Sunil Kumar Samal

Ferric carboxymaltose: A revolution in the treatment of postpartum anemia in Indian women.

Objectives: The objective of the present study is to compare the safety and efficacy of ferric carboxymaltose (FCM), intravenous (IV) iron sucrose and oral iron in the treatment of post = partum anemia (PPA). Materials and Methods: A total of 366 women admitted to SCB Medical College, Cuttack between September 2010 and August 2012 suffering from PPA hemoglobin (Hb) <10 g/dL were randomly assigned to receive either oral iron or IV FCM or iron sucrose. FCM, IV iron sucrose, and oral iron were given as per the protocol. Changes in hemoglobin (Hb) and serum ferritin levels at 2 and 6 weeks after treatment were measured and analyzed using ANOVA. Adverse effects to drug administration were also recorded. Results: A statistically significant increase in Hb and serum ferritin level were observed in all three groups, but the increase in FCM group was significantly higher (P < 0.0001) than conventional iron sucrose and oral iron group. The mean increase in Hb after 2 weeks was 0.8, 2.4, and 3.2 g/dL and 2.1, 3.4, and 4.4 g/dL at 6 weeks in oral iron, iron sucrose and FCM groups, respectively. The mean increase in serum ferritin levels after 2 weeks was 2.5, 193.1, and 307.1 and 14.2, 64, and 106.7 ng/mL after 6 weeks in oral iron, iron sucrose and FCM groups, respectively. Adverse drug reactions were significantly less (P < 0.001) in FCM group when compared with other two groups. Conclusion: Ferric carboxymaltose elevates Hb level and restores iron stores faster than IV iron sucrose and oral iron, without any severe adverse reactions. There was better overall satisfaction reported by the patients who received FCM treatment.

Cervical ectopic pregnancy.

Cervical pregnancy is a rare type of ectopic pregnancy and it represents <1% of all ectopic pregnancies. Early diagnosis and medical management with systemic or local administration of methotrexate is the treatment of choice. If the pregnancy is disturbed, it may lead to massive hemorrhage, which may require hysterectomy to save the patient. We report three cases of cervical pregnancy managed successfully with different approaches of management. Our first case, 28 years old G3P2L2 with previous two lower segment cesarean sections, presented with bleeding per vaginum following 6 weeks of amenorrhea. Clinical examination followed by transvaginal ultrasound confirmed the diagnosis of cervical pregnancy. Total abdominal hysterectomy was done in view of intractable bleeding to save the patient. The second case, a 26-year-old second gravida with previous normal vaginal delivery presented with pain abdomen and single episode of spotting per vaginum following 7 weeks of amenorrhea. Transvaginal ultrasound revealed empty endometrial cavity, closed internal os with gestational sac containing live fetus of 7 weeks gestational age in cervical canal and she was treated with intra-amniotic potassium chloride followed by systemic methotrexate. Follow up with serum beta human chorionic gonadotropin level revealed successful outcome. Our third case, a 27-year-old primigravida with history of infertility treatment admitted with complaints of bleeding per vaginum for 1 day following 8 weeks amenorrhea. She was diagnosed as cervical pregnancy by clinical examination, confirmed by transvaginal ultrasonography and subsequently managed by dilation and curettage with intracervical Foleys’ ballon tamponade.

Sirenomelia: The mermaid syndrome: Report of two cases

Sirenomelia (mermaid syndrome) is a rare congenital fetal anomaly with characteristic feature of complete or partial fusion of lower limbs. Although, this syndrome is incompatible with life due to the association of several congenital visceral abnormalities; however, there are few reports of surviving infants. Our first case was a live born, normally delivered at term by a 27-year-old third gravida of lower socioeconomic status with history of tobacco use. Examination of the baby revealed caudal dysgenesis having fusion of lower limbs, single leg with 1 foot and 5 toes. There was no identifiable external genitalia and anus. The second case was a 34 week, 1.6 kg preterm infant of unidentified sex born to a 28-year-old primigravida mother with overt diabetes mellitus. Incidentally, both the infants died few hours after birth and we report these cases due to their rarity and term live birth.

Non Puerperal Uterine Inversion in a young female- A case report

We report a case of 28-year-old, primipara who presented with complaints of mass descending per vaginum along with excessive bleeding and foul smelling vaginal discharge for the past six months. Clinical examination revealed an inverted uterus, cervix and vagina with a large submucosal fundal fibroid. A diagnosis of non-puerperal uterine inversion was made. Surgical management included vaginal myomectomy with repositioning of the uterus using an abdomino-vaginal approach and a successful outcome. Histopathology confirmed the diagnosis of leiomyoma. Hence, we conclude that uterus-sparing surgery should be considered in young females desirous for future pregnancy until the final pathology is known.

Prune Belly syndrome: A rare case report

Prune Belly syndrome (PBS) is a rare congenital anomaly of uncertain etiology almost exclusive to males. We report a case of term male baby born to a 39-year-old grand multipara with previous four normal vaginal births. There was no history of genetic or congenital anomaly in her family. Examination of the baby revealed hypotonia, deficient abdominal muscle, cryptorchidism, palpable kidney, and bladder. Ultrasound examination of the abdomen revealed bilateral gross hydronephrosis and megaureter. Provisional diagnosis of PBS was made and the baby was admitted in neonatal intensive care units for further management. Routine antenatal care with ultrasonography will help in detecting renal anomalies, which can be followed postnatally. Early diagnosis of this syndrome and determining its optimal treatment are very important in helping to avoid its fatal course.

A rare case of heterotopic pregnancy with ruptured left rudimentary horn pregnancy.

Heterotopic pregnancy(HP) occurs when intrauterine and ectopic pregnancies coexist. We report a case of HP at 14 wk of gestation presenting as ruptured left rudimentary horn ectopic pregnancy with live intrauterine gestation and was managed with emergency laparotomy followed by resection of left rudimentary non communicating horn of uterus. The intrauterine pregnancy continued uneventfully. A female baby was delivered vaginally at 41 wk following induction of labour.

A true cornual pregnancy with placenta percreta resulting in a viable fetus.

Cornual pregnancy is uncommon among ectopic pregnancies. A diagnosis of cornual pregnancy remains challenging, and rupture of a cornual pregnancy causes catastrophic consequence due to massive bleeding. In very rare circumstances, cornual pregnancies can result in a viable fetus. We report a case of a 24-year-old primigravida who presented to us with complaints of decrease fetal movements at 37+5 weeks. Ultrasound revealed a single live intrauterine fetus with anterior low lying placenta with severe oligohydramnios (amniotic fluid index = 1.8). Emergency cesarean section was done and intraoperatively it was diagnosed as a case of placenta percreta with pregnancy in right noncommunicating horn of uterus. Right cornual resection with right salpingectomy done. Uterus, left fallopian tube and bilateral ovary were healthy. Postoperative period was uneventful.

Successful pregnancy outcome in a case of eisenmenger syndrome: a rare case report.

Pregnancy complicated with Eisenmenger syndrome is associated with high risk to the fetus as well as the mother. There is approximately 50% risk of sudden maternal death, frequently occuring a few days postpartum and the overall fetal wastage is reported to be up to 75%. Patients with Eisenmenger syndrome are advised to refrain from pregnancy or to terminate pregnancy by the end of first trimester itself. Management of these patients requires a co-ordinated multi-specialist care when such pregnancies reach a stage where safe termination is not advisable. However, inspite of all the risks, a few patients deliver successfully with a good maternal and neonatal outcome. We present a 27-year-old unbooked G3P1A1L0 admitted at 34 wk gestation with Eisenmenger syndrome. She was treated medically during pregnancy, underwent elective Caesarean section at 37 wk of gestation delivered a healthy baby and was subsequently discharged on the 10(th) postoperative day without any serious complications.

Successful Outcome of Twin Gestation with Partial Mole and Co-Existing Live Fetus: A Case Report.

Sad fetus syndrome comprising of a live twin gestation with a hydatidiform mole is a rare entity. The condition is even rarer when the co-existing live fetus is associated with a partial mole than a complete mole. We report the case of a 24-year-old G2P1L1 at 28 weeks gestation who presented to our casualty in the second stage of labour. She had a previous ultrasound scan at 13 weeks which showed a live fetus with a focal area of multicystic placenta. She delivered an alive preterm male fetus weighing 1.32 kg vaginally. Following expulsion of normal placenta of the live fetus, partial mole was expelled. The fetus was admitted to neonatal ICU and discharged after two weeks. Soon after delivery, β-hCG (human chorionic gonadotropin) was 1,21,993 mIU/ml which decreased to 30mIU/ml within two weeks. The patient was discharged with advice of regular follow up of β-hCG reports.

Fibroepithelial Polyps of the Vagina in Pregnancy.

A 25-year-old primigravida mother at 36 weeks pregnancy presented with mass descending per vaginum for last one month. In the antenatal history she had regular antenatal visits without any pregnancy complication. General and systemic examination revealed no abnormality. On local examination of external genitalia, there was a large pedunculated polyp [Table/Fig-1] of the vagina which measured 8 x 6 cm with multiple large atypical polyps found inside the vagina. Cervix was healthy and os was closed. An excisional biopsy of the largest polyp was done and histopathology revealed benign fibroepithelial polyps. So decision was taken to allow spontaneous vaginal delivery. Since operative vaginal delivery should be avoided in such cases to reduce the risk of trauma and haemorrhage [1]. Her pregnancy continued well and she went in to spontaneous labour at 40+2 weeks. But caesarean section was done for intrapartum fetal distress. On follow up after 6 weeks, the patient is asymptomatic and the polyps were reduced in size and number which proved their hormone dependant nature [Table/Fig-2]. [Table/Fig-1]: Large pedunculated polyp with multiple fibroepithelial polyps of vagina [Table/Fig-2]: After 6 weeks polyps reduced in size and numbers Fibroepithelial polyps of the vagina (FEPV) are mucosal polypoid lesions with a connective tissue core covered by a benign squamous epithelium [2]. They are thought to be rare as few cases are reported in literature and the cases are compared with the present case in [Table/Fig-3]. [Table/Fig-3]: Comparison of reported cases in literature with the present case The aetiology of FEPV may be as a result of a granulation tissue reaction after some local injury of the vaginal mucosa. It is because of delayed differentiation of myofibroblastic stromal cells which explains why granulation tissue sometimes does not contract properly but turns into polyps [2]. But during pregnancy hormonal factors may modulate the growth of FEPVs. Hartmann CA et al., reported after examination with immunohistochemistry that FEPV expressed vimentin, desmin, and receptors for estrogen and progesterone which indicates the hormone dependant nature of these polyps [3]. Although benign, it can be confused with malignant connective tissue lesions because of its bizarre histology. The differential diagnoses are sarcoma botryoides, rhabdomyosarcoma and mixed mesodermal tumour [4]. Histopatholgy confirms the diagnosis. The other terminologies of FEPV reported in literature are Pseudosarcoma botryoides, Cellular pseudosarcomatous fibroepithelial stromal polyps and Polyposis vaginalis [5,6]. Treatment of FEPV is simple local excision [7,8]. It can be performed after pregnancy as an interval procedure when the vaginal vascularity has returned to normal. Recurrence is extremely uncommon [9]. Nucci MR et al., studied 65 cases of FEPV and reported that awareness of the spectrum of histopathologic features that these lesions can exhibit and is crucial in their accurate diagnosis thus avoiding potential overtreatment [5]. FEPV in pregnancy is a rare lesion. Although benign, it can be confused with some malignant tumours. Histopathology confirms the diagnosis. Treatment is simple local excision and recurrence is uncommon. Hence knowledge of clinical and histopathological features of these lesions is important for accurate diagnosis for avoiding potential overtreatment.