Vijay Zutshi

Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions.

Objective: Evaluation of visual inspection of the cervix with acetic acid (VIA) for screening cervical intraepithelial neoplasia. Methods: In this prospective study, 400 women were screened using the Papanicolaou (PAP) smear, VIA and colposcopy. Those who had positive results with any of the screening methods underwent large loop excision of the transformation zone (LLETZ). The sensitivity and specificity of each of the screening methods was analyzed. Results: The sensitivity of VIA (96.7%) was much higher than that of the Pap smear (50%), and almost as high as that of colposcopy (100%). The specificity of VIA (36.4%) was lower than that of the Pap smear (97%) and colposcopy (96.9%), resulting in high false‐positive rates for VIA. Two cases of endocervical lesions were missed with VIA. Conclusion: Visual inspection of the cervix with acetic acid is very sensitive for ectocervical lesions. The advantages of the VIA method are its low cost and ease of use (it can be used by paramedical workers), its high sensitivity and its immediate results (it is possible to “see and treat” at the first visit). Its main limitation is a high rate of false‐positive results, which may lead to overtreatment if a “see and treat” policy is applied.

ROLE OF HYOSCINE N-BUTYL BROMIDE (HBB, BUSCOPAN ® ) AS LABOR ANALGESIC

BACKGROUND Hyoscine N-butyl bromide (HBB) acts by inhibiting cholinergic transmission in the abdomino-pelvic parasympathetic ganglia, thus relieving spasm in the smooth muscles of gastrointestinal, biliary, urinary tract and female genital organs, especially the cervico-uterine plexus and aiding cervical dilatation. AIM The study was undertaken to observe the effects of 40 mg intravenous HBB as a labor analgesic and labor accelerant. SETTINGS AND DESIGN This prospective randomized control trial was carried out on 104 primigravidae with single live fetus in cephalic presentation, with spontaneous onset of labor, between 37-40 weeks of gestation. MATERIALS AND METHODS Women were consecutively randomized into study (group I) and control (group II) groups, each with 52 patients after excluding high risk factors like preeclampsia, antepartum hemorrhage, previous uterine scar, and any contraindications to vaginal delivery. Group I received 40 mg HBB as a slow intravenous injection in the active phase of labor while Group II received 2 mL normal saline. Pain scores were assessed at baseline and two hours later. Secondary outcome measures compared were progress of labor based on injection delivery interval, mode of delivery and neonatal condition at birth. STATISTICAL ANALYSIS Statistical significance was assessed by using Students t-test and Chi-square test. P-value < 0.05 was taken as significant. RESULTS Pain relief of 35.6% was noted on visual analog score with the use of HBB. Mean duration of labor was 3 hours 46 minutes in Group I compared to 8 hours 16 minutes in Group II (P value: < 0.001). Mode of delivery and neonatal outcome were comparable. No adverse maternal effects were noted. CONCLUSIONS Intravenous Hyoscine N-Butyl Bromide causes pain relief of up to 36% and shortens the duration of active phase without any untoward short term fetal or maternal effects.

Vaginal misoprostol versus vaginal estradiol in overcoming unsatisfactory colposcopy.

Background: Unsatisfactory colposcopy, an inability to visualize the entire transformation zone, is found in about 10-20% of the patients undergoing the procedure. These patients usually require conization for a comprehensive evaluation of the cervix. Our study aims to compare the efficacy and safety of vaginal misoprostol versus vaginal estradiol in overcoming unsatisfactory colposcopy. Methods: We studied 48 women with unsatisfactory colposcopy. They were randomized into two groups: group I (n = 24) received 200 µg misoprostol vaginally and colposcopy was repeated after 6 h, while the subjects in group II (n = 24) were prescribed a 7-day course of 50 µg estradiol for vaginal insertion followed by a repeat colposcopy. The efficacy and safety of these two drugs were compared. Results: Repeat colposcopy was satisfactory in 70.8% of the women given vaginal misoprostol compared to 82.6% of the women who used vaginal estradiol. The difference was not statistically significant. The adverse effects were reported more often by the women in the misoprostol group (41.6%) as compared to those in estradiol group (13%) (p = 0.04). Conclusion: Both estradiol and misoprostol were comparable in overcoming unsatisfactory colposcopy. However, a higher incidence of adverse effects was noted with misoprostol as compared to estradiol.

Adult neuroblastoma of the ovary: A rare tumor with review of literature

Neuroblastoma is a tumor of pediatric age group and is extremely rare in adults. Common sites involved in adults are almost similar to that seen in children like retroperitoneum, adrenal gland, pelvis and mediastinum. Ovarian neuroblastoma has never been reported in the literature before. We, hereby, present a case of a 38-year-old lady with bilateral ovarian neuroblastoma diagnosed as Krukenbergs tumor clinicoradiologically.

Obstetric and gynecological outcome in a patient with traumatic pelvic fracture and perineal injuries

A 19‐year‐old woman presented with pelvic trauma following a road accident. She was hemodynamically stable. Examination revealed perineal injuries and type C pelvic fracture, which was stabilized with an external fixator. The broken ends of the pubic bone were brought together by an orthopedic wire. The detached vaginal wall and torn anal sphincter were surgically repaired after making a diverting colostomy. The postoperative period was uneventful. Colostomy was reversed after 3 months. Postoperatively the patient developed a cystocele, dyspareunia and vaginal pain. She conceived spontaneously and was planned for an elective cesarean at 37 weeks gestation; however, she presented in labor at 36 weeks and had a normal vaginal delivery. Pelvic fractures may be associated with genitourinary and anal sphincter injuries, which require management by a multidisciplinary team. On recovery the patient may develop prolapse, dyspareunia and persistent local pain. Spontaneous conception and normal vaginal delivery are nevertheless possible.

Prophylactic antibiotics: what does it mean to the obstetrician in a tertiary care setting?

Antibiotic prophylaxis refers to administration of antibiotics to revent infection. It is distinguished from antibiotic treatment by: i) short courses (up to 24 h), frequently a single dose; and (ii) dministration shortly before or at the time of possible bacterial noculation [1]. The recommended duration of prophylactic antibitics has gradually been reduced from 5 days to 72 h, to 24 h (three oses) and finally to a single dose as more and more studies are pubished in the literature. The National Surgical Infection Prevention roject emphasises that prophylactic antibiotics should be adminstered within 60 min prior to surgical incision and discontinued ithin 24 h after the end of surgery. Common errors in antibiotic rophylaxis are: administration too early (>2 h prior to surgical ncision) or too late (after the surgical incision) as well as continued rophylaxis beyond the first 24 h. These persist despite the publiation of well-designed studies that fail to demonstrate benefits of ong-term prophylaxis. We compared the rates of post-operative morbidity when ntibiotics were given in the perioperative period as a short course ith when they were continued for >24 h by means of a prospecive observational study conducted over 3 months at a tertiary are teaching hospital in New Delhi, India. Subjects included 251 omen undergoing Caesarean delivery at term (37–40 weeks). omen were segregated into two groups based on the antibiotic rescribing preferences of two clinical units in the Department f Obstetrics & Gynaecology at Maulana Azad Medical College Lok Nayak Hospital (New Delhi, India). Group I (n = 115) conisted of patients who received three doses of antibiotics, one dose re-operatively and two doses post-operatively, whilst Group II n = 136) included patients where the post-operative antibiotics ere continued for ≥5 days. Antibiotics used were ampicillin njection (Inj.) 500 mg per dose and gentamicin Inj. 80 mg per ose in both groups administered at the time of induction of naesthesia and continued post-operatively. The two groups were omparable in their sociodemographic characteristics, and conounding factors were equally matched (Table 1). Women with llergy to ampicillin, prolonged rupture of membranes (>12 h), horioamnionitis or obvious evidence of sepsis at admission, heart isease (who are continued antibiotics for endocarditis prophyaxis) and those who were immunocompromised were excluded rom the study. Results were analysed using SPSS v15.0 (SPSS Inc., hicago, IL).

Contralateral ovarian pregnancy after single tubal recanalisation

Ovarian pregnancy accounts for less than 3% of all ectopic pregnancies. A 30‐year‐old who had undergone right tubal reanastomosis seven months prior presented with pain abdomen and spotting. Her last menstrual period was 30 days prior. Examination revealed stable vitals, tenderness and shifting dullness per abdomen, fullness in the pouch of Douglas, a tender left adnexal mass and normal size uterus. Urine pregnancy test was positive. Culdocentesis revealed blood. A heteroechoic 3 × 3.2 × 3.1 cm left adnexal mass and free fluid were detected on ultrasound. There was no intrauterine gestational sac. On laparotomy 800 mL of hemoperitoneum was present. There was no evidence of tubal pregnancy. Left ovary had a 3 × 5 cm hemorrhagic mass. Partial ovariectomy was done and histopathology revealed ovarian pregnancy. This is the first reported case of an ovarian pregnancy occurring after tubal recanalisation. After successful tubal recanalisation procedure, altered motility of the reconstructed tube may cause expulsion of fertilized ovum into the peritoneal cavity and contralateral ovarian implantation.

Emergency aortic valve replacement and Caesarian section in a primigravida with severe aortic stenosis: a case report

Introduction Congenital bicuspid aortic valve with severe aortic stenosis (AS) is a rare condition (3–6% of patients with congenital heart disease). Pregnancy in these patients carries a high risk of maternal and fetal mortality. With advancing gestational age, these women may develop cardiac failure due to increased cardiorespiratory requirements. When medical therapy proves insufficient, cardiac surgery becomes mandatory to save the patients life. Balloon valvuloplasty is only palliative treatment, the duration of benefit being only 6 months. Valve replacement is thus recommended. Cardiopulmonary bypass (CPB) surgery with valve replacement has been reported to carry a lower risk of maternal mortality (1.5–13%) but a very high fetal risk (16–40%). This paper reports the case of a 30-year-old primigravida with severe AS with bicuspid aortic valve and pulmonary congestion clinically uncontrolled, in whom CPB surgery and aortic valve replacement was performed as an emergency procedure, along with a lower segment Caesarian section. Conclusion The outcome of unrelieved severe symptomatic AS in pregnancy is poor. Multidisciplinary management is important to avoid deterioration in cardiac performance in parturients with severe AS. CPB during pregnancy carries a high risk to the fetus. Therefore, open heart surgery during pregnancy should be advised only in extreme emergencies (ie, heart failure refractory to conventional therapy).

Evaluation of intravaginal misoprostol for medical management of pregnancies less than 20 weeks of gestation with absent cardiac activity

Aim:  To assess the efficacy and side‐effects of misoprostol (800 µg used intravaginally) for terminating non‐viable pregnancies up to 20 weeks of gestation.

O850 Abdomino-peritoneal tuberculosis masquerading as ovarian cancer: A retrospective study of 26 cases

The association between in vitro fluconazole and nystatin susceptibility with clinical outcome is poorly understood. The purpose of the study was to correlate fluconazole and nystatin susceptibility with clinical outcome for vulvovaginal candidosis (VVC). Two hundred and eighty-three patients with complicated VVC, which included 27 patients with VVC that had been caused by non-albicans species, were investigated at Peking University Shenzhen Hospital between April 2005 and December 2006. In vitro fluconazole and nystatin susceptibility was tested using E test or commercial agar diffusion test. The patients were treated with fluconazole or nystatin. The resistance rate of candida species for fluconazole and nystatin were 0.8% (1/132) and 0 (0/155). The mycological cure rate at day 7–14 and day 30–35 in fluconazole susceptible-dose dependent isolates was lower than that in fluconazole susceptible isolates (42.9% vs 88.7% and 28.6% vs 76.6%, p < 0.05). The mycological cure rate at day 7–14 and day 30–35 in VVC caused by Candida albicans (C. albicans) group and non-albicans species group was 85.6% (219/256) vs 88.9% (24/27) and 79.3% (203/256) vs 81.5% (22/27), p > 0.05. We conclude that fluconazole resistance was rare and both C. albicans and nonalbicans species were susceptible to nystatin. The decrease of fluconazole susceptibility was related with fluconazole therapeutic failure.