Subhas Chandra Saha

Obstetrical outcomes among women with extrapulmonary tuberculosis

BACKGROUND The prevalence of tuberculosis, especially extrapulmonary tuberculosis, is increasing worldwide. Because information on the outcome of pregnancy among women with extrapulmonary tuberculosis is limited, we studied the course of pregnancy and labor and the perinatal outcome in these women and their infants. METHODS From 1983 to 1993, we followed 33 pregnant women who had extrapulmonary tuberculosis (12 with tuberculous lymphadenitis and 9 with intestinal, 7 with skeletal, 2 with renal, 2 with meningeal, and 1 with endometrial tuberculosis) through their deliveries. Of the 33, 29 received antituberculosis treatment during pregnancy. The antenatal complications, intrapartum events, and perinatal outcomes were compared with those among 132 healthy pregnant women without tuberculosis who were matched for age, parity, and socioeconomic status. RESULTS Tuberculous lymphadenitis did not affect the course of pregnancy or labor or the perinatal outcome. However, as compared with the control women, the 21 women with tubercular involvement of other extrapulmonary sites had higher rates of antenatal hospitalization (24 percent vs. 2 percent, P< 0.001), infants with low Apgar scores (< or =6) soon after birth (19 percent vs. 3 percent, P=0.01), and low-birth-weight (<2500 g) infants (33 percent vs. 11 percent, P=0.01). CONCLUSIONS Extrapulmonary tuberculosis that is confined to the lymph nodes has no effect on obstetrical outcomes, but tuberculosis at other extrapulmonary sites does adversely affect the outcome of pregnancy.

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.

Pregnancy complicated by severe chronic hypertension: a 10-year analysis from a developing country.

Objective: To assess pregnancy outcome in patients with severe chronic hypertension. Methods: A retrospective analysis of a 10-year period (1995–2004) in a referral hospital in northern India. The outcome was compared with those women with mild chronic hypertension who registered in the hypertensive disorders with pregnancy clinic immediately before and after each woman with severe chronic hypertension. Results: Hospital data identified 25 such women. Superimposed preeclampsia (36.4% versus 8%), preterm delivery (86.4% versus 42%), and perinatal mortality (27.2% versus none) were increased in patients with severe chronic hypertension as compared to those with mild hypertension. Conclusions: The small number of cases reflects the lack of antenatal supervision in developing countries. A much larger number of women are referred in the third trimester with eclampsia or severe preeclampsia, at which time it is not possible to identify whether or not they had underlying hypertension. Adverse events were found to occur more often in patients with severe chronic hypertension compared with those with mild hypertension.

Phaeochromocytoma in pregnancy can mimic severe hypertensive disorders

Introduction Phaeochromocytoma is oft en overlooked in pregnancy due to its rarity and because the clinical picture can resemble that of preeclampsia. An unrecognised phaeochromocytoma is particularly dangerous as a fatal hypertensive crisis can be precipitated by anaesthesia, vaginal delivery, mechanical eff ects on the growing gravid uterus, abdominal palpation, uterine contractions and by vigorous fetal movements. We report two cases of phaeochromocytoma complicating the index pregnancy and recurrent pre-eclampsia in subsequent pregnancies.

Advanced germ cell malignancies of the ovary: should neo-adjuvant chemotherapy be the first line of treatment?

Malignant germ cell tumours of the ovary, though classically known for ‘young age’ and ‘early stage’ at presentation, are not uncommonly identified at advanced stages. Little is available in literature on the role of neo-adjuvant chemotherapy (NACT) in this group of tumours. Two patients with advanced stage ovarian germ cell tumours, including one with 45XO/46XY chromosomal mosaicism, were treated at our Institute with neo-adjuvant chemotherapy with Bleomycin, Etoposide and Cisplatin followed by surgery. Besides marked clinical improvement, intraoperatively both the patients presented no difficulty otherwise expected with widespread tumours, and histopathology report revealed no evidence of viable tumour. The article discusses the experience and suggested course of management of these tumours with NACT, which could be offered to patients with advanced malignancy in whom high surgical morbidity is anticipated or in whom only an operative biopsy was performed at laparatomy. Behaviour and management guidelines of dysgenetic gonads with XY mosaicism have also been discussed.

Acute pancreatitis with eclampsia-preeclampsia syndrome and poor maternal outcome: two case reports and review of literature

Acute pancreatitis in pregnancy is a rare entity and has been reported to be associated with preeclampsia in the literature. Fulminant pancreatitis may have a guarded prognosis despite intensive multidisciplinary management. Two cases of maternal mortality in women with acute pancreatitis noted in the setting of preeclampsia-eclampsia syndrome are reported here.

Second trimester abortion in women with and without previous uterine scar: Eleven years experience from a developing country.

ABSTRACT Objectives To study the safety of second trimester abortion in women with previous uterine scar. Methods We screened the records of 518 women who underwent an abortion between 12 and 20 weeks’ gestation at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, from January 2000 to December 2010. Methods used for abortion were: (i) vaginal misoprostol with or without pre-treatment with mifepristone, and (ii) intracervical dinoprostol gel or vaginal misoprostol ± extra-amniotic saline ± oxytocin infusion. Seventeen women, aborted by means of a hysterotomy, were excluded from further analysis. Results Of the remaining 501 women, 44 had a uterine scar (Group 1) and 457 had none (Group 2). In Group 1, 40/44 (91%) and in Group 2, 452/457 (99%) women aborted successfully. The mean induction-abortion interval (IAI) was similar in the two groups (15.03 ± 10.69 hours and 12.52 ± 9.0 hours in Groups 1 and 2, respectively; p = 0.083). There were three uterine ruptures, 1/44 (2%) in group 1 and 2/457 (0.4%) in group 2 (p = 0.132, NS); all three women had received mifepristone followed by vaginal misoprostol. Conclusion In women with a scarred uterus, midtrimester abortion may be successfully achieved using any of the aforementioned regimens.

The Most Favourable Procedure for the Isolation of Cell-free DNA from the Plasma of Iso-immunized RHD-negative Pregnant Women

Background: The ability to achieve quality recovery of cell-free foetal DNA is important for making non-invasive prenatal diagnoses. In this study, we performed quantitative and qualitative analyses of isolated DNA from maternal plasma, using different DNA-isolation methods. Method: DNA was isolated from 30 iso-immunized women via the QIAamp column-based method, using four different elution volumes and two conventionally based methods. Real-time polymerase chain-reaction quantification of RHD and β-globin genes was performed in order to determine foetal-specific sequences and total genome equivalents, respectively. Results: The column-based method at a 3 μl elution volume yielded the highest quality and quantity of total DNA (67.0±0.6 ng/μL). At a 3 μl elution volume, the β-globin and RHD‐gene sequences were estimated to be the highest among all isolation procedures, with 2778.13±1.5 and 66.9±0.6 GEq/mL, respectively, and a 100% sensitivity for RHD‐gene sequence detection. Among the two conventional manual methods, the boiling lysis method yielded a higher DNA concentration (53.8±0.8 ng/μL) and purity (1.73±0.05). In addition, the methods sensitivity for foetal-detection sequences was only 80%, whereas the salting-out methods sensitivity was just 70%. Conclusions: This study confirms the theory that the QIAamp method is a specific and sensitive approach for purifying and quantifying plasma DNA, when used in the minimum elution volume.

The accuracy of integrated [ 18 F] fluorodeoxyglucose-positron emission tomography/computed tomography in detection of pelvic and para-aortic nodal metastasis in patients with high risk endometrial cancer

Lymph nodal (LN) metastasis is the most important prognostic factor in high-risk endometrial cancer. However, the benefit of routine lymphadenectomy in endometrial cancer is controversial. This study was conducted to assess the accuracy of [18F] fluorodeoxyglucose-positron emission tomography/computed tomography ([18F] FDG-PET/CT) in detection of pelvic and para-aortic nodal metastases in high-risk endometrial cancer. 20 patients with high-risk endometrial carcinoma underwent [18F] FDG-PET/CT followed by total abdominal hysterectomy, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy with or without para-aortic lymphadenectomy. The findings on histopathology were compared with [18F] FDG-PET/CT findings to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of [18F] FDG-PET/CT. The pelvic nodal findings were analyzed on a patient and nodal chain based criteria. The para-aortic nodal findings were reported separately. Histopathology documented nodal involvement in two patients (10%). For detection of pelvic nodes, on a patient based analysis, [18F] FDG-PET/CT had a sensitivity of 100%, specificity of 61.11%, PPV of 22.22%, NPV of 100% and accuracy of 65% and on a nodal chain based analysis, [18F] FDG-PET/CT had a sensitivity of 100%, specificity of 80%, PPV of 20%, NPV of 100%, and accuracy of 80.95%. For detection of para-aortic nodes, [18F] FDG-PET/CT had sensitivity of 100%, specificity of 66.67%, PPV of 20%, NPV of 100%, and accuracy of 69.23%. Although [18F] FDG-PET/CT has high sensitivity for detection of LN metastasis in endometrial carcinoma, it had moderate accuracy and high false positivity. However, the high NPV is important in selecting patients in whom lymphadenectomy may be omitted.

Vesical calculus: An unusual cause of labour dystocia

Case report A 36-year-old primigravida was referred to our centre at 22 weeks ’ gestation for routine morphological ultrasound examination. During this scan, focal hyperechogenic findings were detected in the bowel, heart and liver surface (Figure 1). The patient was then closely monitored with serial ultrasound examinations that showed dilated ileal bowel loops with peristalsis present. Maternal virus investigations were negative; she was negative for cystic fibrosis (CFTR gene investigated by oligonucleotide ligation assay for most frequent mutations in our population) and the amniocentesis showed a normal fetal karyotype. The induction of lung maturity was performed, with betamethasone (12 mg/day for 2 days), at 33 weeks, for increasing enlargement of the intestinal loops. Lung maturity was then checked by amniocentesis for L/S ratio and phosphatidylglycerol presence and delivery by caesarean section occurred at 35 weeks. At birth, the infant showed a good adaptation to extrauterine life (weight: 3.160 kg; Apgar scores: 9 at 1 min and 10 at 5 min). In the first hours of life, progressive further abdominal distension was shown. After radiological evaluation, the child was subjected to exploratory laparotomy on the 2nd day of life, which showed a jejunal atresia type IV and double ileal atresia type I (Shorter et al. 2006) and the atresia was recanalised. The baby was discharged on the 31st day with a follow-up programme in place. The child is 3 years old at the time of writing and is in good health.