Uterine artery embolization for uterine arterio-venous malformation

Uterine arteriovenous malformations (AVM) as a cause of abnormal uterine bleeding are listed under “not otherwise classified” in Palm-Coein classification, is an abnormal communication between an artery and vein without an intervening capillary bed resulting in increased pressure and high velocity in the venous system. We report the case of heavy menstrual bleeding in a thirty-five-year-old primiparous lady for five years with fourteen weeks sized uterus and six gm hemoglobin. Ultrasound revealed an enlarged uterus with tubular spaces and color doppler showed tubular anechoic structures, both within the myometrium, with low resistance and high-velocity pattern suggestive of uterine arteriovenous malformations. Because of nonresponse to medical management, uterine artery embolization was carried out following which she had significant reduction in menstrual bleeding emphasizing it as a differential diagnosis in all cases presenting with heavy menses. Uterine artery embolization appears to be an effective modality of treatment especially in women whose wish to preserve fertility

Uterine Pseudoaneurysm: A rare cause of delayed postpartum haemorrhage managed with uterine artery embolisation

MEDICAL IMAG

Early Onset Pre-Eclampsia with Nephrotic Range Proteinuria as the Initial Manifestation of Lupus Nephritis: Report of three cases

Early onset pre-eclampsia (pre-eclampsia at less than 34 gestational weeks) is a severe form of preeclampsia; in addition, some women may also develop nephrotic range proteinuria. De novo diagnosis of lupus nephritis (LN) in pregnancy is challenging as it may present with features similar to commonly occurring preeclampsia. We report three cases of early onset pre-eclampsia with nephrotic range proteinuria and subsequent diagnosis of LN at the Women and Children hospital attached to Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, between 2014 and 2017. These cases highlights the need for further evaluation of the association between nephrotic-range proteinuria and early onset pre-eclampsia. The index of suspicion for underlying LN of these type of cases should be high. Earlier detection of LN will prompt better management that can avert or delay short- and long-term morbidity.  Keywords: Lupus Nephritis; Pre-Eclampsia; Nephrotic Syndrome; Proteinuria; Case Reports; India

Developing a culture of evidence-based practice in gynecology and obstetrics

Evidence-based management/practice is the systematic, explicit, and judicious application of current best evidence in patient care decisions. The individual clinical expertise is integrated with the best available external clinical evidence. Within a hospital and specialty, there may be a wide variation in practice between doctors. It is essential to have uniform standards of care for all patients. Using EBM, we can possibly establish uniform standards of care so that all hospital/unit staff can adhere to evidence-based protocols/treatments. Despite the great strides the medical community has made in the past 10–15 years, a gap exists in developing a culture of evidence-based practice in India. The identifiable reasons are inconsistencies, lack of transparency and collaboration in large healthcare settings, lack of resources for training, and easy access to literature. Clinicians in senior positions may need the right understanding of the concept, resulting in downstream slow acceptance. Embedding the evidence-based practice concept as early as undergraduate medical education has yielded positive results. Focus on developing an organizational willingness through integrated programs and policies could help bring a change in the working systems

Managing pregnancy in women with Sturge-Weber syndrome: case report and review of the literature

Sturge-Weber syndrome (SWS) is a sporadic congenital neuro-cutaneous anomaly with capillary-venous malformation involving the brain, eye, and the ophthalmic division of the trigeminal nerve. In these cases, physiological changes in pregnancy, including hormonal and hemodynamic changes, may predispose to increased seizure frequency and even a life-threatening intracranial haemorrhage. There are only few case reports available about the management of women with pregnancy and SWS. We report two patients with SWS diagnosed in childhood and managed during pregnancy and reviewed the outcomes and complications during pregnancy in women with this disorder

Practice of early initiation of breastfeeding among postnatal mothers in a tertiary hospital in South India

Background: Early initiation of breastfeeding (EIBF) has significant health benefits, but the practice of this in many parts of the world is far beyond the optimal period of initiation. Hence, we planned to assess the time of initiation of breastfeeding among postnatal mothers and to identify the factors associated with practice of early initiation in a tertiary hospital setting. Methods: The study was carried out among 216 postnatal mothers who delivered term healthy babies. All the mother–infant dyads enrolled were interviewed within 6 h postpartum. Data were collected using a structured interview. An in-depth interview of 35 staff nurses, who worked in the labor rooms and postpartum wards, was carried out after 3 months of initial data collection, to assess the factors responsible for delayed breastfeeding. Results: One hundred and twenty-six (58%) mothers were primiparous and 97 (44.9%) had secondary level of education. The median time of initiation of breastfeeding was 94 min (interquartile range 48–126 min). The time of rooming-in and the mother's knowledge on early breastfeeding initiation were found to be associated with the time of initiation of breastfeeding. Conclusion: EIBF was extremely low in the study setting, which is alarming and suggests an immediate need for the change of existing hospital policy

Efficacy and safety of Tramadol as an analgesic in women undergoing vaginoscopic hysteroscopy: a randomized placebo-controlled trial

Pain or discomfort during the hysteroscopy remains a challenge even after the introduction of small calibre instruments and vaginoscopic techniques. Tramadol, a centrally acting analgesic, is one among the medications used to reduce pain; however, the experience with its use in the vaginoscopic technique is limited. This was a randomised double-blind placebo-controlled trial conducted to study the effectiveness of oral Tramadol as an analgesic in 100 women undergoing diagnostic vaginoscopic hysteroscopy. Median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001) Ease of entry, procedure entry time and the adverse effects were similar in both the groups. Administration of oral Tramadol 50 mg, 1 h prior to the procedure may be a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy.Impact statement What is already known on this subject? Even with the use of newer hysteroscopes with small calibres and vaginoscopic techniques, pain and discomfort to the patient during negotiation through the cervix remain the main challenge to the surgeon. Among the several medications reported to reduce pain during the procedure, Tramadol a centrally acting drug with dual analgesic action, both by the µ opioid receptor agonist action and by the inhibiting uptake of serotonin and norepinephrine, can be used. However, studies using oral Tramadol during vaginoscopic hysteroscopy are limited. What do the results of this study add? The median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001). Ease of entry, procedure entry time and the adverse effects were similar in both the groups. What are the implications of these findings for clinical practice and/or further research? This study suggests that administration of oral Tramadol 50 mg, 1 h prior to the procedure, may be used as a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy. Future trial with a larger sample size is required to confirm the tolerability of its use, as the incidence of adverse effects was low in the study