Sushil Kumar

Assessment of Uterine Factor in Infertile Women : Hysterosalpingography vs Hysteroscopy

The objective of this study was to evaluate the diagnostic accuracy of hystero-salpingography (HSG) in detecting uterine cavity abnormalities in infertile patients, with reference to hysteroscopy as the gold standard method. 60 infertile women were investigated with both HSG and hysteroscopy. Statistical analysis was performed. As a test for the detection of uterine cavity abnormalities, HSG in comparison with hysteroscopy had 60% sensitivity, 90% specificity, 10% false positive value and 40% false negative value. HSG is not able to diagnose polyps, septum and submucous fibroids with significant accuracy. Therefore hysteroscopy is indicated for confirmation.

ROLE OF INTRA-UTERINE INSEMINATION AND SPERM PREPARATION TECHNIQUES IN TREATMENT OF UNEXPLAINED INFERTILITY AND MALE INFERTILITY

Role of intrauterine insemination (IUI) in infertile couples is evaluated. Patients selected for the study belonged to two categories-Unexplained infertility(34 patients) and Male infertility (30 patients). In all the patients selected for IUI ovarian hyperstimulation was carried out with clomiphene citrate. Two techniques of sperm preparation were used - swim-up technique and mono-percoll gradient separation technique. Pregnancy rates of 15.6% per patient and 7% per cycle respectively were achieved which are comparable with other studies. Mono-percoll sperm separation technique was found more effective in treatment of Male infertility (oligo-asthenospermic semen sample).

INDUCTION OF LABOUR WITH MISOPROSTOL – A PROSTAGLANDIN E1 ANALOGUE

The purpose of our study was to compare the safety and efficacy of intravaginal misoprostol versus existing hospital protocol of intracervical dinoprostone and oxytocin for cervical ripening and induction of labour. 200 patients with indication for induction of labour were randomly assigned to receive either intravaginal misoprostol or dinoprostone/oxytocin combination. In first group twenty five micrograms of misoprostol was placed intravaginally every 6 hours till the patient reached active stage of labour. In second group dinoprostone gel 0.5 mg was placed in the endocervix at night and oxytocin induction was started in the early morning. The average interval from start to induction of vaginal delivery was shorter in misoprostol group (1315±811 minutes) compared to dinoprostone/oxytocin group (1512±712 minutes) (p < 0.01). There was no significant difference in route of delivery. 18% of misoprostol treated patients and 23% of dinoprostone/oxytocin treated patients required Caesarean section. Complications such as uterine tachysystole were significantly higher in misoprostol group (p < 0.01) but it was not associated with increased incidence of uterine hyperstimulation. Perinatal outcome was similar in both groups.

Multifetal Pregnancy Reduction

The incidence of higher order multiple gestation has undergone a sea change in recent times. Whereas the incidence of triplet is 1 in 64000 in spontaneous conception the same occurs in 1 to 3% of conceptions arising out of assisted reproduction. With increase in the order of multiple pregnancy the number of pregnancy crossing the period of viability decreases. Most of those who do cross end up in preterm delivery. Thus there is an unacceptable rise in pregnancy wastage and neonatal morbidity with long term sequelae. To address these problems multifetal pregnancy reduction (MFPR) was developed with the aim to improve the poor prognosis of pregnancies with three or more fetuses. It is a therapeutic intervention in which potassium chloride is injected under ultrasonic guidance in to thoracic cage of selected cofetus (es). A case is reported because of uncommonness of the procedure. (excerpt)

Placental site trophoblastic tumor with metastasis – A case report

Placental site trophoblastic tumor (PSTT) is a rare form of gestational trophoblastic disease arising from invasive intermediate gestational trophoblasts and constitutes 1–2% of all GTN.1 Historically, it was first described in 1895 and was considered a benign lesion until Scully and Young recognized its malignant potential in 1981.2 Unlike other forms of gestational trophoblastic diseases it produces less quantity of beta HCG and is less chemo sensitive. Thus surgery is the mainstay of treatment. Adjuvant chemotherapy is increasingly being offered in cases of metastasis, high mitotic count and large tumor volume.2,3 In this case report we present a case of PSTT with vaginal and lung metastasis managed with surgery and adjuvant chemotherapy.

Internal Iliac Artery Embolisation in Post LSCS Haemorrhage.

Obstetric hemorrhage is an important cause of maternal morbidity and death [1]. This condition has been traditionally managed by bilateral uterine artery ligation. Of late, life-threatening obstetric hemorrhage is increasingly dealt with using endovascular embolisation technique. Angiographic embolisation is a potentially ‘life and fertility’ saving procedure. It is a safe and effective method of controlling pregnancy related hemorrhagic complications unresponsive to conservative management and maintains reproductive potential [2]. We report our experience in a case of successful arterial embolization following intractable primary post partum hemorrhage complicated by coagulopathy.

Termination of Pregnancy in First Trimester - Medical Option

BACKGROUND The objective of this study was to confirm the effectiveness and safety of methotrexate and misoprostol or misoprostol alone for abortion up to 12 weeks of gestation. METHODS A group of volunteer patients desiring MTP with gestations up to 84 days (12 weeks) were studied. The patients were divided into 2 groups. Group 1 patients with gestation up to 56 days were further subdivided as (a) Patients who received methotrexate 50 mg IM + misoprostol 800 gms intravaginal and (b) patients who only received 800 gms of misoprostol. Group 2 included the patients who were 8-12 weeks pregnant and they received same treatment as group 1 (b). Outcome measures assessed included successful abortion (complete abortion without need for surgery), side effects, decrease in hemoglobin and mean duration of vaginal bleeding. RESULTS Complete abortion occurred in 36 (90%) of 40 patients in group 1 (a), 10 (67%) of 15 patients in group 1(b) and 29 (83%) of 35 patients in group 2. There were only 2 patients with clinically significant decrease in hemoglobin, but none required transfusions. Vaginal bleeding lasted 15 ± 6 days in group 1 (a), 16 ± 6 days in group 1(b) and 16 ± 5 days in group 2. All the patients stopped bleeding when endometrial thickness was < 5mm. Five percent women had stomatitis after methotrexate and 44% patients had fever with chills after misoprostol administration. CONCLUSION Considering the low cost and availability of methotrexate and misoprostol, these drugs constitute a good alternative for medical abortion. They are safe and effective.

Operative Gynecological Laparoscopy – Principles and Techniques

This book is a reference book in laparoscopy for advanced surgeons and beginners alike. It contains four sections, 21 chapters and a colour atlas, covering almost all the aspects of laparoscopic surgery. Like any other good surgical textbook, it has excellent illustrations. Besides, the standard chapters of ectopic pregnancy, endometriosis, ovarian cysts, myomectomy, hysterectomy etc, the book includes some of the topics, which are not available in many standard textbooks. For example, a chapter on laparoscopy in pregnant patients, risk factors have been identified and solutions are given to make the procedures safe in pregnancy. Similarly, a chapter on complilcations – the authors have stressed on need of prevention of complications. Considerable space has been devoted to newer procedures and the instruments like minilaparoscopy. This shows the trend for the future. A chapter on gynaecological malignancy is primarily for those surgeons who have already acquired mastery in standard laparoscopic surgeries and would like to do more. This book is indeed a bible for gynecological endoscopic surgery, therefore it is recommended for all hospital libraries.

Pregnancy in an Intravenous Drug User - Problem of Obstetric Management.

Drug abuse in pregnancy is already known to be a major health hazard in the developed countries. The American College of Obstetricians and Gynaecologists estimates that 10% is the minimum prevalence of substance abuse in pregnancy. Club culture, music and social atmosphere have profoundly influenced the use of drugs by teenagers and teenage pregnant mothers in the west. Fortunately in India, we rarely come across a pregnant patient with history of substance abuse (not counting alcohol and tobacco). Alcohol and tobacco may cause certain problems for the fetus but obstetric management is not as difficult as in case of intravenous (IV) drug users. We are reporting one such case.

SHOULDER DYSTOCIA : OBSTETRICIAN'S NIGHTMARE

Shoulder dystocia is an uncommon complication of delivery. 12 cases of shoulder dystocia are presented. The study suggests that prediction of shoulder dystocia on the basis of clinical profile is difficult A high index of suspicion is to be maintained in the presence of certain risk factors such as multigravida with large baby having prolonged 1(st) (decelarative phase) and 2(nd) stage of labour necessitating instrumental delivery. High neonatal morbidity (brachial palsy 44% and low Apgar score 44%) was found to be associated with shoulder dystocia. Among the manoeuvres used for the delivery of impacted shoulder, no neonatal injuries were associated with successful McRoberts manoeuvre. However, the success rate of the procedure was only 50%. Fundal pressure in absence of other manoeuvres resulted in 100% complication rate, hence should be condemned.