Vatsla Dadhwal

Prediction of perinatal asphyxia with nucleated red blood cells in cord blood of newborns.

Objective: To determine normal level of nucleated red blood cells (NRBC) per 100 white blood cells (WBC) in cord blood of term non‐asphyxiated newborns and to investigate variations in NRBC counts in perinatal asphyxia. Methods: A total of 75 cases were studied. Levels of NRBC per 100 WBC in umbilical venous blood were compared between 26 asphyxiated newborns (group I) and 49 non‐asphyxiated newborns (group II). Correlation with neonatal outcome was also evaluated. Results: The mean (±S.D.) NRBC per 100 WBC level in umbilical blood of newborns in group I was 16.5±6.4, range 3–25; whereas that in group II was 8.6±7.01, range 1–26. This difference was statistically significant (P<0.001). A statistically significant negative correlation existed between NRBC level and markers of acute intrapartum asphyxia, Apgar score and umbilical arterial pH (r=−0.50, P<0.001 and r=−0.48, P<0.001, respectively). Positive correlation was demonstrated with evidence of chronic antepartum asphyxia, presence of pregnancy induced hypertension and intrauterine growth restriction (r=2.66, P=0.02). A high NRBC count in umbilical blood correlated with poor early neonatal outcome. Conclusions: The level of NRBC per 100 WBC correlates both with acute as well as chronic antepartum asphyxia. Further, it can be used as a reliable index of early neonatal outcome.

Medical management of placenta accreta

Placenta accreta is a rare condition associated with considerable maternal morbidity and mortality. Though hysterectomy is definite and recommended treatment, conservative management may be considered in patients desiring future pregnancy and in whom bleeding is not excessive. We report a case successfully managed using methotrexate. A 2%year-old para 1 was referred to us on the second post-par-turn day with adherent placenta. On admission she had mild pallor, was afebrile, the uterus was well retracted up to umbilicus and bleeding per vaginum was minimal. Ultrasound showed that the whole of the placenta was adherent to the uterine wall. Serum was positive for beta human chorionic gonadotropin (BHCG). A high vaginal swab was taken for culture. As the patient was not bleeding and wanted to conserve her uterus, she was started on

Sublingual misoprostol versus methylergometrine for active management of the third stage of labor

Objective: To compare the efficacy and side effects of sublingual misoprostol and intravenous methylergometrine for active management of third stage of labor. Method: One hundred twenty low risk pregnant women at term with spontaneous onset of labor were included in the study. The women were randomized to receive either two tablets of misoprostol (200 μg/tablet) sublingually or 1 ml of methylergometrine (200 μg) intravenous injection, after the delivery of the anterior shoulder of the baby. The main outcome measures were: need for additional oxytocic drugs, blood loss ≥500 ml, change in hemoglobin levels and side effects. Results: Postpartum hemorrhage as defined by hemorrhage ≥500 ml occurred in 3.1% of the women in the sublingual misoprostol group but none of the women in the methylergometrine group (P>0.05). There was a need for additional oxytocic drugs in 5.0% and 8.3% after methylergometrine and misoprostol, respectively (P>0.05). The change in hemoglobin levels at 24 h postpartum were 0.8 and 0.7 gm% in methylergometrine and misoprostol group, respectively(P>0.05). In the misoprostol group, 6.6% women developed fever ≥38 °C and 21.6% had shivering while in methylergometrine group none experienced these side effects. However, the incidence of other side effects like nausea, vomiting, headache and giddiness were similar in both groups. Conclusion: Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.

Corpus luteum hemorrhage: Rare complication of congenital and acquired coagulation abnormalities

Women taking anticoagulants or those with a clotting factor deficiency are at increased risk of corpus luteum rupture due to coagulation abnormalities and three such cases are described here. Case 1 was a 35‐year‐old woman with prosthetic mitral valve replacement who was on anticoagulant therapy, in whom hemoperitoneum secondary to ruptured corpus luteum was seen. Emergency laparotomy revealed 1.2 L of massive hemoperitoneum. Left salpingo‐oophorectomy was performed. Case 2 was two episodes of hemoperitoneum from luteal cyst rupture in a young patient with the rare congenital factor X deficiency. This patient was managed conservatively with fresh frozen plasma and blood transfusion. This is the first case of congenital factor X deficiency manifested as luteal rupture to be managed conservatively. Case 3 was two episodes of hemoperitoneum from luteal cyst rupture in a patient with antiphospholipid antibody syndrome who was on oral anticoagulants. Laparotomy was done twice with left salpingo‐oophorectomy in the first instance and partial excision of the right ovary in the second instance. Hemoperitoneum secondary to rupture of the corpus luteum should be considered in the differential diagnosis of acute abdominal pain in women with congenital and acquired coagulation deficiencies.

Metformin therapy in women with polycystic ovary syndrome.

To determine the clinical, biochemical, hormonal, and ultrasonographic effects of 6 months of metformin therapy in women with polycystic ovary syndrome (PCOS) and compare with pretherapy parameters.

Successful medical management of ovarian pregnancy.

Ovarian pregnancy is a unique form of ectopic pregnancy that must be documented by the four criteria of Spiegelberg. Preoperative diagnosis of an ovarian pregnancy is a challenge to the clinician. Clinical findings are similar to tubal pregnancy; and although transvaginal ultrasound may arouse suspicion, definite diagnosis is reached by laparoscopy or laparotomy. Conservative treatment, as in tubal pregnancy, is of the utmost importance if the patient is young and desires to bear children. A 31-year-old, gravida 2, para 1, with one previous cesarean birth, presented with a 7 weeks’ amenorrhea. She complained of vaginal spotting and a dull pain in the lower abdomen. Her general condition was fair. On examination her uterus was normal in size. There was a tender, mobile cystic mass in the right fornix and the cervix was painful to the touch. The patient was admitted and given a provisional diagnosis of ectopic pregnancy. Serum beta human chorionic gonadotropin (HCG) titers on the same day were 3000 mIUyml. Ultrasound revealed an empty uterus. There was, however, an hypoechoic mass of 3 cm=4 cm with an hyperechoic area in the right adnexa, which was suggestive of ectopic gestation. There was no free

Heterotopic cervical and intrauterine pregnancy in a spontaneous cycle

Early diagnosis and successful management of a case of viable heterotopic cervical and intrauterine pregnancy (IUP) conceived spontaneously is presented. The clinical presentations, treatment modalities and outcome of heterotopic cervical pregnancy (CP) reported in the literature are reviewed.

Primary umbilical endometriosis: a rare entity

Primary umbilical endometriosis accounts for 0.5–1% of extragenital endometriosis. Clinical presentation is typical and treatment involves complete excision. It is important to consider it in differential diagnosis of an umbilical nodule.

Ectopic pregnancy following levonorgestrel emergency contraception: a case report.

Use of levonorgestrel as emergency contraception is a safe and effective measure to prevent unwanted pregnancy. However, ectopic gestation in case of failure is a known risk. Access to levonorgestrel without a prescription in many countries has made it impossible to estimate the exact incidence of this potential adverse event. Thus, spontaneous reporting of cases serves to alert physicians to this possibility. We present a case of ectopic pregnancy following use of levonorgestrel emergency contraception. To our knowledge, this is the first case report from India following introduction of levonorgestrel emergency contraception in 2001.

Uterine arteriovenous malformations: the role of intravenous ‘dual-phase’ CT angiography

The authors describe the use of dual-phase intravenous CT angiography of the pelvis in two female patients, who presented with ongoing excessive vaginal bleeding, to demonstrate large adnexal and uterine arteriovenous malformations (AVMs). Power Doppler was used as the initial modality to diagnose the AVMs. CT angiography, along with 3-D rendering in the form of maximum intensity projections and shaded surface display, were especially useful for anatomical conceptualization to the gynecologist. This greatly helped in the subsequent management in the form of therapeutic embolization in both patients by reducing the time, radiation dose, and contrast required for the procedure. Subsequent surgery, which was required in both patients (due to failed embolization), was also greatly aided by the demonstration of the exact extent of the AVMs on axial CT images. Thus, CT angiography emerged as an impressive non-invasive imaging modality for the complete evaluation and management of the uterine AVMs.