Vaidyanathan Gowri

Saline infusion sonohysterography – an effective tool for evaluation of the endometrial cavity in women with abnormal uterine bleeding

We evaluated the diagnostic accuracy of saline infusion sonohysterography (SISH) over transvaginal sonography (TVS) for the detection of intrauterine abnormalities using hysteroscopy as the gold standard in a retrospective study of 70 women mostly presenting with abnormal uterine bleeding. TVS was normal in 32 women, while in the others polyps or fibroids projecting into the cavity (n = 19) or a thick endometrium (n = 19) were suspected. On performing SISH the uterine cavity was found to be normal in 29 women, while 35 had suspected polyps/fibroids and 6 had other abnormalities. Hysteroscopy proved to be normal in 28 women, 35 had polyps/fibroids and 7 had other abnormalities. The sensitivity, specificity, positive and negative predictive values for TVS were 72.4%, 100%, 100% and 74%, respectively, while for SISH the corresponding figures were 91.4%, 92.6%, 89.3% and 94.1%. SISH is a simple, minimally invasive and cost‐effective investigative tool enhancing the diagnostic accuracy of TVS and can be an effective screening test prior to hysteroscopy.

Obstetric and Non-Obstetric Risk Factors for Cesarean Section in Oman

OBJECTIVE This study aims to explore the risk factors, profiles and neonatal outcomes of Cesarean sections among selected women in Oman. METHODS In this hospital-based case-control study, a total of 500 participants (250 cases who had cesarean section and 250 controls who had spontaneous vaginal delivery), were randomly selected from four hospitals. Cases and controls were matched according to timing and place of delivery. RESULTS THE FOLLOWING PREDICTORS WERE FOUND TO BE SIGNIFICANTLY ASSOCIATED WITH INCREASED RISK OF CESAREAN SECTION: a) advancing age (above the age of 25 years, OR=1.42; p=0.03), b) prior cesarean section (previous cesarean section=1, OR=22.71; p=0.001), c) increased body mass index (obesity, OR=2.11; p=0.07), d) extremes of neonatal birth weight (neonates birth weight <2.5 kg, OR=5.2; neonates birth weight >4.0 kg, OR=7.3; p<0.001), and e) pre-pregnancy diabetes (OR=9.3; p=0.04). On the contrary, increased parity and history of the use of birth spacing methods (OR=0.38; p=0.03) were associated with decreased risk of cesarean section. CONCLUSION The study calls for increasing awareness about clinical and public health majors that would lead to prevention of risk factors associated with increased risk of cesarean section such as maintaining normal BMI and prevention of gestational and type 2 diabetes mellitus.

Torsion of a normal ovary in the third trimester of pregnancy: a case report

IntroductionAdnexal torsion in advanced pregnancy is an uncommon emergency. Torsion usually occurs in ovaries with functional cysts or tumors. It is uncommon for a normal-sized ovary to undergo torsion in advanced gestation. We report torsion of a normal-sized ovary in the third trimester of pregnancy, most probably the first case report of its kind in the English-language literature.Case presentationA 32-year-old Omani woman at 32-weeks gestation (gravida 2 para 1) was admitted with right iliac fossa pain, nausea and vomiting of 2 days duration, as well as a history of a similar episode one month earlier. On examination, a provisional diagnosis of appendicitis was made. Laparotomy revealed, however, that the right ovary was gangrenous and had undergone torsion.ConclusionAdnexal torsion, though rare, should be kept in mind in the differential diagnosis of lower abdominal pain in advanced gestation. Although in our patient, the affected ovary could not be saved, an early diagnosis using imaging like Doppler of the adnexae will enable early intervention to save the ovaries of the patient, especially in young women.

Successful management of severe hemolytic disease of the fetus due to anti-Jsb using intrauterine transfusions with serial maternal blood donations: a case report and a review of the literature

The management of pregnant women with anti‐Jsb is challenging due to the paucity of antigen‐negative blood for fetal and neonatal transfusion.

Caesarean Myomectomy: Feasibility and safety.

OBJECTIVES Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity. METHODS We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed. RESULTS The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1-1.5 litres, 2 lost 1.5-2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients. CONCLUSION In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons.

Prevalence of cesarean delivery in preeclamptic patients with elevated uric acid.

Objective: To study the prevalence of cesarean delivery in hyperuricemic preeclamptic patients. Methods: This is a retrospective study of 94 women with preeclampsia from July 2006 through to December 2007. Serum uric acid was measured on admission. Mode of delivery and neonatal outcome were also recorded. Results: Hyperuricemic preeclamptic mothers were associated with higher probability of delivery by caesarean section (33% versus 12%; p = 0.007). There was a significant negative correlation between uric acid levels and gestational age (rho = −0.456; p < 0.001) but a positive association between uric acid levels and admission to neonatal unit (p < 0.001). There were no neonatal deaths. Conclusion: Hyperuricemia in preeclamptic patients was associated with higher probability of cesarean delivery.

High-sensitivity C-reactive protein is a marker of obesity and not of polycystic ovary syndrome per se

High-sensitivity C-reactive protein is more a marker of obesity than polycystic ovary syndrome itself, in particular in women >30 years of age.

Cotyledonoid leiomyoma in pregnancy

BACKGROUND: Benign smooth-muscle tumors (leiomyomata) are the most frequent tumors found in the female genital tract. They are easy to diagnose in pregnancy and usually managed conservatively. Some variant forms with unusual infiltrative growth pattern have been known, but they are rare in pregnancy. The variant forms pose diagnostic and management difficulties. CASE: An unusual type of leiomyoma (cotyledonoid), adhering to the bowels and occupying the whole left broad ligament, was excised completely at 14 weeks of gestation, and the pregnancy continued to term. CONCLUSION: Familiarity with benign uterine smooth-muscle tumors with unusual growth patterns by gynecologists and pathologists is essential in avoiding over-treatment.

Antenatal prevalence of fear associated with childbirth and depressed mood in primigravid women

Aim: To investigate the antenatal prevalence of fear of childbirth and its association with depressed mood in low-risk primigravidae in a referral teaching hospital. Settings and Design: The study was conducted in a tertiary referral center catering to three districts in the state of Kerala. This was a cross-sectional study with internal comparison of associated factors. Materials and Methods: Malayalam translation (translation back translation) of Edinburgh Postnatal Depression Scale (EPDS) was self-administered by the participants. It was followed by a structured interview based on the International Classification of Diseases 10 (ICD 10) after which the EPDS scale was scored. Statistical Analysis: Chi-square test was used to compare the presence of fear in women with a EPDS of ≥ 12 and the association of fear and depression. Results: Fear associated with childbirth was expressed by 17.7% women. The prevalence of depressed mood based on the EPDS (score > 12) was 9.8% but based on the ICD 10 criteria, the prevalence of depression was 8.7%. A significant number of women with depressed mood and clinical depression had fear of childbirth of some sort. Conclusions: A significant number of primigravid women with depressed mood and clinical depression had fear of childbirth of some sort.

A Clinicopathological Study of Women with Adnexal Masses Presenting with Acute Symptoms

Background: Abdominal pain is one of the most common presentations of adnexal pathology in gynecology. Early diagnosis and intervention is essential especially in adolescent girls and reproductive age group women to conserve reproductive function. Aim: The purpose of the following study is to assess the clinicopathologic outcome of women with adnexal masses presenting with acute pain. Subjects and Methods: A retrospective study of women with adnexal masses who had surgical intervention for acute symptoms from June 2007 to May 2012 was undertaken. During the study period, a total of 57 women were operated for adnexal masses as emergency. Results: Of the 57 women operated for adnexal masses as emergency, the most common pathology was teratoma 26% (15/57) followed by corpus luteal hemorrhage (16%) and endometriosis (14%). Laparoscopy was the initial surgical approach in just over 50% of patients, but surgery was completed laparoscopically only in about one-third of patients. Conservative surgery in the form of ovarian cystectomy was possible in 70% of patients. Conclusion: Complications of adnexal masses such as torsion and hemorrhage are common causes of acute abdominal pain. Timely diagnosis of the adnexal pathology and surgical intervention will help to preserve the reproductive outcome. Conservative surgery was possible in 70% of our study group.