expulsion occurred in 7.5% of cases and partial expulsion was detected in 10%, comparable with rates in other studies using standard IUD insertion techniques. Further study and use of the dedicated inserter may reveal increased convenience and reduced risk of infection among users and could improve acceptability of postpartum IUD provision among providers. Use of the inserter was found to be safe, with high fundal placement in 82% of cases. Complete expulsion occurred in 7.5% of cases and partial expulsion was detected in 10%, comparable with rates in other studies using standard IUD insertion techniques. Further study and use of the dedicated inserter may reveal increased convenience and reduced risk of infection among users and could improve acceptability of postpartum IUD provision among providers. ABSTRACT Objective: To assess the feasibility, acceptability, and safety of a dedicated postpartum intrauterine device (PPIUD) inserter specifically designed for the post-delivery setting. Primary objectives of fundal placement and expulsion rates were assessed. Secondary objectives were participant satisfaction and IUD retention. Methods: In this pilot proof of concept, we enrolled 80 women who presented for PPIUD insertion at 2 government hospitals in Delhi and Lucknow, India, between March and July 2015. PPIUD insertion was completed with the dedicated inserter in all cases, by trained providers with no prior experience in PPIUD insertion, followed immediately by ultrasound to assess location and fundal placement of the IUD. Follow-up took place at 6 to 8 weeks post-insertion, and ultrasound was used to assess IUD location. Providers and participants also completed satisfaction surveys. Results: High fundal placement (≤10 mm from uterine fundus) was achieved with the dedicated PPIUD inserter in 82% of cases (n = 65). There were no perforations or infections among the participants and no other complications associated with use of the dedicated inserter. The mean distance between the IUD and the endometrial verge immediately post-insertion was 5.8 mm (range, 0–31; N = 80); this distance at follow-up was also 5.8 mm (range, 0–25; n = 50). Complete expulsion was observed in 6 cases (7.5%), and asymptomatic partial expulsion in 8 cases (10%). Providers reported the majority (93%, n = 74) of insertions to be easy. The majority (74%, n = 59) of participants reported the same level of pain before and after insertion. Conclusions: This dedicated PPIUD inserter performed as intended and was found to be safe, with high acceptability among the participants and providers. Further study and use of the dedicated inserter may reveal reduced risk of infection among PPIUD users as well as increased convenience compared with standard PPIUD insertion techniques, and could improve acceptability of postpartum IUD provision among providers. The success of this study has led to the initiation of a formal randomized controlled trial in India to further investigate the acceptability of the dedicated inserter.

Risk assessment for psychological disorders in postmenopausal women.

INTRODUCTION Psychological symptoms are common & bothersome in post menopausal women. Hence, screening these women for risk factors for psychological disorders is an important measure to improve their health. OBJECTIVE To study the risk assessment for psychological disorders in postmenopausal women Material & Methods: This was a prospective and observational study conducted in the Department of Obstetrics and Gynecology of a North Indian tertiary care hospital. It included a cross-section of 200 postmenopausal women attending gynecology OPD and menopausal clinic. RESULT Psychological symptoms were present in 32% postmenopausal women while sleep disturbance and decreased concentration were reported by nearly 34%. Irritability, nervousness and depression were the presenting complaints in 31.5%, 28.5% and 23.5% women respectively. Mild depression was present in 41.5%, whereas 3% women suffered from clinical (moderate to severe) depression. Depression was significantly associated with vasomotor symptoms (p=0.000), past history of depression (p=0.048) and psychosocial stressors (p=0.000). CONCLUSION Women during postmenopausal years are at increased risk of psychological disorders; hence assessment of mental health and address of related issues should be an integral part of comprehensive evaluation of these women.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section.

INTRODUCTION Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery. OBJECTIVE To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section. MATERIALS AND METHODS This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months. RESULTS A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively. CONCLUSION Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Giant condyloma acuminatum of vulva treated by surgical excision and reconstruction of defect

Giant condyloma acuminatum (GCA) is a rare sexually transmitted disease caused by Human papilloma virus (HPV) and characterised by invasive growth. Very few cases of GCA of vulva have been reported till now in the English literature [1–3]. We report a case of 34-year-old lady with GCA of vulva who was successfully treated by simple vulvectomy and reconstruction of the defect by ‘‘four-flap technique’’. A 34-year-old, married woman presented with complaints of growth on her vulva for the last 8 months. The patient was 6 months pregnant when she first noted the lesion and did not seek any medical help. Two months after her caesarean delivery, she underwent cryosurgery, but with no improvement. She denied any history of sexual promiscuity. On examination there was a 14 cm 9 10 cm 9 6 cm friable, foul smelling growth on her vulva involving both labia majora, extending anteriorly to mons pubis and posteriorly to perianal region (Fig. 1a). There were a few satellite lesions on labia minora and perianal region. Clitoris, urethra and external anal sphincter were not involved. Colposcopic, proctoscopic and oropharyngeal examinations were normal. The patient and her partner were screened negative for sexually transmitted diseases and high-risk HPV DNA. Incisional biopsy showed squamous cell papilloma with koilocytic changes and it was positive for HPV DNA type 6. A simple vulvectomy, achieving wide margins, was performed. Small lesions in perianal area and labia minora were also excised. Reconstruction of vulva was performed using ‘four flap technique’ (personal communication by Dr. Prakash V, Department of plastic surgery, Safdarjung Hospital, New Delhi). In this technique, four random pattern flaps in the dimension of 1:1 or 1:2 were raised adjacent to the defect and advanced medially to resurface the defect. This resulted in defect being transferred laterally, but this defect was smaller than the original defect and could be closed primarily (Fig. 1b). Final histopathology report confirmed the diagnosis of condyloma acuminatum with mild degree of dysplasia. Functional outcome was good with no sexual complaints. She remained free of recurrence at 12 months of follow-up (Fig. 1c). Many treatment strategies have been documented in the literature for management of GCA, but mainly in the form of case reports. Complete surgical excision with histologically clear margins, with or without adjuvants, is the mainstay of the treatment for GCA, including that of vulva [1, 3]. Other modalities include combined radiotherapy and chemotherapy, topical agents (e.g. podophyllin, 5-FU, imiquimod, bleomycin) and intralesional injections of interferons [4–6]. The skin defects created after excision of GCA in the peri-anal region can be managed with mesh skin grafting, flaps and even healing by secondary intention [1, 7–9]. Flaps have been shown to give better results for reconstruction of vulva [8, 9]. The additional advantage of our ‘four flap technique is that the scars do not extend over the perineum or thighs. In our patient, the postoperative period P. Mittal (&) R. Gupta R. Dewan S. Singhal J. Suri Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi 110029, India e-mail: drpratima@hotmail.com

Clinical outcome of post placental copper T380A and copper 375 IUCD insertion in women delivering by caesarean section

According to the WHO’S medical eligibility criteria recommendations PPIUCD is used in the immediate postpartum period, including intra caesarean has been rated as category. In India Copper T 380A is being supplied by government of India free of cost in all government health centers and also to private practitioners, nowadays Copper 375 is also being used in National Family Health Program. It is observed that the acceptance of Copper 375 IUCDs for interval contraception is higher as compared to Copper T 380A. The efficacy of intracaesarean IUCD insertion without any added risk of infectious morbidity has also been reported by various studies. This technique offers the ABSTRACT

Feto-maternal Outcome Using New Screening Criteria of Serum TSH for Diagnosing Hypothyroidism in Pregnancy

INTRODUCTION Evidence suggests that by using the classical non pregnant reference range for serum TSH (STSH), one might miss hypothyroidism in pregnancy. Therefore, upper normal cut off value of S TSH should be taken as <2.5 mIU/L in the first trimester and <3mIU/L in the second and third trimester. However, two Indian studies have reported higher trimester specific reference ranges in the Indian pregnant women. OBJECTIVES To assess the maternal and fetal outcomes using new screening criteria with upper S TSH cut off as >3mIU/L, for diagnosing hypothyroidism in pregnancy. MATERIALS AND METHODS This study was a cross sectional study, carried out in the Department of Obstetrics and Gynaecology of a tertiary care hospital, in collaboration with the Department of Endocrinology. Pregnant women with ≤ 20 weeks gestation, attending antenatal OPD from December 2010 to January 2012 were included in the study. On the basis of S TSH level, women were divided into Study Group with S TSH level between 3.1 to 6.2 mIU/L, (new range to be studied) and an equal number of age and parity matched Control Group with S TSH levels between 0.4 to 3 mIU/L. The maternal and fetal outcomes were compared between study and control groups. RESULTS During the study period, a total of 66 women had S TSH between 3.1-6.2 mIU/L. Maternal and fetal outcomes in both the groups were comparable. There was no difference in the mode of delivery between study and control groups. CONCLUSION The lower S TSH cut off recommended for diagnosing hypothyroidism in pregnancy may not be applicable to pregnant Indian women.