Sarala Gopalan

Pheochromocytoma associated with pregnancy

Pheochromocytoma associated with pregnancy is rare with potentially lethal consequences. Antepartum diagnosis improves the maternal and perinatal outcome. The issue of mode of delivery is unresolved. Its definitive treatment is surgical resection preceded by medical management. Surgical resection may be done during caesarean section as is reported in the present case.

Abruptio placentae and chorioamnionitis - microbiological and histologic correlation

BACKGROUND To determine the association of chorioamnionitis with placental abruption. SUBJECT AND METHOD Fifty pregnant women admitted with abruptio placentae were compared to an equally large control group in spontaneous labor with no history of antepartum hemorrhage. Swabs from the cervix and placental membranes were cultured for aerobic and anaerobic organisms. Placental membranes were studied histologically in 40 women of study group and 35 of control group for any evidence of chorioamnionitis. RESULTS Specific organisms were isolated in 22 (44%) women in the study group and 19 (38%) women in the control group. The cervical swab microbiological flora was similar in both groups but isolation of specific organisms from placental membrane culture was higher in the study group (40%) compared to the controls (18% p<0.05). Evidence of histologic chorioamnionitis was higher in the study group 12/40 (30%), than in the control group 8/35 (22.85%), but the difference was not significant. CONCLUSION The incidence of silent chorioamnionitis (placental membrane culture positivity) is higher in the abruptio placentae.

Unsafe abortion: a neglected tragedy. Review from a tertiary care hospital in India.

Aim: With 16% of the worlds population, India accounts for over 20% of the worlds maternal deaths. The maternal mortality ratio, defined as the number of maternal deaths per 100 000 live births is incredibly high at 408 per 100 000 live births for the country. Abortion has been legalized in India for the past three decades. However, the share of unsafe abortion as a cause of maternal mortality continues to be alarming. The objective of the present study is to identify the magnitude of problem of unsafe abortion in India.

The routine use of oxytocin after oral misoprostol for labour induction in women with an unfavourable cervix is not of benefit

Background:  Induction of labour with misoprostol is often augmented with oxytocin with the possible consequence of uterine hypercontractility. It is important to determine whether the use of oxytocin in this circumstance has benefit as well as risk.

Estrogen Receptor Beta (erβ) in Endometrial Simple Hyperplasia and Endometrioid Carcinoma

AimsThe aim of this study was to analyze the expression of estrogen receptor (ER) β in endometrioid carcinoma in comparison to non-neoplastic endometrium. MethodsFifty-seven histopathologically confirmed non-neoplastic endometria (22 proliferative phase, 15 secretory phase, and 20 simple hyperplasia without atypia), and 26 cases of endometrioid carcinoma were studied. The ERβ/ERα transcript ratio was determined by semiquantitative reverse transcription-polymerase chain reaction. The receptor protein expression was evaluated by immunohistochemistry using the Allred Scoring System. ResultsDecreased expression of ERβ, ERα, and progesterone receptor proteins was observed in endometrioid carcinoma compared with proliferative endometrium and simple hyperplasia (P<0.01, Mann-Whitney U test). Within the group of endometrioid carcinoma, a correlation of increased ERβ expression with tumors exhibiting ≥50% myoinvasion (P=0.034) was observed, whereas there was no correlation with the grade of tumor (P=0.314). There was a significant association of ERβ with ERα expression in both non-neoplastic and neoplastic endometrium indicating interdependence of expression. Progesterone receptor protein expression was influenced by ERα levels and not by ERβ as shown by regression analysis in non-neoplastic and neoplastic endometrium. ConclusionsThus, ERβ alterations are important in endometrioid carcinoma. The relationship of ERβ expression to myoinvasion warrants further investigation.

Serum soluble Fas levels and prediction of response to platinum-based chemotherapy in epithelial ovarian cancer

Epithelial ovarian cancer (EOC) is treated mainly by platinum‐based combination chemotherapy. Chemotherapy induces apoptosis in which the Fas/Fas ligand pathway is important. Serum soluble Fas (sFas) is a biomarker of this pathway and functionally inhibits Fas‐/FasL‐mediated apoptosis. In this study, we have investigated the role of sFas in prediction of response to chemotherapy in EOC. Thirty‐five patients were recruited and their serum sFas levels were estimated by ELISA at 4 time points—preoperative (sFas1), postoperative (sFas2), midchemotherapy (sFas3) and at the end of chemotherapy (sFas4). The response to chemotherapy was documented clinically, radiologically and by CA‐125 levels, based on which, 2 groups were identified: primary chemosensitive (n = 24) and primary chemoresistant (n = 11). Based on the disease status at last follow‐up, 2 groups were identified: No Evidence of Disease (n = 15) and Evidence of Disease (n = 20). The primary chemoresistant tumors showed significantly higher median sFas2 levels (p = 0.033) with the sFas2/sFas1 ratio ≥1 (p = 0.001). A multivariate Cox proportional hazards regression model identified sFas2/sFas1 ratio as a significant factor for the prediction of response to platinum‐based chemotherapy (p = 0.011). Receiver operating characteristic (ROC) analysis showed that at a ratio of 1.2, sFas2/sFas1 achieved a sensitivity of 82% and specificity of 100% for prediction of chemotherapeutic response. sFas2/sFas1 and sFas3/sFas1 ratio was also higher in patients with evidence of disease (p = 0.018 and p = 0.028, respectively). Progression‐free survival rates in patients with sFas2/sFas1 ratio <1 exceeded those with ratio ≥1 (p = 0.004). In conclusion, serum sFas is a useful biomarker for predicting response to platinum‐based chemotherapy in EOC.

A randomized trial comparing a polyherbal pessary (a complementary and alternative medicine) with Ginlac-V pessary (containing clotrimazole, tinidazole and lactobacilli) for treatment of women with symptomatic vaginal discharge

Background Most women with abnormal vaginal discharge have infection due to candida species, bacterial vaginosis or trichomoniasis and often seek treatment without laboratory confirmation. In this context, a single agent effective against these infections would be useful.AimTo compare the efficacy of two such agents: Praneem polyherbal pessary; a complementary and alternative medicine (CAM) with Ginlac-V pessary (containing clotrimazole, tinidazole and lactobacilli) for treatment of abnormal vaginal discharge.Settings and design A randomized study in a tertiary care hospital in North India. Methods: One hundred women were randomized for treatment with either of the two pessaries. Clinical examination and laboratory evaluation was done before and after treatment.Statistical analysisMc-Nemar test and Chi-square test.Results Overall, 82% (82/100) reported symptomatic relief; 78% (39/50) with Praneem and 86% (43/50) with Ginlac-V. Only 36% (18/50 in each group) had laboratory-confirmed infection; 18% (18/100) candidosis, 17% (17/100) bacterial vaginosis, 1% (1/100) both; none had trichomoniasis. Among these, symptomatic improvement was seen in 72% (13/18) and laboratory cure in 78% (14/18) with Praneem; symptomatic improvement in 78% (14/18) and laboratory cure in 78% (14/18) with Ginlac-V. Clinical or laboratory criteria could assess treatment efficacy equally. Neither drug was efficacious in candidosis. Ginlac-V was efficacious in bacterial vaginosis (100%) and though Praneem showed a similar trend, it was not statistically significant. Vaginal irritation was more frequent with Praneem (16% vs 4% with Ginlac-V).Conclusion Both Praneem and Ginlac-V provided symptomatic relief in most of the women. Either clinical or laboratory criteria could assess treatment efficacy of both drugs. Ginlac-V was efficacious for treating bacterial vaginosis.

Cervical pregnancy and therapeutic options

Of all forms of ectopic gestation, the possibility of fertility catastrophe is highest with a cervical pregnancy. Though rare, it is a potentially life-threatening condition. In the past it was diagnosed late, after there was profuse hemorrhage from the cervix and it usually required hysterectomy. With ultrasound, diagnosis can be made earlier and conservative management attempted in order to preserve the reproductive potential. Methotrexate has been used both systemically and intra-amniotically to treat cervical ectopic gestation conservatively (1).

Home Deliveries and Third Stage Complications

EDITORIAL COMMENT: We have accepted this paper for publication not only because it tells us about the conditions under which obstetrics is practised in a very large proportion of the worlds population but because, by implication, it reminds us of the importance of careful management of the third stage of labour. We learn from this paper that approximately 80% of parturients in India are cared for by an untrained birth attendant and that oxytocic agents are not available or used routinely at delivery. One can only wonder at how many maternal deaths occur in patients who are never referred to hospital. As far as the editorial subcommittee of the Journal is aware the national maternal mortality rates are not available for India and hospital figures are quoted when the proportion due to various complications are discussed. This paper does not allow comparison of third stage complications in home deliveries and hospital deliveries because the 122 cases referred to in this paper come from a population whose size is unknown. It is salutary to note from table 1 that in 13% (16 of 123) of cases the baby had been stillborn. The high incidence of uterine inversion in this series no doubt is explained by attempts at removal of a retained placenta without the use of oxytocic agents. There is a message here for us all ‐ in developed and in developing countries. The third stage of labour is a killer and requires routine management with an oxytocic drug used appropriately.

Papanicolaou smear abnormalities in HIV-infected women in north India

Background:  Dysplasia on Papanicolaou (Pap) smears have been reported in 15–40% of HIV‐positive women. These rates are 10–11 times higher than those observed among HIV‐negative women. Both the Center for Disease Control and Prevention and the Agency for Healthcare Policy and Research recommend that HIV‐infected women have a gynecologic evaluation including a Pap smear and pelvic examination as part of their initial evaluation.